Reassessment of the Long-term Mortality Risks

1

• Reassessment of the Long-term Mortality Risks
• of Active and Passive Smoking
• 1) The Long-term Mortality Risks of Active
  Smoking and the Need for a Reassessment
• James E. Enstrom, Ph.D., UCLA
• Reassessment of the Mortality Risks of Passive
  Smoking in the United States
• Geoffrey C. Kabat, Ph.D., Einstein College of
  Medicine, New York
• Silencing of Science The Phenomenon and Its
  Impact on Passive Smoking Epidemiology
• Sheldon B. Ungar, Ph.D., University of Toronto
• 4) Additional Discussion Trofim Denisovich
  Lysenko and Pseudoscience in the Soviet Union
  (1927-1962)

2
Rationale for Symposium 1) Important
epidemiologic findings regarding active and
passive smoking have been ignored or
mischaracterized in prior assessments 2) Rigorou
s scientific principles require that all
epidemiologic findings must be fairly and
consistently assessed 3) Silencing of
politically incorrect epidemiologic findings is
ethically and scientifically wrong 4) The
credibility of epidemiology is seriously damaged
when ideology and politics replace rigorous
scientific principles
3

• Goals for Symposium
• To present evidence that the long-term mortality
  risks of active smoking are greater than
  generally believed and the long-term mortality
  risks of passive smoking are less than generally
  believed
• To establish the credibility of this largely
  ignored or mischaracterized epidemiologic
  evidence
• To make the case that future research and future
  assessments need to be conducted objectively and
  transparently, free of ideology and politics

4
17 May 2003 British Medical Journal
5
Background on Enstrom 33 years of epidemiologic
research at UCLA 28 years of conducting and/or
analyzing prospective epidemiologic
cohorts California Mormons California
Physicians Prevention Magazine
Subscribers Alameda County Study Cohort United
States Veterans Cohort NHANES Epidemiologic
Followup Study Cohort California Cancer
Prevention Study Cohort Themes low-risk
subgroups and different perspectives
6

• California Cancer Prevention Study
• 1,078,000 total subjects in 25 states enrolled by
  American Cancer Society with late 1959
  questionnaire and followed for mortality during
  1960-1972 (CPS I)
• 2) 118,000 California subjects followed for
  mortality during 1960-1998 and a 1999
  questionnaire survey--at UCLA with special
  permission from ACS (CA CPS I)
• 3) This is the largest epidemiologic cohort
  followed for at least 39 years

7
Need for Reassessment Regarding Active
Smoking 1) BMJ Table 10 shows strong 39-year
relationship between active smoking and lung
cancer 2) 90 reduction in US tar-adjusted per
capita cigarette consumption 3)
Continuing high US lung cancer death rate with
160,000 deaths per year 4) Population
impact of smoking cessation not fully
understood or evaluated
8
BMJ Table
10 1960-1998 Active Smoking and Lung Cancer
Deaths Late 1959 Males
Females smoking status
RR (95 CI) RR (95
CI) Never 1.0
1.0 Former
3.5 (2.8-4.4) 1.5
(1.1-2.0) Current 1-9 cpd 4.1
(2.9-5.8) 2.0 (1.5-2.6) 10-19
7.9 (6.1-10.1) 5.1 (4.2-6.1) 20
12.5 (10.0-15.6) 9.1
(7.7-10.8) 21-39 16.4 (13.0-20.8)
15.1 (12.3-18.7) 40-80 18.7
(14.5-24.0) 15.8 (11.8-21.1) All
current 11.9 (9.6-14.7) 6.2
(5.4-7.2)
9
1900-2005 U.S. Per Capita Cigarette Consumption
and Tar-Adjusted Consumption
Number of cigarettes
Per capita
Tar adjusted
Data source Tobacco Outlook Report, Economic
Research Service, U.S. Dept. of Agriculture.
10
1930-2005 U.S. Age-adjusted Lung Cancer Death
Rates
Deaths per 100,000
Total population
Never smokers
Data Source NCHS Vital Statistics Death rates
are age-adjusted to 2000 US standard population.
11
Conventional Benefits of Smoking Cessation
(Enstrom Heath EPIDEMIOLOGY 1999) CA CPS I
Males Lung cancer death rate ratios by smoking
status at entry
1960-1969 Late 1959 smoking status
Death Rate Ratio Current
12.3 Former Quit lt 1 year
(1959) 13.0 Quit 1-4 years
(1955-58) 8.9 Quit
5-9 years (1950-54) 4.7 Quit
10-19 years (1940-49) 2.7 Quit
20 years (lt1939)
1.8 Never 1.0
12
Natural Experiment of Smoking Cessation (Enstrom
Heath EPIDEMIOLOGY 1999) Cigarette smoking
prevalence among CA CPS I subjects who smoked in
late 1959, based on follow-up surveys of
survivors. Sex 1959
1965 1972
1999 Males 100
74 51 7
Females 100 86
66 7
13
Natural Experiment of Smoking Cessation (Enstrom
Heath EPIDEMIOLOGY 1999) Relative risk of
lung cancer death in CA CPS I cohort 41,000
current cigarette smokers as of late 1959
compared with 50,000 never smokers
Follow-up period (by decade) Sex
1960-1969 1970-1979 1980-1989
1990-1997 Males
12.6 12.1
12.5 10.2
(7.9-20.2) (8.1-18.0) (8.5-18.4)
(6.1-17.0) Females 2.5
6.3 7.0
7.8 (1.7-3.8)
(4.7-8.3) (5.4-9.0) (5.8-10.4)

