Respectful Insolence

One last puff of smoke over Helena, MT

Blogging on Peer-Reviewed ResearchLittle did I know when I posted my first article on the evidence supporting health hazards due to secondhand smoke that it would end up dominating the comments of this blog for three full days and lead me to a site that’s so full of pseudoscience, logical fallacies, and just plain B.S. that it is worthy of the title of the Whale.to of the tobacco nuts. Even less did I expect that the crankfest would spread to fellow SBer Mark’s denialism blog as well. The sheer vitriol that some of these “smoking rights” advocates direct at any suggestion that SHS might be harmful, quite frankly, took me aback. It wasn’t just “you’re wrong” or “the science is bad” but it was that coupled with conspiracy mongering about big pharma somehow influencing the data to sell nicotine replacement patches, ranting attacks on scientists as being dishonest or in the pocket of antismoking organizations (which, in crankworld, seem to have power, influence, and cash on par with the New World Order, Big Pharma, the Illuminati, and the Masons all rolled into one–news to them, I’m guessing), or deceptive quote-mining designed to give the false impression that any relative risk less than 2 can automatically be discounted.

I admit I was surprised. It was a bit more than even I had expected.

One of the things that most took me aback is the vitriol directed at one SHS study in particular. The sheer bile directed at this one study, its authors, and in particular the journal that published the study, rivals the bile directed at the CDC or Paul Offit by antivaccination loons. This was a study that got a fair amount of press about three years ago and involved the examination of hospitalization rates for acute myocardial infarctions in Helena, MT before and after an indoor smoking ban in public places was instituted. Here’s a sampling of some of the attacks on it:

Some of these rants linked to an article published on the ACSH website by Michael J. McFadden and David W. Kuneman a week ago. Seeing this level of hysteria in criticizing a single study, I became curious about this particular study. After all, if the findings of this study were valid, it would be a strong bit of evidence for the beneficial effects of indoor smoking bans. More importantly, was it as bad as it was being represented? Further piquing my interest was that it wasn’t enough for critics just to call it a bad study or to point out its flaws. They had to accuse Dr. Stanton Glantz, the senior author, of fraud, conflict of interest, and all manner of misdeeds. So, I asked myself, what was this study, and what were its findings?

Let’s find out:

Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study

Richard P Sargent, attending physican1, Robert M Shepard, attending physican1, Stanton A Glantz, professor of medicine2

1 HealthCare Quality Performance Council, St Peter’s Community Hospital, 2475 Broadway, Helena, Montana 59601, USA, 2Division of Cardiology, Department of Medicine, University of California, San Francisco, CA 94143-1390, USA

Objective: To determine whether there was a change in hospital admissions for acute myocardial infarction while a local law banning smoking in public and in workplaces was in effect.
Design Analysis of admissions from December 1997 through November 2003 using Poisson analysis.

Setting: Helena, Montana, a geographically isolated community with one hospital serving a population of 68,140.

Participants: All patients admitted for acute myocardial infarction.

Main outcome measures: Number of monthly admissions for acute myocardial infarction for people living in and outside Helena.

Results: During the six months the law was enforced the number of admissions fell significantly (- 16 admissions, 95% confidence interval – 31.7 to – 0.3), from an average of 40 admissions during the same months in the years before and after the law to a total of 24 admissions during the six months the law was effect. There was a non-significant increase of 5.6 (- 5.2 to 16.4) in the number of admissions from outside Helena during the same period, from 12.4 in the years before and after the law to 18 while the law was in effect.

Conclusions: Laws to enforce smoke-free workplaces and public places may be associated with an effect on morbidity from heart disease.

“May” be associated with an effect on morbidity from heart disease? That’s hardly a strong conclusion. Basically, to boil the study down, Glantz found that admissions for acute MIs fell during the six months during which the indoor smoking ban was in place as compared to the same six month periods the year before and after the smoking ban. A provocative finding, to be sure, but it’s not as though the authors represented it as in any way definitive. Indeed, the authors were very cautious in the discussion section as they interpreted their results. They even did something that I don’t think I’ve ever seen before in a scientific paper. In the Discussion section, they included a brief subsection entitled “Strengths of Study” and, appropriately enough, another section entitled “Weaknesses of Study.” According to the authors, the strengths of the study include the geographic isolation of the city and the fact that there is only one hospital to which cardiac patients are admitted, as compared to most other municipalities in which indoor smoking bans have been implemented, where multiple hospitals and people moving across jurisdictional boundaries “smear out” the effect of any smoke-free policy in both place and time. However, the small size of the city, which was one of the strengths, was also one of the weaknesses, making the total number of MIs studied small. Other criticisms include observations that the investigators didn’t look at admissions for MIs solely among nonsmokers and a question about whether patients with premorbid conditions were comparable in both groups. The vast majority of the criticisms of the study later made were discussed and addressed in the paper.

The authors are also quite frank about other limitations of the study, including the use of historical controls, that the study didn’t also include death records because of concerns about the accuracy of the official causes of death, the failure to use biomarkers to estimate the actual exposure of the population to SHS before, during, and after the ban. There was no deception or “scam” involved. Indeed, the authors were quite cautious in their assessment of the results, as any objective reading of the paper, particularly the discussion section, will show. They did not represent the study as anything more than what it is: A preliminary study done to see if any effect could be seen. From my reading, the study was nothing more than a preliminary study, very much like many preliminary studies whose results need to be confirmed or refuted, and, if confirmed, expanded upon in later studies. To me, it appears that what these smoking cranks object to is more how this study was portrayed in the press rather than how it was portrayed among physicians, epidemiologists, and scientists. They may have a valid point about the press and politicians (I note how often I and other SBers complain about bad reporting of science), but that does not justify their smearing the investigators as somehow corrupt or dishonest.

