The Lancet Strikes a Major Blow to the Pope's Flawed Argument Against Condom Use for prevention of HIV transmission

The Lancet, one of the most respected medical journals in the world joins the many public health professionals to call the Pope out for his irresponsible statement on condom use with regard to the HIV epidemic.

The Lancet states in an editorial, "When any influential person, be it a religious or political figure, makes a false scientific statement that could be devastating to the health of millions of people, they should retract or correct the public record."


AFP "Pope 'publicly distorted' condom science: Lancet"

See my previous posts on the Pope's comments here and here .

The Lancet

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Update on the Alatech Condom Hullabaloo: Political Pork

After seeing many papers take the Kansas City Star article on Alatech condoms, I'm very pleased to see some solid reporting by Celia Dugger.

My favorite parts:

"Behind the scenes, the politicians have ensured that companies in Alabama won federal contracts to make billions of condoms over the years for AIDS prevention and family planning programs overseas, though Asian factories could do the job at less than half the cost.

In recent years, the state's condom manufacturers fell hundreds of millions of condoms behind on orders, and the federal aid agency began buying them from Asia. The use of Asian-made condoms has contributed to layoffs that are coming next month.

But Senator Jeff Sessions, Republican of Alabama, has quietly pressed to maintain the unqualified priority for American-made condoms and is likely to prevail if the past is any guide."
....

"From 2003 to 2005, Alatech and one other company making condoms for Usaid fell behind on their orders, agency officials said. Last year, the other company went bankrupt. "

.....

"Senator Sessions wrote Usaid a letter last year saying it should purchase condoms from foreign producers only after it had bought all the condoms American companies could make, noting it was 'extremely important to jobs in my state'."

Read the full Celia Dugger's International Herald Tribune article

Here's my original post on the Kansas City Star Article on Alatech

And here is Ms. Dugger's article in 2006 about Alatech where my favorite line is:

"Duff Gillespie, a retired senior Usaid official who is now a professor at the Johns Hopkins School of Public Health, said that over the years officials at Usaid raised the prospect of foreign competition to tamp down what he called 'the greed factor' of Alabama condom manufacturers.

But whenever the staff pushed to buy in Asia, Alabama politicians pushed right back."

The Chicago Sun Times adds to the growing reports on Alatech's performance saying, "The U.S. Agency for International Development says Alatech has had problems filling orders, and there were complaints from the field about the quality of its condoms."

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Contraceptives and Catholics: "Sex and Drugs" goes to Divinity School for a Day

To understand some of the Catholic Church's recent stances on condoms (See my previous post )and abortion of a nine-year old incest survivor in Brazil (Source: Huffingtonpost), I thought it would be useful to review a key document that informs some of the Pope's recent decisions and statements. I'm no expert in religion and it shows- I just have more questions!

Documentation that Guides Catholic Church

Decisions

While the Old and New Testament address adultery and divorce, there is no Bible-based guidance to Christians on use of contraceptives, which came later. The reference most commonly used in Catholicism is the Humanae Vitae- a document attributed to Pope Paul VI in 1968. (Source: Wikipedia)

The Humane Vitae was written in response to the oral contraception becoming available in 1960 and a Catholic Church Commission Report in 1966 which proposed that, "that artificial birth control was not intrinsically evil and that Catholic couples should be allowed to decide for themselves about the methods to be employed", and a minority report which held that contraception was instrisically evil. (Source: Wikipedia)

The Humanae Vitae prohibits use of artificial contraception, but does not label it as evil and overall is a complicated document which is supposed to reaffirm previous Church positions and embody some of the conflict within the church on contraceptives. (Source: Wikipedia)

Three Catholic Cheers for Sex!

The Humanae Vitae does take a tremendous step and call, "sexual activity, in which husband and wife are intimately and chastely united with one another, through which human life is transmitted, is...noble and worthy.''

Hurrah for the Catholic Church's appreciation of sex!

Asserting an Inseparable Connection and then Severing it?

The Vatican's Humanae Vitae "is based on the inseparable connection, established by God, which man on his own initiative may not break, between the unitive significance and the procreative significance which are both inherent to the marriage act" yet "the Church teaches that married people may then take advantage of the natural cycles immanent in the reproductive system and engage in marital intercourse only during those times that are infertile, thus controlling birth in a way which does not in the least offend the moral principles."

