Public health (heart) lung cancer

by Carl V Phillips

Tobacco control and “public health” have the same attitude toward lung cancer as homophobes do toward AIDS. In both cases, they are motivated by “moral” objections to particular behaviors and are desperately frustrated that people fail to just stop doing what they personally consider sinful/disgusting/unappealing (those are fairly interchangeable concepts for this sort of person). Thus many of them are happy that there is a disease that disproportionately punishes the sinners. Of course gay bashers (as well as also those who object to all sexual promiscuity and the relatively smaller group who hate injection drug users) do not pretend to care about the physical health of the targets of their opprobrium, so they are merely vile; “public health” people are also hypocrites.

About ten years ago, I coined the term “anti-tobacco extremists” to refer to those who take the most extreme view of tobacco use. This was an attempt to push back against anti-THR activists being inaccurately referred to as public health, given that they actively seek to harm the public’s health. I have since given up on that, and recognize that “public health” is an unsalvageable rubric, which should just be relegated to being a pejorative. But the extremist concept remains useful. The test for anti-tobacco extremism is the answer to the following question: If you could magically change the world so that either (a) there was no use of tobacco products or (b) people could continue to enjoy using tobacco but there was a cheap magic pill that they could take to eliminate any excess disease risk it caused, which would you choose? Anyone who would choose (a) over (b) takes anti-tobacco to its logical extreme, making clear that they object to the behavior, not its effects.

Of course, something approximating that magic pill exists — using smoke-free alternatives rather than smoking — and that was the point of the thought experiment. It was designed to separate the pseudo-scientific rationalizations (e.g., inaccurate claims the alternatives are not really low risk) from actual extremist goals. Those who oppose THR are generally extremists, interested in moral cleansing, and do not care about health or people.

But opposition to THR is not the only evidence that anti-tobacco extremists dominate tobacco control and “public health” more generally. There is also their effort to prevent development of better treatments for lung cancer. On a research-spending-per-death basis, lung cancer is practically an orphan disease. Despite it being the leading cause of cancer deaths in the USA and most rich countries, it receives far less research spending than less common cancers. Those in power even take pains to try to hide this fact in their statistics, almost invariably splitting up cancers by sex so that it comes in second on both lists. (There is more lung cancer than either breast or prostate cancer, but the latter top a list that is limited to only women or men.)

[Update: It was pointed out to me that I failed to note that even worse than this is that even this cooking of the numbers depends on reporting diagnosis rather than mortality from the various cancers. Prostate cancer is relatively seldom fatal and likewise breast cancer, though not to such an extent (a large portion of breast cancers detected by screening mammography would never even have caused detectable symptoms, let alone mortality). By contrast, due to the late detection that almost always occurs, most diagnosed lung cancers are fatal. If we consider mortality, lung cancer is worst even when dividing by sex.]

Public health’s love affair with lung cancer was evident in a report from a couple of months ago, about research on a lung cancer vaccine. This got a lot of press only because researchers at Roswell Park will be testing a drug developed in Cuba, and anything about thawing relations with Cuba generates breathless news stories. The medical reporter and Candace Johnson, president and CEO of Roswell Park and oncology professor at SUNY Buffalo, teamed up to create this gem:

These forecasts are years from real-world application, but their implications are worth considering. One such challenge is how to resolve the tension between creating a lung cancer vaccine and keeping the smoking rates low. The U.S. has made tremendous strides since the mid-1960s in eradicating cigarettes, but fears of cancer and disease serve as driving forces of that change. If scientists take them off the table, Johnson admits, there may be less incentive to quit.

“It’s a fine line,” she said of the public health dilemma. In conquering one major form of burden — lung cancer — researchers could unintentionally spark a new one. More  important to her is keeping the rest of the world in mind. “Globally, there’s going to be a need even if we have great results here in this country in smoking cessation.”

So basically she is apologizing for possibly making smoking less unhealthy. As I said, public health loves lung cancer. Now some might think they would believe that making people immune to a disease is even better than preventing people from engaging in the behavior that causes the disease. But that would be the error of believing that “public health” is about health.

