Monthly Archives: June 2011

Unhealthful News 180 – Study of "No Smoking Day" may be a new low in bad epidemiology and health economics

Ok, that is probably not true, given how much other bad anti-tobacco “research” there is out there.  But this is a really good one.  It was so good I stole it from today’s weekly readings in THR post so that I could expand on it here.

It was published in the quasi-journal Tobacco Control, of course.  I will provide the entire abstract here so you do not have to bother with the link.

How cost-effective is ‘No Smoking Day’?

D Kotz, J A Stapleton, L Owen, R West 

Participants: A total of 1309 adults who had smoked in the past year who responded to the surveys in the month following NSD (April 2007–2009) and a comparison group of 2672 adults who smoked in the past year who responded to the survey in the two adjacent months (March and May 2007–2009). 

Main outcome measures: The number of additional smokers who quit permanently in response to NSD was estimated from the survey results. The incremental cost-effectiveness ratio (ICER) was calculated by combining this estimate with established estimates of life years gained and the known costs of NSD. 

Results: The rate of quit attempts was 2.8 percentage points higher in the months following NSD (120/1309) compared with the adjacent months (170/2672; 95% CI 0.99% to 4.62%), leading to an estimated additional 0.07% of the 8.5 million smokers in England quitting permanently in response to NSD. The cost of NSD per smoker was £0.088. The discounted life years gained per smoker in the modal age group 35–44 years was 0.00107, resulting in an ICER of £82.24 (95% CI 49.7 to 231.6). ICER estimates for other age groups were similar. 

Conclusions: NSD emerges as an extremely cost-effective public health intervention.

Taking this from the top, we have to start by observing that they are claiming that about 10% of all smokers attempted to quit each month.  This indicates either some very faulty data or such an expansive definition of “quit attempt” (like “I woke up and decided I was going to quit, but I started again during my morning break”) that it is meaningless.

Moving on, they assume that the entire observed difference is neither random nor the result of Easter/Lent, Passover, spring holidays, the misery of March, or anything else that might make April different from nearby months.  It seems like these might make a wee bit more difference than an arbitrary declared day that most people pay no attention to.  It is kind of interesting that they did not give us a month-by month breakdown, which we might have expected if the month with “No Smoking Day” were the global or even local minimum.

Beyond that, their interpretation of what NSD entails is quite silly.  They treat it as if it is some kind of medical intervention that is independent of other causes of quitting, but really it is (at most, even if it really works) a focusing event, causing people who are considering quitting soon to say “ok, I am going to do it that day”.  So the effect, if there really is one, is to move quit attempts from May and June back to April.  Perhaps not of trivial import (remember that smoking for just a couple more months is as unhealthy as using smokeless tobacco for your entire life), but not the same as causing quitting that would not have otherwise happened.

And this says nothing of their their magical ability to detect permanent cessation from a cross-sectional survey.  Even if they have some standard prediction about permanence, quitting for different motivations, like say a focusing event, will inevitably have different permanency rates.

As if this were not bad enough, where they really jump the shark is the cost-effectiveness analysis.  Reporting the cost of a declared focusing day per smoker is LOL funny.  I wonder how much National Kale Week cost per meal at which kale was served; I will bet it was quite a bargain too. 

That “ICER” is the “incremental cost effectiveness ratio”, which measures the cost-effectiveness of an intervention as compared to an alternative it could replace that is more cost effective (so a better deal) but less effective in total.  In other words it accomplishes an analysis like: “if we are going to take driver protections one step beyond seatbelts and add airbags, which are much more expensive but will save a few more people, we should make sure to not give airbags credit for the people that seatbelts alone would have saved anyway by comparing them to no restraints at all.”  What makes this funny is that they pretend to be using a somewhat complicated good measure, one that is often not done creating erroneous results (e.g., airbags are measured against no restraints at all; pharmaceuticals are measured against placebos rather than existing effective treatments), to look at something that they got totally wrong.  In this case, the alternative that is crowded out by NSD (like airbags+seatbelts crowds out seatbelts-alone) is they same people quitting a bit later, which they completely ignore.  So what they claim is ICER is really just the most basic, and misleading, cost-effectiveness calculation that pretends nothing would motivate quitting were it not for NSD. 

So they go on to calculate the cost-effectiveness, not as £80/life-year-saved, but £82.24.  Even if their estimate of the effect of the intervention were as precise as the 2.8 percentage points they report (which is not even possible given that they are basing this on only a few hundred events) they could not get precision even to the first significant figure, let alone the fourth:  The guess – “estimate” would give it too much credit – about how many life years will be saved by someone quitting (again, even pretending that NSD caused it, and their estimate of permanent quits is based on anything, and that it would not have happened a month later even without NSD) requires assumptions about the next half-century of medical technology and other health effects.  It cannot be reasonably guessed-at within a factor of two, let alone to one part in 10,000 as they imply.  Someone develops a cure for cancer or emphysema, and the benefits plunge; some other breakthrough extends life by 100 years so long as you do not get cancer or emphysema and the benefits shoot up.

