Category Archives: conflict of interest

Anti-smoking policies increase black market sales

It has been known for some time that those who cannot legally buy cigarettes will find other sources. Youth tend to get most of their tobacco from family or friends, or proxy buyers. They know that most retailers will not sell to them. Now, we have yet another report from Ontario that contraband cigarettes are the number one source of cigarettes for youth. No surprise there. Not only does Ontario already have a strong black market but all the drivers of that market keep gaining strength thanks to anti-tobacco activism.

This report Illegal cigarettes lure high schoolers is somewhat misleadingly titled since it is certain anti-tobacco policies (regardless of whether they are considered right or wrong) that cause these consumers to seek other sources.

Contraband cigarettes, often sold in baggies and out of vans, account for 43 per cent of what daily smokers in high school are using, according to a new study by the Centre for Addiction and Mental Health.

This illegal cigarette market is sabotaging traditional tobacco control policies, such as taxation and age restrictions. “Teenagers are more price sensitive,” said Davis Ip, a researcher for the study, which appears online in the journal Tobacco Control. “Since contraband isn’t taxed, the lower-priced cigarettes make it more likely teens will pick up the habit and increase consumption.”

In Ontario, retailers are not allowed to sell cigarettes to anyone younger than 19. Someone hawking illegal smokes is not likely to care about age.

Cracking down on contraband was among the recommendations of a blue-ribbon panel made public last week. The provincial government had asked the panel to suggest a five-year tobacco control strategy.

“The most urgent (problem) is dealing with contraband,” said panel member Michael Perley, director of the Ontario Campaign for Action on Tobacco. “It’s the problem on the streets that’s hooking our kids and undermining everything else we do in tobacco control.”

Perley is worried (and seemingly confused) that his recommendations for higher tobacco taxes (which make contraband a rational consumer choice), plain packaging (which removes obvious differences between legitimate brands and contraband) and increased deligitimization of the legal market will be undermined by the existence of the black market. If he thought this through he would realize that the likely black market response serves as a very good indicator of how effective his proposals would be.

Anti-tobacco activists must be in a state trying to choose what they hate the most -the dastardly undermining black market or the legitimate tobacco industry which they have been successfully denormalizing. The more they succeed at painting the industry as essentially illegal (despite the obvious legal status) the more they cannot complain about the black market. Of course, it is legal sales that collect the taxes that keep the activists in business so they do have every reason to side with the tobacco companies.

Eliminating the black market (which would be a first in human history) could be calamitous for tobacco control. Though it would initially give them the upper hand, it is adult consumers denied this economic safety valve that might actually then stand up and act like citizens tend to when any other of their pleasures are threatened. The black market undermines political action and rebellion as much as it does the system.

-Paul L. Bergen

Advertisements

The CMAJ, IDRC, and Barbara McDougall

Recently we came across an article published in the Canadian Medical Association Journal (CMAJ), commenting on the Chair of the Board of the International Development Research Centre (IDRC), Barbara McDougall, and her role as a tobacco industry executive for Imperial Tobacco.  (This is somewhat old news as this article was published in July, but we did not comment on it then, and thought it worth a blog posting.)   Despite McDougall’s resignation from Imperial Tobacco after her role there became widely publicized, these CMAJ authors still call for her resignation from the IDRC, claiming that her resignation from Imperial Tobacco does not sufficiently remove the conflict of interest.  They state that “Given [McDougall’s] role on the Board of Imperial Tobacco, one can only conclude that tobacco control will no longer be a priority for IDRC and the Government of Canada.”  Apparently CMAJ thinks that a single person is capable of subverting a large organization and an entire country’s tobacco reduction plans.

While conflicts of interest of course should be acknowledged, McDougall’s role at Imperial Tobacco was no secret; she had been there since 2004 (three years prior to her joining IDRC), and biographies found through a Google search have her role at Imperial Tobacco listed.  Not knowing the intimate details of the situation I can’t comment on whether or not she was appropriately transparent at the time of her appointment, but in the response from the IDRC with respect to McDougall, it defends its record and states that it “has processes in place to ensure that no single member’s views or interests prevail over what are ultimately decisions by the Board as a whole.”  They also clarify that McDougall’s role was “as an independent, non-executive director of Imperial Tobacco.” An editorial by the Globe & Mail also defends the Board’s “exemplary track record” and calls for it to resist pressure to fire McDougall.

