Rapid Responses to:

PAPERS: James E Enstrom and Geoffrey C Kabat Environmental tobacco smoke and tobacco related mortality in a prospective study of Californians, 1960-98 BMJ 2003; 326: 1057 [Abstract] [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Need for clarification on competing interest

Martin McKee   (15 May 2003)

Flawed study from the outset

Jayant S Vaidya   (16 May 2003)

Risks for passive smoking are likely to be underestimated.

Trevor LP Watts   (16 May 2003)

Re: Second-hand smokescreens

Brian David Porter, Healthy Communities, LN5 7JH   (16 May 2003)

Irresponsible journalism

Dominic C Horne   (16 May 2003)

Agreeing the limits of conflict of interest

richard horton   (17 May 2003)

Editorial responsibility to publish sound science

Trish A Fraser   (17 May 2003)

Evidence Based Medicine?

Stephen Novick   (17 May 2003)

The letter BMJ failed to write

Pascal A. Diethelm   (17 May 2003)

ETS - Interpretation of the wider evidence

Julia A Critchley   (17 May 2003)

Seondhand Smoke Study is Seriously Flawed

Marty Eckrem   (17 May 2003)

Lies, Damned Lies and Statistics

Richard EK Russell   (17 May 2003)

Timing of publication

Jephat Chifamba   (17 May 2003)

Irresponsible public health message

Sabina Fatima Hussain   (17 May 2003)

Give them enough rope

Daniel F. Hass   (17 May 2003)

Re: Irresponsible journalism

Ellen C G Grant   (17 May 2003)

what does this add?

Paul M Jones   (17 May 2003)

Swimming with sharks

Paul S McDonald   (17 May 2003)

Unproven health impact of environmental smoke: A study with low statistical power

Parthasarathy K S   (17 May 2003)

Biggest impact on developing countries

Judith M Mackay   (17 May 2003)

some thoughts

martin heilweil, PhD   (17 May 2003)

Study Objective Flawed--Fatally

Stephen J. Jay   (17 May 2003)

Re: Need for clarification on competing interest

Geoffrey C Kabat   (17 May 2003)

Nothing new from the antismoking front

Wiel M Maessen   (17 May 2003)

Re: Agreeing the limits of conflict of interest

Clive D Bates   (17 May 2003)

Reply to Bates

Tony Delamothe   (17 May 2003)

From hero to pariah in one easy jump

Richard Smith   (18 May 2003)

Children are not exposed to parental smoke??!!

Andrew J Fall   (18 May 2003)

What in the world were you thinking?

Sera Kirk   (18 May 2003)

Re: Nothing new from the antismoking front

David F. Copeland   (18 May 2003)

FINALLY !! Truth Comes Out of the Closet.

Stephen Hartwell   (18 May 2003)

Funding by EPA,, CDC, WHO equally "tainted"

Natalie P.R. Sirkin   (18 May 2003)

When conflict of interest becomes unacceptable

Deborah Arnott   (18 May 2003)

Did non-smokers REALLY avoid

Simon Chapman   (18 May 2003)

Whither epidemiologic reporting?

Gio B. Gori   (18 May 2003)

Consistency - science for sale?

John R. Polito   (18 May 2003)

Tobacco Toxicity

Ken B. Jones   (18 May 2003)

BMJ-comic or respectable journal?

Raj Thakkar   (18 May 2003)

WHAT THE HELL HAVE THESE PEOPLE BEEN SMOKIN'?

Errol E. POVAH   (19 May 2003)

4 Questions, 2 comments

tOM Trottier, None   (19 May 2003)

RESPONSE TO PAPER ON PASSIVE SMOKING

Christopher W IDE   (19 May 2003)

A "passive smoke" observation

Robert I. Rudolph, M.D., FACP   (19 May 2003)

Remember "Frank Statement to Smokers"?

Joanne L. Addison   (19 May 2003)

Bully for the BMJ

Bryce C. Peterson, M.D.   (19 May 2003)

Six Key Issues

Ronald M. Davis   (19 May 2003)

The bottom line

Andrew S Furber   (19 May 2003)

What killer? Let’s call things with their name.

Gian L. Turci   (19 May 2003)

environmental tobacco smoke paper requires further benefits from critical appraisal

Rosemary Fox, Gwendolyn L. Lowe, Hugo van Woerden   (19 May 2003)

BMJ, Impact Factor and Irresponsible Journalism: A 'nasty' nexus?

Zubair Kabir   (19 May 2003)

Adequacy of age-adjustment?

Eugene Milne   (19 May 2003)

Response to Simon Chapman

Michael J Thun   (19 May 2003)

Why The Double Standard?

Dave Hitt   (19 May 2003)

Pots calling kettles black

GH Hall   (19 May 2003)

SARS causes no harm

Jonathan P. Krueger   (20 May 2003)

Reply to ASH - please be more careful in future

James A Delphi   (20 May 2003)

Inverse effect can be explained

Wiel Maessen   (20 May 2003)

Freedom

Crystal L Pherson   (20 May 2003)

A very interesting coincidence

ELIF DAGLI   (20 May 2003)

Confirmation: Secondhand smoke does cause respiratory disease

Anthony J Hedley, Tai-Hing Lam, Sarah M. McGhee, Gabriel M. Leung, and Megan Pow   (20 May 2003)

Re: Adequacy of age-adjustment - a hypothesis

Eugene Milne   (20 May 2003)

BMA Turns Tabloid

Dale Jackaman   (20 May 2003)

California-smoky offices, windows open at home most of the year ....

