Suddenly, a pulmonologist was working in the tobacco industry

Pediatrician-in-training Wytse van den Bosch and pediatric pulmonologist Harm Tiddens look at each other in amazement. It’s September 2021. Tidden’s office at the Erasmus MC Sophia Children’s Hospital in Rotterdam has the latest news European Respiratory Society open on the computer screen. One of the world’s largest tobacco manufacturers, Philip Morris International, has bought the pharmaceutical company Vectura, which manufactures lung disease drugs. “Ugh,” they stammer. ‘What now?’

Van den Bosch has been doing doctoral research on the effects of inhaled medicine on children with asthma for three years. With a grant from Vectura. “We approached them specifically for this purpose, because Vectura made a nebulizer that delivers drugs deep into the small airways,” says promoter Tiddens. At one stroke, the study was questionable, doctors say.

We meet at Sofia’s children’s hospital, in the examination room, where we can only fit between the table and the treatment table. Van den Bosch is now practicing as a pediatrician in Delft, and Tiddens has recently retired and no longer has his own room.

Then, as a lung researcher, you are suddenly connected to the tobacco industry. Why is that a problem?

Van den Bosch: “I started studying medicine in 2010 because I want to make people better and do good. This goes against the goals of the tobacco industry: to sell as many cigarettes as possible and make people addicted. I feel terrible that my name is now associated with it. It really kept me up at night.

“Secondly, I have problems submitting my scientific publications and grant applications. People are often asked directly: are you connected to the tobacco industry? As soon as you answer “yes”, it will be rejected.

“These rules are also good. In the past, the tobacco industry has been heavily involved in science. The American historian Allan Brandt describes this in his book “The Cigarette Century”. Around 1950, several independent scientific studies showed a convincing link between lung cancer and smoking. Tobacco companies have tried to dispel this message with several lies ways, including paying researchers for research that obscures this association.As a result, colleagues will always be suspicious if your research is related to the tobacco industry.

So your first reaction was: shall we stop?

Van den Bosch: “Yes, absolutely. Because of the takeover, all kinds of international lung health organizations decided to boycott Vectura, Australian, British, American. But I had already been working for three years, all the studies were already underway, we were already publishing. You can stop, but those studies were already done , and Vectura is still listed as a sponsor.

Tiddens: “There are also financial consequences if the PhD is not completed. You also have an obligation to the patients participating in the study and you have an obligation to publish. The contract with Vectura states that the results must be published within a year. It is common to prevent the sponsor from stopping the study because he doesn’t like the result.”

Van den Bosch: “If I had known in advance that this would happen, we would never have done business with Vectura. But it would also be unethical to stop the study and not publish it. This harms the patients. So all things considered, we decided to continue.”

Why is this different from an agreement with the pharmaceutical industry? You just agree that they won’t interfere with the investigation.

Tiddens: “Pharmaceutical companies are really interested in profits. But you’re looking for partners you trust who have the same goals. The goal of these companies is to develop medicines to cure sick people. What would I be as a doctor if I can’t prescribe medicine? But the tobacco industry does not exist to improve humanity.”

The dilemma facing Van den Bosch and Tiddens is part of a much bigger problem: the new strategy, “beyond nicotine,” that tobacco manufacturers have adopted.

Tobacco use is steadily declining worldwide, the WHO reported earlier this year – although not nearly as fast as hoped. In some countries, such as Egypt, Indonesia, Jordan and the Republic of Congo, it is actually increasing. More and more countries are taking measures to curb tobacco sales. Big tobacco manufacturers are therefore developing new survival strategies with buzzy titles such as Creating a better future. To begin with, they offer all kinds of so-called “less harmful” alternatives to the use of highly addictive and harmful nicotine, such as e-cigarettes (vapes), heated tobacco, snuff (a nicotine pouch placed under the upper lip – banned in the Netherlands). The next step in this strategy is the purchase of pharmaceutical companies.