Regardless of all this, however, McDougall resigned from Imperial Tobacco, thus removing the conflict of interest.  The insistence from the anti-tobacco faction and the CMAJ authors that this conflict of interest has not been removed despite her resignation speaks to the prevailing attitude that once tainted by tobacco money, you will always be tainted by tobacco money.  This is no different for researchers working in the field of tobacco; once a tobacco grant has been accepted, you will be publicly expelled from the tobacco control clique, rejected from their conferences and sometimes even entire journals.

It appears that McDougall’s situation became publicized firstly because the Bill & Melinda Gates Foundation pulled $5 million in anti-tobacco funding from the IDRC, stating McDougall’s role at Imperial Tobacco as the reason, and secondly, because the FCTC guidelines exclude the tobacco industry from health groups like the IDRC, because they influence health policy.  The Bill & Melinda Gates Foundation was simply throwing its weight around with respect to the funding. Certainly if you’re wealthy enough, it’s easy to force your ideology onto others and punish those who don’t conform.  And as for the FCTC, the IDRC states that McDougall’s appointment had “predated the adoption of the FCTC Article 5.3 Guidelines,” and reiterates its support for the FCTC and its dedication to following its guidelines.  As we already know, the FCTC – what with its anti-THR and prohibitionist agenda – is unlikely to be anywhere near as successful in reducing smoking-related deaths as THR promotion would be.  The IDRC’s public dedication to the FCTC is even more chilling when we consider that because of the loss of funds from the Bill & Melinda Gates Foundation, there was a re-allocation of funds from other areas in the IDRC to the anti-tobacco area.  No doubt these other areas were likely to have more of an impact in the developing world than any tobacco control program would have.

The indignant cries to have McDougall resign reek of a kind of McCarthyism, and are just a distraction from the real goal of reducing smoking-related disease in the developing world.  To think that having McDougall step down from the Chair of the IDRC will somehow have an impact on smoking-related disease is laughable.  With the IDRC acknowledging their intentions to follow the FCTC guidelines (and the FCTC’s unwavering dedication to the abstinence-only viewpoint), we already know how unsuccessful they are going to be at accomplishing that goal.

 

-CMNissen

GlaxoSmithKline and the FDA entreaty

GlaxosmithKline, the maker of Nicorette and Nicoderm, have petitioned the FDA to remove dissolvable tobacco products on the grounds that a better action would be to enhance their own product and make it more widely accessible. They argue as well that there is a lack of efficacy of smokeless products in regards to smoking cessation and that they are marketed in such a way as to initiate and perpetuate smoking. (Article link here.)

(Let’s just remove that last phrase first since it has been discussed here before: tobacco companies are not allowed to market these products as cessation aids or to accurately describe them as safer; such claims might encourage switching. They are restricted to marketing their much safer than smoking products only as “for when you cannot smoke”. So it is disingenuous to criticize a company for using the only marketing hook left if they are not allowed to promote the rational use of these products.)

This message from this successful company (45 billion in revenue in 2009) has been widely criticized as trying to obtain competitive advantage at a time when smokeless products are at their most vulnerable. Not only is the FDA focusing on these products but the advisory panel is stacked with members who have financial interests in pharmaceutical products. As a business strategy, this makes sense.

What is less obvious is how amoral and possibly evil this action is. Though I hesitate to apply “evil” to these machinations, what else can you call an action that could result in many dying as a result not of their principles but of your own, and principles solely in the interest of profit?

We know that people smoke or do not smoke for many reasons. We know that they vary quite a bit in how difficult it is for those who wish to quit to do so, and that for different people, different methods are successful. It is all about individual differences. This means that some people will not be able to quit using pharmaceutical products which in itself means that if those are the only option, the people that could have succeeded by other means are needlessly doomed by removing those alternatives.

I understand the concerns of makers of these pharmaceutical nicotine products. With the new smokeless tobacco products, the distinctions between the two categories are becoming quite subtle. And if anybody has long term evidence of relative safety on their side, it is the tobacco products. We have decades of good data on populations using these products day in and day out for years and we do not have that for pharmaceutical products. They are likely to be as safe as smokeless tobacco if so used but we don’t have the proof of that because people have not been using them that way.

What we do have is evidence in support of is that smokeless tobacco products outperform pharmaceutical nicotine in helping people quit smoking (see Rodu and Phillips).

And this same press release has the temerity to use the old “Tobacco use, including smokeless tobacco, is the largest cause of preventable death and disease in the world. More than 400,000 Americans die every year from tobacco-related disease.” For one thing, the stale move of collapsing “including smokeless tobacco” into this figure is misleading (one could have included “eating apples and oranges” and the statement does not become false). But the key word as always is preventable. Is not this impeding one of the more successful means of avoiding disease while using nicotine not preventable?

