Monthly Archives: April 2011

Unhealthful News 116 – Yesterday’s non-news about e-cigarettes

I found a great UN example today, but it was a bad health and productivity day, so writing this post for the THR blog was most of my productivity for the day.  So just a few words now about the news reporting that relates to that one, and I will save the more interesting one tomorrow.

The quick background is that the US FDA announced yesterday that it would regulate electronic cigarettes according the rules used for tobacco products instead of the rules for medicines, as they had wanted.  The latter would have effectively banned e-cigarettes, but manufacturers took them to court, and the court required they do what they just announced they are doing.  For a bit more background, you can read my other post at the link, and for more background still, you can follow the links from that.

Every reporter seemed to have either missed or ignored the fact that this was not a choice by FDA, but something the court had required, and that there was really no information provided about what the critical implementation details will be.  It was kind of an inkblot test for the reader, with e-cigarette supporters typically reading in better news than can be assumed.  Despite that, the Associated Press story by Michael Felberbaum did a nice job of explaining the matter.  Covering the pertinent facts for someone to basically understand the matter, without hype, too much hyperbole, or too many unsubstantiated scientific claims.  It was one of the better short health news stories I have read in a while. 

Extra credit goes to the Philadelphia Inquirer, whose version of the AP story left out the flawed attempt to explain why e-cigarettes are much less harmful than smoking, because they do not contain “the more than 4,000 chemicals found in cigarettes”.  You get used to seeing nonsense like that from anti-tobacco propaganda, but it is pretty lame when news reporters decide to gratuitously throw it into stories.  Here is a hint about counting chemicals:  There are pretty much as many of them as you want to count, if you keep looking hard enough, in most any complex natural substances like tobacco, kale, salmon, children, etc.  Also, the counts of thousands of measured and named chemicals refer to the smoke, which has different properties from the cigarettes themselves.  The New York Times version cut out much of the useful material and left that in.

The Los Angeles Times made the mistake of writing their own story, and dredged up the discredited attacks on e-cigarettes that FDA launched as part of their legal strategy.  The Winston-Salem Journal, which often delves more deeply into tobacco-related stories than any other paper, focused on the reactions of various partisans in a way that was probably cryptic to anyone unfamiliar with the topic.  Most of the television news reports cut for length by leaving out the fact that this was fait accompli, implying it was a policy-changing decision.  This is actually what a lot of my expert colleagues did also, interestingly enough.

As far as I could find, no reporter seems aware of how little the FDA announcement told us about what will really happen (see my THR post for my take on that), other than there will be no immediate ban.  But I get the impression that no one they talked to made any effort to explain to them how uncertain the matter still is, so it is hard to blame them.  In this case, it is not so much that we need a more skeptical press corps, as I often scream, but that we need more skeptical pundits.  The only such analysis I noticed came from two small San Francisco newspapers which suggested (as I did) that this paves the way for treating e-cigarettes like cigarettes in all ways.  Because of recent policy debates there, they focused on including e-cigarettes in place-specific smoking bans.  While this obviously does not logically follow from the FDA policy (the rule is that e-cigarettes will be regulated as tobacco products, many of which are smokeless, not as producers of smoke) it seems like an inevitable rhetorical path.

Bottom line: It really is interesting to see so much reporting about a “groundbreaking” “decision”, some of which included some genuinely good background information, without actually seeing any news reporting.

Unhealthful News 115 – Goals are not predictions; sometimes they are not even goals

Numerous headlines over the past few days have reported that the US will/could/should/is expected to have inflexible indoor smoking bans everywhere in the country by 2020, or some variant on that theme (here are some examples).  The thing is that this is merely some people’s goal, and contrary to many of the reports, there was no study supporting the claim.  Moreover there was not even anything “newsworthy”, since there was not even any change in the arbitrary goal.

So what generated the “news”?  There was a simple matter-of-fact report in Morbidity and Mortality Weekly Report (MMWR), CDCs weekly blog.  It is actually a newsletter that predates blogging, but these days the most useful way to think of it is as a blog, to avoid confusing it with a journal or even a carefully-edited periodical.  The report was about the enactment of indoor smoking bans from 2000-2010, and it seemed to be just fine for what it was.

