What is peer review really? (part 4a – case study followup)

by Carl V Phillips

I thought it would be worth taking this series non-linear to follow up on Part 4, which used the recent Popova-Ling “peer-reviewed journal article” as a case-study to illustrate much of what is wrong with journal peer review and the fetishizing thereof in “public health”. Popova and Glantz relied on that paper in the comment to the FDA that I discussed in yesterday’s post about Swedish Match’s MRTP application, which asks permission to remove the false and misleading “warning” labels from their products. This is a great illustration of why the fetishization, “it is in a peer-reviewed journal, so it must be right”, is such a dangerous travesty. (H/t to Brian Carter inspiring some of the observations that appear here.)

You will recall that Popova and Ling did a largely uninformative study, the main result of which is to show that if you expose people to false claims about harms from smoke-free tobacco products, their perception of the risk increases. (What a shock!) To obtain that uninteresting result, they used research methods that were fraught with serious human subjects ethics violations. Of course, they did not really care about the results of the research, as evidenced by the fact that the paper was primarily a statement of their political preferences, with conclusions that in no way followed from the research. There were other serious problems too. The journal’s peer reviewers — being, unfortunately, genuine peers of the authors — were apparently incapable of understanding these problems since they did not identify any of them.

Even though the authors lied and said they had no conflict of interest, they obviously did this study not for the purpose of providing scientific knowledge — there was no way their approach could have contributed to that — but to further their political goals. (Note that details about that observation and what appears in the previous paragraph can be found in the Part 4 post.) They wanted to influence regulators’ choices about “warning” labels on smoke-free tobacco products, and in particular FDA’s response to Swedish Match’s MRTP application. This was obvious from the paper itself, and made concrete in Popova’s comment that I addressed yesterday, which was basically all about the results of that “study”.

The substance of the comment, ignoring the lead-in that reads like the text of a television attack-ad during a political campaign (with about as much scientific sophistication), is based on Popova-Ling. Well, “substance” is too strong a word — they basically just made the three observations, followed by the non sequitur conclusion, that I quoted in yesterday’s post.

What they failed to do in the comment — just like they failed to do in the article — was note that the baseline consumer perception of risk from smokeless tobacco was barely lower than what they found for cigarettes, which means that it was way too high. After consumers got a modicum of accurate information, like they would if shown the proposed new warning, they adjusted their perceptions in the right direction, but they were still way too high. Recall that above I described the study as largely uninformative. This was the one informative bit.

But a funny thing happened on the way to turning the study into a “peer-reviewed journal article”: They dropped the results for cigarettes from the paper. We know those results only because when I researched the paper to do my review of it, I discovered that they had reported them in a previous version before taking them out in the article version. Think about that. The most relevant bit of information from the study for the MRTP application — showing that perceptions of the risk from smokeless tobacco are way too high and remain way too high even after consumers get some corrective information — did not appear in the paper.

So, the paper Popova and Glantz rely on did not include the most relevant result, as Popova obviously knows. Also it has been completely excoriated by the real reviews, including mine, which is published alongside the original paper, and a few others. The problems with the article — and the associated failure of the journal peer review process — were recognized as sufficiently serious that the journal is trying to figure out what to do about it. Currently the following note appears at the top of the paper at the journal:

Editor’s Note: Readers are alerted that concerns have been raised over the study protocol and the reliability of the data presented in this article. Appropriate editorial action will be taken once this matter is resolved.

Before you get too excited about this as evidence that the journal system really works, try to recall a single other occasion when you saw such a reconsideration for anything short of the suspicion that the authors out-and-out fabricated their data. It is not like Popova-Ling was exceptionally bad by the standards of “public health” articles, let alone anti-tobacco “research”. With the possible exception of the gross ethics violation, you can find hundreds of articles a month that are this bad. The difference here is that three independent experts — myself, Clive Bates, and Brian Carter — each put a lot of time into a serious concerted effort to point out the flaws in the research, the irrelevance of the study to the political editorial that the paper really was, and the unethical nature of the human subjects research. Also keep in mind that this is one of the few respectable journals in the public health space.