Finally, our modern anti-tobacco culture has allowed this story to be construed only as a slightly sleazy business move but imagine if RJ Reynolds or some tobacco company had issued the same release regarding pharmaceutical products. They would actually have had the stronger case (not that any alternative should be removed) but imagine the op eds on that, the outcry from the American Heart Association and so many others.

-Paul L. Bergen

From the bookshelf: Being Wrong

“As perverse as it may seem, these many forms of creatively dodging the counterevidence represent a backhanded tribute to its importance. However much we ignore, deny, distort, or misconstrue it, evidence continues to matter to us, enormously. In fact, we ignore, deny, distort, and misconstrue evidence because it matters to us. We know that it is the coin of the epistemological realm: that if we expect our beliefs to seem credible, we will have to furnish their grounds. ….If we think we hold our beliefs because they comport with the evidence, we must also think that we will revise them when new evidence arises. As a consequence, every proposition, no matter how much we might initially resist it, must have an evidentiary threshold somewhere, a line beyond which disbelief passes over into belief. …we see evidentiary thresholds being crosses all the time…

But we also see evidentiary thresholds not being crossed….As powerful as confirmation bias is, it cannot fully account for this: for the persistence and duration with which we sometime fail to accept evidence that could alter our theories. Another factor is the claim, implicit or explicit in many belief systems, that attending to counterevidence can be dangerous – to your health or family or nation, to you moral fiber or your mortal soul,. Confirmation bias is also bolstered by the fact that looking for counterevidence often requires time, energy, learning, liberty, and sufficient social capital to weather the suspicion and derision of defenders of the status quo. If the dominant theory works to your detriment, odds are those are resources you don’t possess. And if the dominant theory works to you advantage, or at least leaves you unscathed – well, why bother challenging it?”

(pg. 129-130)

– Paul L. Bergen

Anti-smoking or anti-tobacco? More like anti-social.

I get the feeling that Betty would have no problem with vaping.

For some time now, and more intensely in the last few weeks, Michael Siegel has been railing against the insanity of the modern tobacco control movement (as exemplified by American Lung Association, American Cancer Society, the American Heart Association and the Campaign for Tobacco Free Kids). The only reason Action of Smoking and Health US is not on that list is that as counterproductive as those other organizations are, they do not even begin to approach the almost pre-literate and certainly pre-logical infantile mulings and screechings of Banzhaf’s self serving vehicle. I may not agree with Siegel’s actual yardstick (“Frankly, there is no longer any difference between the agenda that these groups are supporting and that of Philip Morris. And that is a sad thing.”) but would rather argue that the real problem here is a lack of internal consistency.

One reason that I disagree with Siegel’s parallelism is that what presently seems to be the case is that tobacco companies are developing safer alternatives while these organizations with the help of the FDA seem to be doing everything they can too discourage them. In other words, tobacco companies are working to improve public health while these organizations that profess to be working for that aim are actually discouraging any products that do not originate with pharmaceutical companies, and working to maintain the information barriers about any safer alternatives. (Strangely enough, these organizations also tend to promote pharmaceutically aided quitting over unaided quitting even though the latter has been found to be much more lasting).

If the above mentioned public health organizations had as their mandate to maintain the present levels of disease and death associated with smoking (and even though their funding derives from the continuing sales of cigarettes I will not even mention in passing that that could possibly be a factor), what would their policies look like?

I imagine they would 1. discourage any alternatives (like smokeless tobacco products or electronic cigarettes) that might make nicotine use safer 2. if they cannot make them illegal make sure that people think they are no safer 3. support regulations that do not conform to any other product information guidelines and demand that producers describe their products as more dangerous than they are.

And in this regard, they have been quite successful in making sure that little headway is made while at the same time giving the impression that they are valiantly fighting on our behalf.

And while these anti-tobacco organizations will embrace any pseudo-science that demonstrates exaggerated dangers of 2nd and 3rd hand smoke, they fight any measures that would actually reduce those effects.

None of this is really news, and perhaps the strangest thing of all is that the average person still thinks these organizations are working for the greater good. But what can you possibly think of an organization that on one hand loves to repeat that over 400,000 Americans are dying every year from smoking and on the other does all they can to keep people from moving themselves out of the group most likely to contribute to that number? Or what can you think of a federal agency that decries the health damages due to cigarettes, then sets up a board to deal with the problem, and then populates the board with individuals who have devoted their careers to fighting the best solutions to that problem?

It is time for us to rebrand these organizations. By their actions, they can no longer be identified as anti-smoking or anti-tobacco (since they fight solutions that would reduce smoking and tobacco use); they can only really be described properly as anti-social.

