New address for this blog: EP-ology.com

This blog can now be found at EP-ology.com.  I expect this will be the last post at this location.  

The archives will remain here here to preserve existing links (at least as long as Google keeps providing hosting for blogger archives -- and I should say I appreciate the hosting for all these years, but I now use another platform every day, and it is incredibly frustrating switching back and forth).  The archives have also been copied to the new host/location and I suggest that any new links/searches/etc. use those rather than these.  Comments on the archives here are now closed, but are open at the new site.

Random rant about denominator-free statistics

Not particularly relevant to anything, but offering a chance for a random science lesson, I got really annoyed at a couple of items in my twitter feed over the last few minutes.

The first (in which the tweet was ridiculing the claims) linked to this article about a new journal paper which claimed:

Cat bites to the hand are so dangerous, 1 in 3 patients with such wounds had to be hospitalized, a Mayo Clinic study covering three years showed. Two-third of those hospitalized needed surgery.

Regular readers will know my lack of respect for Mayo's attempts at research on anything other than medical treatments. But this is worse than usual. Contrary to the headlines that this claim is designed to generate, obviously only a tiny fraction of cat bites result in hospitalization. Their error, of course, is using "patients" as the denominator, a completely useless population to base the statistic on. Who becomes a "patient"? Obviously it is people who are suffering serious medical problems. In the case of cat bites, this consists of people who, after being bitten by their cat many times before, and suffering no serious problems from it, develop an infection that will not go away. Does this represent 1/1000th of all cat bites? 1/10,000th? Fewer? We have no way of knowing, so the statistic is worthless. More important, we do not know what degree of seriousness typically makes someone a patient. Someone with a non-trivial cat bite injury has no way of guessing her chance of needing hospitalization or surgery because there is no way of knowing how serious the condition of the average patient was in comparison.

(Note: People bitten by stray cats of unknown rabies status might also end up as patients and be hospitalized on spec, which further biases the number away from how it is being interpreted.)

Note that this is exactly the same error that infection disease "experts" always make when there is an exciting disease like bird flu.  They claim things like "half of those who get it die." Um, no. Half of those who get it and get so sick from it that they are willing to go to the almost-certainly-low-quality hospital that they cannot afford (think about the populations in question) end up dying. A bit different.

(If you are particularly interested in that observation, I have written about it at some length in this blog, but I am feeling too lazy to go look for the link.)

The other version of denominator-challenged innumeracy was this tweet from a group calling itself the Center for Priority Based Budgeting, which was naively retweeted by the Robert Wood Johnson Foundation's public health feed.  It included a coded map of the USA and the observation "Half of the nation's uninsured live in just 116 counties".  I am not going to go check this, but eyeballing the map, I would guess that half of the nation's people live in those 116 counties, so this is not exactly exciting news.

Seriously, did everyone who understands numbers from the last couple of generations go to Wall Street, Google, and the NSA, leaving the rest of the world innumerate?

22% of Australian tobacco controlers support genital mutilation

Ok, as you might have guessed, that is not true.  (Presumably.)  But I did get your attention to make the point that they favor something that is equivalent to genital mutilation.  That is not some hyperbolic Godwin-esque comparison.  There really is a pretty exact analogy, even if the harm caused differs quantitatively.

I have been meaning to search my archives for important posts that have not been read as many times as they deserve.  The great tweeter, @TobaccoTacticss -- whose readership has doubled in the last week and a half (you're welcome :-), helped me choose where to start by posting this table from this survey of Australian tobacco controllers.  It shows that 22% expressed support or strong support for "Vaccinating children and/or adolescents against the effects of nicotine to prevent the uptake of tobacco use."

My archive post in question is here, in which I observed:

Most of the discussion about the topic is not about the rational adult making an informed decision, but about involuntarily inflicting the vaccine [a drug that would -- theoretically permanently -- eliminate the body's ability to respond to nicotine] on kids.  Those proposing it tend to gloss over that "involuntary" bit, and failure to even address this is a serious ethical problem in itself.  But, of course, unless we are talking about a current user who is wanting to quit, this is the only interpretation.  Either the kid is already choosing to not use nicotine, in which case he would see no reason to accept the side effects, or he is currently choosing to use nicotine, in which case he would prefer to avoid the vaccine. 

Of course, we take actions that restrict kids' choices all the time.  But there is something rather different when the method involves altering their bodies to make it impossible to enjoy a particular choice (and that choice is not "inflict violence on others" or "commit suicide" or something of that nature).  If the effect were permanent, I think this would be an ethical no-brainer.  I suspect that a permanent effect is the goal of those pursuing research on this vaccine, and inflicting that on someone would clearly be unethical.  No, that is too mild -- it would be utterly appalling.   

Consider the other example (the only other one I can think of) in which adults permanently alter the body of a child to prevent the child from engaging in a behavior that entails some costs, and where they (the adults) do not approve of the kids enjoying the benefits:  the mutilation of girls' genitals practiced in some African communities, which you have no doubt read about.  Before anyone who cannot follow a logical argument flips out, I will point out that I am not claiming that either the damage done or the loss of benefits from the vaccine is as great as that from genital mutilation.  But the motivation and implications are otherwise similar:  enjoyment of sex/nicotine by youth is considered evil by those in power for some reason; the benefits of sex/nicotine result in temptation that can be removed by altering someone's body to diminish the benefits; yes, the behaviors that are thus prevented can increase risks of disease, but this does not appear to be the genuine motivation (e.g., because there are other ways to avoid disease that the proponents oppose).  I suspect that never in my life have I had a conversation with someone who thinks that genital mutilation is anything other than appalling, so why is there no hint of such ethical concern directed at the nicotine vaccine?

Frankly, I think I understated it a bit there because I was writing primarily for a group of young students and not my usual more hardened readers.  It is really pretty much impossible for me to see any ethical distinction between the two practices.  Presumably "vaccinating" children would only be done with the consent of the parents, but that is also true of genital mutilation as I understand.  In both cases, doing whatever it takes to stop the disliked behavior in question is strongly supported in some communities, so no difference there.  They are both about limiting the behavior of the adult that the child will become also.  And so on.  The only tiny bit of light I can see shining between them is the fact that for most (though not all) people the loss of much of the physical pleasure of sex is a larger cost than the loss of the benefits of nicotine -- but that is only a quantitative difference, not a fundamental one.

The survey also found 38% support for "Vaccinating smokers against the effects of nicotine as a cessation method".  This would not be as troubling if this were "making a vaccine available to smokers who wanted it", but it is actually phrased in terms of inflicting the vaccine, not merely providing the option.  Perhaps most respondents interpreted it as the latter.  But if not, it is arguably even worse.  Not only do nearly half support it, but there is no hiding behind "we have to protect the children" because it is trying to deprive adults of free choice by maiming them.  (You can decide for yourself whether this is even worse depending on your personal trade-offs about issues of freedom, children, etc.)

Finally, notice that "as" I emphasized.  Read the original post to see why merely offering a vaccine to interested adults is -- to borrow a favorite phrase of the tobacco controllers -- a wolf in sheep's clothing.  The pitch, like the promise that accompanies the marketing of NRT and other stop smoking methods, would inevitably be that if you take the drug you will not want to smoke.  The reality is that it would permanently (unlike other drugs) trap someone who wants to smoke or otherwise use nicotine in a body that could not use nicotine.

I wish I could take some consolation in the fact that Australia seems to have the most evil tobacco control people in the world.  But I am afraid that the portion of those people who are willing to maim children and adults to control their behavior is not much lower elsewhere.

Why tobacco use modeling need economic mechanisms - FDA workshop slides

I have not been doing a great job of creating updates about my THR modeling work, so here is one easy very-partial remedy for that.  The FDA Center for Tobacco Products is holding a workshop about modeling and other methods that relate to their regulations and I am presenting a talk using these slides.