Such concerted scrutiny is just not going to happen with many papers. We are talking about a lot more than just writing a letter to the editor. Also notice that the note does not really refer to the worst problem in terms of the implications of the study for the world, that the conclusions do not follow from the study results. Perhaps this was just an oversight, but it does mean that readers of the note are not told of the biggest problem.

But does any of this matter for Glantz’s purposes? Probably not. Despite the red flag that appears on the journal page, he did not hesitate to rely on this article. Was this a tactical error? Probably not. He knows that FDA fetishizes journal articles, as evidenced by the series of posts I wrote early this year about their reviews of e-cigarettes, which were summarized in CASAA’s comment on the proposed deeming regulation.

Nothing short of a retraction — and that basically does not happen for anything short of data fabrication or the equivalent — changes the fact that this is a “peer-reviewed journal article”. Nothing. Not the fact that its conclusions are not supported by the paper, not the fact that the research was unethical, not the fact that it was a terrible excuse for research whose results were misreported, and not the fact that the journal felt it appropriate to put a warning label on it.

The only way to deal with this problem is to push for recognition of the fact that just because something is a “peer-reviewed journal article” does not mean that the conclusions, observations, or even the reported study results are accurate. Indeed, in the realm of tobacco research, it does not even suggest they are probably accurate.

27 responses to “What is peer review really? (part 4a – case study followup)

  1. No way we can take away such a fetish without replacing it. Nature abhors a vacuum. That fetish is all that stands between the responsibility to listen to someone who claims (even if falsely) to be objective vs. doing what your wife’s brother says to do, or taking money to decide what to do. Either we get a better definition of peer-review (starting with it’s not peer reviewed if the peers are not identified) or we need some other body that is not politically appointed or bought and paid for. Even if it’s Encyclopedia Britannica.

    (Step 2 would be that if enough articles reviewed by Dr. Quincy Q. Acadaemia, Ph.D. are shown to be dinosaur poop, Dr. Acadaemia is no longer an acceptable reviewer.)

    • Carl V Phillips

      I don’t think serious people *need* to have a mindless rule of evidence for interpreting science. I am not suggesting I know how to solve the problem of random people on the street naively choosing what to believe. They indeed will probably just replace one faith-based method of “knowing” with another. I guess I am focused on the layer of people who lie just below the most serious experts (who, by definition, would not fall for the fetish), who ought to not fall for the fetish because they know enough to know better.

  2. A superb analysis of the dismal failure of the peer review system. At least with Popova and Ling’s wretched mess we can be like NTSB investigators and see how the process so easily left the rails and who’s responsible. I still have some small hope that someone is going to be held publicly accountable for this seriously flawed “study” being published. Meanwhile, I’m happy you posted the link to Popova’s comment. If you scroll down to the comments section you’ll see an exchange Glantz had with someone about the potential harm of dual use, Glantz’s main argument for denying the Swedish Match application. Here you’ll find Glantz in all his depraved glory asserting the following about dual use:

    “Cigarettes and snus are exposing users to different toxins that can interact, resulting in a more toxic mix or different effects.”

    “The possiblility [sic] of synergism between different toxins is well established and depends on the specifics of the situation. For example breathing asbestos is bad, smoking is bad, but smoking and breathing asbestos is much worse than the sum of the two effects.”

    No way to be charitable. This is sociopathic level lying.

    • Carl V Phillips

      Let’s not forget that he is just clueless. This does not change the fact of sociopath-level lying (no matter how stupid he is, he must be able to understand he is wrong about points where, say, the original author of something says that he is getting it wrong — and yet he keeps lying even then). But with an exchange like that, you really sense stupidity more than dishonesty. It is hard to imagine going off in that direction as a calculated lie. And trying to argue with that would be like going back in time to argue with someone who is genuinely convinced that disease is caused by an imbalance of bodily humours or that the solar system revolves around the Earth — I mean, what do you even say?

  3. The target audience for the “replacement fetish” is serious-minded people who are completely out of their league on the topic in question. Such as humanities majors running a country and needing to make decisions on science. Or lawyers. From their point of view, science is completely mutable, it depends in which experts you hire and how the jury perceives them.

