Saturday, January 31, 2009

IN MY VIEW: Failure to Pay Taxes Should Eliminate Daschle from Consideration for HHS Secretary

According to an article in the Washington Post, former Senator Thomas A. Daschle - who has been nominated by President Obama to be the Secretary of the Department of Health and Human Services (DHHS) - failed to pay more than $128,000 in taxes over three years.

According to the article: "Thomas A. Daschle, nominated to be secretary of the Department of Health and Human Services, did not pay more than $128,000 in taxes over three years, a revelation that poses a potential obstacle to his Senate confirmation. The back taxes, along with $12,000 in interest and penalties, involved unreported consulting fees, questionable charitable contributions, and a car and driver provided by a private equity firm run by entrepreneur and longtime Democratic Party donor Leo J. Hindery Jr., according to a confidential draft report prepared by Senate Finance Committee staff. A spokeswoman for Daschle confirmed last night that he recently paid back taxes in excess of $100,000. She said that Daschle, a former Senate majority leader, and his accountant discovered the error regarding the luxury car service and reported it to the committee after his vetting was completed."

Also according to the article: "Backus, Daschle's spokeswoman, said Daschle "naively" believed the car service was "nothing more than a generous offer from a friend. Last June, Daschle "mentioned the use of the car" to his accountant and asked whether the service could be construed as a reportable gift or payment, Backus said. The accountant intended to correct the error in Daschle's 2008 tax filing, she said. Daschle's "failure to recognize this as an issue and to discuss it with his accountant earlier is something he regrets and for which he takes full responsibility," she said. According to the Senate committee, Daschle used the car 80 percent of the time for personal purposes. That service was worth more than $255,000 in unreported income, according to the committee report. Under tax law, not reporting income -- including free services such as air travel or a car service -- can be a crime. But such lapses must be "willful and intentional" to be prosecuted, according to a tax expert."

The appointment of the next secretary of the Health and Human Services Department is critical to tobacco control issues because the Department heads many federal agencies that deal with tobacco - including the Office of the Surgeon General, the Centers for Disease Control and Prevention, and the NIH - and because if the proposed FDA tobacco legislation is enacted, the head of the DHHS will play a key role in implementing this legislation.

The Rest of the Story

If the facts of this article are true, then I think that Daschle should be eliminated from consideration immediately. These allegations, taken as true, mean that Daschle knowingly misled the Internal Revenue Service for at least seven months and "intentionally" failed to pay taxes he owed for this seven month period.

Based on the information reported in the article, Daschle knew in June 2008 that he had made an error in his 2007 return as he failed to report the car service. But as of early January 2009, he had made no report of this mistake to the Internal Revenue Service. Daschle's spokesperson's claim that he intended to correct the error in his 2008 tax filing is damning, because it indicates that he knew his tax return was in error, but failed to correct it for this seven month period. Once finding the mistake, it was Daschle's responsibility to report the error to the IRS immediately and to pay the back taxes and any penalities.

The magnitude of the reported error is huge. The amount that Daschle owed in back taxes is higher than the entire annual income for 85% of the United States population. This is no small error, and one which clearly should have been reported as soon as it was discovered.

Also, given the magnitude of the tax liability on this income, it is inexcusable that Daschle failed to make a definitive and correct determination of the liability at the time he filed his 2007 return. This is not the type of thing that you ask your accountant about two months after you file your tax return. With implications of tax liability in the arena of six figures, you ask your accountant about it in April, not June. And if you do ask your accountant in June, you pay those taxes in June, rather than waiting for the problem to be caught in January of the following year when you come up for a nomination.

The article states that: "Daschle's 'failure to recognize this as an issue and to discuss it with his accountant earlier is something he regrets and for which he takes full responsibility.'" Baloney. If Daschle were to take full responsibility for the error, he would withdraw his name from consideration for the position of secretary of DHHS. That would be taking full responsibility for his actions. The rest of the population does not have the luxury of failing to pay over $100,000 in taxes and not having to suffer the consequences for it.

To add to Daschle's woes, the New York Times reports today that Daschle has received "more than $300,000 in income from health-related companies that he might regulate as secretary." That alone should disqualify him from the position.

Importantly, the New York Times article also confirms that Daschle was aware of his failure to report the taxes last June, but did not report the error to the IRS until just prior to his confirmation hearing in the Senate Health, Education, Labor, & Pensions Committee.

The rest of the story is that Daschle is in no position to be confirmed as secretary of DHHS. He should have pulled himself out of the running, but short of that, the Senate should send him packing. It will be no skin off his back. After all, he has his own car and driver to chauffeur him back home. And he doesn't need to report the income for it because he'd never face another confirmation hearing.

Friday, January 30, 2009

BU Daily Free Press Article on Employment Discrimination Against Smokers

The Boston University Daily Free Press today features an article about employment discrimination against smokers. I think it's important to point out that the arguments being used to justify the refusal to hire smokers would also justify not hiring people who are overweight. I have yet to hear a compelling response to this argument.

Thursday, January 29, 2009

Law Journal Review Blasts Employment Discrimination Against Smokers; Counterpoint by Anti-Smoking Advocates is Not Convincing

A point-counterpoint series of articles published in June 2008 in the William Mitchell Law Review debates the question of whether it is appropriate for employers to refuse to hire smokers.

Writing in opposition to these policies, Lewis Maltby - the founder and president of the National Workrights Institute - argues that these discriminatory policies violate employees' autonomy and privacy.

Maltby writes: "The Administrative Management Society has estimated that six percent of all employers in the United States discriminate against off-duty smokers. These employers argue that smokers incur higher medical costs that adversely affect profitability. ... But smoking is not the only behavior that increases medical costs. Alcohol isn’t good for you. Neither is junk food, red meat, too much coffee, lack of exercise, or lack of sleep. Many forms of recreation have medical risks, including skiing, scuba diving, and riding motorcycles. Getting to work by bicycle may be good exercise, but it increases the risk of being hurt in a traffic accident. Even your sex life has health care cost implications. People with multiple sexual partners have a greater risk of acquiring STDs than those who are monogamous. If it is acceptable for employers to ban off-duty smoking because it increases costs, it is equally acceptable for employers to control all of these other types of behavior. ... If employers are permitted to control private behavior when it is related to health, virtually every aspect of our private lives is subject to employer control."

Maltby concludes: "Employment decisions should be based on how well you do your job, not on your private life. Most successful companies operate on this principle. There is no reason all companies shouldn’t follow it."

He recommends the enactment of state statutes that would prohibit companies from making employment decisions based on lawful, off-the-job behaviors that are not bona fide job qualifications. And he points out that while anti-smoking groups have opposed this legislation based on the premise that smoking should not be specified as a protected activity, they have also opposed laws in which smoking is not even mentioned: "Legislation has been enacted in most states prohibiting companies from terminating employees based on off-duty smoking. Such laws do not expose employees to second-hand smoke—they simply protect peoples’ right to behave as they want in their own home. Employers can still restrict or ban tobacco use on company property. Anti-smoking groups consistently and vigorously opposed the enactment of these laws. When challenged, they claimed that such laws give undeserved special protection to smokers. But when bills were introduced protecting all forms of legal off-duty conduct, the anti-smoking establishment opposed them too."

Writing in support of these policies, Micah Berman and Rob Crane - both of whom are tobacco control advocates - argue that the employee privacy concerns are not valid because smokers have withdrawal symptoms that reduce productivity.

They write: "Even though there is no legal objection to tobacco-free hiring policies, many people strongly believe that off-duty conduct—even if dangerous or unhealthy—is simply none of an employer’s business. This argument would be more convincing if not for the fact that employees, as we have explained, bring their nicotine addiction to work. Their withdrawal symptoms in the workplace reduce productivity and impose substantial costs on their employers and on other employees."

They also respond to the privacy concern as follows: "the argument that employers are running roughshod over employees’ privacy rights is less convincing where—as in the case of Scotts and Weyco—the employer is willing to provide all the cessation assistance necessary to help the employee break his or her nicotine addiction. Indeed, the CEO of Scotts said that the company will not fire employees who are actively trying to quit smoking, even if it takes years of effort."

The Rest of the Story

Neither of Berman and Crane's arguments in response to the privacy concerns are compelling.

First, they provide no evidence that all smokers are less productive in the workplace because they are suffering withdrawal symptoms that affect their performance. Although it may not have occurred to these authors, everyone is different and so are smokers. The response to short-term nicotine withdrawal and its effects are not the same in every smoker and do not necessarily translate into decreased productivity. Smokers have many different patterns of smoking and some do not smoke during the workday anyway. Others are able to work as productively or more productively than their nonsmoking counterparts. The argument simply doesn't hold water and even if it is true that some smokers suffer withdrawal symptoms that affect their performance, that is no justification for refusing to hire all smokers.

This type of reasoning is in fact quite dangerous. It is precisely the kind of reasoning that has in many cases led to intolerable forms of racism, sexism, and other forms of discrimination in the workplace. It needs to be rejected outright.