Moreover, contrary to the “may” in the quoted passage, of course there will be less incentive to quit if the harm is reduced. It is not exactly hard to understand that if  the cost of something drops, then more people will do it. I know that medics tend to be really bad at economics, but come on! They are at least human actors who make decisions, and so ought to be able to figure that much out. Then again, medical and public health education seem to train the ability to think scientifically out of people. After all, the public health types were astonished to discover that when HIV treatments became available — such that catching the virus was no longer a rapid death sentence — there was a dramatic increase in behaviors that caused a risk of catching the virus. Every economist who weighed in on this issue pointed out that this was inevitable. Indeed, anyone with any common sense could have predicted it. But “public health” denied it would happen and were astonished when it did.

Astonished and also dismayed. Perhaps not quite as much as the gay bashers were, but the similar response does make clear the very fine line that separates “public health” from being a hate group. “Public health” were genuinely unhappy that people took advantage of better technology to live their lives in a way they preferred, rather than continuing to obey the diktats. HIV treatments did not eliminate the costs of risky sexual behavior, or course, nor even the costs of having HIV, just as a magic cure for lung cancer would only eliminate a fraction of the risks from smoking. But in both cases the costs become substantially lower, and so the willingness to accept the costs in order to get the benefits of the behavior is going to be higher. This is only a problem for someone who considers people’s welfare to be unimportant, who only cares about whether people obey the moralistic rules they would impose on the world.

Now in fairness to Johnson, she might not have proactively sought to apologize for making smoking less harmful. Reporters tend to like to report every story as if it were a sports match with simplistic rivalries, and so the reporter probably pushed the conversation in this direction. But it was Johnson who chose to recite the public health party line of not really wanting to do anything about lung cancer. She could have chosen to respond with something like:

Are you kidding me? Are you suggesting that we should not have improved the safety of air travel, leaving it as risky as it was in 1950, to avoid having so many people engage in this risky activity? Or that we should have avoided finding a cure for syphilis or treatments for HIV, because now more people engage in risky sexual behavior? Would you have us remove seat belts from cars? The reason smoking is bad is that causes diseases; if we take away a major disease that it causes, smoking is no longer as bad.

Of course, she is part of the public health establishment and so it is reasonably likely that she would not say this because she does not agree with it.

This absurdity brings to mind the Claudia Henschke debacle. For those who do not recall, Henschke was a medical researcher associated with Cornell/Weill who claimed to have discovered a method of using CT scanning for early detection of lung cancer, when it was still treatable. This became a debacle when the ANTZ figured out that the project got some grant support from a tobacco company. There was criticism that she was inadequately open about this (she disagreed). On the other hand, who cares? It is not as if that changed the results. It is not as if the funder — even if they had controlled the conduct of the research, which they did not — would want to make erroneous claims about the results. Such claims would quickly be discovered to be wrong (unlike, say, most of public health’s anti-tobacco pseudo-science, in which they make sure their rhetoric does not depend on any testable claims).

The real problem was that other research did not show similarly promising results, suggesting that the Henschke results might have been an error (random or otherwise). A 2007 analysis, seriously questioned her 2006 results, for example, well before the 2008 kerfuffle about the funding. There is also the fact that the value of cancer screening is easy to overestimate because it detects a lot of cancers that would not have actually caused health problems. Public health people do not really care about such matters of science (math is hard!). They avoid denouncing the similar problem of screening mammography — which is approximately worthless — because they do not really care whether people fear breast cancer. That fear does not motivate people to behave “properly”. But they tripped over themselves trying to denounce Henschke’s research when they found out about the funding. It was truly comical.

Some good ones that are still available online:

“How can you, as an institution that is based on promoting public health and medical research, take money from an industry that produces a product that causes health problems in the world?” commented Ruth Fadden, director of the John Hopkins Berman Institute of Bioethics, in a report on ABC News.

Um, as opposed to all those corporations that make products that cause no health problems at all? Besides, why not? Apparently these people think it is much better to make sure all the corporate profits enrich the shareholders, rather than skimming some off to fund research that the companies owe to the world. I am sure the rentier class would commend such sentiment.

