ABSTRACT

Objective.

To explore the association between reporting conflict of interest (COI) and having a positive outcome toward vaping in scientific articles.

Methods.

A cross-sectional study that analyzed a sample of 697 articles published between 2017 and 2020 regarding vaping. Information on the reporting of COI, type of COI (no conflict, conflict with the tobacco industry, pharmaceutical industry, or other), and country of publication were collected. To explore the association between reporting COI and having a positive result for vaping, two logistic regression models were fitted, both adjusted by country of publication.

Results.

From 88 articles that reported COI, 23 reported COI with the tobacco industry, 44 with the pharmaceutical industry, and 21 reported another type of conflict. We found that reporting any type of COI increased by 4.7 times the odds (OR 4.70; 95% CI [2.89, 7.65]) of having a positive result for vaping. Additionally, compared to other countries, manuscripts published in England had 2 times higher odds (OR 2.40; 95% CI [1.16, 4.98]) of reporting a positive result for vaping. Reporting COI with the tobacco and pharmaceutical industries increased the odds of favorable results by 29 times (OR 29.95; 95% CI [9.84, 90.98]) and 2 times (OR 2.87; 95% CI [1.45, 5.69]), respectively.

Conclusions.

In scientific articles, reporting COI and having positive results for vaping are highly associated. COI should be considered and caution should be exercised when using data for policy-making.

Keywords
Conflict of interest; public health; electronic nicotine delivery systems; tobacco industry; policy making

RESUMEN

Objetivo.

Explorar la relación entre notificar la existencia de conflictos de intereses y tener un resultado positivo con respecto al vapeo en los artículos científicos.

Métodos.

Se realizó un estudio transversal que analizó una muestra de 697 artículos sobre vapeo publicados entre 2017 y 2020. Se recopiló información sobre la notificación de la existencia de conflictos de intereses, los tipos de conflicto (sin conflicto o conflicto con la industria tabacalera, con la industria farmacéutica o con otras industrias) y el país de publicación. Para explorar la relación entre notificar la existencia de conflictos de intereses y tener un resultado positivo respecto del vapeo, se adaptaron dos modelos de regresión logística, y ambos se ajustaron por país de publicación.

Resultados.

De los 88 artículos en los que se notificó la existencia de conflictos de intereses, 23 informaron sobre conflictos de intereses con la industria tabacalera, 44 sobre conflictos con la industria farmacéutica y 21 sobre otros tipos de conflicto. Se determinó que la notificación de cualquier tipo de conflicto de intereses incrementó en 4,7 veces las probabilidades (OR 4,70; IC del 95 % [2,89; 7,65]) de obtener un resultado positivo con respecto al vapeo. Además, en comparación con otros países, los artículos publicados en Inglaterra mostraron probabilidades 2 veces más altas (OR 2,40; IC del 95 % [1,16; 4,98]) de comunicar un resultado positivo respecto del vapeo. Informar sobre la existencia de conflictos de intereses con las industrias tabacalera y farmacéutica multiplicó las probabilidades de resultados favorables por 29 (OR 29,95; IC del 95 % [9,84; 90,98]) y por 2 (OR 2,87; IC del 95% [1,45; 5,69]), respectivamente.

Conclusiones.

En los artículos científicos, existe una clara relación entre notificar la existencia de conflictos de intereses y tener un resultado positivo con respecto al vapeo. Se debe considerar el conflicto de intereses y actuar con precaución al emplear estos datos para la formulación de políticas.

Palabras clave
Conflicto de intereses; salud pública; sistemas electrónicos de liberación de nicotina; industria del tabaco; formulación de políticas

RESUMO

Objetivo.

Examinar a associação entre declarar conflitos de interesses e obter resultados favoráveis sobre os cigarros eletrônicos em artigos científicos.

Métodos.

Estudo transversal que analisou uma amostra de 697 artigos sobre cigarros eletrônicos publicados entre 2017 e 2020. Foram coletadas informações sobre a declaração de conflito de interesses, tipo de conflito (ausência de conflito, conflito com a indústria tabagista ou farmacêutica, ou outras formas de conflito) e o país de publicação do estudo. Dois modelos de regressão logística foram criados, com ajuste por país de publicação, para examinar a associação entre declarar conflitos de interesses e obter resultados favoráveis para os cigarros eletrônicos.

