28 September 2010

Anna Gilmore adds junk economics to her junk epidemiology portfolio

I have a few other topics I am in the middle of essays about, but I thought I would write a quick comment on this one and save Snowdon the trouble of having to be the one to always point out Anna Gilmore’s junk science.

Gilmore decides to fancy herself an economist in her latest article (Tobacco Control 2010, “The case for OFSMOKE: how tobacco price regulation is needed to promote the health of markets, government revenue and the public” – don’t worry about the title, it does not really have much to do with the article).  Actually, her second author is apparently at a business or public policy school, but if he is actually an economist, more the pity that this is such junk.  The article deals with the concept of “market failure”, economics jargon for factors that interfere with the invisible hand causing the free market to provide optimal allocation of goods, labor, etc.  The most familiar example is probably “negative externalities”, where someone who is not a party to a transaction or decision (and thus cannot demand compensation or otherwise influence what is happening) suffers because of it, anything from pollution to traffic to increased public expenditures on healthcare.  In that case, more of the activity takes place than is optimal from the perspective of economic efficiency (which roughly means maximizing how well off everyone is).  The market failure that they use as their excuse for this article is “market power”.  Basically, market power exists when a seller (or a buyer, but let’s just stick with the one case) controls so much of the market that it can increase its profits by doing something other than selling at the competitive fair market price. 

Generally this refers to being able to raise prices and increase profit.  A grocery store cannot decide “hey, we would make a lot more money if we sold Coke for twice the price; we would sell a bit less, but make a lot more profit”.  What would happen is that they would sell almost none (and perhaps lose other business too) because it is easy for consumers to find a fair price elsewhere.  A movie theater, on the other hand, can sell Coke at many times the competitive price because they have the ultimate form of power over the market:  they are a monopoly seller of Coke for everyone in the theater.  Sure, they might sell twice as much if they offered it at the grocery store price, but they are making five (ten? maybe twenty?) times as much per unit sold, and so they come out ahead.  Because they have that market power, they can increase their profits by selling fewer units for more money, unlike the grocery store in the competitive market that would sell almost nothing at the higher price.

Backing up a step to the more familiar market failure, Gilmore et al. have a throwaway line about externalities existing in the “tobacco” market (alluding to second-hand smoke and the possible increase in medical costs that someone else pays for), though what they do not admit is that taxes on cigarettes pay for considerably more than the external cost to society, and taxes on smokeless tobacco are basically pure revenue since the externalities are trivial, so the market failure is actually in the other direction.  That is, the taxes raise the prices well above what would be efficient to eliminate the market failure.  Put another way, if we really believed that tobacco taxes were just a way to make up for negative externalities (which if not corrected will lead to an inefficiently high level of smoking), as is often claimed, then the rates have been set so that there is too little smoking.  Really!  That is not to say that I think there is too little smoking.  But if Gilmore et al. are going to play the game of pretending to care about market failures, they are stuck with the implications of it, and so apparently they think there is too little smoking.  This becomes even more apparent when we further examine the implications of producers having market power, which they claim bothers them.

A bit of background in basic economics is needed here, so bear with me for a couple of paragraphs.  How can a company with market power increase its profit?  By selling less, but at a higher profit per unit.  The case of the movie theater is a bit misleading because basically they set the price and sell whatever quantity people buy.  A better way to think of it in most cases is that the producer constrains the supply, which means that people are willing to pay more for the last unit because there is what might be called a shortage.  But either way you think of it, this should be obvious:  You cannot sell as much of something if you decide to push the price up to Y as you could at the competitive “market clearing” price X (Y>X).  Whether you can better get your head around that by thinking “if they raise the price, they will sell less” or “if they want the price to be higher, they need to supply less” does not really matter – whichever works for you.  The basic point is that if a seller has market power and so can reduce supply or raise the price then they can make more profit (at the expense of consumers, who are not able to buy as much as cheaply as they could).

So what does this mean?  When a company (say the electricity or cable television/internet company) has a monopoly (in that case a “natural monopoly” because it makes no sense for another company to duplicate their infrastructure by stringing cables), if we do not have strong government controls to keep the price down, the company will jack up the price to an inefficient (from the view of an economist) or unfair (in the typical consumer view) level.  For the case of cigarettes, it means that because there are relatively few cigarette makers supplying most jurisdictions (especially at the high-quality end of the market) and there are not price controls, the suppliers can make a bit more money by restricting supply a bit.  And while they cannot do so as much as the perfect monopoly that controls all the Coke in the theater or cables in a town, they inevitably do so to some extent.  So what Gilmore et al. are complaining about is a market failure that causes a *reduction* in supply.

I can see why Gilmore and friends are so incensed about that – their sense of worth is justified by the popularity of cigarettes, and those evil cigarette companies are reducing the popularity (sales/supply) of the product just to make more money.

To be less glib (but arguably just as damning), when you read the article it becomes clear that what they are really bothered by are the industry profits per se, not market failure or even the consumption of cigarettes.  It is not so much that they worry for humanity as they just hate particular companies.  I guess that should have been obvious.  They try to dress it up a bit with allusions to economic policy, but that is really just an attempt to dress up personal pique.  (Note also that since the Western cigarette companies are publicly traded and widely held, this is basically just an attempt to confiscate the share value held by thousands or perhaps millions of random investors.  If the idea is to attack capitalism, though, there are much better targets.)

They call their proposal (explained below) “radical”, but if they really cared about reducing smoking rather than their pique about shareholder profits, the serious radical proposal would be to figure out how to make the companies profit more by not selling cigarettes. 