As those of you following my work on this subject know, I am rather critical of the usefulness of the existing "models" of tobacco use.  (For those not familiar, follow the tag on this post for previous and future posts on the subject.)  I use the scare-quotes because I argue that most of what are called models in this space fail because they are not actually a simplified version of the real system, but are really just complicated calculation tools.  They completely omit the underlying mechanisms of the system -- the consumer economics -- and thus just translate high-level statistics (e.g., "assume 2% of the smokers transition to e-cigarettes each year") into high-level outcomes (e.g., "the smoking rate over time follows this path").  This does not mean they are not useful, of course.  There is value in that.  But the value is calculating the answer to high-level hypothetical questions, not actually representing the system.

My argument in this talk is about how the lack of that real representation of the system means, most obviously, that it is impossible to make predictions about previously unobserved phenomena.  (If the only use of data is to say "we have observed that when X happened then Y resulted", you cannot say much about situations that have not happened before.)  But it also means that even the high-level predictions are likely to be wrong because they are based on a misuse of the data (which I call superstition rather than science).

I made the tactical error of offering to present on any of several aspects of my research agenda, but fortunately the organizers shared my opinion that this bit is the most crucial for people to understand at this point.  (Note to self: Don't count on that in the future.)  The talk is likely to come as a rather unwelcome coda (it is scheduled very late in the workshop) to a series of presentations about "models" that fail to do what I am saying must be done.  Of course, I might be pleasantly surprised and discover that my message has already been covered.  Such good news for the science would be bad news for my talk, of course, making it awkward with a lot of phrases like "this has already been discussed, but to reiterate the point".  But I am not optimistic/pessimistic that there is much chance this will occur.

Funny how those who worry about greenhouse gas emissions ignore their own biggest contributions

This has long bugged, me but Greg Mankiw's op-ed in today's NYT prompted me to complain about it again.  I have no complaint about his actual thesis, which was the basic, obviously correct economics:  A carbon tax is a much better way to discourage people from causing so much GHG emission (assuming we want to do that) than is the hodgepodge of often inefficient regulations and incentives -- especially if the tax is offset by tax cuts that are targeted at making the cost impact neutral for the average person.  But what bugged me was his musing about what he might personally do to reduce his own emissions.

As is typical for people discussing this, he mentioned driving a more fuel efficient car, adjusting his thermostat, solar panels, and eating locally.  To his credit, he avoided mentioning totally useless and counterproductive gestures like recycling.  Also to his credit, he actually included one of the three biggest things someone can do, three things that are generally ignored by the typical bourgeois self-congratulatory worriers about climate change.  Most important, of course, he was advocating an efficient alternative to hodgepodge and voluntary action that would make the benefits of avoiding particular consumption proportional to the costs of emissions impact of it, solving this problem:  With a carbon tax, the costs would be internalized for everything, including those actions that are typically ignored.  Thus this screed should be seen as directed at the chattering enviro types, not at Mankiw.

It is pretty clear that there are four changes that matter for reducing the carbon emissions you cause that you can do while still maintaining a basic modern lifestyle:  don't fly on airplanes, live in an urban apartment, don't eat meat, and minimize gasoline use.  Everything else is just a rounding error.  Of course none of these are absolutes -- the closer you are to the minimum the less impact.

The funny thing is, the activists who push this topic -- typically upper class, though not 1%-ers -- tend to mention only the last of these, and then only in terms of what to drive, which is solidly down in fourth place.  Why do they conveniently ignore the actions they could personally take that matter a lot more?  The most obvious answer is because they want everyone else to make the sacrifices.  Their only "sacrifice" is driving a Prius and maybe installing solar panels, which are really visible status symbols for them, points of pride that make them happier, rather than sacrifices.  Those actions are kind of like giving up smoking for Lent because you want to quit smoking; a sacrifice is something that makes you worse off, not better.  It much more appealing to offer gestures that actually make you happier and reserve the unhappiness for others.  So, for example, wealthy climate change activists try to force everyone to pay a lot more for electricity, a cost that they personally can just shrug off or even consider a net gain because it makes them happy, but that is painful for the average American or Canadian suffering that wealth shock (to say nothing of the average Chinese). 

Mankiw did not mention living in an urban apartment per se, but he did cite both of its advantages compared to living in a suburban house (as most people I know who chatter about this seem to):  You are closer to where you want to be so you drive far less (which matters a lot more than what vehicle you drive, especially if you can avoid having a private car at all) and the space is smaller (though he only mentioned the reduced climate control costs and not the important costs of building the structure itself and cultivating a grass monoculture in space that could be growing naturally).

He did not, however, mention not eating meat or minimizing how much you eat.  This action is something that most everyone can make without massively disrupting their lives, unlike the others (move to the city, minimizing transport), and is clearly the most effective GHG reduction step that fits that description.  Yet it pretty much never gets mentioned by the enviros as part of their agenda.  Perhaps this is because they do not want to be staring that choice in the face:  There is something huge that any meat-eater can personally do tomorrow, just by deciding to do it.  If they admit that, they have to admit that is true then they cannot keep pretending to themselves that they are willing to personally sacrifice for their cause.

Most notably, Mankiw did not mention what I am sure is his personal biggest contribution to GHG emissions, flying.  How many miles do you have to fly in a year before the total contribution from that equals the sum of all your other consumption (not just driving and household utilities, but the energy impacts the material goods you consume too)?  Don't quote me on this because I am working from memory, but I recall that it is in the order of 25,000.  So for anyone who qualifies for even "silver" level frequent flyer status, that flying is more than half your GHG contribution for the year.  I would be surprised if Mankiw flies less than double that. 

Avoiding flying (or merely flying less), for the class of people who fly on airplanes, dwarfs anything else any of us can do to personally reduce emissions.  This also means that a carbon emissions tax would fall most heavily on plane tickets, where it should.  We could let this create the right financial incentive rather than relying on people who care about this issue to voluntarily avoid flying -- since observation suggests that they do not voluntarily avoid flying.  For the class of people who do not hesitate to hop on a plane because they just want to be in another city for a couple of days, foregoing that option -- and thereby reducing their emissions more than everything else they can do, combined -- is a real sacrifice.  So they decide it is better to just stick to buying those recycling bins, solar panels, and a cute cars (and put a wind turbine bumper sticker on them, of course).  That way when someone drives by their 3500 square foot house while they are off visiting Paris, there will be no missing the message about just how wonderfully Green they are.

Models v. Mechanisms at FDA Center for Tobacco Products

Observed coincidences occur far more often than chance would suggest because we look for them and define our list of what would constitute an interesting coincidence based on what actually occurred (we have no intuition for just how huge the denominator is).  I know that.  Still, I find it pretty remarkable that for the last couple of days I have been trying to nail down exactly how to explain what is missing from the behavioral modeling by FDA CTP, and then discovered in my morning econoblogosphere reading, the answer I needed seems to be the topic of the hour.

Yesterday I posted some advice to FDA CTP about the need to understand social science (mainly economics) in their modeling of behavior. There is relatively little economics that needs to be considered in traditional FDA missions, and that which is needed is relatively simple.  But regulations that are intended to affect preferences about a freely-chosen consumer product where preferences vary across the population (i.e., like tobacco products, in contrast with medicines or food safety) are all about economics.  The failure to include explicit economic analysis in the recent report on the possibility of banning menthol cigarettes illustrated the problems, both scientific and ethical.

But if you were to suggest to the people working in the FDA orbit that they do not really have a model of people's choices about tobacco products (as I have argued), they would probably reply that they do have models.  Several of them.  (For those who are familiar with this field I am, of course, talking about Levy, Mendez, Environ.  For those not familiar, that should present no obstacle to understanding this post -- just know that I am talking about a handful of well-known specifics.)

Ok, there are models.  But there is something fundamentally wrong with them.  They do not offer us any reason to believe in what they say will occur at the micro level (that is, why each individual person whose actions, collectively, result in the outcome, will do what they suggest they will do).  What I mean is that they tell us things like "if X% fewer people start smoking each year", say, due to a menthol ban, "then this graph shows the number of smokers in the future, which is lower than current trends by Y" (if they fill in other information and make a bunch of other assumptions about what is happening, of course).  But as for why X% fewer people would start smoking, there is nothing at all.  There is just the number.