About the only thing that can really be said about their conclusion is that there is no doubt that NSD is more cost-effective than funding people who write articles for Tobacco Control.

Yes, this is what passes for science in anti-tobacco.  Is it any wonder that they can reconcile “hundreds of millions of people are not quitting” with “a tobacco free world by 2030” or whatever?  It would be humorous if it was not so incredibly damaging.  Oh let’s be honest:  In spite of being incredibly damaging, it is frackin’ hilarious.

Unhealthful News 179 – Getting molested by TSA is starting to look pretty good

Oh it is going to be fun to watch this one play out.

A few blogs have started putting out various versions of the story that the new x-ray body scanner airport security machines that are increasingly installed in major US airports (which the bloggers call “naked body scanners”, so they are making clear their opinion about them) are causing an elevated risk of cancer for the Transportation Security Administration officials who are operating them, and that the claims that they were safe were actually based on approximately nothing.  The latter seems quite plausible.  I am a bit doubtful about the former, but it is an interesting story.

In any case, it is a fun day for the Freedom of Information Act, which revealed some of this information, as well as the source of my previous post from earlier today.

There are definitely grounds for suspicion about the whole program.  Some European airports have installed full body scanners that do not use ionizing radiation, and thus are undoubtedly safer, but there are rumors that the US is using an inferior product because the manufacturer is well connected.  I am not sure about that, and it did not show up in anything I saw today, but I am sure it will come back into the narrative, so I will leave it to those who are better at that kind of investigation.  Some of the points that came out this week were rather more interesting:  Far from saying the machines are perfectly safe, as the US authorities claimed they had said, various researchers made clear to the government that they could offer no such assurances and they even suggested that TSA workers should avoid standing near the machines which, of course, is safer than being the passenger standing inside them. 

The claims that the radiation dose is acceptable seemed to be based on the assumption that it was evenly divided throughout the body rather than being concentrated in the skin, creating a much higher local dosage that could cause skin cancer.  However, a lower dosage spread more evenly might create just as much cancer, just at low levels in each organ, and most skin cancers are not that threatening, so this might be a good thing.  It is quite a muddle.  But what is clear is that the information given the public was inaccurate.  It is also interesting that TSA agents asked for dosimeters (which measure cumulative radiation exposure and are common for lab workers, reactor workers, etc.) but were refused.

All of this information makes the government’s behavior look very sketchy, and the charges against them are quite plausible.  Meanwhile, no plausible response to the charges is apparent.  From an epistemic perspective, the existing accusations and criticisms clearly put the burden of proof on those who are claiming safety, and they seem to have nothing.

On the other hand, the claim that will probably generate the most interest is pretty much groundless without further information.  TSA screeners in Boston have complained about elevated cancer rates, and the allegation is that TSA authorities have dismissed the claim and tried to cover it up.  This is a classic case of a cancer cluster, as I have written about in this serious previously.  It is always the case, due to the random distribution of disease occurrence, that some group of people somewhere has a very high rate of some cancer or other disease.  The fact that they self-identify does not tell us much because it is almost impossible to tell a chance cluster from one that is being caused by some exposure.  Indeed, we cannot even be sure that there is an elevated rate in this case, since there seem to be no numbers forthcoming.  Moreover, the claim is that there is also an elevated rate of stroke and heart disease, which are not plausibly related to the low-level radiation.  Finally, the machines have not been in place long, and almost all cancers take much longer than that to manifest; the basal cell carcinoma that has been proposed as the greatest risk typically appears more than a decade after the triggering exposure (usually a bad sunburn). 

So the Boston cluster probably signifies nothing, and the “cover up” – i.e., realizing that there is not a plausible causal relationship and not pursuing the matter – was a reasonable response. But in light of the real cover-ups that have occurred, and the general failure to understand the cancer cluster statistics problem, it could prove mighty embarrassing.

Oh, and for the record, a few days ago, before this story broke, I was directed to go through one of those scanners and refused, insisting on a manual search.  This was not because I was intrigued by the thought of being felt up, but because I never believed the claims about the safety of those machines.  Even though I am sure the risk is very small (and so I would not have done this if the cost to me were high, like I did not have a half hour to kill before my flight boarded anyway), it seems to me to be an obligatory act of civil disobedience, to demand the slow labor-intensive option as a protest against the dishonest way in which we have all been exposed to this bit of potentially dangerous security theater.

