What Medscape Subscribers Really Thought About Its Tobacco Harm Reduction Programs

 

Earlier this year, Medscape, which describes itself as “the leading online global destination for physicians and healthcare professionals worldwide,” invited me to participate in a series of short continuing medical education (CME) programs on tobacco harm reduction (THR).  Medscape clearly disclosed that the series was sponsored by Philip Morris International, but the programs were firewalled; faculty were not in contact with or influenced by the sponsor.

Topics included, among others, an examination of nicotine, and the differential risks of combusted versus smoke-free tobacco/nicotine products.

I recorded two programs.  The first, “Nicotine Misperceptions: What Does the Evidence Say,” was published online by Medscape around March 1.  The second, in collaboration with Dr. Sally Satel, “Harm Reduction From Tobacco: An Evidence-Based Discussion,” was published April 1.  Dr. Satel also recorded a third program.

Following publication, a few anti-tobacco crusaders objected, threatening “a rapid global boycott by healthcare professionals disgusted by [Medscape’s] behaviour” in two British Medical Journal articles and one in The Examination.  I will not provide links to these, as they include ad hominem attacks on me.  Dr. Satel recounts the sorry tale in this article (here).    

As Dr. Satel notes, Medscape buckled, whining that “use of this funder was a misjudgment that was out of character for Medscape Education and that doing so may have disappointed our members.”

But were Medscape members truly offended by the PM sponsorship?  Evidence from an email I received from a Medscape manager says “NO.”  Shortly after my nicotine program aired, I received an unsolicited email from the manager titled, “One of the best CME programs I have seen in a long time…” Following is the text of that email, with some passages highlighted by me.

“We have the preliminary results from your program that was posted less than a month ago, and I am personally flabbergasted by the participation - over 6000 learners and over 2200 test takers!

“The comments from participants have been incredible as well:

• I can better educate and motivate pts on how to cut down their use of nicotine products. I am also more cognizant now that those who use cigarettes may have a more difficult time quitting. Will refer these pts to our clinical pharmacist who can also help advise and prescribe the appropriate tobacco cessation products.
  

• This was fantastic! This down to earth harm reduction approach is absolutely key to help meet people where they are, as nicotine addiction is so strong! Much better outcomes can be achieved as these presenters described, using less harmful forms of nicotine. As the doctors stated, there is a great need to educate providers, and clarify misconceptions about nicotine vs various methods of ingesting nicotine. I hope this presentation reaches a wide audience! One of the best continuing eds I have done in a while.
  

• Dispelled many myths I previously held about nicotine that I will no longer propagate.

• Thank you for bringing up such an important topic that can bring down the costs of healthcare and truly improve the public health. I am a psychiatric provider and have had a large number of patients successfully quit smoking with harm reduction measures!”

It is tragic that Medscape capitulated to rabid tobacco prohibitionists and stopped providing vital, life-saving information to health professionals.

 

The British Medical Journal Falsely Claimed “Harm Reduction Advocates and the Tobacco Industry Capitalised on the Pandemic to Promote Nicotine”

 

The British Medical Journal (BMJ) on June 2 published an article, titled “Research Integrity”, authored by two investigative journalists.  Aping the position of the World Health Organization, they accuse harm reduction advocates and the tobacco industry of undermining decades of tobacco control.  The BMJ notes that the article was “externally peer reviewed.” 

The journal has a rapid-response comment system that is managed by the editors.  I submitted a comment on June 9, detailing specific scientific problems with the article’s content.  It was not published, so I present it here. 

_________________________________________

 

The Editor 

British Medical Journal 

Dear Sir,

The recent article by Stéphane Horel and Ties Keyzer claimed that “the tobacco industry capitalised on the [covid 19] pandemic to promote nicotine” when “two preprints published in quick succession in April 2020… made headlines worldwide. They were also picked up by libertarian media outlets… The World Health Organization worried that decades of tobacco control could be undermined.” (Reference 1) 

Horel and Keyzer then stated: “It has since been roundly disproved that smoking protects against covid-19. Among other studies (2,3,4) the OpenSafely dataset, based on the primary care records of 17.3 million adults in the UK, found that smoking, when adjusted for age and sex, was associated with a 14% increased chance of covid-19 related death (5).”