Second, Berman and Crane defend smoker-free workplace policies against employee privacy concerns by arguing that employers will provide all the smoking cessation resources necessary and will not fire employees if they are making sincere efforts to quit smoking. However, this argument completely destroys their case. After all, they argue that smoker-free workplace policies are necessary specifically because smokers are costing more money in health care expenditures. Thus, it should not matter whether the smoker is making a sincere effort to quit or not. If he or she is smoking, he is costing more money. If the primary concern is indeed whether the employee is trying to quit, then the rationale for the policy is not financial, it is purely moral. Smoking cannot be tolerated but it is acceptable as long as the employee is making a sincere effort to quit. In other words, what the authors are revealing is their real attitude: that the problem is smokers who enjoy smoking and want to continue doing so.

This is, in other words, all about lifestyle disapproval when it really comes down to it. Berman and Crane so readily dismiss the financial justification for these policies when push comes to shove. What underlies their support for these policies, ultimately, appears to be a disdain for the smoker -- or at least for the smoker who doesn't want to quit smoking.

I find it very instructive and revealing to actually take the time to read the justification provided by anti-smoking advocates for smoker-free workplace policies and their defense against arguments made in opposition to these policies. When pushed, it becomes apparent that the issue for them really comes down to an intolerance or disapproval for the lifestyle decision of the smoker.

This is also why anti-smoking advocates so quickly turn away from the argument that these policies would also justify refusing to hire overweight people or people who are not physically active or in poor shape. For these advocates, those behaviors - though unhealthy - are not intolerable or distasteful. They are just unhealthy. There is no moral character issue with them. But not so with smoking. It is not just an unhealthy behavior. It is a defect in moral character. And that is why it is intolerable.

The rest of the story is that when you really get down to the bottom of this debate, the support of anti-smoking groups for smoker-free workplace policies really comes down to intolerance of smokers and distaste for the lifestyle decision to be a smoker. Being obese is also unhealthy and leads to arguably greater health care costs for the employer, but it is not a sign of moral depravity. Thus, these advocates are not calling for employers to refuse to hire obese individuals as well. Only smoking is to be targeted because the smoker is an individual with a moral defect that needs to be repaired.

As long as the smoker desires to quit, then that moral defect is reparable and the smoker can once again be tolerated in the workforce. But a smoker who doesn't desire to quit or who doesn't make a sincere effort to do so is irredeemably defective and we can justify removing that person from the workforce.

Wednesday, January 28, 2009

Former Director of Campaign for Tobacco-Free Kids Trying to Avoid Breaking Ethics Rules, But Destroying Integrity of an Executive Department Instead

According to an article published last week in the New York Times, the former executive director of the Campaign for Tobacco-Free Kids - William Corr - is attempting to avoid a violation of the new White House ethics policies by arguing that he will recuse himself from all tobacco-related issues. Corr was previously a lobbyist for the Campaign for Tobacco-Free Kids, and he lobbied on tobacco issues, including FDA regulation of tobacco. The FDA is under the Department of Human Services, to which Corr was recently appointed as the Deputy Director.

A new ethics policy of the Obama administration precludes any individual who has lobbied within the past year from serving in the adminstration. Thus, Corr could not accept the position of Deputy Director of the Health and Human Services Department without violating this ethics policy. In an apparently desperate effort to be able to accept the position, he apparently agreed to recuse himself from all tobacco issues.

According to the article: "The Republican National Committee criticized the Obama administration for violating this new standard in some of its appointments. Mr. Obama’s ... deputy secretary of health and human services, William V. Corr, lobbied for stricter tobacco regulations as an official with the Campaign for Tobacco-Free Kids. A senior White House official, speaking on the condition of anonymity, conceded the two nominees did not adhere to the new rules. But he said that ... Mr. Corr did not need a waiver because he had agreed to recuse himself from tobacco issues."

The Rest of the Story

In my opinion, a deputy secretary of health and human services who is not able to participate in any discussions related to tobacco is in a position which makes it impossible for him to serve as a leader in this position, and thus he is compromising the integrity of the department by accepting this position.

It's like a deputy director of a social services agency accepting a nomination to lead that agency, but with the proviso that he recuse himself from any issues that relate to welfare.

You simply can't credibly serve as a director of the nation's leading health agency while having to recuse yourself from discussion of anything that relates to the nation's leading cause of preventable death and disease.

In fact, most other issues have some relationship to tobacco. To be sure, funding decisions for the agency are very much related to tobacco policy. Even if Mr. Corr were to recuse himself from making recommendations regarding non-tobacco related aspects of the HHS budget, he is in fact affecting the tobacco budget. Because any money spent for other purposes is not being spent on tobacco. Just as an example, declaring obesity to be a public health priority may mean putting less of an emphasis on tobacco, so Corr could affect tobacco policy even while seemingly recusing himself from any "tobacco-related" issue. Frankly, it's just impossible for him to do that.

It's not like Corr were a lobbyist for funding for some rare disease, and he can easily recuse himself from this issue by not taking part in discussions over a single line-item in the budget for research into this rare disease. Tobacco is a part of all aspects of what the Health and Human Services Department does, and it cannot be separated out as a separate entity that is not at all intertwined with other issues.

The rest of the story is that in an apparent attempt to avoid violating the White House ethics policy, Corr is apparently willing to undermine the integrity of the department.

He should have just said "No."

World Health Organization Warns that Financial Crisis, Unemployment Threaten to Increase Smoking; At the Same Time, WHO Refuses to Hire Smokers

Making an early bid to challenge the Campaign for Tobacco-Free Kids for the 2009 Anti-Smoking Hypocrisy Award, the World Health Organization (WHO) last week warned that the financial crisis and unemployment brought on by the crisis threaten the public's health and in particular, will increase rates of smoking as people turn to substance use to help get through the crisis. At the same time, the WHO is willing to contribute toward this crisis -- as far as smokers are concerned -- by refusing to hire smokers to work in international public health.

According to the AFP article: "The World Health Organisation warned Monday the global financial crisis may spark a rise in mental illness and health problems as people turn to alcohol, tobacco and drugs to get through the downturn. 'This has happened in the past,' said the UN agency's Director-General Margaret Chan at the launch of a conference on the financial crisis' effects on health. 'In times of economic crisis, people tend to forego private care and make more use of publicly financed services,' she said, adding that many country's public health systems are already 'overstretched and underfunded.' Chan also warned that periods of economic instability 'increases the risk that people will neglect health care, with prevention falling by the wayside.'"

The Rest of the Story

The World Health Organization may be attempting to make a serious run at the Campaign for Tobacco-Free Kids for the 2009 Anti-Smoking Hypocrisy Award. It's only January and the WHO has come up with this doozy of a hypocritical position. The WHO bemoans that unemployment is a threat to people's health and causes them to increase tobacco use; however, at the same time it refuses to hire smokers and would apparently prefer that smokers remain unemployed than that qualified job applicants find gainful employment in the public health field, even if smoking has nothing to do with their job.

The pressure is now on the Campaign for Tobacco-Free Kids.

Tuesday, January 27, 2009

Anti-Smoking Groups and Advocates Now Going Off the Deep End in Full Force; Movement is Rapidly Losing Its Credibility; ASH Calls Smokers "Killers"

In a proposal presented at the Fifth World Conference on Nonsmokers' Rights sponsored by Action on Smoking and Health in 2008, an anti-smoking advocate called for statewide campaigns to change the law so that smoking becomes a controlling factor in child custody cases.

Randall Richardson of the Florida Coastal School of Law wrote: "In recent years, courts have begun to take into account second hand smoke issues in child custody proceedings. The courts, using the broad standard “best interest of the child”, have started to use smoking as a factor in determining custody issues. While not deeming it a controlling factor, some courts have used it to determine issue when all other factors were equal. ... What seems to be missing in each of the state family law statutes, is whether the statute specifically states whether the parent smokes or not is a controlling factor in determining child custody. Therefore, what I purpose is to amend through grass-root state campaigns, state family law statutes that make whether or not a parents smokes a controlling factor in determining child custody cases. This can be accomplished by either putting the issue on the ballot in the form of a referendum or by supporting candidates that will vote to change the statutes."

Last week, Action on Smoking and Health (ASH) issued a press release in which it boasted about how the public is growing increasingly "hostile" to smokers. It calls for "no more privileges and toleration" for smokers, which it terms "polluters and killers."

One of the policies for which ASH expresses support is banning smoking by people with children. Other policies which ASH cites as being appropriate ways to treat these "killers" include:
  • not hiring them and firing them if they are already employed;
  • not allowing them to adopt children;
  • refusing to perform certain operations on them;
  • banning smoking on sidewalks; and
  • taking their children from them in custody battles.
According to ASH, smokers "kill thousands of their own children every year."

ASH also equates smokers who smoke in a home or car with children with "child abusers."

And in supporting the denial of surgery to smokers, ASH writes: "Patients seeking a liver transplant may be denied one if they are going to continue drinking alcohol, so why should smokers expect to get all the operations they wish if they are going to continue to smoke and thereby endanger the success of the operation."

The Rest of the Story

If it wasn't clear before, it is now: the anti-smoking movement has completely gone off the deep end.

This is really disgusting. To call smokers "killers" and to say that they "kill thousands of their own children every year" has no place in public health. That is disgusting, hateful, inappropriate, bigoted, and intolerant rhetoric which I unreservedly condemn.