    How are they to decide? Charisma of the speaker? Fame of the speaker? Reputation? The ALA has a BIG reputation. Peer-reviewed articles are the closest they can come at the moment. So, of course, now that is ALSO for sale.

    We have to think of a mechanism. Or fix the one that got broken.

    • Carl V Phillips

      You are being a bit unfair to the court system. Yes, a lot can go very wrong there, and does. And there are some dumb defaults in interpreting science. But the system does allow for expert testimony, and the experts have the option of explaining why a claim is wrong even though it, say, appears in a peer-reviewed journal article. This is much better than the system that CTP seems to have adopted, which is kind of like the styled rules of the game in high school debate: if it is written down, you can quote it and proceed under the assumption it is true.

      And, no, peer-reviewed articles are not the closest they can come at the moment. That is what I am trying to explain in this series. There is almost nothing about the journal review process that provides or promises anything. In the context of public health, this system cannot be fixed.

      • Carl V Phillips

        And by “cannot be fixed” I mean: Cannot be changed in any way that still resembles the current system such that it actually does what people erroneously credit it with doing.

      • So, what is closer? (When I said “closest we can come” I did NOT mean close!!!!) Taking every law to court is a rich man’s game. We can hope for that for our particular cause because we are passionate, but in general, it’s not a very efficient way to get sensible laws or regulations passed. Can we have a law that some bipartisan body must approve boards set up to design or judge regulations? (Kind-of like OMB I guess, but with more teeth?)

      • I look forward to hearing what is closer. (By “closest we can come” I did NOT mean actually close, I meant I don’t see closer mechanism. Though we should use the courts, they make a horrible default mechanism because of expense and uncertainty.)

  4. You can’t say anything to Glantz that will get through. As a psychologist I’ve worked with sociopaths and their most striking feature how they blatantly lie with manipulative ease. I never saw one ever admit to lying or culpability, even when presented with incontrovertible proof. No guilt or remorse, they’d just pile on more lies or claim they were the victim of some other liar. I came to believe that they are so lacking in personal insight they are truly unaware of their dishonesty. Whatever they say at that moment, even if it’s a bald-faced lie, to their minds is the truth. When you’re on a self-aggrandizing moral crusade, and sycophants hang on your every word, it’s easy to become convinced you have outsized expertise and whatever you say is the truth. This still makes Glantz a clueless liar for practical purposes, but I question whether he’s very aware how much of clueless liar he really is.

    • Carl V Phillips

      I think there are (at least) three explanations at play here, which are not completely rivals (and so could all be accurate to some extent) but are quite different. Glantz could be any or all.

      I think a true sociopath is quite capable of being technically aware he is not speaking the truth, though does not recognize the concept of lying (i.e., immorally not speaking the truth). Due to a lack of morals he just does whatever he thinks will be effective in pursuit of his goals, without regard to harming others or any moral code.

      What you describe seems to be a somewhat different explanation. I am not sure what the label du jour of people who make a living applying labels is. But it seems to consist of genuinely not knowing truth from falsehood, due to delusions of grandeur (nothing you say is false if you think your opinion defines Truth). One would not actually have to be a sociopath to be like that — though the difference is probably moot for practical purposes. For this, it is a inability to understand that you are doing something wrong, not a complete lack of concern for the concept of “wrong”.

      And, of course, there is still: He is just so stupid he does not even understand he is lying, even if he might be capable of believing lying is immoral.

  5. Something I don’t hear mentioned that often is how a similarly flawed “peer review” process is used to determine the award of billions in federal grant money. I have sat on scientific review committees for tobacco research, whose putative task was to determine the scientific merit of grant applications. These committees have up to 20 members, but only three people are primary reviewers of a particular grant application and they set the quality score range for that grant. Unless someone else on the committee has an objection (and the reasoning to back it up), no one is allowed to contribute a score outside this initial range. We all have a pretty good idea what kind of average score will get a grant funded. Although grants are reviewed much more strictly than journal articles (one is required to complete a section by section review that runs several pages) I’ve seen a number of grants sail through based solely on the popularity of the applicant and the policy biases of the reviewers, not on the strength of the science.

