by Carl V Phillips
Chris Snowdon understands what constitutes true conflict of interest, and provides us with two critical observations about it relating to THR. I point out that he understands it because most people who invoke the concept, especially those who make it a centerpiece of their rhetoric, clearly do not have a clue about what it means.
Conflict of interest occurs, to put it clearly enough that even those who harp on the concept might understand, when there is an interest someone is supposed to be serving (perhaps due to their job description, but possibly just because of how they are representing themselves), but there is something about that individual that might cause them to favor some other interest that is conflict with the one they are supposed to be serving. Notice that this is not remotely similar to the usual naive misunderstanding of the concept, that COI exists if and only if someone has received funding from industry. Indeed, notice the funding is not only not sufficient for COI to exist, but it is not necessary.
For example, when Stanton Glantz humorously tried to take on Igor Burstyn’s science, he had a severe conflict of interest: He was pretending to offer a scientific analysis, and thus was obliged to fulfill the interest of being an honest scientific analyst, but because Glantz is really motivated entirely by personal politics when he is pretending to be a scientist, there is a conflict of interest. By contrast, if Glantz has published his screed and had made clear his real goal — “here are some talking points that those of you who wish to deny what this study demonstrated can use” — then there would have been no COI. This is because his personal politics would be perfectly aligned with the interest he claimed to be serving, so there could be no conflict. Whether some interest creates a conflict obviously depends on what interest you are claiming to serve. That should seem rather obvious, but again is apparently completely over the head of almost everyone who presumes to make a big deal about COI.
In this brief but completely damning post, which he quite rightly describes as the “conflict of interest of the week”, Snowdon reports on a director at a smoking cessation clinic complaining about the success of e-cigarettes in taking away his clients. The director includes an attack on vaping as part of that. So, what interest is a government-funded smoking cessation employee suppose to be pursuing? Smoking cessation, of course. If he is objecting to successful smoking cessation it must be because he is more interested in serving some other interest, say, keeping his job.
In this much longer post, Snowdon explores how COI seems to being the defining factor in government decision-making about e-cigarettes. The interest of a government official is supposed to be the interests of her constituents or the people. Snowdon recounts a recent story that, by itself, is the typical naive COI story: The expert panel that advised the UK MHRA on e-cigarettes included people who had gotten grants and contracts from pharma companies. Left by itself, that is a major *yawn* — everyone with any skills in health research has gotten grants/contracts from pharma companies. But treating that as if it were somehow noteworthy in isolation is exactly what most commentators did. Would the influence from such funding alone cause someone to lie? Doubtful.
But contrast, Snowdon goes on to put this in the context of the outright bribery that seems to dominate EU parliament votes related to tobacco and THR. Of course, the EU is pretty much purpose-built for COI. The representatives are so incredibly far from their constituents, and barely monitored by them or the press, and live in a disconnected world that is all about power and connections and prestige (and thus the handing out of material benefits). Europe still loves monarchy (though if you have real monarchy there is no COI because there is no obligation to the people — l’etat c’est moi).
Snowdon leaves it to us to connect the dots, but I think he is pointing out that perhaps we should be rather more wary about observations that might suggest there might be a hidden COI (even though they do not themselves represent a real COI) among decision makers. A history of a few grants and contracts means nothing, unless it is a corner of a serious COI scandal. It is as if we were considering tobacco industry behavior and we were still living in 1975 (which, apparently, most of tobacco control thinks is the case) and there were subtle hints of tobacco company influence over decision makers. That would be in the context of definitive evidence of improper influence elsewhere, and would suggest extra scrutiny. Except in this century, of course, it is everyone other than the tobacco industry that seems to warrant the extra scrutiny.
Finally, it is worth noting that while the prospects of personal financial gain might explain the behavior of the MEPs, I actually think it is way down the list of important COIs that caused people to lie about e-cigarettes in the other cases. Tobacco control and smoking cessation people are probably much more conflicted by the desire to personally be responsible for health benefits, a self-centered but not precisely selfish motive. That is, they are desperately afraid that the goal will be achieved in spite of them rather than instead of them. This interest conflict severely with the goal itself when the world moves on and the goal is better served by what others are doing.
Great read. I think press sensationalism is the biggest worry and trumps COI and ideology every time. They love the scare story as we have seen from the way they have reported this “French Study”.
I agree great read. The wheels of ANTZ THR are rolling vigorously with plenty of COI masked with fear spreading propaganda proliferation.
The main conflict of interest that bent medics and academics have who work against THR is their duty of care of some kind (which means that in theory they should work for public health no matter what), combined with their expectation of future work or grants or funding from the commercial interests opposed to THR. Unfortunately a ‘future expectation of reward’ must be about the hardest of any conflict to prove (although it might correlate with past funding), but nevertheless this is the most important driver of all.
Agreed. In fact, the past does not matter at all — it is only the expectation of something in the future. Moreover, it is an expectation that the future funding would be affected by a particular choice. That is almost certainly the the case for funding from ANTZ sources and government. It is actually very unlikely to be the case with industry, who just wants good people. Maybe pharma a little bit, if you were really rallying against them. Not tobacco companies at all — if you were an open tobacco company hater but were willing to take their money for a specific project they wanted to fund (so long as they trusted you to do it honestly, of course), they would probably still do it.