The idea of denying surgery to addicted smokers is also despicable, and it runs contrary to the basic principles of medicine. It clearly violates the Hippocratic oath as well as the principle of "to do no harm." Value judgments regarding lifestyle must absolutely not enter the realm of medical decisions.

Banning smoking on sidewalks, as I have argued, is unsupported by any science and is demonstrative of an extremist, moral-based crusade.

Not allowing smokers to adopt children, even if they agree not to smoke in the presence of the child, is cruel and nothing more than an attempt to punish those individuals for having made an unhealthful decision to smoke.

Denying employment to smokers categorically and when the smoking has no bearing on the qualifications or duties of employment is discrimination and even worse, it represents a manifestation of bigotry.

Finally, while smoking by a parent could certainly be one of a multitude of considerations in child custody decisions, to make it a controlling factor is disgusting, and it is clearly not in the best interest of the child. Whose interest is really being served by making smoking by a parent a controlling factor in child custody? The child's, or the interests of an anti-smoking group that aims to punish smokers by denying them the joy of raising children?

By making smoking a controlling factor, it would actually come above whether or not the parent loves the child and how the child is treated. It would certainly come before the desires of the child himself. This is so narrow-minded that it is clear that some anti-smoking groups and advocates are willing to punish smokers at the expense of the welfare of children.

I condemn these views in the strongest terms possible.

It is quite sad to me to see that the tobacco control movement has gone off the deep end like this. I believe that the jump off the diving board is into such deep water that the reputation and credibility of the movement are all but irretrievable.

Some might argue that the views of several anti-smoking groups and advocates do not represent the entire movement. While technically true, it is also the case that if other anti-smoking groups do not publicly speak out to condemn these views, then they carry the day and are de facto representations of the agenda of the anti-smoking movement. Moreover, it is becoming clear that the views expressed by groups like ASH are not extremist positions, but that they represent the views of many anti-smoking groups. Having ASH speak up has apparently given ammunition and backup to many of these groups to start pursuing these radical policy goals.

The failure to speak out publicly against policies and views like these is tantamount to supporting those policies. When a group talks about smokers as being "killers" and "child abusers" and actively promotes intolerance, hatred, and punishment against this group in the tangible form of denying them basic rights and privileges, such as employment and raising children, then it is imperative that anti-smoking groups and advocates publicly condemn these statements. Silence is not an option. Silence means passive acceptance and passive endorsement of that agenda.

Thus, I argue, by its silence on the matter, the anti-smoking movement as a whole has indeed passively (and in some cases actively) accepted this extremist agenda.

American Lung Association of California Pushing for Smokefree Sidewalks; Nova Scotia Town Follows Just That Advice

It is now official. The mainstream tobacco control movement is now pushing for an extension of smoke-free protections to the outdoors and specifically -- to sidewalks. The American Lung Association of California has released its 2008 State of Tobacco Control report, and one of its criteria in grading the strength of anti-smoking laws is "smoking restrictions on sidewalks in commercial areas." Another criterion is "smoking restrictions at parks, beaches, trails, sports fields, and other similar recreation areas."

Following this advice, the Nova Scotia town of Truro recently banned smoking on a downtown street. Earlier, the town of Bridgewater in Nova Scotia had banned smoking on "all public property, including streets, parks, and other recreational areas. The bylaw was softened from a previous proposal to ban smoking outdoors in the whole community."

The Rest of the Story

The importance of this story is that the push to extend smoking bans to widespread outdoor areas where nonsmokers can easily avoid substantial exposure to secondhand smoke and where there has not been scientific documentation of any serious public health problem is now officially a part of the mainstream tobacco control movement, not simply the whim of an extremist outlying organization. While it was my feeling that these policies were being supported by many tobacco control groups, this is the first official documentation of an organized movement to promote such policies.

Apparently, there has been an official shift in the goal of the nonsmokers' rights movement (unbeknownst to me). Rather than simply trying to protect nonsmokers from the serious health effects of exposure to secondhand smoke, the movement is now trying to protect nonsmokers from having to even see a smoker.

The movement has gone too far, and in doing so, it has crossed the line from being a public health movement to being a moral crusade. It has gone beyond the science and instead of controlling exposure to secondhand smoke, it is now attempting to control lifestyle (follow the link on the website to hear my interview on AM640 Toronto which discusses this transformation in more detail).

Monday, January 26, 2009

Quebec Anti-Smoking Group Looking for Webmaster: Smokers Need Not Apply; Group Defends Its Discrimination Based on Threat of Thirdhand Smoke

A Quebec anti-smoking group - the Quebec Council on Tobacco and Health - is looking for a webmaster. The most qualified applicants are being sought, with just one hitch: smokers need not apply. The group is defending this employment discrimination against smokers by arguing that its employees need to set a good example and that thirdhand smoke residues on smokers pose a threat to nonsmoking employees.

According to a CBC news article, the head of the Quebec Council on Tobacco and Health defended the policy by stating: "We are a non-profit organization that does work to prevent smoking and that's why we ask our employees to be non-smokers or ex-smokers. We promote activities to reduce smoking so we want to set good examples."

A second justification for the policy provided by the Council, according to another article, is "the toxic fumes that settle on smokers even after they have butted out, often called third hand smoke...".

The Canadian group, which promotes the rights of smokers, has criticized the anti-smoking group for its discrimination against smokers in the job posting for the webmaster position. The group's president -Arminda Mota - noted: "They get at least $3 million a year from the government - from taxpayers who are non-smokers, and smokers like me and they are openly discriminating. Even if you're a non-smoker, can you agree with this? What's next? You're not able to apply if you're over 150 pounds?"

The Rest of the Story

Let me just say right now that the refusal to even consider applications from smokers for jobs like this one goes beyond employment discrimination and enters the realm of being just plain bigotry.

There is clearly no public health justification for the categorical exclusion of smokers from employment. The only truly valid explanation for these policies is intolerance of the lifestyle of a particular group of people -- a lifestyle which takes place completely outside the confines of the office and which has no bearing on the actual qualifications for the job. That is defined as bigotry.

Let's tackle each of the two "health" justifications offered by the Quebec Council on Tobacco and Health. First, the Council argues that as an anti-smoking organization, it needs its employees to set a good example for the public. That argument might hold if the smoking were taking place in the office. One could advance the argument that if clients or members of the public came in to the office and saw the webmaster smoking at his or her desk, that would be sending the wrong message or undermining the image that the group wishes to present. However, the issue here is not smoking on the job, but smoking outside of the office, in the employee's private time.

What bothers the group, apparently, is the simple fact of knowing that they have employed a smoker. That is what they apparently find too hard to bear.

In other words, it isn't about job qualifications or any legitimate employment concern. It's about disapproval of a particular lifestyle.

The primary clients of the Quebec Council on Tobacco and Health are smokers. After all, one mission of the group is to encourage smokers to quit. What kind of a message does it send to its clients to let them know that they are not even deemed worthy of employment, simply because of the lifestyle decision they have made?

For a job as a webmaster, how is off-the-job smoking relevant to the position? It is not. I could see a legitimate reason not to hire a smoker as a smoking cessation counselor because you might not want a person who has not successfully overcome a nicotine addiction advising others on how to do that; however, to be a webmaster has nothing to do with whether you smoke or not. Some of the most highly qualified webmasters out there happen to be smokers. What the Quebec Council on Tobacco and Health is saying is that they are explicitly not interested in hiring the most highly qualified person for this job. They are so intolerant of the smoking lifestyle that they would rather hire a less qualified person than give a job to a smoker.

The only one setting a bad example here is the Quebec Council on Tobacco and Health. What they are telling the public is that they hate smokers, cannot tolerate them in their presence, and wish to punish them for this unhealthy choice that they have made. In other words, the real message that the Council is sending is that they are bigots.

The same "health" argument that the Council is making could be applied to any other health behavior or condition, including obesity, as pointed out by If being a smoker doesn't set a good health example, then neither does being overweight. So a company could similarly justify refusing to hire fat people, or even people who are slightly overweight. The precise reasoning being used by the Quebec Council on Tobacco and Health could be advanced to defend a job announcement which read: "Looking for a webmaster. Anyone weighing more than 150 pounds need not apply."

Would we not all agree that if the Council were excluding from employment anyone who weighs over 150 pounds, this would be a clear example of bigotry? Well then so is he exclusion of smokers from employment, as there is no difference in the justification for these two policies.

The second justification advanced by the Council is that smokers emit toxins (thirdhand smoke) and present a danger to nonsmokers. This argument is completely unsupported by any scientific evidence. The same argument could in fact be used to deny employment to anyone who "smells bad," perspires heavily, or wears perfume. To be honest, I not only find it to be a scientifically unsupported argument, I find it disgusting.

It turns out that the Quebec Council on Tobacco and Health is not alone in the anti-smoking movement in using thirdhand smoke as a justification for employment discrimination against smokers. The idea of promoting employment discrimination against smokers based on the contention that the "toxic" thirdhand smoke which smokers emit even when not actively smoking is a danger to nonsmoking employees was formally presented at the Fifth World Conference on Nonsmokers' Rights, held in July 2008 and sponsored by Action on Smoking and Health.

