Nanny ascendant

Kiwi healthists have been busy this past week.

Here's more from Doug Sellman on soft drink addiction (and other addictions):

People needed to find an activity pleasurable to want to repeat it. If they repeated it enough, it would become a habit, which could then become an addiction.

"As they're doing that there are genetic switches that change free will into a dehumanised state of drug craving and compulsion."

Christchurch-based researchers at the University of Otago developed a new list of 49 foods people should avoid and published their findings in the New Zealand Medical Journal earlier this year. The list is of the most addictive foods, Sellman said.

The foods were energy and calorie dense, high in fat and/or added sugars, prepared using a high fat cooking method such as frying or roasting, or low in essential nutrients.

They included muesli bars, ice cream, cakes, chocolate, doughnuts, jam, honey, pies and pastries. Energy drinks, cordial and fruit drinks also made the list. [EC: updated the link to one that works, emphasis added]

Sellman says those 49 foods are the most addictive. The list includes quiche, sausages, salami, and muesli. If I eat enough quiche, I could trigger genetic switches that will turn me into a dehumanised craver of quiche.* We really ought to remember how Sellman sets the bar on addiction whenever we read him about what has to be done about alcohol, tobacco, fatty foods, soft drinks, muesli, or pastries, or when he compares companies selling unhealthy food to drug dealers. Human agency disappears in his model pretty quickly.

Meanwhile, the anti-tobacco folks are pushing not just for plain packaging, discussed last week, but also for some seriously large excise tax increases. 3 News says the Ministry of Health is pushing for $100 per pack prices. And, helpfully, they've linked the OIA-released MoH advice to the Minister of Health.

The MoH document wasn't nearly as bad as I'd expected.** Instead, it looks like they've commissioned NZIER to do some work on what would actually be necessary to achieve the National-led coalition's goal of a tobacco-free New Zealand by 2025. Unsurprisingly, it'll take some pretty big policy changes: large tax increases, lots of anti-tobacco advertising, and potentially stronger alternative measures. I think at paragraph 6 they might be alluding to tobacco by prescription only when they say "At what point might it be preferable to consider alternative approaches, eg. a new regulatory regime that stringently controls tobacco as a highly toxic, hazardous substance and/or as an extremely addictive, harmful drug?"

At paragraph 54, MoH notes the potentially regressive nature of the excise increase but argues "although the tobacco tax is of itself regressive, increases in the tobacco tax are actually progressive." This might actually be true at the tax levels they're talking about. Marginal changes in tobacco excise are highly regressive; few people quit relative to the increase in tax paid by poor smokers who continue smoking. The O'Dea report said that even a 50% increase in tobacco prices would see 36,990 non-quitting Decile 1 households each spend an extra $928 per year while an estimated 4,110 quitting Decile 1 households would save $2,981; the poorest cohort then winds up spending a net extra $22 million in tobacco excise while decile 10 households spend a net extra $31 million. Excise hikes of the magnitudes being thrown around could conceivably wind up reducing total tobacco excise paid by low decile groups. But they would have other problems:

A leading academic says an extreme increase in the price of cigarettes could lead to black market dealing.

Speaking in response to a Ministry of Health discussion to raising the cost of a packet of cigarettes to $100 over the next eight years, Otago University health economics lecturer Des O'Dea said: "We all remember the days of prohibition in the United States and what that did to foster organised crime."

"While I don't think it would be anywhere near the scale of that, we could well see raids on retailers and a black market develop for cigarettes," he said.

I don't put a lot of weight on concerns that plain packaging legislation would lead to counterfeiting and smuggling; at least I'm not yet convinced of it. Is it really that hard currently to print fake labels for cigarette packets or to put anti-counterfeiting features into plain cigarette packs? But $100 packs of cigarettes have to yield a fair bit of home-grown tobacco outside of the excise regime and a fair bit of smuggling.***

Hopefully making it clear just what is needed to achieve the SmokeFree 2025 goal will have the government think again about the whole thing.


* I choose to avoid this risk, preferring the perilous whole milk and butter. I fear for Seamus though.

** I've read it twice, and I can't find a single reference to the "costs of smoking" number that MoH had been pushing a couple of years ago. Matthew Everett's the MoH contact person on the briefing document and is presumably the same Matthew Everett with whom I'd had fairly extensive discussion about the MoH's figure at the time. I'm glad to see that MoH doesn't seem to be pushing that figure any longer in its policy recommendations.