But it also included the tangential observation that the US government’s “Healthy People 2010” goals included enacting exception-free nationwide indoor smoking bans in any space where someone is employed, which did not happen.  So the wish was just carried over to “Healthy People 2020” and the report said this “is achievable if current activity in smoke-free policy adoption is sustained nationally and intensified in certain regions, particularly the South”.  Yeah, that warrants headlines about 2020 being the time to expect nationwide laws – an arbitrary date from an old list of goals combined with a report that simply recounts past events and has no forward-looking analysis.  But wait, there is a one-sentence assertion by a random group of analysts working at CDC, so stop the presses.  This is what passes for health news.

(Someone looking for a more interesting story might focus on how the US government goal was to enact these laws, but they failed and are now wondering if it can be done ten years later.  For those not familiar with the US system, the explanation is simple:  Most laws are controlled by state and local governments and not all of them share the feds’ goal.  The beauty of federalism is that different states and localities can try out different policies, and if they are really important, people can vote with their feet.  Of course, the feds have a habit of thwarting this system in many cases where variety and local freedom is useful and, indeed guaranteed by the Constitution.  Perhaps the confidence in the 2020 goal should be read as the federal government hinting it will withhold funds to force all states to adopt the “right” laws, the usual tactic for ignoring the rights of the states under the Constitution.  Reporting that would be a much more interesting and genuine news story.)

That one phrase from the report that is quoted above was not all that was written.  As with many MMWR reports, the analysts’ useful information is accompanied by an “Editorial Note”.  This one, like many such notes in MMWR, is longer than the actual study report.  Like I said, it is a blog, not a journal or even really the technical report series it is supposed to be.  The editorial waxes about how the existing laws are “remarkable public health achievements” though the data to support that claim is pretty sketchy.  More important, the editorial makes clear that whoever was writing does not consider sufficient laws that allow for any exception whereby consenting adults can gather and smoke, and suggests that restrictions on smoking at home should be added to the goals.

I am not writing this to comment on the anti-tobacco extremists and slippery slopes – there has been plenty written about those.  Rather, this story is a reminder that for any issue with political implications, the health press often take a break from being overly-credulous science reporters and instead become typically-credulous policy reporters.  That is, they report whatever someone in a position of power asserts as if it were information, and report government goals, no matter how extremist, naive, or unpopular, as if they were god-given.  There are few Americans who would insist that if some states chose to allow well-ventilated smoking sections in bars or casinos, or refuse to force old men at the American Legion (a private club for military veterans) to relive their days in Korea by going out into the snow to smoke, that this would be a terrible thing.  And it seems like there is a good chance that some states will allow at least some such exceptions, thwarting the inflexible CDC goals, if they are not blackmailed by Washington. 

I suspect that the debate on this matter will have matured enough by in 2021, or perhaps even become largely moot, so that we will not see a spate of naive stories about how the goal will be met by 2030.  But given the anti-tobacco activist enclaves of the government and the quality of the press corps, I am not willing to rule out the possibility.

Unhealthful News 114 – Krugman takes on some unhealthful news

Paul Krugman has written several posts in the last week about medical financing, including his New York Times column about how medical spending requires limits/choice/rationing and how medical patients are quite dissimilar from people in their role as consumers of ordinary goods.  He pointed out in his blog that this was basically reminding us of something the great Kenneth Arrow wrote in 1963.  I suspect that readers in most of the world understand that these points go without saying, which is why the government needs to exert substantial control over medical financing and, by extension, limits on spending.  But in the US the the debate goes on about whether or not we are going to do anything remotely rational about medical financing.  (For those interested in other recent Krugman writings on the topic, they are here, here, here, and here – I understand that links from blogspot let you into nytimes pages even if you have used up your free articles for the month.)

To summarize, the most important reason that patients do not act as normal consumers – probably obvious to anyone who thinks about it, a category that clearly does not include about half of American commentators on the subject – is that they are not paying most of the bill.  This is because if they had to do so for anything other than routine care, they would not be able to afford it, so insurance of some sort is needed, and there is no getting around how that prevents normal consumer decision making.  A second reason is that the “consumers” seldom have the knowledge and confidence to make a decision, and often are in no condition to think straight, so someone else (neither the patient nor the payer) is also making the decisions.

