Dangers to life and the public health lobby: adverse drug reactions kill more than smoking

Reader What the ... delivered a series of comments on the last blog piece. With the author's consent I have reproduced them below.

Tobacco makes a lot of people a lot of money

There’s quite a bit wrong with the Public Health position. The statement implies that the tobacco industry makes a lot of money. However, there are other groups that make far more money from tobacco. For example, the amount of tax on the retail price of tobacco is in the order of 85% in a number of countries. The government makes at least 10:1 the profit of tobacco companies. And the government doesn’t produce anything: It’s simply a bureaucracy raking in the loot. Then there are so-called Public Health groups that want their cut of the booty so that they can remain in comfortable employment and further “educate” the public. Then there are pharmaceutical companies that have positioned, through much manipulation, their products as the preferred method of treatment for smoking cessation. They price their next-to-useless and cheap-to-manufacture nicotine replacement products according to artificially highly-inflated tobacco prices. The bulk of this inflated price goes directly to pharmaceutical companies. This conduct of looting those who smoke can well be described as a racket.

Routinely overlooked by Public Health is that it, too, is part of an industry making a lot of money. The medical establishment and medically-dominated Public Health has become so large that it can well be described as the medical industrial complex. It dwarfs the tobacco industry. There is plenty of evidence that there is over-servicing, over-medicating, and other fraudulent practices within the medical industrial complex. But these are very rarely considered by participants in this industry. Rather, they have promoted themselves as benevolent, non-materialistic overseers of the public protecting it from “evil” money-making industries, e.g. tobacco. This is just another massive “con job” done on the public.

Consider how the medical establishment/Public Health portrays itself in the “battle” against “evil” Big Tobacco. Antismoking has been obscenely funded by the taxpayer and Pharma interests for the last few decades. The great “skill” of activists is in propaganda – how to make headlines, how to maintain a high media profile. There has essentially been no questioning of their conduct. They are used to getting their way. The more fanatics are accommodated, the more hysterical and inflammatory become their claims, and the more deranged, draconian, and inhumane become their demands. On the rare occasion that fanatics don’t get their way, they resort to “Plan B” which is occurring now concerning “plain packaging” – it’s all a tobacco industry “conspiracy”. “There’s that 'evil' tobacco industry thwarting our wonderful work”, screech the fanatics.

This entire “us vs them” framework was also contrived by the fanatics decades ago. This mythological good vs evil drama was suggested by Chapman at the 1983 [antismoking] World Conference on Smoking & Health. It was in the presentation of his paper, a manual on how to do propaganda, “The Lung Goodbye”:

Such a list could be added to considerably, but most entries would be characterized by being somehow cast in a mythological good versus evil battle in an arena observed by mass numbers of people. The good (health/clean air/children) versus evil (cancer/uncaring, callous industry) dimension is the ineluctable bottom line in the whole issue and a rich reservoir for spawning a great deal of useful social drama, metaphor, and symbolic politics that is the stuff of ‘news value’ and which is almost always to the detriment of the industry. (p. 11)

It’s all for manipulative, theatrical effect and has been quite successful – for decades – on an essentially gullible political class, media, and public. The zealots and their financial partners must have regular belly laughs at how all too easy the brainwashing has been.

 

1. The medical establishment also does much damage, medically.

Consider “iatrogenesis” which refers to any detrimental outcome produced by medical conduct (e.g., adverse drug reactions, medical errors, poor care of the bed-ridden resulting in infected bed sores). In America, from the very few studies that have been done, iatrogenic deaths are estimated at 750,000–1,000,000 per annum. It dwarfs the so-called tobacco “death toll” (400,000) and is approaching half of the total annual death toll in America (2,500,000). The medical establishment is by far the leading cause of preventable death and disability and associated costs.

Further, the iatrogenic toll is far more plausible, causally, than the tobacco “toll”. The tobacco “toll” is based on lifetime use, involving millions of “puffs”, that also brings into play a veritable plethora of other factors over a lifetime. It is also argued from the population level that has very poor extrapolation to the individual level, i.e., it is a “statistical death toll”. Conversely, the iatrogenic toll is argued from the individual level and then estimated for the population level. For iatrogenesis, causation is typically demonstrable at the individual level. For example, with adverse drug reactions (these are properly prescribed, FDA approved drugs), it may take just one or a few pills to produce cardiac arrest in some patients that can be fatal or leave permanent injury. The patient is stable and within an hour of taking a pill goes into atypical catastrophic failure. The temporality of many of these associations is not over a lifetime, but involves hours or days. Of the two – the iatrogenic or tobacco tolls – it is the former that should attract very serious scrutiny. But, as will be seen, it has been the other way around, or upside-down, indicating who is running the show.