So what do they propose?  They propose capping the price that producers can charge (i.e., what the manufactures can charge when they sell cigarettes to distributors/merchants) but imposing huge taxes that raise the retail price well above this to reduce demand (and pull in big money for the government who implements the plan at the expense of smokers).  They wax about how price caps are enforced on public utilities, conveniently ignoring the fact that the reason this is done is not to intentionally hurt the utilities' shareholders but to help consumers buy more.  I.e., the goal is to make sure that prices are kept low so that consumers can enjoy more electricity or cable television at a reasonable price.  In other words, the analogy is “cigarette companies are charging too much and that is hurting consumers who would like to smoke more, so we should impost price caps.”  What they are proposing does not actually do anything to correct the market failure, and so has absolutely nothing to do with the justification they try to give.  Either they do not understand that point or want to mislead their readers about what the science really says (those familiar with Gilmore’s previous writing may have a bit of a conundrum trying to pick between those).

On top of all that, if they understood enough economics to have any business writing this article, they would know that this is effectively equivalent to what is already done.  What they propose is somewhat different, with much more micro-management, but the effect is basically the same as high taxes:  A wedge is driven between what the producer collects and what the consumer pays.  This raises the price (straightaway lowering demand) while reducing the revenue of the producer.  Their plan differs only because *perhaps* they can reduce the profitability of the manufacturers more than just taxing the product does, but that is only if they get the details just right.  If they get the micromanagement wrong then either (a) they effectively eliminate legal manufacture (but not the black market), something that governments could do directly if they really thought it was proper, but do not or (b) the policy is exactly equivalent to the taxes we have already.  Perhaps the regulators could thread the needle and reduce rents without making it impossible to stay in business, but I seriously doubt it; the amount of effort that goes into setting the right prices for public utilities is huge, and manufacturing cigarettes is a rather more complicated market.  To avoid the risk of (a) they will have to tend toward (b).

(I have to include the aside that the market is so much more complicated than electricity and such, which is mostly about just price, and so quality would probably be affected by this regulation.  One thing that would likely happen would be to reduce the availability of premium products in favor of lower-end products, since the former would be more expensive to make but would probably face the same price ceiling.  This would inconvenience high-end consumers who would be forced to smoke something they liked less or turn to the black market.  This might be another bit of a hidden agenda, but again there are easier ways to lower product quality than coming up with some incredibly complicated regulatory scheme, and pretending that such an act is an implication of economic theory is particularly dishonest.)

The most important point is that even if some perfect version of Gilmore's proposal were pulled off by the bureaucrats, it would do nothing on the consumer side that existing excise taxes do not already do.  It would change nothing for public health, in other words.  All it would do is take money from the shareholders of cigarette companies and transfer it to the government, and then only if it worked right.  This could be done much more easily and honestly by simply imposing an extra corporate tax on cigarette companies or just confiscating some fraction of all publicly held shares; such action, along with the sales taxes, would be exactly the same as the Gilmore proposal, but would be much easier to implement.

So this is their “radical” idea?  Putting a new label on basically what is already being done, perhaps with a bit of nationalization of the companies, and making the absurd claim that this has something to do with the economic theory of market failures?  The most charitable interpretation is that this is just an attempt to use junk science as an excuse for a preferred policy, to transfer corporate profits to the government (something that can be done any number of ways that would work better if that is what government decides to do).  Well, I suppose given Gilmore’s demonstrated abuse of epidemiology there was no reason to expect anything else.

Want a real radical idea, backed by actual economic theory and evidence, one that should be embraced by anyone who cares about the health effects of smoking?  How about this:  Alter taxes and other regulations such that consumers can buy low-risk nicotine products (of whatever sort) for about 20% less than cigarettes and such that suppliers (who can include any company that is good at selling high-quality-controlled products to consumers) can make more money selling those products and so have the incentive to encourage smokers to switch.  (For the economists in the audience, the latter refers only to the short run period of disequilibrium, of course, since excess profits are not possible in the competitive long run.)  Unlike the barrage of loony, coercive, and damaging (to the principles of good government and science) proposals that show up with junk science window dressing, I would contend that this would radically reduce the public health burden of nicotine consumption, and it would do so while respecting consumer choice, not making people hate the government, and not undermining the  scientific integrity of epidemiology and public health (and now economics).

Update:  Chris Snowdon has posted at his Velvet Glove Iron Fist blog some further analysis of this nonsense.  He notes some historical examples of supposed anti-smoking activists complaining about manufacturers raising prices and further addresses what this says about their real motives.  Also, the title for his post gets the highest possible praise (i.e., I said "damn, I wish I had thought of that"):  "You can't rip people off, that's our job!"

26 September 2010

Our comments to the FDA re graphical warnings on cigarettes

A bit of a long post, but it would be nice to put this somewhere where a few people will actually read it....

Comment regarding Experimental Study of Graphic Cigarette Warning Labels
OMB Control Number 0910-NEW
Docket No. FDA-2010-N-0079

as appears in Federal Register, v.75 no.164, 25 August 2010, p.52352

by Carl V. Phillips, MPP PhD
on behalf of myself and TobaccoHarmReduction.org (other contributing members of TobaccoHarmReduction.org including Paul Bergen, Karyn Heavner, and Catherine Nissen.

I am a researcher and public educator focused primarily in the area of tobacco harm reduction, as well as various other aspects of epidemiology, health and policy ethics, health communication, and scientific epistemology.  I spent most of my career as a professor of public health and now direct an independent scientific research group.  My CV can be found here: tobaccoharmreduction.org/team.htm.  This year I have done a great deal of secondary research that focused on the effects, politics, and ethics of graphical warning labels, particularly for tobacco products.