HS Roberts   (20 May 2003)

Re: Re: Nothing new from the antismoking front

Wiel M Maessen   (20 May 2003)

Another "competing interest" of James Enstrom

Robert S. Broughton   (20 May 2003)

More details on competing interests

Martin McKee, Pascal Diethelm   (20 May 2003)

Tobacco cartel wants to create a "controversy"

Joseph Cherner   (20 May 2003)

An American Cancer Society Perspective

Michael J. Thun   (20 May 2003)

Defining a set of difficult issues

richard horton   (20 May 2003)

Science as PR

Gene Borio   (20 May 2003)

Read peer review comments

Kamran Abbasi   (20 May 2003)

The Correlation of Smoking and Deep Breathing

Bernard X. Bovasso, none   (21 May 2003)

Reviewers' comments

Martin McKee   (21 May 2003)

Apology Requested

William T Godshall   (21 May 2003)

Jumping out of a 3rd storey window "may not kill" either...

Peter J Flegg   (21 May 2003)

Re: Read peer review comments

Kamran Abbasi   (21 May 2003)

Re: Defining a set of difficult issues

Zubair Kabir   (21 May 2003)

Old habits new diseases?

Teresa Ramos   (22 May 2003)

Re: Science as PR....Bravo, Gene!

Errol E. POVAH   (22 May 2003)

Re: Inverse effect can be explained

Adam Jacobs   (22 May 2003)

Why am I dying from lung cancer caused by second-hand smoke?

Heather S. Crowe   (22 May 2003)

Flawed Study on Passive Smoking

Michael J. Martin   (22 May 2003)

PUT YOUR LUNGS WHERE YOUR MOUTH IS

Emanuel Goldman   (22 May 2003)

Re: Why The Double Standard?

M. L. Herrin   (22 May 2003)

"Serious misclassification of exposure"

Pascal A. Diethelm   (22 May 2003)

It's not always easy

James W Austin   (22 May 2003)

Judging Research

freda lee nason   (22 May 2003)

Re: Six Key Issues

Emma L Dickinson   (23 May 2003)

Lost Credibility

Christopher Lovelidge, http://www.you-are-the-target.com/   (23 May 2003)

Response to McKee and Diethelm

Geoffrey C Kabat   (23 May 2003)

The 'overwhelming evidence' for the links between ETS and lung cancer and heart disease

Wiel M Maessen   (23 May 2003)

Re: Why am I dying from lung cancer caused by second-hand smoke?

Wiel Maessen   (23 May 2003)

Re: Judging Research

Nigel R Winterbottom   (23 May 2003)

Re: Re: Inverse effect can be explained

Wiel M Maessen   (23 May 2003)

What are the tobacco manufacturers saying?

Andrew S Furber   (23 May 2003)

Response to James Austin

Simon Chapman   (23 May 2003)

Smoke: Cancer ingredients or not

George F Sedlacek   (24 May 2003)

The Confounding Urban Factor

David W. Kuneman   (24 May 2003)

Misleading the public about secondhand smoke ... Again

Lisa A Bero, Michael Cummings, Stanton Glantz   (24 May 2003)

Response to Simon Chapman

James W Austin   (25 May 2003)

Re: Misleading the public about secondhand smoke ... Again

B.J. Allen   (25 May 2003)

Wrong conclusion

William Carey   (25 May 2003)

Do any of the "non-smokers" smoke?

John H. Glaser   (26 May 2003)

Research Bias and Science

Michael J. McFadden   (26 May 2003)

Re: Misleading the public about secondhand smoke ... Again

Wiel M Maessen   (27 May 2003)

Re: Response to McKee and Diethelm

Malcolm X. McGarrity   (27 May 2003)

Re: An American Cancer Society Perspective

Daniel Forrest   (29 May 2003)

Re: Do any of the "non-smokers" smoke?

John H. Glaser   (29 May 2003)

Re: Re: Re: Inverse effect can be explained

Adam Jacobs   (29 May 2003)

Re: Defining a set of difficult issues

Beverly A. HARRIS   (29 May 2003)

Cohort bias in the analysis of Californian passive smoking

Eugene Milne   (29 May 2003)

Why the study?

Joshua E. Muscat   (30 May 2003)

Passive smoking: Why all the fuss?

Jeffrey J Johnstone   (30 May 2003)

Environmental tobacco smoke and lung cancer

Allan Hackshaw, Please see the end of the letter   (30 May 2003)

CONTEXT & COMMON SENSE--or: "2nd-HAND POISON'S OK. REALLY!..."

Rick Bernardo   (30 May 2003)

'Fac Ut Gaudeam' : By Dr Joseph Obi

Joseph .C. Obi   (1 June 2003)

On the objectivism of science

Kurt J. Zuckermann   (2 June 2003)

Re: On the objectivism of science

John H. Glaser   (3 June 2003)

health as a confounding factor?

Elliot S Jerud   (3 June 2003)

Anachronism

Matti A Keski-Korpela   (4 June 2003)

Congratulations!

Ken S. Honbo   (5 June 2003)

Article Response and Response to Comments

Scott J. Leischow   (5 June 2003)

Lung Cancer Without Secondhand Smoke Exposure

Sheldon B. Ungar   (5 June 2003)

Science: Talking the talk, or walking the walk?

Rick Bernardo   (10 June 2003)

Editorial U-Turn on Secondhand Smoke "Controversy"?

Gene Gene   (11 June 2003)

Re: Science: Talking the talk, or walking the walk?

Stuart Goldbarg   (12 June 2003)

The anti-smokers lie about smoking and health

Carol AS Thompson   (12 June 2003)

A final thought....

Michael J. McFadden   (16 June 2003)

Publication in BMJ of Tobacco-funded "research"

Stan R Blecher   (20 June 2003)

What do we learn from this research?