I have criticized these as being more like calculators than models.  If a population starts at 1 and doubles, every period then the number after n periods is 2^n.  But it is hard to call the equation "2^n" a model.  Similarly, I argued, the preferred "models" used by the tobacco policy inner circle are just more complicated equations.

I learned, however, that this point was not widely convincing based on sociological empiricism -- i.e., I tried to make the point to people and did not have much success.  I realized perhaps why this was based on my blog reading from this morning:  I was using the wrong words to make my point.  It is not that these are not models; any calculation, no matter how simple, can be called a model if it is representing a worldly phenomenon in some useful way (even that lowly 2^n).  The problem with these models, and the reason they failed as legitimate models, is the lack of mechanism.

A model uses numbers and equations to show how one variable/construct/point-in-time/etc. affects others.  But the model may not capture why a particular effect occurs (the mechanism), as with that X% reduction in smoking initiation.  In such cases, it is really just answering a hypothetical question ("if X were true, then Y") rather than making real predictions ("X appears to be true, therefore Y").  But the models that would be useful for FDA purposes are ones that tell us "therefore" not just "if...then".  Of course, every model is going to have some simplified or hypothetical elements (if there are no simplifications it is not a model, it is reality) and, once again, there are no bright lines since the mechanisms generally are abstractions (i.e., models) in themselves.  But for a model to offer predictions that do not just result from hypothetical inputs, there has to be some "why" built into it.

It seems that the problem is that these models have been developed in a world where the only familiar social science is epidemiology.  Epidemiology usually fails as a social science, and as a science more generally, because there is very little attention paid to mechanisms.  That it fails as a social science is fairly easy to explain: most people doing it do not realize they are engaging in social science, and most people teaching it have no background in social science.  They think they are just doing medical trials.  Sometimes this is literally true, of course, and sometimes the observational epidemiology is legitimately an attempt to substitute for medical trials.  But as soon as what is being studied is not purely biological, and involves people as people, not just as organisms, it is social science.  Medical trials are easy because either the mechanism is obvious or it does not matter -- e.g., this drug makes cancer go away, and we probably have a guess about why, but that guess does not matter because the mechanism does not matter to the epidemiology (though obviously it does for the drug development process).

The failure to be good science at all is less easy to explain or defend.  For almost 15 years, mechanism-oriented methods have been developed and taught (in the few good epidemiology departments).  These tend to be pretty simple, just boxes and arrows that show what is causing what, but that is most of what you need.  Unfortunately these are (a) seldom used at all and (b) almost exclusively used just for identifying confounders.  The latter is useful, of course, and doing it is far better than not doing it.  But what is missing is use of these mechanistic models to address questions like "if X is really causing Y by affecting Z, then I should be able to observe not just an association between X and Y, but also..."  Such scientific hypothesis testing is close to completely absent from epidemiology.  Instead, mechanisms in epidemiology exist entirely in the untested conclusion statements.  You have seen it: An association is observed and there is a discussion of how X must be to be causing Y as a result of Z, or whatever, but whether that really seems to be true is never addressed scientifically.  It is worth reiterating:  In epidemiology, mechanisms live almost entirely in the conclusions and not in the science.

So circling back to the question of tobacco behavior modeling, when the models are developed in the tradition of epidemiology, it is little wonder that there is no mechanism.  The "why" of what happens when a variable changes is not part of epidemiology, and so not part of the models.  It is just assumed that if the effects of a particular variable changing were observed in the past -- or more likely, merely if there was just some association observed in the past, with no effects of changes observed -- then that same association will still occur if an intervention is imposed (e.g., menthol is banned).  But there is usually no reason to believe that, and indeed, often a lot of reason to not believe it.  To take an extreme case, one of the popular models assumes that without menthol, the rate of smoking initiation would drop by the rate at which smoking is initiated with menthol cigarettes.  Put a little more simply, this basically is the assumption is that everyone who would have initiated with menthol will therefore never smoke (it is even a bit worse than that because it is based on past associations which might themselves change).  I suspect I do not need to explain why the implicit mechanism about people choosing to initiate smoking menthol cigarettes is rather absurd.  The absurdity of that seems unfathomable unless you recognize the mechanism-free mindset: "all we know [the mindset goes] is the association we observed before, so we just have to assume that association will always exist".

FDA on menthol cigarettes, some suggestions for research methods

The U.S. FDA is probably the most respected and influential medical research organization in the world.  Sure they have their hiccups and there are criticisms (many legitimate, many not) about the science and the choices about what risks to take (historically entirely in the direction of them being too quick to keep a potentially useful drug off of the market, more recently in both directions).  But all in all, it is hard to imagine engineering an institution that does much better.

But tobacco controllers (including a former head of FDA during his tenure) and their pet congressmen got the bright idea of adding a category of non-medical consumer goods to FDA's scientific purview.  To these non-scientists, it probably seemed that there was no contradiction here.  Science is science, right?  Clinical trials of medicines, monitoring food safety, consumer preferences, social forces, climate change research, isolating the Higgs boson -- if they are good at the first two, and experienced in the related ethical questions, then they must be able to do the rest, right?

Um, no.

It is clear that the FDA scientists who have been asked to look at tobacco products are trying, and it is equally clear they are frustrated.  Their latest report on menthol in cigarettes and the predicted effects of banning it [I got it here but that link seems to not work now], offers an opportunity for some unsolicited advice.  After I collect comments and my thoughts, I might include some of it as a public comment, [UPDATE: link fixed] which they are currently soliciting.

Their evaluation concludes that there is no measurable difference in the biological risk between menthol and non-menthol cigarettes (keeping the quantity of exposure constant).  This is based on research that FDA is pretty good at; it is not quite the same as their core competencies, medical trials and safety testing, but in the neighborhood certainly.

But the crux of the decision about whether to ban menthol is presented in terms of economics.  Unfortunately they do not say this.  This is presumably because economics -- the relevant science when you are looking at consumer choices  -- has never been part of what FDA does.  Drugs and medical devices are evaluated based on people who "need" them and are generally assigned by gatekeeper rather than chosen, so there is limited need to consider economics.  To the extent that economics is considered, it is the rump economics of "cost-effectiveness" and "quality-of-life" measures, which are definitely useful and nontrivial, but only a bit of the picture.  The food side is rather closer to normal consumer goods, but the focus is still on what everyone "needs" (are not willing to give up at any plausible cost), like non-infectious food.  When legitimate economic questions do come up (e.g., some people prefer to be able to consume raw dairy products, even though they are judged not safe enough by the simple bright-line standards), the system has no mechanism for balancing competing preferences, a hint of the challenge in regulating tobacco products.

It is natural that there is no historical capacity to do much economics within FDA.  I would argue that this is the biggest problem the normative side (i.e., ethics -- assessing what is the right thing to do to make people better off), though selling that message is a tough fight.  But it is also a problem on the positive side (assessing how the world works when individual free choices are involved), which ought not to be too tough to sell.  Understanding consumer choices, and being open and explicit about the science, really should be part of the Center for Tobacco Products.

The specific economic question at hand is the effect of menthol on the number of people who choose to smoke, the quantity they choose to smoke, and whether they choose to stop smoking.  These are all economic questions, and when someone tries to address them ad hoc, using epidemiology rather than welfare economics, it does not work out so well.  Indeed, even the description of the question at hand, with the key word "choose" in it, defies the standard narrow medicalized method of looking at products (and does not seem to appear at all in the FDA report, despite how crucial the concept is).

The questions being asked are in the form of "whether" -- e.g., is there likely to be more smoking if menthol is available -- rather than "how much".  But a tiny bit of economics reveals that the "whether" question is like asking "does this object have a weight" rather than "how much does it weigh".  Of course the availability of a flavor that some people like leads to more product use, and therefore its elimination would reduce how much people like the product.  Somewhere out there is someone who is barely on the positive side of indifferent between smoking and not, and very much likes menthol.  Remove the availability of menthol and he would not smoke.

