Monthly Archives: March 2013

Aside

From the blog of author (and one of the most insightful people in the world), David Brin: CITOKATE: Criticism Is The Only Known Antidote to Error. Too bad it tastes so awful, to be on the receiving end…  so that most of … Continue reading

Aside

by Carl V Phillips For those who do not follow me on Twitter, you might like to see my definition and defense of harm reduction in a mere 72 words, using an editor that restricts you to the 1000 most … Continue reading

ANTZ who pursue anti-THR political action are showing that they know they are liars

by Carl V Phillips

For the 100th post on this blog (!) I thought I would tie together the two major areas CASAA works in.  We are engaged in scientific research and education, including pushing back against anti-THR lies.  But of course, CASAA had its origins in, and still devotes the majority of its efforts to, political action to protect the right of consumers to pursue and benefit from THR, fighting against laws and regulations that encourage people to just keep smoking rather than switching.

The popular — indeed, almost mandatory — cynicism is to claim that never the twain shall meet.  That is, that political decisions are not informed by science, and that the political process neither educates nor advances science.  That is obviously true to some extent; the science (the truth) never determines policies for any politicized issue.  When you hear someone saying they want “science based policy”, hold on to your wallet.  On the other hand, science-based popular education can have an enormous impact on politics.  The reason that CASAA wins almost every battle against anti-THR that we take on (and we take on pretty nearly every anti-THR government action that come up in the USA) is because there are so many CASAA members and other citizens who support THR who step up and fight the fight at the grassroots level.

We have also noticed a trend via which the politics can inform the knowledge of the science, if you look at it right.  The anti-THR liars have increasingly resorted to trying to sneak anti-THR measures through in ways that prevent public debate.  They try to get anti-THR measures enacted by hiding them in complicated legalistic language that makes it difficult to even see what they are doing, they whisper to unelected boards who can implement their measures without public debate, and at least once they have managed to use a ballot initiative to enact hidden anti-THR measures that the voters would have no possible way of understanding.

In other words, they are behaving just like any other profit-driven industry that knows it is not acting in the public interest, and so needs to exercise its special-interest power behind the scenes, out of the view of the public.  In so doing, they are providing us with evidence (which is to say, scientific evidence) that they recognize they are not on the side of the public.

But this also tells us a lot about what they think about the quality of their arguments or, to put it more pointedly, the fact that they recognize that they are lying so blatantly about the science that their lies cannot stand up to even a little sunlight.  I think this is a pretty remarkable testament to how powerful science, when combined with successful popular education, is in the political process.

The ANTZ have managed for years to make policies based on ridiculous claims about the harms from environmental tobacco smoke.  There is ample science that shows their claims are exaggerated, often by orders of magnitude, but the good science came after the inaccurate conventional wisdom was locked in, and there has been limited public awareness of it.  Thus, the ANTZ are still able to win political fights based on that claim.

But when they actually try to make unsupportable claims about e-cigarettes in the political arena and there is any chance for public involvement, the lawmakers hear the truth.  And hear it, and hear it, and hear it (sometimes during a political process, we get a note from one of them indicated that he has been won over, so would we please ask our members to stop deluging him with more truth).  Attacks on smokeless tobacco fall somewhere in between — the anti-THR propaganda still tricks a lot of people (including many e-cigarettes supporters, sadly), but there is a lot of push-back.

Just since last year, we have witnessed a substantial reduction in lies-based anti-THR activism.  Several of the anti-harm-reduction activists who CASAA has publicly called-out (on this blog and elsewhere) have largely gone silent.  Undoubtedly this is more a shift in tactics than anything else, since their motives were never really based on their scientific claims.  But trying to keep anti-THR regulations hidden from the public is a pretty clear concession that they do not have a valid case and that, this time, they cannot fool everyone.  They are effectively admitting that their claims are lies and they cannot win an open fight.