Now this point confuses me. The overall point of this document is to say that the benefit the couples gets from sex relating to couple unity and intimacy should never be separate from the other benefit of sex- procreation. Yet then the document goes on to say that it is allowable for couples to time when they have sex to reduce the potential that the sex act will result in a pregnancy.

All is supposed to be "cleared up" when the documents says that "neither the Church nor her doctrine is inconsistent when she considers it lawful for married people to take advantage of the infertile period but condemns as always unlawful the use of means which directly prevent conception".

Oh thanks- all clear now.

My biggest issue with the Humane Vitae is that it states "an act of mutual love which impairs the capacity to transmit life which God the Creator, through specific laws, has built into it, frustrates His design which constitutes the norm of marriage, and contradicts the will of the Author of life. "

This is in conflict with my limited understanding of the Catholic interpretation of the power of God. As I understand, God is all powerful and miracles are possible. Couples who were previously thought to be infertile have been able to conceive and this miracle is attributed to God's will. How can we be so arrogant to belive that these small steps could override God's will?

As the religious right has brought up many times, there is no contraception that is 100%- not condoms, oral contraceptives, even sterilization. "In the United States, most studies of breakage caused by fault in the condom itself have shown breakage rate is less than 2 condoms out of every 100 condoms. Studies also indicate that condoms slip off the penis in about 1-5% of acts of vaginal intercourse and slip down (but not off) about 3-13% of the time." Avert.Org Condom Effectiveness If condoms work only 87-97% of the time, there is room for divine action.

The % chance for divine intervention for condoms is not too far off with perfect practice of contraception by following natural cycles. Chances of pregnancy in a typical ovulation calendar varies by day from 0-20%.

Why must a fertile 20-something be held to a higher standard of self-discipline than an infertile peer or the post menopausal generation? Chances of conceiving post menopause are extremely low per "Ask Our Expert" at drspock.com. Why do the baby boomers get to have all of the fun?

Limiting contraception to "infertile methods" puts the moral burden unevenly on the most fertile part of the population. If we were to truly hold ourselves to not separating the procreative and couple-intimacy benefits, wouldn't those populations who were less fertile be expected to abstain from sex full stop?

Understanding Why the Church Accepts Natural Cycle Contraception, but Not Artificial Contraception- Unpacking the Concept

Why is natural cycle contraception considered ok while artificial contraception (oral contraception, injectables, condoms, etc.) is not? I'll paraphrase the HV's section on this using two couple examples- Couple A live within the church rules of maintaining intimacy while avoiding a pregnancy while Couple B are avoiding a pregnancy using artificial birth control.

There seem to be two major arguments:

(1) Couple A's abstinence during the most fertile times of the ovulation cycle is self control that demonstrates their true love for each other, so they may have sex during infertile times with the intention of avoiding pregnancy within the rules of the church. Couple B is not practicing a method that is time-restrictive and are therefore not sacrificing anything to demonstrate their true love.

(2) Couple A is taking advantage, "of the natural cycles immanent in the reproductive system and engage in marital intercourse only during those times that are infertile, thus controlling birth in a way which does not in the least offend the moral principles", while Couple B obstructs, "the natural development of the generative process".

Is this the Catholic Church's Feminist Manifesto? If So Can I Get an Upgrade?

This document also asserts that that "a man who grows accustomed to the use of contraceptive methods may forget the reverence due to a woman, and, disregarding her physical and emotional equilibrium, reduce her to being a mere instrument for the satisfaction of his own desires, no longer considering her as his partner whom he should surround with care and affection."

It is odd to me that the same document which praises self-discipline could expect such a severe swing to depravity with the simple use of contraceptives. Cases of men's lack of reverence of women, unfortunately, predates contraceptive devices. Regulating use of contraceptives will not change this- though perhaps if men were able to become pregnant this would change. The HV is supposed to be a statement with the Church's, "new understanding of the dignity of woman and her place in society"- but to me, limiting a woman's access to birth control seems to impair her ability to have her dignity.

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Condom production and procurement- Buying American doesn't mean better quality

I read an incendiary piece in the Kansas City Star that pushes buying "American"- even condoms. While my heart goes out to the folks working at Alatech condoms in the US, the company has not necessarily produced condoms superior in quality to those produced in Asia and those problems increase risk of HIV transmission worldwide. Here is my response to the author.

