Liberty and Medicine

Sunday, March 25, 2007

Health Facts And Fears: The Intolerance and Arrogance of the Modern-Day Anti-Smoking Movement

By Elizabeth M. Whelan, Sc.D., M.P.H.

Cigarettes kill. Cigarettes are bad for your health. The American Council on Science and Health has made that clear since we opened our doors in 1978. Cigarette smoking is the leading preventable cause of premature death, accounting for approximately 400,000 deaths annually in the U.S. -- nearly one in every four deaths, and one in every two premature deaths each year.

But we at ACSH hold to the belief that the best way to lose an argument is to overstate it. And overstatement is exactly what a growing number of members of the anti-smoking community are doing. Indeed, anti-smokers are becoming increasingly unscientific, arrogant, absolutist, and intolerant of dissenting views.

Two immediate examples come to mind.

First, scientific studies from around the world have now confirmed that smokeless tobacco is far less hazardous to health than is cigarette smoking.

No sane public health professional would advocate that non-smokers take up the use of smokeless tobacco. But it is an undeniable fact that, for an addicted, inveterate cigarette smoker, the use of a smokeless product instead of cigarettes would dramatically reduce the level of health hazard he or she faces. The switch from cigarettes to smokeless tobacco in men in Sweden -- and the resulting decline in lung cancer and other systemic diseases associated with cigarette smoking -- is stark evidence of this harm-reduction phenomenon. While the risks of oral cancer associated with smokeless tobacco are still a concern, it is important to note that (a) the risks of oral cancer from cigarette smoking have always been significantly greater than the risks of oral cancer from using smokeless and (b) the smokeless products have been chemically altered over the years to significantly reduce the risk of oral cancer.

But the anti-smoking community has been vocal in its rejection of smokeless tobacco as a means of harm reduction for addicted cigarette smokers.

Indeed, their protests against smokeless have been so loud and permeating that they even misled the United States Surgeon General, Dr. Richard Carmona, into stating that smokeless tobacco was no less hazardous than cigarette smoking -- a clearly false statement.

About four years ago, ACSH hosted a media seminar on harm reduction as it relates to cigarette smoking and alcohol abuse. ACSH brought in speakers representing a variety of views, including one anti-smoker who vehemently rejected the option of smokeless tobacco as a means of harm reduction for cigarette smokers. Despite ACSH's attempt at balance, veteran members of the anti-smoking community were irate that ACSH was hosting such a meeting, and one anti-smoking leader called ACSH to announce that I would be "excommunicated" from the anti-smoking movement if I moved forward with this event. (ACSH did move forward, so I guess I am out.)

The message of the anti-smokers seems to be this: "Tobacco in all forms is bad and should not be tolerated. Cigarette smokers have only two choices: give up tobacco or die."

ACSH begs to differ.

Second, the anti-smoking movement has gone off the deep end over secondhand smoke (also known as environmental tobacco smoke).

Sure, exposure to cigarette smoke has all types of negative acute effects, including increased risk of earaches, inner ear infections, asthma, upper respiratory ailments, and more. No argument about that. And it smells nasty, makes your clothes and hair stink, and can ruin a perfectly nice dinner (ACSH did a report in 1999 on the limited but real effects of secondhand smoke).

But anti-smokers can't let it rest at that. They claim that even transient exposure to secondhand smoke causes everything from breast cancer to heart disease.

A few egregious examples: a leading tobacco researcher made the improbable claim that the smoking ban in Helena, Montana resulted in a 40% decline in heart attack admissions in a six-month period after the ban. "We used to think that heart disease came after years of exposure" said Dr. Richard Sargent, an anti-smoking Montana physician, who then went on to argue that even short-term exposure to exhaled smoke can damage the heart: "if you go into a restaurant for a sandwich, if you go into a bar for a beer, and you get exposed to a heavy amount of secondhand smoke, you're just as at risk for a heart attack as a smoker."

Sargent, vice chairman of the Montana Tobacco Advisory Board, noted that secondhand smoke has "an acute, rapid effect on the heart...[T]hirty minutes of exposure doubles your risk for the next forty-eight hours."

Americans for Nonsmokers' Rights makes similar claims: "even a half hour of secondhand smoke exposure causes heart damage similar to that of habitual smokers. Nonsmokers' heart arteries showed a reduced ability to dilate, diminishing the ability of the heart to get life-giving blood."

Give me a break.

While being exposed to cigarette smoke for hours a day for many years certainly could have negative effects, it is unacceptable to use such exaggerated claims to justify a ban on smoking.

The good news is that the radical anti-smoking movement may at last have met its, er, match. Dr. Michael Siegel, a physician specializing in preventive medicine -- and an anti-smoking activist in his own right -- is taking on these hyperbolists. In his Tobacco Analysis blog, he calls these claims -- often used to justify outdoor smoking bans -- "ridiculous."