Unfortunately, that does not mean they cannot win.  Those who are playing power politics with THR behind the scenes (and unfortunately it is not just the ANTZ) have a lot of power and politics to play with.  And, unfortunately, when we look at the political battles, this means we face more, not fewer, challenges.  But when we put on our science and education hats we can take it as a great victory.  The anti-THR activists have a lot of arrows in their quivers, but at least in the context of US politics, we are making serious progress in taking one — public lying — away from them.

The CT Marathon, and seeking how to argue “do not believe anyone who says…”

by Carl V Phillips

Last Friday, CASAA Board members Gregory Conley and Karen Carey, joined by about 20 other vapers (including many long-time CASAA members), testified at a Connecticut (CT) legislature hearing about a bill that would ban vaping wherever smoking is banned, including in e-cigarette stores.  The organization of the day’s testimony (on two dozen different bills) was such a mess that they did not get to testify until after midnight (though, we complement the committee for taking time to hear out every witness who stuck around that long, unlike some panels we have had to deal with).  I comfortably watched this from a distance, going to bed, four timezones to the east, before they even started testifying, and woke up in time to chat with Greg as he made his way back to the station to catch the earliest train home on Saturday morning, having long since missed the last train of the night.

Feeling a little guilty for not being there, I figured I had to devote a blog post to the lies they had to deal with.

But what to say?  I tend to focus on the more complicated and technical lies from ostensibly respectable ostensible experts.  It is a pretty boring post when the message is just, “the Connecticut Academy of Family Physicians claimed in their testimony that e-cigarettes are as harmful as smoking [which they did], and this is a lie.”  Much more interesting — and potentially beneficial — is to try to figure out how to communicate the broader message, “these guys made this obvious false claim, which we can easily show to be wrong; if you have any sense, you will ignore the rest of what they said too.”

Sometimes this is not so critical.  The Family Physicians only made two or three other points about e-cigarettes in their testimony (warning: the links to testimony open pdf or video files — and are really painful to view) that could all be addressed directly if a direct response was ever needed.

But what about, say, the testimony from John O’Rourke, Program Coordinator for CommuniCare’s tobacco cessation program (which appears to be a company that sells smoking cessation services, getting most or all of its money from the government whose policies it is trying to influence (surprise!)).  They make scores of claims about e-cigarettes, one after another.  A very few were accurate.  Many were technically correct but presented in ways that are intended to mislead.  Some were speculative — possibly true, possibly not — but were presented as if they are established facts.  A few were easily-refuted falsehoods.

Trying to produce an itemized response to such piles of crap would be hopeless; it is easy for someone to throw out lies, expending just a few seconds per lie, but it takes quite a while to refute even the most obviously false.  Moreover, there are so many tobacco control industry people like this out there that they can collectively fling their lies at 10,000 times the rate that we can respond.  A war of attrition is a sure loser.

What to do?  One tempting response is to just fling back (hopefully just truths, for they are also able to challenge any lies or errors), but that still leaves us buried by the weight of numbers.  The best hope is to convince sensible readers/listeners that if someone’s claims include statements that are obviously false, it is wise to assume that some or perhaps most of the rest of what they say is also lies, and it would be best to just ignore them.

For example, that tobacco control company’s claims included blaming “marketing” for the increasing popularity of e-cigarettes and “To the spectator, there is no difference in appearance of someone smoking a cigarette and someone using an electronic cigarette.”  These are obviously blatantly false and it is easy to convince someone of that (so obvious and easy that I will not spend the words here).  Renee Coleman-Mitchell of the CT Health Dept claimed that e-cigarettes should be banned until current CDC research on them is complete (as far as anyone knows, CDC is doing no such research; the logic is dumb anyway, but the easy response is about the clear factual lie).  Pamela A. Mautte, on behalf of another government-funded company, claimed as part of their effluent that e-cigarettes taste just like smoking (which they went on to contradict) and that nicotine users cannot monitor their own usage.

