Self-centered Syllogism: Bad in public health, bad anywhere

I recently met someone who had seen a couple of my blog posts, was interested in public health, and asked a few interesting questions. My answers – or, really, comments – were things I have said and written about before, but his questions forced me to put them together, and in my opinion, the issues bear repeating.

The first question he asked was “why do we put so much emphasis on smoking but not on alcohol? After all, smoking never caused someone to beat their children or spouse, or to drive impaired and have an accident, or get into a bar fight and beat, shoot, or stab someone else.” That is true, and it raises the issue of the impact of substance abuse on the individual versus on the society (although second-hand smoke causes a lot of deaths). But the real answer is the incredible mortality caused by smoking. The CDC page identifies tobacco as the cause of nearly a half-million deaths in the US annually. While the data is from 15-20 years ago, and (hopefully) the mortality rate from tobacco has decreased as its usage has decreased, this is an astonishing statistic. Deaths from tobacco exceeded the total of deaths from alcohol, plus illegal drugs, plus accidents, plus homicides, plus suicides. It remains, even as smoking has decreased, a major health problem. The CDC says, “Tobacco is the leading cause of preventable mortality in the United States”. It was, therefore, the focus of public health efforts because of its tremendous impact on mortality.

However, of course, alcohol is also a major problem, causing both death and severe morbidity (bad outcomes besides death). It is, as my questioner noted, highly associated with violence against both family members and strangers, with automobile deaths, with homicide and not-homicide violence. It also, of course, kills people who use it, from diseases such as cirrhosis and heart disease as well as many cancers that are more common in heavy drinkers. We all have heard someone who did something very bad (commit violence against family members or strangers, have a car wreck, etc.) say “It was the alcohol. I wouldn’t have done it if I were sober”. But they were not sober, they had been drinking, and probably had often been.

The American Addiction Centers alcohol.org estimate that 88,000 people die from alcohol-related violence and abuse and accidents. The site also notes that “The American Society of Addiction Medicine notes that between 28% and 43% of violent injuries, and 47% of homicides, alcohol has been estimated to be involved.” That is a lot, and it could be an underestimate, but it is the closest I can get to quantifying the attributable risk for violence from alcohol. The concept of “attributable risk” in public health can be understood as the percentage of “bad outcome X” that would go away if “risky behavior Y” went away. This is different from the amount that it increases an individual’s risk; some behavior “Y” may increase your risk a lot but, because it is relatively uncommon, account for less attributable risk. Examples include asbestos and lung cancer (very high increase in risk but a lower percent of cases, compared to smoking). Or, looking at it inversely in terms of what disease a risk factor causes, smoking and lung cancer vs. heart disease. Smoking increases the risk of lung cancer more than it does heart disease, but because heart disease is so much more common, the attributable risk from smoking, the number of lives that would not be lost if people didn’t smoke, would be more from heart disease than lung cancer. An example of “smaller percentages of larger numbers can be greater than larger percentages of smaller numbers”.

So what did I say about alcohol? He identified the fact that there is a very large industry of alcohol manufacturers and sellers, which have great influence. I noted that there was (is) also a great industry of tobacco manufacturers and sellers. He said that in addition to the manufacturers, there were also many businesses, restaurants and bars whose existence depended on the sale and use of alcohol. The current emphasis we see in “alcohol reform” is “don’t drink too much”, a common “PSA” from alcohol manufacturers. The implicit message, however, is “do drink!”.

I think most of the members of our society, including many of those still smoking, recognize that any amount of smoking is bad for you, and more is worse, but I do not think that the same is true for alcohol use. The general attitude, even among medical and public health professionals, seems to be “a lot of drinking is obviously bad, for you and for others, but a little – like I do – is not.” What could be wrong with a couple of beers? A couple of glasses of wine? Especially if you’re not driving? Aren’t there studies that show a little red wine is good for you?

There are such studies but they are dated, poorly done, and wrong. Pretty much, while more is worse, there is no amount of alcohol consumption that is good for your health, and any amount is somewhat bad. We disparage those who use other drugs (heroin, cocaine, crack, meth, even still cannabis) for entertainment, but much of our society is actually built around alcohol as the “social lubricant”. Restaurants, bars, parties. Family events like weddings and funerals. Most of such entertainment revolves around alcohol. Perhaps the only place where alcohol is not the key component of “having fun” would be at an AA meeting! This issue is seriously joined by Holly Whitaker in her book “Quit Like a Woman: The radical choice not to drink in a culture obsessed by alcohol”.

