COMPASSION FOR FELLOW CITIZENS AND PASSION FOR TRUTH AND CLARITY ARE COMPETING INTERESTS ACCORDING TO THE CMAJ

****** After publishing this post, it was brought to my attention by a reader that my first letter is posted but under a different URL at http://www.cmaj.ca/content/183/18/E1334/reply .   I don’t quite understand why that is, but different URL’s show different letters.  Sometimes mine appears, sometimes it doesn’t.  I think apologies to the CMAJ are in order as far as the first letter goes but I still don’t understand how intellectual passion can be viewed as a competing interest so I will leave my post up. ********

Please note that I have been having a lot of problems getting my links to work in these posts lately.  If any link doesn't work for you, please copy paste it in a new browser.  Thank you.


There has been a lot of talk in the last few months about unintended consequences of smoking bans and how they may actually be hurting the more vulnerable members of society. 

In November The Winnipeg Free Press reported the case of a 54-year old woman who found herself locked out of the hospital when she exited to smoke and was a victim of severe frost bite.  Four fingers on her right hand had to be amputated. She was left with limited mobility in her left hand. http://www.winnipegfreepress.com/local/hospital-smoking-bans-endanger-patients-study-132980933.html

The Canadian Civil Liberties Association reacted to this tragic story by inviting citizens to express their views on hospital smoking bans.  http://www.ccla.org/rightswatch/2011/11/01/do-hospital-smoking-bans-put-addicted-patients-in-danger/comment-page-1/#comment-28655  

The CMAJ (Canadian Medical Association Journal) published an article highlighting that hospitalized smokers require more assistance with compliance and nicotine withdrawal symptoms.  http://www.cmaj.ca/content/early/2011/10/31/cmaj.110235.full.pdf+html
  
There were a few responses to this article.  One was from Dr. Stuart H. Kreisman, endocrinologist at St. Paul's Hospital who opined that ‘’ The distinction between smoking (which is just a habit) and nicotine (which is the addictive drug) becomes blurred at several points in this article and the responses to it. (…) Viewing smoking as addictive, which most of the population superficially does, plays directly into the hands of "smokers' rights" advocates and their claims that smoking bans (be it in hospitals or elsewhere) are discriminatory. Remembering that the actual addiction is to nicotine leads directly to realizing that there are many other forms in which nicotine can be delivered (even if less gratifying) without exposing others.’’  Read complete comment at http://www.cmaj.ca/content/early/2011/10/31/cmaj.110235/reply#cmaj_el_674876

To this, I, Iro Cyr, the writer of this blogpost, replied under my personal name with the following comment:

Conscientious professionals must stop perpetuating the ''nicotine addiction'' theory

It is unfortunate and even a tragedy that so many, if not most, health professionals bought into nicotine being the only substance responsible for addiction in people who smoke. Unbiased studies have consistently shown that NRT has a 93 - 98% long term failure rate to help people stop smoking. Already this should be ringing loud bells. Isn't it time that the medical community who would like us to believe that they care for people, started exploring different avenues that will lead them to understand what motivates a person to continue smoking? How many more years and unnecessary suffering will it take before serious and conscientious professionals stop perpetuating the ''nicotine addiction'' theory and started looking at the issue with an honest critical mind?

In the wise words of Pr. Robert Molimard who spent most of his career analyzing tobacco and helping smokers quit '' The big fraud in the tobacco issue was none other than the publication of the 1988 Surgeon General Report entitled "Nicotine Addiction''. This fraud is incomprehensible unless one sees the link with the launch of the nicotine gum. The major premise of the Report seems to be a syllogism that states: "Tobacco products cause a powerful addiction'' The minor premise is: "Tobacco contains a neurotropic poison - nicotine''. Hence follows the conclusion: "Therefore nicotine is responsible for the addictiveness of tobacco''. But there is no evidence that allows us to draw such a conclusion. A host of other assumptions are possible, and there are even major arguments to oppose it, such as the fact that no cases of nicotine dependence have ever been documented when this substance was used in isolation (...) This duplicity is more than amazing when you consider how common it is for addicts to experiment with the purified extracts of their plants of choice. Since no formal evidence of dependence to pure nicotine has yet to be produced, the conclusion that nicotine alone is addictive is not a syllogism, but rather, pure sophistry. And yet, against all scientific rigor, this fallacy was implanted through repetition, hammered in as an unassailable truth, all with the support of health authorities and politicians (...) '' End of citation. Read English translation of the French original at:
http://cagecanada.blogspot.com/2010/12/beliefs-manipulation-and-lies-in.html