Dear Mr. McGraw,

I believe your article about the condom situation is unfair. Alatech is the sole remaining condom producing company in the US in spite of major investment of the US government to support US-based condom producers. There was another US condom company, but even with major funding from the US gov’t, had to close down. One big issue is that the colloidal latex used in condom production is from latex trees- most of whom grow in Thailand, China, Brazil, and Indonesia. Condom production outside of the global South doesn’t really make sense. Just look at where the Durex and Trojan condoms are produced- in places like India, Thailand, and South Korea- from the same plants USAID gets condoms from.

I bet if you had interviewed someone in procurement at USAID or UNFPA, you would have found out that there have been issues with condoms procured from Alatech- including inconsistent size and thickness and MAJOR delays between ordering and delivery. The US government is not without fault, but I think reducing its use of Alatech condoms was the best decision. Even if these condoms still “worked” to prevent transmission of HIV (not AIDS, as you wrote), the variability in size, shape, and thickness would make the consumer unhappy and may decrease consistency of condom use- a dangerous behavior in these times of HIV. If Alatech had been faster in making changes based on the feedback it was getting- they could have saved those 300 jobs. Perhaps all of this governmental protection from international competition made Alatech lazy. I don’t want condom producers to be lazy- I want them to worry day and night to ensure that they produce the best quality condom they can.

Your use of “cheaper” perhaps should have been “less expensive”- as Unidus and Butterfly plants go through a rigorous pre-procurement vetting and certification procedure. From my experience, Unidus condoms are not only high quality-but are superior to Alatech condoms in their consistency of shape, size, and thickness. There is more than one condom manufacturing plant in China and while some plants have issues with quality- the certified and pre-approved plants have earned going through the quality assurance gauntlet.

I was disappointed that you only interviewed Alatech staff and an Alatech consultant- your readers have only gotten half the story. It is a shame American jobs are in danger- I only wished that the high paid executive staff would have done a better job at defending them.

Read the Kansas City Star article U.S. move to cheaper Chinese condoms threatens American jobs

Update: I've sent another letter with some clarifications and here are some snippets....

It made sense that a greater burden of condom procurement was moving towards Asia because of the ready access to the supply. I'm thinking about what would be more affordable for someone in Africa buying a condom where the latex came from Thailand but the condom was made in the US or buying a condom that was sourced and produced in Thailand and shipped directly to the country. It also sounds like a "greener" system. .....

Government regulations on the acceptability of variation of shape and thickness within an order seems to be a bit more lax than the standard for the commercial companies (ex. Trojan)- so an order may meet gov't needs but still result in some unhappy end-consumers. Thinking about the HIV epidemic, I wouldn't want high risk populations to have any additional reasons (valid or not) to not use a condom. ....

There are issues with quality of different kinds of Chinese products. However, just because there are issues with some plants and some products, this does not mean all Chinese products are poor grade. China has some terrible condom plants, but also have some that meet international standards- they are audited on quality standards regularly to ensure this. The same plants that produce condoms like Durex in places like Thailand and India are held to these same standards. Why are condom companies like Durex, Trojan, or European brands not purchasing from Alatech (to my knowledge, they are not, but I may be mistaken)- is it just price or are there other questions?....

Pope Benedict dicts around with human lives in the face of the HIV epidemic, 359 years until the apology comes?

As a child of a lapsed Catholic, I do care about what the Pope says. As an epidemiologist, I am disappointed with the Pope's recent statements in Africa against the utility of condom use in reducing the spread of HIV. "You can't resolve with the distribution of condoms,"... "On the contrary, it increases the problem." Source: Yahoo News article on the Pope's stance.

In doing so, he ignores the immense body of evidence that condoms used effectively and consistently are very effective in preventing the sexual transmission of HIV and other sexually transmitted infections and that promoting condom use and increasing access to condom do not increase frequency of sex or number of sex partners. (Smoak et al, Sexual Risk Reduction Interventions Do Not Inadvertently Increase the Overall Frequency of Sexual Behavior: A Meta-analysis of 174 Studies With 116,735 Participants J Acquir Immune Defic Syndr 2006;41:374Y384).

He also sets back the progress that has been made to increase condom use in Africa and countries with large Catholic populations.

This is especially sad because in 2006, the current Pope was considering softening the Catholic Church's stance on condoms. Cardinal Carlo Maria Martini, a moderate in the Vatican said in April 2006, "We need to do everything possible to combat AIDS. Under certain conditions, the use of condoms is necessary. Those who are afflicted have an obligation to protect the other partner," and the Vatican's equivalent of health minister, Cardinal Javier Lozano Barragan, said that the Pope had taken the initiative on taking another look at the condom issue. Source: Deutsche Welle.