Some anti-THR liars are clever enough to avoid easily refuted lies, but most are not.  They are either so clueless as to not know what lies are easy to refute or have an arrogant (though not entirely inaccurate) belief that they can get away with anything.  So they make some claims that can be shown to be false in just a few sentences.  The key, then, is explaining to people that they should not believe the rest of it either.  You might think that would be easy.  It seems like it should be obvious.  But scientific exchange and most other human interaction is built on trust, and our natural tendency is to trust.

I know that when I am casually reading something for information on a topic, and have enough expertise to spot some clear errors but not enough to be sure about the rest of it, I just stop reading.  I realize that some or all of the rest of what I might be “learning” is probably also wrong, and I do not want to risk accidentally adding false “knowledge” to my worldview.  Notice that my approach is not to just decide to be skeptical as I keep reading.  That does not work because I have the same programming that most of us do — to believe what we hear/read until educated otherwise.

So the question is how to convince people to withdrawal that trust entirely.  It ought to be possible.  How can it not be possible to convince many (not all) people to not believe obvious liars?  But as you might guess from my lack of a concrete suggestion, I am not sure how to do it.  I tend to resort to the obvious simple plea, which is not sufficiently successful:  point out that someone has made numerous errors in their claims and I do not have time to respond to them all, but I can point out and refute a few examples.  I usually do not assume that the reader will get the next step, and so make it explicit: do not believe the rest of their claims either, because a lot are equally wrong and the author clearly does not know what he is talking about.

How can we do that better?  I will keep thinking about it, though I do not expect any great insight in the next few weeks that I overlook for many years.  Any suggestions?

Basic case for THR, A-; analysis/facts/science, D

by Carl V Phillips

I will have time to write some new analysis in a couple of days.  In the meantime, to keep things from getting too quiet, I will just copy and paste some observations I made in a Facebook conversation (at the Tobacco Harm Reduction page, a still somewhat active artifact from my old University of Alberta research group).

I really hate to have to rubbish (I am in England right now, so I have to talk like that) pro-THR missives, but it is important that our side try to do accurate work.  The anti-THR liars have wealth and power, while our main strengths are the truth and a mobilized population of product consumers and other supporters that know the truth.  We do not help ourselves by embracing bad analysis.  If we are sloppy, or just try to do what they do — created a politicized set of claims that is demonstrably wrong — then they have all the advantages.

The missive if in question, unfortunately, kind of reminded me of a thought I often have when I read instructions that accompany some Asian-manufactured product that are in completely garbled English:  “This company designed and produced a good product, and have an impressive production process, but then made their whole enterprise seem shoddy by not taking the time to get the instructions right.  There are like a billion people in the world who are fluent in English.  Could they not hire one of them to spend ten minutes rewriting this so that it was not such a mess?”

For the case in point, there are obviously not a billion, or even a thousand, people who thoroughly understand the science and other technical points about THR, but there are certainly enough that it is easy to find someone to provide an expert review.  There is no shame in someone who is skilled in product engineering and another language to draft an instruction document, with the inevitable grammar problems, and then ask for help to fix up the English so as to not detract from the value he has created.  It is the refusal to take that last step before going ahead and publishing that does the harm.

So, anyway…

facebook rstreet 1

facebook rstreet 2

As I said, I really hate this, but it needs to be done.  There are some powerful good messages about THR in this document.  There is some useful information.  But….

My first response was an indication of the fact that I was aware of the paper by really just wanted to ignore it and bury my head in the sand.  But that is just irresponsible, and I got called on it.  If we are going to police ourselves — and not just behave like the ANTZ, embracing any statement from “our team” without caring whether it is sound — it has to be done.

Just to save some of you the trouble of the obvious follow-up:  please do not ask me to itemize the errors and explain why they are wrong.  Regular readers should be able to figure out a lot of them anyway.  I will just offer the advice to not rely on this paper for information, and leave it at that.  Well one other thing:  I will also beg to any of you who are writing such things to circulate them for comments before publishing them.  There are experts who can help you get them right (or suggest that you just pare them down to your basic ideas and not try to delve into needless technical analysis).  I can assure you that I do that for anything I write on a similar scope.