(Notice that I am avoiding the question of implementation here, and simply positing the "removal" outcome.  Merely banning menthol cigarettes rather than magically removing them from the world creates all kinds of interesting complications about black markets and do-it-yourself mentholation, which is quite easy.  I will come back to that in a later post.)

The "how much" question is quite a bit more difficult to answer.  To have any hope of making a useful prediction, it is critical to understand what is going on:  people are using a product because they like it better than its close substitute (nonmenthol cigarettes), most of them probably prefer the substitute to abstinence, some of them like their product enough that they would defy the law, etc.  Without these economic points, it is difficult to imagine making a useful prediction.  Indeed, if you look at the models that have been used for prediction, they are clearly based on premises that are indefensible but probably the only premises that someone can come up with if they ignore economics.

Some consist of assuming that any additional use or initiation of cigarettes that is associated with choosing menthol (i.e., smoking rates are higher in subpopulations that use menthol more often) is causal, and thus without menthol the rate would drop to the average.  The economics shows that while this outcome is in the plausible range, it would be mere luck if it really turned out to be right because the basis for the claim does not actually support the claim.  Which is to say, the prediction has no validity because the premise of it is clearly wrong.  It actually gets worse than that, with some of the modeling going so far as to predict that all consumers of menthol cigarettes would be abstinent if menthol were not available, which is not even in the plausible range of values.  (No, I am not kidding -- one of the most cited predictions about the effect of banning menthol is based on this premise.)

Some of the most dramatic errors in the history of science, to say nothing of incorrect claims you see in the news today, result from confusing statistics with mechanism.  That is, researchers who do not know why something is happening (e.g., atomic theory has not yet been discovered so they have no idea why samples of pure elements weigh what they do, to take a classic historical example; or they seem to not realize that people make choices based on preference, to take the example of tobacco control industry researchers) sometimes go to great lengths to make measurements.  But when they try to interpret the observations without understanding the underlying phenomenon, and basically just assume that the measurements are the phenomenon (an example of which is assuming that all observed association is causal), then whether they are right becomes just a matter of luck.

As I mentioned, the other problem with not understanding the underlying mechanism when dealing with worldly questions is that wrong (in the sense of accuracy) can also be wrong (in the sense of unethical).  When tobacco control activists hide the phenomenon of people's preferences, choices, and happiness behind naive statistics, they avoid having to admit that they are a special interest group trying to impose a narrow "moral" view.  Our nation's government is not a special interest group and generally does a pretty good job of resisting imposing narrow moral views on the citizens (thank you, James Madison et al.!).  But if FDA research ignores the economics, it tends to prevent decision-makers from realizing they are making ethical, not technical, decisions.  (And it allows those who know they are imposing narrow "moral" views to pretend they are not doing so.)

Banning menthol would serve only one purpose: intentionally lowering the welfare of people who currently choose a particular product.  As soon as you express the economic situation in economic terms, this becomes immediately apparent.  So, is that justified by the (legitimately predicted) benefits it would produce?  Is such an action by a for-the-people government ever justified?  Do smokers deserve to have their welfare lowered?  None of these questions are answered by economics or any other science, but economics has the advantage of forcing a recognition that those are the questions that need to be addressed.  Anyone who suggests that the question "should we ban menthol cigarettes" can be answered scientifically, rather than ethically, is doing the wrong science.

Finally, as a comparatively minor aside about how to do social science, I note that the first paragraph of the FDA report makes a claim about the portion of the US cigarette market that is menthol, citing it to a 2004 paper.  2004??!  Folks, social science does not work that way.  People who are used to dealing with biology and other sciences that study phenomena that do not change much over time get into the habit of ignoring when a measurement was made.  This is a mistake even then, but it is a fatal error when dealing with social science -- just think about how much has changed in the tobacco product markets in the last decade.  An economist wanting to make such a summary claim would either find a more recent estimate, make a rough general claim without citation (making clear that the exact number is not known to the author but that it does not matter much), or look at the most recent statistics themselves and do the calculation.  Part of the problem is that people who are used to dealing with only one area of science, medical research, get the mistaken impression that all or most useful information is contained in journal articles.  That is clearly not the case in social science, where constantly updated statistics, working papers, and the blogosphere generally contain much better current information and thinking.  Indeed, as with many serious sciences, when an article appears in a good journal it is more like an archiving and awarding of a trophy, and is not really the publication, since anything worth reading has already been circulating long before the final version is etched in stone.  These are just a few of the things that FDA researchers need to understand now that they have entered the world of studying people as people, and not just as biological agents.

[More on this theme in the next post.]

My take on the recent UK NICE Guidance on tobacco harm reduction

The following is my take on the recent UK National Institute for Health Care Excellence (NICE) Guidance on “Tobacco: harm-reduction [sic] approaches to smoking”.  (I know I am a bit late to this, but I kept interrupting my work on it for other projects.  There was a lot in the Guidance to dissect.)

Background
For those not familiar, NICE functions vaguely like the USA’s Institute of Medicine – in terms of function it is basically a governmental think-tank, but is somewhat independent of the political process in terms of conducting analysis.  This means that the Guidance does not create or even explicitly propose government policy action, but it does carry the weight of government imprimatur (for those who consider that to be a good thing).  As for the Guidance, it is not actually about tobacco harm reduction (THR) in general as the name implies, but rather is specifically recommendations about encouraging the use of medicine-like products for THR as partial or total substitutes for smoking.

NICE apparently considers this to be important – rather more important that it really is judging from their (grossly inaccurate) headline claim that this report is “a world first for people who cannot stop smoking in one step”.  I will resist discussing the implications of this narrow view of many people working for governments (namely, that something did not happen until they did it) and their apparent obliviousness to what is going on in the real world.  In reality, the Guidance is approximately the one thousandth statement recommending strategies for helping smokers who do not choose to stop smoking by just quitting.  But especially baffling is that this is not even the first such statement by the UK government:  The MHRA (the unit of government that controls sales of medicines, like the CDER (drug) branch of the US FDA), which actually makes binding policy rather than just recommendations, has already created a category of medicines for THR and has approved one product in the category (at least two others are under review).

Though far short of the inaccurate self-promoting rhetoric, the Guidance does have the potential to be somewhat influential.  Much of the reaction to the Guidance from the real public health community (i.e., THR supporters) has been rather negative, but I tend to differ because I think that the real impact of the negative aspects (which definitely do exist) will be trivial and short-lived, while the positive implications will have legs.

The main negative is that the guidance is specifically about the use of “licensed nicotine-containing products” – that is, pharmaceutical industry “NRT” products that are designed as abstinence-promotion medicines and not as fully-satisfying consumer products.  The authors were clearly so desperately worried that someone might interpret their recommendations as applying to all roughly-equally-low-risk products, like unlicensed e-cigarettes or (gasp!) snus, that they included the phrase “licensed nicotine-containing products” approximately once in every 40 words.  The problem with that plan (and the reason this is not such bad news) is that many people who read and make use of this are not stupid.  Many readers will recognize that everything they say applies equally to all of these products.  Indeed, the Guidance authors make basically no affirmative argument to the contrary.  (They throw in a few lies about risks from snus, but they are so buried deep in the research background section that they are unlikely to be noticed.)

You could imagine a document like this including a tedious argument that there is something so different about non-“licensed” products that the recommendations cannot be extrapolated to them.  But it does not include that.  Perhaps the authors actively wanted to avoid such a claim.  Perhaps they just realized they would look like idiots if they tried to argue obviously incorrect claims.  One might even conclude that some of the authors disagreed with the “licensed products only” spirit of this initiative and managed to keep the document implicitly positive about THR in general despite several of the authors clearly opposing this.

Thus, the Guidance is good news merely because it has positive things to say about one (albeit relatively unimportant) approach to THR.  And moreover, whatever the reason why, it was not actively anti-THR for other products, and therefore it will contribute to the promotion of THR in general, even if some of those in charge of the process might wish otherwise.