Resultados.

De 88 artigos que continham a declaração de conflitos de interesses, 23 informaram conflitos com a indústria tabagista, 44 com a indústria farmacêutica e 21 outras formas de conflito. Declarar qualquer tipo de conflito de interesses foi associado a uma probabilidade 4,7 vezes maior (OR 4,70; IC 95% [2,89, 7,65]) de obter resultados favoráveis aos cigarros eletrônicos. Quanto aos países de publicação, verificou-se uma probabilidade duas vezes maior de os artigos publicados na Inglaterra (OR 2,40; IC 95% [1,16, 4,98]) informarem resultados favoráveis para os cigarros eletrônicos. Quando se declarou o conflito de interesses com as indústrias tabagista e farmacêutica, a chance de resultados favoráveis nos estudos foi 29 vezes maior (OR 29,95; IC 95% [9,84, 90,98]) e 2 vezes maior (OR 2,87; IC 95% [1,45, 5,69]), respectivamente.

Conclusões.

Observa-se uma forte associação entre declarar o conflito de interesses e obter resultados favoráveis para os cigarros eletrônicos em artigos científicos. O conflito de interesses deve ser levado em consideração, recomendando-se cautela ao utilizar os dados de estudos na formulação de políticas.

Palavras-chave
Conflito de interesses; saúde pública; sistemas eletrônicos de liberação de nicotina; indústria do tabaco; formulação de políticas

Nowadays, there is no doubt regarding the harms that tobacco poses to public health (¹1. United States Centers for Disease Control and Prevention [Internet]. Atlanta: CDC; 2020 [cited 2021 Nov 15]. Smoking & Tobacco Use. Health Effects. Available from: https://www.cdc.gov/tobacco/basic_information/health_effects/index.htm
https://www.cdc.gov/tobacco/basic_inform... ). Worldwide, there have been many global efforts to reduce tobacco consumption, led by the World Health Organization’s Framework Convention on Tobacco Control (WHO-FCTC), proposed in 2005 and signed by 182 parties (²2. Pan American Health Organization [Internet]. Washington, DC: PAHO; c2015 [cited 2021 Nov 15]. WHO Framework Convention on Tobacco Control (WHO FCTC). Available from: https://www3.paho.org/hq/index.php?option=com_content&view=article&id=1317:2009-who-framework-convention-on-tobacco-control-who-fctc&Itemid=1185&lang=en
https://www3.paho.org/hq/index.php?optio... ). Thanks to tireless efforts, tobacco consumption trends have decreased around the world (³3. Reitsma MB, Kendrick PJ, Ababneh E, Abbafati C, Abbasi-Kangevari M, Abdoli A, et al. Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet [Internet]. 2021 Jun 19 [cited 2021 Nov 15];397(10292):2337–60. Available from: http://www.thelancet.com/article/S0140673621011697/fulltext
http://www.thelancet.com/article/S014067... ), although the 30% reduction in the prevalence expected for 2025 may not be achieved (⁴4. Organización Panamericana de la Salud. Plan de acción para la prevención y el control de las enfermedades no transmisibles en las Américas 2013-2019 [Internet]. Washington, DC: OPS; 2013 [cited 2021 Nov 15]. Available from: https://www.paho.org/hq/dmdocuments/2015/plan-accion-prevencion-control-ent-americas.pdf
https://www.paho.org/hq/dmdocuments/2015... ). Recently, new products like heat-not-burn and vaping devices have emerged, posing a threat to the achievements made through the implementation of the WHO-FCTC and the ongoing tobacco control policies, in addition to being a potential health risk for the population, especially vulnerable groups like children and youth (⁵5. Reynales-Shigematsu LM, Barrientos-Gutiérrez I, Zavala-Arciniega L, Arillo-Santillán E. Nuevos productos de tabaco, una amenaza para el control de tabaco y la salud pública de México. Salud Publica Mex [Internet]. 2019 Jun 10 [cited 2022 Apr 12];60(5):598–604. https://doi.org/10.21149/9682
https://doi.org/10.21149/9682... ).

