Black is white and white is black

HIV does not cause AIDS. The world was created in 4004 BCE. Smoking does not cause cancer. And if climate change is happening, it is nothing to do with man-made CO2 emissions. Few, if any, of the readers of this journal will believe any of these statements. Yet each can be found easily in the mass media.

The consequences of policies based on views such as these can be fatal. Thabo Mbeki's denial that that HIV caused AIDS prevented thousands of HIV positive mothers in South Africa receiving anti-retrovirals so that they, unnecessarily, transmitted the disease to their children.1 His health minister, Manto Tshabalala-Msimang, famously rejected evidence of the efficacy of these drugs, instead advocating treatment with garlic, beetroot and African potato. It was ironic that their departure from office coincided with the award of the Nobel Prize to Luc Montagnier and Françoise Barré-Sinoussi for their discovery that HIV is indeed the case of AIDS. The rejection of scientific evidence is also apparent in the popularity of creationism, with an estimated 45% of Americans in 2004 believing that God created man in his present form within the past 10 000 years.2 While successive judgements of the US Supreme Court have rejected the teaching of creationism as science, many American schools are cautious about discussing evolution. In the United Kingdom, some faith-based schools teach evolution and creationism as equally valid ‘faith positions’. It remains unclear how they explain the emergence of antibiotic resistance.

Elsewhere, the hand of powerful corporate interests can be seen. It took many decades for the conclusions of authoritative reports by the US Surgeon General3 and the British Royal College of Physicians4 on the harmful effects of smoking to be accepted, while even now, despite clear evidence of rapid reductions in myocardial infarctions where bans have been implemented, there are some who deny that second-hand smoke is dangerous. In large part this was due to the efforts of the tobacco industry to deflect attention to other putative causes of smoking-related diseases, from stress to keeping pet birds. The reports of the Intergovernmental Panel on Climate Change have suffered similar attacks from commentators with links to major oil companies.

All of these examples have one feature in common. There is an overwhelming consensus on the evidence among scientists yet there are also vocal commentators who reject this consensus, convincing many of the public, and often the media too, that the consensus is not based on ‘sound science’ or denying that there is a consensus by exhibiting individual dissenting voices as the ultimate authorities on the topic in question. Their goal is to convince that there are sufficient grounds to reject the case for taking action to tackle threats to health. This phenomenon has led some to draw a historical parallel with the holocaust, another area where the evidence is overwhelming but where a few commentators have continued to sow doubt. All are seen as part of a larger phenomenon of denialism.

Defining and recognizing denialism

The Hoofnagle brothers, a lawyer and a physiologist from the United States, who have done much to develop the concept of denialism, have defined it as the employment of rhetorical arguments to give the appearance of legitimate debate where there is none,5 an approach that has the ultimate goal of rejecting a proposition on which a scientific consensus exists.6 In this viewpoint, we argue that public health scientists should be aware of the features of denialism and be able to recognize and confront it.

Denialism is a process that employs some or all of five characteristic elements in a concerted way. The first is the identification of conspiracies. When the overwhelming body of scientific opinion believes that something is true, it is argued that this is not because those scientists have independently studied the evidence and reached the same conclusion. It is because they have engaged in a complex and secretive conspiracy. The peer review process is seen as a tool by which the conspirators suppress dissent, rather than as a means of weeding out papers and grant applications unsupported by evidence or lacking logical thought. The view of General Jack D Ripper that fluoridation was a Soviet plot to poison American drinking water in Dr Strangelove, Kubrick's black comedy about the Cold War is no less bizarre than those expressed in many of the websites that oppose this measure.

In some cases, denialism exploits genuine concerns, such as the rejection of evidence on the nature of AIDS by African-Americans who perceive them as a manifestation of racist agendas.7 While conspiracy theories cannot simply be dismissed because conspiracies do occur,8 it beggars belief that they can encompass entire scientific communities.

There is also a variant of conspiracy theory, inversionism, in which some of one's own characteristics and motivations are attributed to others. For example, tobacco companies describe academic research into the health effects of smoking as the product of an ‘anti-smoking industry’, described as ‘a vertically integrated, highly concentrated, oligopolistic cartel, combined with some public monopolies’ whose aim is to ‘manufacture alleged evidence, suggestive inferences linking smoking to various diseases and publicity and dissemination and advertising of these so-called findings to the widest possible public’.9