[Unrelated:  Those of you who are working on learning the nuances of epidemiology by reading this series might want to check out my ongoing comments at this post, which currently focus on distinguishing confounding from causal intermediaries, but are expanding into other points.]

Ellen J. Hahn does not libel Brad Rodu so much as expose the ignorance of anti-tobacco "researchers"

(A non-UN post)
Several people have sent me this FOIA-disclosed email, implicitly suggesting I write about it.  In it, University of Kentucky professor Ellen J Hahn writes about my friend Brad Rodu, a prof at rival University of Louisville.  The context was not reported, but the email seems to have been sent to some local health officials, and was presumably intended as an attack to try to prevent them from learning something (which was undoubtedly true) from Brad about harm reduction.  Hahn wrote:

Please note the [sic] Dr. Rodu is on the Board of Directors for US Tobacco and has funding from the smokeless tobacco industry.  He is a big supporter of use of smokeless tobacco to quit smoking.

Brad is quite proud of the latter characterization, and discloses his funding much more aggressively than anyone I know (and far far far more readily than the anti-tobacco people do).  But the first bit, about being on a board, has been characterized as libeling him.  The claim is false, but while I am no lawyer, I really do not think that merely giving someone credit for holding a position, grant, etc. that they do not have is libel.  If we call that, or the false statement that someone has funding from industry, libel per se then we are implying if it were true, it would be crime or at least a terrible embarrassment.  Neither of those is true.  Perhaps if someone was well-known for stating that he does not take industry funding, and then someone claimed otherwise, it would be an explicit accusation of lying, which could be considered libel.  But otherwise it is best not to fall into their trap of implying that corporate efforts to support honest research and THR are a bad thing.

On the other hand, Hahn probably thought such board membership was at least as bad as lying, so maybe its libel-ness should be judged by the standards of the writer.  For example, if someone claimed:

Ellen J. Hahn, a University of Kentucky professor who actively opposes tobacco harm reduction, received competitive grants from a pharmaceutical company that makes nicotine abstinence aids and a cigarette company that is not moving into the low risk tobacco business, both of whom stand to lose business if the public health benefits of THR are realized

she might consider it libel even though it is merely giving her credit she does not deserve.  Of course, I am not claiming that — I have no idea if she has ever received such grants — so, gee, I hope no one takes that paragraph out of context.  Just in case someone wants to, I had better rephrase it using a trick I learned from the tobacco control people:

It is worth considering the possibility that Ellen J. Hahn, a University of Kentucky professor who actively opposes tobacco harm reduction, has received funding from pharmaceutical companies that makes nicotine abstinence aids and cigarette companies that is not moving into the low risk tobacco business, both of whom stand to lose business if the public health benefits of THR are realized.  She certainly sounds like one of those people who is being paid to opposed legitimate public health efforts.

But I have not gotten the really important, and even somewhat funnier, bit.  I noted that Brad would never have bothered to deny he was on the board of “US Tobacco”.  Among the very good reasons for that is that there never was a major company called “US Tobacco”.  There was “United States Tobacco” until 2001, when they changed their name to “US Smokeless Tobacco”.  Hahn’s email was written in 2010, so even if she started writing about this back in the days of the old name (that she only got somewhat wrong) you would think she would have adjusted sometime in the 21st century.  This might seem like a petty distinction, but keep in mind that this was not an ongoing correspondence about a topic in which abbreviations might creep in.  It was a one-off statement of fact, intended as an accusation, and so obviously called for getting the statement just right.  Presumably, then, the error reflects the fact that she did not know what she was talking about.

The bigger problem, that proves she did not know anything about the topic is that UST (their stock ticker and typical shorthand for that company) was acquired by Altria and integrated into that company and put under its board of directors; this was completed in 2009, as anyone writing in 2010 would have known.  At least anyone with a modicum of knowledge about the world of tobacco would have known it, and Hahn signed her letter with “Director, Tobacco Policy Research Program” and “Director, Kentucky Center for Smoke-free Policy”, so she seems to be claiming she is an expert in the matter.

So, Hahn did not commit libel.  She just committed the usual factual sloppiness that is common among the scientific “experts” involved with tobacco control when trying to further their cause, ignoring science and other sources of fact and disciplined reasoning in favor of just saying anything they think might help their case.  And furthermore, it is not even an exceptional case of that by the standards of the tobacco control “research” crowd.  It is important to make this distinction, because these people do commit libel sometimes, and we should reserve the term for those occasions so it does not get worn out.  As for accusing them of simply not knowing what they are talking about and saying anything they think will further their cause without regard to its accuracy, well, there is no way to avoid wearing those out.