It does seem that the Catholic Church does have people who are a bit more sensible on life in the times of HIV. Cardinal Godfried Daneels of Belgium, who was once considered a candidate to suceed John Paul II, had a more sensible position to condom use. In 2004, he stated that someone had HIV could use a condom to protect life. Source: WorldNet Daily.

It took more than 300 years for the Catholic Church to apologize for persecuting Galileo and 60 years to apologize for its inactivity against the Holocaust. Perhaps with another 2 million deaths from AIDS-related complications (annual mortality rate is just over 2 million- source UNAIDS), including sero-negative spouses of people living with HIV, the apology and change from the Catholic Church will come sooner?

The Amazing Dr. Reddy, Condom Genius and Other Grand Condom Inventions

Even in the world of condom distribution, value-added condoms get titters. Value-added condoms include condoms that are studded (also called "dotted), ribbed, there are those which are even packed with Benzocaine (a topical numbing agent and cousin of Novocaine) to help men battle against the old foe, premature ejaculation.

A hero in this field is Dr. Reddy, inventor of some of the more interesting shapes of condoms. Dr. Alla Venkata Krishna Reddy invented:
(1) the Pleasure Plus (with a pouch that is an equivalent of a "waddle" on the lower part of the shaft to create additional sensation)
(2) the Inspiral and (3) the Twisted Pleasure - 2 condoms based on the same principal- a spiral shape for more pleasure.

Salon did an article on Dr. Reddy and the sad legal history of these condoms.

Some organizations even tested some Reddy inventions for use in public health interventions to motivate condom-haters to give protection a try.

While the innovation in India on condoms may have slowed, there is a new young Turk on the scene. Jan Vinzenz Krause in Germany is developing a spray-on condom that can provide a perfect fit with little chance of slip. They are still working on the coverage and vulcanization process, but it has been getting some media coverage-- including from Time Magazine.

Here's a video of the condom and an amusing diagram from the company website (in German).

Condoms for Kids?

I'm of the mind that all sites and literature promoting safer sex should provide guidance based on real situations.

I'm sick of materials designed for high risk groups such as Men who have sex with Men (MSM), sex workers, and injecting drug users that uses child-like cartoons like little condom-men with smiling faces. I've seen more projects that I'd like to admit that have responded to the challenges of trying to reach a young or low-literate target group by making their communications too childlike. Sex is a very adult issue. Treating your target group with a modicum of respect makes for more effective interventions.

Example from: http://www.thethreeamigos.org/

There is hope. I am a big fan of the work at Hard Cell, a website targeting Men who have Sex with Men who address questions of protection with a heavy dose of sexual content. Only those 18 and over should visit.

How Condoms are Made

Gotta love those "how they're made" videos. Listen to a soothing British voice while you see condoms spinning around. How Condoms are Made.


Condoms are made of a mix of liquid and solid latex. Colloids were never so great!

Simply Safer: Basic Sex Ed

I would be remiss if I did not include at least a bare minimum of basic education on how folks can better protect themselves during all of this sexual behavior I'm talking about.

How to Correctly Put on a Male Condom

1. Make sure the condom has not expired and check the condom package & condom for tears
2. Carefully tear open the pack, making sure not to tear the condom (teeth, scissors, and knives are forbidden here!)
3. The shiny, lubricated side of the condom should be on the outside, so the condom can easily be rolled down the penis. If the penis touches the wrong side, throw condom away and use a new condom.
4. Pinching the top of the condom, roll the condom all the way down the erect penis to the base. The entire penis should be covered by condom. Do not skip the PINCH step, this is very important to prevent breakage.
5. If the condom breaks or slips off, stop sex. You should use a new condom.
6. After ejaculation and while the penis is still erect, withdraw the penis, holding the condom by the base so no semen spills on your partner.
7. Holding the base of the condom, pull down. The condom should come off. If you wish, tie it in a knot.
8. Dispose of condoms in a trash can. Do not try to flush condoms!

For advanced male condom tips, I'd also suggest looking up a post by Eric Amaranth on the Dodson and Ross site site. Dr. Betty Dodson is a fabulous resource for any of your questions on sex and your body (not me).