Funny thing about communication in science and medicine. When a politically correct theory or claim takes hold and is loudly trumpeted ( as in "secondhand smoke, even in trace amounts, kills"), dissenters are terrified to step forward and challenge that theory lest (a) they be called apologists for, in this case, the cigarette industry or (b) they be accused of not getting on the bandwagon of what is an inherently good public health cause.

At this point, with their hype and self-righteousness, the anti-smokers really have gone too far -- they have triggered a counterattack. Stay tuned for a major magazine expose by a well-known journalist (and network TV segment) on the smoke-and-mirrors statistics being spewed out by anti-smokers who decry the health effects of secondhand smoke to justify banning even outdoor smoking.

The moral of the story: stick to science. Cigarette smoking is a multi-faceted disaster for the smoker and for those who are exposed to secondhand smoke for long periods of time. Nothing is to be gained by exaggerating this already-grim story to get even more attention. The only result of such hyperbole is the loss of credibility of the public health profession.

Reprinted from the American Council on Science and Health.

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Friday, March 23, 2007

A short course in brain surgery.


Tuesday, March 20, 2007

Can there be too much health care?

I’ve often seen ideologues play with numbers. It’s easy to do but inherently dishonest though some of it is simply due to ignorance and not intentional dishonesty. People have a tendency to stop looking when they find what they want to find.

One of my private passions has been understanding the role of incentives and economics. One thing a decent economist can teach you is to think beyond the obvious. Much of economics is counterintuitive.

For instance, raising the minimum wage doesn’t raise the income of the poorest workers. They tend to become unemployed. Most workers are above the minimum wage so it has no impact on them. Only a small number of workers have productivity levels higher that what their pay scale indicates. They will see their incomes increase and remain employed since their productivity is worth more than their wages. Those with lower productivity, at the bottom of the wage scale, will end up on unemployment. This is a bit more complicated that the simplistic idea that a high wage minimum raises income.

Recently, in the Christian Science Monitor, Donald Boudreaux took on Corinne Maier from the New York Times. She claimed that French workers were more productive than American workers. And since the French work fewer hours this difference is “proof that you can work better by working less.” That may be a good sound bite but its not necessarily good economics.

Boudreaux noted that French labor regulations make hiring people very expensive -- one of the reasons for the very high rates of unemployment especially among the least educated. High labor costs weed out the least productive workers from the workplace.

In Boudreaux’s example he suggests a $500 per hour minimum wage would automatically make American workers the most productive in the world. The reason is simple. Only those whose productivity is worth more than $500 per hour would have jobs while the zero productivity of the unemployed is never factored in to the productivity rates.

Strictly speaking, if the French also included the vast numbers of people who can’t find work in their productivity ratings they wouldn’t look so good. Consider a race between two groups of kids. In one group the teacher goes around breaking the legs of slowest runners. Then they have a competition where only those who can run do so. They add up the times and declare the first class has a higher average speed. Breaking the legs of slow runners would increase the average of those who run. That is what the French do -- they break the “productivity legs” of their slowest runners.

I thought Boudreaux’s editorial was quite enlightening and one of the best things on economics I’ve read in a long time. It takes a “fact,” as the media reports it and scrutinizes it -- something the media is not likely to do for a number of understandable reasons.

Over at Slate Darshak Sanghavi has done something similar. He looks at the much touted infant mortality rate. The Left, in particular, loves to quote this number. America has a higher infant mortality rate than most developed countries. That fact, in isolation, doesn’t tell us much. We really need to ask why this is and what it means. But people assume this is a marker for conclusions they have already drawn. So it is alleged to mean, “that capitalism fails”, that the “lack of national health care” kills people, “that welfare cuts are killing babies”, and a host of other conclusions looking for evidence.

Save the Children had one of the ready made conclusions: “We are the wealthiest country in the world” but children “are not getting the health care they need.” Really? Anna Bernasek, at the New York Times, blamed the high rate on the lack of national health care. Another one of those conclusions looking for evidence.

But Sanghavi says “a closer look reveals the counterintuitive possibility that high infant mortality in the United States might be the unintended side effect of increased spending on medical care.” We should consider this for a moment.

Americans spend more on health care than any other nation. The very idea that the US isn’t spending enough is absurd. The reason couldn’t be a lack of spending as Save the Children claimed. America is condemned by the advocates of socialized health care for both spending too much and for not spending enough. It is condemned no matter the spending level.

You would almost conclude that the reason for the condemnation has nothing to do with the spending patterns. Perhaps the advocates of socialized care condemn both too much spending and not enough spending for reasons that have nothing to do with the actual spending but with their purported solution. If you want to propose a “solution” you sometimes have to invent the crisis that needs solving, or at least convince people that one exists. Condemning US health care for spending too much on Tuesday and too little on Wednesday has a lot to do with the new system they want to impose on Thursday.