The following comments are based primarily on my concerns about good and honest science and health communication, and about policy ethics.  It might be that ignoring some of the cautions contained here might actually benefit the cause of tobacco harm reduction (e.g., seeking graphic labels for cigarettes that fail as warnings because they mislead and merely inflict emotional violence on consumers might drive more consumers to low-risk alternative products).  But that end does not justify conducting misleading science or research that is aimed at supporting unethical public policies.  Moreover, bad science in the area of tobacco policy has a tendency to be particularly damaging to harm reduction efforts, which depend on the science to push back against the political power.

1. For a graphic to be a warning, it needs to primarily convey information.

There seems to be some confusion about what warning labels should do and how they can be assessed.  While there are those within the anti-tobacco activist community who are willing to inflict almost any cost on scientific integrity and good public policy in order to discourage tobacco use, the United States government should not condone this, let alone contribute to it.

It is possible to alter any product’s packaging to lower the overall quality of the experience of buying, having, and consuming the product, and thus reduce consumption (see Thrasher et al 2007 for an illustration of how graphical warnings lower the perceived value of cigarettes).  Options range from requiring ink that rubs off and stains consumers’ hands, to implanting an audio chip that periodically emits an unpleasant noise, to printing offensive graphics on the product.  In general, these could not be called warnings, except if the sound or graphic actually communicates accurate information about risks.  Moreover, context matters.  A picture of a diseased lung might legitimately constitute a graphical warning on a package of cigarettes (at least if it were used in a non-literate community that was somehow not already aware of the risk), but would clearly not be a warning on a package of carrots.  Yet the repulsive picture would lower the quality of the package of carrots to the consumer, even if no consumer were so ill-informed as to believe that carrots cause lung disease.

All of these hypothetical package alterations, including the ones that are not actually warnings, will reduce consumption of legally marketed cigarettes.  (They would increase the demand for black market cigarettes, though the net effect on total consumption should be negative.)  Perhaps a particular alteration would make such a small reduction that it would not be possible to measure it, but welfare economics tells us that any alteration that lowers quality product will result in less demand.  Most of these reductions, however, would not be the result of successfully warning someone about a risk.  For the case of shocking graphics that have not been shown to communicate accurate risk information, but merely to repulse consumers, the correct characterization would not be “warning label”, but rather something along the lines of “emotional assault label”, something that manipulates people by triggering an emotional reaction, in particular by inflicting emotional violence.

The FDA has a long history of successfully and appropriately using legitimate warning labels, and has a mandate regarding graphics-based warning labels for cigarettes.  However, the FDA does not have a mandate to engage in emotional violence via labeling, and moreover, it would be ethically inappropriate for the U.S. government to intentionally inflict emotional violence on a large portion of its citizens, particularly if it does not communicate accurate risk information.  Thus, evaluation of proposed graphical warnings should distinguish between warning and emotional violence.

A graphic that produces distress, but not by way of increasing awareness of a previously unrecognized or underestimated risk, is inflicting emotional violence.  Thus, a study that finds a negative or distressed reaction to a label without an accompanying (accurate) change in the estimate of its risk is merely violence, not warning (see Hammond et al 2004 for an example of a study that measures emotional reactions such as fear and disgust in response to graphical warnings, rather than accurate risk perceptions).  In order to do proper scientific research on this topic and to inform ethical public policy, it is necessary that the evaluation of the effects of the graphics be able to distinguish between conveyance of information and mere behavioral manipulation through the infliction of emotional violence.

2. The measure of the success of a risk warning label is whether it moves people’s perceptions closer to the best scientific estimates.

Some warning labels are intended as immediate alerts rather than warnings about risk.  Such warnings – such as “do not step here or you will fall to your death”, “do not open this case or you will be electrocuted”, or “do not drink any of this because it is a deadly poison”, as well as “absolutely no unauthorized persons should open this door” – are designed to be substitutes for the impossible act of prohibiting an action and physically enforcing the prohibition.  These contrast fundamentally with warnings that are intended to convey decision-relevant information about risk, like the labels that FDA is already very familiar with.  These alert-type labels can be reasonably evaluated based on whether they help ensure that the particular action is not taken, and since the goal is to be the best available substitute for physically prohibiting the action (walking near a cliff, opening the wrong door, etc.) it does not necessarily matter whether people understand the probability of the risks or anything else.

While some anti-smoking activists want people to believe that smoking a cigarette results in immediate peril, this is obviously not a correct characterization.  Obviously smoking is not like accidentally swallowing poison or stepping off a tall cliff, which everyone would want to avoid, and thus be grateful for any signage that prevented it.  Rather, smoking is a voluntary act with a complicated collection of benefits and costs, and even someone who cannot understand why many people feel that the benefits exceed the costs must recognize that the costs do not include peril of sudden death that would warrant alert-type warnings.  Moreover, the FDA’s mandate with regard to tobacco products explicitly excludes prohibition as an option.  Thus, the use of graphics and methods of evaluation that are appropriate for alert warnings (whose intentions are to substitute for a physically enforced prohibition), is inappropriate in the present case since the peril is not imminent and prohibition is not allowed, and thus neither is crypto-prohibition.  (If prohibition is prohibited then extreme measures that are functionally equivalent are also prohibited.  A hypothetical package graphic that was so horrifically emotionally violent that it discouraged almost everyone from buying cigarettes would basically be prohibition, much the same way that imposing a $1000/pack price or restricting cigarette sales to one store in Montana would be.)