A paper presented by a UCLA researcher argued as follows: "By now there are many statutes in place that prohibit smoking in work places. This in turn has forced smokers to go outside on smoking-breaks to indulge their habit. Unfortunately, when they return to the workplace, these smokers give off a pungent odor of smoke that is usually evident to any non-smoker in their vicinity. This odor is offensive and can cause many non-smokers to pick up the odor on their own clothes, develop headaches, and generally feel ill. In effect, it is practically just a step down from being subjected directly to secondhand smoke. My proposal is to make an administrative petition for rule making for a statute that would allow companies to prohibit smokers from re-entering the workplace until their clothing is free of an odor that can be “easily” detected by other people working within a reasonable proximity to the smoker. This would serve the purpose of assuring companies that they would not risk beings sued by smokers if the companies adopted this rule. This can be done in a few ways. Either there can be made a mandatory “wait out” period after a person is done smoking, which may be set as a specified time that allows the smoke to clear from a smoker’s clothing (for example 5-10 minutes). The second way would be to have a slightly more flexible policy that leaves it to the smoker’s discretion as to when the smoke has cleared out, provided that the odor is not offensive to other co-workers."

Thus, anti-smoking advocates throughout the world were being actively encouraged to promote various forms of employment discrimination against smokers based on the non-supported claims of the health effects of thirdhand smoke. Here, the argument is even weaker. It is merely the smell of smoke that is viewed as the problem. Thus, the same reasoning could be used to remove from the workplace anyone who has body odor, excessive perspiration, or perfume.

Once again, this is clearly bigotry, not public health.

Note: Arminda Mota was kind enough to put my interview on AM640 Toronto up on the web site. You can link to the interview from the site (see: "Has the anti-smoking pendulum swung too far?). In the interview, I comment on the loss of a science-base and a public health perspective in the anti-smoking movement. These comments are quite relevant to today's post, as the employment discrimination illustrates how the movement has become a moral crusade rather than a legitimate health-based social movement.

Thursday, January 22, 2009

Article in Tobacco Control Asks Anti-Smoking Practitioners to Rethink Promotion of Policies that Bar Smokers from Employment

An article that appears today in the journal Tobacco Control, written by me and Brian Houle - a graduate student in sociology at the University of Washington - asks anti-smoking advocates and groups to rethink their promotion of policies by which employers refuse to hire smokers or fire existing employees who are unable to quit smoking. The press release, article, and accompanying media coverage challenge the wisdom, health effects, and ethics of these policies (see: Houle B, Siegel M. Smoker-free workplace policies: developing a model of public health consequences of workplace policies barring employment to smokers. Tobacco Control 2009; doi: 10.1136/tc.2008.026229).

To the best of my knowledge, this is the first published article in the tobacco control literature that actually considers the negative health consequences of smoker-free workplace policies, including the potential negative effects of unemployment as well as stigmatization of smokers that may result from employment discrimination against smokers.

Addressing the stigmatization of smokers, the article cites research which documents that smoker-free workplace policies result in measurable stigmatization: "Our interest in creating a model to consider the effects of smoker-free workplace policies is not just a theoretical one. There is empirical evidence that smoker-free as opposed to smoke-free workplace policies have a profoundly different impact on the public; in particular, on smokers. Stuber et al recently published an analysis of the determinants of smoker-related stigma among current and former smokers. They defined stigma as ‘‘the negative labels, pejorative assessments, social distancing, and discrimination that can occur when individuals who lack power deviate from group norms.’’ Stigma was measured using a validated, 12-item scale that specifically considered the role of social policy and the perceived social acceptability of smoking. The authors found that smoke-free air laws actually lowered self-reported smoker-related stigma. In contrast, smoker-free workplace and similar discriminatory policies towards smokers significantly increased smoker-related stigma."

The article outlines a number of adverse consequences of smoker-free workplace policies: "Unemployment can lead to personal, family and economic stressors that adversely impact health outcomes. Since health insurance is often covered by employers—employer-sponsored insurance insures approximately 64.4% of adults in the United States—many of these individuals will become uninsured. In a series of landmark reports, the Institute of Medicine illustrated the potential consequences of lack of insurance on multiple domains of society. The uninsured have a more difficult time finding and utilising healthcare services and the care provided is
often non-reimbursed. Reduced access to care in turn leads to adverse economic, social and health consequences for these smokers and their families. Further, a growing uninsured population can create financial stresses that affect the ability of healthcare providers to provide services to the community." ...

"In broader social terms, smokers may feel stigmatised as well. Modified labelling theory posits that when social forces about behaviour are communicated individuals may experience social devaluation and discrimination. These feelings may increase social isolation, rejection and perceived lack of personal control. Work by Marmot and others has shown that people with the least feeling of control over their lives have the poorest health outcomes. ... Effects of labelling on individuals with mental illness and infectious and chronic diseases have been shown to impact health outcomes. ... Unemployment and potential lack of access to health insurance among some smokers may also increase health disparities. Disparities already exist among those who smoke, their risk factors, insurance coverage, access to healthcare, health outcomes, disease burden and educational and social status."

The press release states that "quite apart from infringements of personal privacy and individual rights, smokers who are sacked or forced to resign many not be able to find other work, which in itself could have a seriously detrimental impact on their and their families' health, contend the authors. Smokers will also be unjustly discriminated against in a way that people who risk their health by drinking or eating too much, and exercising too little, are not. And it may also prompt a shift in thinking about these other behaviours as well, the authors suggest, citing Clarian Health in Indianapolis, which has already pledged to sack employees who smoke, are obese, and whose blood pressure, cholesterol and glucose levels are unhealthily high. The authors call for a much wider public health debate, and for proper evaluation of these policies, on the grounds that 'the potential unintended side effects.. could be far reaching.'"

The article has received considerable media attention. Here is a partial list of the initial coverage:

Los Angeles Times


Science Daily

China View

Science Codex

ZAMP Bionews

Nursing in Practice

The Rest of the Story

I want to emphasize that my opposition to smoker-free workplace policies does not rely upon this analysis showing that there are severe negative health, economic, and social consequences of these policies. My primary opposition to these policies stems from the fact that they are simply unethical. They represent employment discrimination and I believe that such discrimination is wrong. Even if it were true that these policies had a net positive effect on health, I would still oppose and speak out against these policies. They are discriminatory and I believe that employment discrimination is wrong. It is unethical. People of a certain group should not categorically be denied employment when membership in that group is not necessarily and directly related to the qualifications for employment.

While I would hope that this article and its coverage would stimulate a debate in the tobacco control community about the wisdom behind promoting employment discrimination against smokers, I doubt that will occur. As I noted in the Los Angeles Times article, those who publicly oppose anti-smoking policies such as these are instantly viewed as traitors to the cause and thus very few tobacco control practitioners are willing to speak out in opposition to this aspect of tobacco control dogma.

Wednesday, January 21, 2009

Conflict of Interest Not Disclosed Initially in Smokeless Tobacco and Cancer Review; Correction Issued, But Issue is Still Largely Misunderstood

In a review of the literature regarding the relationship between smokeless tobacco use and cancer, a conflict of interest of one of the article's authors was initially not disclosed (see: Boffetta P, Hecht S, Gray N, Gupta P, Straif K. Smokeless tobacco and cancer. Lancet Oncology 2008; 9:667-675). The original article was published in July, 2008. That article stated: "The authors declare no conflicts of interest." After the editor of the journal was notified by a researcher with knowledge of a potential conflict of interest of Dr. Stephen Hecht (one of the study authors), an erratum was published in September 2008, which noted: "During the immediate months preceding submission of the review SH was acting in the capacity of an expert witness for the plaintiff in a future court case against a smokeless tobacco company. SH declares his participation in this case in no way influenced his writing or involvement in the review."

More recently, the researcher with knowledge of this conflict of interest made an inquiry to the journal Nicotine and Tobacco Research, in which appeared a December 2008 article co-authored by Dr. Hecht on toxin and carcinogen levels in various brands of smokeless tobacco without any declared conflict of interest. The article stated: "The authors do not have any competing interest pertaining to this work." (see: Stepanov I, Jensen J, Hatsukami D, Hecht SS. New and traditional smokeless tobacco: Comparison of toxicant and carcinogen levels. Nicotine and Tobacco Research 2008; 10:1773-1782).

Initially, the journal responded by stating: "We agree that it might have been more open to disclose Dr Hecht's involvement in this case. However, he argued that the data presented in this paper represented a scientific report which was in no way influenced by his acting as an expert witness in this case. Indeed, the request to him to act in this way reflected his expertise in the field. My senior editorial board unanimously agreed that there was no intention to deliberately mislead the readers in this instance and, indeed, the need to disclose that an author is serving as an expert witness is a moot point."

A later response from the journal stated: "Before responding to you, I contacted Dr Hecht again and took the views of my team of Deputy Editors. Our list of potential conflicts of interest includes specifically payments for providing expert opinion in court - one of my Deputy Editors reminded me of that. However, in this case it appears that Dr Hecht did not receive any payment - he waived the fee. The law firm involved, as I understand it, made an equivalent donation to a US cancer charity. Thus, we accept that there is no conflict of interest to declare."

The Rest of the Story

There are several interesting issues here that are worthy of discussion.

Q: Can serving as an expert witness represent a conflict of interest?