 

2. Concerning smoking, there have been thousands upon thousands of antismoking “studies” conducted/funded. Many do not break new ground but simply reinforce the agenda. World Conferences on Smoking and Health have been occurring since the 1960s. In the last few decades there are National Conferences on Smoking and Health. There are now even Conferences for Nonsmokers. Then there are Smoking Cessation Conferences run by the Pharma cartel peddling its useless/dangerous “smoking-cessation” wares. Additionally there are numerous antismoking lectures and colloquia and speeches and committees and campaigns. Specific institutes for the study of tobacco have been created as sub-centres of university Public Health Departments (which in turn are sub-centres of the medical faculty). There is a plethora of taxpayer/Pharma-funded antismoking organizations – referred to as “charities” – lobbying government for antismoking policies. There has been a frenzy of antismoking activity over the last three decades. A formidable, lucrative industry has been created that did not exist 30 years ago. And the bulk of it is all under medical direction. The medical establishment has wreaked social havoc, again, to tackle the tobacco “death toll”, and peddled essentially on the basis of the far smaller so-called tobacco “toll” in nonsmokers (SHS).

So we could then ask that if this has been the reaction to the tobacco “death toll”, then there must be an even greater industry addressing/correcting institution-wide iatrogenesis? In fact, there’s not. Compared with the many thousands of antismoking studies, there are but a handful (~20) concerning multi-source or institution-wide iatrogenesis, damning as they are. There are no conferences on iatrogenesis whatsoever. There are no specifically-created institutes addressing the issue. In fact, it attracts almost zero attention within the medical establishment itself. The medical administration doesn’t like talking about it or the public knowing about it. This is the same medical establishment that now wants to “fix-up” the world. Scrutinizing the medical establishment would reveal how unstable its framework is. It would mean a [reasonable] loss of profits and trust. While it tenaciously maintains the spotlight on its favourite social targets such as smoking, it avoids scrutiny like the plague. The contemporary medical establishment has been reduced to a production line, a medical industrial complex, where the tenets of the Hippocratic Oath (particularly the edict of "first do no harm") play little or no part. The medical establishment was out of control 30 years ago. It has since entered a sinister phase. And smokers are one of the first to notice the ugly side of the medical establishment in its world-fixing (eugenics) and financially-compromised aspirations.

 

3. References for iatrogenesis: from 'Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies', JAMA, April 1998 

We estimated that in 1994 overall 2,216,000 (1,721,000–2,711,000) hospitalized patients had serious ADRs [adverse drug reactions] and 106,000 (76,000–137,000) had fatal ADRs, making these reactions between the fourth and sixth leading cause of death.

Including more sources of iatrogenesis:

'Doctors are the third leading cause of death in the US: cause 250,000 deaths every year'

Starfield, B. (2000) 'Is US health really the best in the world?' Journal of the American Medical Association, 284 (4), 483–485. Including even more sources of iatrogenesis:

Null et al. (2003) 'Death by Medicine'

Classen et al. (2008) “'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured"

4. Some recent reports from other countries:

Huffington Post, 14 July 2013, 'NHS scandal report to expose thousands of 'excess' deaths at 14 Trusts'

Australian Broadcasting Corporation, 15 July 2013, 'Aged care crisis: A critical lack of staff and training in some nursing homes means that many elderly people are being left to die unnecessarily or are in great pain without proper palliative care.'

UPI, 28 June 2013, 'Physician reveals the 'hidden agenda' of medical school'

***

The story that emerges from the last few decades is that the medical establishment in developed nations is dangerously out of control. And it’s not as if the above reports are anything new, and some of these reports only touch the tip of the iceberg. These sorts of reports emerge every few years. Nothing is typically done to address the problems, with more reports to emerge a few years down the track, etc. And the problem is set to worsen with the “boomers” coming into old age. Medical practice has been allowed to flourish into a medical industrial complex into which the patient is forced. There is a theme amongst medical practitioners of having the bedside manner and social graces of an oaf. They conduct themselves like “body mechanics” with a “god complex” – delusions of omniscience, infallibility, and benevolence. The medical establishment produces many detrimental outcomes, yet is highly self-serving and self-protecting, where one major constancy is the production of profit, seemingly at the expense of much else, even to the point of a culture of secrecy concerning highly significant iatrogenesis. The doctor/patient relationship has also taken a pounding. Particularly concerning smoking, many doctors adopt a dictatorial stance where patients should even be coerced into quitting. There is also a cruel theme emerging in the medical establishment – see nursing home abuses. And it doesn’t stop there. Is it also not cruel to force patients that want to smoke off the entire medical property – in any weather – to do so? And what about involuntary mental patients that want to smoke? They are restrained physically or chemically, or given multi-day solitary confinement, rather than allow them to have a cigarette – even outside.