Of course the aspect of this study that most provoked skepticism was not so much that there was a drop in the number of MIs due to a smoking ban but how rapidly it occurred and that it was detectable in the whole population, given that restaurant and bar workers, the main beneficiaries of such a ban, make up a relatively small proportion of the population that might not contribute sufficiently to the number of MI patients admitted to be detected. However, even though a healthy skepticism should be maintained about this result, it is not as far-fetched as it seems on the surface. There is growing evidence that smoke and SHS can both induce rapid platelet aggregation and vasoconstriction. This does not necessarily justify some of the more extreme claims that even a 30 minute exposure SHS is dangerous, at least not in healthy people free of heart disease. However, it does provide a possible mechanism to explain how nonsmokers with preexisting heart disease might be prone to the induction of an MI by the platelet aggregation and arterial and haemodynamic changes due to SHS. Certainly, acute MIs often occur when platelets aggregate to form a clot in an already narrowed coronary blood vessel. None of this is certain yet, at least in the case of SHS, but it does at least represent a plausible biological mechanism to explain how an indoor smoking ban might–I repeat, might–cause a rapid decrease in the number of MIs seen in a community. Indeed, at least two other studies, one done in Pueblo, CO and in the Piedmont region of northern Italy, have found similar results, although the Italian study failed to find any decrease in hospital admissions for MI in people over 60 and the study authors pointed out that longterm results would need to be assessed. My take on this is that it’s far from proved that indoor smoking bans can have that much of a rapid effect on the rate of MIs, but that it’s not implausible. The Pueblo, and Italian studies are suggestive, but by no means confirmatory, that the Helena results may not be a fluke.

One of the oddities this study spawned is the aforementioned article posted to ACSH Facts & Fears by David W. Kuneman, a retired pharmaceutical chemist, and Michael J. McFadden, author of Dissecting Antismokers’ Brains (the latter of whom runs a website that is almost as cranky as the Forces.org website to which I’ve linked with amusement recently) that is basically an extended whine about how they have a study with many more patients that failed to find results similar to those observed in Helena and Pueblo. Maybe they do, and maybe they did. Who knows? I will point out that Michael Siegel, a Professor in the Social and Behavioral Sciences Department, Boston University School of Public Health, seems to like their work, although given that McFadden’s paper remains unpublished it remains impossible to for anyone else to evaluate his results.

Whatever its merits (or lack thereof), from my perspective, Dr. Siegel demonstrated rather questionable judgment in publicly giving his stamp of approval to the McFadden and Kuneman study on his blog and, whether intentionally or not, giving the impression that he agrees that the reason it hasn’t been accepted for publication yet is ideological bias at the journals that have thus far rejected it. At the very least, Dr. Siegel’s not doing McFadden and Kuneman any favors if his end goal is truly to get this paper published in a decent peer reviewed journal. After all, if Dr. Siegel thinks it’s such a solid paper and if he indeed did extend help the authors by extending its analysis as he states, then I respectfully submit to him that it would have made far more sense for him to volunteer to sign on as a co-author and help McFadden and Kuneman revise the manuscript to include his extension of the original analysis. The three could then submit the presumably stronger paper to another journal. Not only would Siegel have then improved the paper, but he would have added his academic credentials and reputation to it, which could only have helped get it over the hump, given that neither McFadden nor Kuneman presently have any academic affiliation. I have to wonder why Dr. Siegel did not choose to do this if he thinks the Helena and Pueblo studies are so flawed and that in contrast McFadden’s and Kuneman’s analysis is solid. His defense of his decision to publicize this study on his blog did not reassure me:

This has been a true learning experience for me. Never did I dream that some day, after 21 years of experience in tobacco policy research, as a statistical editor of perhaps the top tobacco control journal, and with over 50 peer-reviewed publications in top public health and medical journals, I would present a reasonably detailed scientific analysis of a tobacco control policy issue and then be publicly attacked and insulted for having the courage to present my opinions.

But because they apparently go against the anti-smoking agenda, I have now been publicly attacked and insulted. That’s a shame.

Why not help McFadden and Siegel publish that detailed scientific analysis in a peer-reviewed journal, then, rather than doing it on your blog? It’s a legitimate question. That would have made your point far more effectively than a rather lame “you’re so mean” defense, don’t you agree? Certainly, if I were either McFadden or Kuneman, I’d be asking Dr. Siegel the very same question.

Finally, I can’t help but get a little suspicious when authors disseminate their findings through websites like ACSH, whose objectivity has been questioned on many issues. Indeed, that the ACSH published the McFadden and Kuneman’s profoundly whiny commentary actually stokes my suspicion of the organization, which prior to this had only been mild to moderate. Also, in my mind, McFadden’s ranting about conspiracies to “suppress” their evidence does them no good at all if their goal is truly to be published. It’s never a smart idea to antagonize potential editors and reviewers this way, regardless of whether your science is any good or not. Perhaps that’s the point, though. Perhaps McFadden and Kuneman would rather play martyr by invoking the Galileo gambit and railing against peer review than actually getting their results published in a peer-reviewed journal. Here’s a hint: Doing this sort of thing is a big red flag that the investigators might–just might–be cranks. It’s not definitive, but it’s highly suggestive.

But then, of course, it’s so much easier to whine than to keep submitting their work until a journal finally accepts it. Whining also has the ancillary benefit of firing up the anti-smoking ban faithful, who seemingly never consider the possibility that perhaps the manuscript was rejected because it just didn’t make the cut. Whatever the true case here, whether McFadden and Kuneman’s manuscript is any good or not, virtually all scientists have had papers rejected out of hand without the invitation to respond to reviews and resubmit. Indeed, I went through that lovely experience myself just a month ago, when I had a paper rejected for what I considered to be specious reasons. Did I whine? Well, maybe a little, but not on my blog and not on websites, but rather just among my colleagues. Nor did I try to fire up a bunch of activists about the injustice of it all and how unfair it all was. Instead, I buckled down, revised the manuscript, sent the revision to some colleagues for opinions and advice, and then moved on, looking for another appropriate journal. (I plan on resubmitting it later this week.) Moreover, according to McFadden and Kuneman, thus far they’ve only submitted their paper to three different journals, the British Medical Journal, Circulation, and Tobacco Control. Give me a break. That, in and of itself, is hardly evidence of “suppression” or ideology blinding editors and reviewers to the value of their work. I’m singularly unimpressed with their complaint. A colleague and I have a paper that we’ve submitted to four journals thus far, all of which rejected it, despite uniformly positive feedback from colleagues to whom we’ve shown it and, more importantly, despite the fact that my colleague now has an NIH R01 grant based in part on the evidence from that paper and that I’ve been awarded a rather large grant from a private foundation to study a different question based–you guessed it–on the much of the same evidence. It’s not at all uncommon to have to shop a manuscript around to multiple journals before getting it published; having to do so is not necessarily evidence of ideology preventing publication. Besides, if McFadden and Kuneman are persistent enough, eventually they will get their study published. Also, McFadden is not limited to just journals. Can’t get your work accepted to a high profile peer-reviewed journal yet? Submit it to the American Society of Clinical Oncology or some other appropriate scientific or medical organization and present it as a poster or a short talk at a national meeting. This approach has the advantage of getting some valuable feedback from interested scientists in a relatively nonhostile environment, and, if you choose the venue right, you can at least get an abstract in a journal indexed on PubMed.

