[Updated Aug 31,2023]

This week the Lancet published an extended piece by Boston University’s Sandro Galea reflecting on a new bioethics book by Jonathan Marks, The Perils of Partnership: Industry Influence, Institutional Integrity, and Public Health.

Galea commences with a truism: “those of us who make a living in public health, be it in the academic world or in practice, have a near reflexive suspicion of working with the private sector. We come by that suspicion honestly. There is abundant research, evidence, and experience of how some industry practices have harmed the health of the public.”

And abundant research is almost an understatement. In medicine, the debate about the ethics of the cash register arises most often over drug company money. Here, the research evidence is clear: those who take pharmaceutical research money tend to not bite the hand that feeds them.

A 1998 New England Journal of Medicine study reported that 23 of 24 authors (96%) defending the safety of calcium channel antagonists had financial ties with manufacturers of these drugs. This compared with 11 of 30 (37%) who were critical of their use.

The University of Sydney’s Charles Perkins Centre Professor Lisa Bero is perhaps the world’s leading authority on competing interests in science and the way that engagement so often evokes the tale about those paying the (research) piper, calling the tune. Bero and others’ 2012 Cochrane Collaboration review investigated the association between pharmaceutical industry funding and research conclusions favourable to the companies funding the research.

Bero’s paper with Jenny White on corporate manipulation of research across five different industries (tobacco, pharmaceuticals, lead, vinyl chloride and silica) is another classic paper in the field.

Several research journals refuse to consider papers for publication which are authored by anyone with tobacco industry financial ties. Their reasoning? As the editors at PLoS put it in 2010:

“We remain concerned about the industry’s long-standing attempts to distort the science of and deflect attention away from the harmful effects of smoking.

That the tobacco industry has behaved disreputably – denying the harms of its products, campaigning against smoking bans, marketing to young people, and hiring public relations firms, consultants, and front groups to enhance the public credibility of their work – is well documented.

There is no reason to believe that these direct assaults on human health will not continue, and we do not wish to provide a forum for companies’ attempts to manipulate the science on tobacco’s harms.”

As PLoS journals charge authors a fee to publish, they also did not want to be accepting money obtained from the sale of tobacco and the millions of deaths involved in those sales.

Tobacco-funded research and the conduct of the industry which oversees it has arguably the worst of all reputations. This explains why that industry is unique among all others in being barred from funding research and scholarships at many universities. My own institution – the University of Sydney – was one of the first to do this in 1982.

Bero’s contributions have been supplemented by Nicholas Freudeberg’s Lethal but legal (2014) and a book by the University of Auckland’s Centre for Addiction Research Peter Adams, Moral Jeopardy: Risks of accepting money from the Alcohol, tobacco and gambling industries (Cambridge University Press 2016).

Adams sets out with enormous erudition and many examples, the conduct of the three industries on which he focuses (alcohol, tobacco and gambling). He describes risks to reputations, governance, scientific neutrality, relationships and even to democracy when the corrupting influence of money from industries whose commercial well-being depends on successfully resisting any policies, laws and regulations that threaten their profitability inhibits those developments.

The main focus of his book is the ethical and moral questions which arise for health-care providers, researchers, universities, journals, and communities when such engagement occurs. The book has extensive sections elaborating on inventories of questions that all organisations contemplating accepting funding from these industries should ask themselves.

Manichaean simplicity?

All universities encourage their staff to engage with industry. But academics lamenting the decline of government funding for universities have often been scathing about this development and mocked industry-sponsored chairs. I recall one in “structural clay brickwork” was mercilessly pilloried. But why? What exactly is the ethical problem with assisting in advancing the quality of commercially made bricks? Or of improving steel through the University of Wollongong’s  BHP funded chair?

Bricks and steel have innumerable uses which enhance human life and well-being. Life would be unarguably worse without them.

Sandro Galea’s Lancet piece notes that a central argument of Marks’ book is that

“Given that private-sector actors inevitably have their own commercial interests as one of their priorities, it is …impossible to maintain institutional integrity when one partners with actors whose mission is misaligned with one’s own.”

But Galea, who highly recommends the book, concludes by disagreeing with its main “disengagement” conclusion

“Simply put, I do not think it is possible, nor desirable, for public health to disengage from corporate sector partners; the public–private relationship is here to stay and we should be using Marks’s work to thoughtfully inform such engagements, not as a guide to disengagement”

My own view on industry engagement runs like this.