Investments

Investigative journalists Examination table, Irene van den Berg and Mathilde de Jeu published a diptych in the Dutch Journal of Medicine in 2023. They looked at four major tobacco companies: Philip Morris International (PMI, maker of Marlboro among others), British American Tobacco (Pall Mall, Lucky Strike), Japan Investments by Tobacco International (Camel, Winston) and Imperial Brands (Gauloises). .

They found that all of these tobacco giants have invested billions in companies that make drugs and other medical products in recent years. These are often products for diseases caused or aggravated by smoking, such as asthma, COPD, cardiovascular disease, lung cancer, other forms of cancer, diabetes and addiction. For example, in 2021, in addition to Vectura, PMI acquired an American start-up company that manufactures an inhaled heart attack medicine, and a Danish company that sells, among other things, nicotine chewing gum. For example, the tobacco industry can sometimes earn up to three times from the same customer: first if he buys cigarettes, then if he wants to get rid of addiction and then if he has become ill from smoking.

And what’s even worse: keeping a researcher, scientific organization or scientific journal out of the influence of that industry proves difficult. Scientific publications in which one or more authors have received funding from a pharmaceutical company with ties to a tobacco manufacturer continue to enter medical journals. The same investigative reporters counted at the end of May British Medical Journal (The BMJ)since 1996, a total of 876 medical-scientific studies where this mattered.

The anti-smoking policy of medical journals seems unfortunate. Of the forty journals examined, only five had a ban: six out of ten pulmonary medicine, every tenth oncology and not a single cardiology journal. Out of ten general medical journals only BMJHe himself has had such a policy since 2013. They tightened this up at the same time as the release. The journal now rejects not only research funded by the tobacco industry, but also work whose authors themselves have financial ties to tobacco companies.

Tiddens and Van den Bosch were not aware of these tobacco industry strategies before the acquisition of Vectura. After that, even more. Van den Bosch decided to write a scientific article about the problems and ethical aspects he made together with the medical ethicists of Erasmus MC.

Did you want to justify your choice to continue research?

Van den Bosch: “Yes, I wanted to make it transparent. You don’t want tobacco interfering with medicine, but maybe you shouldn’t think so black and white in situations like this. You should mainly look at whether the research has value for the patient.

“Publishing this also proved difficult. For European Respiratory Journalscience journal European Respiratory Society, four people viewed it. One of them strongly objected to publication. Then we submitted it to another scientific journal, BMJ Open Respiratory Research. There were also three other versions. We recommended, for example, that as unified lung researchers, we could perhaps make exceptions in the situations we were in. The BMJ wanted us to draw up criteria for this.

“My article has started a conversation. My scientific research has now also been published and Vectura has been mentioned under the title Conflicting Interests in the European Respiratory Journal Open Research.

The publication of the research is in accordance with the rules European Respiratory Societysince the Vectura research grant was established in 2018, says Elin Reeves, the organization’s director of publications, in The BMJ.

Van den Bosch: “The international pulmonology associations have so far kept their hard line. If something like this happens again, my article might help.”

Some pulmonologists recommend that no drug from a pharmaceutical company associated with the tobacco industry be prescribed any longer. Is that the solution?

Van den Bosch: “For example, you can switch to another brand of inhaler. But where do you draw the line? Vectura patents are also used in medicines manufactured by other pharmaceutical companies. Doctors usually do not know which manufacturers are behind the drugs. And if there is no good alternative, this is not possible, you are harming the patient. Medicines are also in short supply. You want to be principled, but it’s too deeply woven. And you can’t stop one company from buying another company.”

It is possible: in March 2022, the WHO rejected Medigaco’s Covid vaccine, which had already been approved in Canada, because Philip Morris International invested in it. PMI withdrew from this business at the end of 2022. Should pharmaceutical authorities such as EMA or MEB play this role?

Van den Bosch: “I think it is very desirable, but not possible.”

Will you carry this with you throughout your scientific career?

Van den Bosch: “It depends on how long the scientific journals ask about it. Sometimes, for example, they ask about your tires for the last five years. Actually, I was hoping to get rid of it. I will answer my doctorate in November. But maybe it will stay in my mind for a long time.”

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