Real public health research on e-cigarettes?

by Carl V Phillips

A funny thing appeared in the abstracts for the upcoming meeting of the Society for Research on Nicotine and Tobacco (SRNT).  Buried amidst the few dozen abstracts about e-cigarettes from the “public health” people is some actual public health research (i.e., research that could inform messages and regulation that would help people be healthier).

Most of the abstracts on e-cigarettes are just dumb make-work projects, presumably by people trying to justify their employment.  There are numerous surveys of attitudes, which mostly just reflect how the questions were asked and are changing by the month, and other variations on how to provide no useful information other than perhaps a historical record about the social dynamics of THR adoption (I will probably try to mine them for that).

Not surprisingly, many of the supposed social science projects violate the ethical norms of social science by using the concocted term “ENDS” rather than using the population’s preferred terminology for e-cigarettes.  This offers absolutely no scientific benefit (e.g., it does not more precisely define the behavior) and was clearly designed to be somewhat derogatory, but most of all it is designed to assert researcher primacy over a population’s own self-identity.  Some types of scientists can make up words when they are helpful, and political actors can have some fun with it when describing the powerful (e.g., “ANTZ”); people doing sociological research are ethically obliged to respect the populations they are studying.  Imagine researchers making up a patronizing name to refer to a self-identifying ethnic/cultural group; their writing would generate serious deserved backlash and be refused by any respectable journal or research organization.  This alone says a lot about these “researchers” and SRNT.

Most of the abstracts contain disinformation and, indeed, the one that I am highlighting has disinformation built into it (see below) despite its possible value.  It is by Alan L. Shihadeh and Thomas Eissenberg, who unlike their SRNT colleagues seem to be trying to do useful work and have some inkling of what useful science looks like.

(However, in spite of his increasingly valuable contributions, I believe the latter still owes the world an apology and/or retraction for his widely-cited publication that claimed that e-cigarettes do not deliver nicotine.  Politicians and activists make errors like that all the time and then pretend it never happened; scientists who make the mistake of epistemic immodesty need to rise to a higher ethical standard.  In science, the phrase “our one-off limited empirical study found something contrary to what all the previous evidence suggests” should always be followed by “so we probably did something wrong, so please ignore this result until we do additional research” rather than by “and therefore what everyone knew before was wrong” (or, better still, they should do the additional research to explain the discrepancy before publishing).  He does however get credit for trapping the ANTZ into starkly illustrating that science is just window-dressing to them and they do not really care what it shows:  When they were foolish enough to believe his claim, they condemned e-cigarettes as failures because they do not provide nicotine.  After it became clear that his claim was wrong, they condemned e-cigarettes because they effectively deliver evil evil nicotine.)

The abstract (or just skip down to my observations about it if you are in a hurry – there is really just one important point in it):

Background: “Electronic cigarettes” (ECIGs) heat a nicotine-containing solution to produce a vapor for inhalation. There is considerable variability in device characteristics and puff topography and each of these factors may be related to vapor toxicant content.

Method: We investigated the role of device voltage and puff duration on vapor toxicant content. We examined total particulate matter, nicotine, and volatile aldehyde emissions from 15 consecutive puffs of V4L™ ECIG cartridges (18 mg/ml nicotine) while varying device voltage (3.7 vs 5.2 volts) and machine-produced puff duration (1.8 vs 3.6 s). We used a puff velocity of 38.8 ml/s and 10 s interpuff interval (Goniewicz et al., 2012). In another study, we investigated a non-cartridge ECIG use method that involves dripping nicotine containing liquid directly onto a heating element and inhaling the resulting vapors. We measured aldehyde emissions from dripping 3 drops of e-liquid (16 microL, similar to the amount of e-liquid consumed in 15 e-cig puffs) onto a 300 C heater surface.