A: Most certainly. If an individual is being paid to be an expert witness in litigation and the research in question is directly related to the testimony to be given in the case, then there is a potential conflict of interest. Think about it the opposite way and it becomes clear. Suppose that a researcher who was testifying on behalf of the tobacco industry in a lawsuit regarding whether smoking causes cancer authored a paper on the causal relationship between smoking and cancer. We would expect that relationship to be disclosed in the paper. It is not less of a conflict just because the expert is testifying for the plaintiff.

Q: In what situations does being paid as an expert witness represent a conflict of interest?

A: Being paid to serve as an expert witness represents a conflict of interest when the research in question is directly related to the testimony to be given. The key question is whether the presence of the financial relationship between the researcher and the attorney/company could be perceived as having influenced the conduct or reporting of the research. If the research is directly related to the expert's testimony, then a reasonable person might question whether the fact of being paid to testify in the trial could have influenced the conduct or reporting of the research.

It is important to note that the research must be directly related to the testimony in order for their to exist a conflict of interest. If I am testifying that an individual's smoking caused his or her lung cancer, then there is no reason why all of my research related to smoking must include a conflict disclosure. However, if my research relates specifically to the issue of lung cancer causation by smoking, then a conflict disclosure would be in order.

In the above case, it is clear that a conflict of interest exists with respect to the Lancet Oncology article. That article reviews the relationship between smokeless tobacco and cancer. Since Dr. Hecht is presumably testifying about the causation of cancer by smokeless tobacco in the lawsuit, the research is directly related to the subject of his testimony, and the conflict should be disclosed. Here, I believe the journal acted correctly in publishing the erratum to note the conflict of interest.

Q: Does the argument that an investigator was not influenced by a significant financial relationship negate the existence of a conflict of interest?

A: This is perhaps the least understood aspect of conflict of interest in research. The answer is no. A conflict of interest is not defined on whether an investigator is influenced due to a financial relationship. A conflict of interest is defined on whether the investigator could be reasonably perceived as being influenced by that financial relationship.

So the initial response of the journal Nicotine and Tobacco Research is inappropriate because Dr. Hecht's argument that "the data presented in this paper represented a scientific report which was in no way influenced by his acting as an expert witness in this case" is not relevant. The relevant question is whether or not the conduct of the review or presentation of the results could be perceived to have been influenced by his being paid as an expert witness in the case. To determine the answer to that question, one does not interview the investigator to assess whether or not he sees himself as having been influenced or not. Instead, one must examine the nature and strength of the relationship between the research in question and the financial interest and assess whether it could reasonably be perceived that the expert testimony might influence the conduct or reporting of the research.

So if the journal is correct in declaring that there is no conflict of interest here, they are correct for the wrong reason. An appropriate reason to declare the lack of a conflict of interest would be a judgment that the subject of the research (the various levels of toxicity of different types of smokeless tobacco products) is not directly related to the testimony. I cannot make such a determination without knowing the expected nature of Dr. Hecht's testimony. If he intends to testify regarding the differing levels of toxicity of various smokeless tobacco brands, then a conflict of interest appears to exist. If that is beyond the scope of his testimony, then there may not be a conflict here - but not for the reason stated by the journal.

Even the erratum published by Lancet Oncology shows a misunderstanding of this central issue. The erratum noted that the investigator "declares his participation in this case in no way influenced his writing or involvement in the review." Again, that is irrelevant. An investigator never declares that his or her participation in a case influenced his work. An investigator never declares that a financial interest caused a bias in his research. If this were about investigators voluntarily coming forward when they believed that they had been influenced by a financial interest, we would be waiting for the cows to come home.

It is critical to recognize that in most situations, the influence of a conflict of interest on the conduct or reporting of research will not be conscious or intentional. The conflict most often works by having a subconscious effect on the research. This is why conflicts of interest should not be defined by whether the financial interest actually affected the research or not. The key issue, instead, is whether the financial interest could reasonably be perceived as having influenced the research or the reporting of its results.

When the journal writes that "there was no intention to deliberately mislead the readers in this instance and, indeed, the need to disclose that an author is serving as an expert witness is a moot point," it is demonstrating a misunderstanding of conflict of interest. It is not about whether there was an acknowledgment of a deliberate attempt to mislead readers. It is about whether or not there was a conflict of interest. If there is no conflict, there is no need to disclose it. If there is a conflict, it should be disclosed. The fact that an investigator is not trying to pull the wool over anyone's eyes does not negate the responsibility to report a conflict of interest if it exists.

Q: Does making a donation to charity in lieu of accepting payment for serving as an expert witness negate an otherwise relevant conflict of interest?

A: Simply, no. The individual is still essentially getting paid for his services. The fact that he chooses to do something with this money other than put it into his personal bank account is his own prerogative, but it does not make the financial interest go away.

Thus, the journal's essential reason for claiming that a conflict of interest does not exist in this case is fallacious. The journal is basically admitting that if Dr. Hecht were being paid for his testimony, a conflict would exist and should be disclosed. However, that is indeed the situation. Whether the money goes into his own bank account or is donated to charity, he is being paid for his testimony. Money is coming out of the law firm that would otherwise not be. And its use is being directed by the expert witness.

Now, let me close by noting that I am not arguing here that a conflict of interest exists with regards to the Nicotine and Tobacco Research article. That judgment depends upon the nature of Dr. Hecht's testimony in the lawsuit and whether or not the differential toxicity of various brands of smokeless tobacco is directly related to his testimony. But in either case, the journal's reason for declaring that there is no conflict of interest is faulty.

Researchers and scientific journals need to understand that conflict of interest is not a matter of wrongdoing. Declaring a conflict of interest does not mean that a researcher has done anything wrong. And the reverse of that is also true. Not doing anything wrong does not mean that a conflict of interest fails to exist.

Conflict of interest is simply about whether or not there is a reasonble perception that an investigator's work could be influenced by a significant financial interest. The disclosure of that conflict is important because it allows readers to take that into consideration in evaluating the research and its conclusions. The disclosure is not intended to alert readers of any wrongdoing. In fact, the only wrongdoing that is commonly present is the failure to disclose these conflicts of interest.

Tuesday, January 20, 2009

Author of Thirdhand Smoke Study Warns that Smokers are Contaminated and Emit Toxins; Suggests that Thirdhand Smoke Causes Lead Poisoning

Scientific American has published a review of the thirdhand smoke issue, including an interview with one of the authors of the study which brought the issue to national attention. In the article, that anti-smoking researcher warns that even when not actively smoking, smokers are contaminated and emit toxins that are hazardous to children. He also suggests that thirdhand smoke can result in lead poisoning among infants because of the presence of lead in tobacco smoke.

The article quotes the researcher as stating, in response to the question "Why is thirdhand smoke dangerous?": "The 2006 surgeon general's report says there is no risk-free level of tobacco exposure. There are 250 poisonous toxins found in cigarette smoke. One such substance is lead. Very good studies show that tiny levels of exposure are associated with diminished IQ."

It also quotes the researcher as stating: "Smokers themselves are also contaminated…smokers actually emit toxins [from clothing and hair]."

The Rest of the Story

While the claims made in this article make for interesting reading, they are not science. There simply isn't scientific support behind the assertions made by this researcher. In fact, Dr. Stanton Glantz himself acknowledges in the article that there is no scientific evidence to document that thirdhand smoke is hazardous to children and infants. According to the article, Dr. Glantz "is not aware of any studies directly linking third-hand smoke to disease."

So if there isn't scientific evidence linking thirdhand smoke with disease, then how can the anti-smoking researcher claim that thirdhand smoke causes lead poisoning?

The answer is that you don't need science behind you to make health claims in the tobacco control movement. You can make any claim you want and rest assured that virtually no one within the tobacco control movement is going to publicly question your statement. Sure, there may be some private discussions in which researchers whisper between themselves how unsupported the claim is. But there is no danger of the dissenting opinions becoming public, because dissent on issues like this is simply not allowed in this religious-like movement.

I am certainly not aware of any evidence that the levels of lead in household dust in homes with a smoker are high enough to cause lead poisoning in infants. For that matter, I am not aware of any evidence that the toxins in thirdhand smoke are ingested or inhaled to the level necessary to actually cause harm to children.

To be sure, speculation is reasonable. But if you're going to speculate, you need to make it clear that what you are doing is speculating. The Pediatrics article and this interview are not what I would characterize as speculation. Both make definitive health claims: that thirdhand smoke causes health damage to infants and children. And to the best of my knowledge, these health claims are not supported by any actual evidence.

It also seems rather obnoxious to call smokers "contaminated" and emphasize that they are "emitting toxins," without having any evidence that such "toxins" are actually causing health damage to nonsmokers. I may well have detectable levels of "toxins" from the smoke to which I am exposed from my pellet stove, but it would not be fair to say that I am contaminated and emitting toxins. (I did fall into a pile of metal hydroxide sludge once and I admit that at that moment I was contaminated.)

I also don't understand exactly what the point is. Is it to cast smokers as social outcasts who should be spurned from society and not allowed to have any contact with "the rest of us?" Is it to try to stimulate efforts to ban smokers from being child care providers or teachers? Because if it is true that smokers are contaminated and emitting toxins, then we certainly wouldn't want our children to be exposed to those toxins in day care centers or schools.