Horel and Keyzer implied that the four research citations (assigned different reference numbers here) “roundly disproved that smoking protects against covid-19.”  It is ironic that the article by Horel and Keyzer was published in BMJ under the topic of “Research Integrity,” because their own research may not have reached the level readers deserve in a quality medical journal.  In fact, a close look at their four studies, and others that they omit, roundly disproves their disproval claim. 

Three of the four studies (2,3,4) cited by Horel and Keyzer report positive associations, but they need further clarification.  For example, the first study did not employ rigorous diagnostic criteria: study participants used an app launched via radio, TV and social media in the UK to report covid-19 “symptoms” and “whether they thought that they already had COVID” (2).  The second study found that smokers were 3.5 times more likely to have confirmed covid-19 (95% confidence interval, CI = 2.4 – 6.1) than never smokers, but this was only true for participants with low education (3).  However, the risk for highly educated smokers was not elevated at all.  A longitudinal follow-up study found that current smokers had a slightly, but non statistically significant, elevated odds of confirmed covid-19 (minimally adjusted odds ratio (AOR) = 1.24, CI = 0.85 – 1.24) (4).  Finally, Horel and Keyzer carefully describe the OpenSafely study (5) as evidence, saying that current smoking, “when adjusted for age and sex, was associated with a 14% increased chance of covid-19 related death.”  True enough.  But what they fail to mention is that, when the result was fully adjusted for confounding factors, the effect of current smoking became statistically significantly protective (AOR = 0.89, CI = 0.82 – 0.97).

Horel and Keyzer also failed to accurately cite and acknowledge studies that have shown a protective effect of current smoking on covid-19 (6,7,8).  They mentioned such a study from China but didn’t reference it, which is unfortunate because it was published in the New England Journal of Medicine (6).  They also mentioned and cited a study from France (7), but characterized it only as published quickly and as the origin of media hype. 

Horel and Keyzer completely omitted other studies, such as one involving veterans in the U.S., which found that smokers were much less likely to test positive for covid-19 than nonsmokers (AOR = 0.45, CI = 0.35 – 0.57) (8).  Another omission was a rapid evidence review of 28 observational studies finding that “Current data suggest that smokers in the community appear to be less likely to test positive for SARS-CoV-2 compared with never smokers,” “Across 405 studies, recorded current but not past smoking prevalence was generally lower than national prevalence estimates. Current smokers were at reduced risk of testing positive for SARS-CoV-2 and former smokers were at increased risk of hospitalisation, disease severity and mortality compared with never smokers.” (9)  However, one omission by Horel and Keyzer is especially inexplicable, because the study was published by this journal (BMJ) (10).  In that study smokers were significantly less likely than non-smokers to be diagnosed with COVID-19 and to be admitted to an intensive care unit (ICU), and the latter effect was dose-dependent.  The adjusted hazard ratios for ICU admission was 0.26 (CI = 0.19 – 0.37) for light smokers and 0.07 (CI = 0.01 – 0.47) for heavy smokers.   

In summary, there is substantial evidence that current smoking may be negatively associated with a covid-19 diagnosis and its subsequent course, including death. 

Brad Rodu

 

References

1.  Horel S, Keyzer T.  Covid 19: How harm reduction advocates and the tobacco industry capitalised on the pandemic to promote nicotine.  BMJ 2021. 373 doi: https://doi.org/10.1136/bmj.n1303 (Published 02 June 2021)

2.  Hopkinson NS, Rossi N, El-Sayed Moustafa J, et al.  Current smoking and COVID-19 risk: results from a population symptom app in over 2.4 million people.  Thorax 2021. https://doi:10.1136/thoraxjnl-2020-216422   

3.  Jackson ‍‍SE, Brown J, Shahab ‍‍L, et al.  COVID-19, smoking and inequalities: a study of 53 002 adults in the UK.  Tob Control 2020. https://doi:10.1136/tobaccocontrol-2020-055933  

4.  Holt H, Talaei M, Greenig M, et al. Risk factors for developing COVID-19: a population-based longitudinal study (COVIDENCE UK). MedRxiv 2021 [preprint]. https://doi:10.1101/2021.03.27.21254452

5.  Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020;584:430-6. https://doi:10.1038/s41586-020-2521-4  pmid:32640463

6.  Guan WJ, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020 382, 1708–1720.  https://DOI:10.1056/NEJMoa2002032

7. Miyara M, Tubach F, Pourcher V, et al. Low rate of daily active tobacco smoking in patients with symptomatic COVID-19. Qeios. 9 May 2020. https://www.qeios.com/read/WPP19W.4

8. Rentsch CT, Kidwai-Khan F, Tate JP, et al. Covid-19 testing, hospital admission, and intensive care among 2,026,227 United States veterans aged 54–75 years. MedRxiv 2020 https://doi.org/10.1101/2020.04.09.20059964.

