Ask SciMoms: Should I use talcum or baby powder?

Recently, Reuters reported that Johnson & Johnson knew that its talcum powder contained asbestos, which has no safe level of exposure. Many parents are now questioning whether they should be using talcum or baby powder on their babies or themselves. I am not a lawyer and I haven’t reviewed the material relevant to this case, so I can’t say whether or not Johnson & Johnson acted negligently or what they knew when. As such, this is not a commentary on the Reuters report or a legal analysis. This post is meant to address what the relevant expert groups recommend and current science tells us about the toxicity of talcum powder.

Image from Flickr (user Rakka)

What does the American Academy of Pediatrics say about using talcum or baby powder for children?

Although the possible association with ovarian cancer is the focus of the report, consumers are probably most familiar with using talcum powder for changing babies’ diapers. However, the American Academy of Pediatrics explicitly recommends against using talcum powder due to risks of inhalation.

“Do not use baby or talcum powders on the baby. If inhaled, talcum-containing powders can cause severe lung damage and breathing problems in babies.”

This recommendation is not new. I found a reference about the risks of talcum powder use from 1969 in Pediatrics, the official journal of the AAP. The letter outlines that risks of talcum powder include “acute or chronic lung disease”, and aspiration that can result in sickness and even death. This highlights that these risks have been common knowledge among pediatricians since the late 60’s.

Note that the risk of inhalation exists whether the powder is talc-based or starch-based. Neither one should be used. In case of a diaper rash, the AAP recommends the use of an oil-based ointment (diaper cream).

What does the American College of Obstetricians and Gynecologists say about using talcum powder as a feminine hygiene product?

The American College of Obstetricians and Gynecologists (ACOG) also specifically recommends against the use of talcum powder and other vaginal treatments, including douche and vaginal spray. This recommendation is related to potential discomfort and pain and not directly related to the observed association with ovarian cancer.

Another important point is that this recommendation is generalized to many vaginal treatments and feminine hygiene products, as discussed in this article, The vagina is self-cleaning – so why does the ‘feminine hygiene’ industry exist?.

With relevant experts specifically recommending against the use of talcum powder and feminine hygiene products in general, it begs the obvious question: why are we using talcum powder at all? Whether the association with cancer is real or not, there are plenty of reasons for parents and women to avoid talcum powder containing products and find alternatives.

Does talcum powder increase the risk of ovarian cancer?

This question remains unresolved.

From a 2017 ACOG statement:

“Despite an observed association, several decades of medical research have not demonstrated a direct causative link between the use of talcum powder and ovarian cancer. Although some case-control studies suggested an association, with a small increase in risk, prospective cohort studies have not demonstrated an increased risk. It is important to note that there are limitations associated with the studies that have investigated this association, which include several types of bias, inadequate sample sizes and the rarity of the disease. Because of concerns regarding potential discomfort or pain, obstetrician-gynecologists do not recommend use of vaginal treatments such as douche, vaginal sprays or talcum powder and the use of talcum powder has declined over the years. There is no medical consensus that talcum powder causes ovarian cancer.”

From the American Cancer Society:

“It is not clear if consumer products containing talcum powder increase cancer risk. Studies of personal use of talcum powder have had mixed results, although there is some suggestion of a possible increase in ovarian cancer risk. There is very little evidence at this time that any other forms of cancer are linked with consumer use of talcum powder.

Until more information is available, people concerned about using talcum powder may want to avoid or limit their use of consumer products that contain it.”

For more details on the difficulties in collecting data on talcum powder and ovarian cancer and why this data remains inconclusive, read at the Journal of the National Cancer Institute here.

In studies that find an association between vaginal use of talcum powder and ovarian cancer, how big is this effect?

The IARC classification of talc as “possibly carcinogenic to humans” is often cited as evidence that talc increases the risk of cancer. However, IARC classifications are hazard classifications based on the strength of evidence; they do not represent the risk posed by a substance. While often used interchangeably in lay language, hazards and risks are different in risk assessment. Briefly, a hazard is anything that has the potential to cause harm given sufficient exposure or dose. Risk is the probability that exposure to a hazard will cause harm. A hazard poses no risk without exposure.

To apply this to the topic of talc and ovarian cancer, if you don’t use talcum powder on your genitals, it doesn’t matter that talc is a hazard. Without exposure, there is no risk. Thus, consumers who are worried may want to limit or avoid the use of products that contain talc. In fact, use of talc-containing cosmetics has been declining since 1975,

Ovarian cancer is rare to start, so even an increased population risk of a third is a small risk and the very large majority of women who use talcum powder will not get ovarian cancer. According to the National Cancer Institute, the lifetime risk of developing ovarian cancer is 1.3% in all women. A 30% increase means groups of people who use talcum powder on their genitals frequently have a 1.69% risk of developing ovarian cancer. To put this in context, smoking cigarettes increases the risk of lung cancer by 15-30 times. This is compared to the 0.3 times increase in risk of ovarian cancer for talcum powder use.

Of course, as consumers, our instinct is to minimize exposures so we can protect ourselves. However, complex diseases such as cancer are typically caused by a combination of factors, both genetic and environmental, and exposures need to be concerned in the context of all other exposures. In the case of ovarian cancer, genetic risk factors can play a fairly large role and use of oral birth control pills can reduce risk by 30-50% percent. I have previously written a series on risk perception that explains this idea of risk landscape in more detail.

An important consideration is that these measures of risk are population risk not individual risk. While epidemiologists can detect differences in the percent of people in various subgroups (by genetics or exposure) that develop a disease, it is not possible to predict an outcome for any specific individual within that population.

Risk in perspective infographic showing population risk is not individual risk. The general population includes people who are genetically predisposed to disease and those who have a protective genotype.

How does potential asbestos contamination change the equation?

I (and many others) have been skeptical about whether there is a causal link between talcum powder and ovarian cancer due to a lack of biological plausibility. However, if there has been continued asbestos contamination of cosmetic grade talc, this changes the conversation completely.

In 2016 I wrote in a post: “We also need to be careful not to conflate studies of cosmetic talcum powder with studies reporting a link to cancer for talc naturally contaminated with asbestos. All consumer products containing talc have been asbestos-free since the 1970s.”

This new Reuters report suggests that consumer products may have been contaminated with asbestos for much longer than we thought. If this report is true, there actually could be a plausible mechanism by which cosmetic talc could cause cancer. This report highlights a need for greater oversight and transparency in the cosmetics industry so that consumers can be confident in the safety of the products they choose.

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