*** For both alcohol and tobacco, if anybody has ever seen estimates on the elasticity of informal supply through home production or smuggled goods with respect to excise changes, I'd love to see it. I worry that measured estimates of price elasticity of demand might overstate actual consumption decreases if there are reasonable shifts into illicit supply.

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.

Upcoming Sydney engagement

I'm giving a talk in Sydney at the Centre for Independent Studies tomorrow night. If you're in Sydney, please do hit the link to RSVP and say hi after the talk. I'd love to be able to put faces to more of my readers, especially the folks who show up in the comments section.

I'll be talking about paternalism. The work I've done on social costs of alcohol (and other sins) will show up, as well as more general discussion on how the framing of paternalistic policy in terms of economic social costs short-circuits public debate about the extent to which government should be doing things to us for our own good.

Misquoted?

Can this really be an accurate quote?

The cancer society has issued its own a clarion call to municipalities, asking them in a position paper to “join the growing trend” of smoke-free outdoor bylaws. The Canadian Council for Tobacco Control says outdoor bans protect families, and that even passing exposure to second-hand smoke is harmful, despite the “false sense that smoke blows away.”

“Smoking is not one of our rights and freedoms,” said Robert Walsh, the council’s executive director. “In a socialist country like Canada, we want regulations that will help people make the choices that will help the common good. It’s part of our culture.” [emphasis added]

I'd thought the anti-tobbac were working hard to avoid the issue's being framed as one of personal liberties versus collective control. Maybe Walsh didn't get the memo.

No slippery slopes

The case for taxing sugar builds explicitly on the work done in the anti-tobacco and anti-alcohol public health movements. Here's the latest from Nature.

HOW TO INTERVENE

How can we reduce sugar consumption? After all, sugar is natural. Sugar is a nutrient. Sugar is pleasure. So too is alcohol, but in both cases, too much of a good thing is toxic. It may be helpful to look to the many generations of international experience with alcohol and tobacco to find models that work ^8,9. So far, evidence shows that individually focused approaches, such as school-based interventions that teach children about diet and exercise, demonstrate little efficacy. Conversely, for both alcohol and tobacco, there is robust evidence that gentle ‘supply side’ control strategies which stop far short of all-out prohibition — taxation, distribution controls, age limits — lower both consumption of the product and the accompanying health harms. Successful interventions share a common end-point: curbing availability ^2,8,9.

Taxing alcohol and tobacco products — in the form of special excise duties, value-added taxes and sales taxes — are the most popular and effective ways to reduce smoking and drinking, and in turn, substance abuse and related harms ². Consequently, we propose adding taxes to processed foods that contain any form of added sugars. ...

Other successful tobacco- and alcohol-control strategies limit availability, such as reducing the hours that retailers are open, controlling the location and density of retail markets and limiting who can legally purchase the products ^2,9. A reasonable parallel for sugar would tighten licensing requirements on vending machines and snack bars that sell sugary products in schools and workplaces. Many schools have removed unhealthy fizzy drinks and candy from vending machines, but often replaced them with juice and sports drinks, which also contain added sugar. States could apply zoning ordinances to control the number of fast-food outlets and convenience stores in low-income communities, and especially around schools, while providing incentives for the establishment of grocery stores and farmer’s markets. ...

Government-imposed regulations on the marketing of alcohol to young people have been quite effective, but there is no such approach to sugar-laden products...

With enough clamour for change, tectonic shifts in policy become possible. Take, for instance, bans on smoking in public places and the use of designated drivers, not to mention airbags in cars and condom dispensers in public bathrooms. These simple measures — which have all been on the battleground of American politics — are now taken for granted as essential tools for our public health and well-being. It’s time to turn our attention to sugar.

And who's next in line after sugar? Remember that the anti-tobacco folks disarmed opposition in the 90s by insisting that there was no next in line.

"They use the 'slippery slope' argument. 'My God, if they can do this to smokers today they can do this to people who eat Haagen-Dazs ice cream or whatever."

I think it's safer to assume that there's no logical end to the line. Every behaviour has health consequences, and if there's a public health system, somebody will say regulation's warranted.

There's a good case to be made for abolishing the combination of American agricultural subsidies and sugar tariffs that together result in substitution from sugar to fructose, but the case for that would be independent of nutritional qualities of fructose and sucrose. There may be a case for changes to USDA nutritional recommendations. But let's not forget that it was the USDA's war on fat that helped prompt the shift to high-carb and higher fructose diets in the first place.