It is worth noting that there are a couple of e-cigarette-type products in the application pipeline for the aforementioned MHRA approval, and the authors of the Guidance knew that.  Thus, they knew that they were implicitly recommending THR using (some) e-cigarettes.  Of course, right after the release of the Guidance, MHRA declared that they planned to regulate all e-cigarettes as medicines, requiring them to meet the licensing requirements (which almost none could meet).  But it is clear from conversations I had that at least some of the authors of the Guidance did not expect that this would be MHRA’s move, so not much can be read into this juxtaposition.

Recommendations in the Guidance
So, finally getting to the substance, what does the Guidance recommend?  It recommends everyone involved in smoking cessation (government agencies, medics, specialty clinics, etc.) provide smokers with information about the benefits of cutting down and of substitution.  These do not appear until after the reader wades through the usual recommendations that they tell smokers the shocking news that smoking is bad for you and such, but that is just boilerplate.  The substance is the recommendations about a THR approach.  The same actors are supposed to tell people about the licensed products themselves.  But unless the clinicians et al. lie about the more consumer-friendly products – which, importantly, NICE clearly does not ask them to do – then people should be able to extrapolate.  Indeed we can hope that anyone working with real live human smokers that they care about, rather than just publishing information, will go ahead and actively recommend e-cigarettes (or even semi-black market snus). 

Of course, we will not know what private conversations clinicians will have with people.  But the Guidance also calls for those who create self-help information to incorporate these recommendations.  Will those who did not already endorse THR in their writings start doing so now?  It is not clear that the Guidance will actually have that kind of impact, but at least we will be able to observe this if it happens, unlike the personal conversations. 

The word “reassure” appears a lot in the Guidance, as in “Reassure them that it is better to use these products and reduce the amount they smoke than to continue smoking at their current level.”  This is a nice touch, acknowledging that the anti-tobacco extremists’ years of efforts to mislead people into believing there are no benefits from THR necessitates an affirmative effort to undo.  I am sure this really grated on those members of the authorship committee who are part of the extremist clique and personally contributed to the disinformation that needs to be corrected.  Or maybe it just flew over their heads – part of the tobacco control job description is to avoid thinking critically, after all.

The discussion of how to counsel smokers about perhaps choosing THR is quite lucid and rational.  It reads like the recommendations that good pro-THR medics or real public health people would write.  It even includes the advice to warn smokers that the recommended products are not so satisfying as smoking, so need to be used differently (not in so many words, of course, but that is the upshot of it).

The recommendation that those who educate clinicians educate them about these recommendations is pretty paltry, but it is there.

There are even recommendations about advising smokers about strategies for “temporary abstinence”.  This is not explained, but it seems that it must refer to helping smokers deal with smoking place restrictions.  If so, this is a rather surprising move in the direction of good government – helping people be happier given the constraints they face, rather than trying to force their choices.  The anti-smoking activists, if they actually think through what this implies, are not going to be happy about this; while they publicly justify place restrictions based on protecting bystanders from smoke, most of them clearly consider the fact that the restrictions can make smokers miserable to be a feature, not a bug. 

I wonder if on this point NICE may actually have been a little too respectful of people’s choices.  They failed to push the recommendation to communicate “now that you have discovered that these products are appealing when you have to deal with place restrictions, you should consider using them all the time.”  There is one buried sentence on this theme, but it is a missed opportunity that they did not make the point more clearly.  (Of course, perhaps they recognized that few smokers with these motives are going to find their licensed products to be so satisfying that they might want to use them all the time.)

Manufacturers are encouraged to include the THR information on their packaging and such.  Of course, this only applies to licensed products and does not change any laws, so unapproved claims about “unapproved” products are still, well, unapproved.

Criticisms of the narrow-mindedness
As noted above, the Guidance is restricted to “licensed products” and this provoked a lot of ire when it came out.  The closest they come to acknowledging the reality that exists beyond their licensing paywall is, “little direct evidence is available on the effectiveness, quality and safety of nicotine-containing products that are not regulated by the MHRA. However, they are expected to be less harmful than tobacco.”  While better than denying that they are less harmful, this is still a lie at a couple levels:  There is a lot of evidence about effectiveness, quality, and safety.  (Perhaps they were trying to hide behind the word “direct”, but since it is basically meaningless, there is no refuge there.)  These products are known (not “expect to be”) a lot less harmful than smoking, but not less harmful than “tobacco”, a category that clearly includes smokeless products that are just a low-risk.  (Indeed, in the minds of many, all the products mentioned here, when used on a long term basis for non-medical reasons, form the category “tobacco”, though that does not tend to be the UK way of thinking).   Just because you cannot buy low-risk smokeless tobacco in the UK is no excuse for pretending that it does not exist.  Still, this cryptically acknowledges that e-cigarettes, despite the government not officially granting people permission to use them, are low risk.

The Guidance goes so far as to say, “Electronic cigarettes are becoming increasingly popular. If the MHRA starts regulating them, or there is positive new evidence of effectiveness, …this guidance should be considered for a rapid update.”  Of course, if e-cigarettes are MHRA-licensed products, the only thing that needs to be updated is adding them to the list of “approved” product types.  Nothing else would need to change.

There are probably a hundred incorrect specific claims in the document, but I am not going to go into that level of detail.  The count goes up to several hundred if you include their “review of the evidence” back-matter; that section is bad enough that it makes me wonder how the recommendations turned out as good as they are.  Indeed, it appears that the authors pretty much used that section for window-dressing and were motivated by better general knowledge, which is a good thing.

A more subtle failure is the refusal to acknowledge how we know that smoke-free tobacco/nicotine products are low risk.  In their desperate attempt to avoid even recognizing the existence of smokeless tobacco, they attribute the knowledge that “licensed” products are low risk to the paltry data about long-term use of those products.  That level of evidence about, say, e-cigarettes would be derided by those who like the medicines as entirely inadequate.  The reason we know that the level of risk caused by smoke-free nicotine is indistinguishable from harmless is the extensive research that shows that smokeless tobacco has no measurable risks.  It is that knowledge that NRT makers cite when they try to argue that their products are low risk.  Too bad NICE could not be as honest.

The recommendations also fail because they think that tobacco harm reduction is really just about harm reduction (see my recent post).  They clearly communicate that the use of low-risk products is always the second-best choice, behind abstinence, and fail to explicitly acknowledge the advantages compared to abstinence.  This was inevitable, of course, but just because it is not surprising does not mean it is not wrong.  The Guidance acknowledges that some smokers do not want to become abstinent, and thereby implicitly acknowledges that there must be some disadvantages to abstinence.  But this is never recognized.  But on the glass-half-full side, those of us inclined to do so can point out that NICE acknowledges that there are benefits from tobacco use.  

Interestingly, the only place where they mention the favorite bogeyman of anti-THR activism, the possibility that some people who would have quit smoking will only reduce if there is any encouragement to do so, is in the cost-effectiveness analysis discussion.  While engineered worries about this in the popular discourse are 90% trumped-up lies, it seems like this should have gotten a bit of explicit attention in the substantive part of the Guidance.  Yes, their recommendations repeatedly include the observation that switching completely or otherwise quitting smoking is much healthier than just reducing, but I would have really liked to have seen some suggested model advice about how to say, “since you are cutting down by using an alternative, you should really consider finishing the switch because any smoking is a lot less healthy than none”.

As an aside from the details of tobacco policy, putting on my political scientist or ethicist hat:  A disturbing theme in the research section of the Guidance (in common with a lot of government activism) is the notion that government should think like a business.  Cost-effectiveness type analysis is great (it is at the core of what I taught for years), but it needs to consider all social costs and benefits.  For a business, something is a good move if it reduces expenditures or increases revenue (or, more precisely, improves the net of those two added together), regardless of its other impacts on the world, and that is exactly why a lot of people, including a large portion of “public health” types, despise business and use “profit” as a rough synonym for “evil”.  But that is what businesses are supposed to do, more or less.  However, it is not what government is supposed to do.  When the government starts trying to maximize its profits, we are all in trouble – that is what feudal and warlord governments do.

