Doctors Under the Influence? The Real Story

About a month ago, my colleague, Dr Michael Steinberg, and I were contacted by a journalist for BusinessWeek magazine, who said she was interested in discussing “smoking cessation” with us, focusing on a paper we had recently published in Annals of Internal Medicine, entitled, “The case for treating tobacco dependence as a chronic disease.” On talking to Ms Weintraub, however, the focus of her questions very swiftly shifted to the topic of whether we have ever done any paid work for pharmaceutical companies and whether that presented a conflict of interest. Of course we explained that we have done some consulting work and presentations for pharmaceutical companies who make smoking cessation products, and we pointed out that this, including the names of the companies, was clearly disclosed at the end of our published paper, as is common practice when publishing in medical journals.

The journalist, recognizing that it is our practice to disclose our funding wherever it comes from, in our publications and presentations, then asked if we do so to our patients. We thought about this a little and stated that we don’t, and that this isn’t normal practice in any area of healthcare. I commented that when I go to see my own doctor about my asthma, I expect her to assess and treat my asthma to the best of her ability, and if she started telling me that she has been paid to do some work for pharma companies, I’d be a bit puzzled as to why she was telling me this. I am neither surprised nor concerned to hear that my doctor might do some work for pharma companies. It is probably a sign that she is regarded as having expertise in that field. Personally I don’t feel this is information I need to be provided with on a routine basis, and that if one day I decided I had a reason to ask, I’d do so and expect to be told. In fact I’ve never asked a medical doctor that question, nor ever thought of it. Similarly I don’t recall being asked by a patient, which is perhaps not surprising given that I’m a psychologist and don’t prescribe medicines at all.

I was then surprised when the journalist’s questions shifted from our article in Annals of Internal Medicine, to the new smoking cessation medicine, Chantix, which was barely mentioned (once) in the article. The questions were all about work we’d done for the manufacturer (Pfizer), and whether that made us biased towards the drug. The journalist appeared to be under the impression that the article aimed to persuade doctors to prescribe Chantix to patients for life. We explained that the article wasn’t about Chantix at all (the patient described in it wasn’t treated with Chantix) and that we do not recommend treating patients with any tobacco treatment medicines for life. We explained that we advise patients to use the medicines for as long as it takes to successfully quit smoking (typically until they have 14 consecutive days without cravings), and that the biggest problem we find is that patients often only use the medicines for a few weeks and go back to smoking. However, despite our repeated clarifications, we had a feeling that she was not particularly interested in the facts, but had an angle she wanted to pursue and was going to do it regardless.

So her article appeared in the June 26 issue of BusinessWeek under the title, “Doctors Under the Influence?” opposite a full-page cartoon depicting a doctor in a white coat being fed cash into his mouth, while simultaneously popping pills into the mouth of an open-mouthed patient. Get the idea? So I’d like to take this opportunity to clarify some facts and some issues that were badly misrepresented in the article.

Misrepresentation 1: In the opening paragraph, the article states that in our Annals of Internal Medicine publication we advised that addicted smokers should take prescription drugs for years to curb their cravings. In fact, nowhere in the paper did we advise that patients should take medicines for years. Rather, we state that some smokers may require extended treatment (both behavioral and pharmacological) to quit smoking. This is entirely consistent with the current US Public Health Service Clinical Practice Guideline, which states:

“For some patients it may be appropriate to continue medication treatment for periods longer than is usually recommended.

Although weaning should be encouraged for all patients using medications, continued use of such medications is clearly preferable to a return to smoking with respect to health consequences.” (p126).

Incidentally, the first of the 10 key recommendations of the US Public Health Service Clinical Practice Guideline states, “Tobacco dependence is a chronic disease that often requires repeated intervention….”.

Misrepresentation 2. The third paragraph points out that the paper was published around the time Pfizer was strengthening warnings on the labeling on its new smoking cessation drug, Chantix, and stated “This timing has fuelled concern that company-paid experts are trying to protect the drug…” In fact the paper described a case report of a patient who was successfully treated with other smoking-cessation medicines (not Chantix) over two years before Chantix was launched, and mentions the drug by its generic name (varenicline) only once in citing a paper showing that it was safe and effective for up to a year. In truth the paper is not about Chantix at all.