Anti-paternalism

Dr. Michael Keane writes in the IPA Review:

Consider a low-socioeconomic status individual who is smoking, drinking, gambling, eating junk, spending on frivolous retail purchases (a ‘shopping addict’) and having indiscriminate sex (‘sex addict’). Does she or he really employ sophisticated risk management equations and decide that the benefits outweigh the costs?

Arousing public anger at those deemed unworthy of the privilege to make choices is a dangerous tactic. However, it is probable that many of the more vocal public health academics do genuinely believe that they, the elite, have a paternalistic duty to control the incapable masses.

As every dysfunctional behaviour can, without many inferential steps, be related to health expenditure, appeals to such imperative have few logical limits. The folly of enforcing interventions against peoples’ will on the basis of economic analyses of the cost to the state is obvious, and educated health professionals should know better than to use such divisive and emotive arguments.

If the growth of the Nanny State is to be curtailed, policy makers must have the confidence to stand firm against the mutton of opinion even when it is dressed up as the lamb of science.

Hear hear.

Even worse, most numbers cast as representing social costs, which most folks interpret as costs to them via the state, consist almost entirely of costs borne by drinkers, smokers, and gamblers themselves. The healthist beancounters don't just assume that the addicts fail to employ cost-benefit analysis; they rather assume that such consumption has no associated benefits. That's how they get to count private costs as being social. Any evidence of potential market failure through imperfect information or irrationality is taken as sufficient reason for dismissing all potential consumption benefits. The argument of course proves too much.

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.

Food Bill revisited

I wish I knew the likely effects of the upcoming food bill. NZCPR asked me for a short piece based on my prior post; here's what I gave them. One link didn't make it through there: 3 News on the Food Bill.

I wonder whether both Minister Kate Wilkinson and the bill's critics couldn't both be right. If the current de jure rules aren't strenuously enforced against small traders, or only are so irregularly, then the de jure loosening of restrictions on small traders could be a de facto toughening if enforcement is tightened.

Radio New Zealand last week featured one small cheese producer on the costs of the prior regime and her worries about the new one. Minister Wilkinson's comments there really aren't reassuring. [HT: Gonzo] She emphasizes that even small-scale cheese-makers will come under the regulatory apparatus:

The cheese that's produced from three cows or three thousand cows is still expected to be safe. ... We want the Biddies [cheese-maker Biddy Fraser-Davies] of this world to keep producing fantastic cheeses, but we also want that cheese to be safe.

But let's recall that the vast majority of costs of food-borne illness are the individually borne intangible costs of being sick. Those costs are very real and the Applied Economics study tabulating them seems pretty sound. But why oughtn't I get to choose to buy cheese from a small producer and take that individual risk without Wellington getting involved? The costs of head injuries from skiing may well be high, but if I'm the one bearing them, oughtn't I be the one who decides to wear a helmet? Wasn't this supposed to be the government of individual responsibility that defeated Helen Clark's Nanny State?

Wilkinson worries about ensuring that people can be confident in the local food system. If information asymmetry is the problem, all the government needs to do is give out stickers to producers wishing to produce under regulatory guidelines so that they can advertise as such; absence of that certification then says you have to be sure you can trust the producer. And, anybody who's paranoid about food poisoning can always choose to purchase from big producers at supermarkets instead of small guys selling home-made stuff at farmers' markets. And, frankly, I'll trust Biddy Fraser-Davies, the small cheese producer interviewed, over Wilkinson's bureaucrats.

I wrote for NZCPR:

Perhaps worse than my potential loss of choice as consumer is the loss of an easy pathway to small-scale entrepreneurship. Even if the monetary costs of registration as a food producer are low, Wellington often weighs too lightly the discrete hurdle thrown in front of a potential entrepreneur who has never otherwise had to worry about compliance regimes. The dread costs of figuring out which forms to fill out, and the fear of getting something wrong, can be very real barriers to would-be new small-scale entrepreneurs. When you’re really not sure if you’ll be able to make a go of a new venture, adding a hurdle of having to seek permission can provide a burden much larger than the nominal $50 registration fee.

