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.

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