There has been a terrible loss of compassion. Practitioners have become blinded by questionable ideological stances (e.g., antismoking) and profit pressures. There is a chilling inhumanity that has been allowed to flourish in the medical establishment.

The issue of iatrogenesis is occasionally put to Michael Siegel. Here’s his response of only a few days ago:

Sadly, the problem of medical errors and iatrogenic illness is one that has not received appropriate attention. You are correct that it causes a great deal of morbidity and mortality. Unfortunately, the medical and health care establishment has been quick to criticize others, but when it makes mistakes, it almost never acknowledges them. Many hospitals have opposed simple right-to-know laws that required them to report medical errors that are made. I experienced this on a personal level during my medical school training (I didn't make the mistake, I observed someone else doing so). 

It should also be noted that all of the detrimental consequences of the antismoking crusade – e.g. irrational fear/hate, social division/isolation, bigotry, economic fallout, contraband market – are also iatrogenic.

Tobacco control industry: policy-led research newspeak

This one from Michael Siegel's blog. A study purported to investigate whether anti-smoking posters were effective in persuading people not to take up smoking. The findings were negative:

The study clearly states these findings: "The signs did not help recent quitters to stay quit or stop smokers from purchasing cigarettes at the current visit to the store."

But the study concludes:

"A policy requiring tobacco retailers to display graphic health warning signs increased awareness of health risks of smoking and stimulated thoughts about quitting smoking. Additional research aimed at evaluating the effect of tobacco control measures in the retail environment is necessary to provide further rationale for implementing these changes and countering legal challenges from the tobacco industry." [emphasis]

Talk about hiding in plain view. They know the graphic posters don't have the intended effect but are prepared to commission further studies to justify producing and using the posters.

Siegel concludes, 'This is another example of how the anti-smoking movement has recently lost its science base in favor of a pre-ordained agenda'. Recently?

This is not unique. One of my favourite pages is from Cancer Research UK's Tobacco Advisory Group. It details research priorities and I have referred to it many times:

• The Tobacco Advisory Group (TAG) considers Project Grant applications for policy research and policy advocacy activities in tobacco control.
  TAG particularly funds research and activities that support:
  - Current UK policy priorities, e.g. see the 'Beyond Smoking Kills' report and the Tobacco Control plans of the four UK nations, especially:
• - Plain packaging of tobacco products
• - Greater tax and/or anti-smuggling measures in the UK
• - Monitoring the impact of NHS changes and/or promoting best practice in smoking cessation, mass media campaigns and local tobacco control activities
• - Health inequalities should be addressed in all projects.

Its terms of reference clearly exclude anyone with an open mind on the issue of tobacco control. The direction of policy is established and the researcher is invited to support it or not expect any funding.

California's Tobacco-Related Disease Research Program similarly has a clear policy agenda, as you would expect from its name. If you look at its research priorities (third menu tab), you will find that the priorities are set and your job as researcher is to find reasons to support it. Environmental Exposure needs: 

Research that will advance policies to reduce environmental exposure to the toxic effects of tobacco smoke, tobacco smoke residue, cigarette butts, and other tobacco products.

Regulatory science:

Research that will expand the scientific basis to inform the regulation of nicotine and tobacco products at the local, state and national levels

Tobacco industry influence:

Research that will advance the ability of communities throughout California to assess and limit the influence of the tobacco industry

and more. 

Absent from any of these research needs is any concept that the science should lead the policy. It's all the wrong way round. Annual reports give an idea of the cost of some of these research grants. 

As part of its regular 2010 funding cycle, The Scientific Advisory Committee recommended, and TRDRP awarded $12.7 million in 46 new grants at California non-profit research institutions. 

As well as the issue of policy determining what is studied and how (rather than an open agenda leading to honest science and well grounded policy) there is an issue of policy being led by wealthy foundations funded from tobacco taxes. The tobacco taxes fund these studies, and this effectively binds researchers into supporting tobacco control, because tobacco control supports them.

