Monday, November 29, 2010

Why are we still paying tobacco executives to kill us?

A few days ago I blogged my dissatisfaction with the coverage of the NLST trial by "The Health Show" on NPR. On the show, the host interviewed Dr. Regina Vidaver, the head of the National Lung Cancer Partnership, and the interview proceeded along predictably sensationalized lines of popular health reporting. For my substantive criticisms you can refer to my previous post. What has followed my posting of the piece is what is unusual, and perhaps tends to get lost in the heat of criticism. Dr. Vidaver promptly contacted me to schedule a time to talk. I just got off the phone with her and felt compelled to write a follow-up (with her consent, of course).

The conversation centered around some of my major criticisms of the interview: not emphasizing enough smoking cessation as the main intervention needed to reduce lung cancer mortality, the issue of false positive CT findings followed by the ensuing potentially invasive work-up with its on occasion adverse consequences, the costs in the setting of finite resources. Dr. Vidaver pointed out, and this did not surprise me, that her strong initial statement on the need to fund smoking cessation did not make it into the final segment. Neither did any discussion of the potential for false positive findings and their consequences. She also articulated to me that, although she and her organization believe that smoking prevention and cessation remain the single most effective public health approach to curtailing lung cancer mortality, they also believe that reliable screening tools are necessary, particularly since never smoking or quitting smoking does not guarantee that one will not die of lung cancer. In fact, she hopes for the development of an intermediate marker to help risk stratify those population members, be it smokers or non-smokers, who are at a heightened risk for lung cancer and who might then be candidates for close and regular radiographic screening. As for the issues of cost, she indicated that her organization does not get involved in this sticky policy issue.

So, this interaction has raised a couple of interesting points for me. First, how much control does the guest, or one being interviewed in general, have over the final content of the interview? I worried about this myself when in 2008 one of my papers on Clostridium difficile epidemiology in the US hospitals garnered some press attention. Out of the blue, I was contacted by Mike Stobbe from the Associated Press, who was interested in asking me some questions. Being largely inexperienced in talking to the press, and unaware of Mike's sophistication and integrity, I was nervous. This made me quite cautious about how I represented our data, as well as other relevant science. For about 48 hours after the paper went live, I received a constant stream of calls and e-mails requesting newspaper and radio interviews. I was even interviewed by Jon LaPook, the CBS health reporter. Throughout that experience I was exceedingly circumspect, and may have missed an opportunity to drive home some messages firmly. This, my friends tell me, is the difference between science and advocacy. So, while I am currently creating the nexus between the two, at that time I clearly chose to keep them separate.

But what about journalism and advocacy? Were the show's host and producers unwittingly engaging in advocacy to get people to accept the screening paradigm to the exclusion of other, possibly more sensible, interventions? Or was it just that there is nothing new and shiny about the smoking cessation message, and they just did not want their listeners to turn the dial? I do not know the answers to these questions, as they have not volunteered their comments. But you can bet that I will be that much more vigilant of their reporting in the future.

The second point raised for me by my interaction with Dr. Vidaver is the issue of costs. I completely understand why a disease advocacy organization would want to steer clear of addressing this third rail of healthcare policy. The impression among most of my fellow Americans is that bringing costs into the equation diminishes the value of one's life. Yet, our lives are constantly being priced, and rather more crudely and expediently than health economics dictates. Paradoxically, no one seems to mind the fact that our politicians and pundits price our lives every day by prioritizing economic interests (such as the entire sector of the economy powered by tobacco) above human lives. How many lives lost to this addiction pay for the jobs and the salaries of Philip Morris executives? Why is this not seen for what it is: a trade-off between a citizen's life and profit for a producer of poison? How is asking the difficult cost of care questions, where the trade-off is often between prolonging suffering at the close of life and redeploying these resources toward preventing disease, so much more deplorable than paying tobacco companies to kill us?

These are odd contradictions, if you ask me, and all emblematic of our predictably irrational human nature. At the same time, these issues will not go away, and just because they are difficult does not mean we should bury our heads in the sand to avoid them. Nothing replaces a cogent national discussion to get at the much needed solutions. Yet, isn't it time we just said no to tobacco? Would this not eliminate the huge policy headaches of how to finance screening for lung cancer and deal with the avalanche of false positive results and ensuing complications among perhaps as many as 10% of the US population? Does it not make more sense to eliminate 85% of all lung cancer deaths by getting rid of the poison than to eliminate 0.3% of all lung cancer deaths while adding untold hundreds of billions of dollars to our already mammoth healthcare bill, not to mention causing further escalation of healthcare-associated injury and death by chasing false positives?                                


  1. Regarding your question on journalism and advocacy? I think there is a clear answer as to whether the show's host and producers were unwittingly engaging in advocacy to get people to accept the screening paradigm (to the exclusion of others) or whether "there is nothing new and shiny about the smoking cessation message... and they did not want their listeners to turn the dial"

    In my opinion it is clearly the latter.

    The work of medical and public health research is performed (in most cases) by conscientious and ethical individuals who make measured statements based on the available evidence. This is the "science" part of the paradigm that you describe. I've been at conferences where the most acclaimed studies literally said that treatment A is no better than treatment B. The conferees "celebrated" these results due to the academic rigor brought to the question and the fact that the question was answered satisfactorily from a medical/scientific standpoint. As we would say no p value less than 0.05 but we were still happy with the way the research was done and what it meant for future study.

    Conferences like this one, I'm sad to say, don't make the evening news.

    In the same manner information like "People need to stop smoking" ends up on the cutting room floor following interviews like the one with Dr. Vidaver.

    This is why the "advocacy" side of the equation needs people like you to... (and I'm using a term I will probably regret here...) "catapult the propaganda".

    Why? Because of the long tail of patient research. Sure, someone watching a newscast or NPR will likely get the edited, sensationalized version of this report. But hopefully; over time, people who really want to delve into the issues involved in this topic will be lead to articles and posts like yours which provide the much needed context and (seemingly obvious) alternatives increasingly missed by the MSM.

    Yes. It will be hard. But its necessary.

  2. Thanks for your thoughtful comment, Chuk! It seems that so much gets lost in translation. I feel like we need to start from the common ground and have community epiphanies about what we really need to do to turn this ship in the right direction.

    I need to do a better post on science and advocacy -- have been thinking a lot about it since I had a conversation about it with a good and respected scientist friend over coffee last week.