There are some industries which make and promote products or provide services where the net consequences of consumption are sometimes hugely negative. My personal list here includes fossil fuel industries, the nuclear power industry, tobacco, firearms, gambling, any industry with a track record of exploitative labour practices, irredeemable environmental pollution, or unsustainable pillaging of forests, land or oceans.

Then there is a huge middle group where simple Manichaean (good or evil) categorisations cannot easily withstand even basic scrutiny, and where significant negative and positive consequences of consumption cannot be ignored. Most people who drink alcohol do not harm others because of their drinking, but derive obvious pleasure from it. They may slightly increase their risk of dying from some diseases and shave some months or years off normal life expectancy, but prefer to take that chance. But alcohol causes massive harms across populations.

Here, Cambridge University’s Prof Sir David Spiegelhalter, a statistician, has eloquently written about the very small absolute risks of harm faced by those who drink alcohol moderately. He writes:

“Next look at 2 drinks a day, that’s 20g, or 2.5 units, slightly above the current UK guidelines of 14 units a week for both men and women.

In this case, compared to non-drinkers an extra 63 (977–914) in 100,000 people experience a health problem each year. That means, to experience one extra problem, 1,600 people need to drink 20g alcohol a day for a year, in which case we would expect 16 instead of 15 problems between them. That’s 7.3 kg a year each, equivalent to around 32 bottles of gin per person. So a total of 50,000 bottles of gin among these 1,600 people is associated with one extra health problem. Which still indicates a very low level of harm in drinkers drinking just more than the UK guidelines.”

I am of course not the only person grateful for the pharmaceutical industry as I reflect on drugs and vaccines I have taken to prevent or manage serious health problems, ameliorate pain or induce anaesthesia in surgery.

The cars, motorbikes, buses, trains and aircraft I’ve used, and electricity and gas have all used polluting fossil fuels. Many hope desperately for the rapid uptake of electric transport powered by renewable energy. Unlike the dilettante tobacco industry which refuses to stop making and promoting cigarettes while trying to spread nicotine addiction with ecigs and posturing about its responsible rebirthing, many major vehicle manufacturers are setting targets for complete transition away from petrol and diesel powered options.

My kitchen pantry is filled with grocery items that I select to consume, and not being heavily into hypocrisy, I don’t gag with ethical confusion when I eat them, despite some being produced by heinous transnational food companies . Instead, I am grateful that these companies are able to manufacture food items that I’m pleased to buy and eat. I can exercise my personal ant’s worth of consumer power by selecting product formulations and companies that tick all the important boxes. I can megaphone the availability of powerful apps like Cluckar (for boycotting misleading “free range” egg brands) and the George Institute’s Food Switch (which provides comparative ingredient information tens of thousands of  grocery items) which help immensely with this.

So with all these examples, only the most doctrinaire or extreme will argue that these profit maximising industries are pure evil and have nothing to contribute to global health and well-being. Here, research engagement between the industries and university researchers is therefore common with constantly evolving effort to ensure research integrity is protected in areas like transparency and full declarations of competing interests.  Researchers should engage with their fully-honed sceptical facilities on open display, as should always be the case in any research engagement.

When collaboration is urgent

Then there is a third category of industry where public health and industry are in all but total lockstep.  Obvious examples here are renewable energy, vaccines, condoms, bicycles and with fruit and vegetable growers (and retailers).

When public health researchers working toward ways of reducing reliance on fossil fuels try to produce breakthroughs on renewable energy costs and efficiencies, they want their work to be commercialised so that it proliferates as fast as possible. That is the whole point of what they are working toward. The dire, accelerating existential threat posed by global warming makes the partnerships between the research and commercial sectors extremely urgent.

When communicable disease researchers produce new vaccines for self-evidently potentially catastrophic diseases like ebola, or partner with vaccine manufacturers in the common goal of maximising distribution, cold-chain standards and intelligence sharing, what’s not to like?

The pharmaceutical industry has more than once engaged in despicable price maximisation at times of communicable disease crises. It is reasonable to fear that specialist researchers affiliated in good faith in partnerships with such companies might self-censor concerns to condemn such practices, not wanting to bite the hand that has been feeding them. But to move from evidence of such conduct to a conclusion that there should be no collaboration in common, important purpose seems disproportionate.

When the world urgently needs to see significant uptake in use of commercially manufactured products, a chorus of criticism that inhibits the sharing of effort between researchers, these industries and government can be very myopic.

