"Abandoning ship": is debunking ineffective screening and therapy removing hope or just removing risk?

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Sometimes I think I sound like a real medical nihilist, since many of my blogs have been about purported treatments that are ineffective, dangerous, done too often, and cost a lot of money (Cardiac stents and profit-driven corruption: do anti-fraud rules address the problem?, December 24, 2010; Greed, corruption and medical procedures: ignoring or suppressing the evidence?, August 12, 2011; Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?, March 15, 2011).  It is a somewhat distressing feeling. I am a doctor; I want to help people, to relieve their suffering, to help facilitate the cure of their diseases. More than that, I am a family doctor, and have a strong preference for prevention, for early detection of disease when it is still treatable rather than waiting for it to be too far gone for treatment to be effective. In addition, I have regularly criticized our health non-system for leaving out too many people, creating financial disincentives for them to seek care early. This leads to their waiting until their diseases become so uncontrolled that they present to the emergency room, then require admission and costly care, making it worse for them (most important) and more expensive for everyone. So I think prevention and early intervention is a really good thing, and it would be great to have tests that could identify disease early in its course so that we can change its trajectory.

But because I want these things to be true doesn’t make them true, as I discuss in the recent post Avastin®, Plan B®, and Magical Thinking, December 31, 2011. Because we can screen you for something doesn’t mean that we should; because a test can be done doesn’t mean that it is a good test. "A good test", in my opinion, is one that has sufficient sensitivity (rate of being positive when a condition is present) or specificity (rate of being negative when a condition is absent) to tell us whether a you have a disease, or if it matters. Because it can be done also doesn’t mean that it is cost-effective. Because a treatment exists doesn’t mean it is a good treatment, a safe treatment, an effective treatment. And, as with most things being sold, the greater the publicity and advertising around it, the more it means someone will be making money on it, which does not exclude its being of benefit, but is certainly not the same thing.

Sometimes, when evidence is discovered that a test or treatment is not of benefit, eventually we stop doing it. "Eventually", however, may be a lot longer than you might think. In a recent “Viewpoint” in JAMA, Prasad, Cifu, and Ionannidis address “Reversals of established medical practice: evidence to abandon ship”[1]. They note that while “Ideally, good medical practices are replaced by better ones, based on robust comparative trials in which new interventions outperform older ones and establish new standards of care. Often, however, established standards must be abandoned not because a better replacement has been identified but simply because what was thought to be beneficial was not.” They go on to discuss a number of treatments that have been “standard of care” but were shown by good, randomized controlled trials, to be ineffective or even dangerous (not to say expensive). These include stenting of coronary arteries for stable coronary artery disease (CAD), postmenopausal hormone therapy to prevent CAD, vertebroplasty for osteoporotic fractures, bevucizamab for breast cancer.

Scarily, but unsurprisingly, “true believers” continued to defend these interventions even after the evidence was clear (their livelihoods depend upon it), and in many cases these treatments continue to be offered and performed. “There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products,” and it is only “Rarely [that]…some investigators find the courage to test established ‘truths’ with large, rigorous randomized trials”. Prasad and colleagues have done many of these latter trials; indeed John Ioannidis is the “guru” of debunking treatments with poor evidence (see David H. Freedman’s article in the November 2011 Atlantic “Lies, damned lies, and medical science.”) The authors have some suggestions, including limiting the role of manufacturers (of drugs, devices, tests) from conducting the trials on them, although they should pay for them: “Large trials of new innovations should be designed and conducted by investigators without conflicts of interest, under the auspices of nonconflicted scientific bodies. Instead of designing, controlling, and conducting the trials, manufacturers may offer the respective budget to a centralized public pool of funding, keeping the trial design and conduct independent.”

