Tag Archives: policy recommendations

The anti-THR preschool funding con (or, Wonkblog does not understand tobacco economics)

by Carl V Phillips

The Washington Post’s Wonkblog (often known as the blog of its first author, Ezra Klein) ran a series of posts yesterday about the proposed tax increase on cigarettes in Obama’s new budget, which would fund preschool education.  For people who are supposed to be carefully reasoning economists and Washington insiders, they sure missed some elephants in the room.

Sarah Kliff started it off with a too-trusting piece, in which she cites various claims about the enormous effect that the proposed 50 cent per pack national tax increase would have on smoking prevalence.  My personal favorite bit is when she cites a study from Tobacco Control that claimed to prove that heavy smokers are especially affected by prices.  Except the data did not support this claim.  That is standard practice for that “journal”, of course, and Kliff can be forgiven for not knowing that.  But someone writing for a blog that claims to be wonkish ought to at least be able to read the graph she reprinted, the one that divided smokers by intensity and showed that each group was reducing smoking, regardless of the price changes, and all by almost exactly the same rate, regardless of price change.  (The exception being the lightest smokers, who apparently smoked more when the price went up, but, hey, little problems with the theory like that are what cherrypicking is for.)

But naivety about the economics is not the real story.  Later that morning, Klien praised his favorite parts of the budget, leading with this one.  It is hard not to agree with his support for more funding for preschool education, but he also expressed support for the mechanism.  This was despite him quoting health policy commentator, Harold Pollack (Chicago prof, old friend of mine, and one of the most anti-smoking people you could ever quote who is actually smart and honest) lamenting that the tax punishes smokers rather than helping them.  Worse, Klein even cited fellow Wonkblogger, Brad Plummer, who posted a few minutes earlier a calculation showing the tax will not be enough if it causes smoking rates, and thus revenue, to drop.  Thus, it is a very bad way to fund a project.

Completely ignored in this is the reduction in smoking that is going to happen because of THR.  People who are not aware of e-cigarettes and the exploding popularity of these and other THR products are likely to get it badly wrong when they write about tobacco policy.  (In fairness, these are reporters, and part of the reason that they get it wrong is that the people they talk to who are making tobacco policy are clueless.)  The projections about the effects of taxes are based on data from before the coming THR explosion.  It is quite possible that they actually understate the effect of the price increase because more smokers will be aware of the good substitutes than before.  But whatever the interaction effect, the predictions are utter garbage because the tobacco/nicotine world of the next 10 years will not be anything that has ever been seen before.  THR is going to cause American smoking rates to drop substantially for the first time in almost a generation, regardless of prices.

Buried in all of this is the truly unforgivable failure to recognize the apparent hidden agenda.  The special interest groups that got this tax into Obama’s budget know very well, though they probably did not tell Obama’s people, that despite their best efforts THR is very likely to make a large dent in smoking rates.  As Plummer and Pollack suggested, a focused tax like this is a pretty good way to fund something that is tied to the quantity of sales (like anti-smoking efforts; even if you hate them, you can see the sense in funding them based on cigarette tax revenue, just like road repair being paid for with gasoline taxes), but it is a terrible way to fund something unrelated, like preschool.  When sales drop funding for some things should also drop, but obviously not for something completely unrelated.

Therein lies the apparent game.  If the anti-THR liar crowd can get the government to fund a popular program with dwindling cigarette taxes, then the next Congress and President will be left scrambling for funding.  They are naturally going to look to the increasingly popular e-cigarettes, smokeless tobacco, and other THR products.  Never mind that there is absolutely no justification for imposing a “sin tax” on these low-risk products, just like we would never impose such a taxes on similarly low-risk consumer goods like meat, bicycles, and leisure travel.  These “other tobacco products” will be in the same mental neighborhood as politicians get frustrated about cigarettes’ drop in popularity, the money will be needed, and so… “well geez, we had to start taxing them.”  The narrow special interests will prevail over consumer interests.  The ANTZ will get their anti-THR tax, and if they are really lucky they will succeed in keeping enough people smoking that they can stay in business.

Yes, I know.  Most anti-THR people seem to be about as clever as a bag of rocks.  But there are people hiding behind them who are running the multi-billion dollar tobacco control industry, and they are probably quite capable of figuring out this long con.  The only good news is that the Obama budget is generally perceived to be dead-on-arrival, so maybe this will just go away.  I hope so, because I have no optimism that anyone will try to block this provision because they recognize that its real goal is to pave the way for a high tax on nonsmokers.

