Friday, February 27, 2009

Northern Territory Medical Association Director Compares Smokers with Pedophiles

The president of the Northern Territory Medical Association has compared smokers to pedophiles, according to an article in the Northern Territory News.

According to the article, the remarks came in the context of the Medical Association president calling for a ban on smokers being employed by the Territory Health Department. He pointed out that smokers would be most inappropriate as employees when working with indigenous Territorians and stated that sending smokers out to work with indigenous people was like allowing convicted pedophiles to work with children:

"Smokers should be discriminated against when applying for jobs with the Territory Health Department, a leading doctor declared yesterday. NT Australian Medical Association president Peter Beaumont said the bias should be strongest when recruiting people to work in Aboriginal communities. He said sending smokers to work with indigenous people was like allowing convicted pedophiles to work with children."

"Sixty per cent of indigenous Territorians smoke, compared with 17 per cent in the general community. Dr. Beaumont said he didn't care if his proposal caused a "backlash". "You wouldn't send pedophiles to work in an area where there were lots of children," he said. "Society wouldn't think there was anything wrong with putting limits on them. "So why shouldn't we limit people who have a very bad health habit?" Dr. Beaumont said discriminating against smokers in the NT public service would set a good example to the rest of the community."

The Rest of the Story

The significance of this story is that this statement is coming not from some commenter on a blog (I have seen such comments), but from a physician who is in a leadership position in the medical profession. This individual runs the Northern Territory Medical Association. Thus, in some respects, his statement characterizes the position of all physicians in the Northern Territory.

Discriminating against smokers is the last thing in the world that you would want to do in the NT. Since rates of smoking among indigenous Territorians are extremely high (about 60%), the Medical Association is promoting a position by which the majority of the indigenous community would not be eligible for employment.

There is no reason why smokers as a group should be categorically denied employment in the health field. While you might not want to hire a smoker as a smoking cessation counselor, virtually any other position in the public health field is one for which a smoker could be equally or more qualified than a nonsmoker. By categorically denying employment to smokers, you are ensuring that you will not have the most qualified work force. By definition, then, you will not be able to provide health services most effectively.

Fortunately, the NT Health Minister immediately rejected the Medical Association's proposal: "We have enough difficulties recruiting health professionals to the Territory. Why would we place further restrictions on them?"

As far as the comparison between smokers and pedophiles, it is a disgusting and despicable comment and a retraction and apology is called for. It is an embarrassment to not only the NT Medical Association, but to physicians everywhere.

(Thanks to Michael McFadden for the tip.)

Thursday, February 26, 2009

Official Data Show No Effect of England's Smoking Ban on Heart Attack Admissions During First Nine Months

Christopher Snowdon over at Velvet Glove Iron Fist has reported that data released yesterday by the National Health Service showed that England's smoking ban had no effect on the trend in the number of heart attack admissions during the first nine months that the ban was in effect.

The National Health Service has reported annual summaries of the total number of emergency room admissions for heart attacks or for admissions in which the patient subsequently suffered a heart attack. These data cover all hospitals in England; thus, there are no gaps in the data. The data cover the fiscal year, starting April 1 of the first calendar year and ending March 30 of the second calendar year. Thus, the 2007-2008 data cover the period from April 1, 2007 through March 30, 2008.

The smoking ban in England took effect on July 1, 2007. Thus, although the 2007-2008 data contain figures for three months during which the ban was not yet in effect (April, May, and June), if the ban had any dramatic effect on heart attacks (such as a 27% which is the figure which anti-smoking researchers are citing), one would expect to see some significant acceleration of the existing secular decline in heart attack admissions during the reported 2007-2008 period.

As Snowdon reports, however, there was only a 2% decline in heart attack admissions in England from 2006-07 to 2007-08, compared to a 2.8% decline in the preceding year and a 3.8% decline in the year preceding that. Thus, these data show no evidence that the smoking ban resulted in any significant, immediate decline in heart attacks.

Also as Snowdon reports, these data are very important, because the sample size is huge. Unlike the small sample sizes in studies from Helena, Pueblo, and Bowling Green, the sample size in this England study is larger than all of the published studies combined. In addition, the study covers a long period of time, not just the year before and after the smoking ban (as is the case with some of the published studies).

Further Analysis

It appears that Snowdon included all hospital discharges with a diagnosis of heart attack, both those in which the heart attack was the presenting reason for admission and those cases in which the patient suffered a heart attack subsequent to admission. While there is nothing wrong with this, someone could argue that it is only the admissions for a presenting heart attack that are relevant, because presumably, subsequent heart attacks experienced in the hospital are not triggered by secondhand smoke exposure.

I re-ran the analysis using only hospital admissions for presenting heart attacks (those which presumably might have been triggered by secondhand smoke, as hypothesized by many tobacco control researchers). The data look like this:

As one can see visually, there is absolutely no change in the trend of declining heart attack admissions in England during the first nine months during which the ban was in effect. There appears to be a relatively steady decline in heart attack admissions from 2002-2008, with no change associated with the smoking ban.

The decline in heart attack admissions from 2006-2007 to 2007-2008 was 3.7%, compared to declines of 3.7% in the preceding year and 3.8% in the year before that.

Thus, this analysis confirms that no matter how you look at it, there was no change in the rate of declines in heart attack admissions in England associated with the first nine months of the smoking ban.

The Rest of the Story

These data are important, because they demonstrate the discrepancy between population-based versus anecdotal evidence related to the immediate effect of smoking bans on heart attacks. The studies which have reported an effect of smoking bans on heart attacks have tended to be based on what are essentially anecdotal observations of declines in heart attacks in small cities. In contrast, when one looks systematically at large populations affected by smoking bans, one doesn't find a similar effect. This probably reflects publication bias. It is unlikely that researchers investigating a change in heart attacks following a smoking ban but not finding a substantial decline would publish such a finding.

These data are also important because they demonstrate that, once again, anti-smoking advocates have jumped the gun in prematurely concluding that smoking bans are lowering heart attack rates. We saw this first in Scotland, where researchers and advocates touted a 17% decline in heart attacks in a sample of Scottish hospitals using a specific diagnostic method. However, subsequent population-based data using a consistent diagnostic method revealed that the initial reports were incorrect and there was no significant acute coronary syndrome decline associated with the smoking ban.

Now, we find that anti-smoking advocates in England have jumped the gun. Last June, as I reported here, three anti-smoking groups in England seized upon anecdotal data showing a 40% decline in heart attacks in one hospital trust and used it to publicly claim that the smoking ban was resulting in a dramatic decline in heart attacks. We now know that these claims were wrong; the conclusions were premature and not borne out by the subsequent data.

We now have large population-based studies in England, Wales, and Scotland which fail to show any immediate effect of smoking bans on heart attacks. In light of these studies, which are based on very large sample sizes and which include all hospitals in the relevant areas, it is impossible to stick with the conclusion that smoking bans lead to dramatic, immediate reductions in heart attacks.

It will be interesting to see whether anti-smoking groups in England and elsewhere retract their earlier claims in light of these new data.

As John Maynard Keynes said: "When the facts change, I change my mind. What do you do, sir?"

My suspicion is that the anti-smoking groups will not change with the facts. Based on my experience, they will stick with their premature and inaccurate claims and shift the debate over to the character and integrity of those who are pointing out these conflicting data. They will not deal with the substance of these new findings. Or, at very best, they will acknowledge that the earlier conclusions may have been premature but will take no serious action to disseminate these new data. It's all for a good cause, so why should the truth actually matter?

Let me close with an admission of my own bias here. As someone who has worked for much of my career to promote workplace smoking bans, I would love to see evidence that these bans are resulting in immediate, substantial declines in heart attacks. I'd love to be able to take some credit for an immediate saving of lives. Thus, it is in my personal interest to try to interpret the findings in the most favorable light possible. However, as a scientist, I just cannot come to conclusions which are clearly not supported by the data.

While I firmly believe that in the long run, smoking bans will reduce cardiovascular disease and heart attacks due to long-term changes in smoking prevalence and secondhand smoke exposure, I do not believe there is evidence to conclude that there has been any substantial, immediate decline in heart attack deaths due to these policies.

Tuesday, February 24, 2009

New Study Shows that Kids Who Are Allowed to Watch R-Rated Movies are More Likely to Start Smoking

A new study published in the American Journal of Preventive Medicine reports that youths whose parents allow them to view R-rated movies and videos are more likely to start smoking.

The study was a longitudinal one: approximately 1,200 Massachusetts youths were followed for four years, from the sixth grade through the ninth grade. At baseline, youths were asked whether their parents allow them to watch R-rated movies. Rates of smoking initiation in the subsequent four years were compared between youths who reported that they were or were not allowed to watch such movies.

The study found that: "Among those who were allowed to watch R-rated movies, smokers were nearly three times as likely and nonsmokers were almost twice as likely to say it would be easy for them to get cigarettes, compared to youngsters who weren't allowed to watch R-rated movies."

According to the study's lead author: "the study shows that parental permission to watch R-rated movies is one of the strongest predictors of children's belief that cigarettes are easily available, about as strong as having friends that smoke. 'We do know that kids who believe it is easy to get a cigarette are at risk of smoking,' Doubeni said. 'Our prior research has already shown that kids who perceive cigarettes as readily accessible are more likely to end up as regular smokers.'"

The researchers offer two potential explanations for the study findings: "It may have to do with a parenting style that is permissive of activities that are not age-appropriate. Or it may be an outcome of all the smoking scenes in R-rated movies."

