"Conflicts of interest" and "political science"

Benefits and hazards of alcohol-the J-shaped curve and public health

Purpose

The purpose of this paper is a review of updated evidence of a J-shaped association between alcohol consumption and the risk of coronary heart disease (CHD) and all-cause mortality in relation to public health issues to create a basis for sensible individual health deliberations.

Design/methodology/approach

A review of the evidence from the first observation of a J-shaped association between a moderate alcohol intake and CHD in 1926 to recent studies of the effect of healthy lifestyles (including moderate alcohol intake) on life expectancy free of cardiovascular disease (CVD), cancer and Type 2 diabetes. An update on the biological plausibility of the J-shaped association with focus on recent findings of the association of alcohol intake and blood lipid levels.

Findings

Plausible J-shaped relations between light to moderate alcohol consumption and the risk of CHD, CVD mortality and all-cause mortality have been found in a large number of robust epidemiological studies. Among the potential mechanisms underlying the proposed protective effects are higher levels of high-density lipoprotein lacking apolipoprotein C3, reduced platelet aggregability, increased level of endothelial cell fibrinolysis, increased insulin sensitivity and decreased inflammation.

Originality/value

The existence of a J-shaped association between alcohol consumption and the risk of CHD and all-cause mortality is based on observational evidence and accordingly challenged by a degree of uncertainty leading some public health circles to state: “there is no safe level of alcohol consumption.” The authors propose that communication on the pros and cons of alcohol intake should emphasize the nadir of a J-shaped curve as a healthy range for the general population while advice regarding the consumption of alcohol should be adjusted to factor in the risks and potential benefits for each individual patient considering age, sex, family history, personal drinking history and specific medical history.

"A delicate diplomatic situation": tobacco industry efforts to gain control of the Framingham Study

BACKGROUND

The Framingham Heart Study (henceforth Framingham) is among the gold standards for epidemiological research. Being a prospective cohort study of 5,000+ men and women, it provided early findings about the causes of coronary heart disease (CHD), following a cohort over the course of 24 years. After US government funding ended, the tobacco industry funded Council for Tobacco Research (CTR) provided continued funding for analyses related to smoking.

OBJECTIVE

This study sought to understand the tobacco industry's motivation and activities in funding Framingham.

STUDY DESIGN AND SETTING

We analyzed previously undisclosed tobacco industry documents, conducting iterative searches of the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu/), and assembled a historical case study.

RESULTS

CTR funded Framingham to obtain full access to Framingham data. CTR planned for long-time industry consultant Carl Seltzer to reanalyze them to suggest that tobacco-related morbidity and mortality primarily resulted from "constitutional" factors, such as age or ethnicity. Once data were obtained, CTR terminated funding for the Framingham principal investigator, who disagreed with Seltzer. Seltzer's critical analyses of subsequently published work by the Framingham team created confusion about the association between CHD and cigarette smoking.

CONCLUSION

Researchers accepting tobacco industry funding risk losing control of data, analysis, and publication.

The controversial controversy of a passionate controversialist

Alvan Feinstein was among the pioneers who perceived the need to apply epidemiologic principles and methods to clinical medicine. In his attempt to convert his peers to his own views, he was very liberal in criticizing the work of others. Epidemiologists still recall his 1988 article in Science entitled "Scientific Standards in Epidemiologic Studies of the Menace of Daily Life," in which he criticized observational epidemiology for its lack of scientific rigor. In this context, Feinstein's work has also been the center of controversies. One in particular, related to the fact that he carried out research and consulted for industries, in particular the tobacco industry, has tainted the last years of Feinstein's career. My purpose in this article is to discuss Feinstein's relationship with the tobacco industry. It is not to judge the validity of his work. Against this background, a question of historic relevance, one that can be discussed on the basis of some evidence, is whether Feinstein, world-reknowned epidemiologist and editor of this journal from 1982 until his recent death, helped the tobacco industry to publish articles minimizing the deleterious effects of smoking in the Journal of Chronic Diseases and (since 1988) the Journal of Clinical Epidemiology. To address this question I have searched the articles related to the effects of tobacco that were published in the Journal since 1978. The tobacco industry has had the opportunity, via its consultants, to defend its own ideas in the "Variance and Dissent" section. Perhaps in hindsight Feinstein could be criticized for not having clearly indicated the sponsorship of the tobacco industry behind these publications, of which he was fully aware. However, this does not suffice to infer that he was the tobacco industry's "man." Feinstein's attitude in matters of publication appears balanced.

Nicotine as an Addictive Substance: A Critical Examination of the Basic Concepts and Empirical Evidence

The present review is a critical analysis of the concepts behind and the empirical data supporting the view that tobacco use represents an addiction to nicotine. It deals with general aspects of the notion of addiction, while concentrating on specific problems associated with incorporating nicotine into current frameworks. The notion of addiction suffers from unprecedented definitional difficulties. The definitions offered by various authorities are very different, even contradictory. Definitions that reasonably include nicotine are so broad and vague that they allow many trivial things, such as salt, sugar, and watching television, to be considered addictive. Definitions that exclude the trivia also exclude nicotine. The addiction hypothesis, in general, is strongly shaped by views that certain drugs bring about a molecular level subversion of rationality. The main human evidence for this is verbal reports of smokers who say that they can't quit. On the other hand, the existence of many millions of successful quitters suggests that most people can quit. Some smokers don't quit, but whether they can't is another matter. The addiction hypothesis would be greatly strengthened by the demonstration that any drug of abuse produces special changes in the brain. It has yet to be shown that any drug produces changes in the brain different from those produced by many innocuous substances and events. The effects of nicotine on the brain are similar to those of sugar, salt, exercise, and other harmless substances and events. Apart from numerous conceptual and definitional inadequacies with the addiction concept in general, the notion that nicotine is addictive lacks reasonable empirical support. Nicotine does not have the properties of reference drugs of abuse. There are so many findings that conflict so starkly with the view that nicotine is addictive that it increasingly appears that adhering to the nicotine addiction thesis is only defensible on extra-scientific grounds.