Why most health policy recommendations are lies

by Carl V Phillips

I taught a class today to a group of public health students, with the theme that policy recommendations made based on an empirical study of a risk factor (e.g., an epidemiology study about the health effects of a behavior, or a study of the chemicals found in e-cigarette vapor) are never justified.  Or, in the terms of this blog, are lies (not in the sense that they do not reflect the authors recommendation, obviously, but the claim that the recommendation follows from the study is a lie).  There are five distinct reasons why making such recommendations are inappropriate.  That list is, I think, rather informative for disciplined thinking about promoting THR, so I thought I would share a summary of the basic points from the class with my rather larger audience here.

I started out by asking them if they had ever read a paper where the authors do a single study about a possible risk factor and then make broad policy pronouncements at the end.  I interrupted before they answered to assure them that I was joking – they are in public health, so of course they have read papers like that.

As motivating examples for the discussion, I had them read the post from a few days ago, about proposals to either ban cigarettes or drastically reduce the nicotine content, and read enough to know about plans to develop nicotine “vaccines” that would prevent someone from experiencing the effects of nicotine.  I also threw in Bloomberg’s soda ban (I love it when the lead headline in the New York Times is on-topic for the day’s class!).

The reasons why it is a lie to tack on policy recommendations to a risk-factor study:

0. The results of the study might not be right.

I did indeed start the counting at zero because this one is a bit different.  It is not about the wisdom of the policy, but about the study result itself.  A single study does not give us a definitive assessment that an exposure causes a particular outcome.  If it is the only such study that exists (which is rare — happens only once per exposure+disease, obviously) there is still whatever other knowledge we might have.  In theory a good paper could review the other evidence and draw conclusions about the totality of the evidence, but that is exceedingly rare (it usually requires a dedicated review paper to try to do that).  Thus, the implication of the particular study in isolation cannot even tell us too much about the risk, let alone how to respond.

Note that this applies to studies that suggest there is no risk.  Indeed, even more so.  The same possible errors that might cause a single study to exaggerate a risk could also cause it to miss a risk that really exists.  In addition, there are plenty of ways to do a study that will miss a phenomenon even if it exists.  Thus, pointing to a single study and claiming it is evidence that we do not need to act is an even greater mistake.  (Thus the reason that I and CASAA make it a point to avoid doing that.)

1. The proposed policy might not accomplish the goal.

It might be that an exposure is really causing a disease, but that a specific proposed intervention might not actually reduce the disease even though a naive knee-jerk impression say it might.  It might even be that no conceivable intervention could accomplish the goal, so even a general “something should be done to…” recommendation cannot be justified.

For example, Bloomberg has been furiously attacking the overturning of his soda ban by repeating observations about obesity being a problem.  But would banning 20 ounce Cokes do anything significant to reduce obesity?  The best guess is “no”, but more important, there is no reason to believe the answer is “yes”.  Governments like to engage in the “logic” of saying “there is a problem and something must be done; this is something; therefore this must be done.”

2. The intervention might create other harm (in the same realm where it is intended to do good — i.e., it might cause other health problems).

Bloomberg also moved to make food less flavorful (by reducing salt); this tends to make people want to eat more and thus become obese.  The proposal to reduce the nicotine in cigarettes would make them less appealing, no doubt, but it would also cause many people to smoke more of them.  The question of whether an intervention might cause other health problems is not answered by the study of a particular exposure+disease combination.

3. There will be costs to implement the policy; is it worth it?

The question of policy making becomes far more complicated still when we realize that most policy actions entail costs, often quite substantial.  No risk-factor study could possibly address this.  Assessing the costs and benefits of a policy generally requires more analysis than an entire risk factor study.

Why not just ban smoking?  If it worked, it would eliminate the health costs.  One reason is that the costs (causing people to lose the benefits of smoking and enforcement costs) would be enormous.  On a less dramatic level, even if Bloomberg’s plan would reduce obesity some, would that be enough to justify the various rather high costs?  It does not appear that anyone bothered to ask that question.

4. Is it ethical to do (even if it would work)?

This is, of course, the question that generates the most animated conversations.  I will not rehash the basic libertarian arguments here.  Nor will I attempt to delve into more subtle points.

