Monthly Archives: November 2011

Unhealthful News 188 – Follow-up on cigarette graphic warnings injunction: NYT chooses to burn its credibility

I suppose it was just too good to be true.  In my previous post, I praised New York Times reporter Duff Wilson, and by implication NYT reporting, for writing a story that was objective and factual about a politicized health issue.  Specifically, he wrote about a US court injunction blocking FDA from requiring large gruesome graphic labels on cigarette packages, and did so without spinning it as a defeat for what any right-thinking person should want (he accurately presented the labels as representing the goal of a particular government faction, nothing more or less).  He emphasized a basis for the decision, that these labels, while often inaccurately described as “warning labels”, had no factual content and did not communicate information.  Thus, they re not warnings), but are merely intended to emotionally manipulate.

Alas, the NYT could not allow objective and accurate reporting to stand when the topic involved one of its pet causes.  So yesterday they published an editorial condemning the judge’s ruling.  They completely ignored the bases for the decision, that the labels violated free speech rights in pursuit of government advocacy of a particular behavior, did not fulfill some compelling responsibility of the government (like issuing genuine warnings), were not the minimal way to intervene in free speech in support of some competing goal (like genuine warnings would be), and perhaps most importantly that there was really no evidence the labels would change behavior.  The editorial concluded:

The Obama administration should appeal Judge Leon’s preliminary injunction, which would put off the labeling changes for months, if not years. A delay on the labels would lead to more needless deaths.

So a bunch of write-about-anything, mostly political-beat journalists who have risen to the level of editor claim to know that these labels would reduce needless deaths.  Hmmm, now how exactly do they know that?  Are they privy to evidence that was not presented in the court case and that has not appeared in the scientific literature?  Or are they simply relying on the deep insight that comes from having a strong belief in a subject one lacks technical expertise in?

The editors also asserted:

If his ruling stands, the government will not be able to warn against the hazards of smoking in a way that’s actually noticed.

Really.  So by being limited to forcing cigarette manufacturers to print only those warnings that are, well, warnings, instead of adding images worthy of a slasher movie, the government has lost its ability to advertise, publish, pontificate, dictate “news” stories to the NYT and other papers that will be dutifully transcribed, and otherwise condemn smoking and smokers.  Gee, this will probably mean that a whole generation will grow up without ever learning that smoking is bad for you.  It is a good thing we have the NYT editors to warn us against this dire future.

It is no wonder that health reporting is usually so bad:  The editors apparently demand that it be bad.

Unhealthful News 187 – Cigarette graphic "warnings" injunction, great characterization of the content, but too bad about the understanding of statistics

Yesterday, a US federal judge ruled that the gruesome graphic labels that the FDA wants to mandate that cigarette manufacturers print on their packages would likely not stand up to first amendment scrutiny, and issued an injunction agains the regulation until the full constitutional issue could be litigated.  (The text of the ruling was online this morning but the link does not seem to work anymore; you can link to my saved copy.)  Since the litigation will likely take years, the judge ruled, requiring the labels appear until they are ruled unconstitutional, if that was indeed the ruling, would do irreparable harm.  Thus the decision must be to not impose the regulation until and unless it was ruled constitutional.

The judge in question, Richard J. Leon of the United States District Court in Washington, was the same one who saved e-cigarettes from being banned in the US, making him the man of the year for tobacco harm reduction and maybe public health in general, though that honor, for which he will never get his deserved nomination for a Nobel Prize, was presumably not his motivation.  He showed similar wisdom in the new ruling and that was very well reported by Duff Wilson in the New York Times.

The core basis of Leon’s ruling was that the labels were not simply the communication of facts.  That is, as I have pointed out a few times, they were not warning labels.  Anyone who refers to them as such apparently has no idea what the word “warning” means.  I have characterized them as “emotional violence”, intentionally infliction of distress, and pointed out that they are designed to manipulate behavior in a particular direction rather than give people the facts they need to make an informed autonomous decision.  Leon did not use the word “violence”, but clearly argued that the graphics do not warn, but merely manipulate emotion; indeed, he emphasizes the legal evidence presented to him that this is what they were designed to do.  He wrote, “they appear to be more about shocking and repelling than warning”.

It is gratifying to see this recognition of the true nature of these graphics.  I wonder if we will see anyone stop incorrectly referring to them as “warnings” as a result.  Not the anti-smoking zealots, of course, or the World Health Organization, but maybe some of the people who try to write about this topic honestly will get the memo.

