Why ignore evidence in the debate about e-cigarettes?
Juul produces research, as well as e-cigarettes
Last month, a scientific journal published a peer-reviewed study with encouraging news for anyone concerned by the toll that smoking takes on people’s health.
The study in the American Journal of Health Behavior identified more than 17,000 cigarette smokers who purchased a Juul starter kit, which includes a rechargeable e-cigarette and four flavored pods. A year later, more than half said they had stopped smoking and switched to e-cigarettes, which, by nearly all accounts, cause much less harm than combustible tobacco.
“It is a startling result,” says Cheryl Healton, the dean of New York University’s School of Public Health and former president of the Truth Initiative, an anti-tobacco nonprofit. The study has limitations, she says, but its findings align with experience in the UK, where smoking has declined sharply as public health authorities encourage smokers to switch to e-cigarettes.
There’s just one problem: The study was conducted by Juul Labs.
The research, as a consequence, has been summarily dismissed by tobacco control activists.
Matthew Myers, president of Campaign for Tobacco-Free Kids, told the British Medical Journal (BMJ):
After decades of tobacco companies paying previously credible scientists to produce studies designed to reach a predetermined outcome to foster their marketing goals and mislead the public about the overall state of the evidence, one thing should be abundantly clear: research funded by tobacco companies cannot be treated as a credible source of science or evidence. No credible scientific journal should allow a tobacco company to use it for this purpose.
This reaction is understandable. It’s also unwise.
Let’s take a closer look.
Prohibiting industry research
Some scientific journals, including the BMJ, Tobacco Control (which is published by the BMJ) and PloS Medicine, refuse to publish research funded by the tobacco industry. The big tobacco companies have “repeatedly and systemically interfered with legitimate scientific research, and repeatedly used industry-funded scientists and their industry-facilitated findings to deceive consumers and undermine public health,” Ruth Malone, editor of Tobacco Control, wrote in 2012 when its editors chose to stop publishing research funded by the tobacco industry.
Others, including the American Journal of Health Behavior, which devoted an entire issue to Juul’s research, remain open. The policy of Nicotine & Tobacco Research, for example, requires disclosure of potential conflicts of interest but says scientific research should be “judged as much as possible on the basis of the data rather than the source of the data.”
There’s little doubt that industry funding influences findings. In the case of e-cigarettes, a 2019 survey in Preventive Medicine found that papers for which industry-related conflicts were disclosed were — surprise! — less likely to find harm in e-cigarettes than studies for which no conflicts were reported.
Juul’s own practices have not helped its cause. A newly-published study in Tobacco Control by Nicholas DeVito et al found that Juul has not fully disclosed all of the outcomes of its clinical trials to ClinicalTrials.gov, a public repository for trial results that enhances their availability and transparency. “We strongly believe it is in the public interest that all outcomes for all trials…be fully and publicly reported in a timely manner,” DeVito wrote. Juul was also faulted for its lack of transparency in a 2019 study in The Lancet. The vaping giant has been under intense scrutiny since Altria, the parent company of Philip Morris USA, which makes Marlboros and other cigarettes, invested $12.8bn in Juul in 2018, acquiring 35 percent of its shares.
All that said, the papers carried out by Juul and its consultants published in the American Journal of Health Behavior went through the customary peer review. They are based on research submitted by Juul to the FDA, whose scientists have access to the underlying data, as part of the company’s effort to win approval for its products. Misleading the FDA could put the company at risk.
They are far from definitive, but they add to a growing body of knowledge about e-cigarettes, a potentially disruptive technology that millions of smokers have used to quit.
So the question is: If anti-tobacco hardliners want to reduce the death, disease and suffering caused by smoking, shouldn’t they, at the very least, be open to new evidence about the impact of e-cigarettes?
Clive Bates, a longtime anti-smoking activist who believes that vaping can reduce the harm caused by smoking, says the refusal of the anti-tobacco forces to even consider JUUL’s research is “absurd, anti-scientific and somewhat disturbing.”
“As Juul rose in popularity, we saw unusually rapid declines in cigarette sales and smoking prevalence in both adults and adolescents,” Bates wrote in a letter to the BMJ. “The right response to that is to want to know more. The wrong response is to try to suppress or discredit informative data and analysis just because it tells a story that is at variance with a narrative about the evils of both e-cigarettes and the companies that make them.”
Elbert Glover, editor-in-chief of the American Journal of Health Behavior, also defended the special issue. “To reject a paper on who funded the work rather than science is wrong,” he told BMJ. Juul scientists, in a letter, expressed hope that the research would be judged “based on the merits of the science, not solely on its provenance.”
The 219-page issue, which covers a range of issues, concludes with a population model that predicts cigarette smoking, the use of electronic cigarettes and mortality rates in the US between 2000 and 2100 under a variety of scenarios. Not surprisingly, the availability of e-cigarettes is projected to reduce smoking and prevent 2.5 million premature deaths by 2100. Take that with a few grains of salt, but be aware that population models by scientists with no industry ties also find that e-cigarettes deliver significant health benefits, all things considered. (For more on the models, see this study by Kenneth Warner and David Mendez, this one by David Levy et al and a critique of the Juul paper by Stanton Glantz.)
Maybe the most surprising thing about the discussion of conflicts and research — surprising to me, at least — is how much of it revolves around industry. Funding from governments or foundations is deemed pure. This is short-sighted if only because the National Cancer Institute, part of the National Institutes of Health (NIH), has as an explicit goal “a world free of tobacco use.”
“There are conflicts of interest on all sides.”
Government grants are, by far, the biggest source of funding for tobacco research. NIH spent nearly $700m on tobacco research in FY2020, according to Brad Rodu, a researcher and harm reduction advocate whose work is partly funded by industry.
“There’s this perception that NIH funding is not biased and there’s no conflict of interest,” Rodu says. “But that’s simply not true. NIH’s mission for a tobacco free society definitely influences all investigators to produce or highlight the worst possible results or interpretations involving all tobacco products.”
“There are conflicts of interest on all sides, and they need to be reported,” Rodu says. “It’s as simple as that.”
Conflicts also arise from sources that get “much less attention — the beliefs, preconceptions and pet theories of individual scientists,” writes Marcus Munafo, the editor of Nicotine and Tobacco Research. Researchers become wedded to their positions, in a field that is increasingly polarized.
The best approach is to listen skeptically to all sources, says psychologist and tobacco researcher Lynn Kozlowski. In a 2016 essay in Science and Engineering Ethics titled Coping with the Conflict-of-Interest Pandemic by Listening to and Doubting Everyone, Including Yourself, Kozlowski wrote that “conflict of interest should generally be assumed, no matter the source of financial support or the expressed declarations of conflicts and even with respect to one’s own work.”
“Listen to everybody, but listen to everybody with one ear,” he wrote. “The advantage of doubting yourself as well might even contribute to a change of position rather than to digging in deeper to defend what you have said before.” That’s good advice for those on all sides of the e-cigarette debate.