The bottom line is simple. The Helena, Pueblo, and Italian studies are preliminary in nature. They have provocative findings. They may or may not be correct. For all I know, McFadden’s study may be the bee’s knees, epidemiologically speaking. Science and epidemiology will have to sort this question out over the next several years, and I strongly suspect that longterm studies will very likely confirm health benefits for workers formerly exposed to large amounts of SHS (such as restaurant and bar employees) due to indoor smoking bans, regardless of what the short-term studies show. Also, as Dr. Siegel himself points out, the scientific merits of such bans do not rise or fall on the basis of these few studies. However, also from my perspective, the histrionic and exaggerated coordinated attacks on these studies by opponents of indoor smoking bans are far more ideologically motivated than even the most fevered imaginings of the cranks paint the motivations of the investigators of the Helena study.

Comments

  1. #1 Hank Roberts
    July 19, 2007

    Wait, you’re _surprised_?

    You’re not cynical enough yet.

  2. #2 MarkH
    July 19, 2007

    Wonderful Orac. That McFadden writes for ACSH is another strike against them. Did you see his ridiculous argument that alcohol releases more carcinogens than a cigarette?

    No, he’s not a crank. That would be crazy.

    I’m sending all the cranks this way consequently rather than have them try to debate you on my thread.

  3. #3 Bill Hannegan
    July 19, 2007

    Since the study of American smoking bans by Jerome Adda and Francesca Cornaglia found that such bans do not reduce the overall secondhand smoke exposure of nonsmokers in communities where they are enacted, why would we expect heart attack rates to change?

    http://www.ifs.org.uk/publications.php?publication_id=3523

  4. #4 Michael J. McFadden
    July 19, 2007

    Mark H wrote, “Wonderful Orac. That McFadden writes for ACSH is another strike against them. Did you see his ridiculous argument that alcohol releases more carcinogens than a cigarette?”

    (Mark is referencing: http://bmj.bmjjournals.com/cgi/eletters/330/7495/812#105082 )

    Mark, since an alcoholic drink *does* release release roughly 2,000 times the amount of unique Class A Carcinogens as a cigarette over the course of an hour, and since that can be easily observed by any layperson who visits that link and follows up on the minimal research involved… I’m not clear on exactly what you find “ridiculous”.

    Could you clarify?

    Aside from Mark’s oddity, I’d like to thank Orac for taking the time to examine the Helena question in such depth.
    It would be nice if the authors of the study utilized the pages of the British Medical Journal to also provide “valuable feedback from interested scientists in a relatively nonhostile environment,” but as any visitors to

    http://bmj.bmjjournals.com/cgi/eletters/328/7446/977#123038

    will find, they have not done so.

    Orac, you’ve certainly presented a more in-depth defense of the Helena authors than they have ever bothered to offer themselves. I will try to address some of your points later today in another post. I’d also like to say that I appreciate your honesty and thoroughness in actually linking to the various sites in question so that readers can indeed check to see if they agree with your claims about “crankiness”.

    For the moment, to give readers something to chew on, let me point to a couple of links that address a couple of your specific statements that stood out for me above.

    You wrote, “The vast majority of the criticisms of the study later made were discussed and addressed in the paper”. I disagree: where were the criticisms raised in

    http://www.bmj.com/cgi/eletters/328/7446/977#67440

    and

    http://www.bmj.com/cgi/eletters/328/7446/977#123038

    so addressed?

    And, in regard to the statement, “They did not represent the study as anything more than what it is: A preliminary study done to see if any effect could be seen.”

    that would seem to be quite clearly incorrect if one examines the statements referenced at:

    http://www.bmj.com/cgi/eletters/bmj.38055.715683.55v1#55832

    While reading you may also notice the curious fact that this “preliminary” study was never “finished” as new data came in. If data for further six-month periods supported the authors’ position it would certainly seem odd that they chose not to return to point that out, wouldn’t you say? On the other hand, if further data indicated their position to be incorrect, shouldn’t they have had an ethical responsibility to point that out?

    Michael J. McFadden
    Author of Dissecting Antismokers’ Brains
    http://pasan.TheTruthIsALie.com

  5. #5 trrll
    July 19, 2007

    Since the study of American smoking bans by Jerome Adda and Francesca Cornaglia found that such bans do not reduce the overall secondhand smoke exposure of nonsmokers in communities where they are enacted, why would we expect heart attack rates to change?

    However, they did find significant reductions for bans in particular places, and also for particular age groups, as well as differential effects for people who lived in nosmoking vs. smoking households. So it may be that the people who are most vulnerable to passive smoke induced heart attacks also fall into a group that is most affected (e.g. nonsmokers in smoking households).

  6. #6 Mark C. Chu-Carroll
    July 19, 2007

    Michael McFadden:

    You know full well how dishonest that claim about alchohol is: you can’t compare quanities without considering relative carcinogenicity. I do the math over at GM/BM:
    http://scienceblogs.com/goodmath/2007/07/if_i_didnt_know_id_wonder_what_1.php

    Doesn’t look so good when you actually consider honest comparisons.

  7. #7 Coin
    July 19, 2007

    So “myocardial infarction” is just a medical-y word for heart attack?

    (It’s kind of a fun word to say. Every time I look at it I think “It’s not news, it’s MYOCARDIAL INFARCTION DOT COM”…)

    Out of curiosity, why did the authors of this study choose to measure rates of “myocardial infarction”, as opposed to any other health issue? Is there reason to expect that SHS will be particularly prone to cause heart attacks as opposed to some other health problem? Was for some reason data on “myocardial infarction” easier to gather than other health indicators would have been?

    Also, my understanding is that California’s indoor smoking ban has now been in effect for some time. Have there so far been any studies to assess the long-term public health effects of that ban?

  8. #8 Orac
    July 19, 2007

    I suspect it was because it was relatively easy to gather data for the number of admissions to that single hospital for myocardial infarction. All you have to do is to look for a few diagnosis and procedure codes related to MI and the procedures typically done on patients with an MI and then review the charts to make sure that the admitting diagnosis didn’t turn out to be in error.