The second is the use of fake experts. These are individuals who purport to be experts in a particular area but whose views are entirely inconsistent with established knowledge. They have been used extensively by the tobacco industry since 1974, when a senior executive with R J Reynolds devised a system to score scientists working on tobacco in relation to the extent to which they were supportive of the industry's position. The industry embraced this concept enthusiastically in the 1980s when a senior executive from Philip Morris developed a strategy to recruit such scientists (referring to them as ‘Whitecoats’) to help counteract the growing evidence on the harmful effects of second-hand smoke. This activity was largely undertaken through front organizations whose links with the tobacco industry were concealed, but under the direction of law firms acting on behalf of the tobacco industry.10 In some countries, such as Germany, the industry created complex and influential networks, allowing it to delay the implementation of tobacco control policies for many years.11 In 1998, the American Petroleum Institute developed a Global Climate Science Communications Plan, involving the recruitment of ‘scientists who share the industry's views of climate science [who can] help convince journalists, politicians and the public that the risk of global warming is too uncertain to justify controls on greenhouse gases’.12 However, this is not limited to the private sector; the administration of President George W Bush was characterized by the promotion of those whose views were based on their religious beliefs or corporate affiliations,13 such as the advisor on reproductive health to the Food and Drug Administration who saw prayer and bible reading as the answer to premenstrual syndrome.14 A related phenomenon is the marginalization of real experts, in some cases through an alliance between industry and government, as when ExxonMobil successfully opposed the reappointment by the US government of the chair of the Intergovernmental Panel on Climate Change.15,16 These events led a group of prominent American scientists to state that ‘stacking these public committees out of fear that they may offer advice that conflicts with administration policies devalues the entire federal advisory committee structure’.17

The use of fake experts is often complemented by denigration of established experts and researchers, with accusations and innuendo that seek to discredit their work and cast doubt on their motivations. Stanton Glantz, professor of medicine at the University of California, San Francisco and who has made a great contribution to exposing tobacco industry tactics, is a frequent target for tobacco denialists. He is described on the Forces website as ‘infamous for being the boldest of liars in “tobacco control” that most ethically challenged gang of con artists’, adding that ‘he cynically implies his research into smoking is science, banking on the sad fact that politicians, let alone the media, have no idea that epidemiology is not real science and that his studies define the term junk science’.18

The third characteristic is selectivity, drawing on isolated papers that challenge the dominant consensus or highlighting the flaws in the weakest papers among those that support it as a means of discrediting the entire field. An example of the former is the much-cited Lancet paper describing intestinal abnormalities in 12 children with autism, which merely suggested a possible link with immunization against measles, mumps and rubella.19 This has been used extensively by campaigners against immunization, even though 10 of the paper's 13 authors subsequently retracted the suggestion of an association.20 Fortunately, the work of the Cochrane Collaboration in promoting systematic reviews has made selective citation easier to detect.

Another is a paper published by the British Medical Journal in 2003,21 later shown to suffer from major flaws, including a failure to report competing interests,22 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 2008.23

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.

The fourth is the creation of impossible expectations of what research can deliver. For example, those denying the reality of climate change point to the absence of accurate temperature records from before the invention of the thermometer. Others use the intrinsic uncertainty of mathematical models to reject them entirely as a means of understanding a phenomenon. In the early 1990s, Philip Morris tried to promote a new standard, entitled Good Epidemiological Practice (GEP) for the conduct of epidemiological studies. Under the GEP guidelines, odds ratios of 2 or less would not be considered strong enough evidence of causation, invalidating in one sweep a large body of research on the health effects of many exposures.24 Although Philip Morris eventually scaled back its GEP programme, as no epidemiological body would agree to such a standard, British American Tobacco still uses this criterion to refute the risk associated with passive smoking.25

The fifth is the use of misrepresentation and logical fallacies. For example, pro-smoking groups have often used the fact that Hitler supported some anti-smoking campaigns to represent those advocating tobacco control as Nazis (even coining the term nico-nazis),26 even though other senior Nazis were smokers, blocking attempts to disseminate anti-smoking propaganda and ensuring that troops has sufficient supplies of cigarettes.27 Logical fallacies include the use of red herrings, or deliberate attempts to change the argument and straw men, where the opposing argument is misrepresented to make it easier to refute. For example, the US Environmental Protection Agency (EPA) determined in 1992 that environmental tobacco smoke (ETS) is carcinogenic, a finding confirmed by many other authoritative national and international public health institutions. The EPA assessment was described by two commentators as an ‘attempt to institutionalize a particular irrational view of the world as the only legitimate perspective, and to replace rationality with dogma as the legitimate basis of public policy’, which they labelled as nothing less than a ‘threat to the very core of democratic values and democratic public policy’.28 Other fallacies used by denialists are false analogy, exemplified by the argument against evolution that, as the universe and a watch are both extremely complex, the universe must have been created by the equivalent of a watchmaker and the excluded middle fallacy (either passive smoking causes a wide range of specified diseases or causes none at all, so doubt about an association with one disease, such as breast cancer, is regarded as sufficient to reject an association with any disease).

Responding to denialism

Denialists are driven by a range of motivations. For some it is greed, lured by the corporate largesse of the oil and tobacco industries. For others it is ideology or faith, causing them to reject anything incompatible with their fundamental beliefs. Finally there is eccentricity and idiosyncrasy, sometimes encouraged by the celebrity status conferred on the maverick by the media.

