ep-ology

I was recently reading about the fights over IWTs (industrial wind turbines) in Australia, and was surprised to learn that Simon Chapman -- who is a visible activist proponent of IWTs, despite apparently not understanding the relevant science -- creates a difficulty because he is considered a scientist and respected for his contributions regarding tobacco, and so has influence in halls of power.  I suspect that few people working on IWTs realize that his "contributions" to science and regarding tobacco are pretty much comical, and that he has undoubtedly done more harm than good for public health.

While I probably cannot do anything to help improve your government's willingness to trust in supposedly serious and technically-expert opinion leaders who are actually clueless hacks (if I knew how to do that, I would start here by doing something about Paul Ryan), I might be able to contribute some useful tools for fighting him.  He may well be able to leverage his supposed respect and accomplishments from tobacco to exert inappropriate influence about IWTs so long as people do not understand what he actually says in that realm, but once that is on the table he might do less damage to the world.  I think I can give you enough information to undermine Chapman's credibility as a respected international ...um... well, whatever the heck he claims to be.  I think this is up to me because I am, as far as I know, the only person I know with substantial expertise in the science and policy of both tobacco and IWTs.  I hope it becomes apparent that Chapman does not fit that description, though he works in both areas.

(For those who are not the target audience, but are interested in the tobacco politics, I expect you will find this interesting also.  As a bit of background: IWTs -- those giant bladed towers that generate electricity from wind -- cause terrible health and other problems for local residents.  While it might be possible to argue that this is a price worth paying for their benefits, the "benefits" of these monstrosities are a barely-positive net contribution to electricity generation at a cost that is ridiculously high.  But that cost-benefit argument is not the one that the industry and those working on their behalf, like Chapman, ever make; instead, they stick to the blatantly absurd claim that there are no local impacts.)

In this post I will address why Chapman does not deserve any respect for his "contributions" regarding tobacco.  In part 2 or maybe even 3, I will address how clueless he seems to be about IWTs and some of his other silliness.

First, it is not clear that anyone currently in tobacco control can claim credit for any major accomplishments; it has basically been a workaday affair for decades.  The reduction in smoking in rich countries began when 25 years of epidemiologic research finally resulted in the public health declarations of the 1960s and the education campaigns that started soon after that.  Since that time, smoking rates have steadily dropped toward their natural minimum, which they are close to now, like treacle (that is a word you use down there, right?) slowly running down a hill. 

The imposition of high taxes had some effect beyond the education.  Bans on indoor smoking in various places have reduced the impact (mostly aesthetic) of smoke on non-smokers.  But other than education, taxes, and substitution of low-risk (smoke-free) alternative products, nothing has had a measurable effect on smoking prevalence.  The substitution of smokeless tobacco or electronic cigarettes is a strategy known as "tobacco harm reduction"; it accomplishes appx 99% of the risk reduction of eliminating tobacco/nicotine use entirely, but leaves former smokers happier and allows for free choice.  Chapman is among those who oppose harm reduction; the motivation seems to be largely a desire to punish (both smokers and manufacturers) rather finding a way out of the current mess that makes everyone better off, and to exert control rather than allow free choice.

There are a few heroes of tobacco control, but they are the original researchers, who were also the core of those who did the first public health education.  Most everyone else who claims credit for reducing smoking basically just marched ahead of the treacle flow, carrying a flag, and claimed to be leading it.

Australia has among the lower rates of smoking in the world (though not nearly as low as the few places where substitution of low-risk alternatives has become popular), but it is not particularly exceptional given demographics and culture. Basically, that country just followed the lead of US, UK, and German researchers and early policy movers, and ended up just where you would expect it to be.  Nothing Chapman ever did made any substantial difference in the inexorable flow.

But "no major impact" is far too kind in this case.  I recently characterized Chapman as The Worst "Public Health" Person in the World.  He has done a lot to earn that title, but the standout contribution is that he
claims personal credit (i.e., blame) for the ban on low-risk alternatives to smoking in his country, making him the person responsible for the most pointless deaths of his countrymen since the guy who ordered the army to GallipoliSo basically it might be that Chapman sometime contributed to raising taxes a month sooner than would have happened without him, or something of that magnitude (though, as will become apparent, if he had such an effect it must have been thanks to his skills as a bully, not as a thinker), but he also claims to have kept Australia from possibly getting the benefits of product substitution.  Since product substitution is the only proven method for getting smoking rates below about what they are now in Australia (or the US or Canada), this has to put him on the negative side of the public health ledger by a huge margin.

Of course, I realize that if you try to explain this, it will probably exceeds the attention span of anyone who thinks that listening to Chapman is a good idea.  Explaining to most people that what they thought they knew about tobacco policy is wrong is probably not a promising tactic in political rhetoric, though I think it might be helpful perspective for those who are most invested in the IWT fight.  I think much more promising approach is on the theme of "whatever he once did, now he is clearly a buffoon who spouts one false, hateful, or silly thing after another":

Recently, his public focus has been the campaign to ban branding or artwork on cigarette packages, which legally basically means abolishing even the most basic rights of free communication, confiscating brand equity, and seizing the packages as conduits for anti-smoking advertising.  This is a violation of international trade treaties, and I have seen arguments that it violates Australian law also, though I have no way to judge that (and, indeed, will bet that the court now hearing arguments will let it pass, given the national trend toward being nanny-state; the international tribunals will undoubtedly find it to be illegal).  On top of that, it is clear that this policy will lead to more counterfeiting and smuggling because it both facilitates it (generic packages are much easier to fake) and increases demand for it (if all packaging is ugly, there is one less barrier to buying the cigarettes in plastic bags off the back of a truck).  Among the effects of such smuggling are much cheaper cigarettes, sold through channels that are not too picky about ages limits and such, enriching of organized crime enterprises, and loss of tax revenue.

So it must be that the benefits of this policy are so great that it is worth the fight against law and norms, right?  Well, no.  This will not have a measurable effect on smoking.  It has never been tried before (and thus Chapman's and others' claims that they have evidence it will be effective are clearly blatant lies), so it theoretically might have some impact.  But "theoretically might", when there is absolutely no basis for believing it will happen, is not a legitimate basis for radical policies -- which the proponents must understand, or they would not lie about the impact being proven.

It will however hurt smokers (making their lives a little bit less happy due to the ugly health graphics rather than pleasant looking branding) and especially major tobacco companies (because it helps the smugglers they compete with, and also because it makes it harder for them to profit from prestige premium brands since smokers will probably shift toward the cheaper brands if they all look the same).  Since hurting smokers and hurting the industry are the goals of pseudo-public-health anti-tobacco people like Chapman, this works out just fine.  For people like him, it is not about public health, and definitely not about helping smokers.  It is about perpetuating his gravy train and punishing people who dare disobey him when he declares the Right Thing To Do.

If that sounds familiar to those in the IWT fight -- an action that does not fulfill any of its ostensible goals, and merely helps the rich get richer at others' expense, but attracts a cadre of useful idiots supporting it because they think it is good for society -- then you are catching on.

For those who are interested in digging deeper into why Australian tobacco control, even the non-buffoons in it, is pushing for an illegal move that has no apparent upside:  I speculated that those who are pulling the strings behind tobacco control are intentionally setting up this useless policy to fail so that they can claim that Evil Big Tobacco thwarted their plan that would have ended smoking once and for all, and thus ensure a continuing funding gravy train for another decade.  Chapman does not seem to have the skills to come up with a clever plan like that, nor the discipline to keep quiet about it.  So if that story is true, Chapman is probably just one of the useful idiots who is playing naive foot soldier.

So, the choices about him are either:  A leader of an activist cadre that has accomplished nothing of value, but does some really stupid things.  -or-  A dupe of the real leaders of that cadre.  Neither one is exactly a qualification to branch out and hurt people in other areas too.

But this flat assessment can never present the picture of him that you get if you look at the details of what he actually writes.  I have listed a few choice examples, and I recommend following the links to fully appreciate them.  I should note that I did not do any active research to gather this information.  I did not do a web search and I do not follow him on Twitter.  I cannot even imagine what you would come up with if you put in that effort.  Instead, these items are mostly those that came across my desk just during the few weeks since I started thinking about writing this guide (really! you would be astonished how often stupid things Simon Chapman has written come across my desk without any effort on my part), along with a few particularly amusing ones I recalled from past months.  Also, these are just the ones about tobacco -- I will include some others in a later post -- and I left out a couple of recent posts that tried to analyze him because I wanted to focus on him condemning his own intellect and integrity with his own words:

• Here he is citing some random bravado by cigarette counterfeiters as the basis claiming that plain packaging will not facilitate counterfeiting.  Actually, the funny part is that it mis-cites the counterfeiters' claim, translating it into something that is utter nonsense -- it is a hilarious read. 

• But don't worry, because counterfeiting is no problem: Here he is claiming that smuggling (of illegal cigarettes) cannot possibly be a problem because if customers know where to buy illegal product, then the police can easily know too, and thus stop it.  Gee, he should probably tell the drug enforcement authorities about that clever bit of sociological analysis.  Maybe he just doesn't want to make the cop dramas really boring ("Chief, we heard some people were selling crack, so we went to where it was happening and stopped it.  So can we get back to directing traffic at the construction site?"

• And, besides, he assured us that "Smuggled tobacco is a major issue in nations with high corruption indexes and open borders. It has never been a major problem in Australia."  Apparently it is all about corrupt nations like Canada and non-island nations like Ireland (which both have enormous cigarette smuggling).  Wait, what?  You say that a major Australian newspaper reported, one week after he published that comment, that Sydney is flooded with black market cigarettes. Interesting.

• Here he is espousing the fallacy that what is bad for industry must be good for public health, but then in the same material admitting that he really understands the truth and thus was mostly lying or such a poor thinker that he does not see the contradiction.

• Here he declares that the many countries who are challenging the seizure of trademarks and such are all just corrupt and basket cases.  Perhaps he was reading the list from the back end of the alphabet and got as far as Zimbabwe before his limited attention span fell off; he apparently did not get to Turkey, Indonesia, Chile, and numerous other, or even as far as Zambia.

• When a member of the UK parliament analyzed his plain packaging plan and pointed out that the costs exceed the benefits, did he respond with analysis?  Of course, not -- he does not do analysis, and does not pursue causes that are supported by analysis.  Instead, he claims that any opposition to his pet policies from the UK reflects that country's support for the slave trade.  I am not kidding.  Read here and here.

• In response to the legal challenges about trade rules and intellectual property, he argues that it must be just fine since Islamist countries ban alcohol sales, overlooking minor points like (a) banning a product category is totally different from confiscating a brand and (b) if your argument is "this is not unacceptably illiberal; Saudi Arabia does something almost as extreme", then you have a problem.

• But plain packaging is only the next of several steps he has planned.  His deep knowledge of sociology leads him to suggest that Australia will shortly embrace a system where smokers have to obtain a government permit that controls how much smoking they can do (more here).

• And just in case you were under the impression that he was trying to help smokers, his hatred of them is apparent here, in his accusing them of absurd acts of bad parenting.

That is long enough for now, because to really appreciate this message, you will need to follow the links.  And it is worth reiterating that compiling this list required no effort or searching, and I am sure it is possible to lengthen it ten-fold.

One of the comments on one of the above-linked posts read:
I have to admit that I love to read about Chapman fails, even though the thought of this man makes me feel ill. He’s a tyrant, using health care issues as a guise to destroy everything he does not like. ... In the fullness of the time, the world will see him as one of the most hateful beings to have lived. He deserves far more scorn than he has yet received. Although, it does feed his enormous ego when we criticise him.No doubt that last point is true.  The man is apparently so unaware of both himself and the world that he will probably see something like this as a tribute to his importance.  I don't really care.  I am trying to help the many people he is wantonly hurting, and the impact on him does not matter.

So, though he can see this as a validation of his impact, I trust that others will actually understand it, and realize the message:  If he is influencing policy about IWTs by coasting on his reputation from tobacco, it might be useful to know that that reputation in that arena is as a junk scientist, a failed thinker, either a liar or incredibly clueless about what he claims expertise on (which is just another form of lying), and an international running joke.

I will take up further spectacular Chapman fails, probably in a week or two.

This posts finishes off my recent mini-series on the nature of addiction and related concepts, in the concept of smoking and other tobacco use.  It started with a post about the implications and ethics of a "vaccine" that prevents someone from getting any effect from nicotine.  I then wrote about a new study that provided some interesting insight into the role of addiction in quitting smoking.  In those posts I introduced the notion of second-order preferences (preferences about changing your preferences) and the Chicago School definition of addiction (focused on someone having increasing marginal returns to consumption, rather than the standard diminishing marginal returns), the only candidate for a legitimate scientific definition of "addiction" that exists in the scientific literature so far as I am aware.  I then suggested that second-order preferences offer an alternative definition of addiction, or at least characterize what is often being thought of when the word is used.

I wanted to tie this together a bit in the context of news reports about a new study that shows that use of nicotine replacement therapy causes approximately zero increase in the success of smokers who are trying to quit.  Actually, I am not sure there are such news reports right now, but since there is such a study result every few weeks, I am just going to say there are. 

[It turns out that between the time I wrote the previous sentence and when I posted, a new example came across my desk.  I am not going to bother with details of it because the key point remains that this is a roughly semi-weekly occurrence.  I will note that the authors -- pharma industry flacks -- tried to sell the story that NRT was effective, when their results showed quite the opposite; this is typical, so it is useful to realize that most new studies that claim to have demonstrated effectiveness are really part of the long list that show so little benefit.  Honest researchers would never claim they observed any effect worth mentioning.  For more on the dishonesty of the new study, see this post by Michael Siegel.]

So, what explains the strange combination of "NRT does not help to a measurable degree" with "people are sufficiently convinced that NRT will help that they keep trying it" and "researchers are are unwilling to accept the evidence that it does not help so keep thinking it will be different next time".  Of course, big money has a lot to do with it:  NRT is obscenely profitable, and so like everything from soda to mobile phones, it is heavily advertised with promises that it will improve your life, and most "public health" researchers I know will do any research someone offers them money to do.  But people would not be vulnerable to the advertising, and the news that it does not help would not be so interesting, if there was not some intuition that the products ought to help.  After all, there are no news stories reporting the shocking discovery that, say, wearing your underwear inside-out turns out to not make it more likely you quit smoking.

It seems pretty clear that most would-be quitters use NRT based on the belief that it will fulfill their second-order preference, "I wish I did not want to smoke."  That is how the products are marketed, as a way to fulfill that wish.  But there is an important nuance in the sales pitch:  It talks about some immediate "urge" or temporarily "taking the edge off" because these products are not supposed to be substitutes, but only tools for making the transition to abstinence easier.  (Of course, the pharma is happy to sell most of the product to former smokers who are using it as a harm reduction substitute, just as long as they can keep pretending that is not their main market, but that is another story.)

The nuances of the message and the wish highlight differences between the two candidate definitions for "addiction", and make it clear why it is obvious that NRT will not work.  If the reason someone has the characteristics "chooses to smoke" and "believes he would rather not smoke" is because it is too tempting to relapse before getting through some transition, then NRT or something with similar properties will help.  NRT is designed to lower that supposedly irresistible high marginal return that results from addiction (in the Chicago School sense of the term) until a few days of abstinence lowers it.  (Arguably the products are woefully bad at providing even this benefit, but that is another story still, so let's ignore that complication for now.)  But then again, most people who are really committed to quitting are quite capable of getting through that transition without aid, at least for smoking and even for the likes of heroin.  This was an implication of the Penn State study.  Still, on-label use of NRT can at least theoretically help with this.

So NRT maybe helps the small minority who only keep smoking because they are not able to avoid starting again after a brief period of abstinence (and so benefit from the aid) but are happy to remain abstinent once they get there (really were motivated by an Chicago School addiction).

But for many among that minority (in the West) of people who smoke, the combination of characteristics "chooses to smoke" and "believes he would rather not smoke" is something different entirely.  It really represents a realization that, all else equal, not smoking would be better, but not all else is equal.  In particular, such individuals have substantially higher utility (econ-speak for "are better off") when smoking compared to not in the medium term.  By "medium" I refer to the period that is longer than just the short weaning off period, but for which some resulting serious health problem has not occurred yet, and so is only a possibility.  For them, there is no reason to expect that NRT would help in quitting, unless it was used as a long-term substitute.  The reason they smoke again after being abstinent is not some failure to escape the short-term high marginal utility, but because of the assessment "I would be better off smoking again".  Perhaps this assessment is often made without fully considering the consequences, but often it is made in fully recognition of the health risks.  (I suspect it is seldom made with the realization that low-risk substitutes that are better nicotine source than NRT -- smokeless tobacco and electronic cigarettes -- offer the best of both worlds, but that it yet another story.)

In other words, if we use the word "addiction" to describe this phenomenon, it is not the Chicago School definition.  The apparent difference between "willing to pay the price to consume something" and "addicted to it" is the second-order preference "I would prefer to not be willing to pay the price to consume it".  That creates the interesting situation, wherein anyone who prefers to smoke and says "I am ok with my preferences/choice" is not addicted, whereas if they change their mind about that, they are.  It also creates a situation where the dedicated quitter must either alter his preferences (as with the vaccine, that leave you no better off when using nicotine as compared to not) or forever fight them.

