How many diseases does it take?

It is not a secret that I dislike tobacco companies. Intensely. I do not see the point of allowing them to sell a product whose value is all in the negative. I am appalled that we are looking for expensive ways to diminish lung cancer mortality before considering a complete ban on this disease promotion apparatus. Yet this story in the LA Times got my goat. Briefly, a woman who has smoked for years and has had smoking-related obstructive lung disease since 1989 decided to sue tobacco companies after developing lung cancer in 2003. The suit has been making the rounds in various levels of courts, since the defendants asserted that she had exceeded the 2-year statute of limitations following the onset of her smoking-caused disease, referring to the 1989 COPD diagnosis. However, the California State Supreme Court has ruled that she can still sue the manufacturers, since she filed her suit within two years of the lung cancer diagnosis. So, why am I bothered?

Well, here is the thing: once you develop lung disease, followed by periodontal disease, as this woman did, had she really remained unaware that cigarettes are bad? That they cause problems? Is it really possible to live in our world and NOT be aware that tobacco kills? And if she was aware and continued to smoke, whose responsibility is it that she developed lung cancer, hers or the manufacturer's? Well, you say, but the tobacco companies are unethical and lied about making cigarettes more addictive by adding undisclosed ingredients. So, how are we, the consumers, to know? Well, this is pretty simple: We have free will, don't we? And if you have the free will, you have to exercise some will power, no? Is this not what the human condition is all about? Consider what would happen if we just let all of our desires run rampant. At the simplest level, who would want to get up early and do back-breaking work to produce food for our communities? And why contain anger at town hall meetings, when my humanity tells me to get into a brawl? These are basic ways in which we conquer our instincts and do what we need to do to live in a society with human beings and other organisms. But what is peculiar is that we have not extended these exercises of will to the area of consumerism. In other words, it seems to me that whichever way the market, and more importantly marketing, goes, so goes the perceived need for personal will and responsibility. Ergo, smoking despite warnings of its dire effects is OK, since the poor soul is addicted, and she can always sue on the back end, while the murderous tobacco CEOs and investors walk away with the profits. I don't know, I think it is embarrassing to give up your will that way personally.

There are two nuances to this view that I want to express. First, I do believe that cigarette companies are unethical, cruel and in debt to us, but the debt that needs to be paid is to the society, not to individuals. It is a debt to our public health that requires complete withdrawal of their product from the market and a large monetary compensation to promote healthy habits among human beings. Second, I believe that there are shades of this personal vs. societal responsibility balance that are important. Take, for example, food options for an inner city youth who lives in poverty. He may want to exercise his free will to get better nutrition than a $1.25 meal at McDonald's offers, or spend his $1.25 on an apple instead of a bag of potato chips, but for this he has to go across town, a trip that he does not have the means to undertake. This, folks, is where this young man's personal responsibility needs to be supplemented with societal commitment to equity.

So, should this unfortunate smoker with severe and life-threatening sequelae of tobacco abuse be able to sue the producer of the poison, even if she knowingly took the poison? I guess as a society we have decided that this is OK, but as an individual I am dubious. Yet it really is in the interest of our common health and wealth to punish and eliminate producers of such poisons as a society. Relying on individuals to do this job is just a perpetuation of the idea that we are not responsible for our actions. And furthermore, this becomes but a small pimple on this giant's ass, a nuisance, and not a necrotizing fasciitis that is required to kill it once and for all. 

The price of marginal thinking in healthcare policy

I find it fascinating how our brains have this propensity to latch on to what is at the margins at the expense of seeing the bulk of what sits in the center. This peripheral only vision is in part responsible for our obscene healthcare expenditures and underwhelming results.

I have blogged ad nauseam about the drivers of early mortality in the US. In one post I reproduced a pie chart from the Rand Corporation, wherein they show explicitly that a mere 10% of all premature deaths in the US can be attributed to being unable to access medical care. The other 90% is split nearly evenly between behavioral, social-environmental and genetic factors, of which 60%, the non-genetic drivers, can be modified. Yet instead of investing the bulk of our resources in this big bucket of behavioral-environmental-social modification, we put 97% of all healthcare dollars towards medical interventions. This investment can at best produce marginal improvements in premature deaths, since the biggest causes of the effect in question are being all but ignored.

A couple of other striking examples of this marginal magical thinking have surfaced in a few recent stories covered with gusto in the press. One of the bigger ones is the obesity epidemic (oh, yes, you bet it was intended), and its causes. This New York Times piece with its magnetic headline "Central Heating May Be Making Us Fat" entertains the possibility that because of the more liberal use of heat in our homes we are no longer engaging our brown fat, which is a furnace for burning calories. And this is all well and good and fascinating, in a rounding out sort of a way. And it is just as interesting to hear that lack of sleep may be contributing to our expanding waistlines. But it is also baffling that we are still expending these enormous amounts of energy (OK, this one was not intended) on finding the silver bullet, when the target is not a supernatural being, but a super-sized expectation. Is it really that mysterious that we are fatter now than we were 20 years ago, when our current portion sizes are 70% bigger and we spend our days worshipping at the temple of the screen, in all its manifestations? While I am all for learning as much as we can, what we need right now is immediate action to abrogate this escalating epidemic, and I think we can all agree that the way to do it is not through lowering house temperatures. Plenty of behavioral research is available to inform our strategies to get people to eat less and move more. Let's start translating it into practice rather than latch on to one marginal magical idea after another.