Ralf Krumkamp   (21 June 2003)

Gori replies to Leishow about Enstrom, Kabat, and beyond

Gio B. Gori   (25 June 2003)

Requesting Media Information from Interested Readers…

Sheldon Ungar, Dennis Bray, Sociologist, GKSS Research Center   (25 June 2003)

Secondhand Smoke Exposure and Disease: No Doubt Remains

Terry F. Pechacek, Stephen Babb   (10 July 2003)

Tobacco : what about Belgium

Christophe De Brouwer, Raphael Lagasse.   (11 July 2003)

The Case of the Footnote Wagging the Article

Phillip S. Gardiner, Charles L. Gruder, Francisco Buchting   (19 August 2003)

Thank you

Mark W. Volovar   (9 September 2003)

Second-Hand Smokescreen

Hugh McGrath Jr.   (16 September 2003)

Family history?

yogi sehgal   (25 September 2003)

Smoking and lung cancer: dose-response and combined exposure i.e. asbestos

John H. Lange   (29 September 2003)

Re: Re: Re: Inverse effect can be explained

Wiel Maessen   (30 November 2003)

Public Health Advocacy and its Five Ps

Niyi Awofeso   (3 December 2003)

A question...

C.A. Caldwell   (11 December 2003)

Re: A question...

Adam Jacobs   (13 December 2003)

Re: Re: A question...

Pete Petrakis, Ph.D., M.P.H.   (14 December 2003)

Re: Re: Re: A question...

Adam Jacobs   (15 December 2003)

Re: Re: Re: Re: A question...

Pete Petrakis, Ph.D., M.P.H.   (16 December 2003)

Re: Re: Re: Re: A question...

C.A. Caldwell   (16 December 2003)

Re: Re: Re: Re: Re: A question...

Pete Petrakis, Ph.D., M.P.H.   (17 December 2003)

Re: Re: Re: Re: Re: Re: A question...

C.A. Caldwell   (24 December 2003)

Re: Re: Re: Re: A question...

Wiel M Maessen   (15 January 2004)

Re. Re. Re. Re.....

Gio B. Gori   (21 January 2004)

Re: Why am I dying from lung cancer caused by second-hand smoke?

lynda duguay   (3 July 2004)

A Sociological Study of the Responses to Enstrom & Kabat

Sheldon B. Ungar, Dennis Bray, GKSS, Geesthacht, Germany   (17 December 2004)

Environmental tobacco smoke: formulating public health policy for environmental carcinogens

Morris Greenberg   (30 August 2005)

Re: Six Key Issues

Belinda Cunnison   (5 December 2005)

Updated Meta-Analysis on ETS and CHD Mortality in the US

James E Enstrom, Geoffrey C Kabat, New Rochelle, NY 10804   (24 January 2006)

Enstrom & Kabat's Exposure Assessment Flawed

James L. Repace   (25 January 2006)

Re: Enstrom & Kabat's Exposure Assessment Flawed

Walt Cody   (18 March 2006)

Is the goal of TC to reduce mortality, or to protect the consensus view

Kevin M. Mulvina   (15 August 2006)

Professor Sir Richard Peto and the House of Lords

James E Enstrom   (26 August 2006)

Defending Legitimate Epidemiologic Research

James E. Enstrom   (27 September 2006)

Risk and Cotinine: A reply to Mr. Cody

James L. Repace   (29 September 2006)

Re: Risk and Cotinine: A reply to Mr. Cody

Kevin Mulvina   (24 November 2006)

General response

David C Atherton   (27 May 2007)

Combating Lysenko Pseudoscience

James E Enstrom, Los Angeles, CA 90095   (16 October 2007)

Re: Combating Lysenko Pseudoscience

Kamal Chaouachi   (27 October 2007)

Let Us Ban Smoking Bans

kerry p. labat junior   (22 November 2007)

The real threat to epidemiology's integrity

William L Holden   (19 January 2008)

The 3,000 claim

thomas r knapp   (6 February 2008)

A clear response from an insider

Richard A. Marden   (7 February 2008)

Forthcoming book on health risks

Geoffrey Kabat   (4 June 2008)

