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.

Tobacco policy experiment

New Zealand seems on course to mandate tobacco plain packaging legislation; we'll see how the Australian court challenge pans out.

There isn't any real-world evidence on the effects of cigarette plain packaging legislation, mostly because nobody's really done it yet. What we have are a bunch of surveys of smokers and non-smokers on how cigarette packaging makes them feel, whether they think different designs are more or less likely to encourage them to smoke, and the like. In other words, a bunch of hypothetical musings in low consequence environments.

If we're stuck having Tariana Turia's proposed legislation, let's do some good with it. Set it up as an experiment. Implement plain packaging in part of the country, but not elsewhere. Then see what happens. If it seems successful after a few years, implement it everywhere; if it doesn't, abandon it. Either way, publish all the results so we have a better handle on what works. So plain packaging in Christchurch but not in Dunedin, in Wellington but not in Rotorua. I'm sure there are plenty of folks who specialize in designing randomised control trials of this sort who'd be able to run things. We may need a third treatment group to avoid problems that can result when you know you're part of a treatment group as compared to the control, but other folks know more about these design issues than I do. We'd probably also need to compensate the tobacco companies for increased distribution costs over the duration of the trial - the excess of current tobacco excise revenues over demonstrable costs to the health system should provide plenty of money that could be used here.

If we apply plain packaging to the whole country at once, we have no way of knowing whether the policy does anything. A careful randomised control trial could tell us something useful.

I've reasonable "get off my lawn" opposition to the policy, but if we're going to be stuck with it, why not learn something at the same time?

Getting tobacco costs wrong

Jason Krupp screwed up the burden tobacco imposes on the New Zealand health system. But it's not entirely his fault. A comment on my prior post finally twigged me to how he screwed up - it should have been obvious. Again, here's what Jason wrote.

According to the World Health Organisation's Economics of Tobacco Toolkit, health costs attributed to smoking account for between 6 per cent and 15 per cent of national healthcare expenditure in developed countries.

In Australia, smoking costs equated to between 2.1 per cent and 3.4 per cent of gross domestic product.

New Zealand was not featured in the report but, if the results were comparable here, it would mean Kiwi taxpayers fork out about $7 billion a year to treat smoking-related diseases.

The first figure is a WHO estimate of the burden borne by government healthcare systems. The health budget here is a bit under $14 billion. So extrapolating from that value would give you a range from $840m - $2100m. That's well in excess of prior estimates from either the Cancer Society or Des O'Dea, but it's only 3-8 times larger than those figures. And far far less than Krupp estimated. But, with Treasury's site down as much as it has been lately, the health budget might not have been readily available.

Krupp's second line is almost certainly an estimate from the Australian Collins & Lapsley report into the social costs of smoking. I have banged on, repeatedly, about how it's easy to conflate these social cost measures with costs to the government. And that's what I think Krupp's done. He took the 2.1-3.4% of GDP estimate, read it as "costs to the health system" rather than as "costs to the country, including costs borne by smokers, and likely including some double-counting as value of statistical life estimates and productivity costs overlap." And he uses that to generate the third line. GDP is around NZD$200 billion.* Multiply that by the 3.4 upper end of the "percent of GDP" figure from Oz and you get a number that, with some upwards rounding, hits $7 billion.

I really really hate "Social costs of Blah" studies. Because it's just so easy for somebody who doesn't know the term of art employed to read it as equating to costs on the taxpayer. Just like Krupp did. "Smoking costs" turned into "Kiwi taxpayers fork out ... to treat smoking-related diseases".

The social costs of social cost studies, in screwing up how the public views the distribution of the burden of various activities and consequently making folks think a paternalistic policy is really a Pigovean one, are not insubstantial.


* I wish Stats NZ would report the actual GDP figures in its quarterly updates. It's surprisingly hard to find "What is the GDP of NZ" anywhere on the Stats NZ site. You'd think it'd be in the "Top Statistics" page; nope. Just growth rates. How about on the GDP page? Lots of link there to estimates on growth rates; can't see a "This is the GDP of NZ" one. Maybe over on National Accounts for year-end? Nope. Latest quarterly update? No. Press release on that update? No.  Why do I have to go to the IMF website and divide by the exchange rate to do this, or add up quarterly numbers from the RBNZ? Stats NZ has the number buried in Tab 6.1 of an Excel sheet here (thanks, Diana, for the pointer!), but shouldn't that be up front somewhere?