Prevention and screening are also subject to the lure of magical-thinking-compounded-by-the-greed-of-the sellers. Screening for prostate cancer with the use of prostate-specific antigen (PSA) testing is a good recent example about which I have written (while the lack of effectiveness of treatments for prostate cancer is would be included in the group of ineffective therapies that Prasad and colleagues have written about). Pap smears are pretty good screening tests for cervical cancer, but most other cancer screening tests (even mammograms and colon cancer screening, probably the next best) are not nearly as good. Every time there is a recommendation to decrease the frequency of screening (Pap smears, mammography) or not do them at all (PSAs or pelvic exams) there is an outcry from people who think that something has been taken from them. In a scientific sense, what has been taken is unnecessary testing that doesn’t lower their risk of bad outcomes, costs money, and can have significant morbidity when positive screens need additional, more invasive tests, to follow up. But, in a more metaphysical sense, what has been taken is hope, the idea that there is something that they can do that will prevent something bad from happening to them. Something that, while perhaps a little risky (if you understand or believe it), is relatively easy. And also, frankly, something someone else, rather than you, can do. Not like, say, dieting or giving up smoking or exercising. And this false concept is encouraged by half-truths promulgated by passionate advocates of interventions with limited proven benefit, whether traditional allopathic or “alternative”.

Even public health advocates sometimes get so passionate about the health benefits of what they are advocating that they may miss other issues. For example, consider a recent discussion on a progressive public health listserve about “portion control” (limiting the amount eaten at one sitting). This is an important and effective method of addressing obesity, which is in fact a major health problem in this country, but the discussion raised many other issues. These included concerns about “blaming the victim” -- expecting self-control (difficult enough) from people who had historically not had that control in the face of major initiatives by fast-food purveyors to push large portions. Another was the economics involved in asking poor people to pay “more for less” while corporations continue to make huge profits from them. It can, and often is, as difficult for public health advocates to recognize problems arising from their positions and passions as it is for providers or manufacturers to back off from theirs.

The difference, of course, is that the former are really invested in the health of the public, while the latter are invested mostly in, well, their investments.

[1] Prasad V, Cifu A, Ioannidis JPA, Reversals of established medical practices: evidence to abandon ship”, JAMA 4Jan2012;307(1):37-8.

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Legislating Public Health and Medical Care

It is pretty tempting, if you are a legislator and don’t like something, to try to pass a law against it. You can always find a constituency to support you, because there are people who will support almost anything. If you are lucky enough you can find a well-off and powerful constituency, or set of advocacy organizations, and then you are more likely to be successful (ref: see almost all laws passed by the Congress). Health and medical care are no exceptions; bills and laws that impact on public health and even how providers interact with their patients are increasingly common.

Some laws are very good for the public health: banning smoking in public places; requiring cars to have seat belts, airbags, and other safety features; requiring vaccination against infectious disease for entry into school. But the plethora of regulations governing the funding of health care providers from Medicare and Medicaid, the kind of documentation that needs to be submitted, and the rules that need to be followed (generally termed, collectively “compliance”) is bewildering. Complying with all the rules put forth put forth by federal agencies (including different division of Health and Human Services, as well as the Department of Justice and the Department of Treasury) requires large providers to have full-time “compliance officers” and small ones to operate at their peril. Then add in state and local regulations. These regulations are often contradictory, so complying with one violates another. The blame is usually placed on the bureaucrats that write these regulations, but in fact many of these bureaucrats are quite aware of these contradictions, but have no option, because the laws that they have to write regulations to implement are often very prescriptive. Beware the Law of Unintended Consequences!

This law, never to my knowledge passed by any legislative body, has a major impact on those that are passed, and this impact is just as true in laws regulating public health and medical practice. These effects are most serious when the law in question is passed to address a political agenda rather than to improve health. A famous example is the “gag rule” implemented in the early GW Bush years that prevented providers receiving federal funds from discussing the option of abortion with their patients. (Overturning this rule was a major, and under-recognized, accomplishment of the early Obama administration.)  A more recent example is the law passed in Florida (and now, thankfully, blocked from implementation by a federal judge) that would prohibit physicians and other medical providers from discussing gun safety with their patients. Let me be clear: the limitation was not on gun possession or use, but on doctors and nurses and public health officials talking to people about the risks that guns in the home posed to their children and themselves and how to keep the guns that they had more safe to limit accidental discharge, injury and death.  Guess what organization pushed this law? If you said “the NRA”, you’re right, but it was a “gimme”. And of course it was signed by the governor, former “health care” magnate Rick Scott, who as CEO of Columbia/HCA led the company in paying huge fines for Medicare fraud.

