Killjoys

Remember that survey of a baker's dozen young smokers that Otago healthists used as basis for recommending banning smoking outside of bars? The Otago Daily Times editorial page wonders, if costs to the health system are the reason for increasingly onerous restrictions on smokers, if there's any logical basis for stopping at smoking.

What social freedoms can be safe in the face of such overweening zeal?

They have a point, particularly as to risk and its relative social costs.

If, for example, costs of medical care are to be pre-eminent criteria in instituting prohibition, should society really continue to allow enthusiasts to ride motorcycles - or to indulge in any number of adventure sports, as a result of which death can be immediate rather than drawn out.

Such logic can be taken to absurd ends: given the high rates of melanoma in this country, and the concomitant social and medical costs, should not sunbathing be prohibited?

Or equally, to combat high levels of diabetes-inducing obesity, should pies and chips be banned?

The serious point is that there is a fine line between prohibitions that seek to minimise harm and social and economic cost, and those which curtail the individual freedom of choice which is a hallmark of developed, democratic societies.

I'd quibble here: any sane analysis finds that smokers pay roughly three times as much in excise as they cost the New Zealand health system, even leaving aside savings to the superannuation system.

The four authors of the paper surveying thirteen people (I wonder who got stuck surveying 4 instead of 3 respondents) respond in a letter to the ODT 6 March that proves rather too much. [Print edition; haven't seen an online version, alas.]

THE claim (ODT editorial, 28.2.12) that smokers make "conscious knowing choices" suggests they make a fully informed decision to become addicted to a behaviour that will kill half of them prematurely. Aside from lacking face validity, this assertion has no empirical basis. 

While most smokers agree that smoking is harmful, few understand all the specific harms it causes. Very few know the level of risk that they will suffer those harms or their prognosis if they do.

It's not necessary to know all of the specific harms to get to the right answer on whether smoking is bad for your health. I don't know exactly how drinking arsenic would kill me, but I know to stay away from it. If smokers systematically underestimate the risks involved in smoking, there can be a case for policy intervention. But what does the data say? Here's Kip Viscusi writing in 1990:

Both smokers and nonsmokers greatly overestimate the lung cancer risk of cigarette smoking, and the extent of the overestimation is much greater than the extent of underestimation. These risk perceptions in turn significantly reduce the probability of smoking, as suggested by an economic model of risky consumption decisions.

There's some evidence that smokers view themselves as being less likely to see the downside outcome themselves, but the same overconfidence bias tends to apply to all such risk elicitation surveys; there's consequently little basis for paying particular attention to smoking as compared to other risky behaviours. If rugby players accurately assess the overall risks involved in the sport but think they're less likely than others to have bad outcomes, does that give cause for government intervention? Back to Hoek, Edwards et al:

Using slippery slope logic to scaremonger avoids evidence-based decision making, something we'd suggest is fundamental to a "developed, democratic society". Adventure sports don't kill around 5000 New Zealanders every year and spurious attempts to argue by analogy aren't a substitute for research evidence.

Except that slippery slope logic is evidence-based. Anti-smoking policy shifted from protecting non-smokers to eradicating tobacco, with each step along the way bringing denunciations of the "slippery slope" people warning of the next step likely to follow. Anti-alcohol policy is starting to be seen as an extension of anti-tobacco policy. Anti-alcohol folks are learning strategy from the anti-tabbac; fat and sugar are next in line. Rizzo and Whitman also show how paternalist policy induces these slippery slopes. As for adventure sports, we have had calls in New Zealand for mandatory ski helmets; Nova Scotia's headed in that direction, with explicit citation of the public health costs. Scaremongering? Hardly.

Hoek, Edwards et al:

Our paper, to which the editorial referred, explored social smoking among a diverse group of young adults; all but one supported making outdoor areas of bars smokefree because this would reduce the pressures they felt to smoke.

It's worth remembering that that one person was 7.7% of the selected sample of 13. But it's also plausible that you could get majorities in sounder surveys agreeing that bans are good ideas. A better idea is letting those folks avoid bars with outdoor smoking areas.

Gimmie some sugar

Ah, those nutty public health folks. Is it plausible that sugar is bad for your health and is one of the reasons for increased diabetes rates? Sure. But that sure isn't sufficient basis for this:

Sugar is so toxic it should be controlled like alcohol, according to new report that goes so far as to suggest setting an age limit of 17 years to buy soda pop.

It points to sugar as a culprit behind many of the world's major killers — heart disease, cancer and diabetes — that are now a greater health burden than infectious disease.

A little sugar "is not a problem, but a lot kills — slowly," says the report to be published Thursday in Nature, a top research journal.

And Count Chocula will be subject to plain packaging legislation? You think I'm kidding...

"We recognize that societal intervention to reduce the supply and demand for sugar faces an uphill political battle against a powerful sugar lobby," the researchers say, "and will require active engagement from all stakeholders." But such "tectonic shifts" in policy are possible, they say, pointing to bans on public smoking, limits on alcohol sales and condom dispensers in public washrooms. "It's time to turn our attention to sugar."

Ah yes. The powerful sugar lobby. They are indeed responsible for many real ills: sugar tariffs and subsidies in the US. But the public health guys, as usual, completely discount an alternative explanation for why people might oppose sugar regulation: that we enjoy eating it.

How long until some dodgy outfit comes up with a Cost of Sugar to Society study that puts together a table of aetiological attributable fractions for the burden of various diseases due to sugar consumption, tallies the costs to the public health system of sugar-related illness (80% of total dentistry expenditures, 50% of diabetes, etc...), adds to that all of the subjective intangible costs experienced by those incurring downside consequences from eating sugar (and all of the costs of growing "harmfully-consumed" sugar), assumes zero private enjoyment from eating tasty sugary snacks, and publishes a massive social cost figure for sugar use that will help fuel demand for sugar regulation?

HT: @JoelWood

Update: Here's Barbara Kay in the National Post on sugar taxes:

Taxes are justified as a deterrent for any substance we know to be harmful in quantities, because we all pay for the health care of people who are negligent of their health in the over-consumption of stuff they know is bad for them.