But comedy aside, the real anti-health mission of public health came through in the more substantive reactions. By not prominently disclosing the source of funding, Henschke performed a very useful experiment of a different sort, pointing out how public health people do not care about accuracy of scientific research or its potential benefits. They only care about whether it was motivated by the extremist goals of their special interest group or by some real societal interest. Their criticism ignored the science that suggested the original study result was wrong because they only care about motives, not truth. For example,

‘Why did the tobacco company want to support her research?’ ” [Dr. Jerome Kassirer, a former editor of The New England Journal of Medicine and the author of a book about conflicts of interest] said. “They want to show that lung cancer is not so bad as everybody thinks because screening can save people; and that’s outrageous.”

Um, what? No, they wanted to make lung cancer genuinely not as bad as it has been. That is the “outrage” that public health did not like. Contrary to the ignorant prejudices of public health people, people who work for corporations are, on average, decent human beings who care about people’s welfare (with a few exceptions, of course — energy companies, banking, and military contractors come to mind). They strongly prefer that their products cause less harm.

Of course, they also like the idea that making their products less harmful would mean that more people will buy the products. But you know who else funds clinical research that is intended to help them sell more of their products? The pharmaceutical industry. It is basically that industry’s entire research business model. Funny that public health seems unbothered by this.

The thing is, if the public health people wanted to question this research based on conflict of interest, they had a good basis for doing so based on information that was prominently disclosed: Henschke owned the IP for the technology she was studying. Unrestricted research grants do not create much conflict of interest; making a middle-class living while doing grant-funded research is not going to motivate any competent and honest researcher to skew her results. Someone would have to have a serious lack of a moral compass for that to matter. Indeed, people who make a big deal about their lack of industry grants are the equivalent of people who tell you “I have not had a drink is over eight years”: The real message is a confession that they personally have a defect such that if they drank (or accepted such a grant) it would create serious problems. This is the speaker admitting there is something wrong with himself, and does not change the fact that most people can drink (or accept research grants) harmlessly.

But owning IP for a potentially breakthrough technology is a different story. It creates dreams of becoming a billionaire, and that is an incentive that poses a serious challenge to intellectual integrity, bigger even than drawing a salary from an organization with an interest in the results, let alone getting grants. But somehow these people who claim to care about conflict of interest — including the one who wrote a (presumably really bad) book on the topic — seemed to not understand the real conflict of interest. It is notable that more than a few anti-THR people own interests in other smoking cessation technologies, but this never seems to get mentioned.

Those who talk the most about conflict of interest seem to understand the least about what it really means. Is there a conflict of interest in a cigarette company supporting research to find a cure for lung cancer? No, not any more than if they supported research to find a cure for malaria. They have an interest in finding a cure for lung cancer, but that does not create any conflict with doing good and honest research. Of course, it does create a conflict with the goals of “public health” tobacco controllers because they do not want a cure to exist. A reduction in the toll from lung cancer would be a threat to their business model — threatening both their funding and their foundational myth of tobacco companies wanting their customers to suffer — and also represent undeserved relief for the sinners who they claim to care about, but really despise.

[Update: See more on this theme by Dick Puddlecote. It also ties closely to several of the themes in my “Why is there anti-THR” series.]

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21 responses to “Public health (heart) lung cancer

  1. Reblogged this on caprizchka and commented:
    Love this: “By not prominently disclosing the source of funding, Henschke performed a very useful experiment of a different sort, pointing out how public health people do not care about accuracy of scientific research or its potential benefits. They only care about whether it was motivated by the extremist goals of their special interest group or by some real societal interest. ” The same would apply to Global Warming chicken littles, Feminists, “Diversity” advocates, and the entire Leftist catalog of public shaming advocates.

  2. Your post makes sense (of course), Carl, but it would make even more sense if you were able to provide an outline of the extent to which treatment for lung cancer has improved over, say, the last 50 years. I do not believe that there is a ‘magic bullet’ as yet. But improved treatment approaches the ‘magic bullet’.
    Does tobacco control oppose improved treatment? It looks like it. It looks as if tobacco control regard improved treatment as a waste of money – better to let the disgusting, filthy, stinking smokers die. Following on from that FANATICAL idea, ecigs must be opposed at all costs since they might delay the extermination of smokers.
    What I find very interesting and amusing is that the scenario is changing all the time. I like that since it promotes the emergence of the sort of nonsense which brought about prohibition of both alcohol and tobacco about 100 years ago.