Need for clarification on competing interest 15 May 2003
Martin McKee, Professor of European Public Health London School of Hygiene and Tropical Medicine, London WC1E 7HT Send response to journal: Re: Need for clarification on competing interest	Dear editor, Given the well documented efforts by the tobacco industry to create confusion about the link between passive smoking and disease,[1] it is essential that researchers working on this topic are seen to be entirely impartial. In this context, there are several aspects of Enstrom and Kabat’s declarations on funding that require some clarification. It is true that the Center for Indoor Air Research (CIAR) is an agency receiving money primarily from US tobacco companies but this rather understates its role. As Barnes and Bero [2] have shown, in a detailed analysis of industry documents, CIAR funded two types of research, peer-reviewed and "special-reviewed", with the latter awarded directly by tobacco industry executives. Barnes and Bero showed that special-reviewed projects were more likely than peer-reviewed projects to support the tobacco industry position and be used by the industry to argue against smoking bans in public places. We should be told which category this research fell into. In the light of experience in another case involving CIAR funded research, the editor may wish to require full documentary disclosure of the process involved.[3] Dr Kabat may also wish to clarify some other matters. He states that he never received tobacco industry funding until last year, when he received support from a law firm that has several tobacco companies as clients. First, given what is known of the central role played in the tobacco industry’s campaign by certain lawyers, we should be told which firm this is and, specifically, whether it is one that has been linked to the industry campaign and if so, what role it played in it. Second, he published a paper in 1997 [4] with co-authors who have played leading roles in the industry campaign, one of whom was recently found by a Swiss court to have been "secretly employed by Philip Morris" as a highly paid consultant, undertaking work the court considered appeared fraudulent.[5] Consequently it will be important to have details of the nature of this earlier collaboration. In these circumstances, the comment by Davey Smith in the accompanying editorial that the authors “may overemphasise the negative nature of their findings” cannot simply be dismissed as a genuine difference of interpretation without much more detailed scrutiny. 1 . Hong MK, Bero LA. How the tobacco industry responded to an influential study of the health effects of secondhand smoke. BMJ. 2002 Dec 14;325(7377):1413-6. 2 . Barnes DE, Bero LA. Industry-funded research and conflict of interest: an analysis of research sponsored by the tobacco industry through the Center for Indoor Air Research. J Health Polit Policy Law 1996; 21: 515-42. 3 . http://www.prevention.ch /rylanderpm.htm [accessed 14 May 2003] 4 . Koo LC, Kabat GC, Rylander R, Tominaga S, Kato I, Ho JH. Dietary and lifestyle correlates of passive smoking in Hong Kong, Japan, Sweden, and the U.S.A. Soc Sci Med 1997; 45: 159-69. 5 . http://www.prevention.ch /ryjueng130103.htm [accessed 14 May 2003] Competing interests: As editor of the European Journal of Public Health, MM published another paper by authors funded by the Center for Indoor Air Research. This publication was the centre of a long-running dispute between the journal and the authors concerning undeclared conflicts of interest. It led to his involvement as a witness in a lengthy legal dispute that has recently been resolved (referred to in response). He has received funding from several national and international agencies for work on tobacco control.
Flawed study from the outset 16 May 2003
Jayant S Vaidya, Hon Lecturer and Specialits Registrar University College London, Dept of Surgery, W1W 7EJ Send response to journal: Re: Flawed study from the outset	Dear Sir/Madame There is a major flaw in the study and the Editors may wish to consider a public retraction. This study assumes that there is a considerable difference in the exposure to ETS of never smokers' spouse compared to ever smoker's spouse. This is obviously not true. Most never smoker's spouses would have been exposed to considerable ETS before the late 1990s, when the general exposure to ETS in California started reducing. It would be only in the last 3-4 years of the 39-year study when the ETS exposure to workplace might have been so reduced that there might be a difference in the two groups. So for most of the data, assuming the spouses meet in their non- working hours, they would be exposed to each other- for typically 2-4 hours a day (assuming a 11 hour work+travel and a 9 hour sleep+eat+bath etc.), whereas they would be exposed to ETS at work for up to 8-10 hours. Thus the study is comparing a 8-10 hour exposure to ETS among spouses of 'never' smokers to a 12 hour exposure to tobacco smoke among spouses of 'ever' smokers. Assuming a 30% increased mortality for passive smoking and assuming never smokers are exposed to ETS for about 10 hours when they are not with their spouse, compared to 12 hours by spouses of ever smokers, the difference in mortality between the groups should be about ((12- 10)/12) x 30= 5%. In addition, there would be many quitters among the ever smokers - thus reducing the ETS to the spouse and many occasional smokers (mainly at the time when they met their spouse) among the never smokers - increasing the ETS exposure to spouse. Despite the large size of the study, it is well known that a 5% difference in RR is extremely difficult to demonstrate in epidemiological studies, and especially in this study, inability to find a difference especially when only a tiny difference was expected cannot be taken as absence of a difference. There is no doubt that however flawed this study, unless it is retracted by the BMJ, tobacco industry will use it extensively to promote their vigorous opposition to anti-smoking legislation in general, and anti-ETS laws in specific. Of course they have an urgent need to replace their loss of customer base of about 10,000 to 20,000 per day with new recruits of young smokers. Competing interests:   None declared
Risks for passive smoking are likely to be underestimated. 16 May 2003