  9. #9 Coin
    July 19, 2007

    I see, thanks.

  10. #10 factician
    July 19, 2007

    The larger effect would be expected to be seen in rates of lung cancer. That said, it will take a lot longer for that to play out, so heart attacks are a faster readout (that, and I’ll bet anything the authors are cardiologists or ER doctors).

  11. #11 D
    July 19, 2007

    Michael, Not all carcinogens were created equal. Alcohol is not as carcinogenic as the compounds in cigarette smoke. You cannot directly compare dose between alcohol and cigarette smoke without first comparing their respective levels of carcinogenicity.

    And alcohol vapor…? Are you serious..? That makes for a rather small dose of a poor carcinogen.

    Your entire argument rests on the false premise that alcohol vapor and second hand smoke cause equal or even comparable levels of harm.

  12. #12 Bill Hannegan
    July 19, 2007

    Glantz and the antismoking lobby, not just the press, used the Helena study as if it were much more than just preliminary research:

    The authors note that this is the first empirical evidence suggesting that smoke-free policies not only protect people from long-term dangers of secondhand smoke, but they also rapidly prevent heart attacks. “This striking finding suggests that protecting people from the toxins in secondhand smoke not only make life more pleasant; it immediately starts saving lives,” said Stanton Glantz, PhD, professor of medicine at UCSF Cardiovascular Research Institute and a statistics authority. “This work substantially raises the stakes in debates over enacting and protecting smoke-free ordinances.”

    http://pub.ucsf.edu/newsservices/releases/2003071812/

    “This clearly shows the great need for controls on smoking in public places,” says Amanda Sandford of UK pressure group Action on Smoking and Health. “Passive smoking is a killer. The public certainly underestimates the impact of passive smoking on the heart.”

    http://www.newscientist.com/article.ns?id=dn3557

    Secondhand smoke can trigger heart attacks and asthma attacks in nonsmokers exposed to it. After a study published in the British Medical Journal showed that heart attack rates in Helena, Montana, dropped 40 percent after a clean indoor air was passed, and returned to previous levels after the law was overturned, the Centers for Disease Control recommended all patients with heart disease avoid all buildings where smoking is permitted.

    http://www.smokefreeohio.org/oh/news/050310LaunchCampaign.aspx

    Cass Wheeler, CEO of the American Heart Association, said that the study should add to existing momentum to enact smoking bans in communities and states across the country. “There has never been better evidence in support of clean indoor air laws,” said Wheeler.

    http://www.americanheart.org/presenter.jhtml?identifier=3020445

    In Illinois, eight people die from exposure to secondhand smoke each and every day. “We know there is a correlation between smoke-free laws and the rate of heart attacks,” said Joni Clark, M.D., American Heart Association, Sangamon County Board of Directors. “A study conducted in Sept. 2001 in Helena, Montana showed that during the six months the city had a smoke-free ordinance, the rate of heart attacks in the Helena area declined by 40 percent. When the law was suspended, the rate of heart attacks increased.

    http://illinoisreview.typepad.com/illinoisreview/2007/01/sen_cullerton_i.html

  13. #13 Bill Hannegan
    July 19, 2007

    The Illinois Licensed Beverage Association, not a typical stronghold of crankery and denialism, saw the Pueblo and Helena studies as enough of a threat to Illinois bars that they specially attack the studies on their website:

    The integrity of the studies cited by these groups is questionable. For example, anti-smoking advocacy groups boast of recent statistics from Pueblo, Colorado citing a dramatic decrease in heart attacks since the inception of their ban. These groups consistently point to the reduction in heart attacks in Pueblo, Colorado and Helena, Montana as incontrovertible proof that secondhand smoke is doubling the heart attack rate among non-smokers.

    These two studies comprise a population base of roughly 200,000 people. However, when you look at the 70 million people that comprise the non-smoking states of California, New York, Florida and Oregon-the heart attack rate has either not decreased at all or decreased such a small amount as to be statistically insignificant.

    Researchers can deliberately sift through enough small local jurisdictions with smoking bans to find a few aberrations in heart attack rates and then claim that elimination of exposure to secondhand smoke will dramatically reduce incidents of heart attacks. Please don’t be taken in by misleading claims based on very select data samples.

    http://www.ilba.net/cgi-bin/ILBA/info.pl?domain=info&name=SmokingBan

  14. #14 Michael J. McFadden
    July 19, 2007

    D, although your question comes later I’ll respond to it first here since I have it in my buffer from one of the related blogs…

    (Speaking of which… Mark, Orac, whoever… would it be possible for all the bats to get into a single belfry on this? I’m a smoker ya know… traipsing up and down all these church tower steps is a bit rough on me and I’m afraid I’ll slip and fall in the guano… ;> )

    D, a Marc C. on Bad Math Good Math offered some information on relative levels of carcinogenicity that I was unfamiliar with. Here’s how I responded:

    ===

    Heh… finding this trail of blogginess makes me think back to the comment (by Mark H? Orac?) yesterday or so about the “Crank Bat Signal” summons.

    Mark C., no dishonesty involved at all. I was unaware of the existence of the tables and information you post above and will examine it. At the moment though I haven’t even gotten back to the denialism/insolence blogs where I believe I am both awaiting some responses and owe a few.

    I noticed your selection of carcinogens though and am wondering, since you seem to be aware of such things, why you did not choose the proper carcinogens for comparison: i.e. the unique Class A carcinogens in tobacco smoke and their quantities. See the 10th IARC report at http://ehp.niehs.nih.gov/roc/toc10.html#search (I believe there’s an 11th by this point but don’t have the URL handy) and the SGR ’89 or ’06 for particulars.

    I think if you do so, and THEN apply your analysis, you may come up with a somewhat different conclusion (you may not also… I haven’t done that analysis myself).

    I also wonder why you seem to think that tobacco smoke in the air would behave so much differently than alcohol vapors. Granted one is a gas form and one a particulate, but I believe that very small particulate matter behaves aerodynamically in ways quite similar to gas. Do you have evidence or reason to believe to the contrary?

    And a final note: I believe your and your blog friends are consistently missing the MAIN point I was making: it *IS* crazy to worry about such exposures to alcohol, and it is similarly crazy to worry about such exposures to secondary smoke. You can argue for a degree of difference, even a *great* degree of difference, but as the Surgeon General has so painstakingly pointed out, “there is no safe level of exposure” to carcinogens. So was he lying? Or is it dangerous to be near you while you’re sipping your Beefeater?