Whatever the motivation, it is important to recognize denialism when confronted with it. The normal academic response to an opposing argument is to engage with it, testing the strengths and weaknesses of the differing views, in the expectations that the truth will emerge through a process of debate. However, this requires that both parties obey certain ground rules, such as a willingness to look at the evidence as a whole, to reject deliberate distortions and to accept principles of logic. A meaningful discourse is impossible when one party rejects these rules. Yet it would be wrong to prevent the denialists having a voice. Instead, we argue, it is necessary to shift the debate from the subject under consideration, instead exposing to public scrutiny the tactics they employ and identifying them publicly for what they are. An understanding of the five tactics listed above provides a useful framework for doing so.

References

1
Bateman
C
Paying the price for AIDS denialism
S Afr Med J
 , 
2007
, vol. 
97
 (pg. 
912
-
14
)
2
Newport
F
Third of Americans say evidence has supported Darwin's evolution theory
Accessed on 29 November 2008 
3
US Department of Health, Education, and Welfare
Smoking and Health. Report of the Advisory Committee to the Surgeon General of the Public Health Service
 , 
1964
Atlanta
Public Health Service, Centers for Disease Control
4
Royal College of Physicians
Smoking and Health. Summary and Report of the Royal College of Physicians of London on Smoking in Relation to Cancer of the Lung and other Diseases
 , 
1962
London
Royal College of Physicians
5
Hoofnagle
M
Hoofnagle
C
What is denialism
Accessed on 29 November 2008 
6
Wikipedia. Denialism
Accessed on 30 December 2008 
7
Bogart
LM
Thorburn
S
Relationship of African Americans’ sociodemographic characteristics to belief in conspiracies about HIV/AIDS and birth control
J Natl Med Assoc
 , 
2006
, vol. 
98
 (pg. 
1144
-
50
)
8
Pigden
CR
Conspiracy theories and the conventional wisdom
Episteme
 , 
2007
, vol. 
4
 (pg. 
219
-
32
)
9
Apt CC
The anti-smoking industry, Philip Morris internal report dated September 1983; Bates No. 2025042325/2332
Accessed on 29 November 2008 
10
Diethelm
PA
Rielle
J-C
McKee
M
The whole truth and nothing but the truth? The research that Philip Morris did not want you to see
Lancet
 , 
2005
, vol. 
366
 (pg. 
86
-
92
)
11
Grüning
T
Gilmore
A
McKee
M
Tobacco industry influence on science and scientists in Germany
Am J Public Health
 , 
2006
, vol. 
96
 (pg. 
20
-
32
)
12
Greenpeace
Denial and deception: a chronicle of ExxonMobil's efforts to corrupt the debate on global warming
Accessed on 29 November 2008 
13
McKee
M
Novotny
TE
Political interference in American science
Eur J Publ Health
 , 
2003
, vol. 
13
 (pg. 
289
-
91
)
14
The
Lancet
Keeping scientific advice non-partisan
Lancet
 , 
2002
, vol. 
360
 pg. 
1525
 
15
Lawler
A
Climate change: battle over IPCC chair renews debate on U.S. climate policy
Science
 , 
2002
, vol. 
296
 (pg. 
232
-
3
)
16
Michaels
D
Doubt is their product: how industry's assault on science threatens your health
 , 
2008
USA
Oxford University Press
17
Michaels
D
Bingham
E
Boden
L
, et al.  . 
Advice without dissent
Science
 , 
2002
, vol. 
298
 pg. 
703
 
18
Accessed on 29 November 2008 
‘Cutting Edge’ Comedy, 17 September 2008, Forces available at http://www.forces.org/News_Portal/news_viewer.php?id=1412
19
Wakefield
AJ
Murch
SH
Anthony
A
, et al.  . 
Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children
Lancet
 , 
1998
, vol. 
351
 (pg. 
637
-
41
)
20
Murch
SH
Anthony
A
Casson
DH
, et al.  . 
Retraction of an interpretation
Lancet
 , 
2004
, vol. 
363
 pg. 
750
 
21
Enstrom
JE
Kabat
GC
Environmental tobacco smoke and tobacco related mortality in a prospective study of Californians, 1960–98
Br Med J
 , 
2003
, vol. 
326
 pg. 
1057
 
22
Bero
LA
Glantz
S
Hong
MK
The limits of competing interest disclosures
Tob Control
 , 
2005
, vol. 
14
 (pg. 
118
-
26
)
23
JTI | Corporate Responsability | Our Positions | Environmental Tobacco Smoke
Accessed on 29 November 2008 
24
Diethelm
PA
McKee
M
Lifting the smokescreen: tobacco industry strategy to defeat smoke free policies and legislation
 , 
2006
Accessed on 30 December 2008
Brussels
European Respiratory Society and Institut National du Cancer
 
25
British American Tobacco, Second-hand smoke
Accessed on 29 November 2008 
26
Schneider
NK
Glantz
SA
‘Nicotine Nazis strike again’: a brief analysis of the use of Nazi rhetoric in attacking tobacco control advocacy
Tob Control
 , 
2008
, vol. 
17
 (pg. 
291
-
6
)
27
Bachinger
E
McKee
M
Gilmore
A
Tobacco policies in Nazi Germany: not as simple as it seems
Public Health
 , 
2008
, vol. 
122
 (pg. 
497
-
505
)
28
Gori
GB
Luik
JC
Passive smoke: The EPA's betrayal of science and policy
1999
Calgary
The Fraser Institute

Comments

7 Comments
Danger: Public Health Could Become a Religious Movement
10 February 2009
Michael Siegel

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.