There is no logical end to that argument.

Drinkers' utility

Folks measuring the social costs of alcohol are often pretty happy to assume that heavy drinkers get no utility from drinking; that lets them count private costs as socially relevant. For example, BERL wrote:


"We assume that it is irrational to drink alcohol to a harmful level and that harmful alcohol use has zero private benefit."

And now we see neurological evidence that the problem might rather be that heavy drinkers get too much enjoyment from alcohol:

Dr Jennifer Mitchell of the University of California San Francisco, who led the study, said: "This is something that we've speculated about for 30 years, based on animal studies, but haven't observed in humans until now.

"It provides the first direct evidence of how alcohol makes people feel good."

Researchers conducted positron emission tomography (PET) scans on the brains of 13 heavy drinkers and 12 non-drinkers immediately after they drank alcohol. Their findings, published in the Science Translational Medicine journal, showed that alcohol caused endorphins to be released in the nucleus accumbens and orbitofrontal cortex brain regions.

In all of the volunteers, larger quantities of endorphins released in the nucleus accumbens were linked to increased feelings of pleasure.

Increased levels of endorphins released in the orbitofrontal cortex were linked to a more pronounced feeling of intoxication in people who were heavy drinkers, but not in non drinkers, the study showed.

Dr Mitchell said: "This indicates that the brains of heavy or problem drinkers are changed in a way that makes them more likely to find alcohol pleasant, and may be a clue to how problem drinking develops in the first place.

"That greater feeling of reward might cause them to drink too much."

I'm happy to grant that heavy drinkers may experience costs in excess of benefits on the later units of consumption. But to assume away the existence of benefits runs contrary to common sense, and to the brain scan machines.

Offsetting behaviour: vaccine edition

I'm more inclined to call stupidity over risk homeostasis on this one:

Some adolescent girls who get the HPV vaccine to prevent cervical cancer wrongly think they no longer need to practice safe sex, U.S. researchers said on Monday.

The study, published in the Archives of Pediatric & Adolescent Medicine, shows the need for better education about the vaccines and their limitations.

...The authors said the study was limited in that subjects came from a single urban clinic serving low-income clients so the findings may not apply to more general populations.

I wonder if anybody's running effects of vaccination on STD and condom use rates. It would be surprising if there weren't some drop-off in condom use with vaccination; the risk has indeed gone down. But I'd love to see numbers on it. Unfortunately, the kinds of things that would predict vaccination likely also predict sexual behaviour regardless of whether vaccination has taken place. Finding an exogenous instrument could be tough.

Alberta nannies

Oh, Alberta. What happened? Back when I was in Manitoba, Alberta was the wild West of Canada - its Texas. Birthplace of the Reform Party, assassin of political correctness, emblem of everything that the rest of Canada wasn't.

And now Lorne Gunter tells me Nanny became Premier via a Tory leadership convention. She's pushing the drink driving limit down from .08 to .05 and aiming to ban smoking in cars. Writes Gunter:

When I pointed out in these pages that even the Traffic Injury Research Foundation thinks it’s a bad idea to impose harsh punishments on low-blood-alcohol drivers, and that instructing police to crack down on social drinkers will mean they have fewer resources to stop habitual drunks, who are the true problem, Ms. Redford had her Transportation Minister, Ray Danyluk, write the Post to say how wrong I was. Mr. Danyluk insisted that drivers above .05 but below the legal limit in the Criminal Code may have caused as many as 28 deaths over the past five years.

Yes, Mr. Danyluk, but would your premier’s intrusive new law have saved them all, or even most of them?

And, further, do we have any clue whether that's a high or a low accident rate given the number of drivers on the road who have BAC between .05 and .08? It's impossible to tell unless the police start releasing stats on the proportion of drivers on breath-check who have that BAC - we need to know the base rate.

Bad things will continue to happen no matter how much social engineering nanny statists engage in. What’s more, on a cost-benefit basis, trying to save 10 or 15 deaths over five years (two to three a year) by harassing tens of thousands of law-abiding drivers is a poor use of resources and could lead to that many extra deaths being caused by criminally drunk drivers who will now escape detection.

A statistical life is worth about $7 million. Suppose that the legislation worked and saved 5 lives per year: $35 million. Add to that a bit of reduced injury cost and property damage. But net out enforcement costs and reduced consumer surplus from folks now too scared to have a glass of wine with dinner... tough call to say there's any prima facie case that this passes cost benefit even assuming that Danyluk's numbers are right. And they're probably not because of failure to account for base rates.

But not content to stop with her pokenose new drinking and driving law — sorry, make that sipping and driving law — Ms. Rutherford now intends to crack down on smoking. She proposes to ban smoking in vehicles with passengers 16 and under and to ban the scourge of flavoured tobacco.

The American satirist H.L. Mencken once wrote that a puritan is a person with a “haunting fear that someone, somewhere may be happy.” Premier Redford is one of the new health and safety puritans who worries constantly that others may not be as informed as she is and so are engaging in vices that are bad for their health.

And, Alberta has a tendency of keeping Premiers around for a while.

Pigovean paternalism

Frances Woolley reports on problems in her students' understanding of Pigovean taxes. After a set-piece question asking students to calculate equilibrium Pigovean tax in an externality case, students were told to answer this last bit:

Opponents of the tax on potato chips take a careful look at Dr. Economides’ study. It turns out that the only people harmed by potato chip consumption are potato chip eaters themselves, as potato chip consumption is associated with bad skin, weight gain and depression. Does this strengthen or weaken the argument for taxing potato chips?

Frances rightly notes that weakens the case for Pigovean taxation; I'd go farther and say that it darn near obliterates it. If the argument for taxation is consumer irrationality, then, as Seamus has noted before, we've stepped rather outside of the rational choice framework that's necessary for assessing costs and benefits in the first place. What does a demand curve even represent in the case where consumers aren't competent to evaluate net personal benefits? Maybe we can derive it from observing consumer behaviour, but revealed preference goes away and the welfare analysis then has to start from a rather different place. Some of the behaviouralists have started building frameworks for that kind of analysis, with multi-self Pareto criteria, but it's hardly canon.