14

• Additional
• Natural Experiments of Smoking Cessation
• US Veterans Study 106,000 males followed
  1954-1979
• (Enstrom J Clin Epi 1999)
• 2) NHEFS 700 males 1100 females followed
  1971-1992 (Enstrom J Clin Epi 1999)
• 3) Iowa Womens Health Study 37,000 women
  1986-1999
• decline in excess lung cancer risk among former
  smokers is prolonged compared with other studies
  . . . excess lung cancer risk persisted up to 30
  years
• (Ebbert, et al. J Clin Oncol 2003)

15
Randomized Controlled Trials With A Smoking
Cessation Intervention 1) Whitehall Civil
Servants Study 1,445 high risk male smokers from
London advised in 1970 (JECH 1978, JECH 1982,
JECH 1992) 2) Multiple Risk Factor Intervention
Trial (MRFIT) 12,866 high risk US males enrolled
in 1972 (JAMA 1982, Circulation 1996, Ann Epi
1997) 3) Lung Health Study (LHS) 5,887 US/CN
male and female smokers enrolled in 1986 (JAMA
1994, AJRCCM 2002, AIM 2005)
16
Smoking cessation in three RCTs intervention
group (I) versus control group (C)
Intervention Average
Cessation Study period (years)
during intervention period
Intervention
Control Whitehall 1
60 25
MRFIT 6
45 20 LHS
5 35
15
17
Initial RCT lung cancer deaths and relative
differences, (I-C)/C, and 95 CI () Study
Follow-up years Lung cancer deaths (I-C)/C
95 CI
I C
() Whitehall 10.5
22 24 - 8.3
MRFIT 7 34 28 21.4
LHS 5 20 19 5.3
TOTAL 76 71 7.0
(-15.5 to 33.7) deaths incident cases,
which are scaled (714/731) only special
interventionplacebo group included
18
Full RCT lung cancer deaths and relative
differences, (I-C)/C, and 95 CI () Study
Follow-up years Lung cancer deaths (I-C)/C
95 CI
I C
() Whitehall 20
45 50 -
10.0 MRFIT 16 135 117 15.0
LHS 14.5 77
89 - 13.5 TOTAL 257
256 0.4 (-11.5 to 13.5) deaths
incident cases, which are scaled (714/731)
only special interventionplacebo group
included
19

• Tobacco Smoke and Involuntary Smoking
• IARC Monographs on the Evaluation of Carcinogenic
  Risks to Humans, Volume 83
• May 2004        1452   pages
• Coverage of Smoking Cessation
• Standard comparison of lung cancer rates among
  former smokers, current smokers, and never
  smokers
• Nothing on population impact versus successful
  quitters
• Nothing on natural experiments
• Nothing on randomized controlled trials