But let's pretend that we agree that smoking is a habit and that addiction is caused by nicotine alone, does the medical profession truly believe that an already stressful hospital stay is the right time to break one of their lifetime habits whether ones wants to or not, causing additional suffering and stress? And being quasi-prisoners of the healthcare establishment, wouldn't insisting on medicating someone with NRT to alleviate them of their withdrawal symptoms caused by their inability to smoke, be considered a form of forced medication? Isn't it comparable to deliberately causing unnecessary physical pain to someone and later insisting that they take pain relievers to make it all better? Only dogmatic ideology bordering sadism justifies entertaining such beliefs.

The CMAJ published my comment and left it posted for a few days but then I received a letter from them as follows : 

Good afternoon Ms. Cyr:

Thank you for your recent eLetter to CMAJ, which was posted on our website (www.cmaj.ca) Dec. 5 in response to the article “A qualitative investigation of smoke-free policies on hospital property.” It has since been brought to my attention that your affiliation with CAGE, a competing interest, was not disclosed in your letter. Could you please comment on that?
Many thanks,
Leesa D. Sullivan
Managing Editor, CMAJ

To which I promptly replied the following: 

Hello Ms. Sullivan,

Thank you for checking with me about this.  Perhaps you are relying upon a definition of “conflict of interest” that I am unaware of?  I don't understand how being an unpaid volunteer for a 100% non-profit grassroots organization that is comprised of ordinary citizens would be a “competing interest.”  I am neither a remunerated activist nor a registered lobbyist.  Sometimes I sign under my own name, sometimes I sign as vice-president of CAGE (I hope you can see clearly that if I had the intention of hiding my affiliation with CAGE, I would not have used my real name in my submission to your publication).

In any case, I am not paid to do what I do.  Are volunteers for groups concerned with patients rights, the Canadian Civil Liberties Union, or similar organizations considered to have “competing interests”? If you could make clear your working definition of “conflict of interest” and “competing interest,” I will be happy to provide you with any additional information to help you determine if such concerns apply in my case.
With thanks,
Iro Cyr

After a couple of days of not getting a reply I attempted to post the following comment, again under my personal name.

Following my last comment, a very timely article appeared (that I translated with Pr. Robert Molimard's kind permission) on how and why Karl Fagerstrom has now changed his famous dependence to nicotine test to become a dependence to cigarettes test. You can read it here :
http://cagecanada.homestead.com/fagerstromfindshiswaytodamascus.html
Dr.Fagerstrom's article that Pr. Molimard refers to can be found here: http://ntr.oxfordjournals.org/content/early/2011/10/20/ntr.ntr137.extract

It all makes sense when one considers what pushed the nicotine addiction theory to become dogma.

Closer to home, ''The Ottawa Model'' is a program implemented in hospitals that seizes the opportunity hospitalization provides, to get as many smokers as possible to quit. The program they offer is strongly focused on pharmacological therapy including nicotine replacement and bupropion and varenicline. When one reads the conflicts of interest of those who promote ''The Ottawa Model'' is it really surprising that they offer pharmacotherapy to supposedly alleviate the symptoms of those patients who have clearly expressed that they don't wish to stop smoking? Wouldn't a sheltered warm designated area be more respectful of these patients' wishes? Apart from conflicts of interest that may arise from '' research support, speaking fees, and honoraria from Pfizer'' to at least two of the promoting medical professionals of this program, Pfizer has financed the Smoking Cessation Rounds Publication that describes the program. http://www.smokingcessationrounds.ca/crus/screng0507.pdf

Note: It has been brought to my attention that I should be declaring my affiliation to C.A.G.E. a 100% Canadian grassroots group that is comprised of a 100% ordinary citizen membership. I do not get paid either directly or indirectly for expressing my own opinion or C.A.G.E.'s point of view. (I am the president of a private company totally unrelated to health, tobacco, pharmaceuticals or anything remotely related to health). Neither I nor C.A.G.E. are registered lobbyists. C.A.G.E. receives no funding from anyone with any competing interests and gets by on tiny donations from its members to cover some of the costs of maintaining its websites, stamps, stationary etc. I am above all a concerned citizen and it is because of my personal deep concern towards the sick, the elderly and the psychiatric patients that I expressed myself in this forum.