Stat of the week

I think I've found a winner for the next StatsChat "Stat of the Week" competition. Auckland University's Statistics Department gives a weekly prize for the best or the worst journalistic use of statistics. This is another submission on the bad side.

The Christchurch Press runs a story by Jason Krupp arguing that tobacco costs the New Zealand public health system $7 billion per year.

According to the World Health Organisation's Economics of Tobacco Toolkit, health costs attributed to smoking account for between 6 per cent and 15 per cent of national healthcare expenditure in developed countries.

In Australia, smoking costs equated to between 2.1 per cent and 3.4 per cent of gross domestic product.

New Zealand was not featured in the report but, if the results were comparable here, it would mean Kiwi taxpayers fork out about $7 billion a year to treat smoking-related diseases.

That number seems very high. Recall that New Zealand is a country of about 4.4 million people. Is it any way plausible that each and every one of us are shelling out about $1600 per year to cover smoking-related illness? That's the first thing that a numerate journalist should have thought about: a sense of scale.

Next plausibility check: how much does the government spend on the health system in total? Treasury's site is down again and so I'll have to trust in this infographic; it's from Keith Ng, so it's almost certainly correct. It cites numbers of $13.2 billion for 2011 and $13.9 billion for 2012. Does it seem plausible that smoking accounts for half of total government health expenditures? That we could double health services but for the existence of smokers?

Numbers that far out of whack demand a bit of fact checking. What would five minutes on Google tell you about prior estimates of the costs borne by the New Zealand Health System? You'd probably find the Ministry of Health's $1.9 billion estimate, but that one was predicated on the assumption that smokers would otherwise live forever with zero health costs: they didn't account for that smokers do eventually have to die, even if they don't smoke, and so most of the health costs of smoking are just bringing forward costs that would otherwise be borne by the health system even if smoking had never existed. Here's a piece from the Christchurch Press noting, and critiquing, that MoH estimate.

Next, you'd find the study by Des O'Dea, commissioned by Action on Smoking and Health, and by the SmokeFree Coalition, that concluded that smokers cost the health system some $350 million in 2005: 5% of the figure cited by Krupp. Inflation hasn't been that high over the last 7 years. O'Dea cites total figures including smokers' spending on tobacco and a bunch of other costs properly viewed as privately borne that amount to $1.7 billion: still rather smaller than Krupp's figure even though in includes a really broad assortment of costs other than those falling on the government.

And, you might find the New Zealand Cancer Society saying the total cost borne by the health system is $250 million.

And we'd also want to remember that smokers pay about a billion dollars a year in excise taxes.

I really hope that Krupp isn't based at the Press and is just part of the Fairfax stable. Because I gave a talk at The Press last year that I'd hoped would cure them of this particular kind of innumeracy.

Is it too much to ask that the Fairfax papers not invent statistics that leave their readers worse-informed for having bought their newspapers?

Botching the counterfactual

The Tobacco Atlas lists the costs of smoking to health systems around the world.

On the plus side, they have a sensible ballpark estimate for New Zealand (if anything, it's likely on the low side).

But there's a problem with the infographic.*

Yes, if tobacco use had no associated health costs, New Zealand would have an extra NZ$350m in real resources floating around for other uses,** and a loss in utility to smokers who enjoyed smoking. But if we magically made smoking disappear, the government would take a very large fiscal hit: tobacco excise revenues utterly dwarf tobacco-associated healthcare expenditures. 

You can view tobacco's health costs as representing forgone government spending in an "if only there were no smoking" sense IF you're willing to assume that, were smoking to disappear, government would increase other tax rates sufficiently to make up the lost tobacco excise revenues and to compensate for the added burden on the superannuation system (net of increased tax revenues from smokers, who tend to be further down the income distribution and consequently more likely to be net tax consumers than tax contributors). Or if you're willing to assume a counterfactual where smoking doesn't have health costs. Neither is quite as simple as "no smoking = more school construction". 

* Theorem: there's a problem with every infographic except perhaps those made by @Keith_Ng. 