These new products have been advertised as “harm reduction” and a powerful tool to help smokers quit tobacco (⁶6. Tobacco Reporter [Internet]. Raleigh, NC: Tobacco Reporter; 2021 Sep 1 [cited 2021 Nov 15]. The Time is Now. Available from: https://tobaccoreporter.com/2021/09/01/the-time-is-now/
https://tobaccoreporter.com/2021/09/01/t... , ⁷7. Adibah N. A harm reduction strategy for smoking cessation. 2020 Nov 20 [cited 2021 Nov 15]. In: Foundation for a Smoke-Free World [Internet]. New York: FSFW; 2020. Available from: https://www.smokefreeworld.org/a-harm-reduction-strategy-for-smoking-cessation/
https://www.smokefreeworld.org/a-harm-re... ). Since their launch, a body of scientific evidence has risen in support of these devices, facilitating their commercialization in many countries (⁸8. Framework Convention Alliance. Eighth session of the Conference of the Parties to the WHO Framework Convention on Tobacco Control, 1-6 October 2018, Geneva, Switzerland. Progress report on regulatory and market developments on electronic nicotine delivery systems (ENDS) and electronic non-nicotine delivery systems (ENNDS) [Internet]. Geneva: FCTC; 2018 [cited 2021 Nov 15]; Available from: https://fctc.org/resource-hub/progress-report-on-regulatory-and-market-developments-on-ends-and-ennds/
https://fctc.org/resource-hub/progress-r... ). However, it is important to take a closer look at the evidence supporting these arguments, as the tobacco industry (TI) has a 44% market control in these new products (⁹9. Foundation for a Smoke-Free World [Internet]. New York: FSFW; 2020 [cited 2021 Nov 15]. Global Trends in Nicotine [Internet]. Available from: https://www.smokefreeworld.org
https://www.smokefreeworld.org... ). While some of the arguments have come from independent sources, others have originated due to sponsorship or ties with the TI, either directly or indirectly, and through TI-sponsored research groups such as the Foundation for a Smoke-Free World, which constitutes a conflict of interest (COI) (¹⁰10. World Health Organization [Internet]. Geneva: WHO; 2017 [cited 2021 Nov 15]. WHO Framework Convention on Tobacco Control Secretariat’s statement on the launch of the Foundation for a Smoke-Free World. Available from: https://untobaccocontrol.org/kh/article-53/framework-convention-tobacco-control-secretariats-statement-launch-foundation-smoke-free-world/
https://untobaccocontrol.org/kh/article-... ). This and other TI activities to undermine or subvert tobacco control efforts have been around for a long time, and Article 5.3 of the WHO-FCTC has established clear guidelines to identify and manage TI interference (¹¹11. World Health Organization. Guidelines for implementation of Article 5.3 of the WHO Framework Convention on Tobacco Control. Geneva: WHO; 2008.).

COI is a set of conditions in which professional judgment concerning a primary interest (patient welfare or the validity of research) tends to be or appears to be unduly influenced by a secondary interest (financial or non-financial gain) (¹²12. Pereira P. Conflict of interest and its importance. Perspect Clin Res [Internet]. 2013 [cited 2021 Nov 15];4(1):41. https://doi.org/10.4103/2229-3485.106375
https://doi.org/10.4103/2229-3485.106375... ). COI leads to the commercialization of science with serious secondary effects to public health, like the support for potentially harmful products in order to obtain funding, direct financial benefits, and/or public recognition. According to the TI, if the scientific method is correctly used, all results are equally valid, and their funding source or relationships of the researchers with the industry should not matter (¹³13. Philip Morris International. In support of the primacy of science: White Paper/Fall 2020 [Internet]. Lausanne: PMI; 2020 [cited 2021 Nov 15]. Available from: https://pmidotcom3-prd.s3.amazonaws.com/docs/default-source/uym/pmi-white-paper-primacy-of-science.pdf
https://pmidotcom3-prd.s3.amazonaws.com/... ). However, the TI has historically used funds to stimulate scientific controversy about the health effects of their products by actively disqualifying and silencing researchers or funding their own research, preventing the advance of public health policies (¹¹11. World Health Organization. Guidelines for implementation of Article 5.3 of the WHO Framework Convention on Tobacco Control. Geneva: WHO; 2008., ¹⁴14. Landman A, Glantz SA. Tobacco Industry Efforts to Undermine Policy-Relevant Research. Am J Public Health [Internet]. 2009 Jan 1 [cited 2022 Apr 12];99(1):45. https://doi.org/10.2105/AJPH.2007.130740
https://doi.org/10.2105/AJPH.2007.130740... ). The aim of this study is to explore the association between reporting COI and having a positive outcome toward vaping.