The makers of NRT (and their subsidiaries in government, clinical medicine, and "charities") try to sell people on the idea that NRT will adjust their first-order preferences to better conform to their second-order preferences.  Perhaps it sort of does that in the very short run.  But it does nothing to change a person from someone who benefits substantially from nicotine to one who does not.  Medium term preferences are not changed.  Since the ANTZ who dominate the discourse like to pretend that no one benefits substantially from nicotine, and NRT merchants are happy to play along with this, understanding of this fundamental phenomenon is rare.

If research on smoking cessation was a science, rather than being a marketing and political activity, the overwhelming evidence that NRT does not work would have led to the rejection of a hypothesis.  The hypothesis about behavior that leads to the conclusion that NRT will be helpful is something a bit more general than the Chicago School notion, though it encompasses it -- something along the lines of "people only do this because they cannot break themselves free of it, so something that aids in that breaking free should lead to substantial quitting."  But lots of people start again after a successful break, so obviously that story does not explain everyone, and indeed near-uselessness of all short-term aids suggests that it explains only a very few current smokers.

Having proposed it as a definition, I will conclude by saying that I think a definition of addiction that is based on second-order preferences is a lousy one.  It seems to be what a lot of people mean when they use the term, but a phenomenon whose existence is determined by what someone wishes is not a very robust one.  So we return to the situation where the term, as generally used, is just noise, and the intriguing possibility that to the extent that it is well-defined, it is the addicted smokers that are most likely to successfully quit.

Yesterday I posted about a new study that seems to shine some light on addiction to smoking, if "addiction" is defined based on the only clean definition I have seen in the literature, the Chicago School economic definition that focuses on increasing marginal(*) benefit from consumption.  I noted that most of the time when "addiction" is used in scientific contexts, it as if it actually means something, but on closer inspection it does not.  This facilitates the very anti-scientific behavior of using a word to mean one thing while letting the reader think it means something else.

[(*)As in "at the margin"="at the edge".  It means the next bit, so in this context, it means the additional benefits from consuming the next bit.  This should not be confused with other meanings of the word like "small" or "fringe".]

An alternative way to use the term misleadingly is to define it to mean something that is idiosyncratic and absurdly different from what people normally interpret it to mean.  This is typical in, for example, studies of youth smoking, where it is often defined as something like "indicates in a survey that he intends to smoke in the future", which can mean that someone who has never smoked, or who smoked once and never did it again is "addicted".  (No, really, I am not kidding.  The "research" by DiFranza et al. does exactly this, as described in this article and the commentary I wrote about it.) 

Today, the New York Times decided to help me out with a great example of this method of misleadingly using the term.  The asks "can exercise help curb addictions?", which is pretty hard to answer if you do not know what the word means in this story.  Fortunately, they define it.  In this case, after providing the background -- "according to an eye-opening new study of cocaine-addicted mice, dedicated exercise may in some cases make it even harder to break an addiction" -- we learn that "break an addiction" means "stop bothering to come back to where the cocaine used to be offered once it is apparent that no more is coming".  It is explained that they are defining addiction in mice to mean "displayed a decided place preference for the spot within their chamber where they received cocaine".

By that standard, I am addicted to the seat I usually take at the cafe, to say nothing of my desk chair.  And the "addicted" mice might just be the ones who are slower to figure out that the world has changed, and so maybe it is common sense that is affected by exercise.  In short, so far as addiction goes, this study only shows that your willingness to hang around and wait for cocaine seems to vary based on your exercise history, assuming you are a mouse.  The only thing that seems particularly "eye-opening" was the effect of the cocaine on the mice.

The fatal flaw is that mice do not display sufficiently complex economic behavior that "addiction" makes sense for them.  Thus, we end up with a lame metaphorical use of the term, in which it means nothing more than "demonstrates a desire to consume by waiting for the next delivery".  Trying to draw conclusions about addiction in mice is like trying to do experiments on mice to inform people about how to have a happier marriage.  The conclusions from critter psych research often end up being right, but only because the truth about people is so clear that it creates a bias such that the researchers declare they are seeing evidence in the mice that supports the obvious facts about humans.

Actually, if you work at it, you can get some economic behavior out of mice and other critters.  By forcing them to pull a lever a particular number of times to get a payoff, we can create a price, and thus with multiple levers and finite time, we have relative prices of various goods and a budget, the essential features of economic behavior.  With that, adding in manipulation of the prices, it would theoretically be possible to measure whether the mice were displaying increasing marginal returns from consumption, a meaningful notion of addiction.  But this would be quite difficult, and would require that the mice understood how the price was changing and other complications.  It would also mean assuming that critters normally share the human trait of getting satiated with a good after consuming some and wanting to next consume something else instead, which runs contrary to my knowledge (i.e., arguably, they are addicted to everything they are positively disposed toward because they keep coming back to the same things).

So the mice researchers do not even bother trying to really measure economic behavior.  However, it is interesting to note that their metaphorical use of "addiction" is still based on a behavior that is about as close to consumer economic behavior as is possible in the absence of prices.  That is, they are implicitly recognizing my point from yesterday, that addiction is clearly a matter of economics rather than biology or epidemiology.

But let us imagine that a mice experiment with prices was created, and the mice displayed a willingness to "pay" (pull the lever) more for cocaine when they had used more recently, rather than getting less interested in it, whereas for goods that we assume are non-addictive, their willingness to pay followed the normal human pattern of dropping off as they consumed more.  Would we still want to say they were truly addicted, as opposed to something like "acquired a very strong taste for it".  Something seems to be missing.

The colloquial notion of addiction has some element of the consumer not wanting to be in that state.  After all, if you have gotten in the habit of doing something, and are experiencing increasing marginal returns, but are loving it and see no reason to stop, how is that addiction?  The Chicago School definition addresses that by including a negative effect on welfare from "addictive stock", defined as how much you have consumed in the past.  This is the "running fast to just stand still" effect.  An addicted smoker gets more benefit from each cigarette than someone else would because of past use, this story goes, but a lot of that benefit is used up just getting out of the hold, back to the neutral state she would be in if she had not smoked anytime recently.  That is something that is theoretically measurable in people (though it is functionally nearly impossible -- you have to ask them about well-being, and then figure out how to calibrate the answers and control for confounding), but not even theoretically measurable in mice.

But there seems to be one other candidate for addressing the "not wanting to be in the state" feature, the concept of second-order preferences. 

(Actually, I can think of another candidate -- it is a terrible concept, but so common it is worth mentioning:  The "and also it is somehow bad" aspect can be defined in terms of the consumption hurting oneself.  The problem with this is that every consumption choice involves hurting yourself, because you are giving up resources and other opportunities.  So this always involves an implicit declarations that some harms that you inflict on yourself are fine, but others are not, which just plays into paternalists' or collectivists' pet notions.  So it is common, but ugly, both politically and scientifically.  Some will merely say you are not allowed to damage your body (because it belongs to the society, not to you), and thus addiction is anything with particular economic/behavioral properties that does any physical damage.  Others will go further and effectively assert ownership over your productivity or even mental state, declaring that a choice to make those go badly is something you should be protected from -- as in "sure smokeless tobacco produces trivial health risks, but it still means that someone is addicted to nicotine, and that is bad in itself, so we cannot allow that."  Even if you do not find that politically repugnant, it should be obvious that it is scientifically useless.)

I wrote about second-order preferences a few days ago (though I have yet to settle on whether it has a hyphen).  I explained that they are a preference about preference, usually discussed in the context of a preference to have a different preference than you do not, as in "I want a cigarette, but I want to not want a cigarette."  This is another economic concept.  Some would argue that it is better seen as a proto-economics concept because, though preferences are at the heart of economics, economics starts with preferences as a fixed point and works from there, and so anything that discusses the source of preferences or wanting to change them exists just before economics.  Others disagree.  Either way, it is in the neighborhood.

Mice may not be even be capable of having second order preferences, but people are tortured by them.  A second order preference could make concrete the negative vibe in "addiction":  You experience increasing marginal returns, and so are best off consuming the good (i.e., you prefer to consume it), but you wish that things were different and you did not prefer to consume it.  This is compatible with wishing you were not in the "running to stand still" hole, but that aspect is not necessary.

A defensible definition of "addiction" could have at its core "like it a lot, but often wish you could stop liking it".  I think this needs some element of varying preference, though maybe not specifically the increasing marginal returns.  After all, if you like the experience/feeling/high and choose to do it, there must be something different about its appeal at the times you wish it did not appeal.  Maybe it is just a moment before you start when you say "I shouldn't do this", but once you are doing it, that feeling is gone; that might be (rapidly) increasing marginal returns once you start.  But it could be that you get satiated, like with a normal good, and that is when you wish you would not want more later. 

One interesting feature of a definition that is partially built on second-order preferences might be that if you do not wish to not like the good, then you are not addicted, no matter what your behavior pattern is.  To someone gathering objective data about you (and thus who cannot see your preference), you cannot be judged to be addicted until and unless you try to quit and fail, and even then you would need more data not sufficient (e.g., a single quit attempt could be an experiment to see if you might be happier without, and the discovery that the answer was no).  But this kind of fits the colloquial usage.  On the other hand, there seem to be some behaviors and preferences that somehow feel like they out to be addiction, if the word is to take its colloquial meaning, but there is no desire to stop liking them, so I am not sure it is wise to tie too tightly to the notion. 

But it seems to play some role.  For example, second-order preferences offer an easy explanation for why the NRT approach is so often tried unsuccessfully.  I will try to get back to that point shortly.

I just realized that the state university system here (Penn State) might well be one of the best contributors to useful research about tobacco after the usual suspects (Rodu, Lund, Snowdon, BAT, etc.). A huge majority of research published on smoking and other tobacco use is either completely useless (telling us what we already know, or being so convoluted that it is impossible to translate into useful information) or is just pure advocacy disguised as research. So a few informative studies is enough to put a person or institution into the top ten. 

I have to say I did cringe when I saw this headline in the Penn State house-organ magazine/feed:
Mobile technology helps explore nicotine addictionI was anticipating something that told us nothing about addiction, and was really just a glorified quit-line with someone gathering some useless noisy data and calling it research. Indeed, the reporter included some of the usual pablum in the article, but the research itself was interesting. The mobile phones were used to get instant feedback from smokers who were trying to quit about their emotions, desire to smoke, and smoking status, which likely give much better quality data than a long survey a week in. The reporting of the research included this gem:
"One thing that really stood out among the relapsers is how their urge to smoke just never dropped, in contrast to those who were successful in quitting for a month -- their urge dropped quickly and systematically -- almost immediately upon quitting," said Stephanie Lanza, scientific director of The Methodology Center at Penn State. "That was surprising to see." That actually tells us something potentially useful about addiction, as promised by the title. However, it is necessary to think a bit about what addiction really means to see what it is saying.

I usually argue that the word "addiction" has no place in scientific discussions, at least not if it is not defined. As typically used, it is the worst kind of terminology: It seems like it means something significant, but if you start drilling down on it, it seems to not mean anything special after all. It is purely a "I know it when I see it" phenomenon in its common usage, and different "I"s definitely see it differently. This makes for terrible science, and use of the undefined term as if it is meaningful always strikes me as a convenient easy clue that an author really does not know how to think scientifically. 

Sometimes "addiction" is used as a synonym for "use", or for use with an element of condemnation (as in "use of something that I [the author] disapprove of"). Sometimes it invokes a theme of users not wanting to quit, though no distinction is offered that defines "addictive" as meaning anything other than highly desirable. Perhaps the most common use of the term is to refer to some overwhelming urge, but that is clearly not what it means (or else breathing, thirst, and wanting to see your child are addictions). A small minority of those who use the term do manage to get closer to some meaningful concept, that it has something to do with a non-typical pattern of preferences and behaviors, though they seldom nail it down.

The one group of researchers that I am aware of that have declared a meaningful formal definition are the Chicago School economists.  This should not be surprising, since the phenomenon clearly has to do with individual preferences and consumer behaviors -- the stuff of microeconomics, not of the biological or epidemiological side of the health sciences. (Note: Yes, in saying this I am declaring that the DSM-type wanderings do not constitute a definition of "addiction" (or "dependence" or the like). Take a look at them. They are just lists of vague considerations.  It is basically a technical-seeming way of saying, "you will know it when you see it; look for characteristics like...." There is no there there. It is much closer to something like "what makes a novel good" than a scientific definition.)

To simplify down to its essence, the Chicago definition of addiction focuses on how past consumption increases the marginal value (i.e., how much you want it) of later consumption. That is, most goods have diminishing marginal returns: if you have consumed a lot lately, you are not so interested in more right now (this is the standard mathematical assumption in economics, and is generally true so long as you choose "a lot" and "lately" right). So if you have just eaten, your desire to eat more is lower than it was before you ate. If you spent yesterday hiking, you are over it for a while and can settle in to work. But for some things, the desire is actually increased by recent consumption, contrary to the standard Econ 101 assumption. So if you did not smoke today, yesterday, or any time in the last decade (or ever), your desire to smoke is pretty low; but if you smoked a pack yesterday, your desire to smoke today is going to be pretty high.

Some readers are probably already picking holes in this construction. If you smoked five minutes ago, your desire to smoke right now is less than it was when you were lighting up that last one, not more. The eating example is mostly right, but if you just ate one bite of baklava (or whatever your favorite dessert is), your urge to eat more is probably increased. The "increasing marginal returns" definition has some complications and exactly when it starts and stops have to be defined ad hoc. Lots of things -- probably most any desirable consumption good -- are addictive on a short time scale after a small amount of consumption ("I just ate one bite of this and so want a second") or a long term scale after frequent habituation ("I had never wanted to try that restaurant, but I started eating there every Thursday and I don't plan to stop"), and nothing is addictive at every time and quantity ("since I did a couple of lines of coke five minutes ago, I don't want any more right now"). But for some values of time and quantity marginal returns are increased, and when that occurs more than is typical, it is interesting.

This makes it a potentially useful conceptualization and basic structure of a definition, but not a complete definition or anything you can push too hard on. (The attempts by Chicago economists and others to do empirical work based on the definition are, thus, pretty much a joke -- and I say this as someone who has done such work.)

Still, if you start with the concept, but do not take the details too literally, you can do some interesting science. Start by realizing that the nature of addiction, so defined, depends on the exact pattern of time and quantity that creates increasing returns, and probably the intensity of that increase. That makes it meaningful and worthy of empiricism. Then look back to the quote from the article. 

From that quote, I think we can conclude that those who have the easiest time quitting are the ones who were mainly motivated by addiction, and get an estimate of the parameters of that addiction. That is, the reason they wanted to smoke today as much as they do is because they smoked yesterday. Once that is gone -- once they have not smoked for just a few days -- the desire to smoke, which was caused by the increasing marginal returns effect, drops off, and quitting is easy.

Who does not quit? Those whose benefits from smoking are not mere addiction. For them, being abstinent for a few days or even a few weeks does not change the sign of their cost-benefit calculation, which says "I am better off smoking than not". It is, of course, possible that their marginal value did drop after a few days of abstinence, but not so much that they decided that quitting was better.

The basic point here is not news to those of us (an extremely small minority among those who study tobacco and such) who understand that smoking and other tobacco use is, first and foremost, a free consumer choice, and the departures from that are quite interesting but fundamentally secondary. But the value of this result is probably lost on the ignorant masses who claim that there is something fundamentally different about smoking compared to other consumption choices.  They are like the astronomers who assumed Earth was a fixed center or chemists before the discovery of isotopes, who generated enormous quantities of completely pointless study results.

Of course, it is possible the the Penn State researchers might have said something dumb, like declaring the non-quitters to the ones they found to be more addicted. But perhaps not. Perhaps they did the cleanest possible science, not even using the word addiction, and simply reported their results. Maybe they even got it right. I have to say that I have chosen to not go look at the actual research so that I do not have to burst this little bubble of believing that someone did some useful novel research about tobacco/nicotine use, and drew accurate conclusions from it.

There are reasons for optimism. The key researchers were methodologists, not public health people. This provided observations like:
"To me, the biggest innovation here is looking at how something like baseline dependence is predictive of that behavior over time or (specifically) the urge to smoke over time," said Lanza. "It's now expressed as a function of time. Instead of saying 'if you're higher on dependence you're going to have a higher urge to smoke over time,' you can now depict how that association between baseline dependence and urge to smoke varies with time in a very fluid and naturalistic way."In other words, it is an attempt to measure addiction based on the one almost-concrete definition of it in the scientific literature, something that has to do with preferences over time as consumption changes. This is genuinely useful stuff, helping us understand people's motivations and thus (*gasp*) helping them make rational choices rather than treating them like agricultural research crops, an object to be manipulated. It would be over-interpreting this one bit of research to out-and-out declare "this confirms the conventional wisdom that the addictive component of smoking wears off in a day or two, and so those who are motivated to smoke mostly by addiction and who want to quit just need to get over that hump; those with other motives are an entirely different story, and their choice to smoke cannot be explained by addiction, at least not on this time/quantity scale". But it definitely points in that direction, and promises some interesting work to come.
"Our goal is to work hand-in-hand with tobacco (and other) researchers, to help them understand these really intricate processes that are happening," said Lanza. "We want to really understand addiction and how to break addiction, so that interventions can be targeted and adaptable."Damn.

Well, maybe they will get another study or two out before they abandon science.