Trevor LP Watts, Senior Lecturer and Consultant in Periodontology Guy's King's and St Thomas' Dental Institute, London, UK, SE1 9RT Send response to journal: Re: Risks for passive smoking are likely to be underestimated.	I think this study (1) suffers from the same bias towards reducing the estimated effect of passive smoking that all previous papers have had. I sent the following rapid response to a previous paper of Copas and Shi(2) on possible overestimation of risks associated with passive smoking. I have long been concerned that all passive smoking studies actually underestimate true risks for the following reasons: 1. Few non-smokers are not frequently exposed to tobacco smoke in their daily activities. I live in a non-smoking house, travel on non- smoking trains, and work in non-smoking buildings. Yet I am exposed to tobacco smoke perhaps 15-20 minutes of each day, for instance when waiting for trains to arrive, entering and leaving my workplace, walking near smokers in towns and when going shopping. It may be impossible to find true negative control subjects for passive smoking studies. 2. The position in my childhood was far worse, with frequent exposure on public transport and many other places; this will have affected many control subjects in past studies. 3. Some subjected to passive smoking will undoubtedly become nicotine addicts, perhaps as children, and therefore become smokers themselves. I know of no good estimate of this risk and the subsequent damage. 4. As well as the serious risk of addiction, it is also unlikely for the above reasons that any study using realistic controls has been able to estimate the absolute effect of exposure versus total non-exposure to tobacco smoke. The effects of passive smoking therefore may be more serious than any studies have shown so far, publication bias notwithstanding. It is also likely that effects of smoking on smokers have been underestimated. I have no competing interests. 1. Enstrom JE, Kabat GC. Environmental tobacco smoke and tobacco related mortality in a prospective study of Californians, 1960-98. BMJ 2003;326:1057. 2. Copas JB, Shi JQ. Reanalysis of epidemiological evidence on lung cancer and passive smoking. BMJ 2000; 320: 417-418. Competing interests:   None declared
Re: Second-hand smokescreens 16 May 2003
Brian David Porter, Manager of an NHS Smoking Cessation Service West Lincolnshire PCT, Healthy Communities, LN5 7JH Send response to journal: Re: Re: Second-hand smokescreens	Medical focussed research only tells part of the story. Commercial links with research inevitably have influence, and that includes tobacco and pharmaceutical companies. However, society gets the research projects that these companies are funding, not necessarily the ones that are really needed. Medical health issues simply add further weight to the drive towards smokefree places. The argument about the LEVELof health risk is facile. There IS an health risk, but there are other important issues. Most smokers know the health risks, and many accept that second-hand smoke has health risks on, for example, their children. But they still smoke - i.e. cognitive dissonance and because they are addicted. Some of the most important issues around second-hand smoke have nothing to do with medical health. Stinging eyes, tobacco ash, unpleasant stale smells, dirty hair and clothing are examples of things that smokefree people don't like, or want. Second-hand smoke imposes itself on people without discrimination, removing from non-smokers their choice of access to clean air in many public places. The majority non-smoking population wants smokefree public places. What's the problem? Competing interests:   None declared
Irresponsible journalism 16 May 2003
Dominic C Horne, GP Principal Huntly Health Centre, Aberdeenshire, AB54 8EX Send response to journal: Re: Irresponsible journalism	I was genuinely shocked to see this splashed across the front page of this week's BMJ, tabloid-style. An industry-sponsored, methodologically flawed study with inconclusive results but with major potential public health implications especially once the lay press get hold of it. 'Passive smoking may not kill': how much would the tobacco industry pay for such a soundbite in a major peer-reviewed medical journal? Since when did I pay my subscription so that you could do their dirty work for them? Email: dominic.horne{at}huntly.grampian.scot.nhs.uk Competing interests:   None declared
Agreeing the limits of conflict of interest 17 May 2003
richard horton, editor the lancet Send response to journal: Re: Agreeing the limits of conflict of interest	The paper by Enstrom and Kabat, sponsored as it is from tobacco- industry related funds, raises an issue that affects all papers with conflicts of interest, one that we at The Lancet struggle with in almost every issue - namely, how much conflict of interest can editors reasonably allow before the findings and interpretation of a particular study are rendered unsafe or, at the very least, too uncertain to be a substantive scientific contribution? In our experience this issue is especially relevant for pharmaceutical industry sponsored studies. Most readers of medical journals might agree that if every author of a paper held US$1million worth of stock in a product that was the subject of their report, and that if the paper described a beneficial effect of the product, an effect that was likely to substantially increase the personal wealth of each author, then an unbiased interpretation of the study would be almost impossible, no matter what the claims for its validity. As an editor, there would be very little point publishing such a study, since it would be immediately disregarded by most readers. Certainly, we have rejected papers - research and review - because we have judged the personal entanglements of authors just too great to sustain the independence of their work, and so its integrity, from the sponsor. My first question, then, is whether our policy is fair. Martin Jarvis is reported in The Independent today as saying that "one must not take the view that anything which has got any association with the industry is wrong". If, as a community, we share this view, then The Lancet's policy is clearly unfair since we judge that some associations with industry are simply too deep to deliver a believable interpretation. But if we feel that there really is a limit to the degree of conflict that we judge reasonable, as some responses to the Enstrom and Kabat paper seem to suggest - eg, Amanda Sandford of Ash: "Questions will inevitably be asked about the decision to publish research conducted by scientists in the pay of the tobacco industry" (The Independent) - then criticism should not be directed at the authors, and still less at the editors of the BMJ, but instead to the entire medical community for having such imprecise thinking over conflicts of interest. In pharma-sponsored studies, we mostly allow conflicts provided they are reported accurately. We deplore them in tobacco-sponsored research. One might argue that these sources of funding are qualitatively different - the first does not set out to sell a product knowing that it kills, while the second surely does. But there are many examples of how both tobacco and pharma have tried to undermine the independence and rigour of research, deliberately bias policy makers, gouge grotesquely huge profit from disease, and so on. The solution that some editors have implemented for pharma-sponsored studies is to require a statement about the role of the funding source in the design, conduct, analysis, and reporting of the data. We publish such a statement for all primary research, irrespective of who the sponsor might be (for-profit, not-for-profit etc). No such statement appears in the Enstrom and Kabat paper - would this have helped readers judge the safety and reliability of their research? Finally, could this paper therefore provide a useful opportunity for us all to clarify what is an acceptable conflict - for readers, researchers, and editors alike - and how that conflict should be reported? Could we agree also about how to handle these matters during pre- publication peer review (should the extent of the conflict be a factor, in addition to the science, in deciding acceptance or rejection?) - ie, well before they might confuse an already difficult scientific issue of great public concern? Richard Horton Competing interests:   None declared
