Nouvelle "Affaire" Enstrom + Kabat
BMJ du 17 mai 2003: Tabagisme passif

BMJ 2003;326:1057 (17 May)
Environmental tobacco smoke and tobacco related mortality in a prospective study of Californians, 1960-98

James E Enstrom, researcher1, Geoffrey C Kabat, associate professor2
- Full Text
- Abstract
- Lettre à l'éditeur de Martin McKee Need for clarification on competing interest
- Lettre de Martin McKee et Pascal Diethelm More details on competing interests
- Rapid responses published

One of the co-authors is Geoffrey Kabat, who in 1997 co-authored a paper with Ragnar Rylander and Linda Koo entitled "Dietary and Lifestyle Correlates of Passive Smoking in Hong Kong, Japan, Sweden and the U.S.A." (PM Bates 2502400372/0382) . A Swiss court has found that Ragnar Rylander "was secretely employed by Philip Morris", that he "was one of Philip Morris' most highly paid consultants", that he "did not hesitate to deceive the general public in order to show himself favourable to the tobacco company that was paying him", and that he organized symposia that were "favorable to the tobacco industry", and that he conducted studies that were "fraudulent". For full text of the Swiss judgment, see http://www.prevention.ch/ryjueng130103.htm

Letter from Womble, Carlyle, Sandridge & Rice, counsel for R.J. Reynolds. This letter seems to indicate that Enstrom worked with the lawyers of RJR, siding with the industry in the EPA litigation, making proposals of studies that could be used as ammunition by the tobacco industry to undermine good research.

Réponse, en 1996, de l'American Medical Association

Document that shows that the analysis of the CPS-I and CPS-II data by Enstrom was "developed" under the close supervision of Philip Morris (Ted Sanders is with PM), with Ragnar Rylander as a resource person, and Peter Lee

L'avis de M. Theodor Abelin, Prof. Université de Berne

La liste des contacts industrie du tabac - Dr. Enstrom

La liste des financements du Dr. Enstrom par l'industrie (p. 119) :


Communiqué de Presse de Pascal Diethelm

Subject: Article "explosif" du BMJ sur la fumée passive

Le Temps 20 mai 2003

Dimanche.ch 18 mai 2003

Bonjour,
Le British Medical Journal publie aujourd'hui une étude qui tendrait à démontrer que le tabagisme passif est inoffensif. Il est fort à parier que cet article sera très largement exploité et médiatisé par l'industrie du tabac, et que la presse risque de recevoir force communiqués mettant en avant ses conclusions. Hors, il se fait que cette étude a été financée par l'industrie du tabac et est totalement déficiente du point de vue scientifique. On ne comprend pas pourquoi le BMJ, l'une des plus prestigieuses revues biomédicales du monde, a accepté de publier un tel article, si ce n'est pour exposer ceux qui l'on rédigé et leurs sponsors.
Nous joignons ci-dessous les commentaires qui émanent des milieux de santé publique américains, qui sont montés les premiers au créneau pour dénoncer cette publication. Toute information équilibrée sur ce sujet se doit donner une large place à leur prise de position, et en particulier à celle de l'American Cancer Society dont les données ont été détournées de leur but initial par les auteurs de l'article du BMJ.
Il faut aussi noter que l'un des deux auteurs, Geoffrey Kabat, a co-signé en 1997 un article avec le Prof. Ragnar Rylander, consultant secret de Philip Morris, dont la Cour de justice de Genève a dit qu'il "n'a pas hésité à tromper le public afin de se montrer favorable au cigarettier qui le rémunérait." Une première version du travail de l'auteur principal de l'article a été sévèrement rejetée par le prestigieux Journal of the American Medical Association (JAMA - copie de la lettre ci-jointe, tirée du site de Philip Morris). Le rédacteur du JAMA a observé que le travail du Dr Enstrom était un "tissu d'opinions fait d'hypothèses spéculatives de valeur scientifique douteuse".
C'est une coincidence surprenante que cet article soit publié deux jours avant l'ouverture de l'Assemblée mondiale de la santé, au cours de laquelle le texte final du traité international de l'OMS, connu sous le nom de Convention-cadre pour la lutte antitabac doit être approuvé par les 190 pays membres de l'organisation mondiale. Le texte du traité indique notamment, dans son Article 8, que "Les Parties reconnaissent qu'il est clairement établi, sur des bases scientifiques, que l'exposition à la fumée du tabac entraîne la maladie, l'incapacité et la mort." Effectivement, l'écrasante majorité des publications traitant des effets du tabagisme passif sur la santé concluent à la haute nocivité de la fumée ambiante. Les seules rares études qui arrrivent à des conclusions contraires ont toutes été financées par l'industrie du tabac, ouvertement ou de façon occulte.
Nous ne pouvons nous empêcher de voir dans l'article du BMJ une tentative de la dernière heure par l'industrie du tabac d'alimenter une "controverse scientifique", qui n'existe plus que dans les souhaits de cette industrie, et de polluer la litérature médicale avec une étude dont le seul but est d'affaiblir les résultats de la recherche lorsque ces résultats sont considérés dans des analyses groupées (méta-analyses). Cette tentative est naturellement vouée à terme à l'échec, comme l'ont été toutes les tentatives similaires précédentes, mais elle risque entre temps de semer le trouble dans l'esprit du public et dans celui des décideurs, trouble dont l'industrie du tabac saura, nous n'en doutons pas, tirer le meilleur parti pour prolonger ses néfastes activités.
Pascal A. Diethelm, Président d'OxyGenève - 2, rue de la Fontaine - CH-1204 Genève - Suisse www.oxygeneve.ch