How to Correctly Use Lubricant

1. Use water or silicone-based lubricant, if the lubricant is flavored, make sure it is sugar-free or you'll risk infectiony revenge (hello yeast!). Do NOT use oil-based lubricants like whipped cream, butter, oil, conditioner, or vaseline. They will break the condom. Do not use spermicides, they also increase the change of infection transmission.
2. Use a male or female condom (lubricant does not replace a condom). For male condom instructions, see above.
3. Liberally apply outside the condom-covered penis and in and around the the rectum/vaginal canal.
4. If drying or friction occurs during sex, apply more lubricant.

How to use a female condom

The "female condom" is a misnomer. More properly named the "insertive condom" it can also be used by the receptive partner during anal sex. Here is some guidance for both uses.

For Vaginal Sex

1. Carefully tear open the packet along the edge and remove the female condom. Inspect to ensure there is no damage to the condom.
2. Hold the condom with the open end hanging down, pinching it the ring with your thumb, index finger and middle finger.
3. Find a comfortable position so you may easily insert the condom (squat, sit with your knees apart or stand with one foot on a chair.)
4. The condom has a smaller inner ring (closed end) and a larger outer ring (open end). Squeezing the inner ring with your three fingers, insert it into your vagina.
5. Put your index finger inside the condom until you can feel the inner ring. Use your finger to push the ring up inside the vagina. You can tell that the condom is in place when the inner ring moves into position behind the pubic bone.
6. The outer ring should lie flat around the outside of your vagina.
7. Use your hand to guide your partner’s penis into the condom. Use your fingers to make sure the outer ring continues to lie flat against the vagina opening during sex. Make sure the penis is not inserted between condom and vagina wall.
8. After sex, remove the female condom by twisting the outer ring and pulling it out gently.
9. Wrap the condom with a paper or plastic bag and throw it into the garbage. Do not flush it.

For anal sex

1. Remove the inner ring from the condom.
2. Apply lubricant in the inside of the rectum and on the penis.
3. Place the erect penis inside the condom. The penis will help you guide the condom inside the rectum just as the inner ring would for vaginal insertion.
4. The outer ring should lie flat around the outside of your anus.
5. Use your fingers to make sure the outer ring lies flat against the anal opening during sex. Make sure the penis is not inserted between the condom and rectum.
8. After sex, remove the condom by twisting the outer ring and pulling it out gently.
9. Wrap the condom with a paper or plastic bag and throw it into the garbage bin or dustbin. Do not flush it.

How to Have Safer Anal Sex that Isn't Painful

1. Use the toilet and empty your bowels
2. Gently clean the anal area with soap and water
3. Put on a latex or polyurethane condom - condoms protect from sexually transmitted infection (STI) & HIV transmission and also protects the insertive partner from bacteria in the rectum (see above)
4. Liberally apply water-based or silicone-based lubricant in the rectum and around the anus and also put it on the outside of the (condom covered) penis
5. Gently insert 1-2 lubricated fingers to loosen your anus (or your partner can do it if his fingers are in a condom)
6. Relax the anus as the (condom covered) penis is inserted
7. If it hurts when the penis is first in, remove the penis and wait about 20 seconds before reinserting
8. If drying or friction occurs during sex, apply more lubricant
9. After intercourse, before the penis become soft, withdraw the penis and the condom together from the anus.

There is no reason anal sex should hurt!

How to Have Safer Oral Sex

Some sexually transmitted infections (STIs) CAN be transmitted through oral sex. Think about the skin on your palms versus the inside of your mouth- which one is more vulnerable to cuts and scratches?

On a penis

1. A male condom can be used starting when the penis is erect. Before then, make use of your hands. It would be even safer to use a pair of unused, sterile latex gloves with lubricant, but your hands are still a better choice than your mouth on an uncovered penis.
2. Put the condom on the penis as above.
3. Now it is mouth ready. Use SUGARLESS, flavored water-based or silicone based lubricant on the outside to address any latex taste.
4. After ejaculation, dispose of the condom in the trash (again, do not flush).

On a female and/or for Rimming

1. Use a dental dam as the barrier between mouth and genital area.
2. Use SUGARLESS, flavored water-based or silicone based lubricant on the outside to address any latex taste.

If you do not have a dental dam, take your scissors to an (empty, new) male condom.

1. Unroll a new condom
2. Cut the tip off of the condom.
3. Cut lengthwise down the condom.

And now you have your own dental dam!