Another key basis for the ruling, a somewhat more technical, and thus not the focus of popular press stories (at least not when written by health reporters — there might be some more thorough reports by law reporters out there), is that the large warnings, covering most of both sides of the package, clearly do not meet the standard for being the minimal infringement on free speech necessary to achieve the government’s purpose.  That part of the ruing actually included the seemingly sarcastic parenthetical, “…purpose (whatever it might be)”.  Indeed, the judge wrote about a previous ruling he was drawing upon and clearly agreed with:

the dimensions alone strongly suggest that the Rule was designed to achieve the very objective articulated by the Secretary ofHealth and Human Services: to “rebrand[] our cigarette packs,” treating (as the FDA Commissioner announced last year) “every single pack of cigarettes in our country” as a “mini-billboard.,,26 Mot. for PI at 6 (citing a June 2001 press briefing with Sec. Sebelius, and an FDA Tobacco Strategy Announcement). A “mini-billboard,” indeed, for its obvious anti-smoking agenda!

And, yes, that exclamation point was in the original — apparently you are allowed two of those in a 29 page judicial opinion.  Interestingly, Wilson’s NYT article quoted the last few words and the punctuation, out of context, as well as another passage that characterizes the government agenda, without suggesting that the the agenda must be legitimate or even quoting some QUANGO activist endorsing the agenda.  It was remarkable restraint and professionalism for a health reporter, since declaring fealty to the government agencies that feed them most of their stories is the standard practice.  Wilson did include the mandatory QUANGO quote from Matt Myers, but chose a technical observation about how there will be an appeal of this ruling, rather than printing the self-appointed holy-man ranting that Myers no doubt also offered.

All in all, that was some pretty healthy health news.  But I have to take a few points off for something — being a professor is a profession and state of mind, after all, not a matter of who writes you a paycheck, and I should stay true to the titular theme of this series.  Both Leon and Wilson did blunder when they wrote about the FDA’s research on the effects of the graphic labels not addressing whether they would have a “statistically significant” effect on consumers’ awareness of the risks of smoking, and specifically the research not being designed to be able to answer that.  Health reporters have no more business writing about statistical significance than they do writing about legal nuances of the First Amendment of the Constitution, and this is a great example of why.  (Judges might also want to shy away from using jargon from highly technical topics except by quoting its use by experts.)  Since it was obviously impossible to study the effect of the labeling before it happened, it is not clear how a study could be designed to test the effect, let alone designed to achieve statistical significance in so doing.

As a more general point about their error, statistical significance is a property of a dataset — or more precisely of a dataset and a particular hypothesis that is being tested — not a property of the world.  It has to do with the chance of seeing a pattern in the data due to chance alone, and relates to how sure we should be about the results.  What people care about, and what the law should care about, is whether there is a substantial effect.  “Substantial” and “significant” (without the “statistical”) are rough synonyms in natural language.  They have to be defined by context and basically mean “it matters”.  By contrast statistical significance is precisely defined (although only a small minority of those who use the term could actually give you the correct definition) and does not necessarily matter.

So, credit for recognizing that the proposed graphic labels are not warnings, and that they are emotional manipulation, and for genuine objective reporting that (contrary to the usual tone of the NYT) made clear that a particular goal of some people in government is just some people’s preference, rather than some God-Given Correct Way.  But points off for still, in spite of all that, not understanding some fundamental points about how science works.

[Update:  The NYT undermines its good reporting with clueless editorializing — has both irony and humor.]

Unhealthful News 186 – Cancer: screening is generally a bad idea; what about vaccines? (Part 2)

In my previous post, I noted that there were several arguments made against recommending (or, for that matter, mandating) HPV vaccines for pre-sexual children, to protect against that sexually-transmitted cancer-causing virus.  The one of these arguments that is actually fairly compelling, that the cancers the vaccine could prevent could very plausibly become easy to treat during the >30 years before they will occur.  But since almost no one seems to understand this, it is interesting to try to understand what took so long to make the recommendation that boys get the vaccine.  I noted that there was one misguided and two deplorable apparent reasons for that.