...it seems that some students really don't believe that people are rational decision-makers, fully taking into account the long-term effects of their consumption choices. Even when people are only harming themselves, they support Pigouvian taxes on paternalistic grounds, to stop people from harming themselves.

It seems to take irrationality of a very particular form for Pigovean taxes to be a solution to internality problems. We need it to be the case that consumers irrationally discount health costs of monetized value x but to respond optimally to taxes of equivalent value. If consumers are also irrationally price-insensitive, you've doubly hurt them by imposing the tax. And we still have the problems that arise once revealed preference can't form a starting point for welfare analysis.

And, despite the explicit framing of the question - that consumers only harm themselves - some students read into it that they were hurting the taxpayer through the public health system:

Some students disputed the basic premise of the question, the idea that potato chip eaters are only harming themselves. Bad skin, weight gain and depression, they argued, are harms to others, because we have a public health system. ...

What interested me about this response was how "health" becomes a lens through which public policy issues are viewed, and a justification of policy choices. Perhaps, though, the students were just mislead by the wording of the question. Guessing that the specific details about bad skin, weight gain and depression must matter in some way, they figured that the question must be asking about health care. 

These are upper level undergrads in economics, and they're messing up the distinction between pecuniary and technological externalities. Costs through the public health system are only a transfer unless these consumers are eating more potato chips than they would in a private system; in that case, only the deadweight costs of the increased portion of consumption get to count as policy-relevant on an efficiency standard.

I hate to keep banging on about this [hit the fiscal externalities tab below]. There's no way that the folks at Carleton wouldn't have hammered home the distinction between technological and pecuniary externalities. But fiscal externalities - externalities that work through the budget constraint but via the tax system - keep seeming technological to students when they're really mostly pecuniary. Partially this is because folks don't start with Buchanan and Stubblebine, but I expect that it has more to do with that fiscal externalities have seemed perhaps an interesting sidebar not worth extensive class time.

We are graduating too many students who know that negative externalities are bad and that government should tax negative externalities, but who have little sense of which ones actually have efficiency consequence.

Platypus economics

My introduction to the latest issue of ANU's Agenda owes a debt to my colleague and barracks co-resident, Andrea Menclova, who provided some of the opening analogy.

A good health economist is a bit like a platypus, or at least so-says a health economist colleague of mine.2 The friendly beast must combine a clinician’s medical knowledge with an economist’s techniques, both theoretical and empirical, and a bureaucrat’s understanding of the administrative structures within which policy operates. Perhaps the health economist’s empirical techniques are not as refined as the theoretical econometrician’s, just as the platypus’s fur is perhaps not quite as soft as that of a kitten, but it does a good job of combining a set of characteristics that are normally not found in one place.

But I'll take the blame for what follows:

Unfortunately, health policy instead seems set by a chimera that rather seems to have taken the design specifications for the platypus and decided that the kitten should in fact provide the beak and the duck provide the fur: we too often find combined the clinician’s goal of health care, as maximand; the economics undergraduate’s captivation by partial equilibrium and neglect of general equilibrium; and the bureaucrat’s inadequate respect for methodological individualism. The papers in this Agenda Special Issue on health economics work to bring more standard economic method back into health policy analysis.

The full issue is here. I especially enjoyed Harrison & Robson's critique of the Australian National Preventative Health Taskforce.

Costs of Smoking: Auld edition

Chris Auld makes the very sensible point that we cannot tally smokers' costs to the public purse by simply adding up the cost of treating smokers; rather, we need to compare the total lifetime costs of smokers with the total lifetime costs of non-smokers. I'd add that we'd also have to adjust for that smokers would likely be greater health risk takers even absent smoking. That's at pretty strong variance with the procedure that New Zealand's Ministry of Health used.

But Auld raises the more interesting question: what happens if leading a healthy lifestyle winds up costing the government more because you spend longer as a superannuitant and you wind up dying of prolonged aging-related diseases rather than the quicker and cheaper vice-related diseases?

If healthy behaviors wind up increasing lifecycle health care costs, we should either subsidize less than we otherwise would, or perhaps even tax, healthy behaviors. Healthy behaviors in this scenario benefit the person exhibiting the behavior but impose costs on everyone else, and this logic demands that we discourage healthy behavior relative to whatever policies we would otherwise have enacted.

This argument does not sit well with me. I dislike the argument that we should penalize smokers because of the health care costs of treating smoking-related illnesses, and I dislike the argument that we should penalize non-smokers because of the health care costs of treating smoking-related illnesses. These external effects smack of standard pecuniary externalities—externalities that operate through market mechanisms and do not require policy to fix, although they are not conventional pecuniary externalities per se. The perverse aspects of arguing that we need to control externalities which are artifacts of government programs is illustrated more forcefully by studies which treat the cost of investigating, arresting, and imprisoning illicit drug users as external costs of drug use itself! (“We are arresting you for this doobie.” “Why?” “Because the costs of arresting you are a negative externality!”)

Cost of drug use figures that count the costs of enforcing prohibition regimes are best deemed police agitprop.

Gresham's Seed

There are lots of ways to clear a market. Specify two countries, D and N. In D, quality differentiation within a product category is allowed to generate price dispersion. Even still, some product grades face so little demand that wholesalers refuse suppliers offering it; the processing costs faced by the wholesaler would swamp potential returns. In N, not only can wholesalers not pay suppliers, suppliers are also faced with potential liability for the use of their product even when the product is exactly as was promised and performs exactly to expectation.

And so we get these fun bits of news. In Denmark:

Ole Schou, Cryos's director, said that there had been a surge in donations in recent years, allowing the facility to become much more picky about its donors. [They're turning down red-headed donors.] ...Cryos pays donors up to $500 (£316), and sends its semen to over 65 countries worldwide.

Meanwhile, in New Zealand:

While one of the world's largest sperm banks has reportedly rejected sperm from red haired men because of little demand, New Zealand sperm banks welcomed swimmers from most men, and were definitely not putting a ban on redheads, Dr Richard Fisher said. Fisher, who works for the country's largest fertility clinic Fertility Associates, said there had always been a shortage of sperm donors in New Zealand.