Another curious statement in the article is that "Studies in rats suggest that tobacco toxin exposure is the leading cause of sudden infant death syndrome (SIDS)." How could studies in rats possibly indicate the degree to which tobacco exposure is causing SIDS in humans? One would certainly need epidemiologic studies, not merely rat studies, to determine the extent to which tobacco smoke exposure is causing SIDS in humans.

While the article concludes by suggesting that the thirdhand smoke danger points to the need for all smokers to quit, I am afraid that the hysterical nature of the thirdhand smoke claims may actually do the opposite. It may convince many smokers that the anti-smoking folks are fanatics and that they should stop listening to this hysteria. It may also undermine the public's appreciation of the hazards of secondhand smoke and convince many smokers not to bother smoking outside of the home (since their children would be damaged anyway by the thirdhand smoke).

One final note. We've known about the offgassing of constituents from tobacco smoke that has absorbed on surfaces for a long time. What scientific evidence is new such that it would warrant a public education campaign about thirdhand smoke?

The most interesting aspect of this story to me is not that an anti-smoking researcher would make unsubstantiated and somewhat hysterical assertions like these, but that almost no one within the movement is willing to publicly challenge these assertions.

Monday, January 19, 2009

Anti-Smoking Advocate Tells Public that Thirdhand Smoke is Just as Lethal as First or Secondhand Smoke

An anti-smoking advocate who was a local coordinator of a state-funded anti-smoking group has communicated to the public, through a letter published in the Jamestown Post-Journal, that thirdhand smoke - the remnants of smoking that remain around smokers and on on surfaces - is just as lethal as active smoking or secondhand smoke exposure.

According to the letter: "Third-hand smoke is the toxic remnants of smoking that surround smokers and lingers in the air and on the surfaces exposed to second-hand smoke. It's just as lethal as first and second hand smoke, especially for kids."

The letter was written by Sam Vanstrom, who apparently was the coordinator of Chautauqua County Reality Check. According to a minor league baseball web site: "Reality Check is a youth-led action program that seeks to expose the manipulative and deceptive marketing tactics of the tobacco industry and to educate the community though civic action, engaging community members and leaders. It is part of a comprehensive tobacco control program developed by the New York State Department of Health." The Reality Check web site confirms that its mission is to challenge the deceptive practices of the tobacco companies and educate the community about the truth.

The Rest of the Story

It looks like the anti-smoking group and/or its advocate is the one who needs the reality check. There is no evidence that thirdhand smoke is as deadly as active smoking or secondhand smoke exposure. Nor is there any evidence that thirdhand smoke is lethal in the first place.

What the evidence actually shows is that thirdhand smoke produces very small levels of exposure and that these low levels of exposure have not been found to have any significant effect. There is absolutely no evidence that these very low levels of exposure are lethal -- i.e., that they can cause death.

I find it ironic that someone who coordinated a program whose goal is to challenge the deceptive practices of the tobacco industry would resort to deceptive practices to scare people about the effects of thirdhand tobacco smoke. The Reality Check organization is supposed to be about exposing the deception of the tobacco industry and telling the truth to the public. But its former coordinator is doing just the opposite.

How are Reality Check and similar organizations going to have any credibility when anti-smoking advocates who are part of these groups are spreading deception on very basic scientific issues, where they have no evidence to support their claims?

I think the tobacco control movement urgently needs a reality check of its own.

(Thanks to JustTheFacts for the tip.)

Thursday, January 15, 2009

New Study Advises that Practitioners Emphasize Effects of Smoking on Obesity; However, Study Doesn't Find Such Effects

A new study published in the just-released February issue of the American Journal of Public Health examines the relationship between adolescent smoking on obesity in early adulthood (see: Saarni SE, et al. Association of smoking in adolescence with abdominal obesity in adulthood: a follow-up study of 5 birth cohorts of Finnish twins. Am J Public Health 2009; 99:348-354).

This study was a prospective cohort study involving five different birth cohorts of Finnish twins, with a total sample size of more than 4,000. They were followed for approximately 11 years, between the ages of 16 and 27. The risk of abdominal obesity in young adulthood was related to whether the individual was a smoker in adolescence, while controlling for a number of potential confounding variables, including diet, physical activity, socioeconomic status, parental body mass index, and individual body mass index.

The study reports that without the confounding variables, there was a significant elevation of the odds ratio for obesity (OR = 1.77; 95% confidence interval, 1.39-2.26). After controlling for the potential confounders, there was no significant elevation of the odds ratio for obesity (OR = 1.34; 95% confidence interval, 0.95-1.88).

The study acknowledges that it failed to find a statistically significant relationship between smoking and obesity and that this may be explained by the hypothesis that it is other factors - not smoking itself - that lead smokers to tend to have a higher incidence of obesity. As the authors state: "The increase in the risk of abdominal obesity or overweight among the women was no longer statistically significant in the fully adjusted models. This may have been caused by insufficient statistical power. Another possible interpretation of our findings is that adolescent smoking is a proxy for other factors or is part of a cluster of factors predisposing to later abdominal obesity."

The authors conclude that: "Given the greater risk of overweight and abdominal obesity among girls who smoked daily and the fact that adolescent smoking is often associated with preoccupation with weight, emphasizing the deleterious effect of smoking on abdominal fat accumulation could be effective in smoking prevention among young women."

The Rest of the Story

Wait one second here. The study fails to find a significant relationship between adolescent smoking and obesity in young adulthood after confounding variables - such as diet, physical activity, parental BMI, and individual BMI - are accounted for. The study acknowledges that one interpretation of the findings is that smoking may simply be a proxy for other factors (such as other health behaviors) that actually are influencing obesity. But then the study concludes by advising readers that we should be telling the public (emphasizing to the public, no less) that one of the deleterious effects of smoking is to cause obesity later in life.

Do you mean to tell me that even though the study cannot conclude that smoking causes obesity, we should tell the public that smoking causes obesity because it might lead to a decrease in smoking initiation?

This is definitely an example of viewing the ends as justifying the means. Because reducing smoking initiation is a good thing, it doesn't matter if we lie to people about the effects of smoking or give them information which is not scientifically supported.

What's most odd is that this conflicting information appears in the very same paper. This suggests that the authors of the study are not concerned about the validity of the information that they are recommending be disseminated to the public.

When the study controlled for all the confounders, including body mass index at age 24, the association between smoking and obesity was no longer statistically significant. This suggests to me that the reason why smoking at an early age is associated with obesity later in life is most likely that smokers tend to have a constellation of poor health habits, including poorer diet and less physical activity. It is most likely that these factors, and not the smoking itself, is what is causing them to become obese.

This doesn't mean that smoking is not associated with obesity; it just means that the relationship is not a causal one. I think what this study really points to is the fact that smoking is just one of a constellation of health behaviors that tend to coincide, including smoking, poor diet, and inadequate physical activity. It is these other behaviors which are directly related to obesity. Smoking just happens to be associated with obesity because it is related to these other causal factors. But once you adequately control for these other factors, smoking is no longer significantly associated with obesity.

In fact, there is not a lot of biological plausibility for such an effect. The paper does not in fact outline any potential mechanisms by which smoking could cause obesity. There is some evidence that smoking may help keep a little bit of weight off, but not so much for the reverse. I think, again, that the most likely explanation here is not that smoking is causing obesity, but that smokers also tend to have poorer behaviors in other areas which lead to the obesity.

This research is still important, because it reinforces that smoking fulfills a need for teens. Teens who are less self-confident and lack self-esteem are more likely to smoke. But they are also more likely to engage in other unhealthy behaviors. This research suggests that public health practitioners may not want to treat smoking, diet, and physical activity separately, but that there may be a unifying cause for poor health behavior in general, and that perhaps we should try to focus more on the underlying reasons for youths to engage in poor health behaviors. There is too much compartmentalization in how we deal with adolescent health issues, and perhaps we need to take a more holistic approach.

But the one thing the paper does not demonstrate is that smoking during adolescence causes obesity or has deleterious efects on abdominal fat accumulation. The authors of the study themselves admit this. The authors themselves point out a plausible alternative explanation for the study findings - that "adolescent smoking is a proxy for other factors ... predisposing to later abdominal obesity." However, this does not stop them from recommending that public health practitioners should be "emphasizing the deleterious effect of smoking on abdominal fat accumulation...".

They could have made that recommendation without conducting the study. In fact, they would actually have been more justified in making that recommendation prior to conducting the study, because at that point there was reasonable speculation about the hypothesis. The study, however, suggests that the hypothesis is incorrect and it removes any justification for telling the public that smoking causes obesity.

As we saw with the thirdhand smoke issue, however, science doesn't appear to be necessary in tobacco control. Anti-smoking groups and advocates are communicating information to the public without any scientific evidence to back it up. Apparently, the attitude is that since this is all for a good cause, it is acceptable to lie or deceive the public.

Needless to say, I disagree. I think that as public health researchers and advocates, we have an ethical responsibility to communicate accurate information to the public and to be able to back up our communications with solid scientific evidence.

As I'm finding out, that's not happening in tobacco control.