While I personally believe the evidence is sufficient to conclude that secondhand smoke causes heart disease and lung cancer, there are a considerable number of reputable scientists who have come to different conclusions. While I believe those scientists are wrong, I would never argue that they are denialists, nor would I ever compare their dissent with Holocaust denial.

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.

Conflict of Interest:

None declared

Submitted on 10/02/2009 7:00 PM GMT
Response to Professor Siegel
12 February 2009
Martin McKee (with Pascal Diethelm)

Professor Siegel completely misrepresents our position. 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)) 1 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,2 a finding that provides some explanation for the now common finding of rapid declines in coronary heart events following introduction of smoking bans.3 So there we have it. First, epidemiological evidence of association, with the association strengthened with improved measures of exposure. Second, biological evidence from animal studies. Third, a reduction in adverse outcomes after removal of exposure in natural experiments. All that is missing is a randomised controlled trial but it is difficult to envisage, given the need to show genuine equipoise, that any ethics committee would ever approve one. Martin McKee, Pascal Diethelm References 1. Whincup PH, Gilg JA, Emberson JR, Jarvis MJ, Feyerabend C, Bryant A, Walker M, Cook DG. Passive smoking and risk of coronary heart disease and stroke: prospective study with cotinine measurement. BMJ. 2004 ;329: 200- 5. 2. Diethelm PA, Rielle JC, McKee M. The whole truth and nothing but the truth? The research that Philip Morris did not want you to see. Lancet 2005; 366: 86-92. 3. Barone-Adesi F, Vizzini L, Merletti F, Richiardi L. Short-term effects of Italian smoking regulation on rates of hospital admission for acute myocardial infarction. Eur Heart J. 2006 Oct;27(20):2468-72.

Conflict of Interest:

None declared

Submitted on 12/02/2009 7:00 PM GMT
On ?Denialism,? Passive Smoking, Orwell, and the Search for Truth
15 February 2009
Geoffrey Kabat

The viewpoint piece by Diethelm and McKee (1) presents itself as a disinterested commentary on the perverse phenomenon of “denialism” – the refusal to accept well-established facts. Jacob Sullum has already astutely pointed out how the authors themselves prefer to avoid any discussion of relevant facts when it comes to issues closer to their immediate concerns than AIDS and climate change, which they cite as prime examples of denialism (2).

As the co-author of one of the few substantive studies cited by Diethelm and McKee (3) – clearly the real target that the authors had in mind -- I would add a number of points that readers should be aware of. These will add to the irony of these authors setting themselves up as lofty defenders of truth in science.

First, Diethelm and McKee state that James Enstrom and I failed to fully disclose our competing interests in our 2003 article in the BMJ. In fact, our article carried a 208-word statement detailing in full our competing interests. This has all been aired in the rapid responses to the BMJ (4) and the paper was defended by the editor-in-chief Richard Smith (5) and by other editors (6). Apparently, none of this satisfied Diethelm and McKee nor apparently merits citing.

For what purports to be an intellectual argument about the ability (or inability) of some to recognize and accept scientific truth, one of the things that is striking about this “viewpoint” is the authors’ failure to make any of the necessary distinctions needed to shed light on this phenomenon. They make no distinction between the incontrovertible evidence demonstrating that HIV is the cause AIDS and the inherently chaotic phenomenon of climate and climate change, where, rather than one truth, there is a range of opinion and a very wide range of estimates (7). More to the point, they make no distinction between the established health effects of active smoking versus those of passive smoking, or the effects of smoking bans. Finally, they do not distinguish between ignorance, or the irrational clinging to anti-scientific beliefs, on the one hand, and reasoned and documented scientific work that goes against their own entrenched beliefs, on the other.

Diethelm and McKee are not interested in the facts that are relevant to the issue of passive smoking. If they had been, they would have acknowledged that the results presented in our BMJ paper do not differ in the slightest from those published by the American Cancer Society (8, 9). [We submitted 16 pages of supporting evidence to the BMJ on June 30, 2003 (8). Unfortunately, it was not published, mostly likely because of the furor created by persons like Diethelm and McKee. Another version of this evidence was published in 2006 (9).] They would have acknowledged that other large recent epidemiologic studies (10) have also found no association of ETS exposure with fatal disease. They would have referred to carefully done monitoring studies both in the U.S. and Europe, which suggest that average ETS exposure in the early 1990s, before stringent restrictions on smoking were enacted, indicated that average ETS exposure of never smokers was on the order of 1/1,000th that of the average active smoker (11, 12). And they would have acknowledged the fact that Sir Richard Peto testified before the House of Lords, making the point that, while undoubtedly carrying some additional risk to the never smoker, environmental tobacco smoke was too dilute to quantitate the risk, and emphasizing that it is active smoking that kills people (13). Is Sir Richard to be numbered among “denialists”?