The Rest of the Story

This study is important because casts some doubt on the conclusion of previous studies that viewing smoking in movies is strongly causally associated with smoking initiation. The present study offers a potential alternative hypothesis: it may be that youths who are allowed to watch movies that have more smoking in them are different than youths who are not allowed to watch these movies, and that those differences (having something to do with parental permissiveness) are related to factors that influence smoking initiation.

If allowing children to watch R-rated movies is a proxy for a general parental permissiveness that relates to higher risk-taking behaviors among children, then it is possible that part of the effect that has been attributed to the viewing of smoking in films is actually due to other variables than the smoking itself.

Most importantly, this study casts serious doubt on the claim by anti-smoking groups that requiring an R-rating for movies that depict smoking would avert 60,000 tobacco deaths per year in the U.S. There are two reasons for this.

First, if the causal relationship between seeing smoking in films and starting smoking has been overestimated, then so too has the estimate of the number of lives that would be saved.

Second, viewing R-rated films has now been shown to predict smoking initiation. Requiring an R-rating for movies that depict smoking might alter parents' approach to allowing their kids to view movies. More youths might end up seeing R-rated movies, resulting in more smoking initiation. In addition, even if the same number of kids continue to see R-rated movies, one would expect the frequency of smoking depiction in such movies to drastically increase, thus leading to increased smoking initiation among those youths (based on the public health groups' own conclusions).

The movement to require R-ratings in all films that depict any fleeting amount of smoking is yet another example of how the tobacco control movement is losing its science base. The movement is making wild, premature claims that are not adequately supported by solid data. Alternative hypotheses have not been adequately considered.

This is, in fact, where disallowing dissent in the movement is hurting it. Anyone who dissents from the dogma - anyone who challenges the strength of the causal conclusion that viewing smoking in movies causes 100,000 kids to start smoking each year - is accused of being a denialist or a tobacco mole. Thus, there is no chance for reasonable alternative hypotheses - such as the one suggested by the authors of the present study - to be seriously considered in the discourse of the movement.

This leaves the more extreme claims to be unchallenged and therefore accepted as the de facto consensus of the movement.

But here we have a situation where tobacco control researchers have published a paper noting that one of two equally plausible hypotheses is that levels of parental permissiveness may explain the relationship between watching R-rated movies and smoking initiation, rather than exposure to the smoking itself.

Finally, I should note that my personal opinion is that viewing smoking in movies has some effect on smoking initiation. However, I believe the magnitude of the effect has been greatly overestimated. And most importantly, I believe that the magnitude of the effect of requiring an R-rating for movies that depict smoking has been vastly overestimated. I do not believe for a moment that such a measure would prevent 60,000 deaths per year.

Monday, February 23, 2009

Anti-Smoking Advocates Argue for Banning Smoking in All Homes with Children

In an op-ed column published earlier this month in the Portland Press-Herald, three Maine anti-smoking advocates - James Tasse (Healthy Maine Partnership Coordinator for Healthy Casco Bay), Joan Ingram (Healthy Maine Partnership Coordinator for Healthy Portland), and Toby Simon (Cumberland County district tobacco coordinator) - argue that smoking should be banned in all homes in which children are present.

The piece responds to an editorial which asserted that banning smoking in cars with children is a slippery slope because it could lead to banning smoking in the home. The authors, however, find no slippery slope because they conceptually have no problem with banning smoking in homes with children. They argue: "It is a parent's responsibility to protect his or her kids from preventable exposure to health risks. If the parent fails to fulfill that responsibility, society has a legitimate interest in intervening to protect the health of the kids, and to protect itself from incurring future costs in the form of treatments for asthma, allergies, cancer and many other conditions. Smoking in the presence of children -- or non-smoking adults, for that matter -- is a practice that should be banned in cars, homes and public places."

The Rest of the Story

Here is why the op-ed's argument is problematic: If it is true that the government has a legitimate interest in intervening to protect the health of kids in any situation in the home in which a parent is failing to protect his or her kids from "preventable exposure to health risks," then are a host of parental behaviors which could and should be banned. Each of the following is an exposure to a health risk that falls into the category that the authors argue make it subject to government intervention (i.e., a ban) because parents have the responsibility to prevent the exposure:
  • allowing one's children to eat food containing trans-fats;
  • allowing one's children to eat high volumes of fast food;
  • allowing one's children to play ice hockey;
  • forcing a child to breathe in fumes from a wood stove;
  • applying pesticides inside the home to get rid of pests;
  • using pesticides in children's hair to control lice;
  • allowing a child to smoke;
  • allowing an infant to sleep on his stomach; and
  • spraying an inside window with sprayable wood finish that contains toxins.
If we accept the authors' reasoning with regards to banning smoking in the home, then we would also have to accept that each of these other preventable health risks to which many parents expose their children ought also be banned. In other words, it basically opens the door to the government entering the home and making all decisions for parents about the risks to which they can or cannot expose their children.

This precise argument would justify government regulation of virtually all parental behavior that has anything to do with exposing their children to health risks.

In order to advance an argument for banning smoking in the home successfully, Tasse, Ingram, and Simon would need to provide a justification for why - of all the preventable health risks to which parents may expose their children - only secondhand smoke should be regulated.

Their op-ed does not provide any such justification. In fact, it justifies the ban on smoking by arguing that parents should not be allowed to expose their children to preventable health risks.

While I believe that these anti-smoking advocates may be well intentioned in that their ultimate desire is to prevent exposure to secondhand smoke, it appears to me that their support of this policy requires a lot more careful thought and consideration.

To give them the benefit of the doubt, it may be that they simply have not thought this out and it did not occur to them that their reasoning would support bans on a host of parental behaviors. If, on the other hand, they truly would support the usurpation of parental autonomy by the government, then such thinking is truly dangerous.

I suspect that like many anti-smoking advocates with good intentions, they simply have not taken the time to carefully consider their position.

Friday, February 20, 2009

Car Driver Receives Ticket for Smoking in Car With Minor as Minor Lights Up Cigarette

The Globe and Mail is reporting that an Ontario driver was "nabbed" for smoking in a car with a minor under a recently enacted provincial law. While the driver was waiting to receive his $155 ticket, the minor got out of the car and lit up a cigarette. Since there is no law prohibiting minors from smoking, the girl was not doing anything illegal. However, the driver was charged with violation of the provincial law that is intended to protect minors from exposure to secondhand smoke.

The Rest of the Story

This story is a perfect illustration of the reason why I have opposed these types of laws. The state either has or has not a justification for intervening into parental autonomy to make decisions regarding the health risks to which their children are exposed. If the state is justified in telling parents that they cannot expose their children to the increased disease risk that comes with exposure to secondhand smoke in a car, then it is also justified (and even more appropriate) for the state to protect children from the even greater risks that come with exposure to smoking in the home and from active smoking itself.

Thus, if the government were truly interested in protecting minors from health risks, it would certainly want to prohibit parents from allowing their children to smoke. The driver in the above story would have been cited both for exposing the minor to secondhand smoke and for allowing the minor to smoke. In fact, the active smoking clearly represents a greater risk to her health than the secondhand smoke.

It is inconsistent for the government to isolate a single health risk to which many parents expose their children and to outlaw that particular risk, but to allow parents to expose their children to all other health risks. It suggests that something else is going on, other than simply a rational expression of health protection that is focused on what is in the best interests of the children.

The problem is precisely that once you agree that it is appropriate for the government to regulate parental decisions regarding health risks to which children are exposed, then there are a whole range of exposures - many which are much more hazardous than secondhand smoke - that should, to be rational and consistent, be regulated.

This story is an illustration not that the law isn't working, but that the law is inconsistent and somewhat irrational.

Thursday, February 19, 2009

Sir Richard Peto - Powerful and Renowned Anti-Smoking Scientist - Would Be Considered Denialist According to Diethelm and McKee

Dr. Geoffrey Kabat Describes "The New McCarthyism in Science" in his New Book

According to the reasoning in the article by anti-smoking advocates Pascal Diethelm and Martin McKee, which was published last week in the European Journal of Public Health, the renowned and highly-esteemed anti-smoking researcher - Sir Richard Peto - would be considered a denialist, on par with those who deny that the Holocaust occurred and unfit to participate in scientific discourse.

Sir Richard Peto was one of the most respected epidemiologists in the world and his research contributed heavily to what we know about the hazardous effects of cigarette smoking. He was a professor of Medical Statistics and Epidemiology at the University of Oxford and a Fellow of the Royal Society, recognized for his contributions to the field of meta-analysis. So he was widely recognized as an expert on the issue of causation.

As Dr. Geoffrey Kabat notes in his new book - Hyping Health Risks: Environmental Hazards in Daily Life and the Science of Epidemiology (New York: Columbia University Press, 2008) - Sir Richard Peto, in testimony before the House of Commons, argued that the risks of secondhand smoke are small and difficult to quantify. Because of this, he refused in his testimony to support the policy of banning smoking in public places.

This position, according to the argument provided by Diethelm and McKee, places Peto in the category of being a denialist, comparable to a Holocaust denier.

I had the opportunity to meet Sir Richard when I was working at the Office on Smoking and Health at CDC. I can assure you that he was an ardent anti-tobacco researcher who was adamant in his commitment to reducing tobacco-related diseases. He was hardly someone who would fit being called a denialist.