U.S. Public Health Groups Statements re. Industry-funded British Medical Journal study on secondhand smoke
The new issue of the British Medical Journal includes a tobacco industry-funded study that claims to find no causal link between exposure to secondhand smoke and risk for lung cancer and coronary heart disease. The study has two major problems: It is funded by the industry and it uses flawed methodology.
The study was funded by an industry-created organization called the Center for Indoor Air Research (CIAR) that was disbanded under the 1998 Master Settlement Agreement. The U.S. Department of Justice, in January 2003 court filing in its lawsuit against the tobacco industry, said "CIAR was officially created... to act as a coordinating organization for Defendants' efforts to fraudulently mislead the American public about the health effects of ETS exposure." The Justice Department also found CAIR "funded research designed not to find answers to health questions, but solely to attack legislative initiatives related to ETS exposure."
The study uses data from an American Cancer Society cancer prevention study despite the fact that ACS scientists repeatedly advised one of the researchers that using these data to study the effects of secondhand smoke would lead to unreliable results. The attached ACS statement (the first of the statements below) provides an excellent summary of the methodological flaws in the study. ACS concludes: "The study suffers from a critical design flaw: the inability to distinguish people who were exposed to secondhand smoke from those who were not."
This study's conclusions are contrary to the findings of the World Health Organization's International Agency for Research on Cancer, the U.S. Surgeon General, the U.S. Environmental Protection Agency, the U.S. National Cancer Institute, the U.S. Public Health Service, and virtually every other major public health organization and authority. The vast majority of studies of secondhand smoke have concluded that secondhand smoke is a cause of lung cancer, heart disease, chronic lung ailments such as bronchitis and asthma, and low birth-weight births. Most industry-funded studies have concluded otherwise.
Below are statements from the American Cancer Society, American Heart Association, American Lung Association, Campaign for Tobacco-Free Kids and American Legacy Foundation and a press release from a press conference held Thursday by former Surgeon General Julius Richmond and other scientific experts.
EDITORS: EMBARGOED UNTIL 7:00 PM EDT MAY 15, 2003
FOR MORE INFORMATION, CONTACT: David Sampson
American Cancer Society 213 368-8523
david.sampson@cancer.org
Shawn Steward
American Cancer Society
404 417-5850
shawn.steward@cancer.org