It is also relevant to note that neither Diethelm nor McKee has ever published any substantive scientific study dealing with ETS. This explains their lack of interest in what the actual evidence really shows. For their purposes, which relate solely to policy, as opposed to science, it is expedient to refer only to the activist consensus concerning ETS.

Rather than engaging in a discussion of the scientific evidence, Diethelm and McKee prefer to engage in ad hominem attacks and to imply guilt by association – methods long-recognized in the field of rhetoric as the lowest form of argumentation. I pointed this out in my reply (14) to the very first “rapid response” to our BMJ paper by Martin McKee (15) in May, 2003 (which, it should be noted, he wrote 2 days before the full, 10- page version of our paper was accessible). For Diethelm and McKee, nothing of note appears to have changed since then.

Diethelm and McKee’s sleight-of-hand is to imply that there should be equal certainty across all the historical and scientific issues they mention. Thus, questioning the weak-to-null association of passive smoking with fatal disease is tantamount to Holocaust denial or denial that HIV causes AIDS. Their true goal is to assert the existence of an unquestionable consensus concerning passive smoking, and to discredit anyone who would dare to bring the best scientific evidence to bear on the question.

It is thus highly ironical that in the opening of their piece, Diethelm and McKee echo George Orwell in his novel Nineteen Eighty-Four. Orwell was a withering critic of the ideology of Fascist and Stalinist regimes which impose a rigid dogma that overrides any relevant facts and which cannot be questioned. Rather than being able to tolerate legitimate scientific inquiry, Diethelm and McKee would set themselves up as the political commissars of right-thinking in public health.

References

1. Diethelm P, McKee M. Denialism: what is it and how should scientists respond? Eur J Public Health, January 2009; 19: 2 - 4.

2. Sullum J. If You Question the Deadliness of Secondhand Smoke, You Might As Well Question the Deadliness of Zyklon B. Reason magazine (Feb. 13, 2009), http://reason.com/blog/show/131691.html

3. Enstrom JE, Kabat GC. Environmental tobacco smoke and tobacco related mortality in a prospective study of Californians, 1960-98. BMJ 325 (May 17, 2003), 1057-1066.

4. Enstrom JE, Kabat GC. “The authors respond.” BMJ 327 (August 30, 2003), A501-A505)

5. Smith R. Comment from the editor. BMJ 2003;327:505.

6. Tonks A. Passsive smoking: summary of rapid responses. BMJ 2003;327:505.

7. Intergovernmental Panel on Climate Change (IPCC). Climate Change 2007: The Physical Science Basis.

8. Enstrom JE, Kabat GC. “Conflicting Results on Environmental Tobacco Smoke from the American Cancer Society.’ Manuscript BMJ/2003/084269, June 30, 2003 (http://www.scientificintegrityinstitute.org/BMJ084269.pdf)

9. Enstrom JE, Kabat GC. Environmental tobacco smoke and coronary heart disease mortality in the United States – a meta-analysis and critique. Inhalation Toxicol 2006;18:199-210. 10. Stranges S, Bonner MR, Fucci F, et al. Lifetime cumulative exposure to secondhand smoke and risk of myocardial infarction in never smokers: results from the Western New York health study, 1995-2001. Arch Intern Med. 2006;166(18):1961-7 11. Jenkins RA, Palausky A, Counts RW, et al. Exposure to environmental tobacco smoke in sixteen cities in the United States as determined by personal breathing zone air sampling. J Expos Anal Environ Epidemiol 1996;6:473-502.

12. Phillips K, Howard DA, Browne D, Lewsley JM. Assessment of personal exposures to environmental tobacco smoke in British nonsmokers. Environ Internatl 1994:20:693-712.

