The Controversy: Mandatory Flu Vaccines

[Julie Reyes]

First, let me just go over some of the symptoms of the flu, and then we will get down to business on the controversy surrounding the push to create mandatory flu vaccines for healthcare workers:

• Sudden onset fever
• Headache
• Chills
• Myalgia
• Dry cough
• Sore throat
• Stuffy nose
• Loss of appetite
• Limb or joint pain
• Difficulty sleeping
• Diarrhea or upset stomach

I can't think of anyone who wants any of these symptoms, or to come down with the flu, can you?

Influenza vaccination research has clearly documented the benefits of receiving the flu vaccine (Google it - you will find a plethora of information...however, I will list some links at the end of this article for your information). However, even though there is sufficient evidence to prove the benefits of receiving the flu vaccine, vaccination rates among healthcare workers are pitifully low. In 2013, only 55% of nurses in the frontlines were vaccinated.

Organizations such as The Joint Commission, the American Nurses Association, the American Academy of Family Physicians, the American Academy of Pediatrics, American College of Physicians, Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the Centers for Medicare & Medicaid Services, the Centers for Disease Control, Healthy People 2020, etc., etc., have stated their position on recommending the flu vaccine for healthcare workers in order to decrease the risk of exposure and reduce deaths. Due to this recommendation, many healthcare facilities are now creating mandatory flu vaccine policies as a condition of employment.

Employers who create mandatory policies will have exemptions, of course. Exemptions are made for medical and religious exceptions. For places that do not have a mandatory flu vaccine, they may "strongly recommend" the vaccination and may have a declination form for employees to submit if they refuse the vaccine. Additionally, some employers will enforce refusers to wear a mask during flu season while they are at work in order to protect the patients and the employee.

What is the purpose behind the push toward flu vaccines?

Evidence has shown that there are more than 36,000 deaths in the US each year related to influenza, and more than 200,000 hospitalizations. Influenza is the 6th leading cause of death. Healthcare workers are the leading cause of influenza outbreaks in the healthcare system. up to 50% of people who are infected by the flu virus do not fill ill for several days and can spread the virus to people at risk of complications and death from the flu. Additionally, evidence shows vaccination decreases mortality by 40%, decreases the spread of nosocomial infections by 43%, and decreases absenteeism by 20-30%.

Additionally, there is the ethics to consider. As healthcare workers, we have all taken an oath to "do no harm". As a nurse caring for patients who are not in their most physically healthy state, do we take the vaccination in order to prevent spreading the flu to our vulnerable patients, in order to "do no harm"? We must consider this when we make our decision to take or refuse the vaccination.

What hospitals have created a mandatory flu vaccine policy?

I have the names of a few hospitals, and this is by no means a comprehensive list. This is based on a ListServe survey of hospitals and these are the responses received:

• Children's Hospital of Philadelphia (Philadelphia, PA) - since 2009
• Children's Mercy Hospitals and Clinics (Kansas City, MO)
• Children's Colorado (Aurora, CO)
• Children's Hospital of the King's Daughters (Norfolk, VA)
• Children's Medical Center Dallas (Dallas, TX) - since 2012
• Riley Children's (Indianapolis, IN) - since 2012
• East Tennessee Children's (Knoxville, TX) - since 2013
• Boston Children's (Boston, MA)
• Sharp Mary Birch Hospital for Women and Newborns (San Diego, CA) - since 2013
• Roger Williams Medical Center (Providence, RI)
• Brookwood Medical Center (Birmingham, AL)
• Johns Hopkins (all hospitals/clinics) (Baltimore, MD)
• Driscoll Children's Hospital (Corpus Christi, TX)
• Spohn Health System (Corpus Christi / San Antonio, TX)
• All Connecticut Hospitals

What are some reasons that people refuse the flu vaccine?

Refusal may be largely due to misconceptions related to the vaccine. Fears that the immune system will cause them to get the flu, beliefs that hygiene and better nutrition are more helpful than the vaccine, fear of needles, beliefs that the vaccine does not work, and fear of side effects. Others believe that they have a constitutional right to refuse the vaccine and that mandatory policies are violating these rights.

Common concerns and myths about the flu vaccination

(taken from the Los Angeles County Department of Public Health outline of flu vaccine talking points for managers)

The flu shot will give me the flu

The flu shot does not give people the flu. It uses inactivated ("dead") virus. People may still catch a cold or other virus that the vaccine is not designed match.

