Tuesday, January 20, 2015

Physician Recommends that Middle-Age Lifelong Nondrinkers Should Be Told to Start Drinking, But Hides Conflict of Interest With Big Alcohol

In the most recent issue of the journal Alcoholism: Clinical and Experimental Research, a physician counsels all doctors to promote moderate alcohol use (one drink per day) among middle age, lifelong nondrinking patients. The author, Dr. Emanuel Rubin, is a pathologist at Thomas Jefferson University in Philadelphia.

(See: Rubin, E. (2014), To Drink or Not to Drink: That Is the Question. Alcoholism: Clinical and Experimental Research, 38: 2889–2892. doi: 10.1111/acer.12585.)

The major conclusion of the article is as follows: "The strongest evidence for a beneficial effect of moderate alcohol intake is the documented reduction in all cause mortality and cardiovascular disease. Indeed, the protection against coronary artery disease is comparable to that produced by the administration of statins. In this context, alcoholic beverages do not require a prescription, are far cheaper, and are certainly more enjoyable. Although a physician's advice to a patient should always be individualized, including a consideration of a person's genetic background, the overwhelming evidence suggests that physicians should counsel lifelong nondrinkers at about 40 to 50 years of age to relax and take a drink a day, preferably with dinner. The “black swan” predicts that the risk/benefit ratio is highly favorable."

I don't know who the "black swan" is but he appears not to be a very good scientist. Calling "comparable" the scientific evidence linking statins to an improvement in heart disease risk with that linking moderate alcohol intake to lower cardiovascular disease mortality is scientifically unsound. The link between statin use and decreased cardiovascular disease is based on several double-blind, placebo-controlled, clinical trials, while the link between moderate alcohol intake and lower cardiovascular disease risk is based on observational studies that are plagued by the problems of selection bias and confounding.

People who do not drink at all are very different from those who drink moderately, and in ways that could influence heart disease risk. For example, there are often medical reasons why people don't drink alcohol. A number of medications recommend that alcohol not be used while on them. If these medical conditions and medications are associated with cardiovascular disease risk, which is highly plausible, then this would confound the relationship between observed heart disease risk and alcohol intake.

Moreover, even if it were true that a drink a day reduced heart disease risk, it does not necessarily follow that advising lifelong non-drinkers to start drinking would create net public health benefits. Since these are people who have not consumed alcohol for 20 to 30 years of adulthood (and perhaps not in childhood as well), it is quite possible that their ability to limit their alcohol intake once they start is not sufficient to keep them at only one drink per day. One of the reasons they are not drinkers may in fact be that they have a family history of alcoholism and are predisposed to alcoholism. A large increase in the number of drinking adults may well lead to an increase in youth alcohol use, since parental drinking is a known risk factor for underage drinking. Thus, for many reasons, Dr. Rubin's advice is premature and ill-advised.

The Rest of the Story

But that's not what this post is about.

This post is about the failure of the author to disclose a significant conflict of interest with Big Alcohol.

According to a 2011 report, Dr. Rubin was at one time a member of the Medical Advisory Council of the Alcoholic Beverage Medical Research Foundation (ABMRF), which is heavily funded by the alcohol industry.  Dr. Rubin is also listed as having been a recipient of grant funding from ABMRF (from 1987-1991 and in 1993). Dr. Rubin also served as an expert witness for Philip Morris on several occasions during the period 1991-2000. During this time, the Miller Brewing Company was owned by Philip Morris.

Moreover, it appears that the conflict of interest with Big Alcohol is indeed current, as Dr. Rubin himself lists himself as being a consultant to the Medical Advisory Board of ABMRF. He lists the relationship as "Current Consultantships - Medical Advisory Council, Alcoholic Beverage Medical Research Foundation 1992-present."

Clearly, Dr. Rubin has a conflict of interest by virtue of his relationship with Big Alcohol, including having been the recipient of grant funding from an alcohol industry foundation and having served on the board of that alcohol industry foundation.

However, nowhere in the article can I find any disclosure of this conflict. 

I can't even find a disclosure of this conflict in a 2004 article in Atherosclerosis that reports the results of a study designed to identify potential benefits of alcohol consumption.

And in a 2013 article that reports the results of an investigation into potential benefits of alcohol consumption, the conflict of interest disclosure statements reads: "No potential conflicts of interest were disclosed."

Interestingly, Dr. Rubin testified that the research conducted by the Council for Tobacco Research (CTR) was of high scientific quality and that the scientific review adhered to widely recognized scientific standards. As the CTR was recently found by a federal court to be part of a vast conspiracy of fraud and deceit by the tobacco industry, Dr. Rubin's testimony in these tobacco cases sheds doubt on his scientific objectivity and judgment.

But the most serious issue here is not the poor medical advice. All physicians are entitled to their opinions. What they are not entitled to do, however, is to issue national recommendations on an issue as important as alcohol use if they have severe financial conflicts of interest, especially if they fail to reveal those conflicts.

The conflict of interest disclosure guidelines for the journal (Alcoholism: Clinical and Experimental Research) seem pretty clear. The guidelines require the disclosure of "any potential sources of conflict of interest," and they do not limit the disclosure to only a certain number of years. Here is the full disclosure requirement guideline:

"Conflict of Interest: This publication requires that all authors disclose any potential sources of conflict of interest. Any interest or relationship, financial or otherwise, that might be perceived as influencing an author's objectivity is considered a potential source of conflict of interest. These must be disclosed when directly relevant or indirectly related to the work that the authors describe in their manuscript. Potential sources of conflict of interest include but are not limited to patent or stock ownership, membership of a company board of directors, membership of an advisory board or committee for a company, and consultancy for or receipt of speaker's fees from a company. The existence of a conflict of interest does not preclude publication in this journal."

"If the authors have no conflict of interest to declare, they must also state this at submission. It is the responsibility of the corresponding author to review this policy with all authors and to collectively list in the cover letter to the Editor, in the manuscript (in the footnotes, or Conflict of Interest or Acknowledgements section), and in the online submission system ALL pertinent commercial and other relationships."

The rest of the story is that this commentary deceives readers by failing to disclose the fact that the author was the recipient of grant funding from an alcohol industry foundation and that he served on a board of that foundation. It also fails to disclose that the author is currently a consultant to the board. Surely, these conflicts are relevant to the ability of readers to properly evaluate the validity of the article's recommendations. I suspect that there are thousands of readers of this article who would be very surprised to find out "the rest of the story."

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