9.  Simons D, Shahab L, Brown J, et al. The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review with Bayesian meta-analyses (version 11). Qeios 2021. https://doi:10.32388/UJR2AW.13

10.  Hippisley-Cox J, Young D, Coupland C, et al.  Risk of severe COVID-19 disease with ACE inhibitors and angiotensin receptor blockers: cohort study including 8.3 million people.  BMJ Volume 106, Issue 19, 2020 https://heart.bmj.com/content/106/19/1503

 

Competing interests: The author’s research is supported by unrestricted grants from tobacco manufacturers to the University of Louisville and by the Kentucky Research Challenge Trust Fund. The sponsors had no knowledge of this work and therefore had no input or other influence in the design, analysis, interpretation, or in the preparation of and decision to submit the rapid response.

 

BMJ Editorial: Holding the Line For Ignorance

The British Medical Journal grossly erred in its January 2 commentary, “Hold the Line Against Tobacco” (here), by editor Dr. Fiona Godlee.

 

BMJ asserts that e-cigarettes pose a “grave risk to public health because of their potential to renormalise and glamourise smoking.”  As Clive Bates pointed out in a scathing critical comment (here), “It requires heroic contortions of logic to regard the emergence of a product that is perhaps 99-100% less risky than cigarettes and a viable alternative to smoking as an adverse development… [The e-cigarette] should really be seen as a disruptive intrusion into the cigarette industry: a new high technology product entering the market for the popular legal recreational drug, nicotine, and posing a threat to the dominant and most harmful delivery system, the cigarette… Your editorial follows the established pattern of prohibitionist public health activists of focusing on minor or implausible risks for which no evidence exists in reality, while ignoring or diminishing the huge potential benefits that are real and visible from adopting e-cigarettes.”

Dr. Godlee’s commentary veers dramatically from the norms of science journal precision, as seen in this extraordinary claim: Moves by New York City Mayor Bloomberg’s administration “against tobacco, trans fats, and sugary drinks, and for promoting physical activity and calorie counts on menus, are credited with improving life expectancy among New Yorkers—now two years higher than the US national average.”

Nothing in the city’s formal report on life expectancy (here) even remotely supports this claim.  The report mentions anti-smoking policies, but offers no proof that they account for differences in mortality from heart diseases and cancer between New York and the U.S. as a whole.  Mr. Bates is right to call for “a BMJ special edition setting out the evidence for the effectiveness of these measures in improving life expectancy in New York.” 

The dominant theme of the BMJ editorial is revulsion of the tobacco industry: “E-cigarettes also legitimise the industry, buying tobacco companies a seat as ‘partners’ at the health policy table,” a position Dr. Godlee rejects.

The reality is that in the U.S., regulation of the tobacco industry has de facto legitimized it and guaranteed companies a seat at the health policy table.  Indeed, FDA officials are compelled to consider industry research and analysis, and if the FDA fails to do so it is subject to repercussions. 

Appropos of this, it is sadly worth noting that the FDA has also lapsed in its adherence to rigorous scientific principles.  Its recently released preliminary report on menthol (here), which I have commented on (here), is a case in point.  Lorillard last November submitted these scathing comments to the FDA public docket (here):

“Unfortunately, FDA’s review of the available scientific information on menthol cigarettes falls far short of FDA’s own established standards of scientific integrity and cannot be used to draw valid conclusions, nor can it serve as the basis for regulatory action.  FDA’s analysis suffers from many significant flaws and its conclusions are at times based upon unsupported speculation and conjecture. Many of the studies relied upon by FDA fail to meet the appropriate standard of scientific evidence, yet numerous high-quality studies are improperly and inexplicably discounted or entirely omitted.”  The 134-page submission backs the company’s claims with robust evidence. 

Rigorous standards imposed by regulation should apply equally to all parties, including regulators themselves.  Such standards may be especially uncomfortable for tobacco prohibitionists, who are prone to gross abuse of the facts.