Editorial responsibility to publish sound science 17 May 2003
Trish A Fraser, Adviser to Action on Smoking and Health 102 Clifton Street, London Send response to journal: Re: Editorial responsibility to publish sound science	Action on Smoking and Health is one of the key health groups promoting smokefree environments and particularly smokefree workplaces in the UK. The Government has shown little or no willingness to protect the health of the public by eliminating tobacco smoke from workplaces and public places. For health advocates working in tobacco control 'clearing the air' in the UK is an extremely difficult task. The latest study on environmental tobacco smoke by Enstrom and Kabat was therefore viewed with alarm and dismay. This study has not been accepted as having any credibility by any public health experts as there is already an overwhelming body of scientific evidence that has proven the health impact of exposure to secondhand smoke [1] [2] [3] [4] [5]. There is also no question that both authors have been funded in the past, and for this particular study by the tobacco industry, so why did the editors of BMJ deem it their role to publish this article? If publication of the article was not bad enough, the problem was intensified by the statement 'Passive Smoking may not Kill' on the cover of the journal, followed by an editorial title which included the word 'controversy' when there is no controversy. The BMJ has now offered the tobacco industry credibility to continue to promote doubt and uncertainty about the health effects of secondhand smoke. This will assist them in their efforts to maintain the status quo of smoky work and public environments as the accepted 'norm'. Is there not a case for the BMJ editors taking some responsibility to provide science that is unbiased and trustworthy? 1. Respiratory health effects of passive smoking: Lung Cancer and other disorders. The report of the US Environmental Protection Agency, 1993. 2.Report of the Scientific Committee on Tobacco and Health. 1998. 3.International Consultation on Environmental Tobacco Smoke (ETS) and Child Health. WHO Tobacco Free Initiative, 1999 4. Health effects of exposure to environmental tobacco smoke. The report of the California Environmental Protection Agency. Smoking and Tobacco Control Monograph 10, National Cancer Institute, 1999 5. Involuntary Smoking. IARC, 2002. Competing interests:   None declared
Evidence Based Medicine? 17 May 2003
Stephen Novick, SCMO Old Age Psychiatry Shelton Hospital, Shrewsbury SY3 8DN Send response to journal: Re: Evidence Based Medicine?	Evidence Based Medicine is a wonderful thing. It seems as though one takes the evidence one likes and uses it, and ignores the rest. Evidence which fits with expected theories and ideas is fine, otherwise it is "flawed" or "biased". I'm afraid evidence is evidence and to dismiss it out of hand just because it is not liked does the medical profession a great disservice. If the evidence doesn't seem to fit, then repeat it, don't just dismiss it. As Karl Popper said, the hypothesis that all swans are white is not strengthened by finding the one thousandth white swan, but is destroyed by finding the first black one. Competing interests:   None declared
The letter BMJ failed to write 17 May 2003
Pascal A. Diethelm, Director, OxyGenève CH-1204 Geneva Switzerland Send response to journal: Re: The letter BMJ failed to write	Dear Editor, If you go to the Philip Morris document web site (www.pmdocs.com), you will find, under Bates No. 2065122062, the letter [1] that BMJ failed to write to James Enstrom and his co-author. It says: "The editors believe that this opinion piece is full of speculative assumptions of doubtful scientific value. We could not judge the merit of your criticisms because your own data and methods were so inadequately described." The letter was written in 1996 by the Deputy Editor of the Journal of the American Medical Association in response to an earlier submission by Enstrom of his tobacco-industry sponsored study. It is saddening that a prestigious publication such as BMJ has lowered its publication standards to the point of letting a piece of rubbish occupy its columns and amplifying it with a complaisant editorial. It is unqualifiable that such an article should manage to get published just a couple of days before the opening of the World Health Assembly at which the the Framework Convention for Tobacco Control is scheduled for adoption, at a moment when the tobacco industry deploys its most intensive efforts to undermine the WHO treaty. A treaty, which, coincidentally, says in its Article 8 : "Parties recognize that scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability." If BMJ had decided to side with the tobacco industry in what it still considers a "controversy", it couldn't have chosen a better move and a better time. 1. http://www.pmdocs.com/getimg.asp? pgno=0 &start=0 &docid=2065122062 Competing interests:   None declared
ETS - Interpretation of the wider evidence 17 May 2003
Julia A Critchley, Lecturer in Epidemiology / Research nSynthesis Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, Send response to journal: Re: ETS - Interpretation of the wider evidence	There appear to me to be several omissions in Enstrom and Kabat’s analysis of environmental tobacco smoke (ETS) and mortality (1). First, although they accept that most epidemiological studies have found that ETS has a positive but not statistically significant relation to coronary heart disease and lung cancer, then argue against the use of meta-analysis to establish a causal relation. This is precisely where systematic reviews, and sometimes meta-analysis, can be of considerable benefit. Many studies have found positive relationships between ETS and mortality – combining them provides greater power to establish a statistically significant effect. The authors suggest that publication bias may explain the positive results in other reviews; but unlike small clinical trials and reports, larger cohort studies are more likely to be published regardless of their results (2). They further ignore the heterogeneity between their study results and many others, simply arguing that none of the other cohort studies on ETS have as many strengths, and none has presented as many detailed results. Although this is a large study, that by itself is not an indicator of ‘quality’. Larger prospective cohort studies may have greater losses to follow-up, or more misclassification, over time (3). A more useful analysis would put this study in context and attempt to explain why it differed from other published cohort studies. Second, though the authors discuss misclassification, it still seems likely that this may explain the lack of statistically significant association. The relative risks reported for active smoking and coronary heart disease (Table 10) are lower than those reported from other cohort studies, such as the British Doctor’s (4). This may be sufficient to obscure a modest but important increase in risk. Thirdly, the author’s state that the increased risk of coronary heart disease due to active smoking is only 70% (a relative risk of 1.70). Other studies have found risks associated with cigarette smoking considerably higher than this (5). The authors also seem to assume a linear relationship between cigarette smoking and mortality; this is not likely to be the case. Presumably they extrapolated the very low estimates of RR, assuming that ETS is equivalent to smoking one cigarette per day, on this basis. This analysis is not clearly described. Placing this study in context, it does not overturn established relationships between ETS and mortality. I would strongly agree with the editorial that the authors ‘over-emphasise’ the negative nature of their findings. 