** I'm going to stick with Des O'Dea's numbers here, which had it at $350m, not the NZ$250m the infographic cites.

HT: NBR who, surprisingly, forget that tobacco users pay excise.

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.

What counts as research

The bar ain't high, if you're in the right field.

Now out in Tobacco Control, impact factor 3.077 (Comparable to Economic Inquiry), a New Zealand study where 13 young adults were interviewed about their smoking habits. The authors then call for a ban on smoking outside of bars on the basis of interviews with these thirteen subjects.

They frequently expressed disgust and remorse at how they felt after binge smoking and drinking, and nearly all saw smoking and drinking as activities that went together.

"Because alcohol plays such a pivotal role in facilitating social smoking, extending smoke-free areas to the outside of bars would decouple drinking from smoking in this environment," the study said.

Such a policy would create a physical barrier that, for some, would make getting to the smoking zone too difficult.

Nearly all participants supported the proposal, and agreed it would lead them to reduce or cease smoking, the study said.

I'm in the wrong field. And the Otago Medical School Public Health Department's press office ought to get some PR award for being most consistently able to sell this kind of thing to the press as having policy significance.

Next time I'm at the bar, I'll interview 13 selected smoking drinkers about what they think ought to be done to the folks who would ban them from smoking and drinking. I don't think the results would be publishable. But they could form the basis for policy improvements.

See also Simon Clarke.

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.

Kreskin, again

Last week I pointed to Richard Edwards' plenary address on tobacco control:

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. [emphasis added]

And today the excellent Chris Snowdon points to TV3:

"The problematic aspect is that since most smokers want to quit, and here, because of the high occurrence of hazardous drinking in the New Zealand situation, they have difficulty quitting," Associate Professor Wilson told NZ Newswire.

Smoking is estimated to cost $1.9 billion in direct costs to the health sector, but the social cost has been estimated as high as $22.5bn.

The researchers recommend lawmakers explore:

• Higher alcohol taxation, given some evidence that tobacco consumption has been found to decline with higher alcohol taxes.
• Raising the legal alcohol purchase age. US evidence shows this reduces adolescent smoking.
• Explore policies to further decouple smoking and drinking by making the outdoor seating areas around cafes and pubs smokefree.
• Consider additional funding health services to to address both heavy drinking and smoking cessation together.

Where to start. First, smoking does not cost the health system $1.9 billion. Here's the post where I summarized things. Long story short: MoH effectively assumed that smokers would live forever and never impose any end-of-life costs on the government if they weren't smokers. Surprisingly, I can no longer find the $1.9bn figure on the MoH website. The best I can now find is their 2010 submission on the proposed excise changes where they wrote:

The social costs of smoking have been estimated at 62,800 life years lost to tobacco-related premature deaths, and 19,000 quality adjusted life-years lost to tobacco-related illness [¹] . A 2007 estimate put the cost of smoking to the health system at $300 to $350 million per annum; however current work within the Ministry of Health suggests that figure may be as high as $1 to $1.6 billion per annum [²].

...

2. Please note that this analysis is work in progress and methodological issues are currently being addressed.

I'm not sure of the source on the $22.5bn figure. But there's no way you can get a number that high without including smokers' spending on tobacco and a rather long list of other costs borne by smokers, with little consideration of that at least some smokers enjoy smoking.

But last week's prediction was right. I hate being right. I hated it last time too.

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.

Memory in journalism

Keith Ng thoroughly documents one instance of a broader phenomenon in New Zealand journalism: very poor apparent institutional memory.

Keith notes that ACR, the Association of Community Retailers, which lobbies against regulations that impose costs on small tobacco retailers like dairies, gets PR support from Imperial Tobacco. Keith calls it astroturfing. That's possible, but I don't think it rules out that the group of represented small retailers genuinely supports the policies promoted by ACR and simply shares interests with Imperial on those issues. 

Either way, it didn't take long after Keith broke the story for the NZ media to forget that ACR enjoyed industry support. Writes Keith:

It seemed like quite a problem, the idea that so much of our news comes from groups which could be hiding all kinds of interests and agendas.

Turns out, the problem isn’t “what are they hiding?”, but “does anyone give a shit?”.