Those are the easy ones to find fault with. But, just as with the “compliance” issues described above, efforts to impose “good” medical practice can be flawed. Vaccine safety and benefit is a big topic I will probably post a separate piece on (short answer: get them), but there are many others. One example is the bill introduced by Sen. Jay Rockefeller (D-WV), along with Sen. Chuck Schumer (D-NY), that would require practitioners who prescribe opiates to have 16 hours of continuing medical education (CME) in their use every 3 years. This is motivated by a serious concern for the abuse of opiates, including re-sale by those receiving prescriptions, which leads to many deaths each year (and in which West Virginia leads the nation). There is no question that this is a huge problem.

We have seen two movements, often in conflict with each other, in recent times. One is the increase in the advocacy for patients with chronic pain to receive adequate treatment; the other is concerned with addiction and prescription drug abuse. Unfortunately, as in West Virginia, the same populations are often afflicted by both. Chronic pain often occurs in those who do physical labor, but people from these same populations are the ones often dying of overdose. The problem is that the same drugs that reduce pain also (initially) get people “high”, and in time create physical addiction where the “positive” effect of the “high” is replaced by pain and misery just from not having the drug. Ideally, there would be a pain reliever that was effective, did not cause any pleasurable symptoms (other than relief from pain), and was non-addictive. We don’t have one.

Will requiring this CME of physicians reduce the problem? I think that it will decrease the number of prescriptions written for opiates, and thus maybe the amount of potentially-abusable narcotics circulating in the community, but perhaps not through the intended mechanism. There is no question that there is a lot that many providers could learn about proper use of opiate pain relievers by taking such courses. One example is the use of long-acting pain relievers (methadone, sustained release patches, long-acting morphine) whose slow release controls pain while decreasing the “high” that results from a sudden infusion of narcotic. (An exception is the most widely-prescribed – and advertised, which might be related – long acting pain reliever, Oxy-Contin®, 30% of which is release immediately, making it more popular among drug abusers than other long-acting opiates.) Another is the use of the “pain contract” that limits a patient to receiving opiates from one physician, at determined intervals, refuses to ever refill if a person is found to be receiving prescriptions from multiple sources, and may require urine tests to be sure that s/he is not using other unprescribed substance.

However, for this plan to work it would require that physicians and other providers want to prescribe narcotics. Obviously some do. Many of these do so because they are concerned about the chronic pain so many patients are in; there are pain medicine specialists who come from a variety of medical backgrounds: anesthesiology, psychiatry, family medicine, internal medicine. There are certainly others (relatively few) who are “Dr. Feelgoods” who make their living prescribing narcotics and other controlled drugs in large amounts, knowing that they will be abused. But the reality is that most doctors find chronic pain patients, well, a chronic pain. They find it difficult to feel certain who is a “legitimate” pain patient and who is “abusing”, or selling, their pain medications. Or who is a “legitimate” chronic pain patient whose family members are using, or selling, that person’s pain medication, leading to both the spread of narcotics in the community and having the patient continue with unrelieved pain. These are the patients who, whether “legitimate” or “abusers”, call the office all the time for refills, call in the middle of the night, yell at the staff because they are in pain (or withdrawing from narcotics, or find their livelihood that comes from selling them is threatened). Most providers would be willing to not take the CME, and have a good excuse to not prescribe opiates, and be free from all these problems. This is, according to testimony at the recent convention of the American Academy of Family Physicians, already happening in some places. Of course, that will also mean reduced access for people who do have chronic pain.

I once lived in a moderately large condominium. I had kids, as did a couple of others, but the majority of residents were older, with no children in their homes. The association would sometimes pass rules that restricted what children could do, especially when the working parents couldn’t make the meetings. These rules affected my children and penalized me. My position was that the association’s rules should be limited to things that affected the safety of the building and maintained its property values, not just anything that 51% of the owners could agree upon. Legislatures, whether federal or state or local, can pass any law that they can get a majority to agree on (with the obvious exception of the US Senate, where apparently, at least with the current President, it requires 60% votes – 59% wouldn’t do it). It doesn’t matter how dumb the laws are, or how much they conflict with existing law, or how much trouble they cause the bureaucrats who have to write the regulations, or how confusing or sometimes impossible it becomes for folks to comply with them all. Unless the courts strike them down, they are law (thank goodness for separation of powers!).