Yet the analysis of costs and benefits focuses totally on government net profits.  There is no apparent acknowledgement of the costs and benefits to the product users, by far the most significant costs and benefits.  This is rather odd since the substance of the Guidance acknowledges that people might prefer switching to abstinence – that is, there is a recognition of the real costs and benefits built in.  At least that makes it much better than the usual “analysis” that bludgeoning smokers into abstinence, even though it makes them unhappy, is “cost-effective”.  In some ways, though, that makes the business balance-sheet analysis even more pathetic.

Besides, should the government require cost-effectiveness at all before deciding it should tell its citizens the truth about something very important to them?  Should the government lie if it looks like it would save money?  (Yes, I know the answer is that they will often do just that.  But they certainly should not.)

Concluding thoughts
I really think that this Guidance is good for the promotion of THR – not as good as it could be, obviously, but not harmful.  Because there are no affirmative arguments against any aspect of THR, it is difficult to see the harm.

The statement that smokers who reduce but do not quit entirely (or, more precisely have not quit entirely, since they still might do so) get some health benefits flatly contradicts currently popular anti-THR lies.  The Guidance agrees with the point that the experts have long been making, that in many cases reducing represents a transition, and in any case the much demonized “dual use” is better than just smoking.  Of course, the anti-THR activists (who do not actually consider evidence, but rather start with their conclusion and then concoct rationalizations for it) can still retreat to their claim that all those people who have cut down would have quit already if they were not taken in by the allure of alternative products, but that is so clearly silly that it becomes much harder for them to defend their rationalization.

It is also gratifying to see the repeated use of language that refers to preferences about tobacco use, rather than suggesting it is some kind of volition-free tic.  There are a few appearances of the “cannot quit” type language, but mostly the languages is about what smokers want – e.g., “may want to stop smoking without necessarily giving up nicotine”, “want to reduce the amount they smoke”, or “may not be able (or do not want) to stop smoking in one step”.  (Yes, they still throw in a bit of the “cannot” language, but at least they still recognize the relevance of “want”).

The implicit acknowledgments of both the use of non-“licensed” products and of the downsides of abstinence are quite useful.  Those of us who want to make points about other products and motives can cite this Guidance and just let the extremists sputter their vapid protests about it just being about medicines.

Tobacco harm reduction, it’s not just about harm reduction

It has recently occurred to me that perhaps the terminology that I and other pioneers of tobacco harm reduction developed is starting to be a drag on our efforts.  I refer specifically to our defining phrase, “tobacco harm reduction”.

When my colleagues at the University of Alberta and I launched our website in 2005, it was not entirely clear what to call it.  We settled on “TobaccoHarmReduction.org”, but there were other candidates at the time.  That term already existed, though was not in widespread use.  The widespread adoption of that term over the ensuing decade validated our choice (though this might be somewhat circular since our use of the term presumably contributed to the validation). 

The term is now locked-in as the description of everything related to efforts to promote low-risk tobacco/nicotine products, including all efforts at education and defending people’s rights to access to these products.  That “everything”, however, is perhaps unfortunate, because it tends to over-medicalize the entire effort, focusing all attention on the reduction (i.e., the value of alternatives as compared to cigarettes).  The tendency to treat the decision to use low-risk tobacco products as purely as a “cure” for the “disease” of smoking was most recently exemplified by the MHRA decision to classify e-cigarettes as medicines, though the tendency is hardly new.  (I had already drafted most of this post long before that came out.)  

It is more politically correct to focus on low-risk tobacco products as purely a cure for smoking, but sometimes politically correct is not optimal for the long-run, or merely for being fully correct.  I try to hedge a bit when I define THR in my writings, with something neutral like “the substitution of low-risk tobacco/nicotine products for cigarettes”.  This does not actually say that the only reason for using the is because otherwise someone would smoke.  However, it is intended to be close enough to pass for that in the eyes of those who demand such a view, suggesting that efforts related to THR are all about getting people off of smoking, and so probably does not provide any benefit with respect to the issues presented here.

It is clearly true that for many people, this is exactly what e-cigarettes and other THR products are – a cure for their smoking habit that they could not find another acceptable path away from.  I trust it is obvious that I am not trying to downplay that at all.  I do a lot of work focused on exactly that angle (e.g., CASAA’s effort to collectstories from people who successfully used THR to stop smoking -- please give us your story if you are one of them).

But suggesting that low-risk tobacco products are merely a cure for smoking narrows the discussion, hurts the cause, and unintentionally fuels the opposition.  Recognizing that low-risk tobacco products are more like coffee than they are like cigarettes, and a lot more than they are like medicines, is crucial for a sensible policy discussion and advocacy.  Breaking the grip of the narrow-minded “public health” types over the discourse cannot be done by adopting their rhetoric.  These products can be enormously welfare enhancing compared to either smoking or abstinence (I have written more about this in my paper about the basic economics, which I finally released – I will write more about the content of that analysis soon, but you can check it out now).

Of course, not everyone who has positive things to say about low-risk tobacco products agrees that it is right to think this way.  Many prominent THR supporters come from a medical or public health background, and still fall into those fields’ unfortunate tendency to ignore any human preference other than health.  To them, THR really is only about the “R”.  They often explicitly state that abstinence is always “better” (without defining their basis for that normative claim), which leads conclusions like "we should restrict education about low-risk products so that they only attract smokers who would not otherwise quit smoking" (setting aside the fact that such targeting is impossible, and recognizing that they may well understand this, they still would prefer to do it if it were possible).

This thinking – whether it comes from those who support THR, oppose it, or are reasonably neutral – invites comparisons to methods for abstinence promotion and implicitly denies that substitution has advantages over abstinence.  This results in the typical discussions about how THR is a more effective method for quitting smoking (for those who are not inclined to just quit) than the alternative methods.  I certainly engage in plenty of those discussions, and I believe it is true.  But focusing entirely on this gives comfort to those who would prefer smokers not have access to a pleasant way to reduce their risks (why would anyone prefer that? read here).  It makes it easy for them to make up claims that THR is not really proven to be more effective for many smokers, and that there are officially “approved” alternatives which therefore must be better, and such.  Those claims are generally full of utter lies, of course, but they is effective at tricking casual observers into doubting the value of THR – so long as THR is only about not smoking.

But since low-risk tobacco products occupy basically the same consumer niche as coffee, I would argue that this is not the battle we should be fighting.  It should be possible to move one step above that fight and argue that low-risk products are better than abstinence for many people.  I am not talking about the constructed and often-invoked (but, in reality, empty) category of those who “cannot” quit smoking.  A focus on that category suggests that THR advocates are conceding that that abstinence is best for everyone in theory, and are merely arguing that a second-best solution is needed for some people.  This, in turn, invites the retorts that “better” cessation methods eliminate the need for this second-best and that low-risk tobacco products really are medicines.  After all, if the only reason we should allow people to buy and use e-cigarettes is because otherwise they would continue their smoking habit, which their personal history shows they are unlikely to stop anytime soon, then why not make them available only by prescription to long-term smokers?  (One answer might be “because under that rule, the only products available would be as unappealing as NRT is”, which is a valid worry, but is a rather different point; a market could be created that is still makes high-quality and innovative products, but is open only to those with diagnosed “cannot quit smoking” syndrome.)

So if this is not just about those who need low-risk tobacco products to “cure” their smoking because nothing else will, who is it about?

To some extent it is about those who experience identifiable health benefits from nicotine, or perhaps other aspects of tobacco use, those who find it to be a good treatment for various psychological conditions and a few physical conditions.  That group that represents one my major motivations for working on this topic.  Efforts by “public health” people to deny such people access to low-risk tobacco, insisting on quit-or-die to those who would suffer terribly from tobacco abstinence (both now, in the world of e-cigarettes, but also for a decade before that when it was demonstrated that smokeless tobacco was a low-risk alternative), is cruelty that is arguably genuinely evil.  It is indefensible from the perspective of any accepted modern ethical system, and exists merely as religious persecution of people who are “different”, with all that implies. 