March is coming to an end, and since this seems to be unofficial "make Simon Chapman regret his habit of saying really dumb things on Twitter" month, I figure I am running out of time to join the party.  It started out with blogs about some of Chapman's tweets, with an absolutely hilarious post by Chris Snowdon, followed by Dick Puddlecote a week later.  Meanwhile, Dave Atherton presented him with a barrage of direct tweets asking Chapman to defend some of his positions in the face of the evidence (Chapman offered no response, as far as I can tell, and I would guess had none).

For those who do not know, Chapman is the Worst "Public Health" Person In The World.  (Like Olbermann, I reserve the right to pick different "Worst Persons" later, but I find it likely that others will remain runners up.)  You can learn a lot more by searching for his name in Snowdon's blog, or mine, but to summarize:  He is the perfect storm of a card-carrying "public health" person who is harmful to both public health science and the public's health:  terrible at scientific/analytic reasoning, and freely promotes junk science; believes that top-down authority, particularly promoting prohibition, is the defining characteristic of public health; will make any sciencey claim that seems to support his political positions, regardless of the lack of scientific support; displays no apparent humanitarian concern despite working in a field that can only be justified by such; is the worst kind of gadfly (parachuting in to topic areas he clearly knows nothing about and making sweeping declarations as if he is an expert); and does not even seem to display much more scientific expertise on tobacco, the subject he has been working on for decades.

None of that would matter much (there are tens of thousands of teenage bloggers who are characterized by all but the last of those, after all, and some write much worse things than Chapman), but for his last characteristic:  He has been granted an inexplicable measure of authority over public health in his country.  Fortunately for 99.5% of us, that country is Australia, but we should worry about people even when they are a minority living in some remote shark-infested flooded desert.  Besides, there is the matter of the spillover via telecom.

[Aside:  I suspect some readers might be thinking, "Worst? But what about Stanton Glantz, who occupies a fairly similar niche and makes even more absurd pseudo-scientific claims."  I see your point, but I have become convinced that Glantz is actually an extended "bit", like Stephen Colbert -- someone playing a character by the same name that is a parody of an absurd group of people.  I mean, seriously, no one could actually believe what he claims to believe and be able to get through the day without some sort of custodial care.  Like Colbert, he has been asked to give sworn testimony while acting in character, and has some clueless followers who believe that the character is actually a real person making those claims.  So "Glantz" is not really in the running unless I turn out to be wrong about this.  Moreover, Chapman claims personal credit (i.e., blame) for the ban on low-risk alternatives to smoking in his country, making him responsible for the pointless deaths of more of his countrymen since the guy who ordered the army to Gallipoli, and Glantz is never going to be able to touch that "accomplishment".]

Getting back to Chapman, I do not have quite the writes-itself quality material that Snowdon did (if you have not read his post, do so -- it is great) and I doubt I can come up with a phrase as catchy as Puddlecote's "Swivel-Eyed Loon", so the following (pictured) is what I have.  It is from just before "make Simon Chapman...month" began, and I have not experienced any cyberstalking from him since then, so maybe the project has already succeeded.  Still, I want to get in on it.


The background is that my government, specifically U.S. FDA's new tobacco regulation unit, has a badly misused Twitter feed.  Keep in mind that this unit of the government is not some third-rate "public education" operation at a county health department.  It has no mandate or expertise to engage in general public education.  Its role is entirely to regulate corporations, making supposedly science-based decisions and issuing top-down edicts.  Despite this, about 20% of its tweets from @FDATobacco are inane anti-tobacco statements, whose style suggests they are intended to target the many fifth-graders who are reading the feed.  (The latest one, at the time I am writing this, is "True or False: Every day, approximately 1,000 youth under age 18 become daily smokers."  That is the full content, down to lack of a question mark and the apparent failure to understand that such a statistic only makes sense if you tell us what population you are talking about.)

About 70% of the traffic from @FDATobacco seems to be thanking others by name for following the feed or for retweeting (funny, they have never once thanked me for any of my retweets -- it might have something to do with the fact that I usually add some analysis).  That leaves maybe 10% that is the actual legitimate activities of this taxpayer funded official government communications channel from an agency that regulates commerce, telling us about what is going on that relates to the intersection of FDA and tobacco.

By far the biggest story of this year in that intersection was the court ruling that blocked FDA's plans to put emotionally violent gory images (often mischaracterized as "warning labels") on cigarettes.  Funny thing: @FDATobacco completely ignored the story, while continuing to post the wastes of space I noted above.  I am fairly certain that most of my readers recognized the intention of my post: biting sarcasm about how completely inappropriate the FDA Twitter feed is.  I hope the subtext was clear, that our government's official communication channels should not be acting as a cheerleader for a particular political position, intentionally ignoring the important news that the government's ultimate authority in the matter has taken an opposing position.  When the agency's efforts fail, it should be reported by the agency; if whoever writes @FDATobacco does not like that, s/he should leave government and get a job in advertising.

So, let's look at the tweet that Chapman sent in reply.  Start with the last line.  I am not sure exactly what "your descent" means.  Tweets are necessarily terse, but he had some slack to explain with a few more words, so I suspect he did not really know either.  Perhaps he is pointing out that my first foray of any significance into the scientific field that he claims expertise in, epidemiology, won several awards and helped redefine the discussion among the real scientists in field about how epidemiology should be done and what is fundamentally wrong with it.  The next topic I pursued was an even more important problem in the field, in my mind, though it did not generate much buzz.  So, most of the directions I could go after my debut were indeed down.  I would be the first to agree that after 13 years, and efforts by me and others, what I tried to promote with that work is still an unfulfilled promise, and epidemiology has not improved.  And I have given up on pursuing improvement from within.

Perhaps that was what he was trying to say.  But I kinda doubt it, given that he is not part of the scientific branch of the field, did not contribute to the attempted revolution I was part of, and seems to be thoroughly ensconced in the "part of the problem" side.

So what did he mean?  Did he think my criticizing the FDA was a descent?  That seems like a strange claim, since the aforementioned debut paper used as its main example an indefensible FDA decision.  Could it be the fact that I am criticizing someone?  Part of the reason epidemiology is so bad is because the non-scientists in the field have an attitude that you should never criticize anyone's work (I am not kidding).  But I have never hesitated to criticize, coming from a scientific background, so there is no trend.

It is unclear, but my best guess is that the claim reflects Chapman's activist zealot mentality, which often manifests in assuming that people in "your" group must agree with you on everything, and refusing to consider that they might have a good reason for not doing so upon finding out otherwise.  In this context, I speculate, he incorrectly assumed, when he followed my early contributions, that I agreed with him on everything, such as favoring emotionally violent labels on cigarettes.  But he interpreted this tweet as being a declaration that I now disagree with his goals, which is the zealot's only basis for judging someone.  Thus, descent.

That takes us to his first sentence.  Setting aside the very incorrect implication that we are on a first-name basis, consider the claim.  I sounded happy?  I am not sure it is possible to sound happy in 140 characters without using words that explicitly declare happiness.  Surly if I had just posted the "Judge blocks..." headline, there would be no basis for a claim about sounding happy.  So it must come from the "Hey @FDATobacco...." part.  But, of course, what I expressed there was my dis-happiness with the high school intern or secretary who controls the @FDATobacco feed (I am going to give them the benefit of the doubt and assume the problem is that the agency is simply not taking it seriously), for their abuse of government authority.

Chapman's misinterpretation of that is a perfect example of what makes him such a bad excuse for a scientist, and not because he misinterpreted (though I am still really not sure how that "you forgot" construction could be interpreted as happiness).

A scientist/scholar would read and understood the actual analyses of opponents of his position, particularly people he presumes to pick fights with, rather than just their feeds.  Had he done so, he would surely be aware that I have repeatedly argued that those graphic labels are bad public policy for numerous substantive reasons.  The last of the above links is to the testimony I offered about FDA's plans which made the same core arguments used in the judge's ruling.  Indeed, some of the phrasing in the ruling is so familiar that I suspect that one of the judge's clerks must have read what I wrote and used some of it in drafting the ruling, which is gratifying.

Thus, my tweet could convey no information about my happiness about the ruling, because anyone familiar with my work would already know I was happy about it.  It was a defense of freedom of speech, a repudiation of pseudo-science, and a push-back against perverse "public health" measures that are designed to harm people who are choosing to do something unhealthy rather than to help them.  Chapman's behavior suggests that he does not care about any of these, but before he presumes to criticize me, he ought to be aware that I do.

Moreover, even allowing for his failure to understand the sarcasm I was conveying to/about the author of @FDATobacco, someone who thinks scientifically would have automatically wondered about the meaning.  There are plenty of ways to express happiness, and I employed none of them.  But apparently it never occurred to him (like it automatically would to someone who thinks scientifically), "wait a minute; my immediate impression of this does not add up; there is something I am not understanding."  Leaping to the conclusion that I was expressing happiness might be another result of his activist mentality:  If everything is measured only in terms of whether it is good for The Cause or bad, and there are no complications other concerns in the world, then someone must either be expressing happiness or sadness about a policy decision.  Of course, if I had more data, I could perhaps do better, and might well figure out that my guess is wrong.

I wonder if Chapman has ever expressed that last thought.

I am tempted to say something about watching Chapman's descent, but I think perhaps he has acted this way since I first became aware of him, and I just did not notice it at first.  A big difference is that he has gained power, and thus his folly is clearer.  And really terribly harmful.  I do not mean some abstract point about his behavior harming the science itself (though it does) or parochial point about his content-free personal attacks on people who are doing good science that he does not like; I refer to harm to the welfare of lots of people.



Oh, and of course the answer to the question in the title is the internet-age variation on the old canard about how you know a politician is lying:  "His fingers are moving."

A couple of weeks ago, I posted about a move in the Wisconsin legislature that would basically declare that being a single mother (however that situation came about) constitutes negligent behavior that contributes to child abuse.  Understandably, there was an uproar about this; not surprisingly, it pretty much overlooked the epidemiology of the situation that I mentioned.

It was pretty clear that the epidemiologic observations (that a child is indeed better off in a two parent household all else equal, and that children in a household with a male partner of their mother who is not their biological father are at enormously greater risk of suffering physical abuse), while based in evidence, were rationalizations, not the real motives.  Other statements by the bill's sponsor made it pretty clear he was not actually trying to improve the lives of the children, let alone their mothers.  A few days ago, that was compounded by a comment by a co-sponsor of the bill, which finishes off any doubt that this has to do with caring about people:
Instead of leaving an abusive situation, women should try to remember the things they love about their husbands, Representative Don Pridemore said. "If they can re-find those reasons and get back to why they got married in the first place it might help,"(h/t to epidemiologist blogger Tara C. Smith for finding this, though I cannot quote her tweet about it without risk of getting my post censored by vocabulary-based filters)

This madness is fascinating in the context of the buzz about the new book by psychologist-turned-political-analyst Jonathan Haidt, The Righteous Mind.  The gist of the buzz (admittedly an oversimplification of the ideas, though so is the book -- if you want a more complete summary, this review provides one) is that behavior of many voters on the American political right baffles thinkers on the left.  The latter think the former are just being duped by the 1% to vote against their interests.  Haidt argues that the conservatives just have a broader set of "moral" concerns.  The claim is that conservatives understand liberals' values of compassion and fairness, and share them to some extent, but also consider as moral values such things as order, loyalty, authority, sanctity, tradition, and feelings of disgust.  These latter concepts are sufficiently foreign to liberals, the claim goes, that it is very difficult for them to even recognize these as morals that someone might have. 

One conclusion that gets drawn is that those on the right just have a richer and deeper moral sense than those narrow thinkers on the left.  I realize that Haidt's intention is to offer a useful positive (i.e., descriptive) analysis, not a normative one, but there is something remarkably disturbing about the moral relativism that leaks through in the the conversation.  Ironically, American liberals are often characterized by or criticized for cultural/moral relativism.  But, this story claims that they do not extend that to a large portion of their fellow citizens. 

Whatever you might think of that observation, it should be clear that there is a good case to be made against relativism in the Wisconsin case.  Some "moral values" are just not, well, moral -- they are not defensible under any set of modern Western moral guidelines I can think of, other than appeals to out-of-context statements from ancient Hebrew mythology.  A taste for sanctity, order, tradition, and authority might explain the urge to support public policies of denying reproductive freedom or encouraging a woman to keep an abusive family together.  Similarly, a sense of disgust and authority leads some people to want to punish tobacco users or deny rights to homosexuals.  But remember that a taste -- for wealth and power at the expense of others -- also explains the behavior of the 0.1%.  All are understandable, can be put in evolutionary terms, etc. but that does not make any of them ethically defensible.

Bringing this back to the epidemiology, I would argue that the use of epidemiologic claims as rationalization for a motive that is in no way motivated by the science is deplorable.  Moreover, it is evidence of the moral bankruptcy of the position.  If someone is not willing to stand up and say "I think people should not be allowed to use tobacco or cannabis, regardless of its effect on health" or "in-tact families are the only moral way to live, even if they are unhealthy on net", then let them do so and see how their ideas stand up with the polity.  But if they are going to twist the evidence to try to pretend they are motivated by creating better physical or social/emotional/developmental health, then we should cry bullshit.

Importantly, from where I sit, it is pretty clear that Haidt and the others who try to put this in terms of standard American party politics are working along the wrong spectrum.  The most ridiculous cases seem to come from Republican state officials.  But Democratic officials and the Democrat-leaning permanent government (the long-term employees in the bureaucracy) pursue their taste for non-humanistic principles with (often junk) epidemiology rationalizations -- they are just usually better at disguising it. 

I follow the comments and observations of hundreds of people who share my inclination to condemn junk science and disingenuous rationalization in pursuit of personal "moral" tastes.  It is fascinating to observe that for the substantial portion of them whose political identity is tied to these feelings, there are remarkably similar numbers who believe that the worst offenders are the political right and who believe it is the political left.

Previously I have posted about the media hype about energy drinks and there is a bizarre fixation on caffeine, to the exclusion of the other ingredients, either when they combined with alcohol or not.  The most criticized drinks -- the original, Red Bull, and the controversial alcopop versions (which seem to have largely disappeared from the market following controversy) -- actually have/had fairly modest amounts of caffeine, less than a small coffee.  But the "energy drink" label general means something contains other active ingredients, including other herbal stimulants (guarana, a source of caffeine and a other identified and perhaps unidentified stimulants; ginseng), taurine (an amino acid that is believed to usually be beneficial, but high doses of an isolated single amino can sometimes do weird things), and megadoses of some vitamins.

Personally, I have always been more worried about the other ingredients, though I hasten to add that there is not solid evidence indicting them.  I based my concern on the observation that (a) there is reasonable evidence that sometimes some people have a bad reaction to these drinks and (b) very few people have a very bad reaction to that quantity of caffeine, as evidenced by the tens of millions of people who drink that much caffeine every day.

This week it was widely reported that a 14-year-old Maryland girl, Anais Fournier, died after drinking two extra large energy drinks in December.  Was it caused by the drinks?  Quite possibly, though if so it seems most likely that they triggered a time-bomb condition rather than being like, say, a car crash that struck down someone who otherwise should have expected a 80 more healthy years.  Blogger Radley Balko suggested on Twitter the Huffington Post (which he writes for) should have headlined it, "Energy drinks demonized after girl w/ heart condition dies." 

But if it was caused by the drinks, was the caffeine to blame? 

Unlike many of the other drinks, this is at least plausible in the recent case because the estimated amount of caffeine she consumed was 480 mg.  Alarmists in the press chose to point out that this was equivalent 14 cans of Coke.  They did not bother to mention that Coke is not really a very potent caffeine delivery system, and that this is in the neighborhood of a large Starbucks coffee.  Drinking a large coffee would not necessarily be the best thing for a girl with a diagnosed heart condition to be drinking, but hardly outside the realm of normal teenage behavior based on my observations at the local Starbucks.  (They also did not mention that volume of the Monster energy drink Fournier consumed was that of 4 cans of Coke or more than two large Starbucks -- far short of downing more than two six-packs, but definitely a deliberate ingestion of a lot.)

We have no information on whether she had ever before drunk a large coffee, so the caffeine alone might have been too much.  But it still seems that there should have been some press mention of the other ingredients of the drink.  A search of the name of the girl or the drink in recent news yielded dozens of news stories, but when adding in the name of the other active ingredients, the only story that repeatedly appear was a post by a marijuana legalization advocate wondering why the drinks with all of these ingredients are legal and their drug of choice was not.  (Note to advocates of drug legalization:  Trying to embolden those who want to ban other substances is probably not your best strategy.)  Guarana showed up in longest story about the girl's death, from her local newspaper, but only in the context of it being a source of caffeine; its several other active chemicals were not mentioned.

Fourneir's death was officially attributed to cardiac arrhythmia due to caffeine toxicity.  Presumably this will be cited as evidence that the caffeine content in these drinks is toxic.  It will no doubt be used to make that claim about energy drinks that contain a more typical 80 mg. of caffeine.  But, obviously no such conclusion can be drawn, even about the 480 mg.  The epidemiology of caffeine is clear:  so few people die from it that we cannot even detect the effect. 