1)Enstrom JE, Kabat, GC. Environmental tobacco smoke and tobacco related mortality in a prospective study of Californians, 1960-98. BMJ 2003; 326: 1057. 2)Sutton AJ, Duval SJ, Tweedie RL et al. Empirical assessment of effect of publication bias on meta-analysis. BMJ 2000; 320:1574-7. 3)Critchley JA, Unal, B. The Health Effects Associated with Smokeless Tobacco Use: A Systematic Review. Thorax 2003; 58:435-443. 4)Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years' observations on male British doctors. BMJ 1994;309:901-11 5)Jousilahti P, Vartiainen E, Korhonen HJ, Puska P, Tuomilehto J. Is the effect of smoking on the risk for coronary heart disease even stronger than was previously thought? J Cardiovasc Risk 1999;6:293-8. Competing interests:   None declared
Seondhand Smoke Study is Seriously Flawed 17 May 2003
Marty Eckrem, Program Manager, Coconino County Dept. of Health Services Flagstaff, AZ 86004 Send response to journal: Re: Seondhand Smoke Study is Seriously Flawed	I can not believe that a reputable journal such as the British Medical Journal can seriously print such a flawed study except to increase readership and create controversy. Since very few people were not exposed to secondhand smoke in the 1950s, this study does not have a reliable control group. Also, during the 38 year interval, a vast number of possiblities exist for the participants, so it would be difficult to reliably classify their secondhand smoke exposure. There are over 50 reliable published studies that confirm the increased risk of lung cancer and heart disease for non-smokers married to smokers. Competing interests:   None declared
Lies, Damned Lies and Statistics 17 May 2003
Richard EK Russell, Consultant Chest Physician Wexham Park Hospital Send response to journal: Re: Lies, Damned Lies and Statistics	Sir, Other commentators are better placed to comment on the methodological flaws and the conflicts of interest stated in the study by Enstrom and Kabat. I would like as a "jobbing" chest doctor to make 3 comments. Firstly, we deal with single patients, such that each patient is an "n" of one. Thus although relative risks may be valid and useful for population studies they are not applicable to the patient in front of us at that time. It is not very reassuring for a passive smoker with lung cancer that they are a statistical abnormality! Secondly, in law any increase in relative risk is considered a causal association. Because passive smoking might cause pulmonary or cardiovascular disease is interpreted,for legal purposes in court, that it did Finally, this paper will be seen by the Tobacco industry as a great victory, particularly as it was widely reported by the national media in very clear tabloid terms. Unfortunately the accompanying editorial, although an depth and accurate description of the available evidence, was not easily accessible and did not give and clear message which might counter the irresponsible, dogmatic conclusions of the paper. Competing interests:   Member of the British Thoracic Society and active supporter of the British Lung Foundation
Timing of publication 17 May 2003
Jephat Chifamba, Medical Physiology Lecturer University of Zimbabwe Medical School Physiology Dept. MP167 Harare Zimbabwe Send response to journal: Re: Timing of publication	I am a little concerned with the timing of this publication. The Framework Convention on Tobacco Control (FCTC)is being tabled and we have this? Who is fooling who? Competing interests:   None declared
Irresponsible public health message 17 May 2003
Sabina Fatima Hussain, SpR Public Health MSc Public Health, London School of hYgiene and Tropical Medicine Send response to journal: Re: Irresponsible public health message	Even if the results of this study with all its limitations are given credence, the message that emerges for the non smoker spouse is that, "Do not fret if you share an intimate environment laden with toxic by products and carcinogens with your spouse who smokes. While his risks of dying of lung cancer, coronary heart disease and chronic obstructive pulmonary disease are sufficiently well established, the wisom derived from this study somehow spares your own chances of dying from the same dreaded killers. You could still suffer the ravages of ill health imposed by various chronic diseases consequent to the fumes inhaled passively but chance of dying from these causes is small!" The only solace comes from the Declaration of Interest where it is noted with relief that these irresponsible themes have not emerged from research sponsored by Public Funds. The conclusions of the study carry a note of desperate bid by the tobacco industry to survive the market that is being increasingly marginalised by public health activists. Dr Sabina F Hussain Specialist Registrar, Public Health Competing interests:   None declared
Give them enough rope 17 May 2003
Daniel F. Hass, U.S. government employee Duluth, MN 55807 USA Send response to journal: Re: Give them enough rope	Since none of the American medical journals saw fit to publish this study, congratulations to the BMJ for showing some courage in the face of what's certain to become a firestorm of protest from entrenched anti- tobacco interests. Although highly entertaining to witness, the righteous indignation displayed here and in the American media from anti-tobacco activists is disingenous at best. Relying on outdated studies, flawed meta-analyses and garden variety junk science in order to further their agenda of social engineering has been a staple of the anti-tobacco industry for decades. Denouncing the results of this study for the same reasons that most anti- tobacco research could--and should--also be denounced is a slap in the face to anyone with even a modest amount of common sense. As the hue and cry from those with a financial stake in the debate increases, so too does my certainty that Enstrom and Kabat have struck a nerve too long left dormant. The shrill response from anti-tobacco special interest groups can only encourage more attention from the mainstream media, if for no other reason than to discover what all the fuss is about. The deceptive nature of the "science" behind the anti-tobacco crusade is a story that needs to be told. Perhaps that day has come. To consider that increased scrutiny of previous anti-tobacco research probably wouldn't happen if the anti-tobacco activists weren't making this such an issue is a delicious slice of irony. Competing interests:   None declared
Re: Irresponsible journalism 17 May 2003