If a smoker believes that his lifetime risk of lung cancer is 90% (a gross overestimate but one that many smokers believe (Slovic 2001)), and the label causes him to revise that estimate to 95%, then the warning label has failed in the particular case (see Magnan et al 2009 for an example of a study that indicates that negative emotional reaction and increased risk perception are measures of success of graphical warning labels; whether or not these risk perceptions are accurate is ignored).  Employing a graphic that systematically caused smokers who overestimated a particular risk to increase their estimate would be a form of lying to the public.  Not only would this be a failure of a risk warning, making people’s understanding worse rather than better, but it would arguably be unacceptable even for an alert warning.  Even in the case of legal and ethically-defensible prohibitions, it is generally concerned unethical for the government to lie to people to manipulate their behavior (e.g., the U.S. government prohibits cocaine use, but should not tell people that using it will inevitably kill them in a year, both because it is unethical and illegal for the government to lie, and because it ruins the credibility of honest health messages the government might want to convey; note also the example of anti-condom rhetoric by the U.S. government).

There are three goals stated for evaluating the effects of the labels on consumers.  The first is “conveying information about various health risks of smoking.”  This accurately describes the proper role of a warning label.  However, the other two goals, “encouraging cessation” and “discouraging initiation” either pre-declare what the data will show or declare that the intention is coercion rather than warning.  Conveying information will only encourage cessation if the information corrects underestimates about risks, either in terms of probability or severity.  In the above example, the smoker who now overestimates his risks even more is more likely to quit smoking, but this represents a success of manipulative propaganda, not a successful ethical warning.   In the Federal Register entry to which these comments respond, FDA defends survey questions about intention to quit against critics who complain that they are not effective measures of actual future quitting.  But both the comments and the defense overlook that measures of intention to quit, whether accurate or not, are not measures of whether the warnings effectively communicated about risk, at least not without substantial further information. 

In sum, if this study were intended to evaluate, say, a project to convince children to stop smoking, then a behavioral outcome measure would be appropriate.  But this is explicitly stated as a study of warning labels, and as such needs to be evaluated based on accuracy of communication, not successful manipulation of people’s behavior through any means.  In the Federal Register is the statement, “FDA agrees that it is important to ensure that the graphic health warnings convey accurate information about smoking risks to consumers,” which makes clear that the FDA is aware of this distinction.

In pursuit of this stated goal of the study, it is important to ask the following about any question posed to subjects:  If the answer is X, will we know whether this represents successful accurate warning of risks or mere emotional manipulation of the subject?  Obviously the answer will be “no” for some individual question in isolation, but if the answer is “no” for most questions, and especially for combinations of answers from multiple questions, then the evaluation instrument will be a failure.  A survey design that creates a situation where a particular combination of answers leaves us knowing only “either Y or Z is true”, when the difference between Y and Z is important, is a bad survey design.  Previous studies relating to this topic have generally (perhaps intentionally) failed to distinguish between successful warning and infliction of emotional violence, declaring to have found the former based on data that equally (or better) supports the latter.

3. It would be very useful to test whether graphical labels can effectively communicate that other nicotine products are far less risky than cigarettes.

The Federal Register entry includes not only the previous quote from FDA that warning labels should provide accurate information, but an outside comment (which FDA reports and implicitly agrees with) that warning labels should communicate about cessation methods.  Since switching to a low risk alternative nicotine product is a very effective method of smoking cessation for many users (many of us conclude from the substantial evidence that exists that it is the most effective method), but the major barrier to switching is inaccurate risk perceptions, learning whether graphic warnings could inform users about that option would make an extremely valuable contribution to public health.  Indeed, if the graphic warnings prove ineffective at improving accuracy of perceptions about smoking risk (which seems quite possible given previous studies), and even emotionally violent graphics have little long-term effect other than inflicting distress (which seems quite likely given previous studies), then learning about ways to communicate harm reduction information could be the only contribution of these labels to public health.  Unlike the risk for lung disease, which is known by basically the entire U.S. population, only a small minority knows about the low risk of other nicotine products.

Furthermore, it is possible for label graphics (particularly the ones that are not legitimate warnings) to convince current smokers that they are already doomed, creating a fatalism that discourages cessation.  Research might show that labels that encouraged switching to low-risk products can help counter such unfortunate messages.

We proposed simple analog quantitative graphics that could communicate this information in Bergen and Heffernan (2010).  Other candidates could easily be created.  We are not aware of any tests of any graphic warnings that communicate this information.  Such tests would be very feasible within the context of the proposed study, and would not substantially take away from other study goals.  If the FDA is genuinely interested in reducing the health costs of smoking and learning about major questions that we do not already have good answers to, it should include one or more graphics that try to communicate comparative risks and test their effectiveness.

Since learning about these labels would in no way create an obligation to use them, debates about the wisdom of promoting tobacco harm reduction have no bearing on the present point:  This is a research study, not a proposed implementation.  It would be useful to know whether the right graphical label could effectively educate people about the potential for harm reduction, even if it is later decided that such is not among the goals for the labels.  Since much of the anti-harm-reduction rhetoric is based on the claim that it is not possible to accurately communicate the relevant information or that smokers are not interested in learning about comparatives risks, only if we learn what the label would accomplish can there be a legitimate informed discussion of whether it is appropriate.  Failure to take the opportunity to confirm or deny those claims, by testing a label that communicated about the option of cessation by switching products, will be interpreted as intentionally avoiding finding out the truth about how effective that could be.

Bergen PL & Heffernan CE (2010). An analog visual comparison of best, current and worst case scenarios in (tobacco) harm reduction; numeracy-aiding tools to get the message across. In Phillips CV & Bergen PL (eds.) 2010. Tobacco Harm Reduction 2010: a yearbook of recent research and analysis.

