Public Health England’s troubled trail
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5826 (Published 03 November 2015) Cite this as: BMJ 2015;351:h5826
Vaper TrailsClick here to see our interactive graphic, showing the evidence that informed Public Health England’s “95% safer” claim.
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Gornall's attack [1] on Public Health England's (PHE) report on e-cigarettes is surprising. It claims the 95% estimate "relied on" a paper which it charges with conflicts of interests. However, PHE's report clearly reassesses that estimate based on its own review of the toxicological data, concluding independently that the figure "appears to remain a reasonable estimate" [2].
References
1 Gornall, J. Public Health England’s troubled trail. BMJ 2015. doi: 10.1136/bmj.h5826
2 McNeill A, Brose LS, Calder R, Hitchman SC, Hajek P, McRobbie H. E-cigarettes: an evidence update. A report commissioned by Public Health England 2015
Competing interests: No competing interests
Dr Anand's response highlights an increasing problem within the NHS, that of the threat to the independent voice.
Many managers and clinicians will only proffer an opinion or evidence if thy are offered anonymity.
There seems to be a belief that the NHS is a corporation that can demand the loyalty of it's staff, even to have supremacy over professional requirements.
I do not know how we can reverse this trend but a start might be Duncan Selbie stating that he would welcome any of his directors taking a contrary stance on 95% and would support them in offering the public a more nuanced and complex answer
Competing interests: No competing interests
To me the most troubling para of Mr Gornall's report is that A DIRECTOR OF PUBLIC HEALTH SPOKE ON CONDITION OF ANONYMITY.
Here is a matter of public health. This director must be open and forthright. If his Council tries to gag him, the public will ungag him.
Public Health England does not employ him, the Department of Health does not employ him. They have no right to gag him.
Surely the Faculty of Public Health of the Royal Colleges of the UK would expect him to speak out.
Certainly the old MOH, the District Community Physician, the District Medical Officer, the Medical Officer of Environmental Health (who was also the "proper officer" for certain local authority functions under the Local Government Act) would not have accepted censorship. Nor purdah.
Competing interests: Member of the public. Relies upon the director of public health being visible, articulate, outspoken.
There is no doubt that smoking is a harmful activity, however people smoke for the nicotine but die from the tar which is a by product of combustion. E-cigarettes and other harm reduced nicotine products have the potential to be a massive public health prize if smokers can be given the confidence to switch to them. In their recent evidence based report PHE estimate that e-cigarettes are 95% safer than smoking. Recent surveys however, have clearly shown that there are a significant and increasing number of people who incorrectly assess the relative safety of e-cigarettes as being overly harmful when compared to smoking traditional cigarettes . This misperception has the potential to cause real harm to those smokers who might otherwise switch.
Criticism of the report based on quibbles over the 95% figure and tenuous insinuations of conflicts of interest in relation to some of the authors of one study out of the 180 cited within it do nothing but create doubt in the public mind, which discourages smokers from switching to the safer product and ultimately, harms their health.
Whilst it is of course important to ensure that information such as the PHE estimate that e-cigarettes are 95% safer than smoking is as accurate as possible based on current evidence, it is more important still that consumers understand the message being put forward. This means that messaging must be clear and unambiguous and framed within their personal experience. This is what the PHE report sought to achieve
As Professors of Public Health, scientists and journalists fight out their battles through the pages of scientific journals and newspapers, smokers and vapers are left unsure about how these products may benefit them. The negative health impact that such confusion brings to every smoker who is discouraged by it should weigh heavily on the conscience of all of those who put pen to paper without considering the consequences of their words.
Competing interests: No competing interests
PHE’s activities and statements are based on all the available evidence, however in many areas this evidence is still evolving. This is especially true of new technologies or emerging threats.
We welcome discussion of the scientific evidence and we undertake extensive peer review of our key outputs. As a national public health body we have a duty to provide timely advice based on what the evidence tells us and to review and update our guidance as this develops.
The topics we work on are controversial and our position may attract criticism, which is not new in public health practice. Every major public health development in history, from the original sanitary movement and vaccination through to the seat belt and smokefree legislation, has been challenged by those who disagree. What we need is balanced and informed scientific debate which can help to clarify the strengths and weaknesses of the available evidence base.
PHE strives to be rigorous in our use of evidence and recognises the need to constantly review this. It can lead to considerable harm if action is not taken or delayed when the balance of available evidence suggests that action would be helpful. In those circumstances we have a duty to speak. We do, in some cases, need to make recommendations which are based on the best evidence we have at the time. There are parallels with clinical practice – doctors regularly give advice to patients based on the available evidence and we in public health must do the same with our information for the public and professionals.
Competing interests: Chief Executive of Public Health England.
Re: Public Health England’s troubled trail
Holland states that he believed “the basic problem” with PHE was that, as it was currently structured, it was “not an academic institution and has not really been able to establish a proper linkage to academe and to expert advice.” Compounding this, it was also “not listening to advice.”
Whatever the figures on smoking and other relevant public health issues, it is clear to anyone visiting Public Health England's (PHE) Government-hosted website that its own trails of advice smoke emanate predominantly from Ministerial fags. That the document on taxing sugar was leaked and not formally published by PHE is but further evidence of this.
Chris Manning
Competing interests: As a retired GP with an interest in harm reduction, I have provided medical consultancy advice to Nicoventures.