I don't believe the flu vaccine actually works

Studies have shown that flu vaccination prevents flu in 70% to 90% of healthy adults younger than 65 years old.

I had the vaccination last year

You need a new vaccine every year - the virus changes over time.

What about possible adverse reactions

Serious adverse reactions are very rare. They are explained on the CDC's Vaccine Information Statement, which is distributed when the vaccine is administered.

Local short-term reactions - such soreness at the vaccination site, slight fever, achy feeling - may occur but usually do not last long. Over the counter medicines are helpful. Even short-term reactions are much less bothersome than catching the flu and feeling very sick for days.

I'm not in a high-risk group

Your patients are at-risk, and possibly some friends and family members. You can be infected with the flu virus but not feel ill - and can still transmit flu to at-risk patients.

The flu vaccine made every year does not match the circulating flu strain

Inactivated influenza vaccine is effective in preventing transmission and reducing complications of the flu. In years when there is a close match between the vaccine and circulating virus strains, the vaccine prevents illness among approximately 70%--90% of healthy adults under 65 years of age. Vaccinating healthy adults also has been proven to lead to decreased work absenteeism and use of health-care resources, including use of antibiotics. Strong protection is also expected when the vaccine is not a close match with circulating strains, with 50%--77% effectiveness in these instances. In addition, effectiveness against influenza-related hospitalization for healthy adults from inactivated vaccine is estimated at 90%.

Knowledge is Power

All healthcare facilities will be facing the choice of creating a mandatory influenza vaccination in the near future, if they have not already. In order to make an informed decision on the topic, we must have information. Knowledge is power. Before you make a blanket statement on pros or cons, have the information you need, know the research, and make an educated decision.

Please respond to this article by answering the following questions:

1. Do you take the flu vaccine yearly? If you do not, what is the reason you do not participate (if you don't mind answering this question)?
2. Does your employer have a mandatory influenza vaccination policy as a condition of employment? If yes, where do you work?
3. What concerns do you have about the flu vaccine?
4. Do you know if anyone who has been released from their job because they did not get the flu vaccine?

References

American Association of Family Practitioners. (2011). AAFP supports mandatory flu vaccinations for healthcare personnel. Retrieved from: AAFP Supports Mandatory Flu Vaccinations for Health Care Personnel

ATrain. (2014). To accept or refuse the flu vaccine. Retrieved from: ZZZ_133_Influenza: Module 7

CDC. (2014). Vaccination: Who should do it, who should not and who should take precautions. Retrieved from: Vaccination: Who Should Do It, Who Should Not and Who Should Take Precautions | Seasonal Influenza (Flu) | CDC

Influenza Action Coalition. (2015). Influenza vaccination honor roll. Retrieved from: Honor Roll: Mandatory Influenza Vaccination Policies for Healthcare Personnel

Los Angeles County Department of Public Health. (2014). Talking points for managers. Retrieved from: http://tinyurl.com/p6nbg2u

National adult and influenza immunization summit. (2015). Vaccinating healthcare personnel. Retrieved from: Vaccinating Healthcare Personnel - National Adult and Influenza Immunization Summit

NursingTimes. (2014). Why do health workers decline flu vaccination? Retrieved from: http://www.nursingtimes.net/Journals/2014/11/28/y/k/x/031214-Why-do-health-workers-decline-flu-vaccination.pdf

TJC. (2012). R3 Report: Requirement, rationale, reference. Retrieved from: http://www.jointcommission.org/assets/1/18/R3_Report_Issue_3_5_18_12_final.pdf

[RNsRWe, ASN, RN]

But I love the the comeback from the anti-vaxxers, ""Why are you worried about my unvaccinated kids if you're so sure vaccines work?"

You "love a comeback" that shows unbelievable ignorance? Really?

There IS REASON to worry about vaccinated individuals when there are enough UNVACCINATED ones spread around to diminish the effectiveness, and SPREAD DISEASE even among those who are vaccinated. That really BASIC concept of herd immunity, that some here seem to liken to a fantastical story rather than a proven means of controlling disease!

As has been said roughly 100,000 times, NO vaccine is designed to prevent 100% of illnesses. But they ARE MOST EFFECTIVE (read, VERY effective) when a significant percentage of the population INSULATES themselves via the protection of---that's right---herd immunity.