Hammond D.; Fong, G. T.; McDonald, P. W.; Brown, K. S.; and Cameron, R.  (2004). Graphic Canadian Cigarette Warning Labels and Adverse Outcomes: Evidence from Canadian Smokers. American Journal of Public Health, 94(8).

Magnan, R.E.; Köblitz, A.R.; Zielke, D.J.; & McCaul, K.D. (2009). The Effects of Warning Smokers on Perceived Risk, Worry, and Motivation to Quit.  Annals of Behavioral Medicine 37, 46–57

Slovic P. (2001). Smoking: risk, perception, policy.  Sage Publications.

Thrasher J. F.; Rousu, M. C.; Anaya-Ocampo, R.; Reynales-Shigematsu, L. M.; Arillo-Santillán, E.; Hernández-Ávila, M.  (2007).  Estimating the impact of different cigarette package warning label policies: The auction method.  Addictive Behaviors 32, 2916–2925

11 September 2010

Another apparent case of trying to intimidate and censor an independent researcher who published an unpopular result

I am not quite sure what the full story is, because I am just going on what was written in an article in the Toronto local newspaper and I am a bit hesitant to ask the principal for an interview (the reason will become clear).  The article recounts how anonymous actors tried to harm the career of David Colby MSc MD, apparently because he wrote a couple of reports that declared that there was no health risk to local residents from Wind Turbines.  Colby's is the Medical Officer (a quasi-governmental appointment as part of the health system, but close to academia in terms of not taking away one’s independence) for a jurisdiction in western Ontario near Detroit USA.  He is also an associate professor at University of Western Ontario, though I am not sure if he is a "real" professor (he does not have a doctorate) or just one of the many clinical trainers at health science programs that get an academic title.  The point is not the specifics of his titles, though, but that he is an independent researcher who speaks only for himself, and thus has the right to do what research he wants and report whatever conclusions he honestly believes his research supports.

The newspaper article portrays the controversy about wind power following the usual mainstream media approach of trying to make complicated scientific and political controversies sound like football matches (or in this case a tennis match, because it portrays it as a one-vs-one battle with another Ontario professor who takes the other side.  (Bob McMurtry, the opponent in the tennis match, also reports hostile reactions to his conclusions -- which are quite similar to my own, and he has invited me to speak at a conference he is hosting on the subject -- but no apparent attacks on his scientific freedom.)  But the details of the article I can verify seem accurate, so I am inclined to believe what was reported.

Colby was the first author of the North American wind energy industry's major report on health risks, a report that I critiqued at some length.  Before that he did a similar analysis for local authorities in his area.  He also apparently accepted an honorarium to give a talk at an industry conference (a sum that was reasonable if he had to do much work for it, though generous if it was a reward for just showing up at a meeting -- the article does not make it clear).  In any case, there was nothing wrong with him doing it but, according to the article, it was this talk and honorarium that was the basis for "someone" -- presumably cowardly hiding behind a veil of secrecy since the article did not offer any further identification -- trying to cause his medical license to be taken away.  Of course, “someone” would not have cared at all about him giving a talk to people who already agreed with him or them paying him for it, and so was undoubtedly really trying to punish him for his published reports.

Fortunately the relevant committee dismissed that attack as groundless.  His cowardly attacker apparently filed an appeal, though, which is pending.  But, according to the article:
The committee did offer one caution that grates on Colby and has been seized upon by those opposing wind turbines: "Colby's expertise is in medical microbiology and infectious diseases, an area quite distinct from audiology or other fields related to the physical impact of wind turbines on human health. Thus, the committee wishes to remind Dr. Colby, going forward, of the importance of fully disclosing the extent of his qualifications in a field in which he has been retained as an 'expert.' "
I found myself absolutely appalled upon reading this, for several reasons.  Importantly, a belief that Colby and his coauthors did good work or genuinely have the expertise to have written what they did is not one of them.  When I was asked to evaluate the scientific quality and accuracy of the North American industry report, what I wrote is the type of thing that puts the word "savaged" in the critical review vocabulary:
It is notable that the Colby et al. panel did not include any population health researchers, even though the question they claim the report addresses is one of population health.  Their expertise seems to be limited to the relevant physical sciences and clinical medicine.  ....  Some clinicians are trained and qualified population health scientists, but there is no evidence that those who participated in the Colby panel have such expertise.  Unfortunately, it is often the case that physicians who may be quite skilled in their clinical abilities do not recognize that population science requires an entirely different set of skills.  ....  [The section that addresses epidemiology in] the Colby report exemplifies the lack of expertise in population health science.  It is difficult to make this clear without seeming petty, but this section reads like it was written by someone who took a single class on how to understand epidemiology, and half understood the material.
Nevertheless, someone trying to take away his medical license is very much like the intimidation and attempted censorship that I (for daring to question the anti-tobacco extremist orthodoxy) and Jim Enstrom (for two different bits of his work) suffered.  And the scolding from the medical committee is equally absurd.  Someone does not lose his right to become an expert on and provide analysis of another substantive area just because he knows something about infectious diseases.  (I speak from the perspective of a repatriated American, but even Canada protects free speech to this extent.)  By that standard, we would not have many people writing about tobacco harm reduction in North America since our original training includes infectious disease epidemiology (Heavner), as well as oral pathology (Rodu), information science (Bergen), and environmental economics (Phillips).  If someone wanted to assess on his merits whether Colby was not really an expert, that is fine -- I certainly did so -- but there is no evidence they did that.