20

THE HEALTH BENEFITS OF SMOKING CESSATION A
Report of the Surgeon General 1990 (628
pages) PREFACE BY THE SURGEON GENERAL Taken
together, the evidence clearly indicates that
smoking cessation has major and immediate health
benefits for men and women of all ages. MAJOR
CONCLUSIONS the health consequences of smoking
cessation for those who quit smoking in
comparison with those who continue to
smoke 1. Smoking cessation has major and
immediate health benefits for men and women of
all ages.
21

• SUMMARY Active Smoking Cessation
• Long-term mortality risk of lung cancer due to
  active smoking is greater than generally believed
  because it less reversible by cessation than
  generally believed based on evidence presented
• The lung cancer mortality risk ratios for
  self-selected former smokers compared with never
  smokers do not accurately reflect the population
  impact of smoking cessation
• 2) Long-term natural experiments in cohorts
  within the United States do not show convergence
  of smoker and never smoker death rates in spite
  of substantial smoking cessation
• 3) Randomized controlled trials involving smoking
  cessation do not show a significant reduction in
  lung cancer deaths in the intervention groups
  relative to the control groups

22
Factors Impeding Reassessment 1) Complex
Issue population impact of cessation versus
focus on successful quitters 2) Wrong Message
negative findings supposedly discourage smokers
from quitting 3) Uncertainty implies lung
cancer etiology and benefits of cessation are not
completely understood 4) Silencing ignored
in major consensus reports and general
information to the public 5) Conflict of
Interest some of the above research has been
funded by the tobacco industry
23
May 2006 EPIDEMIOLOGY Lead Editorial On
Conflicts of Interest Five Commentaries
Kafka's Truth-seeking Dogs What to Declare
and Why? He Who Pays the Piper, Calls the
Tune Why Focus Only on Financial
Interests? A Conflict-of-Interest Policy
for Epidemiology
24

• Conflict of Interest BMJ Paper
• 1) Because the final portion of the funding for
  the CA CPS I study came from the tobacco
  industry, attention was diverted from the
  substance of the BMJ paper to allegations of
  tobacco industry influence
• Because the BMJ findings do not fit the
  anti-smoking advocacy
• agenda, the ACS and key anti-smoking
  activists have conducted an ongoing campaign of
  ad hominem attack, character assassination,
• and silencing with regard to Enstrom
  Kabat
• Most troubling are the false and misleading
  statements made about
• the BMJ paper by certain powerful US
  epidemiologists, which will be presented
  following the discussion of Lysenko Soviet
  pseudoscience
• The Enstrom Kabat experience illustrates the
  difficulty of
• conducting politically incorrect tobacco
  epidemiology

25
Reassessment of the Mortality Risks of Passive
Smoking in the United StatesGeoffrey C. Kabat,
Ph.D.
26
(No Transcript)
27
Background

• ETS contains many carcinogens and toxins
• exposure is widespread and involuntary
• active smoking is a major cause of avoidable
  morbidity and mortality

28
Environmental tobacco smoke

• ETS is a mixture of sidestream smoke from the
  burning tip of the cigarette (70-90) and exhaled
  mainstream smoke (10-30). Over time the
  mixture ages and is deposited on surfaces.
• ETS is both different qualitatively and much more
  dilute than the smoke the active smoker inhales
  -- how much more dilute? 1/10th? 1/100th?
  1/1,000th?
• the effects of ETS can only be studied in never
  smokers

29
Need for reassessment of passive smoking

• implausible that ETS could cause a 30 increase
  in CHD risk given that ETS is much more dilute
  than actively inhaled smoke and RR for active
  smoking is 1.8-2.0
• strength of association depends on which studies
  are included in meta-analysis
• issue is difficult to assess objectively because
  of enormous political stakes

30
Meta-analyses of ETS and LC

• RR 95 CI
• US EPA (1992) US studies 1.19
  (1.04-1.35)
• Hackshaw et al. BMJ (1997) 1.23
  (1.13-1.34)
• IARC (2004) -- females 1.24
  (1.14-1.34)
• IARC (2004) males 1.37
  (1.02-1.83)
• 90 CI

31
Meta-analyses of ETS and CHD

• RR 95 CI
• Law et al. BMJ (1997) 1.30 (1.22-1.38)
• He et al. NEJM (1999) 1.25
  (1.17-1.32)
• Thun et al. EHS (1999) 1.25 (1.17-1.33)