    Or *is* there perhaps a “safe level” in normal parlance that is simply ignored and twisted by the antismoking lobby?

    ====

    Michael J. McFadden
    Author of Dissecting Antismokers’ Brains
    http://pasan.TheTruthIsALie.com

  15. #15 trrll
    July 20, 2007

    also wonder why you seem to think that tobacco smoke in the air would behave so much differently than alcohol vapors. Granted one is a gas form and one a particulate, but I believe that very small particulate matter behaves aerodynamically in ways quite similar to gas.

    Cancer is not solely a matter of aerodynamics; there’s biology involved as well. Small particles are more likely to be trapped in the lungs, where they can continue to cause damage for long periods of time.

  16. #16 Dave K
    July 20, 2007

    Just to clear a few things up, Dr Siegel did review our manuscripts prior to submission to the 3 journals, and he did see all the comments of the referees. Would it have made any difference if Siegel had signed on as a coauthor?..probably not. all 3 journals simply rejected further consideration no matter what changes we would propose, and clearly stated to McFadden and I that there was nothing we could do to change their minds.

    Orac implies that perhaps Dr Siegel posted his support of us whithout knowing all the facts surrounding our saga. I assure all, nothing could be further from the truth. Dr. Siegel very responsibly does know all the details necessary to support what he said in his post. In fact, I personally know that Dr. Siegel accessed the HCUP database to check our facts and figures.

    Now, let’s go to where Orac says perhaps we are ranting over strong claims made by the Helena authors when, in fact they were actually quite cautious in the statements made in the original paper as it appears in the BMJ. I agree, nothing in the statements in the BMJ actually say Helena proved anything and I strongly agree that their use of the word MAY is evidence of that.

    It’s not what they said in the peer reviewed BMJ that I object to. It’s what they said to the media, and in other non-peer reviewed public forums that I take issue with. While I do not have a link handy, I do know that now the ANR ( a group run by one of the authors) is saying that Helena is proof than 30 minutes of SHS exposure can cause a heart attack in a healthy individual.

    Another one of the authors, Sargent, I believe, has now taken his “Brother Sargent’s Trav’ling Salvation Show”, on the road where he testifies to lawmakers considering smoking bans that Helena is indeed proof that SHS is a serious health hazard and that enacting a ban will immediately save lives. Apparantly he does not inform lawmakers of the limitations he so concisely described in his paper, and the very real possibility that Helena may have been an artifact.

    We have continuously noticed this ‘shell game’ being played by antismokers. The 2006 Surgeon Genenral’s report is another example of this same approach, in the peer reviewed part, it clearly states that all of it’s conclusions can alternately be explained by misclassification of former smokers as never smokers. It also states that many of the diseases usually associated with SHS are actualy suggestive of an effect, but that the cause-effect relationship is not conclusive. However, none of these facts show up in public statements made by the Surgeon General either before, or since his “resignation” .

    It is becoming increasingly clear, that the fraud that SHS causes harm has 2 major ingredients: first, someone publishes a study in a peer reviewed journal that SHS “may” , “can” or “could” be associated with some disease, and second, then someone else makes public statements outside of peer-review that that study said that SHS “was” or “is” associated with the disease. – A big, yet subtle difference in meaning.

    I hope this clears up some of these misunderstandings.

    Dave K

  17. #17 Mark C. Chu-Carroll
    July 20, 2007

    Michael McFadden:

    So what you’re saying is:
    * You’re a serious researcher of the link between smoke and cancer.
    * You’ve submitted scientific papers on the matter, which were rejected
    entirely for political reasons.
    and
    * You’re completely unfamiliar with the idea that the degree of
    carcinogenicity varies for different substances.

    Do you really expect anyone to take you seriously when you
    say things like that? If you’re not even familiar with something as
    totally trivial as dose/response variation, then it’s pretty much impossible
    that you’ve written a remotely credibly scientific analysis of the health impacts of second-hand smoke. The key question about
    second hand smoke is whether the quantity of dangerous substances in
    cigarette smoke inhaled by a non-smoker is sufficient to cause harm. If you don’t even understand the idea of different quantities of different substances having different degrees of effect, you simple can’t have done
    the analysis – because you show no comprehension of *the* most fundamental thing that you’d need to analyze.

  18. #18 Orac
    July 20, 2007

    Orac implies that perhaps Dr Siegel posted his support of us whithout knowing all the facts surrounding our saga. I assure all, nothing could be further from the truth. Dr. Siegel very responsibly does know all the details necessary to support what he said in his post.

    Straw man.

    I implied nothing of the sort. I stated that I thought Dr. Siegel was irresponsible to have promoted an unpublished study on his blog, and I still think so. I’d tell him that to his face. I always assumed that he did know the circumstances of its rejection, because you and McFaddena are most definitely not shy about telling everyone in earshot and on the Internet how The Man has kept your study down.

    As a public health researcher, Dr. Siegel must know very well that promoting unpublished results risks tarring them with the whiff of crankery, which is why I said that he almost certainly did your cause more harm than good through his actions. Not only did he help you do what is generally a bad idea if you want to be taken seriously in science (promote unpublished findings on the web) but, because his blog is probably read by some of the very people who might be editors and reviewers for your paper, he risked antagonizing them. Even if you have the greatest epidemiological study in the world, it’s generally not a good idea to risk antagonizing potential editors and reviewers like that before resubmitting a paper. Dr. Siegel must know that, too.

    Be that all as it may, though, don’t you wonder why Dr. Siegel apparently wouldn’t sign on to help you get your study published if he agreed with the findings and thought it was sufficiently worth verifying your conclusions and to do some work of his own to extend the findings? He was willing to promote your study on his blog, sure, but that really costs him nothing in his career. In contrast, he was apparently unwilling to put his reputation where his blog is (in other words, to risk his academic reputation) by signing on as a coauthor, even though it is arguable that he should given his publicly described contribution to you.

    You’re also almost certainly wrong that it wouldn’t make a difference if Dr. Siegel signed on as an author. It might not make a difference in the three journals that already rejected it, but it very likely would for other journals to which you might want to try to submit the manuscript. Academic journals and peer reviewers tend to be skeptical over studies submitted by people without academic affiliations of some sort, particularly if they run an advocacy group that suggests that they have a strong ideological agenda, which both of you do. It is not unreasonable to suggest that getting Dr. Siegel on board as an author would likely go a long way towards obviating that problem. At the very least, he would give you more academic credibility, something you sorely lack now.