So to ask "why are you worried about unvaccinated people if you're so sure they work" is just complete and utter ignorance. I find it strange that anti-vaxxers keep thumping a drum that AT BEST makes them look ignorant, uninformed, and AT WORST stupid because they DO have the information but are incapable of understanding it.

Which begs the question, is it ignorance or stupidity? Which side would one prefer to fall on?

[trinitymaster]

Perhaps we should have one big barbecue where we ate all of the birds, swine, cattle etc..... on the planet and then became vegan after that. The end of swine flu, bird flu, and Moo-Flu:yes: would be upon us and no one would ever have to worry about the flu again.

(Or obesity for that matter)

[trinitymaster]

I propose a double-blind RCT. This could easily be done and I would gladly volunteer. I know there have been studies in the past, but the data collection methods were seriously flawed and left way too much room for bias and confounding variables. Plus, the results only indicate a decrease in number of days absent from work due to "respiratory" problems and not confirmed flu cases.

And I am talking about a study on healthy adults 18-60. Not on seniors.

On a side note: We should refrain from referring to others beliefs as ignorant or stupid. Scientific investigation is itself based on ignorance of the facts and the scientific evidence does not always correlate with the realities of life.

Words such as "ignorant" and "stupid" are divisive insults used to create an "us" vs "them" mentality. In this world.....there is only "we".

[RNsRWe, ASN, RN]

On a side note: We should refrain from referring to others beliefs as ignorant or stupid. Scientific investigation is itself based on ignorance of the facts and the scientific evidence does not always correlate with the realities of life.

Words such as "ignorant" and "stupid" are divisive insults used to create an "us" vs "them" mentality. In this world.....there is only "we".

Words such as 'ignorant' and 'stupid' are also excellent descriptors, applied appropriately.

I use ignorant within the context of its legitimate meaning: lacking knowledge, lacking information. I give the benefit of the doubt when I read something that is nonsensical and offer that the person speaking nonsensically is simply ignorant of what they are speaking about.

I believe it is nicer to assume that someone is ignorant of facts rather than incapable of understanding them (which is where the definition of stupidity would enter into the picture). Every day, in the course of my work, I meet with people who are clearly ignorant of the facts surrounding their need for the visit that day, but who are clearly NOT stupid. Others may well be both, but I cannot determine that until after the facts are presented, have been repeated, yet the individual still cannot grasp the data. In those cases.....very few, thankfully!.....lower intelligence can be to blame for not understanding a diagnosis or course of treatment (or whatever), NOT ignorance.

After awhile, when facts have been presented repeatedly---and I say FACTS, not supposition, not anecdotes, not internet celebrity crap, but actual SCIENTIFIC DATA---but there are individuals who still continue on in the same manner (as though they had not SEEN any facts, it wasn't THERE).....one has to eliminate "ignorant" as the most likely option, and go with stupidity.

Speaking plainly (and yes, sometimes harshly) isn't always popular. But the truth is what it is.

I have NO problem whatsoever with a difference of opinion. Happens on AN all the time, it's the very foundation of the site. But this thread isn't about opinion. It's about facts. Cold data. Evidence. Science. And when someone's response to all uncontroverted evidence is "yeah...well, says YOU...someone's just making all that up".....well then yes I guess I have a problem with it, and I call it as I see it.

[BostonFNP, APRN]

I propose a double-blind RCT. This could easily be done and I would gladly volunteer. I know there have been studies in the past, but the data collection methods were seriously flawed and left way too much room for bias and confounding variables. Plus, the results only indicate a decrease in number of days absent from work due to "respiratory" problems and not confirmed flu cases.

Have you read this study? It's an independent meta-analysis of 31 studies, 17 of which were RCTs, looking at the efficacy influenza vaccine. It considered only virology-confirmed endpoints.

Osterholm, M. T., Kelley, N. S., Sommer, A., & Belongia, E. A. (2012). Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. The Lancet infectious diseases, 12(1), 36-44.

[alt_one]

Vaxxers anti-vaxxers A lot of passion around this subject. I like to see the arguments that avoid the name calling.