The Rest of the Story

In his book, Dr. Kabat explains what he calls "the new McCarthyism in science." He writes: "In this climate, in which so much as at stake -- both in terms of funding and professional advancement, as well as in terms of ideology and public health goals -- anyone who takes the science seriously and wants to assess its strengths and weaknesses is viewed as a threat to be neutralized. This situation has given rise to extraordinary attacks on the integrity of established scientists whose only documentable fault is to report findings in peer-reviewed journals and bring a critical (i.e., scientific) attitude to bear on the question of the long-term health effects of ETS exposure. What is most extraordinary is that these attacks on established and respected researchers rely exclusively on the imputation of guilt by association and on alleged conflicts of interest. Because of the highly polarized climate and the self-proclaimed righteousness of the tobacco control position, those who engage in such attacks are not required to supply any evidence of wrongdoing or fraud."

Dr. Kabat's description of the climate in tobacco control is accurate, based on my own experience. I have experienced exactly those extraordinary attacks that are based solely on the imputation of guilt by virtue of the direction, not the scientific merit, of my position on some issues. Because anti-smoking advocates have not been able to malign my character based on any proven association with the tobacco industry, they have resorted either to defamation (falsely accusing me of taking tobacco money or of simply lying) or to various insults and attacks (including accusations of having become mentally deranged).

In fact, Dr. Kabat discusses the tobacco control movement's reaction to some of my commentaries in his book. He writes: "Another figure who has taken an independent view of the reigning discourse concerning tobacco is Michael Siegel, a physician specializing in preventive medicine and a professor at Boston University. Siegel was a student of one of the prime movers behind the antismoking and clean air movements, Stanton Glantz of the University of California at San Francisco, and he has remained committed to the goal of protecting workers and others from exposure to tobacco smoke. However, a couple of years ago he decided that he had to speak out against what he saw as the increasingly objectionable tactics of the antismoking movement. These include misrepresenting the science on specific topics and an increasingly demagogic treatment of anyone who disagrees with their point of view. For the past two years, Siegel has written a blog entitled "The Rest of the Story: Tobacco News Analysis and Commentary," in which he tirelessly documents specific incidents of abuse or distortion and fills in the aspects of the question that have been ignored. His blog is a model of clarity and devotion to laying out all of the relevant evidence rather than citing selected or distorted facts to cudgel the "enemy." Some of the topics that Siegel has dealt with at length are the overstated claims of effects of smoking bans, the widely disseminated claim that as little as 30 minutes exposure to ETS can induce a heart attack in a nonsmoker, and the American Cancer Society's attack on Enstrom."

It is perhaps important to point out that Dr. Kabat is not approaching the issue as someone who does not believe that secondhand smoke has any adverse health effects or that smoking bans in public places are unjustified. He makes it clear that "my account of the ETS story has nothing to do with questioning whether exposure to secondhand tobacco smoke could cause some additional cases of lung cancer and other diseases in people who never smoked. ETS contains many of the same carcinogens and toxins present in mainstream tobacco smoke, and it is entirely biologically plausible that nonsmokers who are chronically exposed to high levels of ETS and those who have a constitutional susceptibility are at increased risk. In addition, secondhand tobacco smoke is associated with increased incidence of lower respiratory infections in infants and children, exacerbation of preexisting asthma, and other effects. Nor do I have any objection to the most stringent restrictions on smoking -- to my mind they are entirely justified and should have been enacted long ago. The only question at issue here is whether on a topic as important and as sensitive as ETS all of the science should be allowed to be heard, or whether it is acceptable to select and slant the science in order to justify a particular policy."

Dr. Kabat provides a very nice treatment of the issue of scientific McCarthyism in tobacco control and unfortunately, based on my experience, his insights and accounts ring true.

Tuesday, February 17, 2009

Researchers of New Study Link Secondhand Smoke With Dementia, But Do Results Support that Conclusion?

A new study published in the British Medical Journal (BMJ) concludes that secondhand smoke exposure is associated with decreased cognitive function among middle-age adults (see: Llewellyn DJ et al. Exposure to secondhand smoke and cognitive impairment in nonsmokers: national cross sectional study with cotinine measurement. BMJ 2009; 338:b462).

The manuscript reports the results of a cross-sectional study which correlates saliva cotinine levels and cognitive function scores on a battery of neuropsychological tests among a sample of 4809 adults ages 50 and older in the Health Survey for England and English Longitudinal Study of Ageing. Cognitive impairment was defined as performance in the lowest 10% of combined scores on the neuropsychological tests. The primary result of the study was that adults in the highest quartile of cotinine exposure were significantly more likely to have cognitive impairment.

The variables controlled for in the study included "age, sex, ethnicity, education (highest educational qualification), manual occupational class, fourths of net non-housing wealth (measured in pounds sterling), smoking history (never smokers, former smokers who stopped smoking less than 10 years ago, former smokers who stopped smoking 10 years or more ago), obesity (body mass index >29.9), alcohol consumption (g/day), physical inactivity (participating in sport or physical activity less than once a month), and depressive symptoms (more than three symptoms on the eight item version of the Center for Epidemiological Studies depression scale)."

The results of the study are summarized as follows: "Compared with the lowest fourth of cotinine concentration (0.0-0.1 ng/ml) the odds ratios (95% confidence intervals) for cognitive impairment in the second (0.2-0.3 ng/ml), third (0.4-0.7 ng/ml), and highest fourths (0.8-13.5 ng/ml) were 1.08 (0.78 to 1.48), 1.13 (0.81 to 1.56), and 1.44 (1.07 to 1.94; P for trend 0.02), after adjustment for a wide range of established risk factors for cognitive impairment. A similar pattern of associations was observed for never smokers and former smokers."

The article concludes: "our results provide new evidence to suggest that exposure to secondhand smoke may be associated with increased odds of cognitive impairment."

The newspaper coverage of the study reported that secondhand smoke is linked to dementia. For example, the headline of one article read: "Secondhand Smoke Linked to Dementia: Exposure May Increase Risk by 44%, Researchers Say." In this article, a study author is quoted as stating: "There is an association between cognitive function, which is often but not necessarily a precursor of dementia, and exposure to passive smoking. ... We know that active smoking is bad -- being a smoker is bad for your health and increases your risk of Alzheimer's. This study suggests that this is the same for passive smoking."

Also according to this article: "Maria Carrillo, director of medical and scientific relations for the Alzheimer's Association, said this study offers more evidence of the dangers of secondhand smoke and the risk for dementia. Smoking is already recognized as a risk factor for Alzheimer's, and the risk can be extended to exposure to secondhand smoke, she said. 'There are findings that secondhand smoke can be just as detrimental as smoking itself.'"

In another article, a study author was quoted as stating: "Our results suggest that inhaling other people's smoke may damage the brain, impair cognitive functions, such as memory, and make dementia more likely."

The Rest of the Story

The findings of this study are provocative, but in a cross-sectional study such as this one, they should not be viewed as conclusive. The problem is that people at the highest quartile of secondhand smoke exposure are very different in a number of ways from people at the lowest quartile of exposure and there are reasonable alternative explanations for why that subsample might be expected to have lower levels of cognitive function on neuropsychological tests.

Among the differences that one would expect between groups at the highest and lowest levels of secondhand smoke exposure that were not adequately controlled for in the study are baseline levels of cognitive function, parental smoking, parental education, social class, and marijuana and other drug use. It could be reasonably hypothesized that those with higher exposure to secondhand smoke are more likely to have had poorer baseline cognitive function, greater exposure to parental smoking, lower levels of parental education, lower social class, and increased drug use - all of which could serve as alternative explanations for the lower cognitive function observed in this cross-sectional study.

To derive conclusive evidence of a causal link between secondhand smoke and reduced cognitive function, one would have to conduct a longitudinal study, in which decreases in cognitive function over time were shown to occur among individuals with higher secondhand smoke exposure.

The problem here is not the study itself, but the way the researchers appear to have communicated their findings to the media. It appears that they gave the media a very strong impression that their study had concluded that secondhand smoke is a cause of cognitive dysfunction and dementia, when it really just identified an association which needs to be assessed in further studies - especially longitudinal ones.

In addition, it appears that the media were given the impression that these data suggest a link between secondhand smoke and dementia. But dementia was not studied at all - the link is between secondhand smoke and lower levels of cognitive function, which may have no relation at all to the risk of developing dementia.

The Alzheimer's Association also appears to have taken the finding too far, having concluded that there is a causal link between secondhand smoke and Alzheimer's disease.

Monday, February 16, 2009

Anti-Smoking Advocates Reaffirm their Contention that All Who Don't Believe Secondhand Smoke Causes Lung Cancer are Comparable to Holocaust Deniers

In their reply to my response to their article in which they assert that scientists who have challenged the causal connection between secondhand smoke and lung cancer are comparable to Holocaust deniers, anti-smoking advocates Paschal Diethelm and Martin McKee reiterate this contention.

I had asserted that Diethelm and McKee's published article was arguing that anyone who fails to accept the conclusion that secondhand smoke causes lung cancer is a denialist on the order of those who deny that the Holocaust occurred. In their reply, Diethelm and McKee make no effort to soften or qualify their assertion or to suggest that I was over-interpreting their claim. Instead, they reiterate that they are indeed stating that those who don't accept that the small increased relative risk for lung cancer associated with secondhand smoke exposure reflects a causal relationship are denialists comparable to those who deny that the Holocaust happened.