32
Estimates of US deaths due to ETS

• Lung cancer 3,000 -- 5,000
• CHD 35,000 60,000

33
Follow-up of California CPS I cohort

• followed for mortality from 1960 through 1998
• 118,094 adults, of whom 35,561 were never-smokers
  with a spouse
• ETS exposure based on smoking status of the
  spouse in 1959, 1965, 1972
• 7,159 respondents to 1999 questionnaire provided
  assessment of their self-reported total ETS
  exposure

34
(No Transcript)
35
Deaths for analysis of active and passive
smoking 1960-1998

• Total cohort Never smokers
• CHD 19,485 5,932
• Lung Cancer 2,970 156
• COPD 2,243 264

36
Active smoking and CHD death, 1960-1998

• Males Females
• Active smoking status RR 95 CI
  RR 95 CI
  
• Never smoked 1.0 ---
  1.0 ---
• Former smoker 1.2
  (1.1-1.3) 1.0 (0.9-1.1)
• Current smoker
• 1-9 cpd 1.2 (1.1-1.3)
  1.1 (1.0-1.2)
• 10-19 1.4 (1.3-1.5)
  1.4 (1.3-1.5)
• 20 1.6 (1.5-1.7)
  1.8 (1.7-1.9)
• 21-39 1.8 (1.6-1.9)
  2.0 (1.8-2.3)
• 40-80 1.9 (1.7-2.1) 2.4
  (2.0-2.9)
• All current smokers 1.5 (1.5-1.6)
  1.5 (1.4-1.6)

37
ETS and CHD death, 1960-1998

• Males Females
• RR 95 CI RR
  95 CI
• All 1959 participants
• followed 1960-98
• Never 1.00 --- 1.00 ---
• Former 0.94 (0.78-1.12) 1.02
  (0.93-1.11)
• Current 0.94 (0.75-2.22) 1.01
  (0.93-1.09)
• 1-9 cpd
  0.97 (0.78-1.21) 1.13 (0.97-1.33)
• 10-19 0.86
  (0.70-1.05) 1.03 (0.91-1.17)
• 20
  0.92 (0.74-1.15) 1.04 (0.92-1.16)
• 21-39
  1.16 (0.79-1.69) 0.95 (0.80-1.12)
• 40
  1.29 (0.75-2.22) 0.83 (0.65-1.06)
  
  

38
Active smoking and lung cancer death, 1960-1998

• Males Females
• Active smoking status RR 95 CI
  RR 95 CI
  
• Never smoked 1.0 ---
  1.0 ---
• Former smoker 3.5
  (2.8-4.4) 1.5 (1.1-2.0)
• Current smoker
• 1-9 cpd 4.1 (2.9-5.8)
  2.0 (1.5-2.6)
• 10-19 7.9 (6.1-10.1)
  5.1 (4.2-6.1)
• 20 12.5 (10.0-15.6)
  9.1 ( 7.7-10.8)
• 21-39 16.4 (13.0-20.8)
  15.1 (12.3-18.7)
• 40-80 18.7 (14.5-24.0) 15.8
  (11.8-21.1)
• All current smokers 11.9 (9.6-14.7)
  6.2 (5.4-7.2)

39
ETS and lung cancer death, 1960-1998

• Males Females
• RR 95 CI RR
  95 CI
• All 1959 participants
• followed 1960-98
• Never 1.00 --- 1.00 ---
• Former 0.92 (0.37-2.30) 1.08
  (0.73-1.60)
• Current 0.69 (0.34-1.39) 0.93
  (0.65-1.33)

40
Summary of BMJ results

• exposure to spousal smoking was not associated
  with increased mortality from lung cancer or CHD
  (3 follow-up intervals)
• exposure was weakly associated with increased
  mortality from COPD
• active smoking showed strong dose-response
  relationships with lung cancer, CHD, and COPD
  (BMJ table 10)

41
Conclusion of BMJ paper

• The results do not support a causal relationship
  between ETS and mortality, although they do not
  rule out a small effect. The association between
  ETS and CHD and lung cancer may be considerably
  weaker than generally believed.