...But when it came to sperm donors in New Zealand, Fisher said recipients had "very little choice". He said fertility clinics in New Zealand found it particularly difficult to recruit sperm donors who were willing for their sperm to go to a lesbian couple or a single woman. It was easier to get men to donate sperm to heterosexual couples, but there still wasn't enough to meet demand. New Zealand sperm banks did not offer money to donors, which is one of the reasons why supply did not meet demand, Fisher said.

He said it wasn't a case of turning down donors in New Zealand that was an issue, but recruiting them in the first place. "It's almost as easy to get egg donors as it is to get sperm donors," he said. "And egg donors have to go through an in vitro fertilisation cycle, whereas men just have to donate their sperm."

... Sperm donors were required by law to be identifiable. Children who have been conceived via sperm donation could access their donor's details when they reached 18 years.

When you force donation price to zero and saddle donors with potential for resource extraction eighteen years down the line, donors are going to be less likely to provide samples to riskier bets; things clear by recipient queuing. Who might then donate? Maybe foreign tourists who are less likely to be hit up eighteen years later for college money. Maybe ginger donors who felt rejected in their home country and want to feel loved. Alas, Google tells me Denmark hasn't a team in the Rugby World Cup (and yes, I did have to check).

In the absence of red-headed Danish tourists, folks here in need would be stuck with local supply where a version of Gresham's Law will apply.

Previously:

• Price dispersion in gamete market surprisingly low, but still too high for some ethicists.
• Veil arguments and anonymous donation.

This week's nomination

I'm a fan of Auckland's Stats Department's "Bad Stat of the week" contest. I won their inaugural one by nominating John Pagani. I would have won another one but for lack of competition; alas.

Today's entry? Jennie Connor's trashing of a rather nicely conducted study on the health benefits of moderate drinking. Let's start with the study.

Qi Sun and a team including Eric Rimm found that moderate alcohol consumption correlates with good aging and health outcomes in middle-aged nurses in the US: the Nurses' Health Study. They follow a set of over a hundred thousand female registered nurses, starting in 1976 and surveyed every two years subsequently. It was set up to look at the long-term effects of oral contraceptive use but has been used in lots of other studies since.

They averaged reported alcohol intake in the 1980 and 1984 follow-up studies to get a measure of mid-life alcohol consumption, then checked to see whether alcohol consumption at mid-life increased the likelihood of successful aging, defined as being free of major chronic diseases and having no major cognitive or physical impairment and no mental illness.

To avoid the "sick quitter" confound, they dropped from the sample any participants who had:

• Chronic diseases at baseline
• Those diagnosed with alcohol dependence or chronic liver cirrhosis
• Those reporting a significant reduction in alcohol use within 10 years before baseline

So, we shouldn't have former drinkers who quit because of poor health included in the reference group.

Next, they worried about confounding through other health behaviours. They controlled for a wide range of dietary, health, physical activity variables and life history of smoking. When you have observations every two years on a large group of women over a thirty year period, you can do a lot. But, you still can't completely correct for things you can't observe.

What can you do? You can check to see how much of the effect is reduced when you add in all the health behaviours for which you can control. If the effect drops substantially, it's likely there are other things for which you can't control that are correlated with the things for which you can control and might further reduce things. If the effect doesn't move much, it's not likely that other health behaviours are driving things.

Table 2, above, gives the relevant comparisons. Compared to non-drinkers, the odds ratio for those consuming 1.5-3 standard drinks per day was 1.26 in a model adjusting only for age and 1.28 in a model adjusting for all the health and activity correlates. It's exceedingly unlikely that unobserved health behaviours would attenuate the effect if correcting for observed health behaviours accentuates the effect.

They also run things within a cohort restricted to never-smokers. The pattern remains, though statistical significance is lost (you don't get a lot of never-smokers among nurses in a cohort that starts in 1976).

Ok. so what does Connor bang on about then?

The idea that moderate drinking may be good for health is well entrenched, but has been increasingly questioned, including by New Zealand epidemiologists Professors Jennie Connor and Rod Jackson, who challenged the theory in Britain's Lancet journal in 2005.
Professor Connor, of Otago University, told the Science Media Centre the Harvard study added nothing to the many similar studies that were "unreliable for answering questions about the health effects of drinking because of their design".
The supposed health benefit might be due to differences in lifestyle - other than drinking - that were associated with being a low-risk drinker.
"It may be true that women who drink one drink a day are healthier than others, but we do not know if it has anything to do with the alcohol, as these women are not the same as others in a variety of ways."
There was no scientific justification for the promotion of alcohol as health-enhancing for any sub-group of the population.
"The potential for harm is great, and the potential for good is unknown."

What had Connor and Jackson warned about in the Lancet? Two things that Sun, Rimm et al do a pretty good job in ruling out: confounding of never-drinkers with former drinkers, and unobserved health behaviours.

Jennie: if it's unobserved health correlates that are doing the job, why the heck does the relationship get stronger once they corrected for other health behaviours? If some underlying "healthy type" is driving things, that'll correlate with the other health behaviours that we can observe and will reduce the effect of alcohol on successful aging, not increase it. In other specifications, there are small reductions in the odds ratio in the multivariate model as compared to the bivariate one. But the reduction is small, like from 1.43 to 1.35. If throwing in a kitchen sink of health behaviours that are likely to correlate with the unobserved health behaviours reduces the effect by less than twenty percent, it's pretty unlikely that full controls would reduce the odds ratio to 1 or less.

And so I'm nominating Jennie Connor for the bad stat of the week contest for her trashing of what seems a pretty solid study.

Fat taxes, food subsidies

Geoff Simmons is right that we oughtn't mess with New Zealand's clean GST system in pursuit of healthy eating initiatives that aren't likely to do much good. But I'll focus on the part where I disagree. He writes:

For the same cost as removing GST, every family could be given $5 for each child to spend on fruit and veges every week. This would make a much more sizeable difference to the food bill of the poor, not to mention their health.