They write: "We are not suggesting that those whom we define as denialists should be censored. Far from it. We simply propose that, as they established ground rules for debate that are not based on openness to evidence and scientific principles, we should recognise this and frame our arguments accordingly. Where there is genuine scientific controversy we, of course, believe in the need for informed and open debate using scientific evidence. However, this does not apply when one side uses highly selective evidence to suggest that there is genuine scientific uncertainty when this is not the case. Seemingly inadvertently, Professor Siegel makes our point. The 30% increase that he quotes is obtained from studies that compare the risk of disease in spouses of smokers and non-smokers, a weak study design (we will not rehearse the enormous effort by the tobacco industry to discredit even that research or its covert work to promote so-called “good epidemiological practice” that would dismiss relative risks of less than 2 as being unreliable). However, where direct measures of exposure are used (cotinine), the risk is substantially greater (relative hazard for coronary heart disease and stroke 1.57 (95% CI 1.08 to 2.28)). Yet this is only the beginning. As we have shown previously, the tobacco industry has long known (from its own secretly conducted animal experiments) that “room aged sidestream smoke” is much more toxic, volume for volume, than directly inhaled smoke, a finding that provides some explanation for the now common finding of rapid declines in coronary heart events following introduction of smoking bans."

Jacob Sullum nicely summarizes this discussion on's Hit & Run blog. Sullum states: "Writing in the European Journal of Public Health, anti-smoking activists Pascal Diethelm and Martin McKee liken people who question the health hazards of secondhand smoke to people who do not believe HIV causes AIDS, people who think the world was created 6,000 years ago, people who are not persuaded that smoking causes cancer, people who maintain that climate change has "nothing to do with man-made CO2 emissions," and people who deny that the Holocaust happened. They say all are dishonest or deluded "denialists," trying to create controversy where there is no legitimate basis for it. Michael Siegel, an anti-smoking activist who agrees that prolonged exposure to secondhand smoke increases the risk of lung cancer and heart disease but questions some of the more extreme claims made by smoking ban advocates, likens Diethelm and McKee to religious fanatics. He has a point:

"Diethelm and McKee have endangered the integrity of public health by comparing those who challenge the conclusion that secondhand smoke causes heart disease and lung cancer with those who deny the Holocaust. As a primarily science-based movement, public health is supposed to have room for those who dissent from consensus opinions based on reasonable scientific grounds. To argue that those who fail to conclude that the small relative risk for lung cancer of 1.3 among persons exposed to secondhand smoke is indicative of a causal connection are comparable to Holocaust deniers is to turn public health into a religion, where the doctrines must be accepted on blind faith to avoid being branded as a heretic." ...

"In reply, Diethelm and McKee reject Siegel's analogy while hanging on to theirs, saying they are not advocating censorship of denialists. Of course, Siegel never said they were. Instead they are advocating branding, ad hominem attacks, and blithe dismissal."

The Rest of the Story

I was very surprised by Diethelm and McKee's reply. I was expecting them to soften the tone of their assertion or to qualify it in some way. I was also wondering whether they might back off somewhat from their contention that everyone who questions the causal link between secondhand smoke and lung cancer is the equivalent of a Holocaust denialist.

To my surprise, the authors not only reiterated their assertion that all those who question the link are denialists; they also strengthened their assertion by arguing that the use of selective data characterizes someone as a denialist who does not warrant a legitimate role in scientific discourse.

But most ironically, Diethelm and McKee themselves use selective data to argue that smoking bans result in an immediate reduction in heart attacks, which they say demonstrates that secondhand smoke causes heart disease. Specifically, they cite the "common finding" rapid declines in heart attacks following smoking bans as supporting their argument that the link between secondhand smoke and heart disease is undeniable.

Interestingly, if we used Diethelm and McKee's own criteria, we would have to conclude that they are denialists not worthy of scientific discourse because they selectively cite studies which have found rapid declines in heart attacks following smoking bans, yet they ignore both published and population-based data which fail to show any decline in acute cardiac events following smoking bans.

In fact, the one study that they do cite failed to find any significant effect of the smoking ban on heart attacks in Italy (see: Cesaroni G, Forastiere F, Agabiti N, et al. Effect of the Italian Smoking Ban on Population Rates of Acute Coronary Events. Circulation 2008). The data clearly show that the decline in heart attack rates among adults in the two age groups studied began prior to the implementation of the smoking ban. Thus, it is evident that the decline is not attributable to the smoking ban.

Take a look at the data for yourself:

A. Age 65-74

From 2003 to 2004 (prior to the smoking ban), the heart attack rate declined from 7.86 to 7.39, a drop of 6.0%.

From 2004 to 2005 (first year of the smoking ban), the heart attack rate declined from 7.39 to 6.95, a drop of 6.0%.

In other words, the decline in the heart attack rate from 2003 to 2004 was exactly the same as the decline from 2004 to 2005.

B. Age 35-64

From 2002 to 2003 (prior to the smoking ban), the heart attack rate declined from 2.13 to 1.95, a drop of 8.5%.

From 2004 to 2005 (the first year of the smoking ban), the heart attack rate declined from 1.92 to 1.80, a drop of 6.3%.

In other words, the observed decline in the heart attack rate one year prior to the smoking ban was actually greater than the decline in the heart attack rate after the smoking ban.

The average decline in the heart attack rate for the two year period preceding the smoking ban (2002 to 2004) was 4.9%.

The decline in the heart attack rate for the first year following the smoking ban was 6.4%.

Thus, one can see that the decline in the heart attack rate in this age group after the smoking ban was comparable to the decline in the heart attack rate in this age group before the smoking ban.

Once again, these data clearly do not support the conclusion that the smoking ban resulted in a sudden drop in the heart attack rate. If anything, these data document that the decline in the heart attack rate in this age group was about the same post-ban as it was pre-ban.

In light of these data, I find it impossible and highly invalid to conclude that the smoking ban resulted in the observed decline in heart attacks from 2004 to 2005. A more likely, and certainly plausible, explanation is that there was already a trend of declining heart attack rates and that this trend simply continued from 2004 to 2005.

What Diethelm and McKee are doing, then, is selectively citing data which they argue support their position, when in fact, those very data refute their position. In addition, they are leaving out data from published studies which demonstrate that the smoking ban in England had very little, if any, immediate effect on heart attacks as well as from population-based analyses (both in the U.S. and Scotland) which also demonstrate no significant effect of smoking bans on acute coronary events.

While I believe that Diethelm and McKee are not only wrong in their conclusion that smoking bans lead to rapid, dramatic reductions in heart attacks but also that the scientific basis for their conclusion is very shaky, I would never call them denialists for taking that position. It is simply an opinion. I disagree with their opinion and believe it is scientifically shoddy, but this doesn't make them denialists. At very worst, it just makes them wrong.

Or maybe I am wrong. But either way, it's not a question of one or the other of us being a denialist. It's simply a scientific debate.

Furthermore, I could also point out that even if it were true that smoking bans did lead to dramatic reductions in heart attacks, that would not necessarily demonstrate that secondhand smoke causes heart disease. The effects of these smoking bans could well be due to a decrease in active smoking, rather than to a decline in secondhand smoke exposure.

In summary, I strongly agree with Diethelm and McKee that secondhand smoke causes lung cancer and heart disease. I strongly disagree with Diethelm and McKee that smoking bans lead to dramatic, immediate reductions in heart attacks. Where does that leave us? It leaves us with a scientific debate. I respect their opinions in both cases, even though I happen to disagree with one of them. In no way are they denialists and despite what I feel is their selective use of particular data to support their position on smoking bans and heart attacks, I would never accuse them of being denialists. Their position, in fact, has nothing whatsoever to do with their character, which in my mind is simply not a part of the discussion.

For Diethelm and McKee, as for many in the modern-day anti-smoking movement, tobacco control is an ideology, rather than a science-based public health movement. If you disagree with the ideology, you are a denialist and have disqualified yourself from participating in the "scientific discourse." But the truth is that there is no longer any "scientific" discourse, because it is now an ideology where any studies reporting favorable findings are "good science" and any studies reporting unfavorable findings are automatically indicative of scientists of poor character.

As I have questioned the causal connection between smoking bans and immediate reductions in heart attacks, I am apparently of poor character.

Thursday, February 12, 2009

Response to Article Comparing Challengers of Secondhand Smoke Conclusions to Holocaust Deniers Published in European Journal of Public Health

On Monday, I reported here that last week, the European Journal of Public Health published an article in which two anti-smoking advocates - Pascal Diethelm and Martin McKee - accused all those who do not accept the causal relationship between secondhand smoke and lung cancer/heart disease as being denialists comparable to those who deny the existence of the Holocaust.

Diethelm and McKee argue that the paper by Drs. James Enstrom and Geoffrey Kabat - which failed to find evidence of a causal relationship between secondhand smoke and lung cancer or heart disease - and its use by various groups is comparable to Holocaust denial.

As they write: "Another [example of denialism] is a paper published by the British Medical Journal in 2003, later shown to suffer from major flaws, including a failure to report competing interests, that concluded that exposure to tobacco smoke does not increase the risk of lung cancer and heart disease. This paper has been cited extensively by those who deny that passive smoking has any health effects, with the company Japan Tobacco International still quoting it as justification for rejecting ‘the claim that ETS is a cause of lung cancer, heart disease and chronic pulmonary diseases in non-smokers’ as late as the end of 2008. Denialists are usually not deterred by the extreme isolation of their theories, but rather see it as the indication of their intellectual courage against the dominant orthodoxy and the accompanying political correctness, often comparing themselves to Galileo."