What this has shown is that even when the agenda is Big Tobacco’s, even when the connection is the second result on a Google search, even when their own organisation has reported on it, even when it’s stated plainly on their website, even then, the PR industry can get their stories printed with no scrutiny.

It’s a complete and utter rout.

You know, some of my best friends are journalists. And I like to think that they are the better ones. They always complain that they’re under pressure and under-resourced, and that this sort of shit slips through the cracks.

I’m sure it’s true, but here we are, at the point where our biggest news organisations run stories without spending 10 seconds on a Google search, or asking if something makes any goddamn sense. [Emphasis added]

If Richard Green says new laws will cost him $10k for shelves, they run it. If Richard Green says new laws will cost him $27k for shelves, they run it (RNZ newswire, 14 July 2011).

SHELVES.

How many of the facts reported in our media are this dodgy? And if there is so much that we can’t trust – and we can’t distinguish between what can and cannot be trusted – at what point should we simply give up?

You could chalk it all up to that it takes time to build up experience on a file and that erosion of profits in journalism have knocked out the senior folks who remembered what happened a year ago. But that can't be it when a 10-second Google search, or simply "asking if something makes any goddamn sense" would be enough to shoot something down. But when Radio New Zealand happily reports that each smoker costs the economy three times per capita GDP, folks aren't running the simple checks.

It has to come down to demand. If your audience take stats as infotainment, why worry too much if the stats are right? In fact, you can't afford to worry about it too much. And if the customers don't care whether the stats are right, then supply will arise to fill demand for the kinds of stats for which somebody's willing to pay (BERL on alcohol, PWC on Adult and Continuing Ed, many others in the back pages of the blog, the whole InfoGraphics problem cited by Megan McArdle...).

On bad stats, at least we have StatsChat. The University of Auckland's stats department now gives a prize for picking the week's (or month's) worst stat that's appeared in NZ press outlets. I recently nominated Radio NZ's exaggeration of the costs of smoking. Hopefully, shaming news outlets and the producers of bad stats will eventually have some effect. But it's harder to think of useful interventions that fix the kind of sloppiness Keith's citing.

Keith's interview on Radio NZ's interesting; it'll likely here be archived soon.

Accidentally creating big numbers

Remember Radio NZ's reporting that smokers each cost "the economy" $139k annually? The Quit Group helpfully tells me by email that the figure, derived from Des O'Dea's prior report with some help from BERL, was actually the present discounted value of the stream of costs associated with a smoker.

An annual cost of about $11,350 gets you a PDV of $139k at an 8% discount rate. So messing up the difference between the PDV and an annual cost gets you an order of magnitude error.

And recall too that the O'Dea report included a rather extensive list of costs more properly viewed as costs to the smoker than as costs to "the economy". As O'Dea concluded about the costs smokers impose on "the economy":

Leaving aside these difficulties, it is certainly reasonable to assume that most of the additional health-care costs caused by smoking are borne by non-smokers through additional taxes (smokers do pay some share of these taxes). Also it is reasonable to assume that most of the 'lost  production' costs of premature mortality and increased morbidity are borne by smokers and their households (though there is some loss of profits also, and of tax revenue to government). A considerable amount of work would, however, be needed to get precision on these matters.

Without trying to calculate a precise estimate of 'external costs' it does seem reasonably apparent that the tax contribution of approximately $1 billion annually by smokers exceeds substantially the external costs of smoking which fall on non-smokers. If savings on pension costs from premature mortality of smokers were added as well the net fiscal contribution of smokers, to the fiscal gain of non-smokers, would be further increased. [emphasis added]

Here's my prior critique of the O'Dea report (and more detail, with summary of cost components, here). Here's a prior summary post on the health costs of tobacco in New Zealand.

I trust The Quit Group will pass along a correction to Radio NZ. Annual costs aren't quite the same thing as the present discounted value of a stream of annual costs.

$139,000?

Ah, the lazy summer season, when lobby groups can sneak pretty much any kind of rubbish into Radio New Zealand's Inbox and have it be treated as news. Here's the latest:

Cigarettes rose in price on 1 January, for the third time in 21 months.

The price of a packet of 20 cigarettes is now about $14 and a pouch of loose tobacco is about $31.

The Quit Group estimates each smoker costs the economy $139,000 per year in health and other costs.