But ultimately there is only so far that the "health-by-stealth" approach can go. Subsidising good food is certainly the most politically acceptable place to start, but it won't do the job alone.

Energy-dense, micronutrient poor food will continue to get relatively cheaper, and so the subsidy bill will have to grow to keep pace. Meanwhile, the health bill for obesity and diabetes will continue to grow.

The only way to arrest this shift is through a whole raft of other measures, the most unpopular of which will be taxing foods on the basis of the energy they contain.

After all, the biggest threat to our health now is no longer smoking, it is that we eat too much. This will no doubt raise even more fervent opposition than my mother faced at my 5th birthday party.

However, such strong actions will be the only way to deal with our biological programming to eat ourselves to death.

Astronomical excise taxes are now normal for cigarettes, and have played a huge part in getting smoking rates down in this country. A similar approach with fatty and sugary food is only a matter of time.

Where to start? First, I still don't get where the market failure is that justifies government intervention in individual diets. Bernard Hickey tweeted a potential one:

Do buyers of cheap fatty/sugary food have perfect information on the long term health costs? Is that info reflected in cost?

Nobody has perfect information about anything. So here's a short list of reasons why the information failure argument fails:

1. Information-based intervention in this kind of consumption behaviour doesn't really make sense unless information problems are greater here than elsewhere;
2. If information is the problem, interventions subsidizing information are a more direct solution;
3. It's unclear that people are choosing to eat tasty fatty things because they're ignorant about long term health consequences; it's at least as plausible that they're just weighing current consumption and making rational decisions trading off health against consumption benefits. This is consistent with the existing literature that providing health information and calorie counts has negligible effects on consumer choice

Geoff seems to be pointing to the fiscal externality argument for intervention. But most of these health-related fiscal externalities are just a transfer; further, the more efficient solution to any technological externality induced by cost-shifting would be setting actuarily fair health insurance premiums.

I'll agree with Simmons that pretty invasive measures would be needed to change behaviour; I'm just failing to see any good (by which I mean market failure) reason for them. I'll also agree with Simmons that such measures may only be a matter of time, though we may have different views on the normative aspects of the prediction.

And everything that Seamus said about GST on food also applies....

Fat Freedom

Sam Bowman writes:

Politically active groups of doctors are possibly the greatest single threat to personal freedom that there is in the UK today. Their motivation isn't necessarily their wallets, but their egos. Bullies like to use the state to push people around so they feel powerful.

The government (and the electorate, for that matter) forces people to be in the NHS. You have no choice in the matter, and you can’t opt out of it. Jamie Whyte put it well: "first the do-gooders conjure up the external costs by insisting that no one should have to pay for his own medical care, then they tell us that they must interfere with behavior that damages our health because it imposes costs on others." This is perverse and illiberal. The tax would only affect the poor – rich people's spending habits wouldn't be dented. How easy it must be for doctors to pontificate about the need for a fat tax, knowing that such a tax would hardly affect them at all.
...
This creepy, controlling paternalism has plenty of fans in politics on both sides of the partisan divide. Doctors are the politicians' enablers, lending the weight of their “expertise” to the nanny instinct of the political class in exchange for the feeling of being important. No amount of expertise – medical or otherwise – should give somebody the right to interfere with another adult’s choices. Nor should democracy be used as an excuse to violate the sovereignty of the individual. If fat people are costing the NHS money, that's a mark against having an NHS, not against having fat people.

Here's an upcoming conference to be held at Lincoln University, just down the road from Canterbury.

Public Health Association Conference Information
31 August – 2 September
Lincoln University, Canterbury

Creating our Future – Now
The conference Creating our Future – Now is about looking at what current public health practice is doing successfully to create a healthier future for all New Zealanders – across the socioeconomic spectrum. It will examine what makes environments and communities sustainable and resilient, and what it takes to come back from disaster. It will focus on the health of the country’s smaller ethnic groups, particularly the Asian community which is the country’s fastest-growing, but is often overlooked.

The conference is the biggest event on the 2011 public health calendar and will include papers from people working on issues that are current ‘hot topics’, such as:

• Income inequality in New Zealand – what it means for the gap in health status between differing groups of New Zealanders.
• Child home safety – are we tackling a “wicked problem” with tame solutions?
• Junk food sugars resistant even to regular teeth brushing
• The unrecognised value of the “Oldie Army” after the Canterbury quakes
• The harm to male-female relationships contained in beer advertising
• Casinos offering warm welcome to lonely refugees: the harm gambling does to the Asian community
• How to reach teenagers about the dangers of tanning: is technology showing the effects of premature ageing the answer?
• Healthline 10 years on: has it met its goals of saving money and helping those who don’t use primary care services – the elderly, adolescents, Maori, Pasifika and the poor.
• Growing Up in New Zealand – is intervention at birth “a bit late”?
• Diversity versus social justice – how inequities are created
• Climate change and health – what public health practitioners can do to help mitigate the worst effects
• Recovery from disaster – what can Christchurch learn from international experience?

Go check the conference website for abstracts of some of these papers. I, for one, wasn't aware that male self-identity was largely created by beer commercials. I suppose I ought to watch some rather than flip channels....

Preventing arbitrage

Pharmaceuticals are cheaper in Canada than in the States. Even in the absence of Medicare this would likely be the case; income-based price discrimination would have cheaper prices in Canada for goods characterized by very very high fixed costs and trivial marginal cost (adjusting for that the price of everything is higher in Canada). But price discrimination can only be maintained if you make it hard to arbitrage. Car trips to Canada are relatively pricey, but internet sales aren't.

How to prevent re-import this way? Beat the crap out of Google:

Department of Justice

Office of Public Affairs

FOR IMMEDIATE RELEASE

Wednesday, August 24, 2011

Google Forfeits $500 Million Generated by Online Ads & Prescription Drug Sales by Canadian Online Pharmacies

Internet Search Engine Accepted Advertisements from Online Canadian Pharmacies that Targeted U.S. Consumers and Illegally Imported Controlled and Non-Controlled Prescription Drugs into the United States

Ouch. The DoJ's argument is disingenuous though:

“The Department of Justice will continue to hold accountable companies who in their bid for profits violate federal law and put at risk the health and safety of American consumers,” said Deputy Attorney General Cole.  “This settlement ensures that Google will reform its improper advertising practices with regard to these pharmacies while paying one of the largest financial forfeiture penalties in history.” 