And finally, I have to touch upon lung cancer, of course. The current fodder for this was provided by the Washington Post with this story about the growing advocacy among lung cancer patients for early detection. You may recall that recently I did several posts on the heels of the large NCI-sponsored study National Lung Screening Trial (NLST) whose purpose was to understand whether early detection of lung cancer in heavy smokers may improve lung cancer survival. I do not wish to go into all of the specifics of this study and my interpretation of the results -- you can find my thoughts on this study in particular and on screening in general here. What I do want to reiterate is that 85% of all lung cancer is caused by a single exposure: smoking. And guess what? The same behavioral strategies that can help people stop overeating can be deployed towards smoking cessation. Yet, instead of spending 85% of all expenditures on smoking cessation efforts, we prefer to allocate it to early detection. My point is that we need both, but the balance has to be informed by pragmatism, not the marginal magical thinking.

And so it goes that the Pareto principle is bleeding into our healthcare policy decisions -- this is the steep price of the marginal magical thinking. What will it take to get the blinders off and face up to the idea that some intervention points are just more impactful than others? Marginal panaceas will improve our lives, but only at the margins. And without being addressed, the big elephants in the room are likely to stampede us.

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?                                

Journalism or advertising? "The Health Show" on NPR

Addendum 11/22/10:

I want to be very clear that I very much appreciate excellent health reporting by Julie Rovner, JoAnne Silberner, Scott Hensley and other NPR healthcare reporters. What concerns me about this show is that it is popularized coverage, and, as such, may reach a broad audience who does not have the tools to recognize critical gaps in the story.

I love NPR! We are lucky enough to have 2 local NPR stations to choose from, WFCR and WAMC. I love everything about them -- their critical approach to politics, their intellectual curiosity and their local flavor. What I sometimes do not love is their coverage of health news.

Case in point is tonight's broadcast of "The Health Show". I was driving on one of our particularly windy roads while listening to the first story of the show covering the NCI's NLST, and almost drove off the road! I was glad that it was dark, so no one could see the crazy lady behind the wheel yelling back at the radio. Why was I yelling? Here is why.

The story was of course about the staggering success of NLST. The guest interviewed was Dr. Regina Vidaver, the Executive Director of the National Lung Cancer Partnership, a group focused on understanding gender differences in lung cancer. The initial conversation focused on the NLST cancer mortality data, where the enthusiastic host threw a give-away to the equally enthusiastic guest about the main finding. The guest ran with it, breathlessly citing the 20% reduction in cancer deaths. In all fairness, she did not fall into the host's trap of inference as to the cause of this reduction, assumed by him to be due to early detection, as she responded that these data have not been analyzed yet or reported in peer-reviewed literature. Dr. Vidaver further intimated that this is a very promising break-through, sure to change the outcomes of lung cancer among heavy smokers. She even compared it to breast cancer mortality reduction due to mammography screening. What rock has she been living under?

Throughout the interview, I kept waiting for the host to ask some critical questions, like what was the actual (absolute) reduction in mortality? Or how many patients would need to be screened annually and for how long to prevent one death? Or how much will it cost to prevent one death? Or what is the risk and what are the implications of a false positive result (these data have been reported, and it looks like 1 out of 4 screened patients may have a false positive test)? And what about how this testing compares to the costs and effectiveness of smoking prevention and cessation efforts? These are pretty elementary concepts which I discussed at great length here and here. No, none of these issues was explored, just the awe-struck host feeding soft questions to the guest. I swear, I thought I was listening to an infomercial! This is journalism? And on NPR? Come on!

But the most peculiar part of the interview came later. Here the host and the guest emphasized that other potential causes of lung CA exist and cannot be ignored, like radon and second-hand smoke. Strangely, there was no mention of asbestos or other occupational or chemical exposures. Don't take me wrong, these are  important causes. But what do they have to do with the NLST data? Were they implying that everyone should undergo screening and not just those with heavy smoking history, since we do not know always what exposures other than smoking may be present? Furthermore, the big elephant in this interview was the lack of mention that 85% of all lung cancer is caused by smoking -- why not cite this startling statistic? Not compelling enough? Is it not amazing that, if every smoker quit, we could avoid about 190,000 new cases of lung CA in the US annually? Not to mention all the other disease caused by this poison.

But instead of pointing out the potential advantages of public health interventions aimed at smoking cessation, NPR decided to give easy air time to a shiny new technology, holding great promise for the uninformed masses and for the market, but fraught with untold expense and complications. Is this responsible journalism? NPR and WAMC, you can and should do better than this!