Elsewhere I have investigated some of the illusionary arguments used by advocates of socialized medicine noting that Americans have an abundance of health care, especially of the expensive kind. One way to keep health care costs down in nationalized systems is to ration it out. Deny expensive treatments to people and costs will drop. Americans get more of those expensive treatments.

And America’s infant mortality rate may be directly connected to this crisis of abundance. Sanghavi asks what is the cause of infant mortality in the US. He notes that in poor countries the cause is usually easily treated problems such as diarrhea in the first few months of life. Two things are necessary to be included in this statistic. First the infant must be born alive and second it must die before the age of one. If it is born dead it doesn’t count in the statistic.

Sanghavi says that somewhere between one third and one half of all infant mortality in the US is due to complications of prematurity. I checked this out and he’s right. puts the rate even higher: “In the United States, about two-thirds of infant deaths occur in the first month after birth and are due mostly to health problems of the infant or the pregnancy, such as preterm delivery or birth defects.”

Sanghavi argues that modern medicine is not particularly good at preventing premature births. And some new medical techniques actually increases the risk but are still used for understandable reasons. He notes that the number of women using technology to conceive has doubled and that the technology increases the number of multiple births and multiple births are “at a high risk of premature delivery.”

And he writes: “Despite a doubling of health-care spending as a portion of the gross domestic product since 1981, the rate of preterm birth has jumped 30 percent.” If, as Save the Children complained, the problem is not spending enough then the rate of premature births should not have increased as spending increased.

Another counter-intuitive problem for prematures is that the number of neonatal units the country has increased. So much money is available for neonatal care that more care is available than needed. Infants who normally wouldn’t be given this care are sent to the unit as a precaution. Sanghavi writes about a study in the New England Journal of Medicine: “The authors ominously suggest that ‘infants might be harmed by the availability of higher levels of resources.’ They argue that the availability of a NICU may mean that infants with less-serious illnesses may be admitted to one and then ‘subjected to more intensive diagnostic and therapeutic measures, with the attendant risks.’”

He also notes that hospitals which treat large numbers of premature babies have high success rates. The increase in the number of neonatal units has meant that each hospital treats fewer cases. With less experience the number of deaths increases. A study in the Journal of American Medicine noted that concentrating these prematures in fewer hospitals could reduce the death rate and lower costs as well.

If this study is correct then reducing costs by reducing the number of hospitals offering neonatal care may increase the survival rate for premature infants. It is possible that one can have too much of a good thing. And spending more on neonatal care may exacerbate the problem. The reason for it seems obvious. And if I may allow me to use Ikea as an example.

Putting together that furniture is a real chore. Sometimes is it is downright difficult. And if you are doing one of this and one of that each piece is hard work. But if you have ever done multiple examples of the same piece you quickly learn the process. With more experience you make fewer mistakes, are more prone to notice details and faster. Experience makes you better at the work. Why would neonatal health care be any different? The more experience one has the better one becomes.

American health care has so much money thrown at it that care is being diffused. More and more hospitals have neonatal units, even though such units are expensive. The number of patients are spread over a greater number of hospitals reducing the average experience at each hosptial. With reduced experience there is a higher mortality rate. As the JAMA article noted: “Risk-adjusted neonatal mortality was significantly lower for births that occurred in hospitals with large (average census, >15 patients per day) level III NICUs.” So by concentrating such care, in urban areas particularly, “has the potential to decrease neonatal mortality without increasing costs.”

As I said sometimes life is counter-intuitive.

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Friday, March 16, 2007

Swiss voters reject single-payer health care

Left-wing groups in Switzerland tried to force through a measure, by referendum, that would abolish competition between health care insurers. Under Swiss law residents are required to purchase health insurance but are free to pick any policy offered between 87 different companies.

The Leftist Mouvement Populaire des Families gathered 110,000 signatures to force a vote on their measure. They were supported by the Left-wing Social Democrats and various trade unions. Under the measure all insurance policies would be monopolized under one plan. Apparently these groups don’t mind monopolies as long as they create them and they clearly don’t favor freedom of choice for consumers.

Consumers, also known as voters, didn’t find this new plan very appealing. They rejected it with 71% voting against it.

The proponents said the new plan of single-payer would drive down health costs. Of course driving down health costs is easy for a single payer program. First, deny expensive treatment to patients entirely. Reduce, options and cut out certain types of care and medications. That policy alone accounts for much of the “savings” that socialized systems offer.