I call BS. Prosecution protects a price discrimination scheme and consequently works to keep drugs cheaper for Canadians; in the absence of restrictions on arbitrage, drug companies would have to charge Canadians US prices and would forgo profits in doing so.

If Google is to be policeman for international price discrimination regimes, I wonder what Google's policing costs are.....

This Hour costs 22 minutes

Another result I don't believe:

The amount of TV viewed in Australia in 2008 reduced life expectancy at birth by 1.8 years (95% uncertainty interval (UI): 8.4 days to 3.7 years) for men and 1.5 years (95% UI: 6.8 days to 3.1 years) for women. Compared with persons who watch no TV, those who spend a lifetime average of 6 h/day watching TV can expect to live 4.8 years (95% UI: 11 days to 10.4 years) less. On average, every single hour of TV viewed after the age of 25 reduces the viewer's life expectancy by 21.8 (95% UI: 0.3–44.7) min. This study is limited by the low precision with which the relationship between TV viewing time and mortality is currently known.

If people who watch six hours of daily television differ from other folks on margins other than TV-viewing, results here just might be overstated.

The paper just extrapolates to some actuarial tables the results of a prior article in Circulation. A couple things there to note:

• There are no significant reported effects, after correcting for some health-related behaviours, for those watching less than four hours of television per day. And, saying that an hour costs 22 minutes is a bit nuts when the reference category is folks watching 2 hours of TV per day or less. Maybe there are effects for the "more than 6 hours per day" group. But that's hardly the same as saying that an hour of TV costs the moderate viewer 22 minutes.
• The all-cause mortality relative risk even for folks in the >4 hour per day group has a confidence interval running from 1.04-2.05 after adjusting for those health behaviours that could be observed. That's almost touching the 1.0 mark; when the CI spans 1.0, results are insignificant. I wonder what would happen to those CIs on adjusting for more health behaviours.

HT: Alex Robson, who points to this journalistic account...

And MoH responds

I'd sent an OIA request on MoH's decision just to blank out the reference to Rimm and Moats 2007 and to replace it with a reference to another paper more sympathetic to their argument. Here's the result:

OIA 07-2011 Rimm and Moats MoH

They include a short document which I'd not before seen (starts at p. 12 of the attached file) outlining why NZ's Ministry of Health deems there to be no cardioprotective effect of alcohol consumption:

1. Confounding with healthy lifestyles: moderate drinkers have more healthy lifestyles in general
   • There is no way that this is substantial. From Rimm and Moats, which you'll recall is the piece MoH had cited as proving its opposite:

     To address the issue of residual confounding by healthy lifestyle in drinkers, in a large prospective study we restricted analysis to only “healthy” men (who did not smoke, exercised, ate a good diet, and were not obese). Within this group, men who drank moderately had a relative risk for CHD of 0.38 (95% CI, 0.16–0.89) compared with abstainers, providing further evidence to support the hypothesis that the inverse association of alcohol to CHD is causal, and not confounded by healthy lifestyle behaviors.

2. Sick quitters
• But the whole point of Rimm and Moats is that the sick quitters hypothesis doesn't eliminate the J-curve. Again from Rimm and Moats:

  The “sick-quitter” hypothesis and the concern that moderate drinkers lead a healthier lifestyle may explain a small proportion of the benefit attributed to alcohol in some studies, but recent studies which have removed sick quitters, updated alcohol and covariate information on diet and lifestyle factors, and separately documented benefits of alcohol among healthy and unhealthy populations further add to the evidence that moderate alcohol consumption is causally related to a lower risk of CHD.

3. Surveys giving average levels of drinking may mask heterogeneity in drinking patterns: 14 drinks per week could be two binges or a couple of glasses of wine per night.
   • Yeah, sure. But that gives us attenuation bias. If we're finding a substantial J-curve despite that some folks classed as moderate drinkers might really be folks who binge a couple times a week, doesn't that suggest that the health benefits of the couple of glasses of wine per night are understated?

What does MoH cite in support? Middleton Fillmore et al 2006, which tries to do what Castelnuovo and Donati did but with what feels like cherry-picking of which papers counted as high quality for their meta-study - all of their results on cardio hinge on which two studies they deemed high quality in evaluating the effects of alcohol on heart disease. Middleton Fillmore et al 2007 which is just a gloss on Middleton Fillmore et al 2006. Mumaki and Rimm 2001. That's a fun one. What did Mumaki and Rimm 2001 say?

This article has explored whether alcohol consumption per se is responsible for the lower risk of coronary heart disease among moderate drinkers. Based on the results of the meta-analysis of randomized trials by Rimm and colleagues (1999), the answer appears to be yes. If alcohol consumption indeed influences HDL-C, triglyceride, and fibrinogen levels to the degree documented in the meta-analysis, consumption of two standard drinks daily would be expected to lower a person's risk of coronary heart disease by nearly 25 percent, a figure that agrees well with the results of observational studies.

Sure, Mumaki and Rimm refrain from suggesting folks start drinking for their health, but MoH is here citing them on heart disease. And there's no equivocating in Mumaki and Rimm on effects on heart disease. Does MoH even bother reading the articles they cite? Or do they just assume what must be in the article based on its title? Doesn't much matter; when you call them out on it, they just delete the cite and replace it with a friendlier one. MoH isn't engaging the literature; they're playing fill-in-the-blanks looking for cites that support what they already want to say.

They then cite Middleton Fillmore et al 2007 again as showing there's no j-curve in all-source mortality. Middleton Fillmore's results there hinge on seven studies they deemed sufficiently high quality out of more than 50. I would love to hear MoH's reasons for preferring Middleton Fillmore over either di Castelnuovo or Corrao or Rimm and Moats. Is it just the conclusion? In the absence of any discussion by MoH of failings in di Castelnuovo, Rimm and Moats, or Corrao, my money's on conclusion-seeking.