MATERIALS AND METHODS

For this cross-sectional analysis, we used the information collected for the “ENDS Repository.” The ENDS Repository is a study that consisted of a search of all the available scientific evidence from national and international observational studies focused on electronic nicotine delivery systems (ENDS) published from mid-2017 to the beginning of 2020. More details on the ENDS Repository have been published elsewhere (¹⁵15. Gobierno de México, Instituto Nacional de Salud Pública. Evidencia actualizada sobre vapeo: un reporte del Repositorio SEAN. Cuernavaca: INSP; 2021. Available from: https://www.insp.mx/control-tabaco/reportes/evidencia-actualizada-sobre-vapeo-un-reporte-del-repositorio-sean https://www.insp.mx/resources/images/stories/2021/docs/210415_reporte_ends_repository.pdf
https://www.insp.mx/control-tabaco/repor... ). The initial sample of the ENDS Repository was 700 articles; however, 3 articles were excluded because they did not meet the inclusion criteria. A total of 697 articles were included in the analysis, with diverse information on vaping, such as cessation, dual use, flavors, physical harm, marketing, social media, among others.

Outcome

The dependent variable was treated as a dichotomous variable that reflected the overall position of the article as positive or negative toward vaping. Those articles that recommended the use of vapers as cessation tools, as harm reduction devices, or with a general positive tone toward the use of vapers were classified as positive, while those that did not recommended or had a general negative tone were classified as negative. The information for this variable was retrieved from the results and discussion sections of the articles.

Exposures

Two variables were collected as main exposures; the first was the report of any type of COI as a dichotomous variable (yes/no). This variable was constructed using the information reported by the authors in the COI section of each manuscript, and it was collected for the first author, corresponding author, and coauthors. If any of the authors reported COI, the article was considered as having COI, otherwise the article was considered as not having COI. The second exposure was a categorical variable of the type of COI reported, categorized as follows: (a) no conflict reported; (b) conflict with TI reported (including tobacco and vaping industry, and nongovernmental organizations financed by the TI); (c) conflict with the pharmaceutical industry; and (d) other (reported COI due to involvement in court cases or funding from health institutes).

Country of publication information was collected as covariate. It was categorized into four categories according to the highest number of publications, as: United States of America, England, Switzerland, and others that included various countries from all the regions.

Statistical analysis

Frequencies and percentages were calculated for the descriptive analysis. For the association analysis, two logistic regressions were fitted: (¹1. United States Centers for Disease Control and Prevention [Internet]. Atlanta: CDC; 2020 [cited 2021 Nov 15]. Smoking & Tobacco Use. Health Effects. Available from: https://www.cdc.gov/tobacco/basic_information/health_effects/index.htm
https://www.cdc.gov/tobacco/basic_inform... ) to estimate the association between having a positive result toward vaping and having reported COI; and (²2. Pan American Health Organization [Internet]. Washington, DC: PAHO; c2015 [cited 2021 Nov 15]. WHO Framework Convention on Tobacco Control (WHO FCTC). Available from: https://www3.paho.org/hq/index.php?option=com_content&view=article&id=1317:2009-who-framework-convention-on-tobacco-control-who-fctc&Itemid=1185&lang=en
https://www3.paho.org/hq/index.php?optio... ) to estimate the association between a positive result toward vaping and the specific type of COI (with TI, pharmaceutical industry, or other COI). Both analyses were adjusted by country of publication. Statistical significance level was considered <0.05. All analyses were performed using the statistical software Stata v.17 (¹⁶16. StataCorp. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC; 2021.).

RESULTS

A total of 121 manuscripts had positive results for vaping, and 31.4% of those reported COI. From a total of 88 articles that reported COI, 23 reported COI with the TI, 44 with the pharmaceutical industry, and 21 reported another type of conflict. Most of the manuscripts reviewed were published in the United States of America, followed by England (Table 1).

Compared to those articles with no reported COI, those that reported any COI had 4 times (odds ratio [OR] 4.70; 95% CI [2.89, 7.65]) higher odds of having a favorable result for vaping. Manuscripts published in England had 2 times (OR 2.40 95% CI [1.16, 4.98]) higher odds of presenting a favorable result, compared to manuscripts published in other countries (Table 2).