    I did not sit on the committee that evaluated Pamela Ling’s grant that subsequently led to the Popova and Ling travesty. But I know exactly what happened. Here’s the applicant provided description of the grant:


    Ling caught some fellow travelers (like those that reviewed the BMC article) as her primary reviewers. No one else on the committee either read the grant, of if they did, were inexpert enough to recognize the cherry picked misinterpreted data and flawed reasoning behind it. For those of you without the time to review Ling’s description, she basically proposed to do exactly what she and Popova did, and used much the same reasoning for doing it in the grant application as she did in the article. That is, the federal government agreed to pay Popova and Ling a pile of money to produce a complete miscarriage of science, and Popova and Ling dutifully complied.

    It’s one thing for the deeply flawed peer review process to pollute the literature with junk science. It’s quite another when a similarly flawed peer review process blesses people like Pamela Ling with millions of dollars to produce it. The sham of peer review greases the skids for this corrupt enterprise every step of the way.

    • Carl V Phillips

      Yeah. That is an important point and probably worthy of more than a comment in this series. Want to turn it into a guest post?

      It is a bit of a different world as you note, so it is somewhat tangential. The NIH grant review process *tries* to be more serious in terms of who is chosen to review (though obviously fails quite often, as you note). It is rather more accountable. No, scratch that. It has the mechanics in place to be more accountable, but since there is no push to hold these people to account, that is largely moot.

      It is an interesting question as to which failure is worse. Ultimately they are both bad and the question is just a barstool debate. In theory, there is no harm from doing pointless or misguided research (other than spending our tax dollars) because the worst case ought to be that it produces useless results. That would argue in the direction of the journal system being the failure point, where the false and misleading claims are published. However, in a travesty like this example, where the authors promised to make the false and misleading claims and were offered money to do so, that problem traces clear back to the grant. On the other side, once the grant is given then some lousy “public health” journal will publish whatever the authors care to produce from their asses, so a bad grant pretty much guarantees bad “peer-reviewed journal” articles. But that brings it back to being a failing of the journal system to do what people think it does. On the other hand, there are granting organizations that will pay for the worst crap if the captured US government does not, so it is difficult to stop it at that level.

  6. Is it possible for someone to define the difference between a psychopath and a sociopath in relation to some elements of the Public Health industry, please?

    I have often used the term ‘sociopath’ before to describe many in this area of PH, as it seems to be a good description of those who despise consumers with a different viewpoint who they are theoretically there to help; and as a result, a fair number of the population (and perhaps many/most of them). A complete disregard for people’s welfare seems to indicate a problem in those who get paid to minimise harm by improving health, along with their corresponding apparent lack of any wish to reduce death and disease except in some sort of theoretical perfect future world.

    However Glantz is a different creature as he seems to revel in the harm he is paid to cause and the deaths that must result. There is almost a pleasure to be seen in the destruction he causes, a complete indifference to the harm caused by his actions, a total lack of any empathy with his victims or even the public at large, and a determination to make as much money out of it as possible. As far as I can see this is more typical of a psychopath than someone who is just ill-informed, or who doesn’t care, or who worships some form of ideology that is remarkable for its impossible perfection.

    He is easy to criticise due to his dyslexia (or limited literacy, whichever is applicable) but he isn’t paid for writing: he gets paid for his tremendous strength in debate – his uncanny ability with rhetorical fallacy is actually worthy of study in itself, he has elevated it to an artform; his ability to marshal resources for commercial purposes; and his ruthless elimination of anyone who will not comply with his funders’ requirements (or his ideology, if you want to be nice for some reason). The main thing I’m not sure about is the association with love of monetary gain, and the disposal of opponents or unbelievers for money, and if this can be reconciled with a clinical diagnosis of psychopathy? Perhaps in this case money equals power; but then, do psychopaths actively seek power in this way?

    • Carl V Phillips

      Well, “sociopath” is a fairly well defined term, focused on someone’s lack (partial or total) of a conscience (sense of morality, recognition that anything matters other than their personal desires) and thus willingness to do whatever is expedient to get their way (lie, cheat, manipulate) without remorse and thus without hesitation. It is difficult not to conclude that this describes many of the more aggressive “public health” people. It does not have to be about getting money, though that is the most obvious selfish goal — selfish goals can take many other forms, so I see no contradiction there.