But because you can pass a law or rule about something doesn’t always make it a good idea to do so, whether you are a legislature or a condominium association. Because the Law of Unintended Consequences is always present.

Public Health and Changing People's Minds

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In his Perspective “Why we don’t spend enough on public health” in the New England Journal of Medicine (May 6, 2010;362(10):1657-8), David Hemenway of the Harvard School of Public Health goes beyond the familiar complaint of the field that it is underfunded, particularly in contrast to medical care, despite the fact that it responsible for a much greater proportion of, well, the public’s health. He describes, as the title states, why.

“Medicine is primarily a private good — the patient receives the main benefit of any care provided. Payments usually come from the individual patient and, in the developed world, from private and governmental insurance. Public health, on the other hand, provides public goods — such as a good sewer system — and relies almost exclusively on government funding.”

The fact that public health provides a more general good would seem to be, well, good, but because it doesn’t as easily benefit a particular individual (me, or someone I know, or at least someone I can see a picture of) it is less engaging. People, Hemenway points out, are “wired” to value present need more than future benefit; cost today for potential benefit tomorrow is not easy to “buy” and is certainly rarely politically popular. In addition, the absence of disease (because it was prevented) is less obvious – and thus unfortunately less valued – than the cure of a disease that didn’t have to occur. We don’t wake up every morning and say “thank goodness I don’t have cholera because we have a clean water supply!”, but would be very grateful for a cure if we did contract cholera.

In addition, of course, and very importantly, Hemenway notes that while there are well-heeled advocates for spending money on medical care (e.g., pharmaceutical companies, hospitals, doctors), the money is generally working against public health measures which often threaten extra cost to business – regulation of air and water pollution, environmental restrictions, occupational health laws, smoking bans, alcohol restrictions. And especially gun-control, where opposition to minimal studies supported by the CDC on this major health problem were so opposed by congressmen influenced by the gun lobby that they effectively stopped research into this area. Or, more recently, where members of Congress such as Sen. Lindsey Graham (R-SC), tie themselves into verbal knots trying to show how hard they will be on suspected terrorists, and how many Constitutional rights they are willing to abridge – unless it is the Second Amendment, and mainly the NRA. When addressing the issue of restricting the ability of people on the “no-fly” list to buy guns Sen. Graham is uncompromising: “I think you’re going to far here.” (“Congress Up in Arms”, Gail Collins, May 6, 2010) .

Hemenway cites the example of “Baby Jessica” who fell down a well in Texas in 1987 whose story gripped the country: “As a nation, we will spend tens of millions of dollars to save one Baby Jessica but are often unwilling to spend an equivalent amount to prevent the deaths of many statistical babies…The scandal that people remember about Hurricane Katrina is not so much the lack of preventive measures (e.g., stronger levees) that would have averted the calamity but the inadequate rescue efforts.”

This is why TV commercials for “Save the Children” and like charities that show the faces of actual children, or even better the agencies that allow us to “adopt” specific developing-world children by sending money to them, the individual kids, are so much more effective than general appeals for contributions to help the oppressed around the world. It is also why, when the New York Times published “Faces of the Dead” on the 7th anniversary of the Iraq war, it was so much more powerful than simply saying “more than 4,000 have died”, or even listing their names. It is now an interactive site; click on any of the little boxes and the photo changes to that dead serviceman or woman, with their name, age, hometown and service branch. Please check this site out, but have a box of tissues beside you.

The more common tack taken by public health experts has been to try to provide more and more data, to policymakers and the public, about the importance of public health measures past, current, and (potentially) future, in the expectation, or at least hope, that this will convince them and result in a greater commitment (spelled, like all commitment, “M-O-N-E-Y”) to public health undertakings. Hemenway’s piece, demonstrating that anecdote, personal stories, and treatment of existing conditions that are actually hurting people, are more powerfully convincing than data, evidence, and effective prevention, must be very frustrating. Indeed, the issue (and I would say the problem) goes beyond public health to health and medical care in general; indeed it applies to most issues in the policy arena. Data, whether presented in “dry” tables, journal articles, Congressional testimony, or the media, does not seem to change peoples’ minds.