Compared to those articles with no reported COI, those that reported having COI with the TI had 29 times higher odds (OR 29.95; 95% CI [9.84, 90.98]) of having a positive result for vaping, while those with COI with the pharmaceutical industry had 2 times (OR 2.87; 95% CI [1.45, 5.69]) higher odds of having a favorable result. In this model, being published in England had also 2 times (OR 2.48; 95% CI [1.17, 5.27]) higher odds of presenting a favorable result, compared to manuscripts published in other countries (Table 3).

DISCUSSION

COI is not solely financial, it can also be professional, personal, political, or legal, and it can compromise the integrity of the research, undermine the trust in science, and affect the decision-making process (¹⁷17. Resnik DB. Conflicts of Interest in Scientific Research Related to Regulation or Litigation. J Philos Sci Law [Internet]. 2007 Apr 16 [cited 2021 Nov 15];7:1. https://doi.org/10.5840/jpsl2007722
https://doi.org/10.5840/jpsl2007722... ). From a total of 697 articles, 88 reported COI, most of them with pharmaceutical companies (n = 44) and TI (n = 23), and 30.1% of them favored vaping. In general, studies have shown that there is a strong positive correlation between the source of funding and the results of research (¹⁷17. Resnik DB. Conflicts of Interest in Scientific Research Related to Regulation or Litigation. J Philos Sci Law [Internet]. 2007 Apr 16 [cited 2021 Nov 15];7:1. https://doi.org/10.5840/jpsl2007722
https://doi.org/10.5840/jpsl2007722... ). Our results showed 4 times higher probability of having positive results toward vaping if the articles reported any COI. This is not surprising, as industry-sponsored studies tend to be biased in favor of the sponsor’s products (¹⁰10. World Health Organization [Internet]. Geneva: WHO; 2017 [cited 2021 Nov 15]. WHO Framework Convention on Tobacco Control Secretariat’s statement on the launch of the Foundation for a Smoke-Free World. Available from: https://untobaccocontrol.org/kh/article-53/framework-convention-tobacco-control-secretariats-statement-launch-foundation-smoke-free-world/
https://untobaccocontrol.org/kh/article-... ). The bias generated by the COI may affect the research from the design to the reporting of results, sometimes even bending or breaking the rules of science to suit their purposes (¹⁷17. Resnik DB. Conflicts of Interest in Scientific Research Related to Regulation or Litigation. J Philos Sci Law [Internet]. 2007 Apr 16 [cited 2021 Nov 15];7:1. https://doi.org/10.5840/jpsl2007722
https://doi.org/10.5840/jpsl2007722... ).

The TI has a long history of misleading the public about the risks associated with its products (¹⁸18. World Health Organization [Internet]. Geneva: WHO; 2017 [cited 2021 Nov 15]. WHO Statement on Philip Morris funded Foundation for a Smoke-Free World 2017 Available from: https://www.who.int/news/item/28-09-2017-who-statement-on-philip-morris-funded-foundation-for-a-smoke-free-world
https://www.who.int/news/item/28-09-2017... ). Nowadays, the TI has a large body of evidence that supports its claims regarding the alleged lower harm of vaping and other new tobacco products (¹⁹19. Dewhirst T. Co-optation of harm reduction by Big Tobacco. Tob Control [Internet]. 2020 [cited 2021 Nov 15]. http://dx.doi.org/10.1136/tobaccocontrol-2020-056059
http://dx.doi.org/10.1136/tobaccocontrol... ). However, much of this evidence has been funded by the TI, either directly or indirectly through the Foundation for a Smoke-Free World, which despite the claims of independence by its founders, constitutes a clear COI as stated by the World Health Organization (¹⁰10. World Health Organization [Internet]. Geneva: WHO; 2017 [cited 2021 Nov 15]. WHO Framework Convention on Tobacco Control Secretariat’s statement on the launch of the Foundation for a Smoke-Free World. Available from: https://untobaccocontrol.org/kh/article-53/framework-convention-tobacco-control-secretariats-statement-launch-foundation-smoke-free-world/
https://untobaccocontrol.org/kh/article-... ). Our results showed that articles that reported COI with the TI had 29 times higher probability of having positive results toward vaping. The latter has enormous implications for public health, as the TI is used to interfering with tobacco control by political lobbying, campaign contributions, or the financing of research (²⁰20. World Health Organization. Tobacco industry interference with tobacco control [Internet]. Geneva: WHO; 2008 [cited 2021 Nov 15]. Available from: https://www.who.int/publications/i/item/9789241597340
https://www.who.int/publications/i/item/... ), causing laws and regulations to be delayed, withdrawn, or not even voted on.

