Devious Health Canada

It looks like somebody from the Prime Minister's Office in Canada is going to have to have a quiet chat with the healthists over at Health Canada. Terrence Corcoran reports that Health Canada gave the Prime Minister a nice little candy-coated landmine.

In last year's election campaign, Harper promised to crack down on flavoured tobacco products which he characterized as being marketed to children. The campaign promise was to knock out bubble gum flavoured tobacco. The legislation crafted by Health Canada wound up banning the majority of imported cigarettes, including Marlborough and Camels, most of which use some flavouring agents which are on the list of 5,000 now banned ingredients.

While this may look like another case of unintended consequences run amok, it more likely is part of deliberate scheming by Health Canada officials and others who are consciously using fruit-flavoured smokes to create a global tobacco trade bomb against the U.S. and tobacco industries in Europe, South America and Asia.

There is certainly evidence that Health Canada officials misled Parliament on the trade implications of the flavoured tobacco ban.

On Sept. 30, Diane Labelle, Health Canada’s general counsel, legal services unit, appeared before the Senate social affairs committee to review the bill. Several committee members — including Senators Michel Rivard and Hugh Segal — became concerned about the implications of the flavoured tobacco law on Canada’s World Trade Organization commitments. Committee chair Art Eggleton asked: “Is this [bill] compliant with various trade agreements and international obligations that we have on trade?”

Senator Rivard repeated the question: “The WTO assured you that we were in compliance?”

Ms. Labelle: “Yes.”

But when Canadian officials appeared earlier this month before the WTO’s Technical Barriers to Trade Committee in Geneva, they came prepared with briefing notes on what to say when WTO members raised questions “On Canada not notifying Bill C-32 at WTO.” The briefing notes, obtained by Financial Post, suggest a weaselly Canadian response: “We thank you for raising this concern and are talking note of the systemic issues that have been raised.”

In other words, it is not true, as the Senate committee was told, that the WTO had been advised in advance of Bill C-32 and had determined the new child tobacco measure to be compliant with trade law.

Were the Tories snookered by Health Canada officials? It looks like it. It also looks like the Prime Minister’s original campaign gambit, to protect children from flavoured tobacco, was a ruse. Whether Mr. Harper knew that he was getting into is another matter. The zeal with which his staff pushed the issue suggests they were eager to score political points but less keen on understanding what Health Canada was up to.

New Zealand ought to watch out for the sure-to-come ASH/SFC campaign against flavoured tobacco, backed by folks from Otago's Wellington School of Medicine Department of Public Health. And we ought not let the Ministry of Health be the ones providing advice as to the consistency of any such recommendations with our WTO obligations; they have a habit of commissioning shonky analysis.

Recall also that the WHO offers assistance for countries wanting to get around tricky WTO obligations....

Slippery slopes: theory and practice

Glen Whitman continues blogging on paternalism and slippery slopes, this time focusing on hyperbolic discounting. Money quote

Quasi-hyperbolic discounting makes it deceptively simple to choose the “correct” rate of discount, since there appear to be only two options. If real people actually engage in hyperbolic discounting, this implies a gradient or continuum of discount rates over time. If we assume, notwithstanding our earlier objections, that the immediate discount rate is impulsive or ill-considered, which of the longer-term rates is normatively preferable? There is nothing in the logic of new paternalism or behavioral economics that can provide an answer. We are faced with a continuum of normative possibilities. These arguments impel us to the conclusion that among the discount rates revealed in choice or planning behavior, none has a clear claim to normative superiority. Thus, the new paternalist is in a conceptual fog because his underlying standard of evaluation is unspecified. The notion of “excessive impatience” is both theoretically and empirically vague, and that means we have a gradient of possibilities. There is no clear line to resist the gradual creep of higher savings requirements, higher fat taxes, and the like.

In the set of posts so far, Whitman has nicely laid out some of the theory on slippery slopes. Chris Snowdon at Velvet Glove, Iron Fist provides the empirical counterpart, highlighting the shifting positions of the anti-tobacco folks over time. The post is beautiful, do read the whole thing. It opens with Stanton Glantz's assertion that slippery slope arguments are fallacious, then looks at the shifting goals of Action on Smoking and Health over the last forty years.

Back in 1968, ASH ostensibly existed as a pressure group to resist cigarette advertising on television to protect children. When the Los Angeles Times interviewed him in that year, he was insistent that he was anti-smoking, not anti-smoker, as their reporter explained:

"Banzhaf doesn't smoke but he denies his crusade is based on an antipathy for smokers and smoking. "You can smoke," he said. "That's all right. I just don't want children brainwashed into it."