I also dread watching commentators pick up on the word "toxicity" in the diagnosis (which is strictly accurate, assuming it was the caffeine: death due to the acute effects of a chemical taken into the body) and start screaming "this is evidence that caffeine is toxic!!!!!"  Yes, people, of course it is -- how could it be any different than every other chemical or compound, all of which are toxins in some form and quantity.

However, I am not the slightest bit worried that this will result in attacks on our society's (and my personal) favorite caffeine delivery system, coffee (except, perhaps, at some fringe health kook sites, which don't really worry about evidence anyway).  There will be actions in state capitols to ban energy drinks because of the caffeine -- if not now, then after a couple of other headlined deaths.  But no one will give coffee a second thought.  The funny thing is that the people leading the charge are undoubtedly the same ones who worry about "chemicals" in food and the environment (not particular chemicals, just chemicals), and who are overlooking the list of untested chemicals that might really be causing a problem.

Someone just asked me the following.  Since I have not covered how to interpret such things in a while, I though I would put it in a post.
Someone tweeted about some segment of Oregon's youth smoking rate going up.

95% confidence interval for 2008 was 8.0% - 9.3%

95% confidence interval for 2009 was 8.7% - 11.2%

Doesn't this mean we can't be 95% sure that the smoking rate actually increased?First, I will answer a fundamentally different, but similar sounding question that is consistent with the numbers provided:  Is the change statistically significant at the .05 level, or equivalently, does the 95% confidence interval for the difference between the two percentages include zero?

A quick answer to that requires only observing that the (unreported) point estimate for 2008 is in the range of 8.6 or 8.7, the middle of the confidence interval (note for other cases if you do this: for a ratio measure, "middle" means the geometric mean, and when the CI pushes up toward a limit of possible values -- like 0% in this case -- it gets more complicated).  If it was 8.7, even if that were perfectly precise with no random sampling error, the difference would not be statistically significant since that point falls within the CI for the 2009 value -- that is, the random error for the 2009 number alone is enough to make the difference not statistically significant.  Since the point estimate might be a bit below that, it is not quite so clean, but it is still easy to conclude that the difference is not statistically significant because it is so close and there is random error for the 2008 figure.

If you want to do a better job of it, you can back out the missing statistics (the whole thing would be cleaner and easier if they reported the actual data, so you could just compare the sample proportions).  After calculating the point estimate, you can calculate the standard error because the ends of the CI are 1.96*SE away from the point estimate.  With those estimates you can use the formula (e.g., here) for the SE of the difference, giving us the CI for the difference (multiply by 1.96, add to and subtract from the difference), which is -0.1 to 2.7.

But much more interesting than "is the difference statistically significant?" is some variation on the question actually asked, how sure are we that there is a increase.  The answer to that is not available from these statistics.  You see, frequentist statistics never answer the question "how likely is...?  (If "frequentist" is meaningless jargon to you, suffice to say it includes p-values, confidence intervals, about 99.99% of the statistics about error you see in medicine or public health, and about 100% of those you see in the newspaper.)  A 95% confidence interval is defined by an answer to a complicated hypothetical question (you can find it in earlier posts here, or look it up) about what would happen if a particular number (the one at the border of the CI, not the point estimate) were the true value.  It does not address what the chances of particular values being true are.  Indeed, it is based on an epistemic philosophy that denies the validity of that question.

But the thing is that such a question is what we want the answer to.  This is true to such an extent that when you see someone try to translate the frequentist statistics into words, they pretty much always phrase it in terms of the answer we want -- i.e., incorrectly.  But it should be obvious this is wrong if you just think about it:  What if the survey that produced those percentages is known to be of terrible quality?  Then it obviously should not make you feel extremely sure of anything, regardless of how low the random sampling error might be (which would happen if it were a large sample, even if the survey was fatally flawed -- size matters, but a lot less than other things).  Or, what if you had a boatload of other evidence that there was a decrease?  Then you might be quite sure that was true, even though this result nudged you in the direction of believing there was an increase. 

Drawing conclusions about the probability of a worldly phenomenon requires taking into consideration everything we know.  It also calls for Bayesian statistics, the need for which is usually mentioned first, but really this is a technical layer on top of the need to consider everything you know.  This has all kinds of annoying features, like the probability existing in your thoughts rather than having any "real" existence.  Which is why it is tempting to focus on the much less useful, but well-defined, probabilities that appear in frequentist statistics, which are then misinterpreted.

As for what I believe knowing the little that I learned from the question I got, combined with other knowledge about how the world is:  It seems really unlikely that the smoking rate would go up (or down) by 15% in one year.  It is mostly the same population, after all, and smoking behavior is highly serially correlated (i.e., what an individual does in 2008 is very predictive of 2009).  Thus, I am pretty confident the change is overstated, whatever it really was.  Based on this, any government official or other activist trying to make a big deal about this number must not understand statistics, though I would have been 95% sure of that even before I heard what they had to say.

A couple of weeks ago, I taught a class in which I used a study about the new nicotine vaccine as an example, and posted the class outline (which I will shortly update with a few talking point notes for guiding the discussion, just in case anyone is interested in borrowing the curriculum).  This prompted a few questions about my general thoughts about the "vaccine", which I said I would answer.

Those scare quotes reflect that this is a sketchy use of the word:  The technology consists of introducing a substance into the body in order to stimulate the immune system to react to the target, which indeed describes the workings of a vaccine.  However, most definitions of the word include a "to prevent future disease" component, while this "vaccine" only prevents nicotine from affecting the brain in ways that clearly do not constitute disease.  The ability to experience the effects of nicotine is considered a disease only in the minds of a small tribe of aggressive political activists, and even they offer no definition of "disease" that supports such an interpretation.  (Please spare me "logic" like "smoking causes dozens of diseases, and therefore nicotine consumption is a disease"; by that twisted logic, the ability to derive benefit from driving a car or to enjoy sex constitutes a disease.) 

Some definitions of "vaccine" specify that the stimulated immune response is to infectious agents.  Moreover, the immune reaction does not destroy the nicotine, as it would an infectious agent, but merely binds to it, making it too big to get into the brain.  Given these departures, it seems best to think of "vaccine" as a metaphor rather than a literal use of the word.  With that in mind, I will just go ahead and use it without quote marks.






(Keep in mind when reading this that nicotine can be delivered in ways that, unlike smoking, do not cause substantial risk of actual disease.  However, that only amplifies the points I am making; this analysis would still be valid even if all nicotine use created measurable risk of disease.)

So, it is improper to think of this vaccine as something that destroys a disease agent, but how should we think about its impact?  I think it is best characterized as a way of changing your preferences, something that is often desired.  Having a preference for having different preferences, while a bit awkward to write and read, is not unusual at all.  I definitely prefer drinking Coke to water, though if I could switch how much I enjoyed them, I most certainly would:  I would prefer a world in which I liked water as much as I currently like Coke and vice versa, and would pay thousands of dollars to cause that change.  The reasons for this should be fairly obvious, as they are for the preference pattern that most of us experience sometimes, "I really want to take a nap (or play a video game, or whatever) right now rather than working; I wish I could get inspired to work".  Put another way, I might prefer to not work at a particular moment, but I would prefer to prefer to work.

Such preferences about your more basic preference ordering are called "second order preferences".  My colleague at THRo, Catherine Nissen, and I have thought a lot about this concept in the context of smoking.  It seems pretty clear to us that it explains several phenomena (though as far as we can tell, we are the only ones arguing this viewpoint).  One example is the disparity between the common claim that almost all smokers want to quit and the fact that they have not acted on that preference.  It is because the claim about preferences naively misconstrues a second order preference for a basic first order preference. 

The research that produces those "almost everyone" statistics represents standard tobacco research sloppiness, asking questions like "do you want to quit smoking?"  Anyone who is any good at designing surveys, or who merely read this post, should see the flaw in that phrasing.  A question like "would you rather smoke later today or not?" is well defined and if most smokers answered "not", it would be legitimate to say "they want to quit".  But the actual vague questions will often get translated by respondents into something along the lines of "compared to continuing smoking, would you prefer a future that includes you not smoking and being happy to be in that state?"  That is a question about second order preferences, and is no more realistically interpreted as "they want to quit" than my above observation can be read as "I do not want to drink Coke".

So, circling back to the vaccine, if someone has a second order preference to be a non-smoker -- he would prefer to be someone who prefers to not smoke -- but he really prefers to smoke rather than abstain because he likes the effect of nicotine, then he might choose the vaccine to align his preferences (the first order, or basic preferences) with his second order preferences.  The vaccine takes away the effect of nicotine which, in this scenario, leaves him no reason to prefer to smoke. 

There are two important complications with this:

The first is that the vaccine merely lowers the welfare from being in one possible state, using nicotine, without raising the welfare enjoyed in the alternative.  Indeed, such lowering is typically the only available option for reordering our preferences.  After all, if we had a chance to raise our welfare when in a particular state, then we would just do it.  Setting a loud alarm clock across the room does not make us any happier to be awake on time -- it merely makes continuing to lie in bed so unpleasant that it is no longer our preferred option. 

Notice how I phrased my second order preference about drinking Coke: how much I liked the two beverages would be swapped, so drinking water would become as pleasurable as drinking Coke is now.  That would be a win-win.  If there was an option to make that change, I obviously would have already done it.  So, if I wanted to "self-command" (to use Schelling's term) myself to give up Coke in the real world, if somehow I thought that I would be much better off without it but were unable to resist, the best I could hope for would be to make it unappealing.  There is no obvious way to make plain water seem that yummy.

So, the vaccine takes away the pleasure (focus, stimulation, etc.) you get from nicotine when smoking, lowering the benefits to the those you get from nicotine when not smoking -- that is, down to zero.  One's preferences are reordered by taking away benefits from one of the options.  This does not seem like a great deal.  It might be desirable, however, if someones second order preference for wanting to prefer not smoking to smoking was sufficiently strong.  He could rationally choose to take the vaccine, so long as he knew what he was getting himself into.  But he should be clearly told "you know how you feel when you don't smoke?  Well, if you take the vaccine, that is going to be how you feel, whether you smoke or not.  So, you will not want to smoke, but you will not have the option of feeling like you currently do when you smoke."

So, as long as that is honestly communicated, the choice is an informed autonomous one and could be rational.  (And we can have faith that physicians and advocates will make this clear, right?  Of course they would never gloss over the bit where the vaccine will not make you any better off when you became abstinent than you are when you abstain without the vaccine.)  Fortunately, the vaccine's effects appear to mostly or entirely wear off, at least when used for a short period, so if someone tried it once and discovered it was a mistake, they could reverse the choice.

That brings us to the second issue:  Most of the discussion about the topic is not about the rational adult making an informed decision, but about involuntarily inflicting the vaccine on kids.  Those proposing it tend to gloss over that "involuntary" bit, and failure to even address this is a serious ethical problem in itself.  But, of course, unless we are talking about a current user who is wanting to quit, this is the only interpretation.  Either the kid is already choosing to not use nicotine, in which case he would see no reason to accept the side effects, or he is currently choosing to use nicotine, in which case he would prefer to avoid the vaccine.

Of course, we take actions that restrict kids' choices all the time.  But there is something rather different when the method involves altering their bodies to make it impossible to enjoy a particular choice (and that choice is not "inflict violence on others" or "commit suicide" or something of that nature).  If the effect were permanent, I think this would be an ethical no-brainer.  I suspect that a permanent effect is the goal of those pursuing research on this vaccine, and inflicting that on someone would clearly be unethical.  No, that is too mild -- it would be utterly appalling. 

Consider the other example (the only other one I can think of) in which adults permanently alter the body of a child to prevent the child from engaging in a behavior that entails some costs, and where they (the adults) do not approve of the kids enjoying the benefits:  the mutilation of girls' genitals practiced in some African communities, which you have no doubt read about.  Before anyone who cannot follow a logical argument flips out, I will point out that I am not claiming that either the damage done or the loss of benefits from the vaccine is as great as that from genital mutilation.  But the motivation and implications are otherwise similar:  enjoyment of sex/nicotine by youth is considered evil by those in power for some reason; the benefits of sex/nicotine result in temptation that can be removed by altering someone's body to diminish the benefits; yes, the behaviors that are thus prevented can increase risks of disease, but this does not appear to be the genuine motivation (e.g., because there are other ways to avoid disease that the proponents oppose).  I suspect that never in my life have I had a conversation with someone who thinks that genital mutilation is anything other than appalling, so why is there no hint of such ethical concern directed at the nicotine vaccine?

There is a real difference to the extent that the vaccine's effects will wear off completely once someone reaches the age that they can make rational choices about their own health.  But even then, this is pretty scary ethical ground.  Plus there is no solid evidence that years of vaccination can be completely reversed. 

There is room to ethically defend the vaccine with an argument along the lines of the yet-to-be proven, "we have solid evidence that this will wear off in time for an adult to make her own choices" along with "teenagers using nicotine is so unacceptable because ... that we can justify altering their bodies to prevent it".  Or an argument could be made, "yes, we realize that this is basically like genital mutilation, but it differs in the following ways such that we think it is ok...."  I have seen no such justifications offered, presumably because (a) they would be utterly unconvincing and (not "or") (b) the vaccine proponents are so fanatical about their goals that they are unaware that there is any need to defend them. 

Until the proponents of giving the vaccine to kids admit that they are treading on very dangerous ethical ground, and upon recognizing that present a compelling argument to defend their position, I believe we have to consider this, alongside genital mutilation, as an unethical infliction of physical damage and loss of liberty on innocents, motivated by goals that are based entirely on quasi-religious beliefs that are believed only by a minority that happen to hold power over some children.  The term "vaccine" is a bit strained, but the term "child abuse" seems to apply unambiguously.

Most of you probably read something about the most recent study that concluded that eating red meat is bad for you (the one from a few days ago about all-cause mortality risk, not the one reported today that claimed red meat protects against depression -- I just can't keep up with all of them).  I was asked what I thought of a BBC article that tried to put the risk in perspective.  (h/t to Igor Burstyn for asking and discussing the answer)

First, to just mention a few points tangential to that:  Most nutritional epidemiology is among the biggest jokes in the field -- not as bad as tobacco research, but worst than most other subfields.  The big cohort study projects, like the source of this particular study, are notorious for publication bias.  In other words, had they not gotten the "right" answer, there is a good chance the result would have been censored, so on average the results overstate the case for the consensus beliefs.

Additionally almost all nutritional epi is based on "food frequency questionnaires", which ask dozens or hundreds of questions about what someone eats and are notorious for having a huge amount of measurement error (i.e., the data might be useful, but it is always quite wrong).  Have you ever noticed almost every such study takes pains to point out it was a validated food frequency questionnaire.  Notice that they never tell you what this impressive-sounding adjective means.  (Hint: it means that one time they checked to see whether the instrument produced results close to those from some more careful measurement method; notice that they never tell you how that checking worked out.)  One of the more inside/subtle jokes in my "tobacco candy" research parody was a dig at the silly term "validated food frequency questionnaire".

That said, the observation that meat seems to be bad for your longevity and red meat seems to be worse than average has been replicated enough that it is unlikely to be wrong.  Indeed, in despite the new round of headlines, the new study really told us nothing new -- which means that it stands a much better chance of being approximately right than something that made a novel claim.  So, for today, take the result as True and see how people did at explaining what it means.

The main result was that eating red meat increases the hazard rate for dying by 13% for each serving-per-day that you eat.  (I am going to set aside the fact that that fixating on the exact 13% implies far more precision than the research provides -- a common error of those who do not understand study error.)  Note that this is very different from a lot of the results you see in epidemiology in several ways:  

• That "hazard" thing means that whatever the risk of having died would have been this year or next year, it is increased by 13%, and that continues for future years.  It does not just mean that the chance of some bad thing occurring sometime in your life has increased by 13%.  (Note: usually studies that calculate this "hazard ratio" just assume that this pattern -- the same x% change every year -- and force the data to fit it.  In the present case they actually tested that assumption but allowing the curve to wiggle, and while it was clearly not a perfect fit, it was not terribly wrong.)

• Often risks you hear about are an increase in the chance of getting one particular disease, often one that is rather rare, while this is about an increase in a risk for mortality in general.

• The reported change in risk was for a realistic level of change in behavior that someone could make.  Indeed, they could move by multiple increments, like going from 3 servings down to 1, for two increments of benefit.  This contrasts with many studies that only report the comparison of those with the greatest exposure to those with the lowest exposure (ignoring the majority of the population in between), so someone could only see the theoretical change described if they were at the worst extreme and somehow could move clear to the other extreme.

Taken together, that makes this a stand-out risk but the standards of single-item behavioral choices.  It is a lot smaller than that for complete lack of exercise, smoking, or many other patterns of drug use.  But it is a lot bigger than almost every other hazard, like transport, most drug use, and other nutritional choices.

So props to the BBC for taking it seriously and trying to put it in perspective.  Too bad about the answer they got:
The easiest way to understand it is to think of how this might affect two friends who live very similar lives, according to David Spiegelhalter, a Cambridge University biostatistician, and the Winton Professor of the Public Understanding of Risk.

Imagine that the two friends are men aged 40, who are the same weight, do the same amount of exercise and do the same job.  The only difference between them is that one eats an extra portion of red meat every day - an extra 85g, or 3oz.  "Let's say that every work lunchtime one of them had a hamburger and the other didn't.  "What the study found is that the one who likes the meat had a 13% extra risk of dying. They're both going to die in the end, but one has got this extra annual risk of dying."So far, that really adds nothing, other than maybe explaining "hazard ratio" and telling you what "a serving" is, if that jargon was neglected in a news report.  So, continuing:
But what does that extra risk amount to in practice - for these two average people? The paper doesn't say.  Spiegelhalter has been working it out.