    So ask yourself again: Why wouldn’t Dr. Siegel agree to being made a coauthor? Or did you ask him? If you didn’t ask him, you should certainly take the opportunity to ask him now. After all, he’s done two posts touting your study on his blog and one post defending his decision to do so. Presumably he likes it. So why wouldn’t he want to be a part of it and help you get it into a decent peer-reviewed journal, where he apparently think it deserves to be?

  19. #19 GDF
    July 20, 2007

    Just stopping in…

    Mark C — that was completely off the mark (no pun intended). Mr. McFadden did not write a bio-medical paper, he wrote a statistical analysis of a population event (or lack of one). You don’t have to know the chemical formula for alcohol to analyze the effect of Prohibition. Half of “public health” would be out of a job otherwise.

    Orac – THIS topic is of great importance right now. That is, it is a topic on which public policy (policy that has strong meaning for the public) is being made NOW. Even if Mr. McFadden’s paper had flaws, you would expect a revise and resubmit. From my experience, (in other areas of public health) I would think any journal would bend over backwards to publish something as topical as this.

    If (and I don’t know) Mr. McFadden’s example was poorly chosen (and I started all of this alcohol talk by comparing SHS to alcohol traffic fatalities), his main point, about NO SAFE LEVEL being a “political” statement, and unlike the treatment of other risks, still holds.

    You guys can believe what you like about SHS. Take it on “faith” for all I care. But with regard to the corruption in public health — you’ve grabbed this tiger by the wrong end. To change metaphors, how many whistles (Dr. Carmona, Richard Smith, Dr. Siegel, etc.) have to blow before you start to hear them?

  20. #20 Mark C. Chu-Carroll
    July 20, 2007

    GDF:

    There’s a big difference between “knowing the chemical formula for alchohol” (i.e., knowing in great detail all of the science underlying a phenomena) and having some basic awareness of things that are relevant parameters for your statistical analysis.

    It’s not *impossible* to do a good statistical analysis of something you’re clueless about. But it’s *not* likely. Most likely, an author like McFadden who is so incredibly clueless about what he’s analyzing, and who is so unaware of his own cluelessness that he would *publish* a letter making an allegedly scientific argument without giving it the least bit of thought – is an author who’s going to write a sloppy paper making more of the same kinds of clueless, ignorant errors.

    It’s hard to take him seriously when he’s been making the same argument about alchohol for years, and claims to have never heard nor considered the idea that the carcinogenicity of different substances could be different. That’s not rocket science; it’s not even college-level chemistry. That’s basic high-school biology, if that. Either he’s so scientifically clueless that an average high-school freshman has more understanding of cancer than he does, or he’s dishonest. Either way, it’s nearly impossible to believe that he wrote a genuinely good, honest, thorough paper on the statistical analysis of smoking.

  21. #21 Michael J. McFadden
    July 20, 2007

    OK, let me limit myself to a couple of points that I don’t think I’ve addressed on the other blogs here.

    1) Orac wrote, “The vast majority of the criticisms of the (Helena) study later made were discussed and addressed in the paper”.

    I responded with the question, “where were the criticisms raised in

    http://www.bmj.com/cgi/eletters/328/7446/977#67440

    and

    http://www.bmj.com/cgi/eletters/328/7446/977#123038

    so addressed?”

    I have not seen an answer yet.

    2)I wrote, “this “preliminary” study was never “finished” as new data came in. If data for further six-month periods supported the authors’ position it would certainly seem odd that they chose not to return to point that out, wouldn’t you say? On the other hand, if further data indicated their position to be incorrect, shouldn’t they have had an ethical responsibility to point that out?”

    Orac, have you found where they have furnished that further analysis? I actually believe I have a quoted statement from either Shepard or Sargent they were going to do one… but it seems it never happened. They haven’t been very responsive to me in the past, but I could supply you with at their email addresses if you wanted to ask.

    ======
    Now, to address a newer point: I believe I have made clear that I consider Mark C’s point about relative carcinogenicty to a valid concern. I am currently awaiting his analysis of the Class A components of secondary smoke regarding such carcinogenicity with regard to their relative amounts and the relative amounts of alcohol vapor emitted. My response in the BMJ was not a project that was months in the making, and indeed I did neglect to address that possibly quite important aspect in my writing there. Mark has the data handy and I’m quite open to seeing and discussing his results.

    However, I would like to remind Mark and others that the main subject of this particular blog heading is “One last puff of smoke over Helena, MT” and that I think we would all benefit if they were willing to step into the shoes abandoned by the Helena researchers themselves and defend the criticisms raised in the two links above.

    As for the authors being so “careful” not to give misimpressions in the body of their study itself… Well, for a paper that analyzed NO data regarding secondary tobacco smoke it’s kinda funny that they managed to talk about it a full dozen times in the course of the three or four pages.

    Michael J. McFadden
    Author of Dissecting Antismokers’ Brains
    http://pasan.TheTruthIsALie.com

  22. #22 Michael J. McFadden
    July 20, 2007

    And Mark, a brief question: Are you stating that a safe level of exposure to the recognized Class A carcinogen of ethyl alcohol HAS been determined?

  23. #23 GDF
    July 20, 2007

    Mark C. — First, I’m not sure if your characterization of what Mr. McFadden is aware of or not is correct. He can speak to that.

    But in any case, you seem to be making a couple of different points here. I’m trying to sort them out. If the point is that one can’t do a statistical analysis (or evaluation) of a public health policy without advanced knowledge of the biology (or chemistry) of the issue – I repeat, you’re going to put a lot of public health policy analysts out of work.

    If your point is that he made an error in an example he gave in a BMJ response that is grave enough to immediately and forever discredit his later, policy evaluation work (and note that, as I understand it, that work is based on open and available data) – then I think that’s a judgement, and I simply disagree. I also find it improbable that journal editors are rejecting his work for that reason. Orac’s suggestion of a lack of academic affiliation is more plausible — but frankly, I don’t think that’s it either.

    I once made a (it seemed to me) huge error in statistical analysis. Luckily, it was caught by a reviewer and I corrected it. (As I have corrected the errors of others) If it wasn’t caught – it would have been published. I’m embarrassed to even think about it now, but I certainly hope it doesn’t invalidate all of my other work. Doesn’t seem to have.