-PLB

PLOS likes to use the word science but doesn’t exactly like what it stands for

Just yesterday I placed onto our website a link to an article published by the Public Library of Science by Simon Chapman on unassisted cessation. If you had to draw up sides on tobacco harm reduction Chapman would seem to be somewhat against and the PLOS neutral but that had nothing to do with my decision to promote the article. I posted it because it seemed a worthwhile contribution to the ongoing debate.

However, in the same issue of the online journal, a colleague drew my attention to something I had missed, a position statement in which the PLOS editors wrote:

While we continue to be interested in analyses of ways of reducing tobacco use, we will no longer be considering papers where support, in whole or in part, for the study or the researchers comes from a tobacco company.

In other words, PLOS will now only publish materials emanating from politically approved sources. If they are to be consistent in this, they really should change their name to Public Library of Politically-Approved Science (PLOPS).

And of course if I were to follow the same route I should not have posted the article as it came from a suspect source, that is a politically rather than scientifically oriented source. But, we’ve always been more about the message.

In the comments to the position statement, Michael McFadden aptly points out the inconsistency within it by noting how they describe the machinations of the pharmaceutical industry as another example of what the tobacco industry did and then use this as justification for the tobacco ban even while not proscribing pharma funding.

In another comment, Jeff Stier from ACSH writes:

But this is no justification to outright censor any studies published with support of the tobacco industry. Isn’t it the job of peer-reviewers to evaluate studies on their merits? What good is a peer-reviewed journal if a journal doesn’t trust itself to determine whether a study is valid?

The PLOS position is unfortunately not unique. Just two years ago, the editor of JAMA (Journal of the American Medical Association) stated regarding a lung cancer study:

“I would never publish a paper dealing with lung cancer from a person who had taken money from a tobacco company”.

These are sobering developments. These journals which purport to work in the interest of improving public health have decided that if they do not approve of the sources, they will not let us hear the message. It is bad enough when governments are paternalistic but when academic publishing jumps on board, times are bad indeed.

I would like to think that if someone does find a cure for a disease or a good solution to a real problem that who they are does not stop the message from getting through. Using past or even present behavior of an entity to judge a message would remove the moral authority from any source. Why trust anything originating from Germany considering the Holocaust, or the United States considering the recent torture of Guatanamo detainees, or Exxon considering the oil spill, and so forth and so forth.

We have to stick with the message because it is the only thing you can trust.

-PLB

Addendum: Jeff Stier expanded on his comments in this article today (Feb25).

Certainly, there are arguments to be made by on both sides of this issue. So how do we decide whether harm reduction should be used as a legitimate smoking cessation technique? Peer-reviewed scientific literature. In fact, tobacco companies wishing to make harm reduction claims must show the Food and Drug Administration that smokeless tobacco is less harmful, and that the approach would have an overall benefit to public health. To do so, they must present studies in peer-reviewed journals.

But who, if not for the tobacco industry, would fund such studies? Unfortunately, perhaps because of a bias by government scientists and policymakers, U.S. federal agencies are not investing in this type of research, despite the ongoing, frightful toll of preventable smoking addiction.

Why not allow the tobacco industry to fund and offer for publication studies on such issues? Journals should review such studies, like all others, with the highest level of scrutiny—and publish them only if they pass scientific muster. Such attacks on industry-funded science actually undermine the interests of the public, which benefits from the publication of a full range of studies, regardless of who funds them.

Journals should be like referees, deliberating on the substance of studies. If they did so, perhaps they’d stop publishing junk, get over their moralistic censorship, and just publish good science whatever the source. We’d all be better off for it.

Doctor dares to criticize tobacco control

CBC reports in Smoking Defended by Quebec Doctor (link to article here) that psychiatrist Jean-Jacques Borque is of the opinion that smoking can be a comfort to the deeply depressed, that the dangers of second hand smoke are overblown and that smokers are under an unreasonable amount of pressure to quit.

What is most illustrative about this is not the fairly conservative statements of the doctor but the responses to those statements. If he would have said that second hand smoke could kill you within 15 minutes, that warning labels on cigarette packages should actually be larger than the packs themselves or that smokers need to be locked out of government jobs to force them to quit, this would have passed with little comment.

But if you wander through the comments on the article you find the righteous rage of the anti-tobacco extremist at the person who dares to question the prevailing political correctness. Most of the comments suggest that his opinions could only be held by someone in the pay of the tobacco companies or by a smoker. (It seems that being a smoker instantly disqualifies you from being able to think independently on these issues and somehow being a nonsmoker gives you a special insight into why people smoke….of course, neither being the case).