While they talk about alcohol's potential carcinogenic effects, that's a sideshow. What matters is all-source mortality. That's all that can matter when evaluating the overall mortality effects of a substance that helps with some disorders and hurts with others. And that's a scrap between di Castelnuovo / Rimm & Moats and Middleton Fillmore. Rimm & Moats only address coronary heart disease, but that'll be the big one for the J-curve and they show that the J-curve in cardio is massively robust to controlling for sick quitters and for healthy lifestyles. Nowhere does MoH give me a reason to trust Middleton Fillmore over either Rimm & Moats or di Castelnuovo.

Reading through the set of documents, it looks like they read my complaint as being "you're citing the wrong thing in support of your argument" rather than as being "Even the thing you're citing in support of your argument proves the opposite; look again at the science." There's zero evidence of anyone anywhere in MoH having read Rimm & Moats; instead, they just found a reference to Middleton Fillmore to throw in instead.

I don't think I ever received the letter MoH penned for Ryall (p. 23); a lot of stuff got lost in the shuffle around the September earthquake. But Ryall's clearly not getting very good advice from his Ministry on this one.

Previously:

• The J-Curve: Science vs Politics
• How do I love the Ministry of Health? Let me count the ways...
• The J-Curve
• Moderate drinking and health
• Results I don't fully believe

A reasonable nudge

I've two main worries about nudges. They're often a fair bit more coercive than the word "nudge" suggests; and, if they fail to yield the planners' desired outcomes, they may only be harbingers of more forceful interventions.

But this one seems exceptionally mild: drivers in the UK are required to tick either Yes or No in the box indicating whether they'd agree to be organ donors when getting their drivers' licences renewed. The story says similar moves in Illinois did wonders for donor enrolment.

I don't think a similar move in New Zealand would do much absent legislative changes requiring that organ transplant units deem licence enrolment constitute informed consent. From the NZTA FAQ:

Your driver licence is not informed consent

If you've indicated on your driver licence that you wish to be a donor, this does not count as 'informed consent' for your organs and tissues to be retrieved for transplant purposes in the event of your death.

If a person gives 'informed consent', this means that they have enough information to fully understand what they agree to, and that their agreement is given willingly. It's very difficult to prove the circumstances or level of knowledge a person had at the time of making their licence application.

Discuss your decision with your family

Ticking the 'Yes' box on your driver licence form only means that you have indicated your wish to be identified as an organ and tissue donor. It does not automatically mean that your organs or tissues will be donated in the event of your death. In practice, your family will always be asked for their agreement to organ and tissue donation.

If your family knows what your wishes are in regard to donation, they will be more likely to follow them through in the event of your death. Having your wishes displayed on your driver licence is just one way of making them known to your family. You should also discuss your decision with them.

If you would like to donate certain organs or tissues but not others, make sure that you discuss this with your family, too.

A "No" effectively counts as informed consent; a "Yes" doesn't. Great system.

A public responsibility?

When we have a public health system, and when folks worry about costs others impose through the health system, all kinds of private behaviours have external effects. Will Wilkinson rightly chastises Mark Bittman's food nannyism:

Before getting to the problems with Mr Bittman's price-fixing plan, let's ask why this might be thought a legitimate function of government? Mr Bittman says:

[P]ublic health is the role of the government, and our diet is right up there with any other public responsibility you can name, from water treatment to mass transit.

"Our diet"? Interesting. Try this: Our pattern of sexual conduct is a public responsibility. Or: Our convictions are a public responsibility. Right up there with dog-catching, even! After all, one can come down with a killing disease rogering the wrong lad or lass. Moreover, wick-dipping is the leading cause of new citizens, many of whom will turn out to be a net drain on the public purse. Can we afford to continue allowing just anyone to inseminate just anyone? To ask this question is almost to answer it. And how about our convictions?! If folks get their heads full up with wrong notions, they might want to invade Yemen, vote Republican, draw to an inside straight, or eat a Twinkie, to the detriment of us all.

Wilkinson is right to use the reductio. But that can be dangerous; not long after I used mandatory ski helmets as reductio, I started seeing proposals entreating that mandatory helmets would save lives. When I wrote in the NZ Med Journal about the logical end of seeing public health costs as being basis for policy - bringing one's sex life from the private to the public realm - earnest healthists replied that they've happily prescribed subsidised condoms. Setting up signposts about what's logically implied by positions might well be taken as suggestions of where to go next....

Offsetting effects: food police

According to foodservice consultancy Technomic, consumers are also being driven to excess by cultural moralizing over nutrition. That is, as expanding waistlines make more headlines (in Canada, 62 per cent of people are considered overweight, with a quarter qualifying as obese), proselytizing over healthy eating has led many folks to do the opposite.

"Most consumers, when polled, say they follow their 'own diet.' That could mean that they're good Monday through Friday, and then on Saturday and Sunday say, 'To hell with it!'" says Ron Paul, president of Technomic. "They're rejecting the food police, in effect."

Some of the more punk-rock offerings this summer include the aforementioned doughnut burger; pancake breakfast ice cream, featuring maple syrup, chunks of buttermilk pancake and bacon; deep-fried Pop Tarts; mac-and-cheese pizza; and a Monster Burger -- one kilogram of beef, half a pound (0.2 kilogram) of bacon, spiced cheddar cheese and all the fixings -- big enough to feed a family of eight.

From the Winnipeg Free Press, HT: Mom.

Sorting out causality on this one would be tough; I don't know how you'd instrument around that places with more nanny messages are likely the places with worse eating habits ex ante. But fun nevertheless.

And the deep-fried butter discussed in the article does sound tempting....

Academic hype

Is there anything that the healthists at Otago get up to that doesn't call for a press release? This time, Tony Blakely wrote an op-ed for the New Zealand Medical Journal. Press release! An op-ed!

I'm going to have to talk to Canterbury's publicity folks. I've had a couple op-eds in the NZMJ and another short piece but Canterbury's never reckoned an op-ed in the NZMJ warranted a presser. I don't think I've seen Canterbury media releases on anybody else's op-eds either though. The bar here's just a tad higher than that. Good thing too, or I'd be pushing the press guys for a media release for every blog post.