Boston FNP had asked me in an earlier post if I had any specific concern about formaldehyde and mercury in vaccines or if my concern was more of a general concern about the amount of toxins and chemicals we are exposed to. Mercury and aluminum are neurotoxins that have no metabolic function within the human body. I don't think I need to cite any study about that. My overarching concern is the amount of toxins we are exposed to. A child born today has man made chemicals in their bloodstream. They are then exposed to other man made chemicals through diet and vaccines. The human body is very adaptable and resilient but I believe our ability to absorb these chemicals is finite. So I would ask what is the limit we can absorb and not cause harm? What impact do they have on fetal development and childhood diseases? Do adjuvants impact the elderly? Allergies, autism, and Alzheimer's have exploded in the past 30 years. Why? We approved GMO crops in 1982 and have done nothing but increase the amount of herbicides and pesticides we use. Interesting research is being done about the impact of these chemicals on our bodies but so far only hints about possible impacts. No definitive papers out there yet.

I will bring this all back to vaccines in a moment.

I bought a filtration system for the water in my house to eliminate fluoride, chlorine and other pharmacological products from my water even though the water department says my water meets all EPA standards. I grow 80% of the vegetables I eat for the year. I buy meat and eggs from a couple of farms within 15 miles from where I live. My workplace is 3 miles from where I live and I bicycle to work over half the year. I consider my overall health as good and I need no prescription medication. I am responsible for my health and I think I am doing things that are healthy for me. Now along comes the question of a mandatory flu vaccine. My facility recommends but does not require the vaccine. I do have to attend a class on immunization when I refuse. If it was mandatory I would no longer be employed there. While the flu has the potential to be life threatening to some I do not feel the threat warrants me injecting neurotoxins into my body.

This is an old philosophical issue that has gone on for centuries. Aristotle, Martin Luther, Bertrand Russell and many others have debated the issue of individual responsibility and doing what is best for the majority. I've made my decision on how I want to live my life and I respect the decision you have made.

[DeeAngel]

All I know is that years ago before the MMR vaccine was invented I had two childhood friends who died of measles related encephalitis. Their parents would do anything to have been able to prevent this from happening.

[concerned lady]

Methinks (rabidly pro vax folks) thou doth protest too much (taken from Shakespeare), meaning that the anger shown by the pro vax folks, is an attempt to stifle dissent.

But, there IS dissent about vaccines, even if it is quietly shown by

such doctors as DAN docs (DAN=Defeat Autism Now).

Pro vax folks ganging up on dissenters (anti-vax folks) to me, shows some immaturity, and insecurity, and reminds me of the Emperor's Clothes fable. The Emperor was naked (blindly pro vax), but everyone felt s/he HAD to say he had clothes on (had to give in to dictatorial forced vaccines), until the honest child who saw the naked Emperor, shouted out, "But he's naked!".

It's better to avoid the equivalent of putting ones fingers in one's ears, saying "La la la, I can't heeeear you!", and really start to listen to the parents who saw and still see cause and effect from vaccines that adversely affected their own children.

Sincerely, Concerned Lady

[macawake, MSN]

By the way, has your doctor ever heard of the "Cancer Control Society"? Cancer survivors in this generous group, graciously share their own holistic experiences of how they conquered their cancers, for no charge at all, with whoever asks these wonderful souls. I wonder if your doctor would poo poo these cancer survivors, too, because he might be more into cutting (surgery), burning (radiation), and poisoning (chemotherapy), rather than using holistic methods.

Moderators and fellow AN members :), I apologize for veering a bit off course but some statements are so dangerous that I feel that they need to be challenged.

Concerned lady, I would never "poo poo" a cancer survivor but I will call the claim that holistic methods alone has ever cured cancer, rubbish.

If you or anyone else manages to convince even one cancer patient to reject/decline traditional treatment and choose alternative methods instead, that may well cost that patient his or her life. That's why I say it's dangerous to advocate for non-proven methods. The efficacy of these methods is not supported by evidence.

I find your use of words cutting, burning and poisoning to describe successful medical treatment methods, deeply distasteful. I hope that I'm wrong, but it almost seems that the intent is to scare people away from treatments that we know work.

I have to wonder, do you call an emergency c-section when the life of the mother or fetus is at risk, cutting? Are you against all forms of surgical interventions? Or is that term reserved for surgically removing cancerous tumours?

I don't think that you understand the mechanism of action of radiation therapy. It's either that or you're intentionally making it sound like something it isn't. It's not burning.

Radiation therapy can either be external beam, brachy therapy (radiation source temporarily placed inside the tumour or in a body cavity) or (permanent) implantation of seeds (often I-125).