But I will mention an observation I made to the students:  Some portion of the population would probably support giving their kid a vaccination that would prevent the child and the adult he will someday be from experiencing any benefits from nicotine.  Some portion of the population would argue that it should be mandatory (or close to), like the pertussis vaccine.  But probably roughly the same portion of the population would favor a hypothetical vaccine that would ensure that the kid is not gay or a similar magic bullet that would prevent him from ever embracing the teachings of the Koran.

The implication of that is that “public health” — the activist movement, as opposed to actual public health — is a special interest group filled with people who do not seem to realize that the interventions it demands are widely considered just as deplorable as anti-gay or anti-Islam interventions.  I took the opportunity to point out that any student who was planning to go into “public health” (as opposed to working in some more acceptable way to improve people’s health) should realize that they are on the wrong side of history.  While policy advocates in that area were once, legitimately, considered heroes, the generally celebratory reaction to Bloomberg’s plan being struck down by the court should give them pause.

[There are some concrete implications of this list for THR advocacy.  I will come back to that in a later post.]

Sometimes the anti-THR lie is just not mentioning THR

by Carl V Phillips

A recent highly touted op-ed in the NYT claimed to offer two ways to eliminate smoking in our society.  It was written by Richard A. Daynard, a law professor at Boston’s Northeastern University who is head of a “public health advocacy” institute.  If that bio leaves you expecting the content to be out of touch with science, ethics, human behavior, politics, and pretty much everything else someone needs to know to recommend policy, you will not be disappointed.

Daynard starts weak, by attributing a substantial amount of smoking reduction

to Dr. Koop’s antismoking crusade as surgeon general, from 1981 to 1989

In reality, of course, smoking steadily declined for over three decades, starting in the mid-1960s, due almost entirely to people’s decision to not smoke once they were educated about the risk (and such education was basically all anti-smoking consisted of during the most dramatic decline).  To the extent that any effort other than that basic education, which was universal by 1981, (and to a much smaller extent, price increases) had an impact beyond the trend caused by the education, it is really too small to estimate.  That does not stop Daynard from attributing the decline to every anti-smoking measure except the basic education and rational decisions by would-be smokers.

But this standard “public health” boilerplate was only window dressing.  He was clearly using Koop’s recent death as an excuse for publishing some pent-up madness he had sitting on his desk.  His real message was:

What we need is an all-out push to reduce smoking rates to well below 10 percent.

Notice the key noun in there: push.  This is not one of those pansy-ass academic lawyers like you might find across town among the Constitutional scholars at Harvard, who believes that Americans are a free people and who wants to help protect them from tyranny and abusive government.  Oh, no.  He believes that proper behavior of the rabble can only be achieved by government force.

One of his bright ideas is basically to just ban smoking (why did no one think of that before?):

no one born in or after 2000 can ever be sold cigarettes. Under such legislation…the vast majority of this cohort — the oldest are now 13 — would never begin smoking.

Of course.  Since everyone who starts smoking does so legally, dutifully waiting until they are 18 to light up, that should do it.  And since he tells us how this idea is supported by one guy in Singapore and political chatter in Tasmania, it must be a widely accepted good idea.

He does not actually argue that this would be wise.  He cannot.  Rather, his main basis for suggesting this is a claim that the FDA now has the authority to impose such a regulation.  Perhaps he does not realize that most governments have always had the authority to just ban smoking if they wanted to, for any age cohort.  I will not insult my readers by pointing out why not even Australia or Singapore has tried to exercise this authority.

At least the ban is just fantasy.  His other plan is potentially quite deadly:

The F.D.A. would be well within its authority to require nicotine content [of cigarettes] to be below addictive levels

This is nothing new, of course.  As Rodu recently noted, that idea traces to people who include the new head of FDA’s Center for Tobacco Products, and it was always a terrible idea.  Most people smoke primarily to get nicotine.  Reduce the nicotine and they will smoke more.

FDA arguably has the authority to do all kinds of things to lower the quality of cigarettes.  Most of them would cause people to smoke less (so long as you are not worried about pesky details like people’s freedom to choose and inalienable right to pursue happiness — since Daynard seems to like Singapore’s and Australia’s way of doing things, I assume he is fine with that).  But he managed to pick the one way to lower quality that will probably cause more smoking.

Of course he probably does not know enough to understand that.  Missing from this entire missive (not surprisingly, given it is written by someone with “public health institute” in his title), is scientific analysis and evidence.  He does use the word “evidence” twice, but it is not clear he knows what it means.  Regarding what would happen if some locality started imposing draconian restrictions on cigarettes unilaterally:

evidence suggests that border-crossing and smuggling would be minimal

And if you believe that….  Well, if you believe that, you are probably a victim of ANTZ lies and apparently not able to actually understand the evidence.  His other misuse of that word is rather more interesting:

if the F.D.A. insisted on the [reduction in nicotine], and cigarettes ceased to be addictive, ample evidence shows that most smokers would quit or switch to less toxic nicotine products.