Why I Hate the Durex Balloon Animal Ad

The Durex Balloon Animal ad has been blazing through social circles faster than Herpes through Derek Jeter's little black book. (at least, that is what some gossip blogs have been saying).

The ad is cute and a fun little thing to pass on to friends for a joke, but does it make people more likely to USE condoms when they have sex?

Yes and no. Like with most marketing campaigns, you have to imagine the target group they are trying to reach and imagine how they would process seeing the same video.

Yes- What we have seen in condom use research is that consistent condom-users are more likely to report they bought condoms than non-condom users. This may overwhelm you with obviousness, but simple sense dictates is that if you have condoms with you, you are more likely to use them than if you didn't have them. If someone already uses condoms quite often, but not always, this ad may remind him or her to stop by to pick some up before a date.

No- think about people you know who do not use condoms (ever or only rarely). I've give you a picture that comes into my head: a semi-religious young woman who feels uncomfortable carrying or buying condoms because she associates having condoms with "sluts". This playful video may actually reinforce her association between condoms and being slutty and she'll be even more reticent to purchase (and therefore use) condoms.

I must admit that I am also annoyed by the rubbery-squeaking sound. If only they used water-based or silicone-based lubricant, they could have gone to town and protect themselves further from the latex breaking and reduce that annoying sound.

I'd advise people who click on this to see the Durex video (and outtakes) be 18 and older.

Introduction to Sex, Drugs, and Behavior Change

Note: This blog seeks to find ways to better understand complicated issues of behavior change related to sexual and drug-risk related behavior. Some of the issues brought up in this blog are of a sexual nature or relate to drug use and may include notes that are (intended to be) humorous. If you think any of this may offend you, please do not read.
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Sex. We talk about it, we joke about it, we dish about it, we brag about it. Sex has many faces, it can be (re)productive, playful, or risky in more ways than one. We like it because it feels good or, in some cases (as John Mellencamp says) it "hurts so good." Yet why do some not use condoms when they know they should?

Hurts so Good by John Mellencamp

Sex is the perfect example of learning about behavior, why we do what we do, and why it changes. There are hundreds of professionals who have spent their careers working on how to change sexual behavior and yet we all still have a lot to learn.

What have we learned from more than 30 years of behavior change activites? Actually, a good amount. We just need to pay attention to what we already "know" and try to figure out what's left.

As an example, reducing sexual risk requires a focus first on condom use and talking to partners. Avoiding or downplaying condoms only hurts us in the end.

Let's think about the abstinence-focused curriculum promoted by well-intentioned but almost willfully ignorant policy makers and misled parents. The resulting change from this strategy in youth sexual behavior has been largely contrary to goals. While some young people are delaying their sexual debut (i.e. when they first have sex), they are NOT waiting until marriage, and many are not using condoms.

We have also learned that education and awareness-building alone do not change everyone's behavior.

Drug (licit and illicit) use also gives us a great example.

In 1950, Richard Doll and A. Bradford Hill conducted a case control study that first gave the world the idea that smoking and lung cancer were linked*. From 1951-2001, Doll, Hill, et al ran a prospective cohort study that followed up doctors over fifty years to see if those who were smokers had higher rates of cancer than those who were non-smokers**. Starting in 1954, articles were published on their findings to date which showed a strong causal relationship between smoking and cancer.**

In the US, an American study with similar results was described in the Reader's Digest article "Cancer by the Carton" in 1952. While there was a decline in smoking after the buzz from this article, many continued smoke and non-users continued to initiate.

While awareness of the dangers of smoking did spur some to quit, other factors were at play. There is, of course, addiction, but that is not the whole story. But what of the numbers who initiated? Cigarette advertising a la "Mad Men" could explain some of this. We live in the era where increasing cigarette taxes and city-wide smoking bans are increasingly used and have seen a measureable decrease in smoking as a result, so that must be part of the answer. As before, the answer is composed of multiple factors, some which we know, some we guess, and others we have yet to find out.

Welcome to Sex, Drugs, and Behavior Change


* Doll R Hill AB "Smoking and Carcinoma of the Lung" British Medical Journal 1950 (2) 739-748
** Doll R, Hill AB "The Mortality of Doctors in Relation to their Smoking Habits" British Medical Journal 1954 (1) 1451-1455
** Doll R, Peto R Boreham J Sutherland I "Mortality in Relation to Smoking: 50 Years' Observation on Male British Doctors" British Medical Journal 2004 328 (7455) 1519