Hemenway says that “societal change is hard”, but so is individual change. The case for this conclusion is clearly presented by Christie Aschwanden in “Convincing the Public to Accept New Medical Guidelines”, in e-zine Miller-McCune, April 20, 2010. In this important piece, Aschwanden begins by looking at the unwillingness of long-distance runners to change their use of ibuprofen (“Vitamin I”) for preventing pain and inflammation even when studies demonstrated that its use made these problems worse and those results were presented to the athletes. The conflict between the phenomenon called “naïve realism”, which is “the idea that whatever I believe, I believe it simply because it’s true,” versus the actually more naïve belief that “truth wins”. She discusses the recent breast cancer screening recommendations, and the belief (in part the result of a successful program of “education” from cancer awareness organizations) that the more screening of the more people, the better.

“For years, women were taught the necessity of early detection for breast cancer based on the notion that breast cancer is a relentlessly progressive disease that will inevitably kill you if you don’t remove it in time. That story about breast cancer — call it the “relentless progression” mind model — is easy to grasp, makes intuitive sense and offers a measure of comfort: Every cancer is curable as long as you catch it in time.”

This is not a correct model, but it is hard to convince someone who had a mammogram, found cancer, had it treated, and is now alive, that mammography screening for everyone is not a good idea, much less that her cancer had a certain percent chance (much lower than prostate cancer, to be sure) of regressing on its own. I have addressed the breast cancer recommendations previously (Breast Cancer Screening and Evidence-based Medicine, November 25, 2009), so will rather focus on the studies that show, as she quotes social psychologist Robert J. MacCoun, “If a researcher produces a finding that confirms what I already believe, then of course it’s correct. Conversely, when we encounter a finding we don’t like, we have a need to explain it away.” I have previously noted that “data is only useful if it confirms my preconceived notions”; Aschwanden’s article cites study after study showing the same, on medical issues from breast cancer to low back pain. The President has called for more comparative effectiveness research (as have I, Comparative effectiveness research, March 27, 2010) but “How do you convince doctors and patients to dump established, well-loved interventions when evidence shows they don’t actually improve health?”

More generally, this is not just an issue with health beliefs. Aschwanden cites studies that demonstrated that people who believed Sadaam Hussein has weapons of mass destruction continued to believe it after being show evidence that it was not true. The opposite may occur, in fact; the presentation of facts that contradict your beliefs may serve to remind you of why you believe it and reinforce them. “It comes down,” Aschwanden writes, “to something the satirist Stephen Colbert calls ‘truthiness,’ a term he coined in a 2005 episode of his Comedy Central show, "The Colbert Report". ‘Truthiness is what you want the facts to be, as opposed to what the facts are,’ Colbert said. ‘It is the truth that is felt deep down, in the gut.’”

I admit to some my own truthiness. I want to believe, despite all this evidence, that people can be convinced by the evidence. That we will reconfigure the great imbalance of funding for individual medical care and public health because of the opportunity to improve people’s health and prevent disease; that we will choose prevention, screening, and treatment strategies based on evidence of effectiveness rather than myth or the financial benefit that accrues to the vendor of the service, and that we can unlearn that which is wrong as well as learn anew what is right. And that, even in the political arena, policy decisions may be guided by facts and reality rather than convictions. I know this is naïve, but I really want it to be true. Doesn’t that count for something?
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Health Outcomes: The interaction of class and health behaviors

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I have recently discussed (Poverty, Primary Care and the Cost of Medical Care, February 10, 2010) the “Whitehall Studies” conducted by Sir Michael Marmot and colleagues that “demonstrate that there is a more or less linear correlation between health (including longevity) and increasing social class". That piece discussed the report of a panel headed by Marmot, “Fair Society, Healthy Lives”, that shows that these problems have not been resolved. A new paper from the follow-up “Whitehall II” study, conducted by Silvia Stringhini and colleagues from both Britain and France, “Association of socioeconomic position with health behavior and mortality”, (JAMA Mar24/31,2010;303(12):1159-66), examined the role of alcohol, tobacco, diet, and physical activity in accounting for these differences over an extraordinarily long 24-year follow-up period.