Nowadays, England has one of the most comprehensive smoking regulations, including—but not limited to—smoke-free places, plain packaging, health warnings, and cessation aid programs (²¹21. Campaign for Tobacco-Free Kids [Internet] Washington, DC: The Campaign; 2021 [cited 2022 Apr 12]. Tobacco Control Laws. Legislation by Country. England. Available from: https://www.tobaccocontrollaws.org/legislation/country/england/summary
https://www.tobaccocontrollaws.org/legis... ). Around 2007, the Royal College of Physicians issued a report that advocated for alternative sources of medicinal nicotine available to smokers (²²22. Britton J, Bogdanovica I. Electronic cigarettes A report commissioned by Public Health England [Internet]. London: Public Health England; 2014 [cited 2022 Apr 12]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/311887/Ecigarettes_report.pdf
https://assets.publishing.service.gov.uk... ). Since then, e-cigarettes have become part of their smoking reduction strategy, and Public Health England has recommended these as a cessation tool (²³23. McNeill A, Brose LS, Calder R, Hitchman SC, Hajek P, McRobbie H. E-cigarettes: an evidence update. A report commissioned by Public Health England [Internet]. London: Public Health England; 2015 [cited 2022 Apr 12]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/733022/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf
https://assets.publishing.service.gov.uk... ). Public Health England has reported that e-cigarettes are currently the most popular cessation aid, even surpassing nicotine replacement therapy (27.2% vs 18.7%) (²⁴24. United Kingdom, Public Health England [Internet]. London: Public Health England; 2021 Feb 23 [cited 2022 Apr 12]. Vaping better than nicotine replacement therapy for stopping smoking, evidence suggests. Available from: https://www.gov.uk/government/news/vaping-better-than-nicotine-replacement-therapy-for-stopping-smoking-evidence-suggests
https://www.gov.uk/government/news/vapin... ). This could be an explanation why those manuscripts published in England had increased odds of being favorable toward vaping, as this supports the current policy. Nevertheless, it is important to notice that the risk reduction and e-cigarette cessation programs are part of a larger effort, based on the MPOWER measures.

This study has limitations that must be mentioned. First, only self-reported COI was evaluated, meaning that those manuscripts which failed to declare COI despite the existence of one were misclassified. However, this would only lead to an underestimation of our estimates. Second, the analytical time frame covers only mid-2017 to the start of 2020, leaving out most of the evidence regarding the use of ENDS and COVID-19—a period in which the TI funded a large amount of research. Third, due to the limited variability of the sample, we had low statistical power, which contributed to wide confidence intervals in our estimates. Finally, this was a cross-sectional study, therefore causality cannot be established. Nevertheless, to our knowledge this is the first study to explore the association between reporting COI and presenting positive results for the use of e-cigarettes. It contributes to the development of a line of research and the start of a conversation on the importance of COI and its possible effect on results.

In all settings, COI can have serious consequences; however, when it comes to research and public health it can affect millions of lives. There are still many unknowns about vaping and its potential harms; however, the research needed to fill the gaps should not be funded or linked to the TI. As stipulated in the guidelines of Article 5.3 of WHO-FCTC, there is an irreconcilable conflict between the TI and public health interests, and those working with the TI should be accountable and transparent. Regarding tobacco and its new products, there is a need to be aware and analyze who is presenting the information and what possible interests they may have; keeping in mind that the industry is not going to be neutral when it comes to their own products. Research must adhere to ethical principles from funding to publication, especially if it is involved in public health regulations. When presenting or using evidence, researchers, stakeholders, legislators, and any other person involved in the decision-making process, must ensure that the evidence presented is independent and free from COI. Further research on the implications of COI and strict regulations should be considered in scientific research.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública/Pan American Journal of Public Health and/or those of the Pan American Health Organization.

REFERENCES

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History