American Cancer Society Condemns Tobacco Industry Study for Inaccurate Use of Data Study Part of Organized Effort to Confuse Public About Secondhand Smoke
ATLANTA - May 15, 2003 - The American Cancer Society today strongly criticized a misleading tobacco industry-funded study that compromises Society data by using flawed methodology to falsely conclude environmental tobacco smoke (ETS) may not affect lung cancer risk. Dr. James Enstrom, the author of the study published in the British Medical Journal, received funding from a tobacco industry group linked to coordinated attempts to confuse the public about the dangers of secondhand smoke. "We are appalled that the tobacco industry has succeeded in giving visibility to a study with so many problems it literally failed to get a government grant," said Michael J. Thun, MD, the Society's national vice president of epidemiology and surveillance research. "The American Cancer Society welcomes thoughtful, independent peer review of our data. But this study is neither reliable nor independent." Scientific Flaws of the Study The new study uses data from the American Cancer Society's Cancer Prevention Study I (CPS-I). During the course of the analysis, Society researchers repeatedly advised Dr. Enstrom that using CPS-I data to study the effects of secondhand smoke would lead to unreliable results.
* The analysis is based on a small subset (10%) of the CPS-I data.
* The study suffers from a critical design flaw: the inability to distinguish people who were exposed to secondhand smoke from those who were not: o Participants were enrolled in 1959, when exposure to secondhand smoke was so pervasive that virtually everyone was exposed to ETS, whether or not they were married to a smoker. o No information was collected on other sources of ETS exposure besides spousal smoking. o No information on smoking habits after 1972 was included in the analysis, even though the observation period continued for another 26 years. o Study participants were, on average, 52 years old at enrollment. Many spouses who reported smoking in 1959 would have died, quit smoking, or ended the marriage during the 38-year follow-up, yet their surviving partners are still classified as "exposed" to ETS in this analysis. o Much of the follow-up of CPS-I through 1998 pertains to older age groups where the effects of many environmental risk factors become less apparent. Study Problems Lead to Tobacco Money The study was initially funded by the Tobacco-Related Disease Research Program, the group that oversees research funds earmarked from proceeds raised by California's state cigarette tax. When Dr. Enstrom was denied additional funding from the program's scientific, peer-review panel, he sought and received substantial funds from the Center for Indoor Air Research (CIAR), a tobacco company 'research group' funded by Philip Morris, among others. A confidential 1988 industry memo points to CIAR as part of a strategy to "set up a team of scientists organized by one national coordinating scientist and American lawyers, to... carry out work on ETS to keep the controversy alive." News of that memo was reported in the British Medical Journal, the journal publishing the current study (BMJ, May 31, 1997). In a January 15, 1997 letter, Dr. Enstrom tells Richard Carchman, PhD, Philip Morris' director of scientific affairs, that "[a] substantial research commitment on your part is necessary in order for me to effectively compete against the large mountain of epidemiologic data and opinion that already exists regarding the health effects of ETS and active smoking." Philip Morris apparently shared doubts about his methods. An internal document dated February 6, 1997 ("Short Comments to the Proposed Research... Submitted by J.E. Enstrom") reads: "Death certificates are generally considered to be not the best source of information," and "the amount of money asked for seems rather high when considering the work proposed. The outcome, most probably, will not add much new scientific information." The reviewer did see at least one use for Dr. Enstrom: "The applicant seems to have good connections/resources which might be useful in the future for other issues." Dr. Enstrom received the funds. What Is the Relationship Between Secondhand Smoke and Lung Cancer? Far more reliable data exist which clearly show an effect of secondhand smoke. One of those is a much more comprehensive study, also done by the American Cancer Society, called the Cancer Prevention Study II (CPS-II). CPS-II:
* Enrolled patients in the 1980s, when there was much less exposures to tobacco smoke outside the home, and therefore far less 'background noise'
* Is about 10 times as large as Dr. Enstrom's study
* Has much better follow up, with more than 99% of those originally entered into the study having been successfully contacted and followed up
* Clearly shows an increased risk of lung cancer and heart disease
"CPS-II is one of more than 50 studies now published that have shown non-smokers married to smokers have an increased risk of lung cancer," said Harmon J. Eyre, MD, the Society's national chief medical officer. "These studies have been scrutinized by multiple independent scientific consensus committees, as well as the U.S. Surgeon General, all of which certify their credibility. Most recently, the International Agency for Research on Cancer (IARC) reviewed the evidence and concluded secondhand or environmental tobacco smoke is carcinogenic to humans. "Bad science can haunt us for generations," added Dr. Eyre. "And regrettably, if questionable studies make it to publication, the damage is done." The American Cancer Society is dedicated to eliminating cancer as a major health problem by saving lives, diminishing suffering and preventing cancer through research, education, advocacy and service. Founded in 1913 and with national headquarters in Atlanta, the Society has 17 regional Divisions and local offices in 3,400 communities, involving millions of volunteers across the United States. For more information anytime, call toll free 1-800-ACS-2345 or visit www.cancer.org .
For Immediate Release Contact: Charles Hodges Charles.Hodges@heart.org
Eric Bolton Eric.Bolton@heart.org 202-785-7900