The key here is that so many people drink (if “responsibly”, by which they usually mean “not too much” and “not when driving”) that they have to justify themselves by saying it is OK. I call this the “Dirk Gently Phenomenon” from Douglas Adams’ book “Dirk Gently’s Wholistic Detective Agency”. The lead character, who dies on the first page, was a millionaire who made his money by essentially developing syllogisms that took you from the data you had to the conclusion you had foreordained (his biggest client was the US Department of Defense). This is pretty much what we do in lots of areas, including alcohol use; we decide on what we want the answer to be and then look for evidence that supports it.

My new friend noted his son had been in a public health program a few years ago when the big emphasis was on obesity and its health effects. I nodded, but it not so much any more. Obesity has big health effects, yes, but it is also easy to disparage people who are overweight. This is a manifestation of another common tendency among people (including among health professionals): to be critical of people who do (or don’t do) things that come easily to you to do or not do, and conversely minimize the significance of the negative behaviors that you do (or don’t do). If you are naturally thin and have an no difficulty keeping weight off, it is easy to criticize those who are overweight. However, if you like your fancy wine or craft beer or expensive single-malt scotch, you don’t think drinking is such a bad thing. Or, for that matter, being self-righteous.

Public health is good and important. In the US, it is grossly underfunded compared to individual medical care (about 1% of health care dollars). But, like much of medicine it is also subspecialized. To a large degree, public health researchers go where the money is available for grants – in obesity, or smoking, or violence prevention, etc., and become specialists in that area. It is (or should be) different in primary care. As a family doctor, I can measure and counsel you on your blood pressure, but I cannot ignore your diabetes or lung disease and just refer you to another specialist. Similarly, while public health specialists “do obesity” or “do child seats”, this is not an option for the family physician. I need to help you to stop smoking, but cannot ignore that you need to use a seatbelt. Or get vaccinated. Or would have a greater probability of better health outcomes if you lost some weight. Or did not drink so much. Or at all.

Judging others for doing (or not doing) what we find it easy to not do (or do) and minimizing the damage caused by what we ourselves do is a big logical flaw, as is the “Dirk Gently” fallacy. They are not attractive, appropriate, or helpful or good for anyone, and are especially dangerous coming from medical or public health professionals.

Drugs, Tobacco, Doctors and the Health of the Public

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Drugs (the legal prescription type) and drug safety seems to continually return to the news, most recently with reports of serious side effects from a new oral contraceptive pill (OCP), featured on NPR’s "Morning Edition”. With regard to OCPs, it is important to note that virtually all the side effects of oral contraceptives, including the serious ones, are the same as the ones women are at greater risk for from being pregnant. The fact that pregnancy is a “natural” event does not make it risk free; complications such as clots in the veins of the legs (deep venous thrombosis, DVT) do occur, associated with the higher levels of estrogen in pregnancy, and occur more frequently than they do for women taking oral contraceptives. Whatever one’s level of risk for OCPs, a risk that increases with increasing age and dramatically if one smokes, that risk is greater from being pregnant.

However, because the probability of getting pregnant (and thus having serious “side effects” from it) decreases with increasing age while the risk of serious side effects from OCPs goes up, it makes sense for older women who are still fertile to use alternative types of contraception – but, unless they are actively trying to get pregnant, to use contraception. The fact that OCPs can have significant benefits (mainly: preventing unwanted pregnancy) does not make them benign, but neither is pregnancy itself.

The choice to use or not use drugs for any condition (or for prevention of a condition), whether they are prescribed by a health care provider or, in the case of many nonprescription drugs, chosen by the person him/herself, is influenced by number of factors. The best one is that a person has a condition that puts them at risk for bad health outcomes (the “patient important outcomes” of premature death or decreased quality of life; see Calcium, Heart Attack and Osteoporosis, August 2, 2010; Rosiglitazone and the "Holy Grail" July 16, 2010; Statins and scientific integrity, July 6, 2010), and the probability that a drug will decrease that risk is significantly greater than the probability that the drug’s effects will cause a problem. There are sometimes other reasons; a person (patient) will hear from a friend that a drug worked for them, or see on it advertised on television or elsewhere, and decide to try it (if non-prescription) or ask their doctor for it (as so often urged on TV commercials). Depending on a number of factors (whether the drug is in fact useful or potentially useful for something the person has, whether it might create increased risk for the patient, how persistent, or even demanding, the person is) the doctor might in fact prescribe it.