"The person who eats more meat is expected to live one year less than the person who doesn't eat so much meat. You'd expect the 40-year-old who does eat the extra meat to live, on average, another 39 years, up to age 79, and the person who doesn't eat so much meat, you'd expect him to live until age 80."

So all those headlines, and it turns out we are talking about whether you might live to age 79 or 80.  Maybe you feel willing to sacrifice that year in order to enjoy a life full of roast beef and steak sandwiches.Unfortunately, that simplification, though tempting, is not a very useful way to think about this risk.  Indeed, it is quite misleading.  Someone might well make the suggested choice, to sacrifice their 80th year.  But that is not the choice.  The choice includes having a 13% greater chance than your peer of losing your 50th year (and every one thereafter).  Obviously this is still unlikely -- a 13% increase in dying at that age still results in a small increase because it is merely 1.13 times a fairly small risk -- but it might result in different motivation.  Most people are a lot more willing to give up a year of old age than risk the same expected value (statistics talk for "the probability averages out to the same total") of loss across their middle and old age.  Whatever the merits of that preference, it is the predominant preference, so saying "don't over-worry about it -- it is just one fewer years of retirement" understates the real risk.

But the story is not over yet.  The BBC and their consultant go on to propose an error that probably tends toward the other direction to make up for this:
But Spiegelhalter says there is another way to look at the statistics, which might make the issue seem more urgent. That one year off the life of this 40-year-old hypothetical burger eater is equivalent to losing half an hour a day.

"On average, when he's sitting eating his extra burger, that person is losing half an hour of life because of that meal. On average, it's equivalent - scaled up over a lifetime - to smoking two cigarettes a day, which is about half an hour off your life.That may well make it seem more urgent for some people -- but too much so.  Someone who is urgently trying to succeed in school, launch a business, or be a single parent might rationally consider half an hour a day right now to be incredibly urgent, such that they would gladly borrow it from the later in their life.  (I have certainly had those years.  You?)  The loss of half an hour per day would thus be enormously more daunting than a 13% hazard ratio, let alone losing her potential last year. 

On the other hand, many of us who are pretty secure in our day-to-day performance might choose to trade a half hour per day, or even several hours, for getting to see how the next generations turn out for a few extra years (assuming our healthfulness over the years averages out the same).  So this simplification does not work either, overstating the loss for someone who is intensely busy with important stuff, but perhaps understating it for others.

The real mistake here, I believe, is assuming that this is something that people cannot understand if you tell it straight.  Many percentages require some kind of "professor of public understanding of risk" treatment because the risk is of a magnitude that people cannot understand.  People do not understand how truly small something like "a 54% increase in lifetime risk of esophageal cancer" is, and so resorting to one of these misleading simplifications might be an improvement over "ooh, 54% is a big number! -- that must be bad!".  Even worse are environmental exposure risks that are down in the one-in-a-million range; telling someone, "the total lifetime risk from this adds up to losing a minute and a half off the end of your life" is useful because it transforms "there is a risk!!!!" to the rational "oh, never mind."

But the red meat risk is actually big enough that people can understand the numbers and might legitimately care about the difference.  If you tell someone "based on your demographics, there is an X% chance you will die before age 65, and if you eat one fewer servings of meat per day, it will drop to X/(1.13*X)% those are numbers someone can understand.  They would be in the order of 4% and 4.4%.  Ok, not everyone will be able to understand that, but anyone who cannot probably cannot make much sense out of the suggested equivalencies either.

So, if the BBC and their Cambridge consultant cannot figure out how to sum that up, who can?  Credit to Rob Lyons at Spiked:
The authors claim that 9.3 per cent of deaths in men and 7.6 per cent of deaths in women could be avoided by eating little or no red meat. To put that into some back-of-an-envelope statistical perspective: multiplying that 9.3 per cent by the 20 per cent who actually died [by age 75 during the course of the study] shows that about 1.8 per cent of red-meat eaters would die by the time they were 75 because of their meat-eating habit. Even if that claim were absolutely accurate (and even the authors call it an estimate), would you really give up your favourite foods for decades on the slim possibility of an extra year or two of old age?Often the answer is "yes", of course, despite the implication of the phrasing.  Indeed, if you are going to change your behavior to try to live longer, as many people try to do, this change may well have the greatest benefit:effort ratio available.  But that aside, if you ask the question this way (and perhaps extend the same calculation to give the numbers for ages 65 and 85 also), you are answering the right question when you make the choice.

I have five somewhat complicated posts I would really like to write, so naturally I am going to take the easy way out and write a quick and easy one based on today's news.

The inventor of Red Bull (the original Thai concoction, as well as canned phenomenon), Chaleo Yoovidhya, died.  Sorry, no irony about it being sudden cardiac death at an early age -- he lived a full life and sounds like he was generally an impressive guy.

Not so impressive is the press's persistence in talking about his invention as if it were about caffeine.  For example, this NYT article.  At least there is some mention of the what is really different (and perhaps risky) about the drink, though it was subordinated to the caffeine:
...a beverage that was loaded with caffeine, as well as an amino acid called taurine and a carbohydrate called glucuronolactone.However, this appeared in the third paragraph after caffeine (only) was already highlighted in the first paragraph and was emphasized again later.

Those of you who remember my posts about Four Loko and other alcoholic versions of Red Bull will recall me railing about the proposed pathetic, silly, paranoid, out-of-touch, unscientific prohibitionist proposals (we need a name for the construct "pathetic, silly, paranoid, out-of-touch, unscientific prohibitionist" -- it is rather unwieldy but it comes up so often), which focused on the combination of caffeine and alcohol.  The politicians, commentators, and, yes, the health reporters seemed completely oblivious to the fact that what made these drinks different from any other soda were those other stimulants -- you know, the ones for which we do not have billions of person-years of data about the effects.

The Red Bull obituary author, as is typical, seems to think it is mainly about the caffeine.  Twice as much as in Coke!  Wow, hold on to your socks if you drink that.  It will be like what happens when you tell a waiter "I'll have another Coke".  And you know that once you do that, you will probably finish the evening at an all-night dance party, screaming at the top of your lungs -- unless your heart explodes first.

Or, put another way, that much caffeine is like having a cup of coffee as you sit down at your desk in the morning. 

At least this article gets credit for mentioning the other stimulants, the ones that are the difference between Red Bull and coffee.  NYT obit writers are rather better than most health reporters.  Still, it would have been nice to see something about health other than one throw-away sentence that invokes an old newspaper article that warned about mixing Red Bull with vodka.

Can you imagine an obituary about someone involved with inventing or promoting snus or e-cigarettes not spending paragraphs about the controversy and made-up health claims?  And yet everything we know suggests that Red Bull is probably more hazardous for your health than either of those products.  We will presumably never have definitive epidemiology to support that claim, but the smart money would be on that conclusion if we had a sealed envelope from an omniscient being who could settle the bet.

Of course, if Mr. Chaleo had become the 205th richest man in the world (yes, really) in part by selling an alcoholic version of Red Bull, rather than leaving that innovation to others, you can bet that the danger of that evil product would have been the focus of his obituaries.  I really do hope that taurine and glucuronolactone and other under-studied stimulants are not damaging anyone's cardiovascular system, but I am pessimistic enough that I am going to stick with the well-studied drugs -- i.e., all the other ones that are mentioned in this post.

H/t to @cjsnowdon for pointing out the BBC article reporting the oh-so-shocking turn of events, that bans on shisha cafes (hookah bars) have resulted in them going underground.  I mean, who would have ever thought that banning the social component of a popular legal activity might cause people to gather clandestinely instead?  Or that by banning something, the ability to properly regulate it -- e.g., to minimize fire risk -- would vanish?

But what struck me about the article was the claim,
The World Health Organization has advised that a 40-minute session on a waterpipe is the equivalent to the volume of smoke inhaled from at least 100 cigarettes.Yet 84% of those surveyed thought it was fewer than 10.Now maybe Sarah Sturdey (the author of the article, who deserves to be shamed by name for this) could have just transcribed that first bit from somewhere without engaging her brain at all -- basic reporter behavior.  But you would think that immediately following it by a radically different belief would cause her to think "wait, do I believe that?"

The WHO claim is pure fiction.  It is an n-th generation telephone game miscopy of some claims that were basically made up from whole cloth, tied to a tiny bit of reality.  Snowdon wrote an extensive report about the apparent provenance of the disinformation, I have written a couple of brief comments about it, and there are plenty of other analyses out there too.  But let's set aside the crazy option of Ms. Sturdey doing some research before writing her article, and just consider what would happen if she had a third-grader's command of math and had thought about what she was writing during a quick trip to the restroom (or rather, I suppose, it would be the loo):
Hmm -- "volume of smoke inhaled".  To smoke 100 cigarettes in 40 minutes would be more than two per minute.  That is much faster than anyone smokes, and indeed would require more total inhaling then someone normally does in that much time, and for every breath to be smoke.  That is close to physically impossible.She would then have time during her inevitable hand washing -- she is a health reporter after all -- to think:
Smoking even 10 cigarettes in 40 minutes would require about 1/5th of all breaths to be a solid drag.  Smoking that much that fast would be an extreme intense session, whatever was being smoked.    Gee, maybe "those surveyed" are not morons after all.Notice that this requires no subject matter knowledge about the relative harm of a lung-full from a cigarette as compared to a hookah.  Someone could believe the common claim that hookah smoke is much worse for you (an absurd claim, given what we know about heat-not-burn smoking, and one not supported by any evidence), but still be able to do the simple "volume of smoke inhaled" arithmetic.

Frankly, I am a bit concerned about the 16% who thought that it was typical to smoke a greater volume than 10 cigarettes' worth in 40 minutes.  But I guess that is why society has a place for people who are just really bad with numbers and are willing to make claims about matters they are clueless about, like taking a job as....

[You know, just forget it.  It is too easy a parting shot.  I will just let readers finish the sentence themselves if they want.]

The health science aspect of the story has hardly been mentioned, but it should be.  And besides, how can anyone resist writing about this story, even if in the form of a few disjointed snippets.

The story in question is that Republican Wisconsin state senator Glenn Grothman has proposed a bill that would define being a single mother as a "contributing factor" in child abuse.  As far as I can tell, the main implication of this would be that state anti-child-abuse messaging and such would start delivering this declaration.  There might also be some implications for court cases where "contributing factors" are being considered.  The proposal would fortunately not declare that single motherhood is child abuse, in spite the inevitable misinterpretations to that extent (example).

Given that inevitability, though, you have to wonder what Grothman was thinking.  One might think that this is a publicity ploy.  But he is already notorious in his home state, because of his prominent role on attacks on collective bargaining and the other issues that have turned that state's government into such a mess, so there is not much notoriety to be gained at home.  Maybe he is going for national-level loonyness, angling to be Santorum's VP pick or something.  (This was before Tuesday's primaries that pretty much assured Romney of the nomination.  Of course, simple biology means that Santorum still has a chance:  If I could be a major party's nominee for president if and only if my 64-year-old opponent died in the next few months, I would stick around and take that shot.  Well, I would if I wanted to be president anyway -- what a bad idea that would be, huh?)

As you might guess, the outcry against this is coming from the American political left.  Yet once you get past the naive outcry that misinterprets the proposal, it actually looks remarkably similar to the wars on drugs/tobacco that are pushed by the Democrats and increasingly opposed by the right-wingers. 

Note: in pointing out that most of the outcry is naive, I am not implying that the outcry against the proposal that was actually made is not justified -- I certainly think it is.  But just because someone is attacking a bad idea does not mean they are right.  Also, I sympathize with those who cannot figure out what is actually being proposed and claims, given what an utter muddle the press coverage has been.  I had to read a half dozen different reports before I started to figure out what was really going on.  On the other hand, without that, I might have missed such gems as "single mothers far outnumber single fathers in the state and in the rest of the country".  (Yes, I realize that the "outnumber", though not the "far", is probably true, since some unsavory men make a disproportionate contribution; also I realize that they almost certainly failed to notice they had meant to say "custodial" but left it out.  Still, it is pretty funny.)


One of the underlying claims used to justify the proposal is certainly true, and has been known for quite a while (despite implications in some of the coverage that this is a new discovery):  A child is an order of magnitude more likely to be physically abused by a male partner that is living with him and his mother (regardless of marital status) as compared to the risk of abuse from the biological father.  No doubt that biological instinct, the socio-demographics of the women in that situation, the types of men that are more willing to enter into that situation, and other factors all contribute to that.

So, by the standards of modern "public health" making a choice that has negative health effects -- no matter how strong the motivations or how difficult the alternative would be -- deserves to be condemned, aggressively "educated" against, stigmatized, and when circumstances are just right, to be actively punished.   If good, honest, healthy, hard working, moral Americans are going to be subsidizing these no-good smokers/unwed mothers/fatties/junkies, then it is only right that we make it clear that they should shape up. 

Remember back when "public health" identified people at high risk of disease and tried to fix the problem rather than fixing the people?  Actually, I don't either.

What makes this worth writing about in this series  is that it is such a perfect case of identifying a problem (child abuse), identifying a condition that is strongly associated and almost certainly does cause some of it (single motherhood), and then trying to address the problem by trying to punish the condition.  Keep in mind that a government banning, discouraging, and condemning are fundamentally the same thing, differing only in the quantity of punishment imposed for not conforming.

Note to politicians/FDA/DEA/police/etc.:  You need to punish people who do things that hurt others but enrich themselves, like armed robbery, banking, or factory farming.  You do not need to punish people for things that hurt themselves (and their immediate families) far more than they affect anyone else -- they are already suffering plenty of incentives to not be in that condition.  Since, in spite of those incentives, they are choosing that condition as the best of their alternatives, perhaps you might want to try to help by creating better alternatives or by improving that condition.  Of course, some people argue that you have no business at all involving yourself in those personal/family matters.  But even if you do not buy that, how the hell do you justify actively trying to make someone's personal situation worse, so that a previously inferior alternative starts to look better for them?

By saying that, though, I risk being as bad as the press coverage of this matter, just looking at some extreme or our-team-vs.-their-team aspect and not delving into the interesting legitimate issues.  There is a scientific literature that suggests that a highly-imperfect (though not disastrous) two-parent family is better for kids than the alternative, which means that its positives incentives can be created for staying together in spite of the imperfections, action might be warranted.  It is also worth working to try to reduce the abuse from (obviously a small minority of) non-biological father figures.  Some serious exploration of where to draw the line to maximize welfare would also be interesting (and I am sure it has been done -- this is just way outside of my areas of great expertise).  Leave it to the press (at least the 20+ reports and blogs I read) to fail to grapple with any of this.

I was also a little disappointed that no one thought to characterize the proposal as the Santorum approach to single motherhood (condemning and punishing it without offering a solution) and suggested that an alternative would be the Romney solution: allowing polygamy to make up for the shortage of available father figures.  So I guess that is up to me.  (And before my oh so many Mormon readers write to me about that, yes I know, the official LDS church no longer supports polygamy etc. etc.)

Finally, in case what I have written about the issues made the political action seem balanced and thereby suggested that Grothman is not toxic, misogynistic, evil, or loony (and that is not an exclusive or), I should mention that looking at his full agenda makes it clear he is trying to punish single parents and their kids.  He all but says that women become single parents to cash in on the sweet deal offered to them by the state (he apparently thinks he is living in Sweden, or at least Massachusetts -- dude, you live in fracking Wisconsin, and what you offer is a sweet deal only in comparison to central Africa and Afghanistan).  He calls for making public-supported housing more cramped, forbidding those on housing assistance from accumulating more than than a trivial amount of material goods (a limit set so low that someone would have a hard time owning a laptop and mobile phone to try earn a living), and denying those on assistance the right to school choice (it really says something when a government official basically says that forcing someone to attend the public schools is a good way to punish them or at least incentivize them to get off of assistance).  He also has apparently fought the notion that the logic of his position calls for making contraception more available, and takes a Limbaugh-esque position on the matter.

I notice that most every article on the topic notes, without further comment, that Grothman, who appears to be about 55, has never been married or had kids.  This is in spite of his clear commitment to family values (*cough*).  Hmmmmm?  It is too bad that beating up on single mothers is not an "outable" offense.  (For those who do not know, some gay advocacy groups keep files on which politicians and officials are in the closet, and makes clear that such choice will be respected -- so long as they do not take official actions that are actively harmful to GLBT community.)

Oh, wait:  This would apply to all lesbian mothers.  Oh, this could be fun.

[As is probably clear from the title, the primary purpose of this post is as a pre-read for a class.  However, I have composed it so that my regular readers might also find it interesting/useful/entertaining to read.]

Overview:  Epidemiology exists almost entirely to aid in decision making.  Other sciences seek timeless knowledge or to fulfill deep curiosity, but almost every result in epidemiology varies wildly across popular and circumstances, and is frankly not all that inherently interesting.  Yet epidemiologic analysis and education typically ignore most of what should be considered when making a decision.  This is a very (very! -- I would normally spend 30 class hours on this, not 2) brief skate through the considerations that need to be part of any policy recommendation or decision that is informed by epidemiology.