Misrepresentation 3. The title, attached artwork and overall thrust of the article implies that if a health professional has done some work for a pharmaceutical company, they must therefore be being paid by the company to get patients to use the drug. Well let’s think about that for a second. Healthcare providers who gain expertise in treating a specific health problem via their clinical work and research, whether it be tobacco addiction or diabetes, are clearly more likely to be offered paid work (including research funds) for their expertise by a range of interested parties, whether it be government organizations, non-profits, or pharma companies. None of these organizations are allowed to pay anyone to prescribe a specific medicine, and in my case, as a psychologist I don’t prescribe any medicines anyway. My consulting work has involved things like advising on clinical trial design, reviewing applications for research funds, discussing common barriers to quitting smoking, and advising on future potentially effective smoking cessation medicines. I have also provided presentations to doctors about smoking cessation medicines, so that they can become more knowledgeable both about these medicines and about effectively helping smokers to quit. None of these activities are linked to the medicines selected by patients at our clinic. As we very clearly explained to the journalist, our style at the Tobacco Dependence Clinic is to offer individual and group counseling and to show patients all the FDA-approved medicines for smoking cessation, and let them choose the ones they would like to try, based on a discussion of their pros and cons and of their own history. Only a minority of our patients choose Chantix.

Misrepresentation 4. The article implies that we have some kind of problem with disclosing our consulting work with pharma companies. On the contrary, our consulting work is stated very clearly on the specific paper that captured the journalist’s interest. In addition, both Dr Steinberg and I stated that we have no problem disclosing this work to patients if they ask, but we don’t see it as something that patients will want to have provided to them routinely. So we ask readers to consider whether they really want their hospital doctors to have a discussion with them about their various sources of income every time they see them. In considering this question, bear in mind that the more senior and the more “expert” the doctor you see, the greater the likelihood that they will have done work funded by a potentially long list of organizations. If the answer is yes, we will be happy to oblige, but until we hear that request consistently, we are happy to provide the information to patients on request.

Of all the misrepresentations in the article, the one that bothers me most is the entirely inaccurate picture the article paints of my colleague, Dr Michael Steinberg. He is without doubt one of the best medical doctors I have had the privilege to meet or work with. He has chosen to forego far more lucrative career options to focus on working as an academic hospital doctor and internal medicine specialist, with a specific clinical and research focus on helping the most addicted smokers to successfully quit. He has become a national expert on pharmacotherapy for smokers and so it is no surprise that many groups (including pharma companies) seek his expertise. He has every right to be paid for the work he does in sharing that expertise. I have no doubt at all that his clinical work is guided by the best scientific evidence, combined with his own expert judgment of what might be most helpful for the patient and an excellent clinical style that respects patient choice. The development of our Tobacco Dependence Clinic into one of the best clinical services for addicted smokers in the country is largely due to his expertise. Note that the service is funded by the New Jersey State Department of Health and Senior services.

As for myself, I continue to be happy for people to be fully informed about my funding, and to judge my actions and opinions on whether or not they are based on the best scientific evidence. Even the more positive things said about me in the article are inaccurate. I’m not a “celebrity in antismoking circles” and I never “launched an extensive telephone hotline for smokers” (I worked briefly as Director of Research for the UK charity, “Quit” which ran the UK Quitline for many years prior to my involvement). I find it an interesting coincidence that the BusinessWeek article, which appears to attempt to discredit reputations, is published less than a month before I am due to provide testimony as an expert witness in four law suits against tobacco companies. These lawsuits stemmed from the Florida-based “Engle” class-action lawsuit which led to the largest financial judgment of its type, ever ($145 billion against the tobacco industry). The class action was later decertified, resulting in these and numerous other individual cases, which the tobacco industry is obviously very eager not to lose. I’m sure this is just a coincidence, and that a magazine like BusinessWeek wouldn’t dream of being under the influence of big business itself.

FYI here are a couple of tobacco industry-friendly articles on the BusinessWeek website:

http://www.businessweek.com/investor/content/jan2008/pi20080129_262388.htm

http://www.businessweek.com/bwdaily/dnflash/content/jan2008/db20080129_130365.htm

So as far as BusinessWeek is concerned…...
doctors who have ever done work for a pharma company, then providing the most effective treatment to help smokers quit – unethical,
but multinational tobacco companies winning litigation and selling more cigarettes around the world – priceless.

You can find our original article in Annals of Internal Medicine at:
http://www.ncbi.nlm.nih.gov/pubmed/18378950?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

The citation is:
Steinberg MB, Schmelzer AC, Richardson D, Foulds J. Treating tobacco dependence as a chronic disease: a case illustration. Annals of Internal Medicine 2008 Apr 1;148(7):554-6.

Labels: BusinessWeek, Chantix, Chronic Disease, jonathan foulds, Pharmaceutical

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