42
American Cancer Society

• ACS cohort studies CPS I and CPS II account for
  the vast majority of data on ETS and CHD
• ACS contends that CPS I cannot be used to address
  passive smoking because in 1960s everyone was
  exposed

43
Response to ACS criticisms

• not true that everyone was exposed to ETS
• majority of women in CA CPS I cohort were
  homemakers
• in their 1999 meta-analysis, Thun et al. saw fit
  to include 2 cohort studies initiated in the
  1960s
• ACS has the ability to check our analysis for
  1960-1972

44
Misclassification of ETS exposure

• spousal exposure may not reflect total ETS
  exposure since there are other sources of
  exposure
• misclassification was lower in certain
  sub-groups
• 1999 questionnaire showed that smoking status of
  spouses was directly related to a history of
  total exposure to ETS
• misclassification was not sufficient to obscure
  a true association between ETS CHD,
  particularly in women

45
Spousal smoking vs. self-reported ETS exposure
among CA CPS I never smokers -- females

• History of regular ETS exposure
• as of 1999 ()
• 1959 spousal smoking None Light Moderate
  Heavy
• Never 62 24 11 3
• Current 1-19 cigs/day 26 29 39 6
• Current 20-39 cigs/day 20 21 41 18
• Current 40 cigs/day 16 13 48
  24
• Enstrom Kabat, BMJ 2003

46
ETS and CHD comparison of CA CPS I and CPS II

• Females
• Enstrom (CA CPS I) Steenland (CPS II)
• Spousal smoking
• Never 1.00 --- 1.00 ---
• Former 1.02 (0.93-1.11) 1.00 (0.90-1.48)
• Current
• 1-19 cpd 1.07 (0.96-1.19) 1.15 (0.90-1.48)
• 20 cpd 1.04 (0.92-1.16) 1.07 (0.83-1.40)
• 21-39 cpd 0.95 (0.80-1.12) 0.99 (0.67-1.47)
• 40 0.83 (0.65-1.06) 1.04 (0.67-1.61)
• Current total 1.01 (0.93-1.09) 1.10
  (0.96-1.27)
• Ever 1.01 (0.94-1.08) 1.04 (0.95-1.15)

47
New meta-analysis US CHD studies

• Enstrom Kabat, Inhalation Toxicology (2006).
• includes published studies of CPS I and CA CPS I
• applies consistent criteria for inclusion of
  results
• RRcurrent/never 1.04 (0.99-1.10)
• RR ever/never 1.04 (0.99-1.10)
• Thun et al., Environ Health Perspect (1999)
• RRexposed/not exposed 1.22 (1.13-1.30)

48
Meta-analysis of US lung cancer studies

• case-control cohort studies
• includes Enstrom Kabat, 2003
• RRever/never 1.10 (1.00-1.21)

49
Jenkins, 16 Cities Study(1993-94)

• 100 nonsmokers in each of 16 metro areas
  collected 24-hr air samples both at work and away
  from work using personal monitoring
• participants filled out questionnaires about
  their exposures and gave a pre- and post- saliva
  sample
• samples were analyzed for 10 markers of ETS,
  including RSP and nicotine

50
(No Transcript)
51
Estimates of ETS exposure

• Jenkins (1996) mean ETS exposure 8 cigarette
  equivalents/year
• Phillips (1998) housewives with heaviest
  exposure could inhale up to 11 cigarette
  equivalents/year

52
Richard Peto testimony before House of LordsFeb.
14, 2006

• Question
• Sir Richard, I wanted to start by asking if you
  could give us your assessment of the health risks
  associated with passive smoking in the home or at
  work and in other public places. It would be
  helpful if you could give us an indication of
  both absolute and relative magnitudes of the
  health risks and also the degree of uncertainty
  attached to the available statistical evidence.
• Petos response
• I am sorry, I know that is what you would like
  to be given, but the point is that these risks
  are small and difficult to measure directly. What
  is clear is that cigarette smoke itself is far
  and away the most important cause of human cancer
  in the world that is, cigarette smoke taken in
  by the smoker and passive smoking, exposure to
  other peoples smoke, must cause some risk of
  death from the same diseases. Measuring that risk
  reliably and directly is difficult.

53
Factors impeding reassessment of effects of ETS
on mortality

• incomplete analysis of largest available data
  sets (CPS I and CPS II)
• minimal research funding
• publication bias against null findings
• ideological and political agendas

54
Conclusions

• Estimates of the association of ETS with CHD and
  lung cancer appear to have been overstated.
• From the scientific and public health viewpoints,
  the focus should be on the very large and certain
  effects of active smoking rather than on the very
  small and highly uncertain effects of passive
  smoking.