Tuesday, January 13, 2009

New Study Shows that Nicotine Replacement Therapy is Ineffective for Gradual Smoking Cessation, But Concludes the Opposite

Severe Financial Conflicts of Interest are Present and the Resulting Bias is Apparent; Failure to Disclose Conflicts of Interest Also Appears to be a Problem

An article published in the February issue of the American Journal of Preventive Medicine concludes that nicotine replacement therapy - specifically, nicotine gum - is effective in achieving sustained smoking cessation (see: Shiffman S, Ferguson SG, Strahs KR. Quitting by gradual smoking reduction using nicotine gum: a randomized controlled trial. American Journal of Preventive Medicine, February 2009) (press release here).

This was a randomized placebo-controlled trial of nicotine gum for smokers who expressed a desire to quit using gradual reduction of smoking. The chief study finding was that the use of nicotine gum resulted in a three-fold increase in the proportion of subjects who achieved six-month continuous abstinence (OR = 2.86; 95% confidence interval, 1.93, 4.24). The study concludes that "smokers wanting to quit by gradual reduction can substantially increase their success by using nicotine gum to facilitate reduction and cessation. ... Offering this new way to use NRT may enhance the appeal and reach of a treatment that increases success, and thereby have positive public health impact."

The Rest of the Story

While the use of nicotine gum did result in a three-fold increase in the proportion of subjects who achieved six-month abstinence from smoking, the absolute proportion of these subjects was extremely low. Only 5.9% of subjects receiving nicotine gum achieved six-month abstinence, compared to 2.1% of those receiving placebo.

In my view, these results indicate that the use of nicotine replacement therapy was a dismal failure. The appropriate policy recommendation would be to encourage smokers who desire to quit to do so cold turkey. Cessation rates over six-months for cold turkey quitting are better than those observed here for quitting with the aid of nicotine gum. Thus, it is a very biased recommendation to encourage the national use of nicotine gum among subjects who express a desire to quit smoking gradually. From a policy perspective, it would be far more effective to encourage and stimulate smokers who desire to quit to do so cold turkey. This is what the scientific evidence, and the results of this paper itself, actually support.

The extreme bias in the conclusions of this paper would not be so problematic if it were not for the fact that two of the three authors have severe financial conflicts of interest with Big Pharma, and that at least three of the principal investigators in the study have financial relationships with pharmaceutical companies. More specifically, each of these authors and principal investigators have financial relationships with pharmaceutical companies that manufacture smoking cessation medications.

Two of the study authors - Dr. Saul Shiffman and Dr. Stuart Ferguson from the University of Pittsburgh - have financial conflicts of interest by virtue of their employment at a firm that consults for GlaxoSmithKline Consumer Healthcare on issues related to nicotine replacement medication. In addition, Dr. Shiffman has a financial conflict of interest because he has a financial interest in a venture to develop new nicotine replacement medications.

According to the article: "Through their work at Pinney Associates, Drs. Shiffman and Ferguson serve as consultants to GSKCH [GlaxoSmithKline Consumer Healthcare] on matters related to smoking control and/or nicotine replacement medications. Dr. Shiffman also has a financial interest in a venture to develop new nicotine replacement medications." These financial relationships are confirmed elsewhere.

Three of the principal investigators on the study at academic clinical sites also appear to have financial relationships with pharmaceutical companies:

Dr. David Gonzales (Oregon Health Sciences University): "Dr. Gonzales has received research contracts from Pfizer, Sanofi-Aventis, GlaxoSmithKline, Addex Pharmaceuticals, and Nabi Biopharmaceuticals and consulting fees and honoraria from Pfizer, Sanofi-Aventis, and GlaxoSmithKline and owns 5 shares of Pfizer stock."

Dr. Stephen Rennard (University of Nebraska Medical Center): "Dr. Rennard has had or currently has a number of relationships with companies who provide products and/or services relevant to outpatient management of chronic obstructive pulmonary disease. These relationships include serving as a consultant (for Adams, Almirall, Altana, Array Biopharma, AstraZeneca, Aventis, Biolipox, Centocor, Dey, Critical Therapeutics, GlaxoSmithKline, Johnson & Johnson, Merck, Novartis, Ono Pharma, Otsuka, RJ Reynolds, Roche, Sankyo, Schering-Plough, Scios, and Wyeth), advising regarding clinical trials (Altana, AstraZeneca, Aventis, Centocor, GlaxoSmithKline, Novartis, Pfizer, and Philip Morris), speaking at continuing medical education programs and performing funded research at both basic and clinical levels (Altana, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Novartis)."

Dr. Nancy Rigotti (Massachusetts General Hospital): "In the past 5 years, Dr Rigotti has received research grant funding from Pfizer, GlaxoSmithKline, Sanofi Aventis, and Nabi Biopharmaceuticals and has consulted for Pfizer and Sanofi Aventis. These companies have investigational or marketed smoking cessation medications."

There are a number of problems with the disclosure of these financial conflicts of interest. First, while the financial conflicts of interest of the study authors are revealed in the paper itself, they are not disclosed in the press release, so far as I can tell. Thus, reporters and members of the public who read these results and conclusions in the press release, but do not read the full article are not aware of the severe financial conflicts of interest of Dr. Shiffman and Dr. Ferguson.

Second, even in the article itself, the financial conflicts of interest of the study site principal investigators are not disclosed. I was able to find out about these financial conflicts only after hours of research using databases that are not publicly available. I think readers of this article would be shocked to find out, for example, that the principal investigator of this study at the University of Nebraska Medical Center has reported having consulted for GlaxoSmithKline, manufacturer of nicotine gum, as well as for 20 other pharmaceutical companies. This type of information, especially because it is not disclosed, really puts the validity of the study findings and conclusions in question.

The study does not even mention how smoking status was ascertained, who asked the question, who recorded the result, and whether the individual conducting the assessment was blinded as to the subject's intervention vs. placebo status. To have principal investigators of a clinical trial who are financially conflicted and not to reveal this in a manuscript summarizing the findings is extremely problematic. In my view, it violates ethical standards of conduct, since I believe all such financial relationships should be disclosed in the paper.

Beyond the apparent failure of disclosure of financial conflicts of interest of several of the study site principal investigators, an additional problem is the fact that principal investigators at academic institutions were allowed to serve in that capacity in the first place, given that this was a clinical trial in which an actual drug being marketed by the company of interest was being tested in human subjects, and among whom there was a risk of adverse events, which were monitored in the study.

At my institution, it would be extremely unlikely that we would allow an individual with this type of conflict of interest to serve as the principal investigator on a clinical trial such as this. When human subjects are involved in research, conflicted principal investigators are generally not acceptable, unless there is a major compelling reason to make an exception. It would be interesting to know whether conflict of interest advisory committees at the University of Pittsburgh, Massachusetts General Hospital, University of Nebraska Medical Center, and Oregon Health Sciences University reviewed these cases, and if so, what their justifications were for allowing individuals with financial relationships with pharmaceutical companies that manufacture smoking cessation products to serve as principal investigators on a clinical trial involving potential significant risks to human subjects.

It would also be of interest to know whether the human subjects at these institutions were informed of these conflicts of interest of their site principal investigators.

Also of interest would be knowing whether there were procedures in place to ensure that the conflicted principal investigator had no role in collecting or analyzing data in the study. This point, however, is almost moot since by definition, the principal investigator is the primary person with responsibility for the collection and analysis of the data, even if others are performing the primary tasks.

Readers may want to note that the fact that the study was funded by GlaxoSmithKline Consumer Healthcare is not of primary concern to me. My concern is over the financial conflicts of interest of study authors and principal investigators, not with the overall funding by a pharmaceutical company. The funding itself does not represent a financial conflict of interest. The conflict of interest comes from the fact that the study authors and some of the site principal investigators appear to have signficant financial relationships with pharmaceutical companies, including the company that manufacturers nicotine gum and others that manufacture other nicotine replacement therapy or smoking cessation medications.

I do find it problematic that the University of Pittsburgh apparently allowed Dr. Shiffman and Dr. Ferguson to serve as principal investigators of the overall study (which they appear to be since they are the authors of the summary article), since they have significant financial conflicts of interest and because this is human subjects research.

The conflict of interest calls into question the integrity of the process by which study site data were collected, combined, and analyzed. This is not because of any suspicion of anything less than honorable character and intent among the authors. It is because a financial conflict of interest can create an unconscious bias which may be perceived as affecting the conduct of the study and the reporting of the study results.

Let me also take this opportunity to emphasize that I am not accusing anyone of intentional wrongdoing or any lack of individual integrity. Bias related to conflicts of interest can be completely subconscious. But that is precisely why they need to be eliminated or managed properly.

There is little doubt in my mind that the financial conflicts of interest inherent in this research led to a bias (albeit unconscious) in the interpretation and presentation of the study findings and conclusions. Obviously, it led to a much more positive reporting of the findings than was warranted. In fact, I would go so far as to state that the study conclusion is unsupported by the study findings. Nicotine gum should not be recommended for these patients; they should be encouraged to quit smoking cold turkey.

While differences of opinion are appropriate and expected, when one opinion that is being widely disseminated with an eye towards affecting national policy is influenced by a financial conflict of interest - and especially when that conflict is not adequately disclosed - this is problematic.

Finally, while Dr. Shiffman's conflict of interest is disclosed in this article, it does not appear to be disclosed in another article he wrote about women's success in smoking cessation (see: Shiffman S. How when matters for quitting and relapse [commentary]. Addiction 2008; 103:822-823).

