Conflicts of interest a threat to health

Conflict of interest in health research came into sharp focus recently when public health academic Dr Marewa Glover presented a submission opposing a ban on smoking in cars to the Government’s health select committee.

Glover acknowledged research support from the Foundation for a Smoke-Free World in her submission but failed to mention the Foundation, and indirectly the institution she directs, the Centre of Research Excellence: Indigenous Sovereignty & Smoking (COREISS), are funded by tobacco giant Philip Morris International.

So how much of problem is this? And how far should we go to ensure that conflicts of interest are disclosed by those seeking to influence public policy?

Speaker of the House, Trevor Mallard, thinks it's important enough to launch a review into whether people making submissions to Parliament should be required to declare conflicts of interest. Another MP, ACT leader David Seymour, viewed the effort as misguided, unnecessary, and that determining relevant conflicts would be “political”.

This debate is international. In the UK there has been a call for transparency regarding funding of think tanks and others seeking to influence public policy. This followed revelations that a prominent right wing think tank, which ridicules “nanny state” efforts to regulate availability of junk food, alcohol and tobacco, accepts funding from companies marketing these products. There can be little doubt about the conflict of interest here, and from a public health perspective, the usefulness of transparency.

Back home, the staunchly pro-business New Zealand Initiative also lobbies against restrictions on unhealthy consumer products. Its articulate chief economist Eric Crampton gets a lot of media exposure and was quick to defend Glover against criticisms from what he called the “Otago public health cartel”.

The “cartel” presumably includes Otago Professor Richard Edwards, who pointed out Philip Morris’ business strategy in New Zealand prioritises marketing non-combusted tobacco products – including offering free supplies to DHBs and community groups – and funding commercially-driven ‘research’ through its proxy, the Foundation for a Smoke-Free World. Little wonder Marewa Glover and Eric Crampton are so disparaging of the Otago public health academics.

Of course, the NZ market is relatively small so it’s useful to consider how Philip Morris and its euphemistically named Foundation are regarded overseas. In 2012 the company lost a massive lawsuit against the Australian Government’s decision to require plain packaging of cigarettes, and in 2017 was forced to pay costs estimated at $50m. More recently, analysis of the Foundation’s 2018 tax return provides a startling insight into its operations and apparent objectives. The Foundation, unable to secure funding from any source other than the $80m it receives yearly from Philip Morris, spends more on public relations than research. Its extensive use of contract organisations with tobacco industry links, together with an obviously commercially-driven research agenda, belies claims of independence from its parent company. Indigenous public health experts, including from Aotearoa/NZ, have been emphatic in rejecting the Foundation’s (and Philip Morris') agenda.

Now the extent of Big Tobacco’s investment in COREISS and Glover are out in the open, will that be the end of the matter? Hardly. Two things are needed for policymakers and the public to regain trust in health-related research and advocacy. First, a full and honest declaration of relevant conflicts of interest should be required of any person or organisation seeking to influence public policy. Trevor Mallard’s brief addresses submitters to Parliament; the same requirement should arguably apply to advocates’ use of mainstream media, but this cannot be legislated and will require leadership, as has been shown on occasion by state-supported RNZ. David Seymour and others argue it is impossible to effectively manage all possible conflicts of interest since these can arise from a variety of sources, including religion, culture, politics, occupation, etc. For this reason, many authorities, including leading scientific journals and official government committees, limit scrutiny of potential conflicts to overt financial or other material benefits. Not perfect, perhaps, but manageable and much better than nothing.

More fundamentally, transparency regarding conflicts, while necessary, is not sufficient to manage bias. The question then becomes, is enough attention paid to these conflicts and how they impact advocacy? One might hope disclosure of funding by the likes of Phillip Morris might alert policymakers to the possibility of bias, notwithstanding Glover’s protestation that the funder had “no influence” on her research or advocacy. The old adage, “follow the money” is generally apt, particularly when an obvious commercial agenda is at play. Another bit of folk wisdom, attributed to US social critic H.L. Mencken, also applies, “It is difficult to get a man to understand something when his salary depends upon his not understanding it.”

This is not to challenge Glover’s honesty or commitment to addressing the vast harm to indigenous communities caused by tobacco. Rather, that we are notably poor at judging our own conflicts and liability to bias, just as we are generally unaware of our relentless tendency to self-justify. Researchers typically downplay the impact of conflicts arising from their connections with pharmaceutical and other for-profit industries; the resulting bias is largely unconscious but does affect analysis and interpretation of data. As Yogi Berra observed, “If I hadn’t believed it, I wouldn’t have seen it”.

In conclusion, trust in the medical profession requires that presented evidence be safeguarded from distortion by commercial interests. For this reason publication of scientific findings now requires full disclosure of financial conflicts; the same stringency must apply to medical evidence used by those seeking to influence public policy.