Stringhini, et. al., found that in fact adverse health behaviors accounted for about 42% of the increase in mortality in lower socioeconomic groups (which was about 1.6 times as high in lowest than in the highest socioeconomic group). Smoking was the most powerful negative factor, with the others contributing a smaller amount. “There was a marked social gradient in health behaviors at baseline. Participants in the lower socioeconomic positions were more likely to smoke, abstain from alcohol consumption, follow an unhealthy diet, and be physically inactive and less likely to consume heavy amounts of alcohol.” Most of this is consistent with the observations of physicians and epidemiologists in the US, with the surprising exception of alcohol use being lower in lower income groups. This may be a difference between the US and Britain; in Britain, in the 20th century, cirrhosis was a disease largely of the upper class who could afford the highly taxed, and high alcohol content, distilled spirits. Another possibility (and this is my speculation, not data) is that the lower socioeconomic group studied by Whitehall II in England may have a large component of Muslims, who do not drink. In any case, the impact of smoking, poor diet, and physical inactivity accounted for a significant part of the class difference in mortality, although it did not account for even the majority of that difference.

Thus, this study supports two well-established assumptions: 1) that adverse health behaviors are a significant contributor to ill health and higher age-adjusted mortality rate, and 2) that people in lower socioeconomic groups have worse health and higher mortality rates, much, but not all, of which can be associated with their higher rates of adverse health behaviors. Previous work on the results of Whitehall have suggested, and demonstrated evidentiary support for, the hypothesis that stress in daily life (of worrying about how you will pay the rent and feed your family, whether you are going to lose your job, or, particularly in the case of ethnic and racial minorities, not only whether you will be arrested or harassed by the authorities but the indignities of ongoing discrimination), mediated through only partially understood neurochemical pathways, account for much of this effect. However, to the extent that people can divest themselves of risky health behaviors, they can decrease, if not eliminate, their higher risk for adverse health outcomes.

In the same issue of JAMA, James R. Dunn of McMaster University in Canada, has a very insightful editorial commenting on the Stringhini article, “Health behavior vs the stress of low socioeconomic status and health outcomes” (JAMA, Mar24/31, 2010;303(12):1199-1200). He repeats the caution of the Whitehall authors that the population studied in the Whitehall cohort may not be representative of the British population overall (and, by extension, of the US or Canadian population). Indeed, the cohort was originally selected by Marmot and colleagues to reduce the confounding that might come from general studies of people in different classes because of occupational risks. Dunn points to the association of the stress of low socioeconomic status and the prevalence of adverse health behaviors: “…it is possible to consider both factors [stress and behavior] as part of the same pathway between relatively low socioeconomic status and health. Unhealthy behaviors are more common among individuals with low socioeconomic status because of the stress of low socioeconomic status. Accordingly, there is a direct causal pathway between low socioeconomic status and poor health as well as an indirect causal pathway through health behavior, which reinforce one another over the lifecourse.” That is, the stress of being poor makes you more likely to do unhealthful things that we know about (smoking, poor diet, low physical activity) that make you less healthy, and also makes you less healthy through a pathway that we don’t completely understand.

Dunn notes that while changing health behaviors in lower socioeconomic populations would be a good thing, “The problem is that traditional individually oriented health behavior education interventions are not very effective, and individuals with low socioeconomic status have been notoriously difficult to reach with such programs”. He discusses a variety of early childhood developmental characteristics, especially “executive function” and “self regulation” which might increase the probability of not adopting or stopping adverse health behaviors, which are on average less well developed in those growing up in lower socioeconomic groups, presumably also as a result of the stress impacting them as young children.

The relatively good news from the Stringhini study is that the prevalence of many adverse health behaviors did decrease over the time period studied. For smoking, the prevalence decrease from 10.1% to 4.8% in the highest, and from 29.7% to 16.5% in the lowest socioeconomic groups and unhealthy diet from 5.8% to 1.0% and 14.9% to 5.2% respectively diet; on the other hand, sedentary behavior increased from 6.6% to 21.4% in the highest and from 35.4% to 41.6% in the lowest socioeconomic groups. Again, extending this to the whole British population is uncertain, and in the US the prevalence of obesity (a combination of both poor diet and physical inactivity) is growing at a staggering rate in all age groups, and especially in low socioeconomic groups.