Blakely's on about health inequalities again. I'm with Tony on caring a lot about bad health outcomes for folks in the lower income deciles. But I've never cared about health inequalities per se; if I did, forcing healthy higher income folks to donate kidneys to poor folks on dialysis might start sounding like reasonable policy.

I'm also nervous about ascribing too many of the measured health differences across income cohorts to income differences. The same factors that give rise to income differences may themselves cause differences in health outcomes. Linda Gottfredson points to general intelligence as a fundamental underlying confound in the health-income literature: effects of income on health status are strongly attenuated when we correct for intelligence. That gives strong reason for differential targeting of health interventions for lower decile populations but also, as I've noted before, ought to make us reluctant to draw strong conclusions about the potential for reducing health inequalities through measures like heavy income redistribution. But that's Blakely's first recommended policy:

Ten next most important actions to reduce health inequities in Aotearoa New Zealand

1. Equitable and fair fiscal and social welfare policy, including progressive taxation, comprehensive and fair social policy, and ensuring that everyone has a minimum income for healthy living. Policy needs to be proportionate to need – what is termed proportionate universalism in the Marmot Review 9, or a balance of targeting and universalism.

As for the rest of the list, I'm a bit worried that Blakely's proposed  policies may work at cross-purposes. I'm not sure that "Aligning climate change, sustainability and pro-equity policies" ought be anywhere near a top-ten priority list for dealing with poor health outcomes among low-decile Kiwis. And country-wide bans on smoking and regulation of food salt content (priority 6!) probably are a bit broad, especially since the Cochrane Review's finding that reduced salt intake doesn't really help anything. If Blakely's push for higher incomes among lower deciles may be inconsistent with his preference for lower unemployment, depending on the specific policy proposed. Higher minimum wages won't do it, but wage subsidies might. It's not unreasonable to conclude that the Top 10 list (in the press release) reflects a few goals other than just improving health outcomes among low income folks.

But there's stuff to like too in Blakely's op-ed. We'd probably do well to shift resources by increasing the age of superannuation eligibility and redirect the resources towards interventions targeting low-decile child health. I could be convinced to push the button for that. The Ministry of Health's recent push to increase vaccination rates among Maori (here too) is probably one of the most cost-effective things it's done lately.

HT: Ed.co.nz, who always finds a way of getting me angry in the morning.

How do I love the Ministry of Health? Let me count the ways.... [updated]

Ok, not very much.

Readers will recall that I jumped up and down a bit last year about the MoH pulling a fast one in its Nutritional Guidelines for Older People. In short, they cited Rimm and Moats, 2007, as providing evidence that uncontrolled confounds eliminate measured coronary health benefits of moderate alcohol use when in fact Rimm and Moats prove the exact opposite: they show that controlling for those confounds only mildly reduces the J-curve effect.

I emailed MoH, I sent a sharply worded letter to Tony Ryall's office. I didn't hear anything back other than a perfunctory note saying that Ryall had received my letter.

Today I went to check the nutritional guidelines. My old link didn't work for some reason, but I was able to find it here. And lo and behold, they've made a slight change. Did they get rid of the section saying there's no J-Curve? Did they note the new evidence showing the J-Curve to be robust to the prior confounds? Oh, loyal readers, you know our Ministry of Health better than that. They just deleted the reference to Rimm and Moats 2007 from that paragraph while keeping all of the shouting about how there isn't a J-Curve; they instead referenced Middleton Fillmore et al 2007.

Ok. So what does Middleton Fillmore et al 2007 say? They've a metastudy where they claim that high quality studies that separate out abstainers from sick quitters shows no J-curve. But all of their results hinge on the two studies that they deem as being of high quality for coronary heart disease and seven for all-source mortality. By contrast, Di Castelnuovo and Donati's 2006 metastudy compared results in 21 papers results that lumped light and former drinkers with abstainers against those from 27 papers results that specifically excluded light and former drinkers from the reference category. Sorry, but the latter result's just more robust.

Bottom line, Ministry of Health, when they figured out that they were citing a paper that provided contrary results instead of the results they liked, nixed the cite and threw in one that gave them better results, utterly ignoring contrary evidence from more robust studies. Again, the kind of thing that would have me chastising an undergrad or hauling a grad student into the HoD's office for academic dishonesty. But academic dishonesty is the norm at MoH.

Oh, and there's still a reference to Rimm and Moats (2007) in your paper, MoH. It's at page 104:

Methodological issues that suggest the protective effects of alcohol on cardiovascular health may have been overestimated include:

• difficulties categorising amounts and patterns of drinking, and in choosing an appropriate
  reference category to measure drinking against (Emberson and Bennett 2006)
• the inclusion of people reducing or stopping their alcohol intake (often associated with
  ageing or illness) in the ‘abstainer’ category for data analysis, which may have overestimated
  the protective effect of alcohol, as it is not the absence of alcohol that increases the risk of
  cardiovascular disease but ill health ([Middleton] Fillmore et al 2007)
• uncontrolled confounding of healthy lifestyle factors among light to moderate drinkers, such as healthy eating and physical activity (Jackson et al 2005; Rimm and Moats 2007).

MoH pulled the quote I'd highlighted, pulled Rimm and Moats from the bibliography, but forgot to run a full text search to see whether they'd cited Rimm and Moats elsewhere in the paper. They can't even cheat right. [Note, I've saved the PDF of the current version and probably have the old one saved somewhere too. It pays to be a pack-rat when the Ministry of Health runs a memory hole.]

Why oh why can't we get a better Ministry of Health?

Update: I sent the following OIA request and will let folks know what comes of it.

In terms of the Official Information Act, please provide all internal and external memorandums, emails, file notes and written notes regarding the revision of the 2010 Nutritional Guidelines for Older People to delete the reference to Rimm and Moats (2007) from section 4.15 of those guidelines. The reference was present in the Guidelines in August 2010 but has since been replaced with an alternative.