I have to admit some sympathy with the "stick to your own expertise" attitude.  But the real problem is not expanding one's area of topical expertise, but rather that when most physicians, regardless of specialty, are asked to comment on epidemiology (or at least any epidemiology that involves data that is more complicated than a simple clinical trial) they are wading into territory they are not expert in.  But because medical training includes teaching people to pretend certainty about everything they know a bit about, and they start to believe their own rhetoric, physicians seldom seem to know they are not experts.  On average they are probably better at epidemiology than the average educated person, but still only qualify as educated consumers of it, not able to produce quality research let alone evaluate the evidence.  But threatening their medical licenses because they are mediocre scientists makes about as much sense as trying to prevent me from doing scientific analysis because I did a bad job of applying a bandage or misdiagnosed why my shoulder hurts so much.  I am a mediocre medic and they are mediocre analysts of science -- that does not mean either of us is bad at what we are really expert in.

More generally, trying to punish someone for exceeding their officially-approved expertise is a very scary behavior.  Do we really want quasi-governmental authorities deciding who is qualified to carry out particular scientific analyses (and who is forbidden from doing so)?

This is especially true when the real solution is rather obvious:  First, the health press, regulators, and everyone else need to get a clue that most physicians do not have very much expertise in populaton science that is any more complicated than a randomized trial (and even then the average physician is pretty sketchy).  It is not their job to understand public health science, and they are generally not trained in it.  I suspect that the average field biology researcher would be better at it, and there is no doubt that the average economist would -- public health research looks a lot more like economics than it looks like clinical medicine.

[Note:  I apologizing for insulting my readers with this caveat, but I have a feeling someone is going to blow a gasket if I don't help them out with the logic:  This is not to say that there are not people who happen to be physicians who also happen to be educated in population science and have practiced it enough to be good at it.  Being a physician does not prevent someone from also being a good scientist.  There are quite a few good scientists among physicians, and the best of them are among the best epidemiologists I have known.  My experience is that medics who take the time to study epidemiology are generally much better than average students in the field.  It is just that most physicians are not scientists (beyond the engineering science that is part of clinical practice) and most of the best public health scientists are not physicians.]

Second, health science oriented reporters and regulators need to become educated enough to understand the difference between a genuine scientific critique and someone just saying "nuh uh! he's wrong because his side is evil!" (or retain some consultants who have that education).  To my knowledge, no one has ever written anything that is even a prima facie case disputing the legitimacy of Enstrom's controversial studies or any of my work on tobacco harm reduction.  I would like to think that any reporter or regulator, upon hearing someone dismiss our analyses, could ask "what is your scientific basis for that conclusion, and you must answer without using any phrase like ‘there is a general consensus that….’."  In Colby's case there would be a response to that (the detailed content of my report or others').  Perhaps at that point the questioner would be over his head and not be able to assess which of the competing analyses was right, but this is quite different from cases where there is not even a competing analysis.

It is kind of interesting that in all of the cases I have mentioned here, it is the self-styled enforcers of the health promotion orthodoxy that have tried to censor research.  You hear a lot about industry trying to intimidate and censor research it does not like, and I am sure it happens in some areas, but I have not heard of the tobacco industry (the Enstrom and Phillips cases) doing any such thing for decades, nor the diesel industry (Enstrom case) though I am not so familiar with that, nor the wind energy industry (Colby and Phillips cases).  Even though the wind energy industry has repeatedly tried to deny the existence of evidence it does not like, and has not actively supported the research that it is morally obligated to do (indeed, acting so unethically as to declare that research should not be done even as it asserts scientific opinions that could easily be tested), at least it has not launched any inquisitions.

In any case, should the opportunity ever present it, I would offer a fierce defense of Colby's right to do the work he did and present the conclusions he did, though I somehow doubt he is going to ask me for my support.

07 September 2010

Using evidence that a policy would do no good as a basis for proposing the policy (this time it is about airplanes)

There is a political faction that for years has been pushing for regulators to require that babies on planes be secured in a car seat, thus requiring that they be in a seat of their own rather than on an adult's lap.  It is not clear why anyone actually wants this.  The usual explanation for weird regulation (it helps the industry profit) does not make sense -- after all, the airlines could change their own rules themselves.  The only thing I can come up with is that there is a cabal of frequent fliers who are really sick of 18-month-old lap babies kicking the backs of their seats and want to restrain them.  The reason this is such a mystery is that health concerns about the babies cannot possible explain their motivations, because -- as has been pointed out in numerous analyses -- this would kill more babies than it saved and injure many many more, as well as killing a lot of grownups.

Why is that?  Because the extra cost of another airplane seat for a young family would be just enough to tip some of them into driving rather than flying, and driving is far more dangerous than commercial airline travel.  And not only is air travel a lot safer than car travel, but most of the fatalities that do occur are in crashes in which a safety seat could not provide any protection (roughly half of all fatalities in crashes are on flights where there are no survivors).  Thus, unlike safety restraints in cars, which save the lives of roughly half of all the people who would have died in unrestrained crashes, the potential benefit is low.  Of course, occasionally someone is saved from injury by restraints on a plane, but it is rare enough that the benefit would be outweighed by the shift to driving.

There is pretty good data for calculating what would happen (data about price, response to price, accident statistics), so this makes a great teaching example that I have used many times.  It is a wonderful lesson in how policies do not necessarily have a particular effect just because who ever proposed them says that they have that effect.  One year, using one particularly good version of my class's analysis, a student and I presented the results at the annual epidemiology meetings and she won an award for the work.  That version is not currently online, so no link, but anyone who is interested can find someone else's version:  every few years, going back to when I was a student, someone repeats this analysis and concludes that the policy would kill far more people than it saved.

