The Lancet is a highly respected medical journal, ranking number 2 in the world. It publishes papers for peer-review but also carries editorial statements penned by Richard Horton, the editor. It has been at the centre of controversies in the past – not least when the editorial team were censured for their attempts to cover up the fact that they created the scare over (and then tried to cover up) a non-existent link between the MMR jabs and autism.
Where is the editorial?
It is titled E-cigarettes: Public Health England's evidence-based confusion and the full text can be found here.
What does the editorial say?
They open by selectively quoting the PHE report: “The headline in their press release quoted their top-line finding—‘E-cigarettes around 95% less harmful than tobacco’.”
What didn’t they quote from the PHE report then?
“None of the studies reviewed above alter the conclusion of Professor Britton’s 2014 review for PHE. While vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent and the chemicals that are present pose limited danger. It had previously been estimated that EC are around 95% safer than smoking. This appears to remain a reasonable estimate.”
Is this a problem?
Well, Doctor Farsalinos said: “the editorial ignores the first sentence and focuses on reference 10 ... which estimated the harms of several nicotine-containing products.” Farsalinos is upset that The Lancet names his friend Doctor Polosa and that they picked on one reference source while ignoring the other 184.
Why did they pick on one report and name Polosa?
Because of the headlines in the media taking the key message from the PHE report’s forward that says: “In a nutshell, best estimates show e-cigarettes are 95% less harmful to your health than normal cigarettes.”
When Duncan Selbie, PHE chief executive, signed his name to the report he didn’t talk in general terms and made reference to Peter Hajek’s conclusion regarding the level of safety. Although Hajek and Selbie state “best estimates” (plural) there is only one paper that approximates a figure – and that one paper features Ricardo Polosa on the team. Polosa is a consultant for an electronic cigarette company.
The Lancet editorial takes issue that such a remarkable claim features so strongly in the PHE report on the back of a single piece of research and casts aspersions on its reliability due to possible undue influence.
But wasn’t a second piece of research also cited regarding the 95%?
Yes, Hajek refered to a piece of work by Robert West that mentioned vaping presented 1/20th of the danger of smoking.
That’s awesome then – so two reports agreed...
Well, no. Robert West also got his figure from the same work The Lancet has an issue with.
What does The Lancet say about this?
“The reliance by PHE on work that the authors themselves accept is methodologically weak, and which is made all the more perilous by the declared conflicts of interest surrounding its funding, raises serious questions not only about the conclusions of the PHE report, but also about the quality of the agency's peer review process. PHE claims that it protects and improves the nation's health and wellbeing. To do so, it needs to rely on the highest quality evidence. On this occasion, it has fallen short of its mission.”
So does the inclusion of Polosa on the 95% study really bring the whole thing into question?
Farsalinos claims: “What the Lancet implies is that 2 of the 12 authors of the Nutt paper framed everyone else into creating a biased document to support their financial interests.” He goes on to explain that all twelve members of the research team “were among the most active researchers in tobacco smoking ... and of course they based their conclusions on evidence.”
Has the lead scientist from the 95% study made comment?
Yes. David Nutt explained the full process: “The funding of the MCDA nicotine study was provided by a Swiss-based consulting firm interested in this question as an unrestricted grant to the charity DrugScience. They had no involvement in the subsequent meetings and publications. An Italian anti-smoking charity made a small financial contribution at the publication stage to help pay for open access. The expert group was chosen by members of the DrugScience scientific panel with the help of other UK experts to provide international expert group with expertise across the various disciplines of health, psychology, addiction, pharmacology, toxicology, neuroscience etc; the final panel was an impressive group. As is inevitable in such a field several had or had had “interests” in aspects of nicotine and tobacco supply or harm reduction, and these were declared at the time. However it is important to re-emphasise that the MCDA process is such that neither individuals nor even groups with particular biases can significantly influence the outcomes.”
Have the authors of the Public Health England report made comment?
“The Lancet editorial criticises our Public Health England commissioned evidence update report on the basis of perceived flaws in one of the 185 references we used, ignoring the rest of our 111 page document, which addresses population effects of e-cigarette use, regulations, attitudes as well as concerns over its safety.”
They summarise: “We would encourage people to read our full report before criticising it. Current evidence indicates that smokers who switch from smoking to e-cigarettes reduce the risks to their health dramatically. We believe this needs to be communicated and that undermining this message will keep smokers smoking and dying as a result.”
And anybody else?
ASH UK have also written a press release where they say: “ASH was saddened to see the Lancet editorial today attacking Public Health England (PHE) for having ‘fallen short of its mission’. To criticise Public Health England for quoting an estimate, contained in the expert review it commissioned, that e-cigarettes are 95% less harmful than tobacco on the basis that the methodology behind the estimate was weak is to miss the point.”
So what does this all mean?
In short, the PHE report remains an excellent document full of sound research. Vaping remains far, far safer than smoking but it is possible the PHE regret the phrasing of some sections and how the press release to the media was worded. In many ways they offered an open goal to those who would wish to see the entire report tarnished.
As has been pointed out from many sources, The Lancet failed to challenge any of the outlandish claims made against vaping in the past and thereby fails its own criteria for credibility by appearing bias – but it does highlight the need for further studies in order to win over the detractors.