Today, the European Journal of Public Health published my response to the article, which I entitled "Danger: Public Health Could Become a Religious Movement."

In the response, I write: "Diethelm and McKee have endangered the integrity of public health by comparing those who challenge the conclusion that secondhand smoke causes heart disease and lung cancer with those who deny the Holocaust. As a primarily science-based movement, public health is supposed to have room for those who dissent from consensus opinions based on reasonable scientific grounds. To argue that those who fail to conclude that the small relative risk for lung cancer of 1.3 among persons exposed to secondhand smoke is indicative of a causal connection are comparable to Holocaust deniers is to turn public health into a religion, where the doctrines must be accepted on blind faith to avoid being branded as a heretic." ...

"Diethelm and McKee appear to be basing their assessment that secondhand smoke "dissenters" are "denialists" not on the reasonableness of the scientific arguments, but on the position of these arguments. This is a dangerous proposition which threatens the integrity of public health by turning it into a purely ideological movement, rather than a scientific one. Clearly, no dissent is allowable from the doctrines of tobacco control in Diethelm's and McKee's perspective. This perspective brands hundreds of reputable scientists throughout the world as denialists, no different from Holocaust deniers. While I disagree wholeheartedly with these scientists, I will stand up for their right to express their dissenting opinions without having their characters assassinated because of the direction, rather than the scientific reasonableness, of their positions."

The Rest of the Story

There are many reputable scientists who have challenged the conclusion that secondhand smoke causes heart disease and lung cancer. While I disagree with their interpretation of the scientific evidence, I would never suggest that their opposing opinion is denialism and that it is comparable to Holocaust denial.

Apparently, Diethelm and McKee view the anti-smoking movement as a religion. You have to accept the claims on blind faith and if you don't, you are guilty of heresy. Even worse, you will be publicly attacked and have your character maligned in an attempt to silence you by blacklisting you out of public discourse on the issue.

Diethelm and McKee criticize the paper by Enstrom and Kabat on the basis that it suffers from major flaws. This is hardly grounds for calling the authors denialists. If we used that criterion to define denialism, most researchers would be considered denialists. Most of us - including myself - have from time to time used flawed methodology in a study. By this criterion, I would have to argue that many anti-smoking researchers are denialists.

The loss of reason and perspective among many in tobacco control is striking to me. It appears that there are no shades of grey in the movement any more. Everything is black and white. Either you support the conclusion that secondhand smoke causes chronic disease or you are a denialist, akin to those who deny the Holocaust. Either you agree that smoking bans result in a dramatic decrease in heart attacks or you are akin to those who deny that AIDS is caused by the HIV virus.

No dissent is allowed. Even reasonable (though possibly incorrect) scientific arguments cannot be brought to bear to challenge scientific conclusions that are favorable to tobacco control.

Tobacco control is becoming a religious-like movement which is guided by ideology and not science. Hopefully, this trend will not spread to other areas of public health.

Wednesday, February 11, 2009

Article Points Out Folly of Using Cigarette Taxes to Fund Children's Health Insurance

An article on the KXMB news web site (Bismarck, ND) points out a new concern that the government has to worry about, now that Congress has tied the financial solvency of the SCHIP (children's health insurance) program to continued cigarette consumption. "Cigarettes To Cost $10/Pack In New York, Government Worries About Too Few People Smoking," the article warns.

Noting that the price of cigarettes in New York City will be over $10 per pack, which will drive many to quit or at least cut down on their smoking, the article notes that these decreases in cigarette consumption will lower the tax revenues in future years, thus threatening the solvency of the SCHIP program and ensuring that children will need to be kicked out of the program if the government doesn't do something to maintain current levels of cigarette consumption or find alternative revenue sources.

But, notes the article, if the government needs to find alternative revenue sources anyway than why not identify those sources now to create a fiscally sustainable program, rather than create the appearance of a solvent program, which appears to be somewhat deceptive.

According to the article: "While the idea of smokers quitting their habit may seem like a good thing to some ... what’s problematic is that if people quit smoking tobacco taxes are never going to fund the CHIP expansion. ... That’s why the CHIP bill is such a fraud. Anybody with common sense knew that taxing tobacco use into extinction is not a sustainable way to fund government-provided health care. The taxes are too high, and the tax base is too small. ... the point wasn’t ever to have tobacco users fund the bill inevitably. The point was just to get the foot of government health care expansion in the door. Once they had the CHIP expansion in place they knew full well that it would never go away, even if tax revenues from tobacco users did. So while we Americans were sold on the idea of getting government-provided health care at the expense of a not-so-sympathetic demographic like smokers the reality is that we’re all going to end up paying for CHIP as soon as the smokers finally give up their freedom to smoke in the face of blatant economic prohibition. It was a bait-and-switch from the get-go."

The Rest of the Story

I really hate to admit it, but I think this article has it exactly right. By definition, tying children's health insurance to cigarette revenues means that the program is in trouble if cigarette consumption falls. Sustained levels of smoking are necessary to keep children insured. The only way to maintain the program in the future is either to kick children off the rolls or to find an alternative, sustainable revenue source. But if there is a need to find a sustainable revenue source in the future, then why not find one now. If there is not a consensus about how to find such a source in the future, then the program may really be in jeopardy.

It's not like the government's economic woes are not great enough. Now we have to worry about the possibility that our budgets are going to be further hampered by, and the health coverage of our children hampered by, the fact that people might quit or cut down on their smoking.

(Thanks to Harry for the tip).

IN MY VIEW: FDA Tobacco Legislation Would Kill Grassroots Tobacco Control Movement, But Alternative Legislation Would Save It

While my criticism of the FDA tobacco legislation and my support for alternative legislation that would approach the tobacco problem in a different way (from the demand side rather than the supply side) have been based largely on an analysis of the likely public health effects of each approach, it is also worth considering the implications of these proposals for the tobacco control movement itself. After all, over the long term it is community-based actions by tobacco control practitioners and community advocates that will have the greatest effect on tobacco use, as it has been for the past four decades.

If there is one lesson I have learned from 23 years of practice in tobacco control, it is that the greatest gains have been made by tireless grassroots activists and communities working day-to-day at the front lines, not by grand public policies. Without a doubt, the most successful stories in tobacco control have been those derived from comprehensive, statewide tobacco control programs, such as those in California and Massachusetts, which have not only utilized state-of-the-art media campaigns as air cover, but which have also made it a priority to fund local community groups and coalitions as the ground attack (sorry for the war analogy, but it seems to work).

The local programs are essential not only because grassroots, community activism is what most effectively creates change, but also because the focus on the local level allows programs to be targeted to particular populations, thus ensuring - for example - that communities of color are not left behind in generic tobacco control plans and that these programs serve not only to reduce tobacco use but to reduce disparities in tobacco use as well. (See my 2004 article from the American Journal of Public Health for an example of how tobacco control programs may increase health protection overall, but actually increase rather than decrease health disparities -- Skeer M, George S, Hamilton WL, Cheng DM, Siegel M. Town-level characteristics and smoking policy adoption in Massachusetts: Are local restaurant smoking regulations fostering disparities in health protection? Am J Public Health 2004; 94:286-292).

To me, the unsung heroes of tobacco control have been those who have worked at the front lines and never brought attention to themselves, but focused all of their efforts on the mobilization and empowerment of communities to take action for themselves: Makani Themba, Sharyn Sutton, the Reverend Michael Crosby, the Reverend Jesse Brown, and the Reverend Hessie Harris come immediately to mind.

And some of the greatest effects on tobacco use have come from the most basic social activism - communities rising up together to fight efforts to addict their members: arguably, the uprising against X cigarettes and later Uptown cigarettes had a lasting effect on reducing the appeal of smoking initiation among African American youths -- an effect which did not notably wane until the mid- to late-1990s.

The profound changes in social norms regarding smoking in the past decade are largely due to community-based efforts to protect nonsmokers from secondhand smoke through workplace, casino, bar and restuarant smoking bans. My research has shown that these local policies - resulting from local grassroots activism - have a substantial effect both on smoking-related social norms and on smoking initiation.

Thus, any national strategy to reduce tobacco use and protect the public's health must be viewed not only in terms of direct protection provided to the public, but also in terms of the capacity of communities to become engaged in and successfully practice tobacco control.

The Proposed FDA Tobacco Legislation Will Decimate Grassroots Tobacco Control

If the FDA legislation is enacted, especially in its current form, it will essentially destroy the grassroots tobacco control movement as we know it. I have already provided a detailed analysis of the reasons for this. Briefly, if the FDA asserts jurisdiction over cigarettes, there will be a perception on the state level that there is no more need for tobacco control action. In particular,I think it will become impossible to obtain state funding for tobacco control if the FDA legislation is enacted. Efforts to get state legislatures to allocate tobacco settlement monies for tobacco control are already quite dismal. If the federal government is charged with the major responsibility for addressing the tobacco problem, it will be impossible to convince state legislators that their states need to allocate a substantial amount of funding (that could be used for other purposes) to tobacco control. This is especially true now, when state budgets are already strapped.