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At this point I have to apologise for so much anti-pharma stuff, but those in the US need to appreciate that there is no MSA in the UK/EU, and pharma has taken up the slack here. A multi-billion $$ hole in potential anti-THR funding over this side has had a considerable effect, not least in making me slightly more bitter and twisted, for which, again, I apologise :)
No need to apologize, but it is worth a bit of thinking about whether the mechanism is valid. The total amount of profit from anti-smoking drugs, while a big number, is not so big (by their standards) that it would cause an all-out effort by those companies.
The MSA is, of course, an unconstitutional tax on smokers. Since you don’t even have a constitution, there are no barriers to just confiscating people’s money and giving it to anti-THR liars in order to harm the people whose money was taken — basically the same thing, either here or there.
Yes, we don’t have a constitution, although I get the impression that it can be ignored as convenient. I think our democracy is perhaps more like the Greek version than some appreciate: not applicable to women, slaves, etc.
Pharma has multiple income channels from smoking, and there is an inverse relationship between the speed each channel is affected and its size. For example, smoking cessation product sales are rapidly affected by smokers switching to THR products, but the market size is small (in their terms – maybe $5bn global). The hit comes in months, not years.
Next comes the big boost to multiple drug sales from smokers increasing demand: diabetes, cholesterol, blood pressure meds etc. This is a very large market effect (would be interesting to get an estimate of how much larger than the cessation market): a smoker is >40% more likely to be a diabetic, and a 1PAD smoker >60% more likely to be a diabetic (so I hear, anyway). You have to be talking $20bn + here. This is a medium term affected market – maybe 1 year to 5 years or something like that, as smokers switch away from cigs to THR products.
Last comes the biggie: the monster drug market for treating sick smokers – $50bn? $100bn? Who knows. All the chemotherapy drugs, COPD drugs, vascular drugs etc, plus a multiplicity of other related channels such as private healthcare etc. This is a long-term hit, maybe 10 – 20 years or so.
I think they take it all into account and plan for a future 50% hit on their smoking-related channels overall. I can’t see how smoking contributes less than 10% to pharma’s gross, and it’s probably nearer 20%. Some have said the figure is inconsequential, but they are way, way off – pharma’s global gross was about $500bn in 2010 so you can see that the smoking-affected channels clearly do count, they have to total over $50bn easily, and $100bn looks more likely. The $5bn for NRTs/psychotropics is just chump change to them.
I would assume that most everyone who is suggesting the market is too small for them to really care are focusing on the first category and a bit more, and are not quite cynical enough to count the rest. I mean, what are you going to say next, that weapons manufacturers hate peace? Or that medics who are paid more for doing more (as in the US) recommend a lot more useless tests and interventions? Or that pharma companies focus on developing slightly better medicines for lowering cholesterol and such, rather than the desperately needed new classes of antibiotics or treatments for tropical diseases.
(good luck trying to extract my views from that bundle of half-sarcasm)
One more concrete thing to keep in mind when analyzing corporate behavior is that time horizons are actually far too short to worry much about, in this case, people getting sick in 20 years. That is why it has always been absurd when the ANTZ made claims about tobacco companies needing to attract children, because otherwise all of the customers will die off over the next 40 years. Companies do not care what will happen in 40 years, pretty nearly at all, for numerous reasons.
I think that Mr Philips is suffering from my problem – his mind works best with the assistance of a little alcohol.
Tobacco Control has, for years, claimed that any research funded by tobacco companies is FRAUDULENT. They do not say that, but their carefully crafted public statements infer it.
There has been another ‘Judgement’ in Scotland which is relevant. I give you the URL for that ‘Judgement’:
Very briefly, a person suffering from schizophrenia was banged up. He was a smoker. The Authorities imposed an absolute ban on smoking, even in the open air in the (enclosed, prison-like) hospital grounds. He brought the Action against this persecution and won. Reluctant though the Judge was to say that a person has a ‘human right to smoke’, he did say that a person WHO IS BANGED UP has a ‘human right’ not to be prevented from enjoying such pleasures as his counterparts outside can enjoy, give or take.
The Judge ruled that the Hospital acted unlawfully.
The important thing about the above is THE EXPERIMENT with people who have mental problems of the nature of the person in the Case. These events show that Tobacco Control is indeed out of control. It has become a world-wide abomination.
It never cease to amaze me when people lie, thinking that they can get away with it.
Brett: politics is pretty much based entirely on lies. It is probably better for the public if they don’t know the truth, after all. The extended problem is twofold: when (a) a politician becomes immune to reality and eventually cannot discern between the fictional version promoted by government and what the public are actually well aware of – a common effect experienced by career politicians in proportion to their power and time in office (example: Blair), and (b) when the politician’s perception becomes distorted by time and pressure and they fall victim to the belief that the State is the only important reality, and the public hardly exist as a body with rights and especially with any individual rights that may overrule the State’s preferred options. There aren’t many politicians immune to the carcinogenic and ultimately highly toxic effect of power.
As a follow-up to my previous comments about the effect of pharma’s influence on health policy, I have come to the conclusion that their most important and valuable property is the principle that they own all health-related influences on policy; and that as a result, their principal currency is any/all factors influencing health. It means that what they will fight hardest to protect, above any other consideration, is their ownership of influence on policy and their ability to control any and all aspects of it. This is what they are in reality fighting to preserve; the minutiae such as a specific threat to their power or income (like e-cigarettes) are not as important as the general principle that nothing be allowed to affect their control of anything that affects health in any way (since this is ultimately the deciding influence on their income overall).
That is an interesting nuance, Chris. It certainly has more face validity than believing they really care much about the sums involved from their anti-smoking properties. You might start to win me over with this one.
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