Monthly Archives: July 2010

Obesity spending and the long-since diminished marginal returns of anti-tobacco spending

“In our reaction to the obesity epidemic, sometimes we have taken our eye off other issues.”

There has been quite a bit of sound a fury in the popular press lately, about the supposed battle for funding between researchers and health practitioners focusing on obesity and those focusing on smoking.  The press is generally best at reporting on sporting events (people who only read the sports section and ignore the rest of the paper are often criticized as being out of touch; but perhaps they just are just aficionados of top-quality reporting).  Playing to their strength, reporters try to cover everything – elections, political struggles, environmental catastrophes, and now public health spending priorities – as if it were a football rivalry and a series of matches.

Today’s New York Times included one such report.  The report began with a fundamental flaw, focusing on how the Robert Wood Johnson Foundation had scaled back its spending on anti-smoking (really anti-tobacco – they were not on the side of effective harm reduction measures) and was moving toward anti-obesity efforts.  Even ignoring the fact that RWJF’s shift away from anti-tobacco funding occurred several years before obesity became the thing, this does not demonstrate what the reporter wanted to pretend it does.  The suggestion is that RWJF should, or does, just keep pouring money at a single issue.  But that foundation has always focused on following the judgment of smart people and swinging resources toward where they are most effective.  It is not the U.S. government or Gates and Bloomberg, who decide to own an issue and throw billions of dollars at it.  Indeed, with those bottomless pockets pursuing anti-tobacco, there is little room left for the clever contributions of the likes of RWJF.  (Disclosure: RWJF paid my salary for two years and for the costs of me becoming educated as a public health expert.)

The quotation at the top of the page is from Terry Pechacek of the U.S. CDC, one of the most hard-core drug warrior types in the anti-tobacco industry.  In fairness, that statement may have not sounded quite so ridiculous in context rather than as a soundbite in the aforementioned NYT article.  But it is hard to see how any context could make it other than incredibly ironic.  The Big Anti-Tobacco Money guy worrying about one over-emphasized issue taking away attention from other issues?  That was not even the most absurd quote.  Steve Schroeder, who ran RWJF during its anti-smoking days (the foundation’s emphasis also is influenced by who happens to be in charge, of course), complained “The sad thing is, smoking, despite all the harm it does, is left pretty much an orphan.”  Seriously?  I never would have guessed that the RWJF retirement package for ex-presidents was so good that you could spend the ensuing years yachting around the world, cut off from the news.

Have they truly not seen what the marginal dollar spend on anti-tobacco is used for?  It pretty clearly has low cost-effectiveness, and arguably actually does more harm to the world than good, even apart from the money (which is to say, we are currently to the right of the vertical line in the graph that is shown, which I hope many of you will recognize from introductory economics).

Therein lies the fundamental lack of understanding by the press and other commentators.  When someone pretends to lend substance to arguments, they talk about only total number who have a particular behavior, what fraction of them die and other average or total values (almost always this is by way of pointing out that these numbers are still worse for smoking – it is pretty clear that this “controversy” has been engineered by those worried about losing their unending supply of anti-tobacco funding, taking advantage of their current power and influence, including with the press, to defend their empire against anyone with another priority).  In the same article, Stanton Glantz is quoted, “Given that tobacco kills four times as many people as obesity does, why is the government putting more money into obesity?”  Since he seems to be believe that passing exposure to second hand smoke causes 1/3 of all heart attacks, I can only assume that he actually thinks that is a valid argument.  But sadly, most others seem to miss the point also: What matters is the marginal effect of additional spending.

This is a very simple economic principle:  For most decisions, what matters is marginal cost and marginal benefit.  You cannot justify spending $200 on a restaurant meal by saying “I only spend $10,000 per year on food and without food I would die, so how can you suggest I reduce my budget?”  The average spent per day does not matter, and what would happen if you dropped spending to zero obviously does not matter; all that matters is the marginal (additional) benefit from that meal compared to the big price tag.  Similarly, when assessing spending priorities, it does not matter how many people smoke or how many total disease cases will result from the exposure.  What matters is whether the last dollar spent is doing much to improve that (and what harm it might be doing too), as compared to what another dollar of spending to try to help people not be obese will accomplish.  Apparently the smart money is on the value of the latter.