55
View of Major ETS Reports

• NAS 1986
• Surgeon General 1986
• US EPA 1992
• California EPA 1986
• IARC 2004
• California ARB 2005

56
(No Transcript)
57

• Additional slidesto be used during Lysenko
  session

58
Silencing of Science The Phenomenon and Its
Impact on Passive Smoking Epidemiology

• Shelly Ungar
• University of Toronto

59
Consider this

• 1 in 3 Americans is convinced Darwinian evolution
  is definitely false
• 1 in 7 is convinced its true

60
George Bush on Intelligent Design

• Teach the debate
• Bumper sticker
• God Said It, I Believe It, and That Settles It.

61
Scientists as Secular Shamans

• Deliver the goods
• Invested with authority
• But scientific authority is precarious
• No infallible source
• Ideally open to debate and revision
• Internal disinterested debate
• BUT

62
Vulnerable to agenda science

• Partisans
• Not disinterested, or truth-seeking
• unreasoned allegiance to belief or cause or
• aim to conscript science to own ends
• use of a wide range of tactics
• Publication bias
• Selective disclosure
• silencing

63
Silencing

• efforts to prevent the making of specific
  scientific claims in arenas in which these claims
  are typically reported.
• Range from gagging to publication bias
• Can morph into fraud
• (Note too not all claims of silencing are
  valid)

64
State Silencing

• USSR
• Lysenkoism
• Denmark
• Lomborg, The Skeptical Environmentalist
• US
• Climate Scientists
• Reproductive issues
• Canada
• Climate Scientists

65
Corporate Silencing

• Pharmaceutical industry
• Vioxx
• Paxil
• Food corporations
• aspartame

66
Silencing by scientists

• Lomborg,
• The Skeptical Environmentalist
• Climate Scientists
• skeptics
• AIDS research (?)
• Tobacco research

67
Silencing by advocates

• Environmentalists
• Climate change
• Lomborg
• Health authorities ( laypersons)
• Second-hand smoke

68
Enstrom, J., Kabat, G. Environmental
tobacco smoke and tobacco relatedmortality in a
prospective study of Californians, 1960-98.
British Medical Journal, 2003 326, 1057-1100.
69
Silencing skirmishes start

• BMJ turns tabloid
• Thanks for turning back the clock on public
  health decades or more. We dont need this kind
  of negligence from what used to be a professional
  medical publication. I seriously wonder who got
  paid off at BMJ to publish this utter garbage.
• Dale Jackman
• Seriously Annoyed
• I wont dignify this rag with my credentials

70
(No Transcript)
71
Level of Expertise Evaluation
of Publication
Decision Expert Knowledgeable Layperson Total
Positive 5 12 11 28
Negative 20 44 19 83
Neutral 6 12 5 23
Total 31 68 35 134
Includes those who provide no credentials
72
Irresponsible Journalism

• I was genuinely shocked to see this splashed
  across the
• front page of this weeks BMJ, tabloid-style. An
  industry-
• sponsored, methodologically flawed study with
  inconclusive
• results but with major potential public health
  implications
• especially once the press get hold of it.
• Passive smoking may not kill. How much would
  the
• tobacco industry pay for such a soundbite in a
  major peer-
• reviewed journal? Since when did I pay my
  subscription
• so that you could do their dirty work for them?

73
Level of Expertise

Target of Negative Evaluations
Expert (N20) "Knowledgeable" (n44) Layperson (n19)
Article per se 4 10 5
Flaw in the article 15 13 5
Tobacco/Authors 10 22 13
Journal/Editor 1 24 11
Media/Public 3 21 8
Total 33 90 42
74
From hero to pariah in one easy jump Richard
Smith BMJ Editor May 18, 2003 We long ago
decided that we would not have a blanket policy
of refusing to publish research funded by the
tobacco industry, as some journals have done.
Our argument was that a ban would be antiscience,
systematically distorting the scientific record.
. . . Once the research has been done it should
be published, and if it passes our peer review
process it can be published in the BMJ. . . . I
find it distrubing that so many people and
organisatons --including the BMA, our owners--
refer to the flaws in the study without
specifying what they are. . . . We judged this
paper to be a useful contribution to an important
debate. We may be wrong as we are with many
papers. Thats science. But I remain convinced
that it would have been wrong to reject the paper
simply because it was funded by the tobacco
industry.
75
Fear of Media Coverage

• The study has already been widely cited by the
  lay press and is being used by the tobacco
  industry to block public health efforts to enact
  smoke-free policies.