Ellen C G Grant, physician and medical gynaecologist 20 Coombe Ridings, kingston-upon-Thames, Surrey KT2 7JU Send response to journal: Re: Re: Irresponsible journalism	Tobacco smoke kills Enstrom and Kabat state they did not rule out an effect of environmental tobacco smoke on mortality. They say an increase in coronary artery disease of 30% is generally accepted. This matches their only significant finding of a 30% increase in mortality in women, defined in 1972 and followed 1973-98, whose husbands’ smoked 20 cigarettes/day, which was the commonest smoking exposure category in both sexes. There were 5-6 times more women exposed to spouses’ smoking than men but there is no mention of the powerful synergistic effect of using contraceptive and /or menopausal hormones on heart disease and lung cancer. Most children brought up in the 1930s and 1940s were subject to parental smoking. This also needs to be taken into account. Smoking killed my father at age 72 and, although my mother remained healthy until her sudden death at age 95, my sister was stillborn and I react badly to tobacco smoke. Infertility, recurrent miscarriages, stillbirths, small for -dates babies, sudden infant death syndrome are increased by parental smoking. I agree that it is irresponsible to minimise the far-reaching effects of tobacco smoke. Competing interests:   None declared
what does this add? 17 May 2003
Paul M Jones, dietitian Southern Downs Health Services, Queensland, Australia Send response to journal: Re: what does this add?	The way the article is written certainly comes across as promoting the tobacco point of view. Quote from the abstract "Conclusions The results do not support a causal relation between environmental tobacco smoke and tobacco related mortality, although they do not rule out a small effect. The association between exposure to environmental tobacco smoke and coronary heart disease and lung cancer may be considerably weaker than generally believed. " Many people dont read the whole articles - many may just read the conclusion in the abstract. "Enviromental tobacco smoke" is a lot more than just whether the spouse smokes. How about studying people who have to work with smoke (eg. hotel workers)? They are probably exposed to more smoke. Many people with smoking spouses send them outside to have a smoke, so exposure by this way may be minimal. This type of research adds nothing to the debate, and plays into the hands of those who want more people addicted to deady poisons - to make a bit more profit for themselves. It should be our role to promote health - not act against it. All we can do now is hope that this research does not result in any slowing down of smoking being banned in public places. Non-smokers are by far the majority of the population, their interests should be respected. Competing interests:   Competing interests? 1. I have a concern for public health. 2. I think cigarette smoke stinks.
Swimming with sharks 17 May 2003
Paul S McDonald, Senior Lecturer (Research) University College Worcester Send response to journal: Re: Swimming with sharks	I am surprised that this study has been published in the BMJ. Emstrom & Kabat have been swimming with sharks. Our thoughts should now be with those whose health HAS suffered as a direct consequence of passive smoking. Any future legal action by these people will be be made all the more difficult. Are the 310 words written under 'funding' and 'competing interests' a BMJ record ? Competing interests:   None declared
Unproven health impact of environmental smoke: A study with low statistical power 17 May 2003
Parthasarathy K S, Director, Information and Technical Services Division, Atomic Energy Regulatory Board Mumbai 400094 Send response to journal: Re: Unproven health impact of environmental smoke: A study with low statistical power	The article by Enstrom and Kabat gave unexpected results.I request a biostatistician to examine the results to see whether the sample size was adequate to give clear results.The study reported by Enstrom and Kabat may not have sufficient statistical power. A 40 cigarettes -a-day smoker inhales pollutants from over 4kg of tobacco annually.This estimate is based on the assumption that each cigarette contains a gramme of tobacco and about 30% of the smoke from every cigarette enters the lungs.When the lungs of hundreds of people are subjected to such atrocious abuse one or two of them get lung cancer! Obviously lung tissues are made of sterner stuff. Seventy percent of the smoke from every cigarette remains airborne.These smoke particles have sizes of fraction of a micrometre and will remain for ever in the respirable range. During passive smoking there is significant dilution. Also the "surface chemistry" of the smoke particle in the passive smoke stream may be very different from that of a fresh, nascent smoke particle directly inhaled by the smoker. The particle from passive smoke is likely to be less reactive.There are thus several mitigatory mechanisms in place to reduce the carcinogenic potential of side stream smoke. This would mean that we must get more number of passive smokers in the study to establish the harmful potential of side stream smoke.It is not surprising that relatively fewer passive smokers may be stricken by smoking related diseases. Competing interests:   None declared
Biggest impact on developing countries 17 May 2003
Judith M Mackay, Director, Asian Consultancy on Tobacco Control Hong Kong, China (no pc or zipcode) Send response to journal: Re: Biggest impact on developing countries	The biggest effect of this article, the accompanying editorial, and the front page of the journal, lies not within Europe and North America, but in developing countries in Asia and Africa. Here colleagues, the media, politicians, other decision makers, and the population in general may not have access to the lively debate that the article has stimulated in developed countries, particularly in relation to methadology and tobacco industry funded research. Developing countries are struggling to introduce tobacco control measures, often in the face of considerable opposition. It is unfortunate that the "take-home" message from this article may be that such measures are probably unnecessary. The tobacco industry must be delighted with the timing; the very week that delegates from member states are heading to Geneva for the adoption of the Framework Convention on Tobacco Control at the World Health Assembly. Competing interests:   None declared
some thoughts 17 May 2003
martin heilweil, PhD, retired retired Send response to journal: Re: some thoughts	I have a PhD in Social Research from the University of Michigan, and worked for ten years as a biostatistician/ data analyst/ data manager at Memorial Sloan Kettering Cancer Center in New York City. Our work used the same proportional hazards general linear models Cox regressions that this study seems to use. I did not look much at smoking issues but rather other cancer inquiries, although one study of cervical esophageal cancer had 100% (small Ns) of decedents having been smokers. Ouch. I am a believer. I then worked similarly for a few years in FDA submissions in one or another US pharmaceutical company. I have long been skeptical of ETS as a cause of mortality. I first became a skeptic when I saw that an early report, early 1990s, probably a meta analysis, moved the goalposts, from a p level of .05 to a p level of .15. This was buried in the background of the report. Nothing since then has been persuasive. Junk science. I continued as a skepti