Chief executive Paula Snowden says the group returns $38 to the economy for every $1 it is funded, but has had no increase since 2007.

She expects the price increase to save the economy up to $73 million.

Let's start with what's right about the piece. I have no reason to believe that they've lied about the price of a packet of cigarettes. The rest isn't so good.

Recall that GDP per capita in New Zealand is somewhere around $45,000*. So Snowden is claiming that a smoker costs "the economy" three times per capita GDP. And recall that median income is less than per capita GDP, which also includes payments to capital. Snowden's number is three times that. It's utterly implausible.

Next, she expects the price increase to save the economy up to $73 million. If flipping a smoker from smoking to non-smoking saves those costs, then she's expecting about 525 people to quit. If only a fifth of costs are avoidable and the rest are sunk, the price increase results in around 2600 people quitting smoking. But the last survey numbers I'd seen have about 22% of the population aged 16-65 smoking. Again, see asterisk below, but there are about 4.5 million people in the country. Let's be conservative and say 300,000 smokers; 2,600 quit. This is all ballpark, but it suggests maybe one percent of smokers are expected to quit with the price hike. And, that's with me granting the $73 million. I'd really need to see the workings to figure out what they're doing here.

Finally, let's aggregate up for a final plausibility check. Say there are 300,000 smokers in the country. If they each cost $139k, that's about $41 billion that Paula Snowden claims smokers are costing the country. And even the ridiculously high Collins & Lapsley numbers have smoking costing all of Australia only $32 billion. And there are just a few more people in Australia than in New Zealand.

Every decent journalist should have a few of these numbers just rattling around in the back of his head to give numbers like Snowden's a rough plausibility check. It's not plausible that a smoker costs the country three times per capita GDP. That's the first bit of stink. If the implied participation elasticities are as suggested by a quick ballparking, then we'd wonder about the costs imposed on poor people who continue to smoke even if everything else is right. That's the second bit of stink that should have been queried.

But the biggest howler is that Snowden claims a 38:1 benefit to cost ratio for her organization's work.

When did they stop teaching scepticism in journalism school? Radio NZ, you've been pwned by The Quit Group. You can do better.

*Please note that I'm working off memory for a lot of these figures. No Internet at the guest house in Nelson where we've been avoiding earthquakes for the last week, so I'm burning through Vodafone Pay-As-You-Go data. Back in quakeland tomorrow.

Previously: Bogus MoH figures on smoking costs.

Update: Sarah Woods of The Quit Group advises that the $139,000 figure is the present discounted value of costs, with the estimate based on Des O'Dea's prior figure (which included a raft of costs borne by smokers that don't really count as costs to "the economy") and with ROI calculations undertaken by BERL. I'll have a look through their report. But Radio NZ has inflated The Quit Group's figure by an order of magnitude by transforming a present discounted value figure into an annual cost figure. At an 8% discount rate, the PDV of $139k is about $1.7 million. And let's remember exactly what the O'Dea report concluded about the costs smokers impose on "the economy":

Leaving aside these difficulties, it is certainly reasonable to assume that most of the additional health-care costs caused by smoking are borne by non-smokers through additional taxes (smokers do pay some share of these taxes). Also it is reasonable to assume that most of the 'lost  production' costs of premature mortality and increased morbidity are borne by smokers and their households (though there is some loss of profits also, and of tax revenue to government). A considerable amount of work would, however, be needed to get precision on these matters.

Without trying to calculate a precise estimate of 'external costs' it does seem reasonably apparent that the tax contribution of approximately $1 billion annually by smokers exceeds substantially the external costs of smoking which fall on non-smokers. If savings on pension costs from premature mortality of smokers were added as well the net fiscal contribution of smokers, to the fiscal gain of non-smokers, would be further increased. [emphasis added]

E-cigarettes

Murray Laugsen writes in The Listener about measures that could help folks quit smoking. The government claims to want to eradicate smoking by 2025. What helps folks quit? Giving them substitutes that are less harmful. A smoker has a better chance of quitting if he complements quitting either with smoking low-nicotine cigarettes or with e-cigarette inhalers which deliver nicotine but without the other substances that form the bulk of smoking's health risks.