External beam therapy uses ionizing radiation. This means that the energy used is sufficiently high to either excite an atom (displacing an electron further from the atom nucleus) or ionize it (the electron isn't just displaced, but removed from the atom thus forming an ion pair).

In Europe (and I assume in the US too) the most commonly used external beam method is photon radiation (ie electromagnetic radiation, zero mass, zero charge) but also partlicle radiation like electrons and protons are used. Electrons are good for tumours and sometimes lymph nodes near the surface of the body as electrons don't penetrate as deeply as photons.

Anyhow.. what ionizing radiation does is that starts a process that causes damage to the cell's DNA (it does other things too, but I don't want to bore you to tears on the off-chance that you're still reading this ). If we're lucky we get double strand breaks. Why do we want double strand breaks? Because we don't want the cancerous cells to keep on replicating. We actually want apoptosis or atrophy and the replication to cease. Cancerous cells usually replicate more rapidly than normal cells. And fortunately for us they are also usually less successful at repairing themselves after damage to their DNA than normal/healthy cells.

Do you know the cell cycle?

G0 --> G1 --> S --> G2 --> M --> G0 and on and on and on...

G2 and M (mitosis) phases are normally radiosensitive and very radiosensitive, G1 and S moderately resistant and G0 (resting state) pretty much resistant. So we aim to "attack" the cancer cells just as are they are structurally preparing to divide or when they actually are dividing. Cancer cells typically cycle through this rather quickly and we "attack" with radiation.

So as you see, there's no burning involved.

To help increase your understanding of radiations therapy, here's a text that describes the biologic basis for RT.

Biologic Basis of Radiation Therapy - Holland-Frei Cancer Medicine - NCBI Bookshelf

If you want to learn more about ionizing radiation interacts (lose energy) with cells in the body you can look up photoelectric effect, Compton scattering and pair production. Again, no burning!

Forgive me people, I've always been a physics nerd

Concerned lady, could you please describe the mechanism of action of holistic methods on cancer cells and how they manage to cure cancer and link some relevant research.

[JustBeachyNurse, LPN]

DAN doctors often advocate bleach enemas and unnecessary painful chelation and other bizarre non tested "therapies" ranging from bleach injection, high dose homeopathy (probably least dangerous) inflate false hope and charge exorbitant fees.

On the same token the founders of Autism Speaks decline to put any autistic person on their board, does have a big wig from Home Depot that takes in big $$ from blue lightbulb sales every year , essentially advocates genocide and has referred to autistic children as "lepers" in public presentations. But they don't believe vaccines cause autism.

There has been no correlation or even the tiny suggestion of correlation between influenza vaccines from (even Jenny McCarthy) and autism so I have no idea where this non sequitur came from

I don't base my care of my child on either of these non-medical organizations.

I'm still confused on the ability to shed a live virus after being vaccinated (not inoculated) with a dead virus.

Vaccination is a choice, you may not like the consequences of choosing to not vaccinate (termination, wear a mask, excluded from school or clinical assignments). It's up to the adult to do due diligence and make an educated decision based upon objective facts not anecdotal evidence such as "I won't vaccinate because I don't want the government telling me what to do" (and I know at least two who don't vaccinate for that very reason.)

[RNsRWe, ASN, RN]

Methinks (rabidly pro vax folks) thou doth protest too much (taken from Shakespeare), meaning that the anger shown by the pro vax folks, is an attempt to stifle dissent.

No, it's frustration that there are people who absolutely refuse to recognize scientific data as valid, preferring to cloak themselves in tabloid sensationalism instead.

Better to leave Shakespeare (and any other 16th century writer who would have used the same phrases) out of it, he doesn't deserve the association

[concerned lady]

Dear Macawake,

Thank you for your heartfelt posting! (even if it doesn't agree with my ideas, I respect where you're coming from!)

True science doesn't fear "dangerous" questions and/or dissent.

To reply to your question, that you posed: "Concerned lady, could you please describe the mechanism of action of holistic methods on cancer cells and how they manage to cure cancer and link some relevant research."

1) FIRST, "DO NO HARM!" This means, remove carcinogens (cancer causing substances) as much as humanly possible, from the air, water, foods, medications, etc.