The take-home message is that all people should be encouraged and supported to adopt healthful and eschew unhealthful behaviors, particularly related to smoking, diet and exercise, and the degree to which any programs can be demonstrated to be successful for large numbers of individuals or, better yet, groups, they should be promulgated and replicated. However, to have greater success, programs will have to strike closer at the etiologies of these behaviors. A lower level, achievable (and achieved in some jurisdictions) by legislation, exemplified by indoor smoking bans, calorie and fat content labeling of foods, especially fast foods, and banning the use of toys as gifts in fast-food meals (as recently done in Santa Clara County, CA), can have much more significant impact (see “Promoting health through tobacco taxation” by Ali and Koplan from JAMA, and “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis” by Meyer, et. al., in JACC, cited in The Public’s Health: Smoking and Salt, February 6, 2010).

The greatest changes, however, involve even more significant societal changes: the elimination of the wide disparity in income and opportunity, thus socioeconomic status, and of racism. Health-focused, as well as social justice focused, policies should try to achieve this end, but in the US it will be a long time coming. In the meantime, it remains a good idea to choose your parents wisely; being born white and rich still significantly enhances your health status.
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The Public’s Health: Smoking and Salt

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People pretty much know that smoking is bad for you. You, the smoker, and you, the person exposed to secondhand smoke. Smoking accounts for over 450,000 deaths a year in the US, more than alcohol, accidents, homicides, suicides, and illegal drugs. It is good for people’s health – both the smokers and those who are exposed to that smoke in their homes, workplaces and places of recreation – that people are smoking less; fewer people are smoking and those who do are, on average, smoking fewer cigarettes. Most of the people who have quit have done it on their own, rarely the first time that they tried (“Quitting smoking is easy,” said Mark Twain, “I’ve done it hundreds of times.”) Others have had help – from support groups, physicians, therapists, drugs.

But more important than individual efforts to change individual behavior is the positive impact public policy can have on public health. Mandatory immunizations for school, seat-belt laws, laws governing the safety of manufactured automobiles, helmet laws etc., have all had measurable and significant impact on our health. The two most common and important public policy initiatives regarding smoking are taxing tobacco and banning smoking in public places. In the January 27, 2010 JAMA, Mohammed K. Ali and Jeffrey P. Koplan look at “Promoting health through tobacco taxation”.[1] They show that increasing tobacco taxes decreases tobacco use, especially in young people, and thus the morbidity and mortality that comes from tobacco.

The beneficial effect of smoking bans is so enormous it suprises even tobacco control advocates. “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, published by David G. Meyers, John S. Neuberger, and Jianghua He in the Journal of the American College of Cardiology, September 29, 2009,[2] examined 11 studies of smoking bans done in 10 different locations and found that there was a 17% overall reduction in acute myocardial infarction (AMI = heart attack) when these bans were implemented, and that the risk incrementally decreased 26% for each year that the ban was in place. In Helena, MT a smoking ban instituted in June 2002 and resulted in a 40% decrease in AMI by the time the ban was suspended by a court order in December. After the ban was lifted, the AMI rate returned to baseline within 6 months. The impact on AMI is in addition to any effect on other diseases, such as cancers, which were not examined in this study (and would take many more years to have an effect). While much of this improvement in the public’s health comes from reducing the impact from second hand smoke on non-smokers, such bans also unquestionably encourage smokers, especially younger ones, to stop smoking. This is particularly true when quitting is something that the smoker had wanted and planned to do, with the smoking ban or increase in the tobacco tax acting as the “final straw”.

Ronald Bayer and Matthew Kelly, in the New England Journal of Medicine January 28, 2010 discuss “Tobacco control and free speech”[3] and look at how the courts are likely to decide on cases brought to them on tobacco control. While not, so far, opposing tobacco bans, the American Civil Liberties Union is supporting objections to limits on tobacco advertising on the basis of their restriction of free speech: “Burt Neuborne of the New York Civil Liberties Union told Congress that the proposed bans represented ‘a vote of no confidence in the capacity of ordinary Americans to judge for themselves how to react to tobacco advertising”. Bayer and Kelly cite the Posadas decision, written by former Chief Justice Rehnquist in 1986, that limited the advertising for a casino. The quote his opinion “It would surely…be a strange constitutional doctrine which would concede to the legislature the authority to totally ban a product or activity [such as gambling] but deny to the legislature the authority to forbid the stimulation of demand for the product or activity [advertising]”. I would argue that it is unreasonable to suggest that we can outlaw products (such as heroin, marijuana) or activities (gambling) but not restrict others (e.g., smoking in public places) and thus most often bans have been supported.