76
Use by Tobacco Industry

• As the industry is already demonstrating, this
  result will be pumped throughout the globe in
  industry PR, in the mouths of its front
  organizations, as controversy over passive
  smoking.

77
Multi-pronged search of international newspaper
coverage

• Not even a blip of coverage
• Silencing by media
• About 60 articles worldwide
• Minor papers
• Gwinnett Daily Post, Georgia.

78
Interactive research

• Email
• I can tell you that I have closely followed the
  effects of this article in the Dutch press. It's
  incredible how little newspapers have reported on
  this study. Only two Dutch newspapers have
  published it this EK study looks to be
  self-censored by the public Dutch media
  (Maessen, Forces).

79
Not balanced coverage

• A new study downplaying the effects of
  secondhand smoke on the health of smokers
  spouses is being condemned even before it has
  appeared in print
• Its a pretty crappy piece of science
• Sacramento Bee (California)

80
4 articles defend publication

• To believe that second-hand smoke may not be
  very harmful has become a thought-crime almost
  akin to Holocaust denial. Those who dare express
  doubts must expect hysterical abuse from every
  point of the PC compass.
• National Post (Toronto)

81
Misuse of the Study?

• Tobacco companies
• Not trumpet it heavily
• Smokers rights groups
• Enshrine as proof that threat is exaggerated

82
The Washington Times
Ban the bans By Jay AmbrosePublished March 26,
2006
nonsmokers with easily offended nostrils and who
are probably mostly ignorant of the most
exhaustive research project ever completed on
secondhand smoke.
The study involved 118,000 Californians. It
followed their health history for four decades,
and was conducted by highly respected scientists
and published in the highly respected British
Medical Journal. Here is what it said There is
no evidence of a "causal relationship" between
"exposure" to tobacco smoke in the air around you
and death. A "small effect" cannot be ruled out,
the scientists reported, but that's it. Period.
83
Misunderstand science

• No single study definitive
• Especially when dealing with small risks
  research
• Same overestimation of outlier climate studies

84
Mismeasure of science

• Not covered by media because
• Changes nothing
• regime of truth surrounding smoking
• Cannot be intelligibly questioned
• Not about dueling scientists

85
Smokers are deviants of choice

• Secondhand smoke created a moral panic
• Smokers as folk devils

86
Google Alert Secondhand

• Study Finds DNA Risk From Secondhand Casino Smoke
• Secondhand smoke can affect pets' health
• Exposing infants to secondhand smoke could
  contribute to cancer risks later in life
• STAT Medical News Secondhand Smoke Detectable in
  Babies
• Cigarette smoke, even secondhand smoke, can
  weaken bones
• Stroke Preventionavoid exposure to secondhand
  smoke
• Secondhand smoke linked to acting out by
  children
• Small children exposed to secondhand smoke are
  more likely to develop ear infections, upper
  respiratory infections and asthma.
• A link exists between secondhand smoke and type 2
  diabetes.

87
Eurobarometer poll, 2005

• 95 said smoking in the presence of a pregnant
  woman could harm the baby
• 75 said they would not smoke in the presence of
  a child
• 75 said they were aware smoke could be dangerous
  for non-smokers
• 53 of people aged 15 to 24 were worried about
  second-hand smoking

88
Eurobarometer poll, 2005

• SUPPORT FOR BANS
• Office/indoor workplace 86
• Any indoor public space 84
• Restaurants 77
• Bars or pubs 61