All very unsatisfactory and I am grateful to Dr Siegel for reminding me of the issue – but like many I am curious how long it will take him to realise that tobacco control has not recently lost its science base in favour of policy-driven research.

Liquor license group challenges Health Director Wymyslow, Ohio

The Buckeye Liquor Permit Holders' Association issued this press release yesterday. They state that a new Executive Summary Report published by the Ohio Department of Health misrepresents the main study, 'Analysis of the Impact of Ohio's Smokefree Workplace Act', by failing to refer to vital data presented in the report. It was not reported that fewer than 1 per cent of smokers increased their patronage of bars after the smoking ban came in. The fact that venues in the lowest tax bracket were excluded from the study was also left out of the summary report. The group also points to the claim in Ohio Health Department's report that heart attacks dropped drastically (by 26 per cent) following the smoking ban, referring to Michael Siegel, smoking ban advocate of 25 years' standing, who shows that there were more heart attacks after the smoking ban than before it.

The group also questions the appointment of employees of the Public Health and Health Promotion departments of the administration to write an economic study, when their career interests are at stake in the outcome.  The omission of information in the Executive Summary concerning bars specifically is achieved by collating information for the entire hospitality sector, which conceals damage to bars. Leaving out establishments in the low tax bracket enhances the focus on bars and restaurants in areas less affected by the ban (in districts with fewer smokers). (Both these issues are covered in an enlightening 2008 paper by Michael Marlow entitled 'Honestly, who else would fund such research?')

Opponents of Ohio Bans have today gone even further and called for the resignation of the Health Director Dr Theodore Wymyslow, on the grounds that the Executive Summary Report gives misleading and essentially fraudulent information to the press – both broadcast and print media. This report has been released one month before a debate on the constitutionality of the smoking ban is heard in the Ohio Supreme Court and the Ohio group holds that this is a deliberate attempt to influence the outcome of this debate.

The methodology of the Ohio report rings bells. Professor Linda Bauld, a professor in Socio-management recently appointed to Stirling University, published a significant report on the economics of the smoking ban in March: The Impact of Smokefree Legislation in England: Evidence Review. It is curious that the public accepts as impartial and authoritative economic reports about smoking bans that are written by researchers in public health departments, who in general lack insight into the economics of the hospitality industry and are swayed by the requirements of their paymasters.

We should take a leaf from Michael Marlow's paper and remember the 'rhetoric of assent' referred to in Michael Marlow's paper: 'that is an initial readiness to suppose that the other guy or gal is also fairminded and trustworthy and deserves to be heard out'. Unfortunately the influence of the Framework Convention on Tobacco Control makes this very difficult, as the FCTC works to resist 'tobacco industry interference' (interpreted as widely as they can) in public policy (Article 5.3). It is hard not to dismiss the insights of the other camp when they are so determined to dismiss any take on the issue that doesn't emanate from public health.

I look forward to an update on Ohio.

Scotland bribes smokers to quit: the efficacy of medication

NHS Tayside is extending its programme that offers money to people who use NHS services in order to attempt to stop smoking, on a postcode lottery basis. It targets its efforts towards those in deprived areas whose postcode indicates that they are probably heavy smokers, in order to try and close the 'health inequality' gap. 


The Courier explains. The scheme (which pays £12.50 a week in supermarket vouchers) has allegedly reached a quit rate of 50 per cent after four weeks. (Only five readers have left comments on this story, and they don't seem very happy about the outlay on the scheme.) This stupendously high quit rate (compared with what is normally achieved – see Michael Siegel's review of a recent study) apparently justifies the roll-out of the scheme, known as quit4u, from Dundee into neighbouring towns. 


Interesting that arch anti-smoker (and plain packaging advocate) Simon Chapman doesn't buy the line that NRT works, or that expenditure on it is justified.

The pharmaceutical industry has a clear commercial interest in eroding public and professional confidence in unassisted smoking cessation, yet easily implemented ideas, such as graphic health warnings, are more effective than nicotine replacement therapy. 