American Heart Association questions validity of new second-hand smoke study Study questioning second-hand smoke's role in chronic diseases is based on flawed science
WASHINGTON (May 15, 2003) - A new study about second-hand smoke and health is seriously flawed and contradicted by decades of credible scientific research that clearly and irrefutably shows a connection between passive smoking and serious health problems, according to the American Heart Association. The study, "Environmental tobacco smoke and tobacco related mortality in a prospective study of Californians, 1960-98," contends that there is little or no correlation between environmental tobacco smoke, also known as second-hand tobacco smoke, and death from various diseases like coronary heart disease and lung cancer. The study will be published in the May 17 issue of the British Medical Journal.
"Respected, science-based organizations have agreed for over twenty years that second-hand smoke is linked to coronary heart disease, lung cancer and respiratory diseases," said Robert O. Bonow, M.D., president of the American Heart Association. "Credible health organizations from around the world, including the U.S. Environmental Protection Agency, the California Environmental Protection Agency, the World Health Organization and several U.S. Surgeons General, have all concluded that second-hand smoke is responsible for thousands of deaths each year."
Recent evidence has added to this scientific consensus. Just last month, researchers in Helena, Montana, showed that the incidence of heart attacks dropped by 60 percent following the city's adoption of a smoke-free policy in local restaurants and bars.
Chief among the scientific concerns with the study is that the measure of exposure to second-hand smoke was whether or not a person was married to a smoker. "The conclusion that there was no measurable difference in mortality between people married to smokers and those married to non-smokers during the period 1960-1998 implies that living with a non-smoker constituted no exposure to second-hand smoke," Bonow said.
"Participants were enrolled in 1959, when exposure to second-hand smoke was so pervasive that virtually everyone was exposed to second-hand smoke, whether or not they were married to a smoker," said Bonow. This is especially true for data from the 1960s, the 1970s, and even the 1980s, because of the prevalence of second-hand smoke in many venues outside the home, such as offices, restaurants, bars, even airlines and trains, during these decades. Indeed, the concept of "environmental tobacco smoke" was not even acknowledged at the time this study was begun.
Another concern about the study involves its source of funding. The authors received funding from the tobacco industry. "Although acceptance of tobacco industry funding does not, in and of itself, prove malicious intent or incompetent research, when the result of that funding is a study that offers conclusions contrary to the consensus of the world's scientific community, it may be necessary to question whether the design of the study was adequate and appropriate. It would seem the only studies that have not found a correlation between second-hand smoke and heart disease and lung cancer are those funded by the tobacco industry," Bonow concluded.
EMBARGOED UNTIL 7 PM EDT, MAY 15, 2003 CONTACT: Abby Nash
212/315-8814
Statement of John L. Kirkwood, President and CEO
American Lung Association
American Lung Association Questions Credibility Of Tobacco Industry-Funded Study on Secondhand Smoke
Tobacco industry-funded researchers writing in today's British Medical Journal claim that nonsmokers living with smokers are not at increased risk of developing serious health problems. This contention runs counter to a large body of credible research linking exposure to secondhand smoke to respiratory illness, lung cancer and heart disease. Consider the source. The study was funded by tainted money from Big Tobacco - Philip Morris, RJ Reynolds and Lorillard - through the Center for Indoor Air Research, which was so spurious that it was disbanded under the 1998 Master Settlement Agreement. The lead researcher, Geoffrey Kabat, has well-known ties to the tobacco industry. This study used good data from the American Cancer Society (ACS) and, according to the ACS itself, distorted it. Not surprisingly, the study was funded by the same people who in 1994 stood before Congress and swore that "tobacco is not addictive," and now they want the public to believe that "secondhand smoke is not harmful." Their latest pack of lies should not be believed. The U.S. Environmental Protection Agency, the California Environmental Protection Agency (CalEPA) and the International Agency for Research on Cancer, a body of the World Health Organization, have all concluded that secondhand smoke causes lung cancer and other health problems. CalEPA estimates that secondhand smoke causes approximately 35,000 to 62,000 deaths each year. Sadly, some smokers will see this study as an excuse to continue to smoke around their families. The bogus study also may be used by policymakers to dismiss efforts to enact laws to protect everyone from secondhand smoke. People who live with smokers are at increased risk. They should take no comfort in the latest data manipulations being promoted by tobacco industry-funded researchers. We are greatly concerned about the death and disease caused by secondhand smoke. The American Lung Association, now in its second century of existence, will use expanded means through policy, research and education to address scientific misinformation put forth on secondhand smoke.
The American Lung Association has been fighting lung disease for nearly 100 years. With the generous support of the public and the help of volunteers, we have seen many advances against lung disease. However, our work is not finished. As we look forward to our second century, we will continue to strive to make breathing easier for everyone through programs of education, community service, advocacy, and research. The American Lung Association's activities are supported by donations to Christmas Sealâ and other voluntary contributions. You may obtain additional information via the American Lung Association Web site at http://www.lungusa.org.
EMBARGOED FOR RELEASE CONTACT: Joel Spivak 7 p.m. EDT May 15, 2003 202-296-5469
Statement of Matthew L. Myers, President
Campaign for Tobacco-Free Kids
New Study on Secondhand Smoke
Is Based on Flawed Science and Funded by the Tobacco Industry