Muriel Newman at NZCPR (link currently here, but likely to suffer linkrot) also comments:

For a government that claims to be committed to encouraging wealth creation and reducing compliance costs on small business, the Food Bill could be a major step backwards. It appears to be being driven more by bureaucratic considerations rather than the need to encourage entrepreneurship in the food sector - within the bounds of stringent food safety imperatives. It is also not clear what the answer is to a fundamental question that should be asked of all new legislation: Is there a problem to be fixed and if so will this Bill fix it?

At least raw milk doesn't seem likely to be killed under the new bill.

Evidence and Tobacco

Action on Smoking and Health told us evidence for banning "powerwall" retail tobacco displays was overwhelming. They said legal challenges against such retail display bans in other jurisdictions failed "as the health benefits of eliminating advertising are overwhelming." Indeed, "[a] total ban of tobacco product displays, together with other measures, is required to achieve the goals and objectives set in the five-year plan of Ministry of Health for tobacco control." The evidence is overwhelming and a ban is necessary. Ok.

So it's fun to read Professor Richard Edwards's plenary address to the Oceania Tobacco Control Conference in Brisbane of last October.

[W]hen Janine Paynter and I carried out a systematic review in 2009 of the evidence on point of sale (PoS) displays, there were some obvious weaknesses and gaps. For example, all but one of the observational studies investigating links between exposure to PoS and children’s smoking were cross-sectional (and hence have limitations in determining direction of causality) and many were carried out in California, which had some important differences in the policy context limiting the application of the findings to other settings. Experimental studies are hampered in many ways e.g. by the difficulty of replicating ubiquitous and recurring exposures like PoS displays in an experimental design. Use of self-reports of the impact of PoS on smoking, purchase and quitting in a variety of study designs have some obvious possible limitations. There was no peer-reviewed evidence from the evaluation of PoS bans in jurisdictions like Canadian States, Iceland and Thailand. Even now there is only published evidence from one jurisdiction, Ireland, and then from a somewhat poorly resourced evaluation carried out after the event with funding cobbled together from sources mainly from outside of the country. 

So a total ban on retail displays was required, but there wasn't really any evidence for it. As for plain packaging, which is likely on the horizon for New Zealand:

Plain packs have not been implemented, so evidence of the probable population impact must come from experimental studies, focus groups, surveys and so on; rather than rigorous controlled studies of the impact of the actual intervention in the real setting, as would be the ideal.

We can learn from those kinds of studies; we just need to be a bit cautious in extrapolating to population-level effects from them. It would be surprising if evidence coming from those studies would be sufficient to say anything like "The evidence for plain packaging is overwhelming; it's necessary, along with other measures, to achieve objectives...". So keep an eye out for ASH's eventual submissions on eventual plain packaging proposals.

Edwards' whole address is worth reading. Some highlights:

• Comparing the 1996 and 2006 censuses, there's been a drop in smoking prevalence among 14-15 year olds but no change in uptake among young adults. Excise tax did rise substantially over the period. Edwards says the "evidence base" for successful interventions in the older cohort is weak, "and the ethical and moral framework to justify some interventions is less clear cut." We'll have to remember that when interventions are proposed.


• He cites increased "social smoking" among young adults - folks that might have a cigarette while out drinking, but otherwise don't smoke. I'd find it a bit surprising if that level of smoking resulted in substantial negative health effects. Says Edwards "The frequency of XS alcohol consumption, and its role in promoting uptake and maintenance of smoking and undermining quitting, suggests co-interventions may be needed and that we cannot tackle smoking in isolation." So anti-alcohol policy may be part of anti-tobacco policy...stay tuned.


• Edwards worries about FOREST's framing of tobacco control as an issue of freedom versus authoritarianism; he later suggests emphasizing "how tobacco control measures are pro-freedom by freeing smokers from an unwanted addiction, and by protecting our children from the risk of addiction and premature death." I can buy arguments about the conflicting freedoms of smokers and non-smokers in public spaces, but framing pure paternalism as being freedom-promoting is Orwellian. 


• Despite spending a fair bit of time talking about the importance of de-normalizing tobacco, he then says:

  We need to be very careful that interventions do not stigmatise smokers. Once again this involves keeping in close touch with how smokers are feeling through in-depth research. These quotes show how the experience of stigma among smokers and practice of stigmatising behaviours can be very real. This reduces support among smokes (and also among non-smokers) for tobacco control and the tobacco free vision, and may drive smokers together in a sort of Dunkirk spirit against the perceived assault from a marginalising society or harden the determination of smokers to smoke, as encapsulated in this last quote. We should be anti-smoking, but never anti-smoker.