13. Peto R. Testimony before the House of Lords Economic Affairs Committee, Feb. 2006.

14. Kabat GC. Response to “Need for clarification of competing interest. BMJ.com, May 17th, 2003, http://www.bmj.com.elibrary.aecom.yu.edu/cgi/eletters/326/7398/1057#32294

15. McKee M. Need for clarification of competing interest. BMJ.com, May 15th, 2003, http://www.bmj.com.elibrary.aecom.yu.edu/cgi/eletters/326/7398/1057#32294

Conflict of Interest:

None declared

Submitted on 15/02/2009 7:00 PM GMT
"Denialism, Hookah Environmental Tobacco Smoke, and the ""Overwhelming Consensus on the Evidence"""
16 February 2009
Kamal Chaouachi

ÂÂ

Two social scientists looked into the “famous” case of ENSTROM & KABAT cited by DIETHELM & McKEE (D&M)[ 1-3 ]. Interestingly, they found that “the public consensus about the negative effects of passive smoke is so strong that it has become part of a regime of truth that cannot be intelligibly questioned” [ 3 ]. D&M abuse of strong phrases and words such as “fake experts”, “denialism”, etc. and even draw a parallel with a black period of Western history. As for their critique of  the former US president, it would have been praised if it had been published when the individual was still in office…

In Europe, a top tobacco national authority has recently exposed the fraud about the ETS science contained in a supranational official report entitled “Lifting the Smokescreen”. Stressing that this document had been used to support the passing of laws banning smoking in public places (cafes, etc.), the critic literally asks: “Epidemiologic Study or Manipulation ?”[ 4 ]. Indeed, among the 5,863 ETS(Environmental Tobacco Smoke)-induced estimated deaths, 4,749 concerned everyday smokers and the 1,114 “non-smokers” happened to be former smokers... Consequently, the remaining risk could hardly be attributed to ETS. Last but not least, all ethical norms were actually violated since the report was openly sponsored by the pharmaceutical industry [ 4 ]. Will hunters of “denialism” also say that this brave scientist is a “fake expert” or a “denialist” or that he has conflicting interests ?

D&M suggest a wise rule for debate: “[…] testing the strengthsand weaknesses of the differing views, […] and to accept principles of logic » [ 1 ]. Since the issue at the core of D&M’s paper is about the great hazards of ETS, “the strength and weaknesses” of DIETHELM’s views on this topic have been tested accordingly. The Swiss expert has authored a scientific article (May 2007) on the hazards of hookah (narghile, shisha) smoking [ 5 ]. The material was mainly based on the pre-released information about a study on UFP (Ultra-Fine Particles) in hookah smoke by MONN et al. later published in an anti-smoking research journal [ 6 ]. Hookah ETS hazards are hyped and this practice would be highly noxious for both the active and passive smoker. Its ETS is even more dangerous than that of cigarettes (Original in French: « la fumée passive produite par le narguilé est en fait beaucoup plus dangereuse […] »[ 5 ].

DIETHELM’s emphasis on the importance of the peer-review process for validating sound science unfortunately collides with the scientific contents of his article on hookah ETS. In fact, the expert has completely misunderstood MONN et al’ study which did not analyse hookah ETS but only its MSS (MainStream smoke), i.e. the smoke supposed to be inhaled by the hookah smoker [ 6 ]. If, in cigarettes, ETS is a rough “sum” of EMSS (Exhaled MainStream smoke) and SSS (Side-Stream Smoke), aged and diluted, the case of hookah is completely different because this kind of pipe does generate almost no SSS… This fact was confirmed in a recent nuclear study conducted by Egyptian and Saudi researchers”[ 7 ]. A few years earlier, a US team pointed out that “one of the only articulated benefits to this tobacco alternative is the minimal release of side-stream smoke, which would ultimately place by-standers at risk for ETS exposure” [ 8 ].

Furthermore, What MONN et al.’ study actually shows is that UFP and CO concentrations in hookah smoke are  2.76 and 13.21 smaller, respectively, than in cigarette smoke. This is not all as DIETHELM has also dismissed important facts such as the very high proportions of glycerol and water in hookah smoke. His emphasis on Carbon Monoxide is totally irrelevant because all published peer-reviewed studies show that the mean expired CO levels in non-smokers exposed to hookah smoke virtually do not vary: e.g. a study co-authored by HAMMOND, member of WHO TobReg [ 9 ]. Notably, DIETHELM relies to a great extent on the WHO flawed report, peer-reviewed by the top experts of TobReg [ 10 ].

As for ETS “social aspects”, the WHO experts were wrong when stating that it is common (“not uncommon”) for children in the Arab world to smoke narghile with their parents [ 10 ]. Here, DIETHELM appeared to be “more Catholic than the Pope” and stressed that numerous parents (in Switzerland, apparently immigrants and likely from the same region) allow their children, sometimes aged less than 12 years, to gather at home and smoke hookah in group (Original: « […] de nombreux parents, […] parfois de très jeunes adolescents de 12 ans ou moins […] dans le logement familial […]” ). It appeared that the authors of the WHO report had no data to support what they apparently put down in a hurry. For this reason, DIETHELM is kindly requested to inform on the scientific sources supporting his harder (than WHO’s) facts.