      “Psychopath” is sometimes used to mean more or less the same thing, sometimes limited to a stronger version of it, but it also gets used to imply tendencies toward physical violence and associated criminal behavior, and thus is somewhat fuzzier in exactly what it mean. A sociopath need not be violent or even criminal (they would avoid criminality just because there are more expedient methods than crime, not because it is wrong — see, e.g., a large portion of people working in Wall Street and the like).

      I think maybe the additional dimension you are hunting for is what I would term “evil”, which I would define as taking pleasure in the suffering of others and seeking to inflict such suffering. (You can nuance that with “undeserved suffering” or whatever to exclude legitimate retributive justice, war, etc.) Sociopaths do not care about the welfare of others, so causing suffering is incidental. It becomes evil when causing suffering is actively sought or is incidentally caused but delighted in.

      I would agree that anyone fitting either of those descriptions is quite at home in “public health” but obviously those traits are anathema to real public health. It just turns out that “public health” is a good home for people like that if they cannot pass the physical to join the police or did not go to Yale so they do not have an entrée to work on CIA black ops.

      So then, what is Glantz. He clearly lies, cheats, and manipulates without hesitation or apparent remorse. He does not express any concern for those he hurts. I think someone would have a very tough case to make, based on the public record, that he is not a sociopath; the only case for it I can imagine is that his true self has actual human feelings, but he has decided that playing the part of a sociopath in his public behavior is useful (again, for some morally defensible reason) — seems like a stretch. But I am not entirely convinced he is evil. The harm he causes might be all incidental. You mention that he revels in it, but I do not see him reveling so much as do, e.g., Chapman or the anti-ecig cabal in England. Certainly some specific acts of his are evil, but how prevalent is that.

  7. I don’t think Glantz revels in the suffering he causes; he seems wholly unaware and unconcerned about it. Professions that provide the opportunity to manipulate and exert power over others seem to attract more than their share of sociopaths and narcissists. I’ve ran into many, from medical doctors to professors to politicians. In the health profession the absolute worst are the two-year certified alcohol and drug counselors. I’ve worked at a few drug and alcohol treatment centers and it was very common for the counseling staff to openly revel in the manipulation and suffering of the inpatient addicts. Being almost 100% “recovering” addicts themselves I found such behavior inexplicable. They’re mostly AA true believers, having had their road to Damascus conversion, now in a position of petty power, treating their fellow addicts like unwashed rubes deserving of punishment. They are ostensibly in the profession to help their fellow addicts, but their real interest is finding an outlet for their narcissism. Perhaps there are some parallels with many who go into “public health.”

    • Carl V Phillips

      I definitely agree that this fits the model of those who go into “public health”. Not those who go into real public health and are actually helping people (e.g., delivering immunizations), nor those who go into the dwindling area of real public health sciences, of course. But the people who are the face of public health are largely just that.

      I guess this falls somewhere between “just a sociopath” and “full-on evil”. It is people who are causing harm to others because they get off on exercising power, and causing harm to others is the most obvious way to demonstrate their power (if others are benefitting from something, it might be because of their own choices rather than a demonstration of your power over them). This is not incidental, as with just-a-sociopath who merely does not care about whether others suffer or not, though it is not quite full-on evil, in which the suffering itself is what the actor takes pleasure in. Of course, it is difficult to imagine anyone pursuing that without being, at least to a substantial degree, a sociopath, because it requires not feeling bad about the suffering of others. But even though causing the suffering is deliberate, it is not for purposes of per se evil.

      So, hmmm, yeah, this does seem to explain a lot of them better than either “just” sociopath or full-on evil. I think a few of them in this space are full-on evil, but not most of them.

      I find myself thinking of the moral development of a c.4 year-old. At some point many young boys (this behavior is predominantly, though obviously not entirely, male) are pre-conscience — sociopath by virtue of not yet having gotten to the point of morality and empathy — but able to, and wired to, exert power over their world (particularly people) and intrigued by the possibility of inflicting violence. Lord Of The Flies, and all that.