The first of those is that, in contrast with cancer screening, vaccines provide no stories of miraculous life-saving success.  Well, actually that is true for screening too.  There are lots of stories, but they are usually wrong.  That is, most people who are uncritically quoted in the unhealthful news reports, in any story about a particular screening regimen looking like bad idea, sobbing “I am living proof that this screening saves lives!” are probably wrong.  Most such screening tests detect many cancers that never would have led to morbidity, and others that would have been detected and successfully treated without that mass screening.  In other words many, often most, of the “saved lives” were not.  But they make a good story for the statistically illiterate decision makers, and are enough to let them be talked into funding/recommending/mandating the screens by those who stand to profit from that policy.

There is no such misguided constituency for vaccines.  No one realizes that their life was saved from a disease they never got.  Indeed, this is undoubtedly why vaccines for infectious agents that have other nasty effects are often forgone or even hated.  News stories never report on the person who insists “I would have died without that vaccine”, even though the speaker would be no less certain than someone making that claim about the screening test.  Perhaps some of us should form a patient advocacy group as survivors of polio who never got it thanks to vaccination.

I will leave that for another day and move on to the even worse reasons the HPV vaccine has been only reluctantly embraced.  HPV can be transmitted sexually even if condoms are always used.  This means that, absent the vaccine, HPV risk is a reason to avoid even “safe sex”.  While it is obviously not a reason that affects behavior to any measurable degree, as evidenced by extensive journal peer reviewed…  just kidding, I meant: as is obvious to anyone who is not totally clueless.  But that incentive, or more accurately, that opportunity for anti-sex propaganda, is something that those who want to scare people into not having sex do not want to lose.  Some have said as much, while others clearly share that sentiment but pretend to have other motives.  They are quite willing to hurt people to save their souls or whatever.

If this sounds familiar to many of my readers, it should.  It is basically equivalent to the anti-harm-reduction tactics used by anti-tobacco extremists.  In both cases, prohibitionists actively oppose making the activity in question less risky because they want to maximize the incentives for abstinence.  But that is not the only deplorable connection.  It seems fairly likely that one reason the recommendation boys get the vaccine (rather than just girls, to protect against cervical cancer) was so long in coming was because of the refusal to recognize that for at least a decade the evidence suggested an increasing number of oral cavity cancers are caused by HPV.  Indeed, many of the articles about the new recommendation have emphasized protection against anal cancer and anal warts, probably trying to create controversy by making it “a gay thing” and mention only throat (esophageal) cancer in addition to that, mysteriously not mentioning the dreaded oral cancer.

Why the failure?  It is difficult to say for sure, but it is also difficult to not attribute it to the anti-tobacco extremists claiming oral cancer as “their” disease.  They use it for misleading people into believing that smokeless tobacco poses substantial disease risk and is responsible for a growing epidemic of oral cancer.  There has never been the slightest doubt that smoking causes far more oral cancer than smokeless tobacco, but the notion that “switching to smokeless just trades lung cancer for oral cancer” has been a major contributor to delaying tobacco harm reduction for years.  The extremists — pretending to be concerned with public health, just like the “Christians” who would intentionally avoid curing the lepers if leprosy was sexually transmitted — got this myth so well established that it is quite difficult to communicate the causes of oral cancer.

There is a certain elegant symmetry in it.  The lefty pseudo-“public health” sermonizers who despise the right-wing anti-harm-reduction sermonizers who oppose safer sex or needle exchanges have ended up working in tandem with them on this issue.  Maybe it will be a wake up call to them and they will… just kidding again.

Finally, the symmetry extends to that one good argument I noted.  Just as an 12-year-old who gets the HPV vaccine will be protected from a disease that will not occur for decades, and might be quite easy to deal with by then, a young person who picks up a dangerous behavior now might be saved by advancing medical science.  The analogy is far from perfect:  HPV-caused cancer is a specific cancer that, if fully cured or prevented at the last minute, might do no damage.  By contrast, smoking damages lung and other tissue over time, and contributes to many diseases in complex ways, and that damage seems a lot less likely to be able to avoid or reverse.  On the other hand, if smokeless tobacco causes an oral cancer in someone who starts using it now, the evidence suggests that this will happen many decades from now, making it again like the HPV case.

So, screening is loved based on non-evidence; vaccine-based harm reduction for sexually transmitted disease is embraced by the health authorities but suspect among some political factions; uptake of that vaccine is limited, though no one seems to be motivated by the one good reason for not bothering with the vaccine; the oral cancer vaccine is not being recognized as such; and none of this will affect the behavior of the various extremists and activists.  The funny part, and the only reason this is not completely mortifying, is that a remarkable amount of the stupidity/naivety/dishonesty is canceling out other bits of the stupidity/naivety/dishonesty.