I do not really know where anti-obesity money is going, but you could imagine that a bit of spending on some basic education and life skills – akin to telling people in the 1960s that smoking kills, a very effective intervention – could be very effective.  Compare that to the marginal spending on anti-smoking:  yet another study that shows that smoking causes lung cancer (but very little to learn to better treat lung cancer – we would not want to reduce the incentives to quit smoking); hundreds of ad hoc school and community interventions and the studies that show they are incredibly effective (apparently we actually eliminated all smoking years ago); and they even have to start making things up (third hand smoke, etc.), damaging the integrity of health science, just to pretend to have something to do.

It is pretty clear that basic education about risks works wonders, but that has been completed for smoking (in the West) and probably does not even require any spending to make sure each new generation picks up the conventional wisdom.  Also seemingly effective is torturing smokers (I think they use different terms for it, but I forget what they are right now) by restricting their behavior and imposing punitive taxes, and now the FDA trying to lower the quality of the products.  But these do not cost much either, except when it is necessary to fund a propaganda machine to convince a generally sensible public that these are a good idea, and that is pretty hard to justify spending on from an ethical perspective. 

A massive education campaign to encourage switching to low-risk alternatives (and more research on those alternatives) would be a great use of funds.  It might be almost as cost-effective as the original education campaigns about smoking.  But since this – the only proven method to dramatically reduce smoking prevalence once the “smoking kills” message is generally understood – is opposed by the people who want to keep the money flowing, it is difficult to imagine that anything of value will be lost by switching money from anti-smoking to anti-obesity.

I cannot wait to see their reactions when a paper funded by the anti-obesity initiatives comes out that shows that smoke-free nicotine products seem to be an effective way to reduce obesity.

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Krugman and economic policy analogies revisited

I did not plan to make a running theme of this when I first posted about analogies between my work on tobacco harm reduction (THR) and the attempts to introduce some Keynesian sanity into current discussions government economic policy.  But I just keep seeing more and more parallels.

A recent analysis by Christopher Hayes included a point that was picked up on and extended by Paul Krugman:  Regarding the current economic situation in the West, their fear is that eventually everyone who is remotely honest will have to come to realize and admit that push to constrain government spending to reduce deficits right now is a bad idea.  Krugman and Hayes each offer comparisons to the run up to the Iraq War which struck me as also being good metaphors for anti-THR.

Krugman points out that the people who are demanding austerity in the face of a liquidity trap and devastating unemployment are the ones who are currently considered the Serious analysts, in contrast with those calling for more stimulus, even though the latter position is better supported by the science as being good for the economy and certainly more humane.  He likens this to the war where it was quite clear as the invasion approached that the justification was flawed, the potential for disaster was great, and the upside was sketchy.  But after it became clear that the justifications were bogus and the overall experience was a disaster, we have a situation where only those people who originally supported the war and then reluctantly came to accept concerns about it after they were absolutely impossible to ignore are considered Serious, while analysts with the sense and honesty to understand and testify that it was a bad idea from the start are considered “flaky and unreliable”.

This seems quite similar to the experience with THR.  Among those who support THR are several people and organizations that once were part of the “tobacco control” – aka anti-tobacco extremist / “quit or die” / abstinence-only –  community before recognizing that harm reduction is a more effective way to promote health or recognizing that promoting THR is demanded by any accepted standard of social ethics.  (Most often only the the former – these individuals usually support only a narrow form of THR, caring only about health outcomes, rather than fully embracing the harm reduction principle of improving welfare.)  For some reason, their analyses on the subject are taken more seriously than analyses by those of us who were never active in the abstinence-only community and recognized the value of harm reduction from the time we first contributed any substantial work on smoking and public health.

Even casual vague assessments by these actors are often taken more seriously than careful, scientific, in-depth analyses by those of us who have focused on THR from the start.  Perhaps the most absurd example of this is how a baseless and obviously wrong figure about the comparative risk of smokeless tobacco versus smoking – that appears to be little more than guesswork, but was produced by people who were part of the extremist camp – is cited more than the much more accurate estimates (based on actual calculations that anyone could verify) by those of us who take THR seriously.  This strange bias seems to favor even more strongly those who have done a bit to support harm reduction but ostentatiously claim to waver on the topic.  Their tendencies to bury everything they say in tortured caveats and calls for more research that is clearly redundant or irrelevant, as well as to half cling to incommensurate extremist position (usually, it seems, because that is where all the money is and they do not want to risk their gravy trains), are treated as a reasons to trust them. 