It is unlikely that we will see again the successful program models such as in California and Massachusetts, where state cigarette excise tax increases are used to fund comprehensive statewide tobacco control programs. If cigarette taxes are increased, the revenues will almost certainly be used to fund unrelated programs, such as health care, building roads and bridges, etc. If the FDA tobacco legislation is enacted, there will be zero incentive for state governments to continue to take on the tobacco issue with any seriousness. The legislation will permanently displace tobacco control activity from the state to the federal level. In short, it will decimate community capacity in tobacco control.

On top of this, the FDA legislation would all but put an end to tobacco litigation. The legislation directly preempts state legislation and legal claims related to tobacco product standards, premarket approval, adulteration, misbranding, labeling, registration, good manufacturing standards, or modified risk tobacco products. But more importantly, by placing cigarette production and marketing under the FDA's jurisdiction, the legislation would all but preclude punitive damages in litigation, thus taking away any incentive for future tobacco litigation.

Enactment of the FDA legislation would also provide cigarette companies with a very strong argument to shield themselves from any significant punitive damages in existing litigation. They could argue, quite correctly, that they are now under the jurisdiction of the FDA. Thus, there is no need to impose substantial punitive damages upon them as an incentive for them to change their behavior. I believe that the unavailability of punitive damages would decimate most existing tobacco litigation.

The Alternative National Tobacco Control Legislation Would Allow Community Tobacco Control to Flourish

In contrast, the alternative national tobacco control legislation would specifically support a new (in many cases) infrastructure that would allow grassroots, community-based tobacco control activism to flourish. The proposal would use revenues from penalties to tobacco companies based on youth smoking to fund a national tobacco control campaign as well as campaigns in all 50 states. Much of the funding would be used for state-of-the-art media campaigns that would provide (sorry about this...) the air cover for the ground attack of community-based coalitions and groups. Funding would specifically be allocated towards communities of color, representatives of which would be requisite partners in all aspects of program planning and revenue allocation. Targeted initiatives to support community development would be a key part of the strategy. Elimination of disparities within population subgroups would stand side-by-side with overall population reductions in tobacco use as dual goals of the program. The potential role of harm reduction (no, I don't persume to have any answers) could be discussed in an informed, inclusive manner to determine the appropriate nature, scope, and targeting of particular harm reduction messages.

The presence of community coalitions would allow local and state-level tobacco legislation to continue on as well. Legislation related to tobacco product standards, premarket approval, adulteration, misbranding, labeling, registration, good manufacturing standards, or modified risk tobacco products would still be allowed. States, for example, could decide to eliminate menthol from cigarettes (New Jersey recently considered a bill that would have eliminated cigarette flavorings, but as expected, menthol was exempted in the legislation). Fire-safe cigarette standards could also continue to be enacted. And of course, the movement to promote smoke-free workplaces for all employees in the nation would receive a huge boost. This is especially important, because the safety of working conditions are becoming a huge source of disparity in health protection between people living in different regions of the country.

You can call this back to basics. You can call this old school if you want to. But the point is: it works. And frankly, it's the only intervention that has ever been demonstrated to work (other than increasing the federal cigarette tax, which has already been done in 2009 and is probably a no-go for the remainder of this Congressional session).

On the McCarthyistic Element in Tobacco Control: No Wrongdoing by Any Individual Advocate, but a McCarthyist Element Among the Movement as a Whole

In light of Monday's post, in which I argued (in response to two recent journal articles that have called those who disagree with the scientific positions of anti-smoking groups "denialists") that there is a McCarthyistic element present in the modern day anti-smoking movement, I wanted to take this opportunity to further explain my position and thinking.

First, I am not calling anyone in tobacco control a McCarthyist. I'm arguing that the movement as an entity has acquired an element of McCarthyism in its actions. That doesn't mean that any particular individual is guilty of wrongdoing. But what it means is that the climate as a whole - the groupthink mentality in the movement - has fostered an environment in which these types of tactics can flourish. And no, not every organization is using them. The problem is that when a few organizations use them and they are not publicly condemned and when those few who do condemn those actions are defamed publicly, then those tactics do in fact become the de facto characterizing position of the movement as a whole. While only a few groups might be using these types of tactics, virtually all groups in tobacco control are supporting actions like this by remaining silent and failing to condemn this approach.

Second, I think we need to remind ourselves of exactly what ASH-UK was saying in its published article. It attacked Michael Blastland and accused him of being a tobacco industry hack who was not expressing his sincere opinion but was being orchestrated by the tobacco industry. With respect to Blastland and others like him who have challenged the notion that the Scotland smoking ban led to a dramatic decline in heart attacks, Dockrell wrote: "While AIDS dissidence was largely an indigenous phenomenon, tobacco dissidence is the carefully conceived creature of tobacco industry lobbyists."

So the tactic seems quite clear: ASH-UK is trying to discredit Blastland and to essentially silence him by taking him out of the discourse on this issue through tying his name and character to Big Tobacco, whether that is true or not. No evidence was presented in the article to support the contention that Blastland's character is in question because of his financial ties to tobacco companies. But that is the insinuation that the article is making.

In other words, ASH UK is publicly maligning Blastland's character, not merely refuting his scientific arguments. That's the key point I think people need to realize.

Moreover, this tactic in tobacco control is a common one. I am not picking this one particular anecdote and trying to use it to make a broad and sweeping statement about the movement as a whole. It is a good illustration, but just one of numerous examples of the use of these tactics.

In fact, as I noted, just last week, another published article used the same tactic to try to discredit those who argue that the scientific evidence is not sufficient to conclude that secondhand smoke causes heart disease and lung cancer. Diethelm and McKee compared such individuals with Holocaust deniars.

I would note that there are many prominent scientists who fit into the category that Diethelm and McKee argue essentially represent Holocaust denialists. These include Dr. James Enstrom, Dr. Geoffrey Kabat, Dr. Elizabeth Whelan, and a panel of reviewing scientists for the American Council on Science and Health. At worst, these scientists may simply be wrong. Or I may be wrong. But to put either of us in the same category as those who deny that the Holocaust occurred is despicable.

This is how serious the allegations are that are being leveled in these two published papers. And I wouldn't be so critical of the accusations if they were simply careless or hasty insults lobbed angrily during the course of a heated blog discussion. The point is: these accusations are well thought-out, carefully planned ones which were in print for many months and presumably reviewed many times. Presumably, what they said was precisely what they meant to say. So the accusations take on more meaning.

Third, I have personally experienced personal attacks and treatment from the tobacco control movement which can accurately be described as being McCarthyistic in nature. In a previous post, I recount some of these experiences. For example, I was expelled from a tobacco control list-serve because they didn't like my opinions. I was expelled from another list-serve because they also didn't agree with my opinions and wanted to censor me. I also received personal attacks simply for expressing my opinion that perhaps the science showing that smoking bans cause immediate, dramatic reductions in heart attacks isn't as strong as was being purported. There were also public insults.

The bottom line is that dissent could not be tolerated in the movement and I had to be blacklisted from public discourse in order to discredit and silence me. This doesn't mean that any particular individual is a McCarthyist or that every organization or even many organizations in tobacco control are engaging in such tactics. But what it does mean is that the climate within the tobacco control movement is such that it is conducive to these types of tactics. While no particular individual is to blame and while the use of these tactics may not be widespread among many groups, the acceptance of such tactics by the movement leads to the conclusion that this is the de facto characterization of the movement.

Fourth, I am not the first to argue that the tobacco control movement contains an element of McCarthyism.

Another example of what might be termed "scientific McCarthyism" is the American Cancer Society's (ACS) attack on Dr. James Enstrom. The ACS formally accused Enstrom of scientific misconduct because it didn't like his conclusions regarding the relationship between secondhand smoke and chronic disease risk. This threatened Dr. Enstrom's career and could potentially have lost him his job. No grounds for scientific misconduct were presented, however. And none were found by the University of California after an investigation.

In recounting this experience in the journal Epidemiologic Perspectives & Innovations, Dr. Enstrom writes: "Being able to distinguish between real and implied scientific misconduct is important to the integrity of science in general and to the integrity of individual scientists in particular. Falsely accusing an honest scientist of scientific misconduct is just as wrong as scientific misconduct itself. Implying that an honest scientist has committed scientific misconduct because he has published unpopular findings or has used an unpopular funding source is wrong and falls under the category of “scientific McCarthyism”."

Dr. Kenneth Rothman warned about McCarthyism in science which could arise when science was judged based on the presumed character of the individual rather than on the validity of the science itself (see: Rothman KJ. Conflict of interest: the new McCarthyism in science. JAMA 1993; 269:2782-2784.). Rothman predicted in his commentary that focusing on the scientist rather than on the merits of the science could lead to a “new McCarthyism in science.” He argued that every piece of scientific work and criticism should be judged solely on its scientific merit, and that any attacks on these works should be science-based, not ad hominem attacks.

But this is exactly what is happening in tobacco control, and exactly what the two articles I reviewed on Monday demonstrate. They seem to fit perfectly into what Rothman called McCarthyism in science.

I would love to be able to, upon further reflection, retract my opinion that the tobacco control movement exhibits elements of scientific McCarthyism. But unfortunately, such a retraction is not warranted. If anything, I think I am being generous in opining that there is no ill-will among individuals or groups in the movement and that the element of scientific McCarthyism that has arisen is merely a result of the climate and groupthink mentality which has allowed that element to arise and flourish.

Tuesday, February 10, 2009

My Commentary on the ASH-UK Article on Tobacco Dissidence Appears on Medical News Today

Medical News Today was kind enough to publish my commentary regarding ASH-UK's press release which appeared on its site promoting the recent article by ASH in the Expert Review of Pharmacoeconomics and Outcomes Research.