    • Carl V Phillips

      Treatment has improved some, certainly, but remarkably poorly. The probability of surviving five years after a lung cancer diagnosis — at the state it is actually diagnosed usually because of a lack of a viable early detection method — is horrifically low. Those in power regard pursuing methods for detection or cure to be a waste of money, yes. But it is even worse than that, as evidenced by the passage I quoted: They actually actively think it would be bad even if it were free. And I also agree that the lies and fanaticism are exactly those of other prohibitionists, whether there personal vision of evil is alcohol, tobacco, cocaine, homosexuality, or whatever.

  3. natepickering

    As with any abstinence-only ideology, “punishing the sinner” is of paramount importance to tobacco controllers. It’s one of the main reasons why they’re so vehemently opposed to vapor products, because they simply can’t tolerate a scenario in which smokers can quit smoking, enjoy all of the health benefits associated with smoking cessation, AND not have to sacrifice any of the pleasure they derived from smoking and/or nicotine.

    In the worldview of the tobacco controller, smokers must either quit or die, and if they go the former route, there MUST be some sort of torment and suffering involved, because smokers must be punished for having chosen to smoke in the first place.

  4. lecroixkwdjer

    Brilliant as always, but I personally don’t believe smoking causes lung cancer or any other disease. I believe it is mainly harmless and only people with grave medical problems may find their conditions aggravated because of smoking. And I say “may”. Anti tobacco extremists simply invented, out of thin air, a relationship between smoking and lung disease. It looked rather believable and even “obvious”, since the smoke goes directly into the lungs. But there is no real relationship, as numbers show.

    Therefore it’s not of much importance to me whether antis want a vaccine or not. I regard them as completely dishonest and evil, no matter what. They are fueled by hate and greed and by no means care about anyone’s health (or job, for that matter)

    • Carl V Phillips

      Well, I hate to be the millionth bearer of bad news, but doubting that smoking causes lung cancer is kind of like doubting that THR works or that the Earth is round. I totally agree that the quantitative claims that the ANTZ put out about the number of lung cancer cases/deaths — and even more so for other diseases — are basically just made-up numbers and undoubtedly higher than the truth. Anyone who believes the quantitative claims are accurate is a naive dupe (and I include lots of THR supporters in that category). But long before there were anti-THR liars, or even anti-smoking liars, there was overwhelming evidence of substantially elevated risk.

      • lecroixkwdjer

        Yeah well, before the Earth was round, the consensus was it wasn’t :) Just because many believe one thing it doesn’t necessarily mean that thing is true. But anyway, I agree the antis make up figures, because their numbers are simply impossible to know. Their figures are just prejudice. And since they are wiling to lie in some figures, the rest of their figures are not to be trusted either, in my view. Besides, they do not agree with reality. Yet, to me, it is good enough that more and more are beginning to question some of their figures.

        • natepickering

          “Yeah well, before the Earth was round, the consensus was it wasn’t”

          The key difference here is that no one ever walked off the edge of the Earth and plunged to their death.

      • Have you heard about the McTear case ? Full case here http://www.scotcourts.gov.uk/search-judgments/judgment?id=c77c86a6-8980-69d2-b500-ff0000d74aa7 The creme de la creme of UK’s antismoking movement circa 2005, including Richard Doll weren’t able to convince a judge that smoking causes lung cancer. Actually, they made themselves look rather bad, being short on facts and long on propaganda and appeal to authority (Surgeon General). What do you know that they didn’t ?

  5. I was dx with lung cancer five years ago. Purely incidental when I had a CT for an unrelated condition. I had surgery, no further treatment, stopped smoking for a while then decided I didn’t want to give up. I have my five year scan next month and so far I have been fine on all previous scans. As I had no symptoms I don’t know when it would have been found but it does show that early dx makes a difference. I had smoked for over 50 years when dx and I am happy to take my chances in future. There has been an increase in non and never smokers getting LC, especially women and young people. I have yet to hear an explanation for that.