Why is having been badly wrong, let alone refusing to distance oneself from the false claims after making it quite clear that one knows they are false, a source of credibility?

Just to clarify, a few of the aforementioned people are my friends and/or colleagues I respect greatly, and I am not suggesting their actual contributions to the discourse are faulty.   But their contributions are valuable because they are good, not because the author was wrong before.  I would even say that the contributions are good despite the author being wrong before.

I also wonder about the possible future that some of us predicted for years (see, e.g., the Introduction of Tobacco Harm Reduction 2010), wherein current opponents of THR figure out a way to take credit for the inevitable march of THR.  I wonder if, when THR happens despite the efforts to stop it, those who were trying (lying, maneuvering) to stop it will become the Serious People whose opinions about it are considered most reliable.  

Hayes also points out a rather different point, that the leaders of the forces supporting the Iraq War or the current calls for austerity undoubtedly knew that there was no real worry about weapons of mass destruction or that trying to reduce budget deficits while in a slump is counterproductive, but just used the claims (about WMDs or deficits) as sellable and popular stalking horses for their rather more oligarchic aims (imperialism and securing oil wealth; further shifting wealth from the poor to the rich).  Thus, even though the facts did not support their claims they do not really care, because what they were claiming was never actually what motivated them.  This again rings familiar.  It is pretty clear that the thousands of naive foot soldiers for the leading anti-THR activists – local health officials, politicians, teachers, clinicians, and others who really do not understand what they are saying but blindly trust influential people who (dishonestly) claim to be on the side of public health – do not actually favor anti-tobacco extremism over public health and human welfare, but they have been tricked.  Unlike the extremist leaders who undoubtedly know better and are just looking for a way to rationalize their policies, their followers actually believe that no one benefits from nicotine use, universal abstinence is coming soon, and that low-risk nicotine products are 100 times more harmful than they really are.  It is much the same as the lower-middle class conservative families – those whose members paid almost all the human costs, and more than their share of the financial costs, of the Iraq war – blindly supporting the oligarchs.

I am open to the possibility that I am exaggerating the parallels of the current socio-economic fights and the struggle for THR.  Seeing connections everywhere is an occupational hazard when one is immersed in particular topics, so I invite my readers to point that out to me if it seems to be the case.  But I just cannot help but see the same right-wing playbook being used in both cases.

Wind turbines and health – CVP Report for Wisconsin (errata posted here)

Apologies for relatively content-free blog entry, but I needed somewhere people could find this information and this seemed like the best chose at the moment.

I recently completed a report on the evidence supporting the claim that wind turbines cause health problems for some nearby residents.  The report was submitted to the state of Wisconsin and can be found here.  There is something odd about that page, however (I could download it using Safari but not Firefox) so I will note that you can find it reposted here (and, I believe, other places; note that the reposting does not represent any relationship between me and those who have reposted it other than me agreeing to their request to let them repost it in a better file format).  Also, the oral testimony I gave in that case is recorded here.

It was pointed out to me that the last page of the report is missing, which was probably my fault.  It contained references.  Since I cannot add errata to the the original posting, I will post it here.  Missing were the following:

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Roberts M, Roberts J. Evaluation of the scientific literature on the health effects associated with wind turbines and low frequency sound.  Exponent Inc.  Prepared for Wisconsin Public Service Commission Docket No. 6630-CE-302 (the identity of the actual client for whom this was prepared is not disclosed in the document). October 2009.

Waye K. Effects of low-frequency noise on sleep. Noise and Health 6(23):87-91, 2004.

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Also, minor typo that was pointed out  to me by an attentive reader: page 23 in the 3rd line of paragraph #3:  the word “as” should be “has”

Should any other errors or need for clarifications be identified by or to me, I will update this entry.  I recognize that this is the not the most prominent place to post corrections, but at least it is better than the practice of most people in the field (to never post any corrections of their mistakes anywhere).