89
(No Transcript)
90
Ministers accused of exaggerating risks of
passive smoking By JANE MERRICK, Daily Mail
0850am 7th June 2006 Peers said the ban was not
justified by the relatively low risks of passive
smoking Ministers exaggerated the risk of passive
smoking to force through a blanket ban on
lighting up in public, a report has claimed. The
Government ignored scientific research on the
effects of secondhand smoke in enclosed public
places, according to the report from the Lords
economic affairs committee. It says that the
smoking ban, which comes into effect in all pubs,
clubs and workplaces next summer, was a political
decision by Labour's nanny state tendency - and
not justified by the relatively low risk of
passive smoking.
91
Not long ago I was something of a hero of the
antitobacco movement-- because I resigned my
professorship at Nottingham University when it
accepted money from British American Tobacco. I
felt somewhat embarrassed by the whole episode. I
was no hero. But now I'm a pariah for publishing
a piece of research funded by the tobacco
industry. Because of some sort of personality
defect that is common among editors I'm more
attracted to being a pariah than a hero, but I
don't think that I deserve to be a pariah. We
long ago decided that we would not have a blanket
policy of refusing to publish research funded by
the tobacco industry, as some journals have done.
(1) Our argument was that a ban would be
antiscience, systematically distorting the
scientific record. I would try to dissuade
anybody from accepting tobacco company money, and
I resigned from Nottingham because it did so.
Isn't it thus hypocritical to publish research
funded by the industry? To my mind it isn't. With
some difficulty, I'm setting the ethic that all
science should be published above the ethic that
you shouldn't take money from the tobacco
industry. Once the research has been done it
should be published, and if it passes our peer
review process it can be published in the BMJ.
Our way of making decision on research papers is
first to ask if we are interested in the
question. We are certainly interested in the
question of whether passive soming kills, and
it's clear to us that the question has not been
definitively answered. Indeed, it may well never
be answered definitively. It's a hard
question,and our methods are inadequate. We then
peer review the study. Two top epidemiologists--
including George Davey-Smith--reviewed the paper.
Then the paper went to our hanging committee,
which always includes a statistician as well as
practising doctors and some of us. Everybody
reads every word of every paper. We asked for
extensive changes to the paper, and the paper we
published was different from the paper
submitted--which is usually the case. We are
planning to post on our website all the comments
of the reviewers, our statistician, and the
hanging committee. I hope that they will be up
soon after the weekend. Of course the paper has
flaws --all papers do-- but it also has
considerable strengths-- long follow up, large
sample size, and more complete follow up than
many such studies. I find it distrubring that so
many people and organisatons --including the BMA,
our owners-- refer to the flaws in the study
without specifying what they are. We judged this
paper to be a useful contribution to an important
debate. We may be wrong, as we are are with many
papers. That's science. But I remain convinced
that it would have been wrong to reject the study
simply because it was funded by the tobacco
industry. Richard Smith Editor, BMJ
92
Trofim Denisovich Lysenko Pseudoscience in
the Soviet Union (1927-1962)
93
Trofim Denisovich Lysenko was a self-promoting
Soviet agronomist who invented a procedure called
vernalization, which he claimed would lead to
dramatically increased crop yields. Lysenko's
claims violated Mendelian genetics and never
faced a rigorous test. However, Joseph Stalin
was impressed because Lysenko promised improved
agricultural output unbounded by hereditary
constraints. Lysenko was portrayed as a genius
and rose rapidly in power and prestige with the
backing of Stalin and the media. He was
especially skillful at denouncing geneticists who
disagreed with him as enemies of the state. The
result was purges that sent hundreds of
dissenting Soviet scientists to the gulags or
killed.
94
Lysenko and his theories dominated Soviet
biology for over thirty years. However,
vernalization never increased crop yields and
there were two major famines that killed
millions. Current Russian biology still has not
entirely recovered from the Lysenko era. This
episode dramatizes the dangers of political
ideology influencing science and of uncritical
media promoting false concepts. A crude analogy
can be made with certain aspects of tobacco
epidemiology. With the goal of reducing
smoking, activists exaggerate the dangers of
passive smoking and attack scientists want to do
objective work in this area. In this climate
attention is diverted from the real dangers of
active smoking and from a complete understanding
of lung cancer etiology. And the lung cancer
epidemic continues.
95

• Statement of Major Points of Symposium
• all epidemiologic findings must be evaluated in a
  fair and consistent manner in order to obtain an
  accurate assessment of the mortality risks of
  active and passive smoking
• epidemiologic findings must be judged on their
  merits and not on extraneous factors
• additional epidemiologic research in this area
  needs to be conducted free of partisanship.