BMJ  2004;328:110 (10 January), doi:10.1136/bmj.328.7431.110-b

Letter

Five Ps in mix of public health advocacy

EDITOR—The over 140 truly rapid responses to Enstrom and Kabat's smoking study demonstrate the use and abuse of the mix of public health advocacy.¹ Contrary to a muted response to another article on the same theme,² responses to this article were characterised by Smith as "more remarkable for [their] passion than [their] precision."³ My formulation of the mix in public health advocacy includes three additional Ps—promptitude, perseverance, and personality.⁴

The antismoking passion of most respondents was palpable, but only 3% showed commensurate precision by detailing the article's scientific flaws. The promptitude of response should be viewed in the context of recent advances in knowledge about tobacco's effects, which make the study seem anachronistic. However, without adequate precision, much of the passion and promptitude seem misdirected.

Perseverance is most effective when advocates are able to show continually the reliability and validity of their perspectives. In this context, two controversial issues need to be addressed rigorously.

The first issue is the extent to which the study was flawed by the authors' definition of passive smoking and the deficiencies of their methods. Repace has made progress in this respect,⁵ but such analyses need to be more focused on disproving the authors' rationales.³

The second issue is the level of acceptable conflict of interest for publication of scholarly articles.³ The authors insist that any perceived conflict falls well below this acceptable limit. If incontrovertible evidence against the authors' position is obtained, the BMJ should consider its publication in its upcoming theme issue: "What doesn't work and how to show it."

The towering personality of the BMJ as a leading medical journal partly explains the feelings of betrayal by critics of the study. Ironically, by not properly applying the mix of public health advocacy, some responding antismoking advocates have inadvertently compromised their personality as objective seekers of knowledge.

School of Public Health, University of New South Wales, Sydney, NSW 2052, Australia niyiawofeso{at}hotmail.com

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Competing interests: NA is an active anti-smoking campaigner and the initiator of a structured smoking cessation programme for prisoners in New South Wales.

References

1. Enstrom JE, Kabat GC. Environmental tobacco smoke and tobacco-related mortality in a prospective study of Californians, 1960-98. BMJ 2003;326: 1057.[Abstract/Free Full Text]
2. Laurent AM, Bevan A, Chakroun N, Courtois Y, Valois B, Roussel M, Festy B. Health effects of chronic exposure to tobacco smoke on a non-smoker population. Rev Pneumol Clin 1992;48: 65-70. [In French.][Medline]
3. Correspondence. Passive smoking. BMJ 2003;327: 501-5. (30 August.)[Free Full Text]
4. Awofeso N. Influence of "bounded ness" on public health advocacy—lessons from polio and tuberculosis advocacy outcomes. Eur J Public Health (in press).
5. Repace JL. Passive smoking risks: from publication, not bias. Electronic response to: Passive smoking. bmj.com 2003. bmj.bmjjournals.com/cgi/eletters/327/7413/503-a#42025 (accessed 3 Dec 2003.)

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