As for the need for some kind of rationing, it is not possible for us to provide everyone with every beneficial medical treatment, a category that includes a lot of expensive treatments that will probably fail, but might offer a little benefit.  We understand this for most goods, but the thing about medical care (this is my claim, not Krugman’s) is that until recently the total cost of all beneficial treatments for anyone who might benefit from them was quite small.  Moreover, during a brief period that included the formative years of most current American pundits, we were rich enough to afford all of those treatments for everyone in rich countries.  That odd situation has changed.  But our usual method for rationing consumer goods – making people choose what they want, constrained by what they can afford – does not work, so someone has to make the decision.  It can be private insurers who are looking for any excuse to not pay for something, or it can be – gulp! – government.

Rationing is tough, but it would be better if we acted like adults and recognized that it was necessary, and best to do it in some sensible way.  I had a conversation this morning with someone who is on Medicare (for those who do not know, that is America’s efficient, popular, tax-funded socialized medicine, available to everyone assuming they survive their lack of health insurance and reach age 65).  She told me about how she and her husband were constantly getting calls from companies trying to sell them (which means deliver for free and bill Medicare) motorized wheelchairs, anti-sleep-apnea machines, and various other boondoggles.  She also recounted tales of oncologists making a fortune by selling the in-office chemotherapy delivery that they themselves chose to recommend over other options.  I was aware of the latter of these but had not realized how bad the former had gotten.

Anyway, the point is not that much of American medical care is making a few people rich at the expense of people who just need basic care – that is not a very impressive insight.  What Krugman’s posts and that conversation got me thinking about is how badly backwards the entire system is when people are allowed to buy, at the expense of their insurance (government provided or otherwise), an electric scooter if they can get some scamming medic to declare that they have a medical need, but they cannot buy (to pick just three examples I have written about recently) soda in various public buildings, or caffeinated alcoholic drinks, or electronic cigarettes if the FDA has its way.  The latter are legitimate consumer decisions where someone can understand the ramifications and make a choice about how to expend their money (and time and perhaps their thin waist or even a few hours of long-term memory if they so choose).  We would not all make the same choices, but that is the beauty of functioning free markets:  we do not have to agree and no one has to understand why.  The same is not true for medical care, where someone often has to figure out how to choose for everyone.

The point is that it is not just offensive to liberty that “health promotion” busybodies (not to be confused with real public health advocates) try to restrict consumer choices about food, drugs, etc. and bastardize the epidemiologic science in the process.  But since they often do so in the name of reducing medical expenditures, it is downright insulting (and bastardizes the economic science).  People are told they must not smoke or otherwise enjoy nicotine because the resulting health costs increase government expenditures (which is not actually true, but let’s run with it for now).  But the aforementioned medical device companies and oncologists cost the system orders of magnitude more, but are allowed to keep acting the way they do.  The burden is put upon the rest of us, and the victims are blamed.

Krugman waxes about how, because of the aspects of the relationship that are simply beyond the standard merchant-consumer interaction, medical providers have to be something more that just profitable producers, how they have to have super-human ethics and heroism.  But, you know, I am not seeing that happening anytime soon after a few decades of this “consumer” attitude.  The wheelchair makers are certainly not headed in that direction, and the millionaire oncologists probably did not choose that specialty because all the positions as a desperately-needed general practitioner in an under-served rural area were taken.  So the only hope for reigning in these costs is – again, gasp! – aggressive government intervention.  But this does not make it all right for the government to intervene to alter people’s private possibly-health-affecting choices via any method other than education, suggestion, and perhaps a bit of nudging.  More pointedly, the embarrassment of those in power over the government’s failure to have enough …um… let’s say fortitude to stand up those who are getting rich providing needlessly expensive medical care – let alone the embarrassment of those who are providing that needlessly expensive medical care – is a pathetic motive (though one with understandable self-interested as well as pscyhological motives) for blaming consumers for the uncontrolled costs.