Wrong again.  It is undoubtedly true that this change would drive some to quit and many to switch.  But this is based on general knowledge about people, and not what would normally be called “ample evidence”.  There is obviously an absence of what is normally called evidence when we are talking about what would happen following an extreme change that has never been tried before.

What is interesting, though is the acknowledgment of alternative products.  The alternative products that would fill the gap — if someone actually tried to implement this rule, and it actually succeeded rather than leading to a popular revolution — would probably be e-cigarettes and smokeless tobacco (assuming FDA did not try to ruin them first).  Some people who advocate THR favor efforts to push smokers into switching, while others believe they should be informed and encouraged, but left free to choose.

But Daynard says absolutely nothing more about the alternative products.  It seems rather unlikely that he actually understands THR, despite his claim of expertise about smoking cessation.  If he did, he would realize that the only evidence-based — and, indeed, proven — method for lowering smoking prevalence to that 10%, and the only conceivable way to do it without ruining a lot of people’s lives, is adoption of THR.  Instead, he proposes approaches that are based on wild speculation and that would seriously hurt a lot of people.  Despite his recognition of alternatives to smoking, his failure to even mention THR, along with the presentation of his radical alternatives to THR as if they were promising and practical, mean that his message is ultimately an anti-THR lie.

Kelvin Choi is a liar

by Carl V Phillips

A new ANTZ on the scene seems to be aspiring to be the new Ellen Hahn.  I supposed it is possible, given that he is at University of Minnesota that he aspires to the be the new Stephen Hecht, but that might be a stretch since Hecht seems to do somewhat useful bench science, and then just lies about the health and political implications.  Choi, by contrast, seems to be fully ensconced in the “public health” junk science paradigm.  Consider this recent abstract:

Objectives. We assessed the characteristics associated with the awareness, perceptions, and use of electronic nicotine delivery systems (e-cigarettes) among young adults. Methods. We collected data in 2010-2011 from a cohort of 2624 US Midwestern adults aged 20 to 28 years. We assessed awareness and use of e-cigarettes, perceptions of them as a smoking cessation aid, and beliefs about their harmfulness and addictiveness relative to cigarettes and estimated their associations with demographic characteristics, smoking status, and peer smoking. Results. Overall, 69.9% of respondents were aware of e-cigarettes, 7.0% had ever used e-cigarettes, and 1.2% had used e-cigarettes in the past 30 days. Men, current and former smokers, and participants who had at least 1 close friend who smoked were more likely to be aware of and to have used e-cigarettes. Among those who were aware of e-cigarettes, 44.5% agreed e-cigarettes can help people quit smoking, 52.8% agreed e-cigarettes are less harmful than cigarettes, and 26.3% agreed e-cigarettes are less addictive than cigarettes. Conclusions. Health communication interventions to provide correct information about e-cigarettes and regulation of e-cigarette marketing may be effective in reducing young adults’ experimentation with e-cigarettes. (Am J Public Health. Published online ahead of print January 17, 2013: e1-e6. doi:10.2105/AJPH.2012.300947).

Let’s set aside obvious problems, like the limited value for anything other than historical tracking of an awareness survey about e-cigarettes from 2010, or describing 20-something-year-olds as “experimenting”, as if they are children.  (Many of those crazy kids are also experimenting with buying houses, military service, and parenthood.)  Consider the core conclusion.  How can a simple cross-sectional survey of awareness and belief tell us anything about the effects of communication and regulatory interventions?  If you said, “I have no idea”, you nailed it.  It is a complete lie that the conclusion follows from the research.

And, of course, there is the little matter of which bits of information he wants to correct.  Does he want to help the 55.5% who do not realize that e-cigarettes help smokers quit?  Or is it the 47.2% who do not realize they are lower risk than smoking?  As you might guess, it is the ones who actually know the truth that he wants to “correct”.

(Note:  I trust my regular readers will recognize as subtle ridicule my use of three significant figures in reporting those numbers.  As anyone who understands sampling — and anyone familiar with my writing — knows that reporting that level of unwarranted precision is a bit of junk science in itself.)