      • Carl V Phillips

        A further thought on this: It would be statistically unlikely for *all* the “public health” people who are inflicting this suffering on the public to be sociopaths, let alone evil. Similarly, we would not expect every heir to a dictatorial fiefdom or everyone who ends up working at a factory farm to be a sociopath or evil (though it is convenient for them if they are). Moreover, there is affirmative evidence that some of the vocal anti-tobacco activists are not sociopaths. Of those previously featured in this blog, Ken Warner and maybe Cheryl Healton come to mind. So what is their story?

        I think it is more Hitler’s Willing Executioners than Lord Of The Flies. That is, these people believe in the general goals of the state/cause/industry and are willing to be a loyal part of it. Since some of those goals are positive, they can gloss over the negative impacts as being the necessary price. But they are not off the hook, of course — not when they are senior enough to have some influence and smart enough to see what is going on. The heir to a fiefdom can convince himself that ruthless dictatorship is the only way to rule, even though there is plenty of hope for going in a different direction and some of the specific excesses clearly are not necessary; he is just a poor victim of circumstance, in his mind. The same might explain people like Warner. They are quite capable of seeing that their enterprise is now dominated by people who seek to cause suffering. But they are unwilling to speak up about it because (a) they avoid contact with the suffering people so can pretend it is not really happening except when forced to think about it, (b) they believe in the supposed mission of the enterprise and refuse to acknowledge that it is really mostly doing other things, and (c) they prefer comfort over making any sacrifices to do what is right.

        I am just spitballing here, by the way. I am not sure of this. But it is an interesting question, to explain the willing support of the sociopaths that is provided by reasonably decent people who seem wise enough to know they are being played.

  8. More spitballing. The flip side of the question of what kind of people go into “public health” is what makes “public health” so attractive to these people? The legitimate field of public health, when it works properly, is an endeavor of fact finding and understanding. If the low SES population has particularly poor nutritional habits you first have to investigate these people fully. Where do they get their food? Why do they like the food they do? What is it about they way their lives are structured that makes them at nutritional risk? After gathering a ton of data and dispassionately analyzing it you’re ready to start formulating policy ideas. Then you test them on a small sample of the population before implementing them nationwide.

    Tobacco control works in exactly the opposite way. They already know the global policies they want to implement. I couldn’t sum it up any better than the Legacy Foundation does on its home page: “We’re Creating the First Tobacco-Free Generation.” They’ve decided on the policy of ridding the world of tobacco. If you’re already set in your policy goals, what need do you have to learn anything more about tobacco or why people use it? You don’t. What you need is research that supports the tortured logic of your policy goals and how best to implement those goals. This is why tobacco control is an absolute mess as a scientific discipline. They are not seekers of truth and understanding, but seekers of confirmation of what they have believed for decades.

    Who would be attracted to such a back-asswards field? 1) People who aren’t very skilled at doing rigorous thoughtful science. It simply isn’t required, and may be a serious drawback. All you need to know of science is how to act and sound like a scientist, because your mission is to support policy, not conduct legitimate science. Exhibit A: Popova, Ling, Glantz, et al. 2) People who are full-throated supporters of the policy goals before they even enter the field. This combines with a lack of curiosity regarding the utility or validity of these goals. They don’t have the skill set to investigate them anyway. 3) People who are prone to becoming “true believers.” Tobacco control is a far more a political movement than it is a science. It needs the kind of people who will honor and respect the articles of faith and take to the barricades in the face of opposition. 4) People who are uncomfortable with ambiguity. Real science is a messy business. Data conflict. There’s often more than one interpretation. But when you have a set of policy goals as your touchstone, it all falls neatly into place. Any solid evidence that shows you’re wrong is simply rejected or ignored. See smokeless tobacco. 5) People who’ve been traumatized by smoking or smokers. I’ll bet nearly everyone in “public health” has a story of why they got into it, and it involves the horrible loss of a loved one, or a smoking parent or bully that made their lives miserable. The visceral hatred of tobacco and the impulse to punish and otherwise ignore the plight of smokers has to come from somewhere. 6) People who are sociopaths, for reasons that have already been noted.