Is this the golden standard the critic of “denialism” wishes to use when assessing opponents’ views ? Should everyone blindly agree with a supposed « overwhelming consensus on the evidence » ? Should we also name “denialists” DECKERS et al, AL-NACHEF and HAMMOND and all researchers who come up with unexpected results ? Should SIEGEL be defamed the same way he who, interestingly, argued that ETS kills over 50,000 US Americans each year and whose testimony expertise contributed towards a 145 billion dollars verdict against tobacco companies [ 11 ] ? Or the only criterion should be the scientific merit of any contribution to a debate ? Because of the lack of a free debate, even the Cochrane review ( “golden standard in evidence-based medicine”) on ““waterpipe”” proved to be not empty of serious errors [ 7 ][ 12 ]. Criticising, pinpointing and pinning down errors and debating is good for the advance of science. Finally, D&M consider Galileo as a reference that tobacco “denialists” should refrain from citing in support of their unacceptable views. What is not understood here is that the problems related to tobacco and drug research and policy are very similar. From there, Galileo is and will remain a universal reference [ 13 ].

____________

REFERENCES

[1] Diethelm, P, McKee, M. Denialism: what is it and how should scientists respond? Eur J Public Health. 2009; 19:2-4.

[2] Enstrom JE. Defending legitimate epidemiologic research: combating Lysenko pseudoscience. Epidemiologic Perspectives & Innovations 2007 (10 Oct);4:11.

[3] Ungar S, Bray D. Silencing science: partisanship and the career of a publication disputing the dangers of secondhand smoke. Publ Understand Sci 2005;14:5-23.

[4] Molimard R. Le rapport Européen Lifting the SmokeSc reen: Etude épidémiologique ou manipulation ? [The European Report "Lifting the SmokeScreen": Epidemiological study or manipulation?] Rev Epidemiol Sante Publique. 2008 Aug;56(4):286-90. [in French. Abstract in English]

http://www.formindep.org/L-article-integral-du-professeur [English full text translation]

[5] Diethelm P. Narguilé : attention, danger ! Dossier 07-003 - 2007-05-29. OxyGenève 2007 (May).

http://www.oxygeneve.ch/dossier.php?id=67 (accessed 31 Jan 2009)

[6] Monn Ch, Kindler P, Meile A, Brändli O. Ultrafine particle emissions from waterpipes. Tob Control 2007; 16: 390–3.

[7] Khater AE, Abd El-Aziz NS, Al-Sewaidan HA, Chaouachi K. Radiological hazards of Narghile (hookah, shisha, goza) smoking: activity concentrations and dose assessment. J Environ Radioact. 2008 Dec;99(12):1808-14.

[8] Deckers SK, Farley J, Heath J. Tobacco and its trendy alternatives: implications for pediatric nurses. Crit Care Nurs Clin North Am 2006 (Mar);18(1):95-104.

[9] El-Nachef WN, Hammond SK. Exhaled carbon monoxide with waterpipe use in US students. JAMA. 2008 Jan 2;299(1):36-8.

[10] Chaouachi K. A Critique of the WHO's TobReg "Advisory Note" entitled: "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17.

http://www.jnrbm.com/content/5/1/17 ÂÂ

[11] Siegel M. ASH Compares Critics Of Link Between Smoking Bans And Dramatic Heart Attack Reductions AIDS Dissidents WHo Deny Link Between HIV And AIDS. Medical News Today. 2009 (9 Feb)

http://www.medicalnewstoday.com/articles/138355.php

[12] Sajid KM, Chaouachi K, Mahmood R. Hookah smoking and cancer. Carcinoembryonic Antigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduction Journal 2008 24 May;5(19)

http://www.harmreductionjournal.com/content/5/1/19

[13] Small D, Drucker E. Return to Galileo? The inquisition of the international narcotic control board. Harm Reduct J. 2008 May 7;5:16.

http://www.harmreductionjournal.com/content/5/1/16

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Conflict of Interest:

Submitted on 16/02/2009 7:00 PM GMT
Response to G. Kabat
24 February 2009
Pascal A Diethelm (with Martin McKee)

In his rather emotional comments, G. Kabat, purporting to read our mind, claims that the 2003 BMJ paper he wrote with J. Enstrom is the "real target" of our Viewpoint. He should read carefully what we wrote. We presented their article simply as an example of "isolated papers that challenge the dominant consensus," to illustrate how these papers are used very selectively by those who deny any link between passive smoking and diseases. It is a fact that the tobacco industry has made extensive use of the Enstrom-Kabat paper in its denial campaign (unsurprisingly, as they paid and directed it). We mention how Japan Tobacco International still uses it to reject "the claim that ETS is a cause of lung cancer, heart disease and chronic pulmonary diseases in non-smokers." Another example is provided by Judge Gladys Kessler, who states in her Final Opinion that cigarette company BATCo promoted the EK study to "fraudulently deny ... that passive smoke is a health hazard to adults or children." [1, pp. 1555 -1556]

Our statement that the EK paper was "later shown to suffer from major flaws, including a failure to report competing interests" is supported by the reference we cited [2]. Using internal tobacco industry documents, Bero et al. describe how the statement detailing the authors' competing interests, in spite of its length, "does not reveal the full extent of the relationship the authors had with the tobacco industry." Reading the section dedicated to the EK study in Judge Kessler's Final Opinion also reveals the enormous gap between the authors' statement and the evidence found by the US federal court.[1, pp. 1380-1383]