There is some potential usefulness in the actual survey in terms of helping us learn about the rate of at which accurate knowledge of e-cigarettes and THR has spread.  However, what has no apparent usefulness are Choi’s thoughts and opinions, as evidenced by this interview.

I will skip past his first answer, a remarkably amateurish description of what e-cigarettes are, something that could be corrected by basically anyone who is familiar with the topic.  (But go ahead and read the whole interview if you are inclined to find unintentional comedy in ANTZ rantings — it is a good one for that.)  I skip that because it gets far worse:

There are a variety of reasons why e-cigarettes are unhealthy. First, they contain nicotine, which is a known addictive chemical. A recent study conducted by Vansickel and Eissenberg found that experienced e-cigarette users can obtain a significant amount of nicotine through e-cigarettes, which may be comparable to smoking cigarettes.

E-cigarettes deliver nicotine?  Who knew?  Glad we had that study (by the guy who originally claimed just the opposite and never admitted his error — but that is another story).  And the reason that they are unhealthy is that this chemical is addictive (whatever the heck that means), not because it is harmful.  Choi might want to ask for a tuition refund from whoever claims to have taught him about health.

Second, previous chemical analyses of the e-cigarette nicotine liquid found that some samples contain tobacco-specific cancer-causing agents and anti-freeze.

Yawn.  Yes, this PhD “researcher” cannot do any better than some random county public health nurse, citing the propaganda (rather than the actual scientific results) from the FDA.  Another tuition refund, please.  Oh, but wait.  Maybe that nurse could do better.  She probably would not claim that e-cigarettes actually “contain…anti-freeze” [sic], but merely “an ingredient found in antifreeze”.  The latter form of this is an example of lying with literal truths, of course, as previously discussed in this blog (did you know that breast milk contains an ingredient found in antifreeze?!! we should stop nursing babies immediately!).  Apparently Hahn Junior does not even realize that he is reciting propaganda meant to confuse people — he is among the genuinely confused.

Third, with the product being promoted as a cigarette alternative at places where smoking is not allowed, smokers may use these products to sustain their nicotine addiction, and may therefore be less likely to quit smoking

And another “problem” that is not an actual health risk from e-cigarettes.  That “where smoking is not allowed” pseudo-argument deserves a post or two of its own, which I will do that soon.  So today I will politely refrain from pointing out how utterly moronic it is.

And that is all he offers.  Not even a single claim of health risk.  Apparently he wants to keep people from “experimenting” with e-cigarettes because they… …um… cause no health risk at all.

Oh, but it gets dumber.  So much dumber.

I think the perception of e-cigarettes as cessation aids is of the greatest concern. First, this perception may drive young adults to use e-cigarettes when trying to quit smoking instead of proven-effective cessation treatments. To date, no studies have shown that e-cigarettes are more effective than proven-effective cessation treatments such as nicotine replacement therapy and counseling. Therefore, e-cigarettes may hinder young adult smokers from quitting smoking.

E-cigarettes are (correctly) perceived as being useful for quitting smoking?  Well, that is a dire concern indeed.  As for the claim they are not shown to be more effective than other methods that are “proven” to help a mid-single-digit percentage of smokers quit (to charitably take a best-case figure from the biased research on the topic), so what?  Even setting aside the fact that he is baldly lying about that — the evidence strongly supports the claim that e-cigarettes are more effective — how exactly do they prevent someone who wants to quit smoking from trying those other methods if the e-cigarettes do not work?

Anyone with a basic understanding about smokers and quitting — even at the casual layperson level of knowing actual humans who smoke or smoked — understands that most people who are interested in quitting try multiple methods.  How exactly can one method, even if he genuinely believes it is of no value at all, interfere with the others?  Does he really think that smokers are so dumb as to say “well, I wanted to quit and tried an e-cigarette, but it did not work for me, so I will just keep smoking because I have never heard of any other method I might try.”  Gee, if only there were some way to inform smokers that the powers-that-be think they should try NRT and counseling.  Someone should really get on that.

And if Choi really believes that introducing a new method of quitting will actually prevent the use of other options, does he rail against the introduction of new NRT products or counseling methods because they will keep people from trying the existing methods he thinks are actually “proven”?  I didn’t think so.

In short, either he has not even given enough thought to this topic to be considered even a generally aware layperson, and so is grossly lying about his expertise, or he is just making up lies because he wants a ride on the ANTZ gravy train.

Is there more?  Oh, yes, there is more.  It will have to wait until the next post.