North Sydney local Council has voted unanimously to ban smoking in all public areas under Council control. These include parks, streets and plazas and outdoor footpath dining areas of cafes. The move follows similar bans in other local government areas and the receipt of over 600 submissions from local residents and workers, the overwhelming majority of which (80%) urged the Council to adopt the policy.

The Council has no plans to fine smokers, and it is not clear if the policy will also apply to vaping. It believes that community education and signage will be enough to ensure the policy succeeds. Good luck with that. Fines have been necessary to support every other restriction on smoking.

Throughout my 40 years in tobacco control, I’ve advocated with many others for polices and campaigns designed to reduce the uptake of smoking, to encourage quitting and to protect people from the known risks of exposure to secondhand smoke. The triple, inviolate bedrocks of all these policies and campaigns were that there needed to be evidence that each policy would likely achieve its goals, that the measures posed were proportionate to the problem being addressed and that they were ethically justifiable.

Perhaps the most protracted struggle in all of tobacco control was efforts to  reduce exposure to other people’s tobacco smoke. In NSW, these started in 1976 with the ban on smoking on government buses and trains was introduced by transport minister Peter Cox. In the longest ever saga of half-pregnant policy, it took a full 34 years until the Northern Territory, the last bastion of smoking inside pubs, finally joined every other state and territory in introducing that policy.

Pubs were the last setting to go, while they rationally should have been the first if intensity of exposure was the key criterion. Bar staff’s occupational health was relegated to a secondary consideration in industry  campaigns promoting the freedom of smokers to ignore these workers’ health because it was argued it was the birthright of any Aussie to have a smoke, a beer, a meat pie and a bet in a pub and bar staff should just have to suck it up.

Today, it is only high roller rooms in some casinos which still allow smoking. This is because of the little appreciated fact that tobacco smoke from wealthy gamblers’ cigarettes is apparently, unlike that from everyone else’s, not toxic to other people.

While the evidence for the harms of exposure to other people’s smoke has long been voluminous and overwhelming when pooled in reviews, that evidence has been almost totally based on chronic exposures occurring over many years in homes with smokers and to a lesser extent, in smoky workplaces.

This brings us to outdoor smoking and policies like that just adopted by North Sydney Council.

Here, there are some important differentiations to make. Outdoor settings can include the sardine-can like proximities to others we often experience in sporting or concert stadia, where in the past, if you had the misfortune to be sitting or standing next to smokers for many hours across a day’s play in the cricket or at a music festival, you copped a lot of their smoke point-blank.

Similarly, when smoking was banned inside cafes and restaurants in NSW in 2000 (thank you then Premier Bob Carr and health minister Craig Knowles), many smokers simply moved to the outdoor, al fresco tables. There you could find yourself in their haze across an entire meal. It was manifestly unreasonable that smokers should be rewarded with access to prized seats in the outdoor sun, so arguments for amenity carried the day on smokefree outdoor eating and drinking in many jurisdictions.

There was some evidence that acute (ie short term cigarette smoke exposure) can be detrimental to people, especially those with respiratory problems (and there are many such people in any community). For example, acute exposure to ambient smoke in healthy young adults has been shown to be associated with dose related impairment of endothelium dependent dilation, suggesting early arterial damage. However, the transitory and fleeting exposure to others’ smoking in open outdoor settings is not remotely comparable to that experienced in confined indoor settings such as were involved in the study I just cited.

When we reviewed the research literature in 2012 about studies assessing particle concentrations in outdoor smoking settings, there were very few available. And predictably, these mostly showed that the concentrations even in close proximity to the smokers were negligible.

This was always going to be obvious. Smoke particle concentrations in enclosed spaces, often with lots of people smoking, are clearly going to be far higher than in any outdoor setting where the smoke is diluted by the boundless surrounding air and dissipates rapidly in the slightest breeze.

In some Japanese cities, smoking is banned on streets except for designated smoking hubs which can get very crowded. The reason for these street bans is that the density of pedestrians can be so great that burns quite often occur to clothing and flesh from carried lit cigarettes.  Yet, bizarrely, Japan still allows smoking inside restaurants.  Smoking bans in very crowded outdoor shopping precincts like Sydney’s Pitt Street Mall can be justified on similar concerns.