WASHINGTON, DC (May 15, 2003) - A study being published today that claims to show there is no link between exposure to secondhand tobacco smoke and coronary heart disease and lung cancer is based on flawed science and, not surprisingly, is funded by the tobacco industry. This study's conclusions are contrary to the findings of the World Health Organization's International Agency for Research on Cancer, the U.S. Surgeon General, the U.S. Environmental Protection Agency, the U.S. National Cancer Institute, the U.S. Public Health Service, and virtually every other major public health organization and authority in the United States. These scientific authorities and the vast majority of studies of secondhand smoke have concluded that secondhand smoke is a cause of lung cancer, heart disease, chronic lung ailments such as bronchitis and asthma (particularly in children), and low birth-weight births. Like the new study, which is being published in the British Medical Journal, almost every study that has concluded secondhand smoke does not cause disease has been funded by the tobacco industry.
The new study must be placed in the context of the tobacco industry's long history of funding junk science aimed at discrediting legitimate studies about secondhand smoke and sowing doubt and confusion among the public, the media and policy makers. In fact, the tobacco industry organization that funded the new study - the Center for Indoor Air Research (CIAR) - was created for the very purpose of spearheading these deceptive industry efforts and was shut down by the state attorneys general as part of the 1998 state tobacco settlement. In January 29, 2003 court filings to support its racketeering lawsuit against the tobacco industry, the U.S. Department of Justice stated, "CIAR was officially created ... to act as a coordinating organization for Defendants' efforts to fraudulently mislead the American public about the health effects of ETS [environmental tobacco smoke] exposure." The Justice Department also stated that CIAR "was not only used for litigation and public relations, but it was [sp] also funded research designed not to find answers to health questions, but solely to attack legislative initiatives related to ETS exposure. Lawyers specifically engineered and constructed scientific studies to get results that would be useful for public relations, litigation, and legislative battles, as opposed to results that would assist the scientific community in further understanding the health effects of ETS exposure." (Brackets added.)
It is a tremendous disservice to the public, the scientific community and the media that the tobacco industry's funding of the new study and the involvement of CIAR were disclosed only in the fine print at the end of the study. In addition to CIAR's involvement, the fine print also notes that one of the researchers "conducted an epidemiological review for a law firm which has several tobacco companies as clients."
The new study analyzed data from an American Cancer Society cancer prevention study and tracked 118,094 California adults from 1959 to 1998. The American Cancer Society has stated that its scientists repeatedly advised one of the researchers that using these data to study the effects of secondhand smoke would lead to unreliable results. According to the Cancer Society, "The study suffers from a critical design flaw: the inability to distinguish people who were exposed to secondhand smoke from those who were not." Among its methodological problems, the study used a flawed measure of exposure to secondhand smoke based on whether a non-smoker was married to a smoker in 1959, when smoking was much more pervasive than today and non-smokers were exposed to secondhand smoke in most workplaces and other settings. It did not collect information on other forms of exposure to secondhand smoke or fully track changes in exposure in the home over time. (For more information on the American Cancer Society's analysis, please contact David Sampson at 213-368-8523).
A larger and more recent study, which was also based on American Cancer Society data and began in the 1980s, when there was less exposure to secondhand smoke outside the home, clearly showed an increased risk of lung cancer and heart disease as a result of exposure to secondhand smoke. Other studies have reached similar conclusions. Based on a review of more than 3,000 studies, the International Agency for Research on Cancer (IARC), a branch of the World Health Organization, concluded in June 2002 that there is a "statistically significant and consistent association between lung cancer risk in spouses of smokers and exposure to secondhand tobacco smoke from the spouse who smokes." The IARC also found that "epidemiological studies have demonstrated that exposure to secondhand tobacco smoke is causally associated with coronary heart disease." (Summaries of studies on the health harms of secondhand smoke can be found at www.tobaccofreekids.org/research/factsheets/pdf/0103.pdf .)
It is not surprising that the new study is being published as a growing number of governments in the United States, Britain and around the world are enacting smoke-free indoor workplace policies to protect workers and customers from the dangers of secondhand smoke. In addition to protecting non-smokers, such measures are proven effective at preventing non-smokers from starting to smoke and spurring smokers to quit or reduce smoking, all of which reduce cigarette sales and hurt the tobacco industry's bottom line. State and local governments should act on the vast majority of studies showing the health harms of secondhand smoke, not on studies funded by the tobacco industry, and protect the public's right to breathe clean, smoke-free air.
Nicole Dueffert Assistant Manager, Media Relations
Campaign For Tobacco-Free Kids 1400 I Street, N.W., Suite 1200
Washington, D.C. 20005 - USA - 202-296-5469 (p) - 202-296-5427 (f) www.tobaccofreekids.org




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