Cancelled by Medscape

Science should be judged on its merits, not on its funders

We think a lot about considering the importance of funding when we read trials and editorials. There is no question that this is appropriate. Conflict of interest abounds in study design, their, and the creation of clinical guidelines. But, can consideration of funding source blind us to important research and opinions?

Sally Satel always gets me thinking. Her essay about paying people for organ donations remains one of my favorite Sensible Medicine articles and has become part of my “teaching arsenal.”

Adam Cifu

Over the years, I have watched dozens of educational videos on Medscape and used the CME credits toward license renewals. I was excited when the platform invited me to participate as an instructor in two planned videos on the topic of tobacco harm reduction (THR), the practice of delivering nicotine in safer ways through lower-risk products such as e-cigarettes and smokeless tobacco. I have previously written two pieces on the topic for sensible medicine.

The videos would show why THR is an answer to combustible tobacco (aka cigarettes), for people unable or unwilling to quit smoking using FDA-approved cessation tools, such as nicotine patch or gum.

On April 1, our two 30-minute videos went live as part of a five-module series.[i]

Days later, tobacco-control advocates erupted in protest. “Outcry as Philip Morris International funds smoking cessation courses on Medscape,” read an April 9 headline in the British Medical Journal. “The idea that the lethal and immoral tobacco industry has a role in medical education is absurd,” a professor of respiratory medicine at Imperial College London told a BMJ reporter. If Medscape were to put the courses back up – they had removed the videos on April 5 -- the professor warned, there “would be a rapid global boycott by healthcare professionals disgusted by their behavior.”

I must note, no one objected to content that my co-presenters and I fully controlled. We observed the standard firewall between funder and faculty in continuing-medical-education programs. The videos were dense with evidence. We showed that e-cigarettes, the most popular quit-smoking aid, are far less hazardous than smoking in terms of toxin emission – 95 percent less according to the Royal College of Physicians (“only a small fraction of the risks of smoking” is how another UK agency puts it).

We discussed improvements in asthma, COPD, vascular function, and hypertension in smokers who had switched to vaping, and reported on vaping’s demonstrated superiority as a cessation method in randomized controlled trials and a large review study. We showed that e-cigarette use has not led to smoking among youth, and further explained why the claim that nicotine impairs teen brain development is speculative at best.

Throughout, we insisted on the importance of continued epidemiological follow-up to detect the rare or later complications that might be associated with long-term use. Yet, our fact-based efforts were not enough. In opposing tobacco-harm-reduction research and communication, the playbook is clear: blame the funder, evoke outrage, suppress the content.

At one time, of course, the tobacco industry was brazen. In the 1950s, for example, major cigarette manufacturers launched a campaign to refute the robust evidence that their products caused lung cancer. The companies hired a few skeptical scientists to raise doubt about smoking-related harm and they buried their own internal research if unfavorable to their interests.  Many remember the 1994 congressional hearing where top executives of seven major tobacco companies asserted, one after the other, that nicotine was not addictive.

But times have changed, and the tobacco industry is now held accountable for its research by the Food and Drug Administration. My partner on one video, Brad Rodu of the University of Louisville, conducted work on smokeless tobacco between 1999 and 2018 with support from unrestricted industry grants to his universities. “My grants were disclosed publicly,” he told me, “and the universities’ agreements assured complete independence to publish results without informing the sponsors, regardless of the results’ impact on them.” Most universities, however, won’t take any grants at all.

The Medscape fiasco reflects widespread efforts to shut down much of the scholarship in tobacco-harm reduction. Scientific journals, for example, often refuse to publish scholars whose work is funded by tobacco companies. The American Thoracic Society publishes a family of journals that will not accept “any research that has been funded by tobacco entities.” The BMJ and other journals of the British Medical Association, such as Tobacco Control, and the Public Library of Science (PLOS) journals, including PLOS Medicine, PLOS Global Public Health, and the European Journal of Public Health impose similar restrictions. This policy extends to the Society for Research on Nicotine and Tobacco, which hosts the largest international tobacco and nicotine conference annually and bars tobacco-industry scientists from attending its annual meeting or submitting research abstracts for publication in the meeting handbook. The Society says that it needs to maintain the forum as a “safe space.”

Science, ideally, should be immune to guilt-by-association charges. As six world-renowned researchers noted in a 2018 article, “the level of accountability and transparency by the FDA is similar to or greater than that for pharmaceuticals and exceeds that expected of academic scientists.” And, critically, PMI and other companies are seeking to make use safer by inventing and promoting non-combustibles. “If the tobacco industry seeks to make money by marketing reduced risk products instead of more risky products,” the authors note, “we fail to see this as a menace to public health.”

On April 22, I learned from the BMJ reporter that Medscape had capitulated and permanently removed the educational videos. Who loses? Doctors – including the roughly 260,000 primary care doctors, 7,700 pulmonologists, 180,000 nurse practitioners, 118,000 physicians’ assistants, and 165,000 pharmacists that Medscape planned to reach – and millions of patients those doctors could have helped.

Those who helped squash the THR courses seem blind to the paradox: erecting barriers to creating and sharing data on low-risk nicotine products only helps cigarette makers worldwide, keeping millions of people smoking — and dying.

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[i] The topics of the videos were: “Focus on Harm Reduction in Certain Patient Populations: Why Smoke-Free Products?”; “Counseling Patients on Nicotine Replacement Therapy: One Size Does Not Fit All”;  "Health Impact of Tobacco Products: What Do We Know in 2024?"; "Harm Reduction From Tobacco: An Evidence-Based Discussion"; “Nicotine Misperceptions”

Sally Satel is a psychiatrist and senior fellow at the American Enterprise Institute. She has received no direct funding from the tobacco industry.