So the key evidence needed to underscore any policy seeking to reduce significant risk to the public in wide open spaces simply  does not exist. Yet this week I have heard North Sydney Council spokespeople saying that passive smoking is harmful to others. Yes it is: but in indoor settings, particularly with long term exposure, not in wide-open spaces like parks, car parks, typical streets and on beaches. Conflating the evidence on passive smoking hazards between indoor and outdoor locations is simply ignorant. All occupational air quality standards for any potentially noxious agent differentiate between indoor and outdoor settings set different standards for both.

Other arguments

The ethical justification for restricting where smoking can occur derives entirely from the Millean principle of preventing harm to others. There are also important collateral benefits of banning smoking in workplaces: smokers reduce their daily consumption by about 21% when they cannot smoke at work and more importantly many quit, welcoming the bans as a form of imposed self-discipline on a behaviour that 90% of smokers regret ever starting. Smoking bans fomented a rapid denormalisation of smoking: venues associated with relaxation, pleasure and conviviality like restaurants, bars, cinemas have no smoking, while smokers excuse themselves to go outside to footpaths in any weather  or sit morosely in the fug of smoke in those desperate airport smoking rooms, wondering  about how much they really enjoy smoking.

Dubai airport smoking lounge. Note smoker with a mask

The proliferation of smoke free areas certainly contributed to reducing both the frequency of smoking and the proportion of people who smoke. But so would forced incarceration,  forfeiting smokers’ rights to health care or other draconian strategies too tame for the Ottoman Sultan Murad IV who had smokers executed in the sixteenth century. Very obviously, the ethical test of any policy is not only its efficiency in achieving outcomes. We don’t try to reduce smoking by any means possible. We interrogate a policy for its ethical considerations and reject those where  the breaches are unjustifiable.

Because outdoor smoking ban proponents cannot point to any robust evidence to support claims that the fleeting exposures we might occasionally get from a passing smoker in a park or street are meaningfully harmful, they often reach beyond that evidence. The momentum to outdoor bans has incorporated three arguments that go well beyond evidence of direct health effects. First, large majorities of the population do not like being exposed to any tobacco smoke. Outdoor bans premised on communities’ amenity preferences are not about public health but akin to ordinances about playing music in parks, bans on public nudity and littering. Outdoor smoking bans based on amenity should not be dressed up in the language of public health.

Second, cigarette butts and packaging constitute a significant proportion of  litter. North Sydney has named litter reduction as a justification for its policy, but it has not banned single use plastics for example, so its selective concern for one litter source might be questioned.  Local governments wanting to abate this relentless litter source should not appropriate public health arguments in justifying their decisions but be upfront about the litter problem and ideally consistent in their concerns across all litter.

Third, some have invoked the virtues of shielding children from the sight of smoking as worthy evidence in this debate. They may concede that smoking in wide open spaces like parks and beaches poses near homeopathic levels of risk to others, but point to indirect negative impact from the mere sight of smoking. Kids see smoking and this can sometimes make it look intriguing and attractive. This line of reasoning is pernicious and redolent of the worst excesses of totalitarian regimes’ penchants for repressing various liberties, communication and cultural expression not sanctioned by the state.  North Koreans are routinely subjected to such fiats, but many would recoil at the advance of such reasoning elsewhere. If it is fine to tell smokers that they cannot smoke anywhere in public view, why not extend the same reasoning to  people wolfing supersized orders in family fast food outlets, to name just one example?

Coercing smokers to stop smoking in settings where their smoking poses negligible risk to others is openly paternalistic. Well-intentioned advocates for such policies argue, as paternalists always do, that such actions are for smokers’ own good, that many will be sooner or later grateful (which is often true). Paternalistic for-you-own-good laws about seats belts and motorcycle helmets involve trivial restrictions on liberty. Telling smokers they cannot smoke in public sight is a restriction of a different, worrying magnitude.

Finally, of all the factors which have been identified in risk perception research as tending to increase public outrage, risks which are imposed rather than voluntary explain much of the variance in public perceptions. Passive smoking represents a quintessential imposed risk and, together with the possibility of dreaded outcomes (like lung cancer), often incites public demand for zero exposure. This explains why many will get incensed about exposure to a mere whiff of tobacco smoke in a park, but will not hesitate to sit around a romantic smoky campfire where they will, by choice, be exposed to a large range and volume of carcinogenic particulates and gases for sometimes hours on end.

My university, the University of Sydney, has long banned smoking in all indoor areas, and more recently in outdoor areas like those in front of coffee shops and the iconic front lawn. But it provides small designated outdoor smoking areas, well away from buildings and heavy pedestrian areas.  North Sydney council would do well to follow suit.