That article discusses factors that relate to the success of smoking cessation among women and treatment for smoking cessation and prevention of relapse. Thus, it would seem that Dr. Shiffman's conflict of interest by virtue of his consulting for GlaxoSmithKline and his venture to develop new smoking cessation medications would be relevant. However, this conflict of interest does not appear to be disclosed in the article. The declaration of interest statement says only: "The author is a co-founder of invivodata, inc., which provides electronic diaries for clinical trials."

If anything, I would think that the conflict of interest with a pharmaceutical company that manufacturers products for treatment of nicotine dependence and the interest in a venture to develop new such treatments would be of even more relevance than the interest in electronic diaries, which actually don't seem to be particularly relevant here. But the point is, if electronic diaries were thought to be relevant, then why weren't the pharmaceutical conflicts of interest disclosed?

It's always possible that I'm missing something here. I've examined the full text of the articles mentioned as well as the press release in detail.

The rest of the story is that this research appears to be an example of: (1) Failure to disclose relevant financial conflicts of interest in a study press release; (2) Failure to disclose some relevant conflicts of interest in the study itself; and (3) Inappropriate conflicts of interest among principal investigators on human subjects research.

That these issues are arising in tobacco control research does not come as a surprise to me.

For a previous discussion of the inappropriate role of conflicts of interest in tobacco control research and policy, see the following posts:

Executive Director of Campaign for Tobacco-Free Kids Violates President-Elect Obama's New Rules for Lobbyists on Transition Team

New Report Warns of Serious Risk Profile of Chantix; Recommendation of Chantix by Anti-Smoking Researchers with Conflicts of Interest is Unacceptable

International Tobacco Control List-Serve and Discussion Site Now Sponsored by Big Pharma

Chantix Lawsuits Piling Up; Dangers from Severe Financial Conflicts of Interests of Tobacco Control Researchers and Institutions Revealed

With $50,000 in Annual Resources from GlaxoSmithKline, Chair of Expert Panel on Smoking Cessation Should Have Recused Himself, or Been Removed

Press Release on Smoking Cessation Guidelines Fails to Disclose Financial Conflict of Interest of Expert Panelists

NIH Expert Panel Recommends Smoking Cessation Pharmaceuticals for Every Smoking Patient; Panel Chair and 8 Members Have Financial Ties to Big Pharma

Financial Conflict of Interest Not Disclosed in Article on Smoking Cessation; Another Example of Failed Disclosure in Tobacco Control Research

Weill Cornell Medical College Again Defends Researcher's Failure to Disclose Tobacco Funding and Financial Conflict of Interest

Monday, January 12, 2009

Original Study on Thirdhand Smoke Does Not Support Conclusion that Health Threat is Significant

It is important to evaluate the original study which is being used to support the idea that thirdhand smoke poses a significant risk to nonsmokers, especially to children and infants. That study appeared in Tobacco Control in 2004 (see: Matt GE, et al. Households contaminated by environmental tobacco smoke: sources of infant exposures. Tobacco Control 2004; 13:29-37).

The study compares airborne nicotine levels and urine cotinine levels in rooms and infants, respectively, in three settings:

1. Homes in which there are no smokers (referred to in the study as "no exposure").
2. Homes in which there are smokers, but they report making great efforts not to expose the infant (referred to in the study as "indirect exposure").
3. Homes in which there are smokers who do not report making great efforts not to expose the infant (referred to in the study as "direct exposure").

The major findings of the study are that air nicotine levels were 2-3 times higher in homes under the indirect exposure conditions as compared to the no exposure condition and that urine cotinine levels of infants living in indirect exposure conditions were about 8 times higher than among infants living in no exposure conditions. Based on these findings, the article (and subsequent articles which use this as a basis) concludes that thirdhand smoke is a significant health hazard.

The Rest of the Story

There are so many aspects of the rest of the story that it's difficult to know where to begin. To make it easier to follow, let me number each point.

1. Twice As High As a Miniscule Number is Also a Miniscule Number

While at first glance it may sound dangerous to have airborne nicotine levels that are twice as high as in a nonsmoking home, the level of nicotine in nonexposure homes is so low that even at twice this level, it does not appear to represent any substantial health threat. The average airborne nicotine level in nonexposure homes was about 0.1 ug/m3 (micrograms per cubic meter). In indirect exposure homes, the average nicotine level was between 0.2 and 0.3 ug/m3. These are extremely low levels; in fact, they are lower than levels which have been measured in many nonsmoking environments. So the simple fact that nicotine levels in indirect exposure conditions was twice as high as in direct exposure conditions does not necessarily mean that thirdhand smoke is a substantial health risk. In fact, based on the nicotine levels reported in the paper, it does not appear that thirdhand smoke results in airborne exposure to nicotine that is high enough to represent a significant health risk.

2. Some of the Indirect Exposure Homes in the Study Were Almost Certainly Direct Exposure Homes

The study relies upon self-report to determine whether parents smoke in the home or not. Almost certainly, parents are going to under-report smoking in the home. Given the societal scorn that is placed upon parents who expose their children to secondhand smoke (believe it or not, some anti-smoking groups and advocates go so far as to call them child abusers), it is not surprising that in a survey, parents are going to be hesitant to admit that they do smoke in the home around the child.

Thus, the indirect exposure condition almost certainly contains a number of homes in which the parents do smoke around the child. This misclassification severely biases the results of the study and makes it impossible to conclude that the levels of exposure of infants in "indirect" exposure homes is actually due to thirdhand smoke, rather than to secondhand smoke.

Ironically, one way to verify the presence of absence of smoking in the household would be to measure ambient nicotine levels, which would indicate whether smoking is taking place or not. So ironically, this study uses as an outcome measure a variable that actually should have been used as a verification of the parents' non-smoking status in the home.

To make matters worse, most of the homes had multiple smokers, so even if the parent interviewed was telling the truth, it may have been the case that another household member smoked inside the home. Even worse, a large proportion of these infants were exposed directly to smokers outside the home, which could well explain their elevated cotinine levels. In fact, in the indirect exposure group, one-third of the respondents reported that the infant had visited someone who smokes in the past 30 days. Thus, these subjects should not have been used in the study, especially for the measurement of cotinine levels, because it messes up the results.

While many parents in the indirect exposure group reported not smoking in the home in the past 30 days, 8% admitted to smoking in the home occasionally. These cannot be used as true indirect exposure homes, since the parent is admitting to smoking inside the home.

The bottom line is that this study is almost certainly not measuring the true exposure of infants who live in conditions in which parents never smoke in the home. These results therefore cannot be used reliably to evaluate the risk of thirdhand smoke.

3. Examining the Minimum Exposure Levels Appears to Confirm that if Stringently Adhered to, Smoking Outside the Home Results in No Significant Airborne Nicotine

Given the likelihood that many of the indirect exposure homes were actually direct exposure homes, it now becomes important to examine the minimum airborne nicotine levels in these homes. Importantly, the minimum airborne nicotine level in an indirect exposure home was about 0.1 ug/m3. This is no different from the airborne nicotine level in a nonexposure home. It therefore suggests that it is possible to smoke outside the home and to have the infant exposed to no significant airborne nicotine inside the home.

More provocatively, perhaps what the range of airborne nicotine levels indicates is the degree to which smoking is taking place inside the home, rather than the differences between homes, all of which represent the complete absence of any smoking.

The bottom line here is that it is possible for a smoker to protect the infant from any significant airborne nicotine exposure by smoking outside the home and perhaps taking other measures (such as ensuring that doors and windows are shut when smoking).

It is also interesting to note that the minimum level of nicotine in dust from the indirect exposure homes was 0. Again, this confirms that it is possible to have no infant airborne or dust nicotine exposure, even though the parent is a regular smoker.

This same pattern of results held for urine cotinine measurements as well.

4. The Study Does Not Acknowledge Any of These Limitations

Most concerning and worrisome to me is that the paper does not acknowledge as a limitation the possibility that parents are not being accurate in their reporting of smoking inside the home. We know that there is significant under-reporting even of just a person's smoking status. In other words, people are reluctant to even admit that they smoke, much less to admit that they smoke in the presence of infants. If there is significant under-reporting of smoking status, then the under-reporting of smoking in the presence of infants has to be very substantial.

That this is not even mentioned in the paper is concerning and has two important implications. First, it renders the conclusions of the study invalid. If researchers cannot defend their conclusions against the most plausible and likely limitation such as this, then there are plausible alternative explanations of the study findings, and the study conclusion cannot be accepted.

Second, it raises the spectre of investigator bias. One would not expect to see an omission of this magnitude in a situation where the researchers were free of substantial bias. Unfortunately, it raises the possibility that the researchers were trying to show that thirdhand smoke is harmful, rather than to objectively discover whether there is significant child exposure to tobacco smoke toxins when a parent is careful to never smoke in the home or around the child.

For further commentary on this study, see the insightful discussion of the study's conclusions and limitations over at Velvet Glove Iron Fist.

See also Dr. Alan Blum's take on the thirdhand smoke issue at The Birmingham News blog.

And here is Sandy Swarc's commentary on the issue over at her Junkfood Science blog.