To do this, one must at least, READ LABELS, and if there's anything in household products, skin care products, foods, beverages, etc., that is unpronounceable, or unfamiliar--PUT IT BACK, AND DON'T BUY IT!

2) Find out what may be depressing one's immune system, and stop contributing to depressing the immune system. Example: If gluten sensitive (either Celiac Disease, &/or non-Celiac forms of gluten sensitivity), AVOID EATING & AVOID CONTACTING GLUTEN.

An interesting and informative (not dangerous) read is "Before the Villi Are Gone", by Dallas, TX gastroenterologist, Dr. Kenneth Fine, M.D. See Welcome to EnteroLab - EnteroLab.com (or, one can avoid gluten for 3 months, and see if it helps).

If "sensitive" to milk proteins (casein, whey, etc.), avoid ingesting (eating or drinking) anything containing milk proteins.

Try "holistic" supplements (OK'd by one's physician, preferably), if "regular" drugs are depressing one's immune system, making cancer more likely to happen.

3) Talk to some of the generous Cancer Control Society cancer SURVIVORS, and they will gladly share what helped them to conquer their cancers.

Here are some of their ideas (Call recovered cancer patients, for more specific "anecdotal" info):

a) Eat ORGANIC produce and organic anything, when possible, to avoid ingesting (eating or drinking) pesticides, herbicides, fungicides, rodenticides, etc.

b) Avoid SPRAYING POISONOUS HERBICIDES, on so-called "noxious weeds". Pull the weeds, instead. Or, let the non-violent prisoners in orange do some community service, by pulling the weeds.

c) Try edible medicinal mushrooms, (in capsule form, for example) such as Reishi, Shitaki, and Maitaki.

d) Red clover blossoms as tea (fresh or dried--species is Trifolium praetense), are anti-cancer, but avoid if one is on anti-coagulants, because red clover blossoms are slightly anti-coagulant in nature.

e) Carrots (if not allergic) are very anti-cancer, due to the beta carotene in them. Even when heated (cooked), the beta carotene is not destroyed, and is anti-cancer.

Many green veggies (including organic DANDELION LEAVES), have much beta carotene (orange in color), in them, but it's "masked" (hidden) by chlorophyll.

f) The cruciferous family of veggies is anti-cancer. Examples include red cabbage (eat raw, or make cole slaw, etc.), broccali, radishes, kale, etc. One can make or buy Kim Chee. (If one is quite hypothyroid, don't over-do on this family of plants, which can, if overdone, promote more hypothyroidism).

g) Some cancers are diminished by eating the inner (softer) seed of (hard) apricot pits, known as apricot kernels. These apricot kernels contain the precursor of "laetrile". Don't over-do, because the cyanide in these members of the rose family, if over-done, is poisonous to the whole body, not just attacking the cancer cells.

Almonds have a small amount of amygdalin in them (the pre-cursor of laetrile), so EAT ALMONDS, if not allergic to them.

h) Look up Cancer Control Society on the internet, and read their patient sheets, etc.

You may be pleasantly surprised, when speaking with these iconoclastic (image-breaking) cancer survivors.

i) If one waits until one knows exactly how something works, (and this is true of "allopathic" as well as "holistic" medicine), one might die, while waiting for the "evidence" to be "shown". How many times has one's doctor said something like this:

"Let's try this drug, and see if it helps you. If it doesn't, we'll try something else". ?

j) Avoid ionizing radiation (includes xrays and mammograms, for example). Some feel that taking repeated mammograms can actually bring on breast cancer, by subjecting the delicate breast tissue to repeated assault by "ionizing radiation".

k) Read the book "Dressed to Kill" showing dangers of wearing bras too long (and too tightly), causing a situation similar to that of men wearing tight bike shorts--in both cases, the carcinogens hang around too long and are not easily swept out by lymph--so men get more testicular cancers from wearing those tight bike shorts, and women seem to get more breast cancer partly from wearing tight bras, too long in a day (and night in some cases).

l) If one can't quit smoking (due to nicotine addiction), at least use organic tobacco, which hasn't been contaminated by radioactive particles from phosphate fertilizer. See work done by scientist (the late but great Dr. Ed Martell) who showed this connection between phosphate fertilizers having radioactive particles being taken up into tobacco leaves, causing "low level radiation", causing mutations, resulting in lung cancers!

4) Don't be afraid to question authority--keep asking questions!

Sincerely, Concerned Lady