    It seems to me, that in a reasonable and open scientific debate, one would say — “Mr. McFadden – although I understand (or don’t) the point you were making, do you realize that you made an error here?” Then, Mr. McFadden would defend or correct the error, and we would all decide if the error invalidated the point he was attempting to make. As I understand it, that’s what the BMJ rapid responses are intended for in the first place. — to provide an opportunity for response and to encourage open debate.

  24. #24 trrll
    July 20, 2007

    If the point is that one can’t do a statistical analysis (or evaluation) of a public health policy without advanced knowledge of the biology (or chemistry) of the issue – I repeat, you’re going to put a lot of public health policy analysts out of work.

    Do you seriously believe that the fact that different substances commonly differ in potency with respect to their effects on the body is “advanced” knowledge of chemistry or biology? Even people who have no training at all in chemistry or biology will have likely noticed that different doses of different drugs are commonly required, even when the drugs do the same thing.

    I find it incomprehensible that somebody who is interested in environmental causes of cancer would have not bothered to read enough to acquire this very basic bit of information. I find it even more incomprehensible in somebody who would attempt to submit a paper on the topic to a journal. While you might argue that it is a paper on pure statistics, it is very likely that a journal’s editors will send it to reviewers with some interest in, and knowledge of, cancer biology. If the reviewers ran across similar biological “howlers” in the Introduction or Discussion of the paper, it could have a lot to do with why they are having such trouble getting published. When a reviewer encounters elementary errors, the reviewer is likely to conclude that the authors simply don’t know what they are doing, and may start to worry that the authors have made other, less obvious, errors that invalidate their conclusions. Pair that with authors who have no academic track record and who appear to be approaching the question with a great deal of bias, and it would be hard to get published in any peer reviewed journal.

  25. #25 GDF
    July 20, 2007

    No trrll — I seriously believe that Mr. McFadden may have made an error in a BMJ rapid response by overlooking a key factor in the analysis, in an example that wasn’t crucial to his point about “safe levels” anyway. I don’t know how many other ways I can say it.

    I further believe that if this wasn’t all about “winning” debates this discussion would be a lot more profitable for everyone.

  26. #26 Bill Hannegan
    July 20, 2007

    Why did we have to wait for two independent researchers of limited means for a study of statewide smoking bans and heart attack data? Glantz could have snapped his fingers and had such a study completed and published in no time. Now half of America has a smoking ban and Helena is still being used to push bans. I guess Helena gave Glantz all the answer he wanted or needed.

  27. #27 Michael J. McFadden
    July 22, 2007

    Bill Hannegan wrote, “I guess Helena gave Glantz all the answer he wanted or needed.”

    Actually, Helena, Pueblo, and Bowling Green. Amazingly enough, honest scientific researchers just seem to have somehow completely innocently and accidently found three towns where the statistical results were radically different than we would see in entire states.

    Amazing, isn’t it?

    And now I would like to repeat my question to Mark H above, since he seems to have missed it:

    Mark, you wrote, “The vast majority of the criticisms of the study later made were discussed and addressed in the paper”. I disagree: where were the criticisms raised in

    http://www.bmj.com/cgi/eletters/328/7446/977#67440

    and

    http://www.bmj.com/cgi/eletters/328/7446/977#123038

    so addressed?

    =====

    Well Mark?

    Michael J. McFadden
    Author of Dissecting Antismokers’ Brains
    http://pasan.TheTruthIsALie.com

  28. #28 Orac
    July 22, 2007

    Mr. McFadden:

    You still haven’t answered my question about why it is that Dr. Siegel hasn’t been willing to add his name to your paper and thus help get it published if he agrees that the Helena study is not a good one and that yours is. I’d suggest that you ask him. Certainly if I were you that would be one question I’d be wondering about.

    Aren’t you in the least bit curious? Or does it serve your purpose better to be able to cry “martyr”?

  29. #29 Michael J. McFadden
    July 22, 2007

    Orac wrote, “You still haven’t answered my question about why it is that Dr. Siegel hasn’t been willing to add his name to your paper and thus help get it published if he agrees that the Helena study is not a good one and that yours is.”

    er… maybe because he didn’t write the paper? Is it normal practice in the world of medical journals to seek co-authors not on the basis of their contributions to the work but simply because they have names/affiliations that might convince a journal to publish?

    Forgive me… I’d rather have my work judged on its own substance and quality.

    And, now that I have answered virtually EVERY comment and criticism that you have raised here and elsewhere (quite unlike the supposedly responsible and accredited Helena authors), how about responding to mine? To wit:

    ======
    1) Orac wrote, “The vast majority of the criticisms of the (Helena) study later made were discussed and addressed in the paper”.

    I responded with the question, “where were the criticisms raised in

    http://www.bmj.com/cgi/eletters/328/7446/977#67440

    and

    http://www.bmj.com/cgi/eletters/328/7446/977#123038

    so addressed?”

    I have not seen an answer yet.

    2)I wrote, “this “preliminary” study was never “finished” as new data came in. If data for further six-month periods supported the authors’ position it would certainly seem odd that they chose not to return to point that out, wouldn’t you say? On the other hand, if further data indicated their position to be incorrect, shouldn’t they have had an ethical responsibility to point that out?”

    Orac, have you found where they have furnished that further analysis? I actually believe I have a quoted statement from either Shepard or Sargent they were going to do one… but it seems it never happened. They haven’t been very responsive to me in the past, but I could supply you with at their email addresses if you wanted to ask.

    =======

    Orac?

    Michael J. McFadden
    Author of Dissecting Antismokers’ Brains
    http://pasan.TheTruthIsALie.com

    Michael J. McFadden
    Author of Dissecting Antismokers’ Brains
    http://pasan.TheTruthIsALie.com

  30. #30 GDF
    July 22, 2007

    I await Orac’s response but meanwhile,

    “er… maybe because he didn’t write the paper?”

    In the first version of the question, I noticed Orac added the “extend the analysis” to cover the fact that Dr. Siegel didn’t actually WRITE the paper as it stands (and yes, it would be unethical to add his name to a paper to which he didn’t contribute). I think Orac was straddling the ethical line by suggesting that “extend the analysis”…

    “Is it normal practice in the world of medical journals to seek co-authors not on the basis of their contributions to the work but simply because they have names/affiliations that might convince a journal to publish?”

    err… yes. Shouldn’t be, but it is sometimes. Doesn’t make it right.