1. If you only come away from this with one lesson, it should be:  Any statement in a research paper (or a press release, or anywhere else) that paraphrases to,
This study demonstrates that E causes D, and therefore we should....is wrong.   No example reading for this; you have seen it hundreds of times.

Perhaps even worse is the phrase "unintended consequences", as it is typically used with "might exist" phrasing.  Together, such statements call into question the intellectual integrity of not just those who write them, but any field in which they are common in the journals.

2. Every policy, proposed or existing, has costs (aka "unintended consequences").  Almost every policy has benefits (ideally that would also be "every", but there are some really stupid policies out there).  "Should" statements require a consideration of all of those costs and benefits, as well as the ethical standards and quantification needed to trade them off.  Generally, about 95% of that is missing from epidemiology papers that conclude with "...should...".

3. Group exercise breakout:  List the important costs and benefits that should be considered when making policies related to the background readings: installing IWTs; promoting THR; giving the nicotine "vaccine" to teenagers (optional if you have time: other anti-smoking measures touted to the press by Gartner et al., at the end of the popular press article).   Just list them -- do not attempt to compare or quantify.  Hint: costs and benefits are just words that both mean "resulting changes in the world that people care about", and differ only in sign; figuring out the sign for a particular change is useful, but identifying what changes is the first step.

Background readings:

(a) Industrial Wind Turbines

• Random news story from this week that gives pretty good background on the subject
• My paper about the health effects
• (Optional, in case you want to learn more about the topic sometime: an hour-long talk I gave that covers the breadth of the issue, not just health; more on health here; more in general here)

(b) Anti-smoking methods

• FAQ re concept of Tobacco Harm Reduction (a bit outdated and simple, but useful if you have never even heard of the concept)
• Gartner et al. (2012) Would vaccination against nicotine be a cost-effective way to prevent smoking uptake in adolescents?
• What Gartner said to the popular press (aside: it is always an interesting exercise to observe how this differs from what the paper actually looked at)

(c) A bit of each

• Strangely, not only do I work on both of these unrelated topics, but the world's most unhealthful professor of public health is active on the wrong side of both

4. A ridiculously brief discussion of public health policy ethical considerations (but probably more than you will get in your public health ethics class):  What costs and benefits should be considered when making a policy recommendation?  What other ethical concerns should also be considered (hint: think about the non-childish bit of the American "pledge of allegiance", the last few words).

5. How can we deal with difficult-to-compare and completely incommensurate considerations:  money spent vs. lives saved; present vs. future; rights vs. consequences; the needs of the many vs. the needs of the few?

6. Group exercise breakout:  Pick one of the policy decisions that is addressed in the readings and sketch out (very brief and abbreviated, of course) what you would want to consider in making a decision or recommendation.  Identify quantifiable factors you would want to quantify (using epidemiology or other methods).  Identify tradeoffs that are not merely matters of adding-up that need to be considered (extra if you have time: Discuss how you might try to deal with one or more of the tough tradeoffs).

under review at Tobacco Command
(29 Feb 2012)

Demonstrating that children believe that deadly tobacco products are harmless candy, an experimental study

C.V. Phillips, P.S. Heavner-Phillips, I.Q. Burstyn, P.L. Bergen
Populi Health Institute, Wayne, Pennsylvania USA
UASPH, Edmonton, Alberta Canada


Abbreviations
FDA = United States Food and Drug Administration
NRT = Nicotine Replacement Therapy
OR = Odds Ratio
OTC = Over the Counter
QUANGO = Quasi-non governmental organization
SES = Socioeconomic Status
TCACS = Tobacco Control Alarm-Call System
UASPH = Unaffiliated Alberta Scientific Public Health researcher

Figures and Tables
Table 1
Figure 1
Figure 2


Abstract
Background: There has been concern expressed about children mistaking smoke-free tobacco products for candy.  There is evidence that anyone doing a study on the topic will have a inappropriately great influence on policy, and meta-regression suggests an inverse association between study quality and impact on public health discourse.
Methods: Children of aged 15 months to 15 years were presented with a tableau of smokeless tobacco products, along with benign alternatives like candy, breath mints, dietary supplements, and medicine.  A second experiment presented the younger children with sippy cups that contained water, nicotine solution (e-cigarette refill liquid), and other liquids.  A third experiment presented the older children with selected products in de-branded original packaging.
Results:  The children could not distinguish between tobacco products and candy (p=0.86).  The younger children were more likely to reach for a cup of nicotine solution than a cup of water (OR=2.2645, p<.0314).  When products were presented in their original packaging, subjects successfully identified medicine, but half the tobacco products were still most often identified as candy.
Conclusions: Smokeless tobacco products should be stored with the same care recommended for other somewhat hazardous items found in the household, rather than displayed on plates or stored with candy.  Children should not be presented with toxic substances in contexts that send the message they should eat them, and should not be told to think of them as candy. 


Introduction
Dissolvable tobacco products consist of finely ground or powdered tobacco in a confectionary base that are held in the mouth while they dissolve, thereby delivering nicotine and perhaps other psychoactive alkoloids in a similar manner as other low-risk oral smokeless tobacco products.  These include products that have been available in the United States for about a decade (Stonewall and Ariva lozenges), as well as several new products that have entered the market or are expected to do so soon (new lozenge and toothpick-shaped products from the tobacco companies RJ Reynolds and Altria).  None of those products have sold widely to date.  However, trend analysis by TCACS indicates that the major-brand products will gain in popularity.  Moreover, one popular form of dissolvable tobacco product that is known by the street name "NRT" or "nert", which are the same as the others except that the nicotine is extracted from the tobacco and then put in the confectionary base, are already widely consumed.

There has recently been an explosion of organized concern about the risk of accidental poisoning of children who mistake dissolvable smokeless tobacco products for candy.  It is already known that that young children may be at risk of ingesting small objects that come within their grasp.  However, since tobacco is completely unlike any other consumer product, previous research on other products cannot be considered informative.  The nicotine lozenge variants of dissolvable tobacco products have already been implicated in a significant number of toxicant exposure events, which suggests that there is risk that one of the tobacco company products might someday poison someone also. 

Several previous studies demonstrate that there is a view that the public health community should encourage worry about the poisoning risk:

An anti-tobacco QUANGO of the Virginia state government calling itself "Virginia Foundation for Healthy Youth" issued a press release [1] reporting that when teens were presented with dissolvable tobacco products without any context, they often thought they were mints or candies.  While it might be considered a minor limitation of the study that the methods and actual results of the study were never reported or that the research was designed and conducted by high school students without any apparent supervision by scientists, the subsequent wide coverage in the popular press confirms that it was credible, important, high-quality research.

The Indiana Department of Health has mined social networking comments and otherwise gathered comments from teens about dissolvable smokeless tobacco products.  Some commentators have expressed concern that they have never reported their methods and their results appear to be unrepresentative cherry-picked out-of-context quotes.  However, these concerns can be ignored because the importance of this research is demonstrated by the production of high aesthetic quality slideshows that have generated repeated invitations to report to government agencies and public health gatherings [e.g., 2]. 

Additionally, there is even one study where a vague description of the methods and results was published, though unfortunately it has still never appeared in a scientific journal [3].  The study, from a research group calling itself "Harvard School of Public Health", was widely cited in the popular press.  (Note that while this organization does not seem to be related to the prestigious research institution called "Harvard University", the allegations in the literature that it is actually a lobbying front group for shadowy government agencies and industry have not been proven, and so cannot be considered a reason to doubt their research.  Thus, we consider their work to be just as credible as the other studies cited herein.) 

News reports, based on the highly touted press release from the "Harvard" study authors, indicated there was a dire risk of accidental poisoning from "tobacco candy".  One possible limitation of this work is the almost complete lack of correlation between the study results and the claims touted to the press (p=.984).  For example, popular media reports based on what was communicated to the press by the research team leader include the claim that "600 children a year" are poisoned by "tobacco candy" [e.g., 4], though this differs (p<0.001) from the actual study results by 600/yr.  This lack of correlation should be interpreted as further evidence of the seriousness of the public health worries.  Creating fear as a substitute for evidence is a standard invocation of the Precautionary Principle, which should be applied in situations where it appears there will never be enough evidence to support the necessary warnings.

Related research from several government and activist organization has looked at children's perceptions of flavored (though not necessarily dissolvable) tobacco products.  For example, work conducted by the Utah Health Department used an innovative method in juvenile research, in which a researcher disguised as Santa Claus first tricks the children into thinking they are in a benign situation, and then warns them about the dire risk the researchers just exposed them to [5].

There is evidence that these results are being taken very seriously.  For example, a spokesperson associated with the Indiana studies was invited to present for half an hour at length at recent FDA hearings on dissolvable tobacco products, while the experts on the public health benefits of introducing new low-risk tobacco products were restricted to three minutes each.  The lead author of the "Harvard" study is frequently invited to participate in policy discussions, including in some forums that normally restrict participation to people who draw only those conclusions that are related to their research results.

A group of US Senators recently wrote a letter to the FDA urging removal of a "dangerous loophole" about dissolvable tobacco products [6].  Once again, concern was so great that the fact that the "loophole" was irrelevant to the concern (it was a legalistic trick by FDA to delay acting on a statutory requirement that they recognize certain products as less harmful than smoking) and the "solution" did not address the "danger" (the matter had no relevance to whether young children could be given access to the products) posed no obstacle to decisive action by respected politicians. 

Given that concern about this matter is so intense even in the absence of supporting evidence, it is clear that this is an important public health issue.  It is established practice in modern public health that the assessment of a risk is most reliably determined by those who express the most concern.  This is especially true in cases where, if action is not taken immediately, the concern might be proven unfounded.  Thus, a public health activist Code Gamma Alert has already been issued, including the monthly television news stories and invoking of the mandatory opinion-alignment rules for professors at public health schools and employees of public health advocacy organizations. 
[CARL, WE ARE NOT SUPPOSED TO TALK ABOUT THE ACTIVIST ALERT SYSTEM. YOU SHOULD PROBABLY TAKE THIS OUT BEFORE WE PUBLISH.]

While further evidence may be unimportant now that policy action is underway, we were curious about whether the results about children confusing dissolvable tobacco products with candy could generalize.  In particular, we were interested in whether they could be replicated in a scientific paper authored by real researchers with scientific skills.

Methods
A convenience sample of 42 children, aged 15 months to 15 years was recruited.  They were divided into the "younger" (n=25) and "older" (n=17) subsamples based on a cutpoint of age 7 years, as measured by a validated birthday frequency survey.

In the first experiment, a tableau was created that included a collection of the candy and candy-like items listed in Table 1.

-------------------------------

Table 1. Product list

Dissolvable Tobacco Products
Ariva (Star Scientific)*
Camel Orbs (RJ Reynolds)
Nicorette Lozenges (GlaxoSmithKline)*
Nicorette Mini-Lozenges (GlaxoSmithKline)*
Stonewall (Star Scientific)

Medicines and Supplements
Pepcid AC 10mg*
Tums Extra-Strength tablets
Vicodin*
Zicam Cold Remedy "homeopathic"*

Candies
Junior Mints
M&Ms dark chocolate mint
Mentos mint*
Skittles*
SweeTarts giant chewy
Tic Tac mint*

All listed products were used in the first experiment.  Those noted with * were also used in the third experiment.
Brand names are given for identification purposes only and do not represent an endorsement of any listed product.

-------------------------------

Each subject viewed tableaus of 10 items.  The first that was presented included positive and negative controls.  The positive control consisted of a marshmallow Peep candy, chosen because of its history as a model species in research [e.g., 7].  The negative control was a rubber ducky.  The other items were chosen at random in each trial, thus eliminating any bias that might have been created by the grouping of particular products.  An example of one of the the tableaus, as presented to the subjects, appears in Figure 1.  The objects were always arranged in an attractive pattern (e.g., the circle in Figure 1); this served no scientific purpose, but it amused us. 

Figure 1.  Example of one random tableau from first experiment

Note: Pictured items are, clockwise from bottom center (numbers correspond to order of list in Table 1): 14, 12, 11, 3, positive control, 9, 4, 7, negative control, 6, 13.Older subjects were individually presented with a tableaus and asked "what are these items"; if answers were not provided for each item, they were prompted to respond about the remaining items.  A second tableau was then presented, for a total of 20 observations (which generally included some duplicate items) per subject.  Results were recorded as open-ended answers and coded as "candy" if the the word "candy", "mint", "breath freshener", "sweet", "sugar", or the product name of a specific candy was offered as part of the answer.

The younger subjects, for whom the former methodology would not be age-appropriate, were grouped into pairs and presented with a tableau.  The were asked "candy! who wants candy? pick out a piece of candy!"  Results were recorded for which items were reached for or picked up.  After grabbing ceased, another tableau was presented and this was repeated until a total of 20 grabs were recorded.  When some pairs of the younger children demonstrated hesitation about reaching for any of the objects, the protocol was quietly rewritten to require that the researcher reach for and pretend to eat a random (non-ducky) item until the children complied.

A second study expanded the target of the study to include e-cigarettes.  The failure to ban these new devices, so far, demonstrates that more research is needed about them and their components.  The younger subgroup were presented with six sippy cups, that contained (pictured from left to right in Figure 2) e-cigarette refill liquid (a 6mg/ml nicotine solution), water, vodka, antifreeze, fruit juice (white grape), and e-cigarette refill liquid (a 20 mg/ml nicotine solution).  Inclusion of milk and soy-based formula were considered, but concerns about the allergies mandated their removal.  Coke and Sunny Delight were also eliminated from the experiment because of the recent discovery that sugary drinks are the world's most dangerous public health threat.  The cup(s) that each child reached for or picked up were recorded.  Picked-up cups were immediately removed from the children's hands and returned to the tableau.  Children that started crying at that point were removed removed and thanked for their contribution.

Figure 2.  Sippy cup arrangement

Note: Contents ordered as listed in text. For the third study, the older subgroup were presented with some of the products (noted in Table 1) in their original packaging, with the branding and labeling information obscured with olive-green paint or tape.  A disposable e-cigarette that closely mimics the appearance of a real cigarette was added as a positive control.  Subjects were then asked to classify each into the categories candy/mint; medicine/vitamin; tobacco product.

No incentives were offered to the study participants, no matter how much they begged (though the Junior Mints and vodka mysteriously disappeared).  All of the recovered study materials were disposed of following appropriate biohazard protocols.  The liquids were returned to their bottles; most of the solid objects were consumed by the research team; the drooled-on products from the young children tableaus were autoclaved and put in the municipal trash (there was no budget for analyzing biological samples); the NRT products, considered too unpalatable to consume but too expensive to throw away, were saved for future research.  A count of the tobacco and medicine products revealed that approximately all of them had been recovered from the children (the measurement error was at a level that does not affect the study results).

Statistical analyses were conducted using SAS (vers. 9.1.3, SAS Institute, Cary NC), the preferred choice for researchers who want to show off that they are real scientists, but do not understand the statistics they are using well enough to just do the calculations in the spreadsheet where they recorded the data.

Results
During the first experiment, five of the youngest children had to be dropped (from the experiment).  Two refused to participate, wandering away and/or crying.  Two others were apparently unfamiliar with candy, and thus did not produce reliable results.  Another seemed to be claiming that every object in the tableau was a cat. 

The remaining 37 subjects completed the first experiment, and all members of the younger and older subgroups completed their other experiment.

Subjects in the older subgroup all correctly identified the negative control (rubber ducky) as something other than candy/food, and 16 (94.1176%) correctly identified the positive control as either "candy", "a Peep", or "those things are so gross".  The younger children were more likely to pick up the Peep than the rubber ducky at a rate that was borderline statistically significant after correcting for latent confounding by race, gender, and SES (p<0.1).  Older children were more likely to volunteer an observation that the experiment seemed to be designed to intentionally trick them (p-value for trend = 0.03 after correcting for mutations in the data).

In the first experiment, the rate at which the tobacco (82%) and other non-candy products (78%) were identified as candy was the same as the rate for candy products (86%).  The faster grabbing younger children demonstrated a preference for the larger items, but the trend did not achieve statistical significance.  However, at a statistically significant rate, the older children identified the Vicodin (which had a distinctive pill shape, including scoring for breaking in half) as non-candy.  The older children also identified the Stonewall (which has a color and shape that are unusual for candy) and Pepcid (smaller than most candies) as non-candy more often, but the difference was not statistically significant.

In the second experiment, the younger children were significantly more likely to reach for a nicotine solution cup than any of the other liquids.  Compared to water, the odds ratio for reaching for the nicotine was 2.2645 (p<0.0314).  The other liquids were chosen at rates that were statistically identical to the water.

In the third experiment, all of the older children recognized the positive control as a tobacco product and the Vicodin (in a prescription bottle) as medicine.  For other non-candy products, most identified them as something other than candy: 94% for the Ariva and for the Pepcid (both are in a distinctly medicinal blister pack and do not look like typical candy).  65% identified the Zicam (in a distinctive supplement pill style OTC bottle) as non-candy and 35% as candy; given that it is a fruity sugary tablet, sold as homeopathic remedy, it is not clear who is correct, and in retrospect we realize that its inclusion in the study introduces unnecessary ambiguity.