In general, it is fine if you ask your doctor about a medication that you have reason to think might benefit you, but probably not such a good idea to persist/insist if s/he suggests it would not be advisable to take it. A few cautions and things to think about, some of which I have previously discussed (“Conservative” Drug Prescribing March 11 2009):

• Not everything is effectively treatable with a drug. Taking a pill may be easier than changing your diet or exercising or doing other hard or proactive things, but without those other activities it may not work or work as well, and may well be worse;

• Not all drugs are “bad”. Some are really helpful for the right people with the conditions that they are effective in treating, and the potential side effects are far less than the benefits.

• Because some drugs do not require a prescription this does not make them “safe”. They should still only be used when the same criteria are fulfilled: scientific evidence demonstrates that the probability of benefit significantly exceeds the probability of harm. The same applies to any “nutritional supplement”. Because it is not called a “drug” doesn’t make it safe. Everything has potential for harm in the wrong people, the wrong circumstances or the wrong dose (Dietary Supplements can be Dangerous for your Health, October 31,2009)

• If a little is good, more is not necessarily better. Nor is less necessarily better. The right amount is: the right amount!

• Despite our culture’s fascination for the “NEW!!”, new is not necessarily better. Frequently it is worse. Drugs are not cars or cell phones. Newer drugs may have side effects that have not become apparent in the necessarily limited testing that is done before they are marketed, but do manifest when many times more people take them. They sometimes have therapeutic benefit for some people that is greater than old drugs, but often they do not. The only reason to even consider a drug that is new on the market is if your old drug, and the other available old (=”well established”) drugs don’t work adequately or have intolerable side effects, and there is reason (=”evidence”) that the new one will (work better), or won’t (have those side effects).

• Advertising drugs, whether to physicians or to patients, is pretty much a bad thing. As in all advertising, the goal is to sell stuff; it is not (despite pharmaceutical company slogans) improving people’s health. This is highly tied to “NEW!!” because it is the new drugs that are the ones that are advertised. This is because they are the ones that cost the most, that have the highest profit margin, and that the companies need to develop a market for. They also have to amortize their research and development costs, as they will often point out. This would be a less offensive claim if most of the drugs that came out and are heavily marketed were not “me too” drugs – modifications (often quite minor) of existing drugs that are no longer under patent and are being sold generically. Drugs that the doctor may have in his/her “sample closet” will always be these same drugs – the newest, highest cost (and highest profit) options. In health care, if something is being advertised, whether a drug or a procedure available at a local hospital, the meaning is “we would like it if you would buy this because we will make money” and not at all necessarily “this will be good for your health”. By the way, in the case of advertised procedures that you may see on billboards for a hospital or clinic, it means also “if you have insurance”.

The issue of advertising to physicians is addressed in an excellent editorial by Matthew Anderson in the current issue of Social Medicine. It examines the historic and current collaboration by medical organizations with big corporations. In addition to the AAFP/Coca-Cola alliance that I have recently written about, it examines the relationship between the American Academy of Pediatrics (AAP) and infant formula manufacturers and the tight involvement of the AMA with pharmaceutical companies. It is eye opening. In addition, the journal contains a powerful piece by Alan Blum introducing two classic articles about physician activism around tobacco written by the same Dr. Blum when he was, 20 years ago, editor of the New York State Journal of Medicine: “Cigarette smoking and its promotion: Editorials are not enough” and When “More doctors smoked Camels”: Cigarette advertising in the Journal” . The introductory quotation to the first article, from Ira Gershwin of all people, cannot be repeated often enough “One man's death is another man's living”.

And, for those who doubt that, given the current shameful practices, sometimes, given enough time pressure and public awareness, progress is possible, it is worth just looking at the Social Medicine’s cover to see how far we have come, in at least the relationships between doctors and tobacco.
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