The second method of “saving” is to cut salaries of health care workers to below market levels. This technically doesn’t cut health costs as it merely transfers costs from taxpayers in general to the health workers instead. The downside of this is that you find health workers seeking employment in countries that don’t penalize them for working in this field.

The first proven method of cutting costs reduces the amount of health care. The second proven method of cutting costs reduces the numer of health care workers. Anyone can cut costs by offering less.

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Wednesday, March 14, 2007

Ageing, population and the welfare state

The United Nations Population Division is estimating that the world’s population will top out at 9.2 billion in 2050. They increased it a slight increase from their previous projection of 9.1 billion because of anticipated declines in the death rate from AIDS and other diseases.

There are some who will take this as bad news. I am reminded of a “reviewer” who attacked something I wrote on population. He first admitted he had never read the manuscript in question and then said that my thesis was “not that birth rates are too high but that death rates are declining”. He then attacked me for not offering “a solution to this problem.” The problem being declining death rates. My reply was that he should think globally and act locally and that he always had the power to reduce the population of the world by one. Of course when he whines about low death rates it is always the death rates of others that worry him not his own.

I actually question the UN’s projection and I do so for a very understandable reason. I’ve been watching the population issue for some years now and I’ve read their population reports regularly. They are consistently wrong and drop their projections as they get closer to the dates in question.

More importantly they are always wrong in the same direction. They constantly overestimate population growth rates. To their credit they do give a low, middle, and high estimate. But the reality tends to be closer to the low estimate than the high estimate. I suspect, based on this record, that one should take a position somewhere between their low and middle estimates and you will be far closer to the truth. In fact a good case can be made for their low estimates being the most likely.

The new report, as per the media, gives a distorted picture in one important sense. It says that “46 countries are expected to lose population by mid-century.” But more nations than that already have birth rates below replacement levels. The reason for the difference is the time lag between one being born and one dying -- a lag most of us appreciate and work at extending. That lag increases as death rates decline. As people live longer the population continues to grow even though the total fertility rate is below replacement levels. Of course once the two catch up there is a rapid decline in population numbers.

Another report in the press says that “Fertility has already reached below replacement levels in 28 developing countries which account for 25 percent of the world’s population...:” Again you need to be careful in what you read. This is 28 “developing” countries not 28 countries. For instance most the countries that are already developed need to be added to that list.

In 1999 the UN noted that 61 countries had already reaching below-replacement fertility rates and said that by 2015 that would be true for 87 nations. One indication of how rapid the deceleration of the world’s population will be is that the number of people over the age of 60 will triple in the next few decades. The population grows but at some point soon large numbers of old people start to die and when that happens population numbers will plummet with all sorts of consequences. Expect numerous government commissions urgently trying to reverse the situation even while today they are urgently trying to create it.

The UN says that there will be more people over the age of 60 than there will be under the age of 15 for the first time in history. Consider the crisis for the welfare states of Europe. Already the number of people under the age of 60 is in decline in Europe while the number over 60 is increasing. The number aged 0 to 14 went into decline in 1965. And those aged 15 to 59 went into decline in 2005. But every years the number over 60 has been increasing. This trend will happen in every region of the world.

In fact the UN’s report, if you read their material yourself, focuses on the rapidly ageing population of the world. The media report focuses an a relatively minor increase in the projected maximum, from 9.1 billion to 9.2 billion. After years of conditioning by hysterical population gurus like Paul Ehrlich the media can’t get over the idea that the population explosion ended years ago. All that is happening now is that the world is waiting for the old people to die! Shocking but true.

The UN report says that the world has gone through a transition where birth rates are low and the numbers of children, and working aged people, will go into decline while the number of elderly will skyrocket. They write: “Today most countries in the world are already well into the demographic transition...” Most countries! Yet you won’t have trouble finding groups proclaiming that the UN report is a “wake-up call” due to over population.

You have to realize that there will be entire nations, by 2050, where the median age of the population will be over 50. Consider what this means to the issue of welfare, pensions and medical costs. And the disaster is particularly dangerous for those nations stupid enough to go down the welfare state road.

The number of people relying on such benefits will grow rapidly but those who work and pay into the system will be disappearing. There will be fewer and fewer people sustaining the system just as more and more people need it. Millions of elderly people are suddenly going to find out that the safety net they were building over their lifetime can’t sustain them. And because of the high taxes they haven’t had the opportunity to create private alternatives. They will be left out in the cold -- sometimes literally -- because the welfare state is built on a model that is the complete opposite of demographic reality.

I personally suspect, based on past overestimates, that the world’s population will peak at 8.9 billion and in the year 2045 not 2050. But the real story here is not one of “birth control” (which I happen to support) but one of welfare control. The disaster we face is not one of an overpopulated world. That disaster has not been looming for decades. But a world filled with elderly people reliant upon a safety net that doesn’t exist scares the hell out of me.

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