Results: The higher voltage tripled vapor nicotine content, and doubling puff duration doubled nicotine content. We also found that longer puffs resulted in greater cartridge temperatures, and that, for a given puff duration, higher puff velocities resulted in lower temperatures. Dripping liquid onto a heater surface produced more than 200 micrograms of formaldehyde, compared to 0.03 micrograms for 15 puffs of an ECIG cartridge (V4L™cartridge, topography of Goniewicz et al., 2012). We also measured 2-20 fold greater emissions of other aldehydes (9 species in total).

Conclusions: Overall, these results demonstrate that device characteristics (e.g., voltage), puff topography, and use behavior (i.e.,“dripping”) can influence vapor toxicant content. Indeed, these findings suggest that ECIG aficionados who take longer duration, slower puffs (Hua et al., 2011) are working to obtain higher nicotine doses and that those who drip liquid directlyon the heater (McQueen et al., 2011) risk significant exposure to formaldehyde that is a human carcinogen and is associated with COPD in conventional tobacco product users.

Most of the results fall into the “incredibly obvious” category:  Faster puffs result in lower temperatures (because more cool liquid moves across the atomizer, cooling it faster than it can heat).  Longer puffs extracted more nicotine, approximately proportional to the length of the puff (anyone surprised by that?).

It was interesting to see how much delivery (reported as nicotine quantities, but that is obviously just a measure of how much total liquid was aerosolized) increased with the increase in voltage.  This, of course, is not some universal finding for the ages, like something that might be discovered about the behavior of a molecule (though undoubtedly countless naive readers will interpret it as such).  Every result in this research depends heavily on the exact variables of the equipment and other methods they were using, and every device and every user is different.  But the authors get credit for actually varying a few of the variables a bit.  Reading most of the research on e-cigarettes would give the impression that there are no such variables, so actually the authors get a lot of credit for starting to correct that error.

The result that is potentially real health-affecting knowledge (unlike, as far as I can tell, every other bit of research on e-cigarettes in the SRNT abstracts) is the result of dripping e-cigarette liquid onto a heater at 300C.  This result is, unfortunately, also the germ of more disinformation because this is far hotter than what actually occurs (except, perhaps, with a seriously ill-advised novelty mod).  This presumably explains why the concentration of formaldehyde they found is enormously higher than that observed in analyses of real e-cigarette vapor.  Even if you preheat an atomizer to that temperature before dripping on it, it will rapidly cool toward an equilibrium temperature.  I am guessing that the “heater surface” they used was a piece of lab equipment that has a much larger mass than an atomizer filament, and thus maintained close to the original temperature rather than rapidly cooling when the first bit of liquid touched it.

We can safely assume that some people will spin this result as showing that e-cigarettes generate this quantity of formaldehyde, and thus the way the information was presented is a gift to the liars.  (Perhaps such an offering to the liars is the price of admission to SRNT.)  Still, this might offer a genuine contribution to health.  It does suggest that using very-high-temperature mods or a high preheating of the atomizer (by holding the switch on for too long before starting to draw) might increases vapors’ health risks.  Even if most of the liquid would not be heated to 300C, a bit of it might.  That is intuitive if you think about it:  higher peak temperature = more pyrolysis = more nasty chemicals.  But it is not clear there has been much thinking about it.

There should be more.  Good scientists who have more knowledge than I about the chemistry should really think this through — a little bit of theory and existing general knowledge would be worth for more than a series of one-off experiments on particular equipment.  If there is going to be any actual health-improving research about e-cigarettes, it obviously will not be the attempts to demonize them out of existence, but it also cannot be the attempts to claim everything about them is always just fine.  Real public health researchers do not behave like “public health” people who just look for an excuse to say “never do this, no matter how much you want to”; they figure out how to advise “if you are going to do this, you are better off doing it this way….”  This is, of course, the reasoning behind THR in the first place, and also describes what real health research about nicotine inhaler technologies should look like.  I suspect that most of this public health learning will have to wait until the tobacco companies report what they are doing, but it is good that at least one independent research team is headed in that direction.