Is Chapman biting the hand that feeds him? It is not hard to find pharmaceutical links with the anti-smoking industry. Indeed health professionals were cautioned about this close relationship only a few weeks ago, by the World Health Organisation. Some of Chapman's anti-smoking colleagues are puzzled by his line of argument. Many have taken issue with him.  Not only does he not believe in smoking cessation treatments, he believes that pharmaceutical interests exaggerate the difficulties of smoking cessation, and that anti-smoking campaigning should not attempt to make out that people can't quit without help. Two years ago he published a major study that made the following points:

• - Research shows that two-thirds to three-quarters of ex-smokers stop unaided. In contrast, the increasing medicalisation of smoking cessation implies that cessation need be pharmacologically or professionally mediated.
• - Most published papers of smoking cessation interventions are studies or reviews of assisted cessation; very few describe the cessation impact of policies or campaigns in which cessation is not assisted at the individual level.
• - Many assisted cessation studies, but few if any unassisted cessation studies, are funded by pharmaceutical companies manufacturing cessation products.
• - Health authorities should emphasise the positive message that the most successful method used by most ex-smokers is unassisted cessation.

The message still hasn't got through to Tayside. 


I would love to know how Chapman expects the anti-smoking bandwagon to get pharmaceutical industry support if he goes about dissing the effects of nicotine replacement therapy. Does he expect to extort the money from the tobacco industry? Only time will tell.

Calls for e-cigarettes to be banned while Champix remains on sale

Michael Siegel asks quite fairly why Champix, known to have links with psychotic, suicidal episodes and worse, is freely available, when certain anti-smoking groups have called for the banning of e-cigarettes, which have no documented safety record or pending lawsuits on behalf of users.

He shows links between the US anti-smoker groups and pharmaceutical giants including Pfizer, which manufactures Champix. He also addresses the ideology of anti-smokers (popularly tagged 'quit or die'). Your quitting aid mustn't even look like a cigarette or it doesn't count:

The ideology is simply this: nothing that looks like cigarette smoking can possibly be a good thing, even if it saves lives. People need to quit smoking the way we say they should quit smoking. There is a right way and a wrong way to quit smoking. The right way is our way and the wrong way is any other way. If it looks like smoking, it's still smoking, even if there are no adverse health effects and the individual has achieved smoking cessation. 

 His logic is persuasive:

If anti-smoking groups want to argue that any smoking cessation product on the market has to first be unequivocally proven safe, then fine. They can argue that e-cigarettes should be removed from the market but they must also call for Chantix to be pulled from the market for the same reason.

Alternatively, if they believe that the burden of proof is on others to demonstrate that Chantix is unsafe before pulling it from the market, then that's fine too. But then they must apply the same reasoning to electronic cigarettes and ask that these products remain on the market until such time as they are demonstrated to be unreasonably unsafe.

More on Champix here.

American public health charity calls for moderation in tobacco education

Although the USA largely subscribes to the idea that passive smoking kills, the American Council on Science and Health (like Michael Siegel) criticises more extreme claims made by other public health bodies. It takes the following example (which also typifies the kind of claim often criticised by Michael Siegel), claiming that it risks rendering all tobacco education too incredible to be taken seriously.

The report states, “[T]here is no safe level of exposure to tobacco smoke and that smoke causes damage immediately to the cardiovascular system. Even low levels of tobacco exposure lead to disease and death, including heart attack, stroke, weakened immune system, and asthma attacks.” 

 “Has the Lung Association damaged its credibility in making such a dramatic, unqualified assertion?” asks Dr Elizabeth Whelan of ACSH, not for the first time. This body does not shrink from criticising the Surgeon General's report, which includes similar claims about secondary smoke, and calls for a zero tolerance policy towards tobacco smoke:

Upon reading this statement, ACSH’s Dr. Gilbert Ross is left wondering whether basic toxicology and cancer-causation principles were considered in the drafting of the Surgeon General report. “Whether indirect exposure to tobacco smoke leads to disease is a matter of dose — the amount of smoke it takes to trigger adverse health outcomes such as heart disease or cancer — but the question of dose-response and exposure levels never made it into the report.” 

ACSH stops short of recommending spending much time exposed to tobacco smoke, but their suggestion to observe dose:reponse principles could be well observed by other bodies, especially in the United States, where they take the concept of third hand smoke seriously. University of Berkeley, California, scientists have pretty much dispensed with any such principles in their study of third hand smoke, as tobacco researcher and author Chris Snowdon writes here.

Noting that ASH Scotland has managed to set up an anti-smoking conference offering Learning Outcomes in (for want of a better expression) anti-smoking propaganda, I wonder how long before Scottish National Certificate qualifications are issued in Junk Science for being able to describe the damage to children from third hand smoke? What an outcome that would be for a small country with a proud educational record.

Or perhaps we will start to take science seriously again instead!