  6. Public health doesn’t seem to be really interested in protecting our health,does it.Perhaps,one day it will,but I doubt it!

  7. The a priori thought is that smoking “causes” lung cancer, …just as sure as the sun revolves around the earth.

    In a 2011 preliminary study of LC patients in the (highly stressed) Veteran population, Campling et al found that for 1/3 of their sample, symptom presentation was related to cessation without difficulty. This suggests an adaptive self medication effect for stress related respiratory disorders. They suspect “Insular Stroke” a pathological condition, may be involved in the cessation process.

    “Spontaneous smoking cessation before lung cancer diagnosis.”
    http://www.ncbi.nlm.nih.gov/pubmed/21258255

    Typically those who currently and formerly smoke are lumped together as “smokers”. Well, “causation” is not that clear cut when the temporal aspects of cessation are properly taken into account.

    Yet, the Tobacco Control influence suggests “Our study could be dangerously misinterpreted to suggest that those who have smoked heavily for most of their lives might be better off to continue smoking.”

    But that is exactly what those with an obviously functional Insula are doing when they continue to smoke. Galileo is turning in his grave.

    • Carl V Phillips

      As I noted, many quantitative claims are exaggerated. But it does no one any good to try to deny what is obviously true.

      The bit about study results being spun to deny what they actually imply (even if it happens to be wrong) is a common game. I am not sure what the deal is with this one (I am not going to follow up on it, I am afraid), but the characterization of it reminds me of one that Rodu and I wrote a letter about. It is in the blog archives somewhere if anyone wants to find it. The claim was that people who kept using snus and smoking after an MI (I think that was the disease) had a worse outcome than those who quit then. What they carefully avoided admitting was that those who quit also had better outcomes than those who did not use the products in the first place (which were about the same as those who kept using). So the implication really was that if you have an MI, you should hope you use tobacco, because then you can quit and be in the lowest risk group. I believe I titled the post something along the lines of “If you have an MI, you should hope that you use tobacco.”

    • I have personally known five people who had smoked for many years then suddenly and easily stopped. All developed Cancer within two years, two lung, two colon, and one oesophageal. No wonder I decided to keep smoking!

      • Carl V Phillips

        Um, we do have a whole science devoted to detecting whether phenomena like that really exist, you know. It is often abused and badly practiced, but it is pretty good at detecting such effects, looking at not just exposed cases but the other three boxes in the 2×2 table that is needed to figure out whether there really is an elevated risk. There happen to be a lot of studies that would show this pattern if it really existed.

  8. Bill Godshall

    Just because some public health officials, agencies and advocates staunchly oppose THR products and policies (especially those appointed and funded during the Obama administration) doesn’t mean that everyone in the field of “public health” opposes THR products and policies.

    Many/most THR advocates are public health advocates, and some public health agencies (e.g. PHE in the UK) support THR.

    So while its accurate to claim that tobacco controllers oppose THR,
    it is not accurate or fair to claim that public health opposes THR.

    • Carl V Phillips

      It is silly to suggest that this has anything to do with the Obama administration. The U.S. government was the leading anti-THR liar from the dawn of serious anti-THR (when Clinton was POTUS) and throughout the time Bush was POTUS. The only reason that there is more activity now is because THR and anti-THR have both continued to increase over time, and because an act of congress created CTP. Oh, and don’t forget the states, in terms of both the MSA and current activity.

      It is undoubtedly the case that some people who self-identify as public health oppose the turn toward junk science and nanny statism (of which anti-THR is only one symptom) that that once respectable field has taken. But they had their chance to defend their brand and did not do it. The only viable response when something like that happen is to write off the whole lot of them. We should not feel any sympathy for those who are not part of the problem if they made no attempt to be part of the solution. There is not a single institution — school, journal, organization — I can think of that identifies as being public health (except for some of us like CASAA you use it ironically as a slap at those people) but that pushes back against the perversion of the concept. So they can just all sink together. It is no different when a political party does not have any visible faction pushing back against its prominent racists, feudalists, and junk-economics espousers: there no doubt are members of the party who are not racists and who understand basic economics, but if they do not stand up, then it is the party of racism, feudalism, and junk economics.

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