American Dental Assocation now lying less about smokeless tobacco

by Carl V Phillips

Brad Rodu recently posted the observation that the ADA no longer erroneously lists smokeless tobacco as a major contributor to oral cancer.

ADA was always one of the worst anti-ST liars out there from the time I first started documenting anti-THR lies. This was due to a combination of the usual reasons and dentists’ obsession with oral cancer.  The least charitable (and widely believed) explanation for this is that many dentists in the US are physician-wannabes who could not get into medical school, so they are looking for some way to claim that they too are saving lives and not just tidying up our smiles.  (Of course, this does not include my dentist, who seems very happy with his role in life — I just wanted to point that out in case he reads this just before sticking pointy things into my mouth.)

[Update:  A dentist who read this informed me that the above was far more hurtful than I ever intended it to be.  It was meant to be lighthearted and merely a lead in to the point about over-emphasis on oral cancer.  But it came across as me, as a health researcher, endorsing a dismissive attitude toward the entire profession (and perhaps that I do not understand how complicated health care is, whatever the body parts involved, which obviously I do know) —  that was not what I meant to do.  I do not think very highly of their trade organizations like ADA because of the anti-THR lies, but the same is true for physicians and some areas of health science, and that does not reflect on the individuals in any of those professions.  The stereotype really does exist (obviously — offhand references to stereotypes cause offense because they exist), but I should not have trafficked in it as a literary device, especially because I am not sure I know anyone who fits it: every dentist as friend, clinician, or colleague I know actively chose the profession as far as I know.  I am not going to change what I wrote to fix the poor choice of words after the fact — memory-holing errors is an ANTZ tactic that I will not adopt.  We should recant and apologize when we make errors, not pretend we did not make them, so I am doing just that.]

The thing is, oral cancer is relatively rare — so much so that the average American dentist will diagnose exactly zero cases of it in his entire career (this is a calculation that I believe Brad — or maybe it was he and I together — did a long time ago).  So even when it was possible to defend the claim that ST increased the risk, it was still a very small risk.  Back when anti-THR was all about hyping the supposed risks from ST, it appeared that there was a concerted effort to “give” oral cancer to ST.   That is, even though other exposures always clearly caused greater risks for oral cancer, those exposures (smoking, drinking heavily, sex) all had “their own” risks, so the nanny-types decided to create a fake correspondence:  {ST is to oral cancer} as {smoking is to lung cancer} and {drinking is to liver disease}.

That is finally changing.  Unfortunately, as Rodu’s post goes on to point out, the ADA is still lying about ST in other ways, with the usual scare tactics, implying it is worse than cigarettes through such tactics as pointing out there is more nicotine in the product itself (which obviously does not matter, but can trick most people) and with weasel words about “chemicals”.   It “has over 3,000 chemicals, including 28 cancer-causing substances” — um, yeah, just like apples.

The biggest lie, in my opinion, is, “People may think that smokeless means harmless, but nothing could be further from the truth.”  Rodu points out that this is a strawman argument, because no expert or respectable advocate argues that ST, or anything else, is completely harmless.

I will take this one step further, though, and say that it is not just misdirection (like the other mentioned claims) but wrong:  Calling ST harmless, while not exactly right, is not all that far from the truth.  Since most people believe the risks are so much higher than the really are, making such a claim would tend to get people closer to the truth, so it might even be considered a kind of a higher truth.  Moreover, there are a lot of claims that are much further from the truth, like suggesting ST is similar to cigarettes in terms of risk.  When comparing the claims “ST is completely harmless” and “ST is like cigarettes”, neither is right, but the former is not very far off (and, indeed, is not inconsistent with the evidence), whereas the latter is an out-and-out lie.

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.]