Most important, for several tobacco products with the labels hidden many subjects still thought they might be candy, including 53% for Orbs (in a unique package, clearly meant to be childproof, but not similar to packages normally used for medicines) and 94% for the Nicorette products (non child-proof packages that are quite similar to mint or candy packages).  One subject appeared to subconsciously mimic the Nicorette television ad where a consumer jauntily pops open the plastic tube with his thumb and smoothly pours a lozenge into his mouth one-handed.  (Note: fearing this possibility, we replaced the content of the Nicorette packages with Tic Tacs and Mentos; since this part of the experiment was focused on the packages and those candies are almost visually identical to the tobacco products, we believe this precaution did not bias the results.)

Discussion
The accurate identification of the positive and negative control items proved that our methodology was scientifically valid.  Both older and younger children can differentiate candy from other objects, and older children can clearly identify tobacco products that are not shaped like candy.  Given the reliability with which products can be made to not look like candy, even to young children, the persistent refusal of tobacco companies to employ non-candy shapes (e.g., plastic water fowl morphology) is evidence that they are marketing to children.

Our results replicate the previous research that showed that children can be convinced that non-candy tablets/lozenges are candy when they are presented in a context that suggests candy and lacks any clues that some products are not candy.  This is the first study to demonstrate that children apparently cannot distinguish dangerous nicotine solutions from water or other liquids when they are presented in translucent vessels.  It follows immediately from these findings that all smoke-free tobacco products that could lead to accidental poisoning should be banned, unless they have been approved by the FDA as a smoking cessation aid.  In particular, those who use e-cigarette refill liquid -- "modders", as they are called in gang patois -- should not be allowed to continue to exploit a loophole that allows adults to legally possess poisonous liquids so long as they are not explicitly marketed as children's beverages.

Our findings suggest that package design might reduce the risk of mistaken identity and accidental toxification events.  In other areas of consumer product regulation, there is a belief that in such circumstances, clear labeling and distinctive packaging should be required for potentially toxic products, with shapes and markings that make clear they are not food.  For example, minimalist plain labels that would be similar to the obscured labels that we used to trick the children are generally forbidden.  However, because tobacco is unlike any other consumer product, different standards should apply.

Nicotine lozenge manufacturers should not be required to change their packaging:  If smokers were not able to flip the attractively-shaped bottle open with one hand and stylishly pour one (or all) of the lozenges into their mouths, then these products might no longer be considered "cool".  That could, in turn, interfere with their proven ability to increase users' chance of quitting smoking by 0.0027%.

Packaging-based regulation is also an inappropriate approach for tobacco industry products, since reducing risk is never acceptable for health-affecting choices when prohibition is an option.  Moreover, there is no evidence that younger children understand the cues from packaging.  While it is possible that children might be less likely to try to drink nicotine solution if it is not in a sippy cup, there is no scientific proof of this claim.  The only proven method of reducing the risk from these products is eliminating them entirely.

Strengths of this study compared to previous research on the subject include the fact that the authors understand irony and are not lying fanatics.  Moreover, only one of them is functionally illiterate, and even he apparently understands scientific inference better than many of the authors of previous studies.  Additionally, we have introduced to this field, for the first time, the methodologic innovation of not sending out a press release containing conclusions that are in no way supported by the content of the study.  We consider this to be an important scientific breakthrough in itself, and suggest that future tobacco products researcher attempt to replicate the methodology.

This study has a few possible limitations.  The older children proved surprisingly adept at detecting that they were being manipulated for some political purpose.  This may have resulted from selection bias, since this work was carried out in a community of educated professionals with high-quality schools.  The same demographic selection bias may explain why some young children were not practiced consumers of candy.  If the experiment were repeated in a community where most of the teens were poorly educated, raised by public health officials, or otherwise never taught to think critically, we expect the results would be different.  This would further strengthen our conclusions.

An additional factor that might be considered a limitation of the study, though it provides several important advantages in the context of tobacco research, is that we did not actually do it.  That is, the methods narrative is pure fiction and we just made up the data (however -- and we realize it is difficult to believe, given that even one of the authors of this paper was sure we were making it up -- the literature review in the introduction is all true, down to the name of the author of reference #2).  There were multiple reasons for not actually doing the study.  First, we do not have access to a Romanian orphanage or a sample of foster children, and no halfway decent parent would ever allow their children to participate in such research.  Second, we did not want to ruin perfectly good sippy cups and the Russian member of the research team would not allow us to waste vodka. 

Third, we would never conduct experimental research on children without getting human subjects ethics approval, and no legitimate ethicist would ever consent to an experiment like this.  Human subjects ethics requires a balancing of possible costs to the subjects against the potential benefit of the knowledge gained.  Since it is obvious to any casual observer that it is possible to trick children into thinking that small pill-like items are candy, and to generally concoct situations that create confusion about objects that look, are scented, or are flavored like comestibles (be they medicine, cosmetics, tobacco products, air fresheners, industrial chemicals, etc.), there is no knowledge to be gained by these studies.  While the risks of such a study would be reasonably low (assuming the children were carefully monitored and restrained from consuming any of the products), the mere act of including children in research, as well as taking actions that might convince a group of children that a collection of non-food objects are candy, creates a cost.  Thus, such research could never be ethically justified.

Fortunately, such concerns did not create fatal limitations.  Even though we did not recruit subjects or make observations, we carefully predicted what imaginary subjects would have said and done.  While this may have created some confounding and measurement error bias in the results, it is well known in epidemiology that when a result is really strong, like most of ours are, it cannot be explained by study errors.  Additionally, we conducted a sensitivity analysis that proved that our results are would have been similar had we actually gathered data (details omitted). 

Moreover, in social science research related to tobacco, the drawing of conclusions based on how the researchers think subjects should act, rather than actual observations, is an established and accepted practice.  For example, it is well documented that discussion and conclusions sections are frequently written before any data is collected.  Furthermore, even patently false statements are so common in this field's research reports that it appears that they are mandatory.  Thus, neither our methodology nor the fictional statements in this paper are outside the bounds of anti-tobacco research.  Indeed, had we actually carried out the field study and adhered to legitimate scientific standards in our analysis and conclusions, our results would have been less useful, as such methodology would render our work incommensurate with the existing public health and tobacco research literature.

Conclusions
This study provides clear evidence that children can be persuaded to consume dissolvable tobacco products.  The risk is clear even though -- in contrast with nearly every other toxic or small object in the world -- it does not appear that, so far, any children have suffered serious harm from these products (other than the NRT versions), or that they have frequently mistaken them for candy when encountering them in natural situations.  Because they pose a risk, these products should be banned as is appropriate for any product that causes risk but serves no necessary medical purpose.

Smokeless tobacco and e-cigarettes are not a safe alternative to smoking, and smokers should use only clinically proven cessation methods like NRT, social stigmatization, and lung cancer.  Giving adults legal access to low-risk, affordable, appealing, satisfying nicotine products creates the risk that they might decide they are better off using nicotine rather than being abstinent, but without offering any profits to the pharmaceutical industry.  Such a risk is not considered acceptable by public health authorities, even if the availability of the products might cause thousands of smokers to quit smoking.  Tobacco harm reduction is a serious threat to public health officials and other career activists, and the tobacco industry must be stopped from making misleading claims like some nicotine products are much lower risk than cigarettes and that citizens in our society have free choice.

Additionally, we conclude that it is unethical and dangerous, and should be criminal, for anyone to try to create confusion between dissolvable tobacco products and candy.  This would include such actions as a parent putting the tobacco products in a candy jar, or activists constantly referring to the products as candy and encouraging the popular media to do the same.

Finally, we conclude that anyone who would actually carry out an experiment on children like the one described herein is in violation of basic rules of human research ethics, and may be guilty of criminal offenses.  There is no evidence that previous researchers who carried out and published similar experiments sought human subjects ethics approval; indeed, it seems impossible that they would have gotten such approval.  We recommend that national and local authorities consider whether sanctions are appropriate against the authors and sponsoring organizations.


Acknowledgments and author contributions: Support for this study was provided by Blue Cross (paid for the pharmaceuticals), Populi Health Institute (paid for the candy), and random donations of products from companies and advocates received over the years.  CVP conceived of the study and wrote the manuscript.  PSHP watched the process with fascination, contributed random strings of characters to the manuscript; he is responsible for any typos that appear in the text.  IQB contributed statistics and words; he offered some amusing suggestions for embellishing the stories about the previous research, and was utterly floored to learn that we could not make those changes because the reported background was actually an accurate description of reality.  PLB contributed content to the manuscript.  The following bears repeating:  None of the authors every seriously considered carrying out the human subjects research described herein; to do so would have been criminally unethical.


References

1. Virginia Foundation for Health Youth (2010). Press Release: More than 1/3 of Teens Surveyed ID Flavored Tobacco as Candy.

2. M Spitznagle (2012). Indiana’s Experience: Marketing of Dissolvable Tobacco Products.  Invited slideshow, FDA Tobacco Products Scientific Activism Committee (TPSAC), available at http://1.usa.gov/yuB1MO

3. GN Connolly, P Richter, A Alequas, TF Pechacek, et al. (2010). Unintentional Child Poisonings Through Ingestion of Conventional and Novel Tobacco Products. Pediatrics 125:896-899.

4. The Week (2010). Fact Sheet: What is 'tobacco candy'? Available at theweek.com/article/index/202095/what-is-tobacco-candy

5. M Cortez (2010). Santa demonstrates danger of 'sweetened' tobacco products. Deseret News, available at http://www.deseretnews.com/article/705362953/Santa-demonstrates-danger-of-sweetened-tobacco-products.html

6. J Merkley, S Brown, T Harkin, B Mikulski, et al. (2011). Senators to FDA: It's Time to Close the Door on Tobacco Candy.  Available at http://www.merkley.senate.gov/newsroom/press/release/?id=ea7b14e4-c4aa-490f-bc98-19713218acaf

7. www.peepresearch.org

Today I will defer to my clever colleagues, and link to two very brief and insightful posts.  (I am just too much the philosopher to do brief, so I have to delegate that :-)

First, check out Chris Snowdon's expose of UK government plans to lie to the public as they try to implement minimum alcoholic beverage pricing and an anti-alcohol social engineering plan.  (Further explanation and analysis can be found in some of his previous posts.)  What is interesting about it is that it is not just the usual catching the government in a lie, but watching de facto government actors overtly present their plan for lying, almost like they figure they can so easily get away with it that they do not have to cover it up.

Second, read Kristin Noll-Marsh's empirical economic analysis of the effects of smoking bans on bars.  Those fancy words, by the way, mean that unlike the government and those who control it in this area, who assert that the bans benefit the bars, she went out and made a couple of observations to figure out cui bono, or rather cui amittit (note: I depended on a translate bot to figure out how to say "who loses", so corrections are welcome).

It is just such a shame that we do not have some major institution whose job includes monitoring government (and its allies) and reporting when it is lying to us.  Oh, wait.

Well, at least we have bloggers and a few good reporters.  On the latter note, and off topic, check out Jeremy Scahill's reporting on Yemen, about the Obama administration's stupid little war that you may have never even heard of.

Anyway, how did they get these scoops?  Snowdon looked at materials posted on the web from a 2010 meeting.  Noll-Marsh apparently thought about the implications of one news report, unlike those reporting it, and drove down the road with a camera.  No wonder health reporters have so much trouble seeing through governments' lies -- who has time to do complicated research like that when there is so much transcribing to be done?

Last week I was struck by one line from a news story about a new study that claims that the death toll from malaria may be underestimated by half.  The claim is based on revising the current conventional wisdom that basically only young children die and everyone who survives childhood in malaria zones has immunity that keeps all but a very few from dying.  I will admit to a soft spot for any study that that seems to claim "it has generally be believed that X, but that was not really based on evidence, and now we show Y" -- perhaps it is because I have contributed a tiny bit of that in my own work and found it to be a real high point. 

The new study depends on the controversial method of "verbal autopsies", which is just a silly medical-speak way of saying that when a cause of death cannot otherwise be determined, it is based on interviews with those who were around the decedent toward the end and can describe his symptoms.  The authors obviously believed that this works; others (such as in this very well-reasoned and balanced news story about it in Nature) have argued that there is a huge amount of measurement error.  (On the other hand, official death certificates have a lot of measurement error too, but that is another story.)  At the WHO, which kind of owns the malaria issue, the head of the malaria unit responded to the article with a memo that said the agency stood with its estimate and believes the study is importantly flawed.

The subject matter is very important and the question of that methodology interesting, but I have to concede that I am unlikely to learn enough to judge either -- certainly not this month.  So I am one of those educated non-experts who I try to empower to judge.

What I can judge for sure is that this remark by an advisor to the UN envoy for malaria about the scientific disagreement, reported in the NYT article, is really really dumb:
Some experts were dismayed. The dispute “is a little like Gingrich and Romney going at each other — it’s only going to hurt the whole field,”Huh?  The act of scientists seriously debating scientific beliefs and offering divergent positions about the merits of a key research method is like two exceptionally dishonest politicians talking past the issues, misrepresenting the state of the world and their opponents' beliefs, and launching attacks on each others' character with a level of sophistication reminiscent of a grade-school brawl?  Really?

Exactly how does science advance, except for someone making a new claim based on their best analysis, criticizing the old beliefs, and (a minority of the time) turning out to be right?  And what do we expect from those who believe the current view and that the evidence supports it when confronted with a radical new claim?  We should hope that they respond by acknowledging the new analysis and pointing out why it is inferior to the basis for the existing belief.  In totally political realms, they would just ignore the new result; we should praise them for identifying points of disagreement.  And we should hope that their beliefs are based on enough information that they are inclined to defend them.  There are, in science, rare "head smack" moments when someone points out a previous error in such a definitive way that any honest expert has to say "yup, they're right; we were wrong all this time", but rare is the key word there.

Part of the problem was created by the editor of the journal that published the new paper, The Lancet, who in advance of the article tweeted "a revolution is about to strike" about malaria.  A tendency of big name journals to traffic junk science (and that kind of hype about a single inherently uncertain paper is junk science, even if the analysis in the new paper is spot on) is a lot of the problem.

How about the contribution to the bad science by the politicians, like the UN envoy.  Nothing to see there, it turns out.   It sounds like the envoy offered the sensible observation that the optimal intervention tactics are not affected, so it does not matter much which claim is right.  Similar sentiments were expressed by other officials in anti-malaria, as reported in the various news stories.

Anyway, whatever the stupid hype by the Lancet editor, that quote by the advisor is still the worst bit.  It really exemplifies the difficulties in getting non-scientist people to understand scientific debate.  It is hard enough to get lay people to realize that genuine scientific debate is...

(a) ...not like elections, and especially not like how they are reported.  Election coverage should really be more scientific -- there is analysis about what promised policies would really cause and the truth about someone's past policies.  But the press likes to report on football matches, so they turn election coverage into that, and convince everyone that it is just a silly bickering match between scientifically and ethically symmetrical opponents even when it is not.  Then they cover science as if it were just like such an election. 

(b) ...not all whiny and weepy.  Scientists say "you got that wrong; that method has been shown to produce bad data" not "I understand that this claim is important to you, and since everyone is entitled to their own belief, we might have to agree to disagree, but I feel that your new method -- which is creative and clever, and represents a really good effort that I have the utmost respect for -- does not cause me to change my own feelings about this, which should be seen as valid also."  It is so damn frustrating to try to talk through a scientific disagreement in the company of people who are clueless about how science works, who think that things are just "discovered" and everyone agrees.  The worst is when they freak out about typical patterns of disagreement, clutching their pearls and fanning themselves to try not to faint.  It is like a voter getting mad at a candidate for "going negative" because he points out that his opponent's economic plan is based on making up numbers -- it's just arrogant and mean to say something like that in polite company!

So, anyway, who was the advisor who offered up the quote that played so well into all the reasons people do not understand science?  You are probably figuring it is some political hack or public relations guy who himself does not understand science.  You may well be right, but it is attributed to Jay A. Winsten; no affiliation or any other information attached to the name, but the "Jay A. Winsten" who dominates a web search is Associate Dean for Health Communication and Director for the Center for Health Communication at the Harvard School of Public Health.  Not that this disproves your original hypothesis (though shame on you for saying such disparaging things about a presumably respected professor from a unit that is often considered by some to kinda sorta be part of Harvard University).

I wish it was harder to figure out why the reporting of public health science is as bad as it is, and I wish we could just blame the reporters.

A random observation for the day.  The NYT reported that an American of Chinese birth recently traveled to China and was detained and tortured by state security officials (fortunately, just in an ad hoc street cop kind of a way, not sent-to-Guantanamo style) because he engages in the mildest of human rights activism, particularly posting to Twitter.  Apparently they mostly wanted his Twitter password, which could only serve to let them hijack his account and mimic him, since public broadcast of all the info that is there is kind of the point of Twitter.

What struck me about the story, beyond the always useful reminder about the behavior of governments and our "important partners" in China, was the following:

In a phone interview on Monday from his home in Fremont, Calif., Mr. Ge described how the agents, infuriated by his assertion that bloggers in the United States were volunteers and not government-sponsored agitators, demanded that he turn over his Twitter password.That seemed vaguely familiar.  Kind of like the cries from members of the anti-tobacco extremist industry when confronted with human rights or good-science activists who challenge their bullshit, accusing people of doing it under the secret employ of industry.  Low-lifes like Chinese government thugs or paid astroturf activists simply cannot understand that someone might take a principled position and devote their time because they simply care about the world.  Since said thugs personally would never do something they were not getting paid for, they reason (to the extent they are able), no one else would either.