In spite of how there is no upside for anyone to this policy (other than that kicking thing), it is the official position of the American Academy of Pediatrics that not only should the regulation be put in place, but pediatricians should take desperately valuable time during office visits to advise new parents to spend the extra money to buy their baby her own airplane seat.  This was published in Pediatrics about a decade ago, in an article that basically said "yes, the economic analyses say more young families will drive and die as a result of this, but we do not believe in economic evidence."  Keep in mind that this is long before Pediatrics decided to strive for the title of Dumbest Health Science Journal with their articles about "third hand smoke" and such.

The latest is a push by the U.S. National Transportation Safety Board to implement the safety seat regulation.  They do this periodically, and the Federal Aviation Administration that makes the rules pays attention to the evidence about what would really happen and refuse.  But what is remarkable is the basis of NTSB's latest recommendation:  They cite the recent crash of a small commercial flight in which everyone was killed and no one could realistically have survived, but where the bodies of some of the children on board were flung from the wreckage, and thus were apparently not restrained.  Horrible without a doubt, but how does this possibly support the call for safety seats?  Is it because if the babies had been restrained then they only would have been killed once due to the crash and not killed again because they were then flung away from the wreckage?  Being flung from a vehicle is often the cause of death in car crashes, but not plane crashes.  Perhaps NTSB should have put airplane experts in charge of this one rather than their highway guys.

04 September 2010

Still reporting that there are 76 million cases of foodborne disease? Seriously?

More than a decade ago, some researchers at the U.S. CDC created an incredibly complicated model that was highly dependent on what were basically wild guesses, and came out with the estimate that there were 76 million cases of foodborne disease in the U.S. annually.  Several researchers, including one of my students and me, pointed out that this estimate was ridiculously over-precise, given the complete guesswork that went into it.  Also, it was almost certainly biased downward (i.e., a lot too low).  Our article was a general analysis about accounting for errors in estimates and just used that estimate as a particularly glaring example of researchers who apparently do not understand the concept of error bars.

The reason I bring it up is that every time there is an outbreak of foodborne disease that makes the U.S. newspapers (i.e., it had a lot of victims in the U.S.), this number gets toted out again, like in this New York Times article, written by Walecia Konrad yesterday.  Granted, I have never heard of Konrad and she(?) is not one of NYT’s expert health writers, but I have seen the big names make this mistake also, as well as numerous others.  And sure enough, the CDC website has that figure (and some others from the same original paper, which are also repeated by Konrad) in multiple places on its website.  Several of these have date stamps as recent as 2009 and as far as a few minutes of searching revealed, there is no acknowledgment that this is a very rough estimate and the only way a reader would even learn the age of the statistic would be to find one of the rare invocations that actually cited the original paper.

Why is this such an embarrassment for both health reporters and epidemiologists?

Even if we assume that most of the inputs into the model were unbiased (i.e., really were the best possible guesses – which is an incredibly charitable assumption), given the uncertainty of the guesses, it would be bold to assume that the estimate was correct within a factor of two.   (If you want details, they are in our paper.)  But think about the implications of reporting that “76 million” figure that has been repeated a zillion times since then (plus or minus half a zillion).  If they had claimed the round figure “about 75 million”, it could be read as something as imprecise as “more than 50 million but less than 100 million”.  That would probably have still been too precise a claim, based on the quality of the model used to derive the estimate, but it would at least have been in the ballpark.  If they had rounded their estimate to 80 million it would have implied something like “between 75 and 85 million” (because 74 million would round to 70, while 86 would round to 90).  That would be way too precise a claim, but at least representing some vague awareness that their estimate is not perfect.  By claiming 76 million and offering no indication of uncertainty bounds around it, however, they are effectively saying "we are quite sure the answer is between 75.5 million and 76.5 million".

So the reported figure was ridiculous the day it was originally written.  But it is even more absurd to continue to make the same quantitative claim.  This figure, even if it had been correctly estimated in the late 1990s (using data that often was years older), is obviously not a scientific constant like the speed of light.  This should be fairly obvious to reporters who use this number, since the reason they are writing the story is because there is an unusual event happening, as in the present case, that did not happen the year before.  More important, food handling practices change over time, some for the better and some for the worse.  At the very least, I would like to think that newspaper reporters and the CDC are aware of the little matter of the U.S. population increasing by more than 10% since the original analysis was done, so unless improvements in food safety perfectly balanced out the expanding population with just the right decrease in per capita disease rates, year after year, the number could not possibly remain constant.

In other words, pretending that this number is accurate is like estimating the number of Americans that voted Republican or were Hispanic with one study in the 1990s, and then continuing to claim the number is exactly that value forevermore.  I would assume that political scientists would not make those mistakes.  It is a real shame that CDC’s epidemiologists lack equivalent understanding of the way the world works.

The source of the error hardly lets Konrad and other reporters off the hook however.  The NYT article, like many others, presents the figures as if they were God’s Own Truth, not even reporting the source let alone including caveats like “CDC claims…”.  You would think that following the huge embarrassment of playing stenographer for the U.S. government’s lies that started the Iraq war, the NYT’s instructions to its reporters would include “never repeat something the U.S. government claims as if it were an indisputable fact.”

Why does this matter, and why did I decide to write about it today since reporters have been repeating this error for years?  The answer to the latter was that I was tipped over the edge by seeing on the front page of the newspaper an article about back-to-school shopping that declared that “on average, fathers are expected to spend 23 percent more on their … children than mothers”.  It boggles the mind to think that anyone would believe that this prediction could be made with that kind of accuracy (not “about one quarter more than”, but down to the last percentage point).  Do people not realize that even if we had a complete cash register data from every purchase made during the season, we would not be able to estimate that figure so accurately retrospectively?  We could not figure out how many were made by dads rather than moms that precisely (e.g., if they are both at the store, who gets credit?) or what constitutes a back-to-school purchase.  Do people not realize that we probably cannot even estimate how many schoolkids have dads who buy them anything with that degree of precision (due to uncertainty about who constitutes a dad, whether they are actually in the kids’ lives, etc.)? 