So policy should then encourage e-cigarettes and, perhaps, place less tax on low-nicotine cigarettes to encourage their use as part of quitting.

But MedSafe last year banned the sale of the nicotine cartridges; those wishing to use them to quit have to import them for personal use. Pharmacies had made claims about the cartridges' effectiveness as a cessation aid; that made them a medical device.

And less risky alternatives, like Swedish "snus", described by the Royal College of Physicians as the least risky tobacco product, are also here banned. 

My best working model of the current situation: anti-tobacco zealots get to the top of the Ministry of Health and hate tobacco and nicotine more than they care about harm reduction. And folks selling cigarettes don't like substitutes. Then it's just Bootleggers and Baptists. But if anybody has a better model, I'd love to hear it. The problem for my model is that even SFC seems to have come around on e-cigarettes, if not on snus. Inertia? 

Mutant smoking statistics [updated]

TVNZ reports:

Australia's Cancer Council said the Senate should end the political delays and get on with passing the legislation, with authorities estimating smoking now kills 15,000 Australians each year and costs the health system $32 billion.

Oh please. What's the source on the $32 billion? Almost certainly Collins & Lapsley, who found that the total costs of smoking in Australia were $32 billion. How much of that $32 billion was health? $318.4 million. Is that much much less than the aggregate tobacco excise tax take? Certainly. I'm just going to copy Collins & Lapsley's tables here.

Here we have tangible costs divvied up by category (intangible costs of premature death and the like make up the bulk of the purported costs of tobacco and aren't in this table). Note that we've disputed the alcohol figures rather strongly. But what do we see? By C&L's figures, tobacco costs the Australian health system $318.4 million. That's somewhat less than the figure claimed by the Australian Cancer Council, assuming that they're quoted correctly [Update: see below]. Two orders of magnitude less. The costs to the health system are ONE PERCENT of the costs cited by TVNZ.

As for overall costs to the country, here's Collins and Lapsley again:

So tobacco leaves the Australian federal government up $2.7 billion and state governments up $833 million.

But the Australian Cancer Council gets to build support for beating on tobacco by helping to make folks think that smoking costs the health system $32 billion, again assuming that they've been correctly cited or that I've not missed their post clarifying that they'd been mis-cited. [Update: see below.]

And, this isn't the first time that the total C&L tobacco cost figure has been cited as a cost to the health care system; here's Chris Snowdon fisking a May story from The Age.

I wish TVNZ would check its sources from time to time. But, they've provided my nomination for Stat of the Week.

Update: Paul Grogan of the Australian Cancer Council emails noting that they're not the source of the $32b figure: "I am not aware of any Cancer Council Australia document that claims tobacco costs $32b in annual healthcare costs." Excellent news. The TVNZ / Reuters story linked then either is misleading or misquotes and ought to be updated. I trust that the Cancer Council will soon be issuing notice to Reuters that the annual health care costs of smoking are one percent of the figure Reuters quoted. They might also note the billions in tobacco excise tax revenues that swamp any fiscal cost smokers impose on the health care system.

I report, you decide

Ok. In the comments, tell me whether the Otago Daily Times editorial staff are:

1. Lazy and don't check their figures: they just copied from the NZ Herald editorial (noted here) and couldn't be bothered to check anything. Seriously, check the Herald piece; they totally lifted the Herald's argument.
2. Idiots
3. Deliberately trying to mislead their readers

My vote's for the first. But I'm curious what others think. The more often they do this, the more inclined I am towards the third. From today's editorial:

Those who argue anti-smoking legislation goes too far do so on grounds it intervenes in rational personal choice, even when that choice is for an addictive drug. The difficulty with this argument is a right of personal liberty ceases to be that when it affects the rights of others. It has been well demonstrated passive smoking can be harmful to individuals forced to inhale the smoke exhaled by others.
The case for liberty is on less solid ground, too, when the cost of smoking to the public purse, estimated to be $1.7 billion a year, is considered.

Again, the $1.7 billion figure comes from Des O'Dea's study of the costs of smoking. The $1.7 billion figure includes a whole pile of costs that smokers impose upon themselves and only about $350 million that smokers cost others via the health system. And again, quoting from Des's study:

...it does seem reasonably apparent that the tax contribution of approximately $1 billion annually by smokers exceeds substantially the external costs of smoking which fall on non-smokers. If savings on pension costs from premature mortality of smokers were added as well the net fiscal contribution of smokers, to the fiscal gain of non-smokers, would be further increased. 