But it is not just that group either.  This is also about the welfare of everyone that likes or might like the experience of using low-risk tobacco products enough to accept the risk that they might cause a very small reduction in life-expectancy (or they might be beneficial for health on net – we do not know for sure).

Many such individuals are, of course, the aforementioned groups of those who “cannot” quit – i.e., do not quit despite every legal effort being taken to make them suffer for their choice – and those who get serious psychological or other health benefits from smoking (these categories probably refer to mostly the same group of people).  There are many such people who will smoke if there were no other satisfying option, and so this their harm is indeed being reduced if low-risk products are made satisfying and available.  But they will also benefit from the products as compared to abstinence.  If they would choose smoking over abstinence but choose the low-risk product over smoking, then they are almost certainly getting great benefit from using the low-risk product rather than being abstinent.

But for those who are or will be abstinent rather than smoking, possible use of low-risk products is not about the harm reduction.  There is no harm to reduce.  Since this includes everyone who could be bludgeoned into abstinence using other methods, failure to consider the welfare of this group is what gives comfort to the enemy.  In the extremists' rhetoric, everyone will soon be in this category (never mind that this is some combination of mistaking a hope for a plan and out-and-out lying on their part – they still make the claim), and so in their imaginary world there is no harm to reduce.  Arguing that “tobacco-free 2025” is an absurd fantasy is simply not effective – it ought to be because the idea is utterly crazy, but somehow it is not.  I am tending toward the conclusion that only by pointing out that this fantasy future is inferior to a world of minimally-harmful or non-harmful tobacco use, rather than merely arguing that the fantasy is not happening, is it possible to gain the upper hand.

If it is just about harm reduction, then their solution of discovering some magic bullet that will eliminate all harm by eliminating all use is indeed a superior option.  Never mind that a hope is not a plan and there is no legitimate expectation; experience makes clear that the anti-tobacco extremists can make such claims without being subject to any scrutiny from the government or the press, or from most of the public.  But they also might find a slightly more honest argument looking at “clinical” interventions (i.e., treating e-cigarettes or other low-risk products as if they were medicines and, in a medical-like setting, trying to push them on average smokers to try to get them to quit) and finding that – when you do not focus on the right group, smokers who want an alternative – relatively few can be pushed to switch.  As evidence about such artificial and inappropriate efforts to push or cajole random smokers into switching trickles in, it shows that this does not work much better than any other aggressive approach.  If (and only if) these products are medicines, then such evidence indeed represents a failure.

But what if we were to focus on the fact that any risks are minor – down in the range of everyday hazards – and there are net benefits to be had?  In other words, this is a choice that is not very similar to cigarettes, and is more like coffee, soda, snacking, travel, sports, and computer games, all of which have their health costs, but substantial and widely-appreciated benefits.  Moreover, as a choice and not a clinical intervention, any observed failure of trying to clinically force products on currently uninterested smokers is is not damning.  That is simply not the role of the products among free living adult consumers.

Yes, there is some such effort now.  But it is not very concerted, and it is overshadowed by the harm-reduction-only rhetoric (which, again, is unfortunately partially locked-in due to terminology).  Yes, that effort would have to struggle against decades of fairly successful demonization of people who use tobacco products.  But that is the point.  Even if people understand that low-risk tobacco use creates about 99% less risk than smoking, it is still creates 50% or perhaps even 99% of the scorn.  This will clearly no longer be the case after low-risk tobacco product use becomes the norm and those who have been brainwashed by anti-tobacco rhetoric slowly come to their sense (or die off).  But that is a long time, and in the meantime there will be needless loss of welfare, both among smokers who are discouraged from quitting and those who benefit from tobacco/nicotine who are discouraged from using anything.  Perhaps the process can be accelerated.

One challenge is that there will be pushback from some people who support THR, but only as HR.  For them, the term is exactly right.  This seems to include most of the medics who have been won over to THR, and includes a few of those who are considered strong public backers of THR.  These are good people trying to make the world better; they genuinely care about health (they want to improve health rather than merely make people behave “correctly”) and they are pragmatic (they favor something that works over mere hopes).  But ultimately, a lot of them are still anti-tobacco extremists – that is, they ultimately hold the extreme anti-tobacco view of preferring a world in which there were no tobacco use, regardless of whether the benefits of use might exceed the costs for many people.  Many of them long refused and still refuse to embrace smokeless tobacco as a THR product (even though it is the proven low-risk product and probably lower risk than e-cigarettes) and endorse e-cigarettes only because they can take refuge in the rather tortured rationalization that “they are not really tobacco”.  While far from being like the “public health” people who actually care more about destroying tobacco companies than they do about improving people’s health, there are plenty of e-cigarette advocates who ultimately still hate all free-chosen tobacco/nicotine use and only like the product that they can think of as being like a medicine.

It is my assessment that attempts to defend access to and promote awareness of low-risk tobacco products – even if motivated primarily or entirely by trying to reduce harm for current smokers – would benefit substantially if there was more attention devoted to arguing that low-risk tobacco products are little different from everyday consumption choices (except in the minds of an zealous minority who think that there is something evil about this plant).  Many of the popular protests about the MHRA announcement focused on the point about e-cigarettes being a consumer choice, not a medicine.  But that may not push quite far enough.  They are not just a choice, but a fairly unexceptional choice – with the added benefit that if a smoker chooses to use them to “cure” their smoking, they can.

How to convince someone they really don't understand what they are talking about

Finally some time to do some general knowledge journal reading!  On my list was a fascinating paper (pdf of the free working paper version - the journal version is paywalled) by Philip M. Fernbach, Todd Rogers, Craig R. Fox and Steven A. Sloman that investigates how to convince people that they really do not understand a topic they think they understand.  It has been blogged about in the context of extreme political positions, but it seems to have even greater relevance to more technical science-based topics like tobacco harm reduction (though, of course, much of traditional political extremism involves a failure to understand science also -- e.g., IS/LM macroeconomic models).

The most promising approach to persuade someone that something they strongly believe is just not so is definitely not to present contrary evidence.  It has clearly been demonstrated, repeatedly, that for most people (the vast majority who do not think like scientists or philosophers, including most "scientists" in health, and presumably in lots of other fields), presenting contrary evidence leads to a non-intellectual gut-level defensive reaction which tends to just harden their belief.  Expecting to get a rational reaction to evidence is usually a nonstarter.  Sigh!  But it is not much more useful to simply ask people to explain the basis of their claims -- they will just do a biased search for confirmatory evidence (or, quite likely, mere assertions of others who agree with them) and, again, become more hardened in their position.  Rather, the solution is to ask them to explain the mechanism that supports their view of the world.

The abstract reads:

People often hold extreme political attitudes about complex policies. We hypothesized that people typically know less about such policies than they think they do (the illusion of explanatory depth; Rozenblit & Keil, 2002) and that polarized attitudes are enabled by simplistic causal models. We find that asking people to explain policies in detail both undermines the illusion of explanatory depth and leads to more moderate attitudes (Experiments 1 and 2). We also demonstrate that although these effects occur when people are asked to generate a mechanistic explanation, they do not occur when people are instead asked to enumerate reasons for their policy preferences (Experiment 2). Finally, we show that generating mechanistic explanations reduces donations to relevant political advocacy groups (Experiment 3). The evidence suggests that people’s mistaken sense that they understand the causal processes underlying policies contributes to polarization.

As motivating examples, the authors note that most people will express confidence that they understand how such familiar mechanisms as toilets and combination locks work, but when asked to explain the mechanism, they change their mind and recognize that they do not really understand after all.  To the extent that extreme political positions often result from similar overconfidence (as the authors claim), a similar tactic can be used to show someone his beliefs are based on overconfidence.  Causing a recognition, by asking for a mechanistic explanation, goes a long way to lowering misplaced confidence.  This then might(!) lead to a softening of malformed extreme positions (I am not so sure that the author's conclusions that this does happen, based on their artificial experiment, is completely convincing).  