Article Provides Convincing Explanation of Why Scotland Heart Attack - Smoking Ban Study is Invalid

An article by Robert Wagner published over at Christopher Snowdon's Velvet Glove Iron Fist provides a novel and very convincing explanation for why the results from the Pell et al. study published in the New England Journal of Medicine are so different from population-based results for all of Scotland and why the study conclusions are invalid.


Pell et al. compared the number of admissions for acute coronary syndrome in nine hospitals in Scotland (representing 63% of admissions for acute coronary syndrome in the country) during the 10-month period prior to the smoking ban and the corresponding 10-month period the following year. The number of admissions declined from 3235 to 2684, a drop of 17%.

This 17% drop was compared to the trend in overall hospital admissions in all of Scotland for acute coronary syndrome during the preceding 10 years. According to the study, "the trend during the 10 years before legislation was a 3% mean annual reduction, with a maximum reduction of 9% in 2000."

Because the observed 17% reduction in admissions for acute coronary syndrome was much higher than the annual reduction during the 10 previous years and exceeded the highest annual decline between any two years, the study concluded that the observed reduction is attributable to the smoking ban.

Importantly, acute coronary syndrome was defined differently in the two time periods that were compared. In Pell et al.'s study of nine hospitals, acute coronary syndrome was defined as any detectable levels of cardiac troponin in the blood. In the population-based data for all of Scotland, acute coronary syndrome was defined by a physician's diagnosis based on the conclusion that the patient suffered either a heart attack or unstable angina. While troponin levels may have been used in the diagnosis, the troponin levels were not definitive in making the diagnosis.

The Rest of the Story

The key point that Wagner makes is that cardiac troponin is not 100% specific for acute coronary syndrome. There are a number of conditions not related to acute coronary syndrome that can cause low levels of troponin in the blood. But high levels are specific to heart damage. Thus, clinicians usually set a threshold level - a level high enough to rule out non-cardiac causes of troponin in the blood.

As Wagner explains: "The troponin test came into common usage in 2000, replacing earlier tests such as creatinine (CK) which were less specific to the heart muscle. A major complaint about troponin is that it delivers too many false positives at low levels. Many conditions cause small concentrations of troponin in the blood; only heart muscle damage causes large concentrations (with a few rare exceptions). The threshold level for a positive reading must be set high enough to eliminate the false positives. Setting the threshold at zero, as Pell did, is scientific nonsense, because it opens the door to MANY false positives."

"The Joint European Society of Cardiology/ACC Committee for the Redefinition of Myocardial Infarction has recommended that an increased concentration of cTn be defined as a measurement exceeding the 99th percentile of cTn concentrations observed in a healthy reference group."

So basing a diagnosis of acute coronary syndrome on ANY detectable level of cardiac troponin - as Pell et al. did - is going to include not only patients with acute coronary syndrome but also a substantial number of false positives.

But here is the clincher: as the cardiac troponin test is relatively new, it has undergone changes over time. New generations of the test have increased specificity for heart damage. Thus, the proportion of false positive tests is decreasing over time.

What does this mean for the Pell et al. study? What it means is that it is quite possible that a major reason for the 17% decline in admitted patients with suspected heart disease who have detectable troponin levels is that the troponin test became more specific and decreased the number of false positives.

In other words, patients who previously might have had a detectable troponin level because of non-cardiac causes would now (in the next generation of test) have a non-detectable level because of improved test specificity.

Wagner does not posit that the increased specificity of the troponin assay is the sole reason for the 17% decline in acute coronary syndrome cases observed in the Pell et al. study. He argues that the increased specificity of the test explains a portion of the decline. In particular, he argues that the changes in the test explain that portion of the 17% decline that exceeds the observed population-based decline in acute coronary syndrome cases, which was about 7%. Thus, there was an "appearance" of an additional 10% decline in acute coronary syndrome cases due to a decline in false positives.

Now, one might ask whether it is possible that the decline in cases of detectable cardiac troponin was so high that it could not be explained by the combination of declining secular trends in heart attacks and declining false positive tests, and thus implicating a role for the smoking ban. The answer is that the only way to determine this would be to compare the decline in cases of detectable cardiac troponin observed in Scotland to that in some comparison country or location without a smoking ban. However, Pell et al. failed to conduct such a comparison. Thus, their study cannot assess whether to smoking ban played any role at all in the observed 17% decline in cases of detectable cardiac troponin in the nine hospitals they studied.

The comparison of the decline in detectable cardiac troponin levels in the nine Scottish hospitals to declines over time in acute coronary syndrome as diagnosed clinically (not based solely on cardiac troponin and using a reasonable minimum cutoff value when troponin is used) during previous time periods is truly comparing apples to oranges, as I argued previously. Wagner's commentary helps to explain exactly why this is.

I should emphasize that the diagnosis of acute coronary syndrome is based on the totality of clinical information available about a patient, including the history, physical exam, electrocardiogram, echocardiogram or other diagnostic tests, and a variety of laboratory tests which may include cardiac troponin. But in Pell's study, what was being measured was not truly the diagnosis of acute coronary syndrome, but rather - the presence of detectable levels of troponin.

Given the decreases in false positive rates over time using the troponin test, it is unclear why Pell et al. would have chosen to include these false positives in their definition of acute coronary syndrome, rather than set a reasonable cut-off level that would have excluded the false positives.

At any rate, what Pell et al. did was not appropriate to make a determination of whether the observed changes were attributable to the smoking ban and for that reason, the conclusions of the study are not valid.

Population-based data on acute coronary events in Scotland have confirmed that there were no significant changes in the rate of decline from before to after the smoking ban. Thus, non-biased analytic techniques have failed to support the hypothesis that the smoking ban in Scotland has resulted in an immediate and dramatic decline in heart attacks.

Monday, February 09, 2009

ASH-UK Compares Critics of Link Between Smoking Bans and Dramatic Heart Attack Reductions to AIDS Dissidents Who Deny Link Between HIV and AIDS

In an article published this month online ahead of print in the journal Expert Review of Pharmacoeconomics and Outcomes Research, Martin Dockrell - policy and campaigns manager for Action on Smoking and Health in London (ASH-UK) - argues that those who have questioned the causal relationship between smoking bans and dramatic, immediate reductions in heart attacks are comparable to dissidents who deny the causal link between the HIV virus and AIDS (see: Dockrell M. Eye and heart at mortal war: coronaries and controversy in a smoke-free Scotland. Expert Review of Pharmacoeconomics and Outcomes Research 2009).

Dockrell argues that the Pell et al. study, which reported a 17% decline in acute coronary syndrome cases during the first year following the implementation of a smoking ban in Scotland, is conclusive evidence of a causal relationship between the smoking ban and a dramatic and immediate decline in acute cardiac events. He further argues that anyone who disagrees with this conclusion is a denialist, similar to the AIDS denialists, and that such opinion is an orchestrated artifact of tobacco industry lobbying, rather than sincere scientific criticism of the study conclusions.

Specifically, Dockrell argues that: "Organized groups who seek to deny and discredit this work are comparable in nature and intent, but not in origin, to the self-styled AIDS dissidents who continue to deny the causal link between HIV and AIDS and offer a comparable threat to an evidence-based health policy."

Moreover, Dockrell asserts that this dissidence is not pure: it is the result of orchestration by the tobacco industry: "While AIDS dissidence was largely an indigenous phenomenon, tobacco dissidence is the carefully conceived creature of tobacco industry lobbyists."

Readers should keep in mind that I am in fact a major dissenter, as I have criticized the Pell et al. study (critique 1; critique 2; critique 3; critique 4; critique 5; critique 6) and in fact have reported follow-up data which I believe demonstrate that the conclusion from that study was wrong. I have challenged anti-smoking groups to publicize the follow-up data which show that the decline in cardiac events during the first-year after Scotland's smoking ban was followed by an increase in cardiac events during the second year, thus disproving Pell et al.'s conclusion (post 1; post 2).

I take it this means that Dockrell is calling me a denialist and comparing me to AIDS dissidents who still deny that HIV causes AIDS. I also take it to mean that Dockrell is accusing me of being in the pocket of the tobacco companies and acting at their beck and call and presumably -their payments.

In fact, ASH-UK appears to make precisely such an accusation when it states in its press release to accompany the article: "A number of studies have been published recently showing a decline in admissions to hospital for heart attack following the implementation of smokefree laws in various countries. Many of these studies, including one on the impact of the Scottish smoking ban have also been the subject of criticism by so-called "dissidents" who claim that the research is nothing more than 'junk' science. In a recently published review ASH's Director of Policy and Research, Martin Dockrell, looks behind the scenes to see what has prompted this criticism and to what extent it is justified. The analysis finds parallels with those who were in denial about the causes of AIDS long after the scientific debate was over. ... We found an unholy alliance of conspiracy theorists, tobacco industry lobbyists and journalists impatient for a good story."

Dockrell is particularly critical of Michael Blastland, who wrote a commentary published by BBC News on November 14, 2007 which presented data showing that the actual decline in heart attacks in all of Scotland in the year following the smoking ban was similar to that observed in the three years preceding the ban, and that a dramatic decline in heart attacks occurred in 2000, in the absence of a smoking ban. Based on these findings, Blastland questioned the validity of the study's conclusion that the smoking ban was causally related to a 17% decline in acute cardiac events.