However, the Supreme Court is moving away from the Posadas position, Bayer and Kelly tell us, in the 2001 case of Lorillard Tobacco Company v. Reilly, and given the 2010 Citizens United decision in which the Court has made the bizarre declaration that corporations have First Amendment rights to give money directly to political candidates, it is far from certain that they would support tobacco bans, taxes, or restrictions on advertising in the future. Clearly, these justices who have previously styled themselves as “strict constructionists” looking at original intent”, have clearly demonstrated that they have no such belief, radically making new law and reading their own beliefs into the Constitution. But what is certain is that all these restrictions, without directly forbidding any adult from smoking, have a dramatic positive impact on the public’s health.

Another article in the New England Journal of Medcine, published on-line January 20, 2010, by Kristen Bibbins-Domingo, et. al., looks at the “Projected effect of dietary salt reductions on future cardiovascular disease”, and notes that reducing dietary salt by 3g per day (or about 1/3) would reduce the annual number of deaths from all causes by 44,000 to 92,000, and new cases of coronary heart disease by 60,000 to 120,000, stroke by 32,000 to 66,000 and AMI by 54,000 to 99,000. This is important, because in recent years the emphasis on salt reduction as a method of treating hypertension (high blood pressure), one of the big vehicles for these bad outcomes, has diminished with the marketing of large numbers of anti-hypertensive drugs. We, as physicians and the public, need reminders of the dramatic efficacy of this sort of dietary change.

The article does not address how that reduction might be accomplished; clearly, as with smoking, the effect could occur if people as individuals just reduce their salt intake. But the probability of this happening is again low. Programs such as labeling the salt/sodium content on foods in both grocery stores and restaurants, especially “fast-food” restaurants, have been implemented in a number of cities. Further regulation, actually requiring lowering of the amount of salt in these foods, would have an even greater impact. Unlike smoking bans, which have a great part of their effect through elimination of exposure of non-smokers to secondhand smoke, the benefit of salt restriction is mostly to the individual consumer. However, this does not mean that societal impetus for this change is not a critical part of changing people’s behavior. Indeed, as noted by Mark Doescher, Director of the Rural Health Research Center and the Center for Health Workforce Studies at the University of Washington in his comments on the important new textbook Community Based Health Interventions [4], “…environmental factors, such as safe streets, healthy food choices, and smoke-free establishments govern individual behavior.”

Experts in occupational safety have long recognized that changing individual behavior is the least effective way of increasing safety. If we want to prevent people from slipping on a factory floor and going through a plate glass window, the first choice is architectural (don’t put a plate glass window next to a shop floor where substances may be spilled that people can slip on). The second choice is engineering, or retrofitting (put a steel mesh over the window). The least effective choice is changing human behavior (telling people to be careful!). The dramatic reduction in deaths from car accidents over the last 30 years has had virtually nothing to do with people driving more safely, and everything to do with car manufacture (engines that collapse down instead of into your lap, air bags, etc., all of which were resisted by the automobile industry) and safer road construction. With regard to the health of the public, the same rules apply. Tobacco bans, tobacco taxes, and efforts to reduce salt intake by honest labeling are much more likely to have a salubrious impact than efforts to get people to change their behavior individual by individual. We need to encourage the latter, but because Doescher is correct, we must also implement the policy changes. We must no longer allow the economic benefit to special interests to continue to endanger the public’s health.

[1] Ali MK, Koplan JP, “Promoting health through tobacco taxation”, JAMA 27Jan10;303(4)357-8.
[2] Meyers DG, Neuberger JS, He J, “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, J Amer Coll Card 29Sep09;54(14):1249-55.
[3] Bayer R, Kelly M, “Tobacco control and free speech”, NEJM 28Jan10; 262(4):281-3.
[4] Guttmacher S, Kelly PJ, Ruiz-Janecko Y, eds., Community-based health interventions, Jossey-Bass, San Francisco, 2010.