    • What about
      “people who agree with the person conducting the job interview.”

      • Carl V Phillips

        Well, I think that is a result of the conditions Brian cites (which I will respond to when I have a few more minutes) rather than a new condition, but yes, that is an important observation. In scientific fields, a common sentiment is the hiring process is “wow, this guy will really keep us on our toes and bring some new ideas”, but you pretty much never hear that in “public health”, where those would be negative traits. Also it is worth noting that in academia, hiring many of your own graduates is a sign of failure at several levels (you did not train them well enough to get a job anywhere else, etc.) and a waste of potential (you already know everything they have to say); in public health units, it is practically the rule rather than the exception.

        • I would add one more to my list. 7) People who have a certain level of narcissism. Their superior intellect and deep understanding gives them the right to interfere in the personal decision making of lesser beings. They know best, and if they can’t convince you of it they’ll force you into proper behavior through policy and law.

        • Carl V Phillips

          I finally circled back to this discussion because I wanted to write a post that relates to it. That is a lot to respond to, but let me at least try to do part of it.

          It is definitely the case that tobacco control is an anti-science. Like, say, creationism, it just uses the trappings of science when they are convenient for tricking people into believing the religion-based claims that are not actually subject to scientific scrutiny. It is merely used to create the illusion of respectability. So that means that people who are not capable of real scientific reasoning are at home there. Does it attract particular people for that reason? I am not sure. After all, 99% of the jobs in the world do not really require any scientific reasoning (many would actually benefit from some, but they certainly do not require it). However, there probably is some sorting within those who decide to go into public health in the first place, for whatever reason. Those with skills might gravitate to real epidemiology (if they are one of the fortunate few whose public health program has anyone capable of teaching real epidemiology) or chemistry, while the innumerate in the bunch gravitate toward “health promotion”, as what we call “public health” is often called within public health schools. I think the “uncomfortable with ambiguity” point is more or less the same one. Not being able to think scientifically and not liking ambiguity are pretty similar.

          No doubt tobacco control attracts those who are true believers, who were indoctrinated as children and did not mature enough in adolescence to throw off the Orwellian propaganda. Many are those who were traumatized. But this does not explain why so many stick to the TCI party line — lying, hurting consumers, anti-THR — once they have had a chance to learn something. I cannot count how many times I have seen someone explain their opposition to THR with “my mother died from smoking!” WTF? It may just be sorting: some people go into tobacco control for these reasons but because they have some scientific skill or conscience, they leave it.

          Among those who do not leave are those who are prone to be True Believers. This certainly explains a lot of them. True Believers make the best useful idiots. That type can be found in every simple-minded political cause, religion, and hate group you see, and are often the ones out in front. I would add to that, however, those who are just looking for an excuse to hate. You get a lot of hate-filled people on the front lines of those causes. You would expect that, of course, for the anti-LGBT groups, of course. But you also see in such things as animal rights groups — it is just people who are looking for an outlet for their general feelings of hate, and happened to have found something that was socially acceptable (which is gay bashing or racism in some social circles and “public health” in others, but the motivations are basically the same).

          That starts to stray back into the sociopathy and narcissism territory. And proper evil too. All of those clearly motivate many in “public health” — tobacco control in particular — and especially those who rise to the top (as such people tend to do). They are undoubtedly over-represented in the entire tobacco control population because it is an attractive place for them to go, but far from dominant. But they become dominant among those who are highly visible and powerful for obvious reasons.

          I think it is usually impossible to draw clear dividing lines among those related characteristics in practice. It is possible to identify some clear pure sociopaths in the world — people who just do whatever it takes to get rich and get laid, without any apparent hatred or narcissism. But once we are dealing with those who are involved in politics rather than just greed, it becomes less clear. As alluded to earlier in the conversation, if someone is getting off on exerting power over others (or, similarly, is motivated by hatred or evil) then they do not demonstrate the complete indifference to the feelings of others of a pure sociopath. They care enough to like it that someone is being hurt. Of course, that still all but requires the sociopath’s lack of conscience; you do not see much evidence in the non-literary world, of these people struggling with their conscience even as they let their preference for inflicting harm to determine their behavior.

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