Dockrell argues in the article that Blastland is a denialist and conspiracy theorist and concludes that his criticism has been carefully conceived and orchestrated by the tobacco industry: "While AIDS dissidence was largely an indigenous phenomenon, tobacco dissidence is the carefully conceived creature of tobacco industry lobbyists."

The Rest of the Story

This article demonstrates the religious-like and McCarthyist-like nature of the modern-day anti-smoking movement. If you do not subscribe to the accepted dogma of the movement, even when there is legitimate scientific evidence that brings that dogma into question, you are a dissident and a denialist -- on no firmer ground than those who deny that AIDS is caused by the HIV virus. Moreover, you are not expressing a sincere opinion, but are in the pocket of the tobacco industry, part of an orchestrated industry campaign.

The absurdity of the article is evident in its implication that I - a strong anti-smoking advocate - am a denialist who is being orchestrated by the tobacco companies to disseminate conspiracy theories - since I myself have been a vocal critic of the conclusions of these heart attack/smoking ban studies.

Someone who has argued that secondhand smoke kills over 50,000 Americans each year and whose testimony about the tobacco industry's deception of the public contributed towards a $145 billion verdict against the companies is hardly someone who fits the description of being a denialist who is waving around conspiracy theories under orchestration by Big Tobacco.

To be sure, historically the tobacco industry has orchestrated campaigns to undermine the public's appreciation of the recognized hazards of active smoking and secondhand smoke exposure. If you want to read about that history, you need go only so far as to read my testimony in the Engle tobacco case, which initially resulted in a $145 billion verdict against the tobacco companies. It is also true that a number of supposedly independent scientists who have challenged the link between smoking or secondhand smoke and disease have been funded by the industry and have been part of a campaign orchestrated by the industry.

However, the criticism of the research linking smoking bans with a causal effect on acute cardiac events is largely a different story. First, the nature of the evidence is very different. While there is abundant evidence linking smoking and disease and one would have to be a denialist to argue that smoking is not harmful, the research being used to conclude that smoking bans result in huge, immediate declines in heart attacks is very weak. These conclusions are based on time trend analyses, often without a control group, they cannot adequately determine whether observed changes reflect random variation, secular trends, or a real effect of the smoking ban, and thus causal conclusions from these studies are very shaky.

I will not take the time here to explain all the methodologic weaknesses of these studies, but interested readers will find an extensive set of commentaries on my blog which critique this literature.

Perhaps the most important fact to point out here is that studies which have used national, population-based data for all of Scotland have failed to find a 17% decline in heart attacks in Scotland in the year after the smoking ban, and actually found that overall heart attack and angina admissions increased in the second year after the ban, thus negating the earlier decline. Overall, there was little change in heart attack admissions in all of Scotland from before the smoking ban to two years after the ban.

As Christopher Snowdon explained: "Much was made of an apparent reduction in the number of patients being diagnosed with the life-threatening heart condition after the smoking ban came into effect in 2006, including a study published in the New England Journal of Medicine which claimed that the ban had caused emergency ACS [acute coronary syndrome] admissions to fall by 17%. However, official statistics show that the decline in hospitals admissions for acute coronary syndrome has been greatly exaggerated. The real decline in the first year of the smoking ban was just 7.2% - not 17% - and the rate then rose by 7.8% in the second year, cancelling out the earlier drop."

"In the last 12 months before Scotland enacted its smoking ban (April 05 to March 06) there were 16,199 admissions for acute coronary syndrome. In the second year of the smoking ban (April 07 to March 08) there were 16,212 admissions, slightly more than there had been before the legislation was enacted." ...

"Hospital admissions for acute coronary syndrome have been declining in Scotland for many years. The new data show that the well-publicised fall in admissions following Scotland's smoke-free legislation was in line with the existing downward trend and was significantly less steep than has previously been claimed." ... "If the 2006-07 decline had really been the result of the smoke-free legislation, it would be expected for rates to remain low in subsequent years. The fact that Scottish hospitals have seen an unusually sharp rise - despite the smoking ban being rigorously enforced - suggests that whatever lay behind the 2006-07 dip, it was not the smoking ban."

Despite the accusation that Blastland is part of some tobacco-industry orchestrated campaign and that he nothing more than a denialist, Dockrell presents no evidence that either of these is the case. First, he fails to present any evidence showing that Blastland is being paid by Big Tobacco or that he has had any alliance, association, or communication with tobacco companies over his commentaries. Reading other articles written by Blastland, it appears that he is in fact not particularly focused on tobacco, but that he writes in general about many areas in which he believes that statistics have been inaccurately used to draw policy-relevant conclusions.

Second, Dockrell fails to present any evidence to suggest that Blastland's critiques of the smoking ban studies are anything other than legitimate scientific opinions. In fact, I find Blastland's commentary to be quite compelling and from a scientific standpoint, on much more solid ground than the Pell et al. article which was published in the New England Journal of Medicine.

The problem with the Pell et al. study is that its conclusion is based on a comparison of apples to oranges. In order to compare the change in heart attacks in Scotland from 2006-2007 to the trend in heart attacks during the preceding ten-year period, one needs to use the same data source to compare these trends. In the Pell et al. article, the researchers use one source of data to estimate the change in heart attacks from 2006-2007 (observed changes in admissions for nine hospitals representing a portion of the country) and a different source of data to estimate the trend in heart attacks from 1996-2006 (national data from the Scottish National Health Service).

A critical basis for the article's conclusion is that the year-to-year decline in heart attacks in Scotland never exceeded 10%, while the researchers found a 17% decline in heart attacks during the year following the smoking ban. However, the relevant question is not what the national health service data show, but what changes in heart attack admissions would have been found using the same methods employed by the researchers to count heart attack admissions for 2006-2007. What would the annual changes have been using the same 9 hospitals and using the same method of counting heart attack admissions?

In contrast, Blastland presents a consistent data source for hospital admissions throughout all of Scotland for a long period of time: 1998-2007. The graph he presents illustrates that there is no visible change in heart attacks in Scotland in 2006-2007. In fact, the graph shows that the rate of decline in heart attacks in Scotland remained exactly the same as it was prior to the smoking ban.

In addition, the graph shows that there was a substantial decline in heart attacks from 1999-2000 which occurred in the absence of a smoking ban, illustrating that the magnitude of decline in heart attacks in 2006-2007 is actually less than the random variation and secular trends in heart attacks that were observed in Scotland in prior years.

Thus, rather than being denialism, Blastland's criticism of the study is well-founded. Whether he is correct or not, there are absolutely no grounds to dismiss his criticism as being denialism, conspiracy theory, or tobacco industry propaganda being delivered by a paid hack, all of which are implied by Dockrell in his article and press release.

Action on Smoking and Health (UK) evidently views the anti-smoking movement as a religion. Any challenge to the doctrines of the religion amounts to heresy. Scientific discourse is not allowed. You have to accept everything anti-smoking researchers claim with blind faith.

ASH-UK would have the tobacco control movement turn into non-critical automatons, who merely accept, on blind faith, any research which is favorable to the cause. Science would no longer play a role. It would, in fact, become a religion rather than a science-based public health movement.

Moreover, Dockrell's article illustrates the McCarthyist nature of the modern day anti-smoking movement. If you challenge the doctrines of the movement, not only are you viewed as a denialist, but you are automatically attacked as being a Big Tobacco hack. In other words, without any evidence, you are publicly maligned in an attempt to permanently discredit you and blacklist you from any further participation in public discourse.

Dockrell has accused Michael Blastland of being a tobacco industry hack who is not expressing his sincere scientific criticism, but instead is being orchestrated by the tobacco industry to spout out conspiracy theories. This is not only arguably defamation, but it is essentially McCarthyism. It is an attempt to permanently malign Blastland's reputation and remove him from public discourse. And all of this solely because of the nature, not the quality, of his scientific argument.

Lest readers think that this article from ASH-UK is simply an isolated example, consider that just last week, the European Journal of Public Health published an article in which two other anti-smoking advocates - Pascal Diethelm and Martin McKee - accused all those who do not accept the causal relationship between secondhand smoke and lung cancer/heart disease as being denialists comparable to those who deny the existence of the Holocaust.

Diethelm and McKee argue that the paper by Drs. James Enstrom and Geoffrey Kabat - a meta-analysis which failed to find evidence of a causal relationship between secondhand smoke and lung cancer or heart disease - and its use by various groups is comparable to Holocaust denial.

There are many reputable scientists who have challenged the conclusion that secondhand smoke causes heart disease and lung cancer. While I disagree with their interpretation of the scientific evidence, I would never suggest that their opposing opinion is denialism and that it is comparable to Holocaust denial.

Once again, Diethelm and McKee view the anti-smoking movement as a religion. You have to accept the claims on blind faith and if you don't, you are guilty of heresy. Even worse, you will be publicly attacked and have your character maligned in an attempt to silence you by blacklisting you out of public discourse on the issue.

The rest of the story is that the anti-smoking movement is quickly losing its science base. It is becoming a religious-like, McCarthyist-like movement which attacks and attempts to blacklist anyone who doesn't accept the doctrines of the movement. Its personal attacks are on character, not on science, and are doled out based not on the quality of science in the opposing arguments, but the position that the dissenter has taken.

The most important implication of today's story is that this shift in the movement is now evident not only in the informal statements of the anti-smoking groups, but in the peer-reviewed, published literature. Tobacco control as a religion, rather than as a science-based field of public health practice, is now becoming formally institutionalized.