    Nonetheless, I can’t imagine Dr. Siegel *would* (even if asked) add his name to this paper – if for no other reason, he learned the lesson of Enstrom. A blog is one thing… but to wreck your career and invite the full wrath of the anti-tobacco establishment… (Just speculating…)

  31. #31 Steve Hartwell
    July 22, 2007

    CARS, LIGHT TRUCKS, VANS & SUVs
    ‘Exhale’ the same alleged bad components as do Tobacco Smokers

    It is also alleged today that motor
    vehicle pollution emissions have been Reduced by 96 % since the 1960s,

    however, the real-world facts are
    that
    emissions of hydrocarbons have been reduced by about two-thirds,
    emissions of carbon monoxide have dropped only a third,
    and nitrogen oxide emissions have actually increased more than a fifth over the
    past 30 years.
    http://www.ucsusa.org/clean_vehicles/vehicles_health/realworld-emissions.html

    So, that’s (66 + 33 – 20) / 3 =
    overall emissions reduction of about 26 %

    not much – overall

    Still
    compared to the 1960s, significantly Reduced Vehicle Emissions have been
    achieved, more is expected over time,
    and it is generally accepted that Health and Environment Risks from each Vehicle
    have also been Significantly Reduced,
    regardless of the fact that there are many many more Vehicles on the Road today,
    driving much further each year, every year.

    It is estimated there are over 600
    Million Motor Vehicles belching around our little planet today, and, to double
    by 2030.

    It is estimated that each Tobacco
    Smoker exhales approximately 500 to 700 milligrams of alleged bad components per
    day.

    It is also estimated that each
    motor vehicle made ‘today’ exhales the equivalent of 60,000 to 90,000
    cigarettes – per day.


    http://www.forces.org/evidence/files/aircare.htm

    You can see ‘it’ choking every city
    on earth,
    you breath ‘it’ every day you leave the house,
    you contribute to it every time you drive your motor vehicle.

    Which source of the alleged bad
    components do you think really should be banned ?

    If I were a motor vehicle
    manufacturer,
    I would prefer you believe the Junk Science that Tobacco Smoking should be
    banned
    not Motor Vehicles.

    When is the majority going to wise up and
    finally realize that

    you really are far Far more
    ‘exposed’ to the same alleged harmful components
    on the outside of a pub full of tobacco smokers
    than on the inside

    If newspapers suddenly printed
    today on their front pages
    that all motor vehicles now have 61 % less emissions than they did yesterday
    and are 82 % healthier for people and the environment,
    ??
    wouldn’t the whole world cheer ??
    HORAAH !

    Since Motor Vehicles are allowed to
    Reduce the Risk of their Emissions by, at best so far, averagely about 26 %
    and each Motor Vehicle still averagely belches out the equivalent of about
    60,000 to 90,000 cigarettes per day
    that there are way far more Motor Vehicles than there are cigarette smokers
    and that this pitiful Motor Vehicle ‘achievement’ is considered to be an
    acceptable Reduced Risk

    it only logically stands to reason
    and common sense to accept about 3 times better than Motor Vehicle Reduced Risk

    for Cigarettes

    ———————————————————————————–

    Reduced Risk Cigarettes
    that Reduce The Alleged Bad Components in Tobacco Smoke
    by at least 61 %, and, improve the body’s ability to ‘defend’ itself by at least
    82 %

    that Smokers will still Enjoy Smoking

    ARE HERE NOW !


    http://www.reducedriskcigarettes.ca

  32. #32 Bill Hannegan
    July 22, 2007

    Interestingly, in his Nov. 30, 2005 blog entry entitled “New Study Casts Doubt on Claim that Smoking Bans Substantially Reduce Heart Attack Admissions”, Dr. Siegel already did “extend the analysis”:

    In addition to confirming Kuneman and McFadden’s findings, I extended their analysis by:

    examining trends going back in time as far as 1997, the earliest available online data (in order to have a more stable baseline period to establish secular patterns); and

    examining trends in heart attack admissions in all the other states in the online database without smoking bans that included data for the entire study period 1997-2003 (a total of 8 states – New Jersey, South Carolina, Utah, Washington, Arizona, Colorado, Hawaii, and Iowa; Massachusetts was not included because of the extensive local smoking bans) (in order to have a comparison group).

    For California, I compared heart attack admission trends during the period 1997-2002 for California versus the 8 non-ban states in the HCUP online database and versus the nation as a whole. Trend lines were essentially parallel throughout the period. From 1997 to 1998, heart attack admissions in California increased by 6.0%, compared to a 3.8% increase in the comparison states and a 6.2% increase in the remainder of the nation. From 1997 to 1999, heart attack admissions increased by 9.9% in California, compared to 4.8% in the comparison states and 4.3% in the remainder of the nation.

    For New York, overall trends were similar to those in the comparison states and to the nation as a whole, except that New York did not experience the slight decline in heart attack admissions during 2003 that was observed elsewhere. In New York, admissions for heart attacks increased by 0.4% from 2002 to 2003, while heart attacks decreased by 3.1% in the comparison states and by 2.8% nationally during the same time period.

    For Florida, heart attack admissions increased slightly faster than in the comparison states between 1997 and 2000, but the patterns were similar from 2000-2003. There was a slight decrease in heart attacks between 2002 and 2003 in Florida (0.7%), the comparison states (3.1%), and the nation as a whole (2.8%).

    For Oregon, there was a 0.4% increase in heart attack admissions from 2000 to 2002, while admissions in the comparison states dropped by 0.7% during the same period, and admissions nationally increased by 4.3%.

    http://tobaccoanalysis.blogspot.com/2005/11/new-study-casts-doubt-on-claim-that.html

  33. #33 Bill Hannegan
    July 23, 2007

    “I think Kuneman and McFadden are to be congratulated for having made an important contribution to the analysis of this research question. I think that their analysis, along with my extension of that analysis, provides compelling evidence that brings into question the conclusion that smoking bans have an immediate and drastic effect on heart attack incidence.

    In fact, these analyses demonstrate that on a state-wide level, there is no suggestion of any large-scale effect on heart attack admissions associated with the implementation of statewide bans on smoking in child-friendly restaurants, all restaurants, bars, or bars and restaurants.”

    http://tobaccoanalysis.blogspot.com/2005/11/new-study-casts-doubt-on-claim-that.html

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