In my mind, the more obvious uses of this observation do not relate to policies at the big picture level, but specific individual claims.

An obvious application is one I always thought was a good idea (and, indeed, embedded in some of my analysis on the topic):  "So you think that snus or e-cigarettes might be as harmful as smoking?  Can you tell me what particular diseases you think might be caused, and at what rates, that would add up to the total risk from smoking?"  Of course, someone can still retreat into a nihilistic "we just don't know, and therefore anything is possible", and those who are just generating rhetoric in support of some hidden financial or "moralizing" interest will not be persuaded because they never really cared whether it was true or not.  But those who actually believe the claim is true, and care whether that is really the case, tend to rapidly realize it is absolutely implausible.

A related example is the claim that low-risk tobacco/nicotine products are a "gateway" to smoking.  But just ask someone to explain the mechanism by which a consumer who would not otherwise choose to smoke would choose to smoke after learning about a low-risk alternative and trying it.  Among those who actually believe the myth and are motivated by (not those reciting it to support some hidden goal), lightbulbs appear over their heads.

Of course, sometimes this step alone gets you nowhere because someone is way too far from understanding for one question to get them there.  For example, if you ask someone who thinks that installing a lot of industrial wind turbines are a good idea to explain the mechanism by which benefit is created, he will probably assert that they reduce the awful pollution from coal burning and produce electricity with no emissions, and feel not the least bit less confident of their knowledge.  The naive belief is simply so far away from the actual mechanism in this case that the believer does not even understand that there is an ultimate mechanistic process.  The situation is unlike the case of "should we impose unilateral sanctions on Iran?" (one of the questions in the Fernbach study, which lends itself to simple "how might that accomplish what you think it accomplishes" thinking) and more like "should we be fighting a war in Afghanistan?" (which is several layers away from the goals someone might support).

This still might open the door for better conversation.  You could to explain why the electricity from IWTs displaces the relative benign burning of gas, not coal, and that the manufacture and installation of IWTs, and the extra gas burning that is needed to stabilize the power grid because of their intermittent performance, are obviously not emissions-free.  But at that point you are back to relying on someone being open to hearing evidence and actually learning something, because if you try to continue the proposed tactic, it will fail:  If you ask, "so how can IWTs substantially reduce coal burning or the installation of fossil fuel plants when they always need to be backed up by dispatchable [can be turned on immediately] gas-burning turbines", you are depending on them being willing to recognize the truths implicit in the question, not their mere inability to answer it.

But with such caveats in mind, this is still a very promising tactic.  I suppose I have always recognized that and used it, but this study is a great reminder to do it more, and that other approaches that seem similar really are not, and that they seldom work.

A primer on the buffoonery of Simon Chapman for Australian IWT opponents (part 2)

There is a self-deprecating joke in academia how to recognize a scholar (I am talking about myself here, not giving credit for that status to the subject of the post):  You know you are a true scholar if you consider every project you have ever worked on to be a work in progress.  I wrote Part 1 about what a buffoon Simon Chapman is a while ago.  But, hey, it was not even a full year ago, so of course it was still a work in progress.  Also on this blog I have written this and this and especially this.

There has been a renewed flurry of interest in what a dangerous oaf he is.  See, e.g., the Stop These Things blog or the new Twitter parody of him -- though a search for him in any of several other forums will show that there has never been any end to his dangerous games -- e.g., Nannying Tyrants, Dick Puddlecote (especially this recent gem -- read through to the end to get to the punchline), Velvet Glove, Iron Fist.  So I realized it was time to return to this project a bit.

It is quite remarkable how much damage this one nasty individual has inflicted on the lives of smokers (especially those who he killed because he kept them smoking, campaigning for Australia to ban low-risk alternatives rather than letting smokers switch to those alternatives as they have done elsewhere), and now to people suffering the effects of wind turbines in Australia (fortunately he has little reach beyond the sea, though there are hints that he has meddled in UK politics).  He has also done rather substantial damage to the scientific integrity of public health, and has contributed to a general feeling in the rest of the world (among those who are aware of "public health" and nanny state issues) that Australia might be better off being re-colonized.  Influential nasty idiot is a bad combination.  The only saving grace is that he does not have the self-discipline of a high-functioning sociopath, which would have allowed him to succeed in politics, else he might have done even more damage.

And, yes, I know that people like him thrive on the attention generated by their vandalism, bullying, and bravado.  It is so transparent in his case that I feel kind of silly taking the time to mention it.  But this particular vandal does so much damage that trying to avoid rewarding his antics with attention, like we might if trying to train a pet or educate a child, is not socially responsible.  Those of us who care about public health and good public policy have to fight back against people like him.  In the big picture it does not matter that we are just playing into what he wants, because it is his victims that matter. 

So, just one point of substance today and more later (work in progress, you know).  As those involved with the wind turbine and health issue know, despite Chapman spouting off in support of the electric power industry's denialism about the harms that are being caused, he has only made one "contribution" to the knowledge base:  He poured through the adverse event reports (AERs) of nearby residents who suffered the health effects looking for mentions of odd diseases that were probably not actually caused by the wind turbines.  He then proceeded to claim that because so many diseases were mentioned once, somehow the clear pattern of diseases that is consistent across these reports somehow does not count.  And, no, I have no idea why someone might think such a thing.  (For more information on the importance the adverse event reports as epidemiologic evidence and how to properly interpret the evidence, you can read my paper on that topic.)

He seems to have spent most of a year on this utterly pointless exercise.  And yet I debunked the whole thing in one paragraph in some testimony I wrote recently:
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It is true that many individual AERs also report various health problems that are not apparently related to wind turbine exposure.  This is not surprising since people will have various health problems that start after they are exposed to wind turbines purely by coincidence, just as they would have had those problems had they not been exposed.  We would expect people to report these, along with the common outcomes that do seem to be caused by the exposure, in an attempt to provide a complete record of their experiences.  Indeed, such reporting is good scientific practice; it is optimal to report all of your data because you do not know what might prove to be useful information.  Some non-expert commentators have tried to claim that this scattering of apparently unrelated problems is evidence that the AERs are uninformative.  But this is obviously not true, since the occasional apparently unrelated disease does not change the almost universal pattern of commonly reported diseases.  The misinterpretation represents a failure by non-experts to understand that scientific analysis always involves identifying the signal amidst the inevitable noise (which in this case is quite easy), rather than obsessing about the noise.

And, yes, I think this means that the rough equivalence is that 5 minutes of my time is what is required to rebut a year's worth of Chapman pseudo-science.  I did not take the space in that testimony to mention that in most cases, he was probably misrepresenting the claims (though because he did not actually report actual results or methodology it is hard to be sure -- he not only got the science wrong, but he did not even know enough to ape how science is done):  He presents these claims as if everyone expressed certainty that the ailments were caused by wind turbines, when in fact many probably did not make such causal claims, but merely reported their experiences.  This is good scientific practice (what the residents did, that is); someone reporting adverse events they have experienced cannot necessarily know which of them might fit a pattern, and thus be scientifically useful, so the proper thing to do is to report everything and let the experts who have the big picture sort it out.

But Chapman did not merely demonstrate that he lacks a rudimentary understanding of how science works.  He opened a window into a rather evil soul.  As he was collecting these examples, he repeatedly published expressions of his glee about what he was finding, openly mocking and actively expressing his joy in people's reports that they had gotten cancer or some other disease.  Any normal human being who actually cared about people -- someone who was honestly disagreeing with a particular causal claim -- would say something like "I am sorry to hear about your suffering, but it seems there is really no basis for claiming the cause is what you think it was".  I realize that people in "public health" often get away with doing junk science that is proven wrong, time and again, for a very long time.  But it is difficult to understand why anyone listens to him after he has also so clearly revealed his lack of humanity.