Actually, I guess the answer is that most people do not realize.  Therein lies why this matters.  As soon as something has a number attached, reporters and others seem to turn off even their most basic critical abilities and common sense.  It never occurs to them to ask even the simple “how could anyone possibly know this (e.g., exactly what portion of back-to-school purchases will be made by fathers)?”  People seem to think that those who cook up these numbers have some magical sciences available to them.  Modern science lets us measure the concentration of cadmium or BPA in biological samples down to the parts per billion level, so it stands to reason that they must be right when they claim that many people are being sickened by it, right?  If they tell us that 47,318 people die each year in the U.S. from environmental tobacco smoke then it must be true, right?  Surely a science so precise could not coexist with genuine controversy about whether there is any major mortality risk from ETS exposure. 

And so, since we know that the U.S. government can count foodborne disease cases (which are almost never definitively diagnosed, by the way) within 1% accuracy, surely when they flatly declare “salmon genetically engineered to grow quickly is safe to eat and poses little risk to the environment”, they must be right.  Right?  The first bit seems likely, but the declaration by the Food and Drug Administration that there is basically no chance of ecological pollution from the new genes rings a little hollow.  Maybe the country’s regulators of pain relievers and pacemakers somehow know more than the rest of us about the risk of introducing novel agents into the ecology, but I do not share the New York Times’s faith in the government (at least they attributed the claim to the FDA rather than just declaring it true).  Perhaps if New York Times reporters read the New York Times, they might have noticed their several articles this year about the spread of the “Roundup ready” engineered gene from crops to weeds, making the latter resistant to what had been the best available herbicide.  This is not to take a position on genetic engineering, mind you, just to speak up in favor of not being so gullible about any declaration made using the language of science.

02 September 2010

Just for the record - documenting the movie lie

As I have written about several times this year, the claims about smoking in movies causing a large portion of smoking initiation are a great example of the "if only..." claims made by anti-tobacco extremists to support more and more draconian manipulations of society.  The usual script is "if only X were changed then smoking/tobacco use would be reduced by Y%".  Of course, because the extremists wield so much power, X is often changed in just the way they demand and then ...... nothing changes, much to the surprise, of, well, no one at all.  Why no surprise?  Because the extremists who made the claim conveniently forget they ever did so, and rewrite their history to exclude it.

These are not the grossest most malicious type of lies (see the comments from this TobaccoHarmReduction.org blog post for an interesting discussion related to that point), but it is probably the second-most harmful set of extremist claims from the narrow perspective of public health (the most harmful being the lies that attempt to discourage smokers from adopting harm reduction).  To make it a bit more difficult for them to pretend they never said it, I and others are making a habit of documenting these claims.  So in case there is any confusion about it in the future, Physicians for a Smoke Free Canada recently published the claim (pdf) that baldly stated that just under half of all smoking among 15 to 19-year-olds in Canada was caused by them seeing smoking in movies.   Note that this would mean that pretty close to half of all smoking was caused by film portrayals among those in their 20s and 30s and however long movies have had this thrall, since most smokers start during this age range.

So, they are effectively claiming that once smoking in films is gone, smoking incidence (initiation rate) will have dropped by almost half compared to the bad old days, even after controlling for the effects of all other anti-smoking efforts, and so prevalence (usage rate) will be lower by half in the cohorts that were teenagers after smoking was removed from films.  It is not necessary to go into the use of statistics (either worthy of a failing grade in an intro class or highly skilled, depending on one's take on how statistics should be used) employed to cook up this claim.  They made the claim, clearly an unambiguously, burying the statistics that were used to rationalize it.

Anyone want to place a little wager in support of their prediction?

I am sure they would not do so.  They are assuming that by the time their prediction is shown to be wrong they will have skated on to some other, quite possibly equally nutty, claim that they can trick the mainstream media into repeating.  Indeed, it is not necessary to wait very long to show they are wrong.  Since most smoking has been eliminated from movies over the last decade, we should have seen a huge drop in smoking initiation according to their prediction, even after subtracting the reduction attributable to the effects of increased taxes, education campaigns, etc.  Since the actual drop has been quite a bit smaller than the movie model would predict, it must mean that in spite of all the other anti-smoking efforts, smoking initiation would have dramatically increased had it not been for getting rid of it in movies.  Whew!  Canadian youth sure dodged a bullet there.

I expect that some of you are saying "so what?", since Physicians for Smoke Free Canada is one of the more dishonest anti-tobacco extremists groups.  Granted, this publication may reflect their particularly poor judgment: other groups who have touted similar claims have avoided publishing a 40 page report in PDF, which is much harder to make disappear than an html page or a billboard.  But this claim has been made by most of the other Tobacco Drug War types also, and even by the otherwise respectable health groups who are willing to squander their credibility on anti-tobacco extremism. 

However, I have to say that  this one strikes me as strange even for them.  I understand why they might make up any claim they can think of to get taxes increased -- they get to keep a lot of the money, after all.  I have written about why they are so desperate to discourage harm reduction.  But why risk burning quite so much credibility over what appears in movies?  Even if it really mattered, there is not really much fight left to fight:  They have already succeeded in bullying studios into removing almost all smoking.  Are they really that desperate to find an excuse for why their last decade or two of promises to dramatically reduce smoking have failed?