I understand that a number of interested parties have made complaints or accusations against me, but these are usually done covertly, in secret and without my having an opportunity to respond. Should you receive any such accusations, I would request that you accord me the basic courtesy of disregarding any statements to which I am not made a party and to which I have not had an opportunity to respond.

The CMAJ editor replied with this comment: 

Thank you for the following eLetter to CMAJ and your email of Dec. 7. I
want to clarify what is meant by competing interests from the point of
view of the journal. It is not just about a monetary association.

For the purposes of the journal, the International Committee of Medical
Journal Editors has defined competing interests as:

"Conflict of interest exists when an author (or the author's institution), reviewer, or editor has financial or personal relationships that inappropriately influence (bias) his or her actions
(such relationships are also known as dual commitments, competing interests, or competing loyalties). These relationships vary from those with negligible potential to those with great potential to influence
judgment, and not all relationships represent true conflict of interest. The potential for conflict of interest can exist whether or not an individual believes that the relationship affects his or her scientific
judgment. Financial relationships (such as employment, consultancies, stock ownership, honoraria, paid expert testimony) are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the journal, the authors, and of science itself. However, conflicts can occur for other reasons, such as personal relationships, academic competition, and intellectual passion."

You are an author (given that you have submitted and have had a letter posted online at cmaj.ca) and therefore should have mentioned your affiliation for the benefit of our readers.

We ask that you declare your involvement in CAGE as a potential competing interest. If you agree to cite this information as we suggest, then perhaps you'll want to revise the final two paragraphs in the
letter below before we consider it for online publication.

With thanks

To which I replied : 

Thank you for your explanation of your working definition of "competing  interests."  I suppose your journal believes that CAGE represents a "competing interest" as a result of "intellectual passion," since I don't  see any other way it could be constructed as a competing interest.  In this case, the "intellectual passion" comes from a commitment against coercive  forms of health promotion.  I personally do not feel that such adherence to basic liberal principles represents a competing interest (and I would ask  you to apply the same standard as you do to other authors and organizations), but I defer to your judgement on the matter given that this  is your journal.  If you prefer, I can sign as Iro Cyr, Vice-President, C.A.G.E. but I will not declare any competing interests because that would
neither be true nor fair.   I have less of a competing interest than Mr.  Povah from the anti-smoking group Airspace Action on Smoking and Health, who  did not declare any competing interest when he submitted his letter to you.

If you agree with this I can revise my letter taking off the two last  paragraphs and resubmitting it under Vice-President of C.A.G.E..  Would you like me to resubmit it through an e-mail form or through the comment section of your website?

Thank you very much.

Evidently that wasn’t good enough because she replied : 

I have added an editor's note to your first letter, stating your affiliation, and reposted the letter it this morning.

I have spoken at length with our senior editors about your latest email. We will consider posting your second letter, but only if you declare your affiliation with CAGE as a competing interest, according to the definition I sent you previously. If you agree, then yes, please resubmit your revised letter (with the deleted two paragraphs, as discussed) through the CMAJ eLetters process.

Many thanks for your patience

She never reposted my first letter that she had taken down although she said she would.  And because I refuse to declare a competing interest that I absolutely don’t consider I have, she never posted the second either.  ****please see note on top of this page****
 

If the CMAJ considers intellectual passion a competing interest, why are the letters from the following two entities still up with undeclared competing interests? 

Dr. Stuart H. Kreisman  has been instrumental in instituting smoking bans in parks and beaches in Vancouver and is now actively promoting multi unit housing bans. 

Errol Povah, President of Airspace Action on Smoking and Health B.C., as it appears on their web site:   ''Canada's Sworn Enemies of the Tobacco Industry’’  ****Mr. Povah's letter no longer appears on the URL mentionned on top of this page****

In conclusion, it appears that concern and compassion for fellow humans is  considered a "competing interest" according to an association that purports to care for the health and well being of the people.  The CMAJ will not tolerate our efforts to state documented facts that may help hospitalized patients for the sole reason that these facts contradict the accepted dogma of  The Canadian Medical Association.  Being a member of any organization that questions the established medical and scientific dogma is a competing interest according to them.  How reasonable is that?  I call it tyranny of the medical establishment.  I have no stakes whatsoever in this issue except for a deep concern for the truth.  If working hard for the purpose of truth and clarity is considered a competing interest by the CMAJ who will apply a double standard depending on who the authors are, then I am now certain that the medical establishment is suffering from its own form of competing interests bias.