Bero et al. also mention a major flaw of the EK study: there was no real "unexposed" group in the CPS-I dataset that Enstrom and Kabat used. Judge Kessler made the same observation: "The American Cancer Society had repeatedly warned Enstrom that using its CPS-I data in the manner he was using it would lead to unreliable results. Enstrom used only a small subset of the overall data, and, more importantly, the data corresponded to participants who enrolled in 1959, a time when exposure to tobacco smoke was common."[1, pp. 1382-1383] Members of the 2002 working group on involuntary smoking and cancer for the International Agency for Research on Cancer made the following assessment - reported in Judge Kessler's Final Opinion [1, p. 1382]: "Enstrom and Kabat's conclusions are not supported by the weak evidence they offer, and although the accompanying editorial alluded to 'debate' and 'controversy', we judge the issue to be resolved scientifically, even though the 'debate' is cynically continued by the tobacco industry."

We therefore think that our statement that the EK paper was "shown to suffer from major flaws, including a failure to report competing interests" is based on solid references. Given what is today known about this paper, we stretch the charity principle to the maximum extent possible when we present it simply as an example of "isolated papers that challenge the dominant consensus."

1. Gladys Kessler, United States District Court Judge, Final Opinion, August 17, 2006 http://www.usdoj.gov/civil/cases/tobacco2/amended%20opinion.pdf

2. Bero LA, Glantz S, Hong MK. The limits of competing interest disclosures. Tob Control 2005;14:11826.

Conflict of Interest:

None declared

Submitted on 24/02/2009 7:00 PM GMT
Response to Pascal Diethelm and Martin McKee
26 February 2009
Jonathan H Bagley

The following extract from the paper perfectly illustrates why many people question the claims of anti-tobacco groups.

"......while even now, despite clear evidence of rapid reductions in myocardial infarctions where bans have been implemented, there are some who deny that second-hand smoke is dangerous."

England has a population of 51,000,000. The data for heart attack incidence for the period following the July 2007 English smoking ban is now available [1]. The most recent figure covers the period April 2007 to March 2008 and shows a year on year fall of 2%; compared to 2.8% for 06/07 and 3.8% for 05/06. Although the last period does not start in July 2007, it is implausible that the decline in the year following the ban exceeds 3%. The situation is similar in both Scotland and Wales.

In the USA, smoking bans are often implemented county by county, do not cover all non-residential premises and appear to be frequently violated. The exact opposite has been the case in England. On one day, a total smoking ban was imposed on 51,000,000 people. There was no rapid reduction in myocardial infarctions. To argue otherwise using small samples from the target or similar populations is akin to attempting to overturn an election result by taking an opinion poll a week later.

[1] HESonline. http://www.hesonline.nhs.uk

Conflict of Interest:

smoker

Submitted on 26/02/2009 7:00 PM GMT
Real denial
19 March 2009
Jeffrey R. Johnstone (with None)

Two examples of real denial.

First, the 1998 WHO study of passive smoking and lung cancer, the largest case-control study yet conducted.:

http://jnci.oxfordjournals.org/cgi/reprint/90/19/1440

“Results: ETS exposure during childhood was not associated with an increased risk of lung cancer (odds ratio [OR] for ever exposure = 0.78; 95% confidence interval [CI] = 0.64–0.96).”

It is clear that the authors could not bear to put into words their own numerical results which show that passive smoking in childhood is associated with a reduced incidence of lung cancer. This was their only significant result, the other two exposures being spouse and workplace. Their quoted statement is at best deceptive.

Second, a missing report from the US Surgeon General. In 1964 the American Surgeon General published "Smoking and Health", the first of many reports about public health. There are dozens of them.most of which relate to smoking and health. A list of them can be found at:

http://www.surgeongeneral.gov/library/reports.htm

But one is missing. At the time of the first report the Surgeon General had exercised his right to commission the Bureau of the Census to survey the population and compare the health of smokers, nonsmokers and exsmokers.The results were published in 1967 as`"Cigarette Smoking and Health Characteristics" with "William H. Stewart Surgeon General" on the title-page. The results were unexpected and, it seems, unwelcome: the healthiest people were not the nonsmokers but those who smoked 1 - 11 cigarettes per day

http://members.iinet.net.au/~ray//sr10_034acc.pdf

Forty years ago when antismoking hysteria had yet to develop this didn't matter too much. Today it very different: how can the message "there is no safe level of smoking" be promoted when we have evidence - from the Surgeon General himself - that a few cigarettes are not merely harmless but positively beneficial? The solution is simple. Delete it. It has been deleted and there is no trace of it at the Surgeon General site.

These are examples of serious denial.

Conflict of Interest:

None declared

Submitted on 19/03/2009 8:00 PM GMT