• He wonders whether achieving tobacco-free goals given broader societal failings:

  Can we achieve tobacco free goals among Pacific, among Māori, among aboriginal communities without wealth redistribution, without equalisation of power? The answer is uncertain, but it is certainly a strong argument that we in tobacco control need also to be at the forefront of campaigns for wider social and political justice. The additional advantage is of course that addressing the broader social and economic inequalities will also benefit a whole range of other public health issues such as excessive alcohol use, accidents and obesity and the related morbidity and mortality.

  I'm reminded of Edwards' colleagues' argument for massive income redistribution in order to reduce disparities in life expectancy. But I love that he wants explicitly to link large-scale intervention in your private life in anti-tobacco policy with large-scale intervention in the economy and social justice. It helps us remember that the pro-freedom or pro-intervention framing is the right one.

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.

Bennett's (hopefully not Last) Stand

Joe Bennett ably defended his right to live in his own home today on Radio NZ. Council claims his home stands in extreme danger of rockfall, but has refused to provide him any evidence to substantiate the claim. By his assessment, there is negligible risk. Here's the Press story.

The Council's "Regulation and Democracy Manager" now promises to arrange for that Bennett be able to chat with their geotech engineers. But he also threatens a court order.

I love Joe's stand in favour of individual autonomy and liberty:

The Council is not responsible for my personal safety. It is not a public safety issue as they claim. It is a private safety issue... I can understand their legal fear of being held in the gun... but I accept responsibility for my fate. I could go and climb Mt. Cook naked singing the Hallelujah chorus and the Council won't stop me and nor should they... please, I don't need another mother!"

I've also enjoyed Joe's series of columns in the Christchurch Press in which he warns Council of the Bulgarian transvestite sniper who lies in wait for their officials.

Nova Scotia reductio

I'd suggested mandatory ski helmets as the the absurd end of the logic requiring the internalization of costs externalized by the public health system. There was a brief subsequent push for mandatory helmets in New Zealand, but it came to nothing.

But Nova Scotia's going to go there. Here's Chris Selley at the National Post:

Nova Scotia bolted into the lead this week in the epic race among North American jurisdictions to make us slightly safer - barely overtaking King County, Wash., which in June banned swimming and wading in rivers without wearing a life jacket.

Bill 131, tabled Tuesday at the House of Assembly in Halifax, would make it illegal to ski or snowboard without a helmet, effective Nov. 1, 2012. A helmet cuts the risk of head injury by at least 60%, according to a news release from the Nova Scotia Department of Health and Wellness. And Minister Maureen MacDonald assures me there will, indeed, be helmet cops on the slopes. The minimum fine is $250.

Ms. MacDonald offers two justifications for this: brain injuries, and the terrible consequences they often entail; and the money it costs to treat them. According to the province, a "traumatic brain injury" costs roughly $400,000 a year to treat. And since 2000, 11 helmetless skiers and snowboarders have suffered such an injury on the slopes of Nova Scotia. Call it one a year.

Selley starts pushing to see how far Nova Scotia Health Minister Maureen MacDonald will toboggan down that slope:

People who slide quickly down mountains put a huge burden on the public health system, if you're inclined to look at it that way - I'm certainly not, but clearly many Canadians are - and that will still be true when the last dinosaur buys a helmet. Most snow sports injuries aren't head injuries anyway. All four people who died at Canadian ski resorts last season were wearing helmets.

So, aren't we trying to save lives? Aren't we trying to save the healthcare system money?

"This legislation doesn't ban skiing," says Ms. MacDonald, sounding a bit exasperated.

According to her own logic, and in her own words, I have to ask: Why not?

My short answer: social stigma doesn't yet attach to skiers. Politically disfavoured groups that impose costs through the public health system see taxation, regulation, and eventually bans on activity. Tobacco's nearing the end of that slope, alcohol's moving along, and fat people are next at the gate. Bans don't come until participants have been sufficiently stigmatized - anti-smoking ads don't just encourage people to quit smoking, they also do a nice job in painting smokers as antisocial people who hate their kids. Dodgy cost reports painting costs borne by smokers, drinkers, and the obese as costs to the country help fuel demand for greater regulation and taxation.

If every sort of risky activity that potentially imposed cost through the public health system merited tax or regulatory treatment, it is hard to think of any part of private life that would escape attention.

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....

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....