For some reason, being a psychiatrist and having first hand knowledge of the effects of depression, and of smoking in that context, counts for nothing. And of course, were he to offer the opposing opinion, his status would suddenly become relevant.

The knee jerk reactions to this honest position seems to come from that well entrenched tobacco control idea that smoking has no conceivable benefits. People only smoke because they do not know any better or that they don’t care. Everybody who smokes, hates it and wants to quit.

The point is that any behavior, even one with so many negative effects as smoking, has to be considered within a context. All other things being equal, it is better not to smoke. But if you are deeply depressed, the depression could affect your health in many ways including an increased risk of suicide, and if you find relief in smoking, what you are doing is balancing an immediate and certain danger against a future potential danger. It then makes all the sense in the world to smoke.

As I have written previously, ironically, for us in tobacco harm reduction, a hard line against smoking would seem supportive of our position. After all, we are trying to get people to adopt safer alternatives. But also ironically, our greatest foes in reducing the risks to smokers are those same hardliners in tobacco control and in positions of authority in many health departments.

Ultimately, health initiatives work best when politics are not part of the equation. Vilifying smokers, smoking and tobacco only preserves the status quo and keeps us locked in this impoverished quit or die mode.

-PLB

The Rest of the Story Announces the 2009 Lie of the Year Award and the Pants on Fire Runner-Up Awards for 2009

Just read it.

New catalog of financial conflict of interest re anti-e-cig activism

For anyone who is not aware of pharmaceutical industry funding of the leading anti-THR activists, E Cigarette Direct recently produced this list. Anyone who understand the concept and implications of conflict of interest (i.e., does not just use accusations of COI when they lack the expertise to make substantive criticisms of an analysis they want to denigrate) will realize that any issue with worldly implications will unavoidably generate COI on all sides. It cannot be avoided so needs to be appropriately dealt with. In the case at hand, the obvious minimum step is for entities with ties to the pharmaceutical industry to disclose them and (until the public understands this) point out that pharma loses business when smokers adopt THR.

There is nothing inherently bad (or inherently good) about pharma giving grants. Some naive commentators argue that pharma grants must be better than other grants because those companies create good things. But, of course, the companies do many things. They (a) invent lifesaving drugs for serious diseases, which make huge net social contributions; (b) convince people that they should start treating some condition with drugs though it has been done not before, creating their own demand rather than meeting pent-up demand – i.e., they are akin to the fashion industry; and (c) create and heavily market drugs that are needlessly expensive or harmful, creating a profit but a net social loss – i.e., they are akin to the modern finance industry.

In other words, they are companies. If we substitute (a) creating hybrid and electric cars, (b) hyping minor design tweaks, and (c) pushing the sale of gas-guzzling trucks for commuters, then we have described the automobile industry. Indeed, if we substitute (a) developing and marketing smokeless products, (b) trying to entice brand switching, and (c) making cigarettes available to each new cohort, then we have described most of the major tobacco companies.

Lacking both saints and unrepentant demons in the world that controls the money that the rest of us need to do our work (I trust everyone understands that governments and foundations are as imperfect as corporations), it is up to researchers and advocates to be transparent about our relationships and to try to minimize their influences when we do science or engage in education/advocacy in the public interest. The lack of transparency is where ASH, ACS, and others clearly cross the line into unethical behavior – there is no excuse for them hiding relevant funding information from the public and journal readers. However, there is a good argument to be made that these organizations already have extremist positions that happen to coincide with the goals of pharma (and thus their politics could not be influenced by the funding). In particular, anyone whose worldly goal is the extreme position, elimination of all self-administered nicotine regardless of its costs and benefits, already have the incentive to discourage THR because they know they will fail in their goal if people learn that there are satisfying low-risk alternatives to smoking.

Thus the strongest COI is this goal, which therefore should be disclosed. Once that is done, knowing the goals of the funder offers no additional information – we know that the authors already supported that goal, so how could they be influenced by funding to support that goal? In keeping with this, my colleagues and I recognize that our concern about people’s freedom and welfare means that we want to encourage THR and resist the “quit or die” orthodoxy, and we try to disclose this information whenever it might not be obvious – i.e., when writing something that might tend to encourage THR, but is not a clear statement about why we support THR. I am not aware of any examples of the abstinence-only advocates meeting this ethical standard of disclosure. An interesting question is whether they know they are hiding something that they should be disclosing or are they simply so immersed in their insular political culture that they have convinced themselves that they have no COI, nor even any ethical duties.

–Carl V Phillips