Of course, I realize that this is not the story for everyone.  Some pro-government thugs in China etc. might be decent people who simply have no access to honest information and have been brainwashed -- it is not that difficult to persuade idealistic young men to become monsters.  Western "public health" activists have no such excuse, though in fairness to them, presumably many of them are just lying as part of their jobs and do not genuinely believe that everyone who calls them out is as dishonest as they are.

As a side note of warning from that story:
In the end, Mr. Ge and his captors came up with a compromise: he did not reveal his password but logged on to Twitter and allowed them to peek inside his account. “The truth is I have nothing to hide,” he said. Unfortunately, he might as well have just given them his password, because he undoubtedly did so, as the reporter should have known if he read his own newspaper's article about how Chinese and Russian officials are adept at installing password stealing software and otherwise breaking into computers.  Companies with security concerns have taken to not allowing employees to take their computers or phones to these countries or log in from there, bringing only temporary burner devices that they sometimes then forbid from ever plugging into the company network based on the assumption that the spyware is so good that it cannot be removed.  A good lesson for all of us.  And don't forget that the border guards even from "free" countries sometimes seize and search computers, your email, etc. when you come through customs, even if your own country -- Canada did it to me once.

My colleagues in the UK are currently reporting on the disturbing proposed regulation that would impose a minimum retail price on drinks, on a per-unit-of-ethanol basis.  This is justified based on (false) claims of increasing public health impacts of alcohol, but it is immediately obvious to any clear thinker (a group which apparently includes 0.3% of members of that country's parliament) that the penalty will fall on those who buy inexpensive drinks, not those who drink inadvisably.  That is, this interference in the market by rich people will have almost no effect on rich people who already choose expensive drinks instead of the bargain brands (including those who are problem drinkers), but it does take money from the poor and gives it to corporations.  It would probably financially punish poor people who drink too much without substantially changing their behavior, though I suspect that inflicting punishment is what a lot of the proponents really want anyway.

In the US we famously love the free market.  Unfortunately those who want to intervene to stop demand they do not like still think they should blame supply, but the free market leaves them using the free-market version of regulation, lawsuits.  Specifically, it was reported that a South Dakota Native American nation
sued some of the world’s largest beer makers on Thursday, saying they knowingly contributed to devastating alcohol-related problems on the Pine Ridge Indian Reservation. The tribe said it wanted $500 million in damages for the cost of health care, social services and child rehabilitation caused by chronic alcoholism on the reservation. The suit ... also names four beer stores in Whiteclay, a Nebraska town near the reservation that, despite having only about a dozen residents, sold nearly five million cans of beer in 2010. The suit names Anheuser-Busch InBev Worldwide, SABMiller, Molson Coors Brewing Company, MillerCoors LLC and Pabst Brewing Company. Make no mistake:  Being concerned about problem drinking in many North American aboriginal population is reasonable.  But the solutions lie with the consumers or the circumstance that create the demand, not the merchants.

What exactly were the defendants in this case supposed to have done?  What would have happened if one of those manufacturers had refused to supply towns near the reservation?  No doubt their local distributor would raise an outcry, prompting concern nationwide about possible future arbitrary cutoffs.  Moreover, there would inevitably be cries of racism, quite possibly by the same people who are leading the lawsuit.  But the most important effect would be that the others on the list would happen is that the others would increase their shipments to the area to make up the shortfall.

So, could all manufacturers agree to stop the shipments?  That would almost certainly be a violation of US antitrust laws, for good reasons.  And even if they could, this would all depend on the assumption that no one in Nebraska owns a truck and can figure out the nearest place that they are still shipping to.  I have seen Nebraska, and there are a lot of trucks.

What about those retailers.  Surely they must have known that most of their sales were going to people who live on the reservation and not the other eleven guys in town.  Of course they did.  So should they have been saying "we don't serve your kind in here" when someone from the reservation walked in?  Yeah, that would be a great plan. 

But, the argument might go, it was not that they were treating Native Americans equitably, but that they existed to serve them.  Fair enough.  But what could any of the four do?  Shut down?  That would just boost the sales of the others by 25%.  What if they all agreed to shut down (setting aside the problems of illegal collusion, accusations of racism, etc.)?  Well, gee, I wonder if perhaps there might be another enterprising soul around who might want to open a new store.

Of course, all of these speculations are absurd, because these merchants had no reason to want to curtail their operations, even apart from the fact that it would not work.  The suppliers responded to the demand created by the residents of the reservation.  When the tribal elders decided that their own people were not being properly obedient about drinking, they decided to re-aim their commend-and-control approach.

Undoubtedly the lawsuit will invoke a comparison to the gun manufacturers who supply a few retailers with an absurdly huge quantity of their product (a product that is intended to kill people, despite that silly claims you hear about cigarettes being "the only...when used as intended").  But in the gun case, it is evident that the sales are being illegally diverted.  The huge supply of alcohol is arguably often used unwisely, but this is not illegal activity that the suppliers are obliged to stop.

So that brings us back to the UK solution:  Since the private market will not (indeed, cannot) attempt to thwart these consumption choices that someone in power does not like, some believe is up to government to use force.  Government could theoretically shut down sales in Whiteclay, Nebraska, or impose a minimum price there.  That would make the aforementioned guy with the truck a black marketeer, but that would not change his existence as a profitable entrepreneur. 

So they would need a bigger law, like the one we have that keeps people from unwisely consuming heroin.  Oh wait, oops.  Well perhaps, as with heroin, the US military could just invade and occupy the place that grows the raw material.  So where do they produce the raw materials for beer?  Really?  Nebraska and South Dakota?  Well I suppose that is convenient.  Maybe as long as they are there, they could pick up where they left off in the 19th century and massacre those annoying problem drinkers, solving the problem once and for all.

I can hear my colleagues in the UK cringing as they read that, fearing that someone in their government might read it and think it is a good plan.

To my regular readers: This is obviously not a regular entry for this blog.  I needed somewhere to post an outline and reading list for this three-session course, and this blog seemed like the easiest place.  Moreover, someday it might be useful for someone else, and maybe some of you will want to read it, so I might as well put it someplace easy to find.
To those outside the primary target audience who might find this:  The class is being taught at Main Line Unitarian Church, in response to a Unitarian Universalist initiative, and thus the emphasis on UUA document and other faith-based material which I would not include for a different audience.  However, the UUA approach is very much a secular activist-left approach to the topics, and I believe that anyone who is interested could study or borrow this curriculum without even noticing the provenience of the documents if the letterhead was stripped off (for those not familiar, the UU is probably the least religious of any American church, if that makes sense).
Disclaimer: This is my own volunteer work; it does not represent the views or official curriculum of MLUC, UUA, the Humane Society of the United States, or any other organization.
I will update this throughout February 2012 as a working tool (without flagging what is an update) but it will then become a regular published fixed document.
To those participating in the class or considering it:  I understand that this is a casual discussion-oriented evening gathering, and you are not my graduate students, so please do not panic about how much I have here.  I like to be organized and to provide extra background and reading for anyone who wants to really delve deeper, but I am not going to assume that anyone did all, or indeed any of the readings.

Course Overview
The Unitarian Universalist Association of Congregations (UUA) recently made "ethical eating" part of the discussion about worldly and spiritual ethics that UU congregations are asked to consider.  The ethics of choosing food involves its impacts on treatment of agricultural animals, on the natural environment, on the human-affecting environment, on producers and other consumers, and on one's own health and social life.  As worldly ethical questions go, dietary choice tends to be relatively simple technically (it is easy to understand the suffering experienced by food animals, though the environmental impacts are a bit more complicated).  But it tends to be particularly thorny from the perspective of ethical judgment.  As a result, this class will necessarily include some technical material, but will mostly focus on ethical conundrums.
My relevant background includes two decades of studying (teaching, writing about) animal well-being, agricultural and environmental economics, and the study of ethics, as well as a passing background in nutrition and consumer behavior.  Content will draw upon the UUA statement about ethical eating, material from my colleagues at the Humane Society of the United States, my own research, and lots of other material, highly distilled down to three classes.
The format will be primarily led discussion, based on some information from suggested readings and brief background talks.  Topics will include:
The environmental impacts of food choices-dietary choice is among the most important choices people like us make, in terms of environmental impact; for most middle-class Westerners it is the most important-in particular, a meat-centered diet causes greater environmental impact than most any choice you can make, including land use and causing more energy use and greenhouse gas emissions than anything other than flying a lot-choices like eating organic or more "natural" foods turn out to have minimal impact; eating locally and in-season helps, though, as do some other choices
The ethics of eating animals-the secular ethical concepts of animal rights and animal welfare, and religious concepts such as dominion-understanding animal agriculture practices and differences
Food as a standard consumption choice-food as a consumer good comes from companies that differ in how they treat workers (the same is true for all other goods, but we consume more food, so it is arguably more important)-treatment of slaughterhouse workers is among the worst in the US, and that of migrant harvesters is quite bad too-food can be produced by people who have no access to other productivity options, so food markets have greater effects on the world's poorest poor than other goods; public policies matter a lot more, but individual choices can have a small impact
Hunger-the UUA statements include the common misconception that there is a strong connection between dietary choice and hunger; however, it turns out that others' hunger is caused by forces that have nothing to do with our food choice-food policies can affect hunger, but probably not in the way you think-we will cover the basic economics needed to understand what really causes or reduces hunger
The conundrum of making ethical choices that affect social norms, health, comfort, and family values-unlike most actions we might take to as acts of ethics, dietary choice is impossible to look at as a technical matter or simple contribution of one's resources-how far does it make sense to personally deviate from common practice in pursuit of more ethical actions?

Session 1 - Overview 
The first session will touch briefly on all of the points in the above outline, and the following material.  My plan before the start is to focus the second session on issues relating to food animals and the third session on environmental impacts (both of which will be briefly addressed in the first session.  I will also prepare follow-up material on other topics based on what generates the most interest in the first session.
As an opening point, it is useful to figure out what ethical behavior means (hint: many of the points in the UUA documents have little or not ethical importance by any standard notion of the term).
The UUA statements about ethical eating is the motivation for this class. This consists primarily of a Statement of Conscience and a longer Study Guide.  These documents are almost perfect for teaching about issues related to food and ethics; unfortunately, this is because the perfect teaching tool includes the most important good points, but also all of the common errors.  The Statement presents idealistic goals, which combine well-presented critical ethical issues with politically popular red herrings, combined with proposed solutions that include the most promising and important options, but mostly would do nothing to further the goals.  (The Guide almost seems to intentionally take the weakest points from the Statement and takes them even further, while almost expressing hostility toward the most useful point.  I plan to avoid it entirely unless there is interest in dissecting it.)
The Statement of Conscience includes the following passages (indented material) which seem like a good way to organize the initial discussion.  Discussion points follow each quotation.We acknowledge that aggressive action needs to be taken that will ensure an adequate food supply for the world population; reduce the use of energy, water, fertilizer, pesticides, and hormones in food production; mitigate climate change; and end the inhumane treatment of animals. These steps call for an evolution of our eating habits to include more locally grown, minimally processed whole foods.For most of us, our food uses more energy and water (and land), and impacts climate greenhouse gas emission than any other consumption.
It is not clear that the proposed "evolution" actually would improve the stated problems rather than making them worse.  Eating locally offers the valuable benefit of minimizing transport costs.  However, most processing also reduces transport and other input costs (fresh food uses a lot more energy than frozen, canned, and concentrated).  The treatment of animals is better some places than others, but proximity promises nothing; a slab of meat wrapped in plastic is "minimally processed", but likely involves the inhumane treatment of animals and workers and much greater environmental impact than a Clif Bar.
However, proper use of pesticides, and even hormones and antibiotics whatever other impacts they might have, decreases how much of the macro inputs are needed.  Fertilizer use is also critical for productivity, though it is on both sides of the equation (it largely derives from petrochemicals).  Eating "organic" matters little; it reduces some environmental impacts, but it increases others and is not "sustainable" in the sense of being able to feed everyone.
And so long as we employ modern methods, there is no conceivable risk of us not being able to produce an adequate food supply for everyone.  Hunger is not caused by global shortages of food, but by local shortages of wealth (and modern famine is always caused by a complete failure of government).  The Study Guide devotes almost half its content to issues of hunger without any apparent realization that it is not caused by supply shortages.
Food production involving growing, processing, packaging, transporting, and distributing food has become a vast worldwide industry. The mass production of food often maximizes production while minimizing price. This mass production has greatly increased food supply, but has resulted in the overuse of fertilizers and pesticides with crops and the mistreatment of animals and workers in food production. Both this overuse and the large waste streams from concentrated animal feeding operations (CAFOs) result in pollution of water, land, and air.Environmental concerns include the use of fertilizers, herbicides, pesticides, and hormones and high volumes of animal wastes produced by CAFOs, all of which can contaminate soil, air, and water. Contributors to global warming include the overreliance on fossil fuels for food production; the methane produced by animals, including but not limited to cattle, sheep, and pigs; and the long-distance transport of food. Expanding agriculture and animal farming often removes natural habitats and reduces natural biodiversity. An additional environmental concern is the deterioration of the oceans and their life forms due to overfishing and pollution.Human Health concerns include producers' use of growth promoters, pesticides, and antibiotics that can affect child development, antibiotic resistance, and other health conditions.Which concerns are photogenic and chemophobic, or just an anti-industry bias, and which are real ethical (or health) concerns?  packaging hardly matters, but transporting is expensive; "overuse" of pesticides has little impact; lakes of manure are impressive, but an even greater environmental impact of intensive animal agriculture is growing feedcrops; use of hormones can hurt animals but has no measurable evidence on those who eat them; antibiotic use, on the other hand, can help the animals but is bad for human health
What is the relationship between minimizing price (not always a good thing) and maximizing productivity (hard to complain about)?
There is a remarkable amount of confusion about what characteristics of your food really matter in terms of your health, to say nothing of whether these represent ethical issues in the first place.  However, it is interesting that there is no mention at all in the documents of food allergens, which do have effects on others (think: letting your kid go out with a peanut butter sandwich).
We...recognize that many food decisions will require us to make trade-offs between competing priorities. These priorities include: taste, selection, price, human health, environmental protection, sustainability, adequate food supply, humane treatment of animals used for food, and fair treatment of farm and food workers.We acknowledge that this evolution must respect diversity in cultures, nutritional requirements, and religious practices. Funny how the choices we make that have the biggest ethical implications tend to be the ones with the biggest other implications too.  (actually, it is not at all surprising)
The document's list of complications about food choice still manages to overlook some of the most important points, particularly ease of functioning in society, self identity, and group identity (particularly family).
Policy concerns include agricultural subsidies that reward the production of certain crops and animal products that are less healthful and environmentally friendly than unsubsidized ones and that penalize small to moderate-sized farming operations. Agricultural subsidies of exported crops have driven small farmers in developing countries off their land.This is only tangentially related to ethical eating, since our dietary choice has no impact on these policies.  The points are valid, however.
Some of us will not be able to pay more for ethical food. Others of us will.There is little chance that anyone who reads or is directly influenced by that document (or the present one) cannot afford more ethical food.  Some of us can definitely afford nicer food than others can.  But except in cases where poverty limits access to markets, it is not difficult to consume cheap ethical food.
Lack of funding is similarly not the reason that school lunches (mentioned elsewhere) are so awful.

The "Call to Action" at the end of the document, which follows, would make an excellent exam on the topic:  Which of these could have a major positive impact, which are positive but of minimal impact, which actually would cause more harm than good, and which seem to have little to do with ethical eating?Recognizing that individual circumstances vary, we aspire to buy, raise, and consume food for ourselves and our families that:increases our proportionate consumption of plant-based foods, which increases the global access to calories, provides health benefits, and prevents injuring animals;minimizes the pain and suffering of animals by purchasing meat or seafood produced under humane conditions, for those who choose to eat meat or seafood;minimizes the negative environmental effects of raising animals or plants by purchasing organically produced food, and seafood certified as responsibly farmed or harvested;minimizes transportation-related carbon dioxide emissions by obtaining foods locally produced through home or community gardens, farmers markets, or community supported agriculture (CSA);provides farm workers with living wages and safe working environments;contributes to social harmony by encouraging communal eating;promotes health, consuming food in quantities that do not lead to obesity;We advocate for the benefit of animals, plants, food workers, the environment and humanity by:purchasing fair trade--certified products as available.asking food sellers and producers to label where their products come from to determine distance of transport and whether the products were irradiated or contain Genetically Modified Organisms (GMOs);pressing food sellers to require that their suppliers certify the humane treatment of animals;supporting legislation that requires the labeling of products that are irradiated or contain Genetically Modified Organisms (GMOs), distribution of adequate ethical food supplies, effective safety inspection of food production, and realignment of agricultural subsidies to support growing more produce and the viability of small farmers; andprotecting and encouraging organic food production and its producers.


Session 2 - The ethics of eating animals; Issues or how far to go (and follow up on topics from previous session)
Animal agriculture, animal welfare, and choosing to eat meat or not.
When pursuing an ethical choice, how far is rational / sensible / ethical to go?

Session 3 -  Environmental impacts (and follow up)