If the Herald and ODT repeat a lie often enough, it becomes a public truth.

Overstating tobacco costs

Remember how I've been banging on about how cost studies get used dishonestly to push illiberal policy? Here's the NZ Herald (HT: @CJSBishop):

Smokers may complain that they are being victimised, but their arguments about personal liberty founder on a fundamental point of principle: you don't have the right to hurt yourself if you are hurting other people in the process.

Three Act MPs voted against the law requiring products to be kept out of sight, because they supported "rational personal choice". But is it rational to avail yourself of a product which inescapably harms the user when used as directed? Certainly not, when that harm becomes a drain on the public health system and society as a whole.

The tangible economic costs of smoking - in health care and loss of production because of illness or early death - are of the order of $1.7 billion a year, almost twice what is collected in tax.

Anyone claiming the right to set fire to that sort of public money needs to come up with an argument more cogent than personal liberty.

To their credit, Maori MPs are driving this. Associate Health Minister Tariana Turia introduced the latest bill and Hone Harawira, when a Maori Party MP, forced a select committee inquiry into the tobacco industry.

I'd like to thank the Herald for making my argument for me.

IF smokers actually cost the health system substantially more than they contribute to the health system via tobacco excise taxes and to the fisc in general by drawing lower overall superannuation payments (due to premature mortality), there could be a case for increasing tobacco excise taxes. We'd need to do some analysis to make sure things held at the margin, but there'd likely be a good case for increasing taxes.

Here the Herald is citing not the MoH's bogus figure on the health costs of figure (fisked here). Rather, it's Des O'Dea's commissioned report for ASH and SFC. Here's the bit from the O'Dea study that the Herald didn't cite:

Leaving aside these difficulties, it is certainly reasonable to assume that most of the additional health-care costs caused by smoking are borne by non-smokers through additional taxes (smokers do pay some share of these taxes). Also it is reasonable to assume that most of the 'lost  production' costs of premature mortality and increased morbidity are borne by smokers and their households (though there is some loss of profits also, and of tax revenue to government). A considerable amount of work would, however, be needed to get precision on these matters.

Without trying to calculate a precise estimate of 'external costs' it does seem reasonably apparent that the tax contribution of approximately $1 billion annually by smokers exceeds substantially the external costs of smoking which fall on non-smokers. If savings on pension costs from premature mortality of smokers were added as well the net fiscal contribution of smokers, to the fiscal gain of non-smokers, would be further increased. [emphasis added]

To reiterate our point, however, our argument for continuing, and increasing, high taxation of smoking is not based on an 'externality' argument. It is based on the argument that the total costs of smoking are high, and that taxation is an effective means of reducing these total costs. By far the largest component of these total costs, however it is valued, is the 'health loss' experienced by smokers themselves – their lost years of life and diminished quality of life. (p.46)

Read that again: even without counting savings to the pension system, smokers cover their costs about three times over. Des O'Dea is dead honest in his work here: he's not trying to sell private costs as being social. ASH wanted a number that included private costs; he gave them one. And, he honestly said that the case for increased taxation is to reduce the costs that smokers impose on themselves. That's an honest paternalism.

Unfortunately, once these figures get out into the wild, they're interpreted as costs smokers impose on others. Here are the components of O'Dea's $1.7 billion figure (Table B.1, p.44); you judge for yourself whether the Herald's right to call these costs on the public:

• Reduced production from mortality: $570m (I call private)
• Reduced production from morbidity: $280m (I call private)
• Resources diverted for tobacco consumption: $650m (I call batsh*t insane to consider this public: it's what smokers spend on their cigarettes net of excise taxes)
• Resources required to treat induced diseases and other consequences: $350m (public external transfer cost. This is the real cost to the health system)
• Smoking-induced fires: $15m (largely private, barely worth arguing about as such a small part of the overall figure)

So more than a third of the $1.685 billion is smokers' spending on cigarettes and only $350m are real external costs through the health system.

I wish that the Herald's editorial writers were just a bit more careful in how they present these things.