Fast forward to 2009 and Banzhaf has a very different attitude. He now describes ASH as "a national organization leading the fight to protect nonsmokers from thirdhand smoke." ('Thirdhand smoke' being an ill-defined chimera based on a telephone survey which has no credibilty amongst serious scientists). For several years, he has been a leading voice in the campaign for smokers to be discriminated against in custody battles. Not only has he called for the children of divorced couples to be given to the nonsmoking parent, but he now believes that the smoking parent should be compelled by law to "change clothing and use a mouthwash before the child visits." Last year, he appeared on television to explain why it was "legal and profitable" for companies to "fire smokers and employ only nonsmokers."

It is safe to say that Banzhaf would have never been taken seriously had he proposed even one of these policies in the 1970s. Instead he has taken baby steps to win a long series of small victories, all the while calling for compromise and reasonable accommodation. This article documents a few examples of how he has achieved this.

Note that much of the above quote, at the original source, comes with nice links to the relevant sources.

Snowdon then gives the nice set of quotes over time from Banzhaf (all my paraphrasings unless in quotes)

• 1977: Banning smoking on the streets would cause problems, but having laws mandating separate smoking sections, with the restrictions not too onerous, that should be reasonable.


• 1979: "We have no objection whatsoever if you ...want to go into smokeasies and smoke all day long. We just object that you do it around us."


• 1986: Anti-smoking organisations don't want to ban smoking, we just want separate sections for non-smokers.


• 1993: "A non-smoking section? There ain't no such thing. Tobacco smoke drifts, it is recirculated."


• 2006: "The ultimate goal is to have a smoke-free society...we will not be tolerating it on public places, streets, outdoors, or anywhere else."

Lots more great stuff at the original post, showing the slippery slopes on smoking in bars, planes, smoking and non-smoking sections... do read the whole thing.

Alcohol's already part way down the slope. The New Zealand Law Commission has an open ear for suggestions of reasonable accommodations between the prohibitionists and the status quo; when the whole thing is revisited again in ten years' time, the status-quo's goalposts will again have shifted, and we'll find a new midpoint between tomorrow's status quo and complete prohibition. The asymptotic result is pretty obvious. Next up is fatty foods.

Wouldn't it be nice if the folks on the chopping block would pull together against paternalism, full stop, rather than seeing the piecemeal regulatory changes as ways of getting temporary advantage against competitors.

Afternoon roundup

• Colby Cosh: No other society could have created a "Balloon Boy"


• And now a push in the US for tobacco-free campuses: no smoking, not even outdoors, and they'll even ban forms of tobacco that cannot have any possible negative health effect on others:

  The ACHA’s recommendations go even further. They ban not just the use of cigarettes, cigars and other smoke-producing products but also the use of snuff, chewing tobacco and other smokeless tobacco products. The eventual goal, as described in the position statement, is “becoming or maintaining tobacco-free living and learning environments that support the achievement of personal and academic goals.”

  Lousy healthists. Comments section there decent.


• If I wanted some fancy seat covers, looks like I could just take a walk five minutes down the beach at home.


• Net migration to NZ highest in six years; cue housing price increases

Evidence-based medicine

Norbert Gleicher warns in the Wall Street Journal against relying too heavily on academic metastudies in health:

The idea of creating expert panels has a certain logic to it. After all, who is better qualified to determine best medical practices than medical experts? The medical field itself has been edging toward a similar approach in recent years with "evidence based medicine," an approach that assumes it is possible to determine what works and what doesn't by reviewing published medical literature.

Evidence-based medicine has some value, but it can provide misleading information. Determining which studies to review, for example, can introduce biases. Whether investigators accept published data at face value or repeat primary data analyses also matters. If the data in a published study were poorly analyzed or, for argument's sake, completely invented, relying on it can lead to faulty conclusions. It's an unfortunate reality, but our medical literature is significantly contaminated by poorly conducted studies, inappropriate statistical methodologies, and sometimes scientific fraud.

...
Studies published in the medical literature are mostly produced by academics who face an imperative to publish or watch their careers perish. These academics aren't basing their careers on their clinical skills and experiences. Paradoxically, if we allow the academic literature to set guidelines for accepted practices, we are allowing those who are often academics first and clinicians second to determine what clinical care is appropriate.

Consciously or not, those who provide the peer review for medical journals are influenced by whether the work they are reviewing will impact their standing in the medical community. This is a dilemma. The experts who serve as reviewers compete with the work they are reviewing. Leaders in every community, therefore, exert disproportional influence on what gets published. We expect reviewers to be objective and free of conflicts, but in truth, only rarely is that the case.

If the medical literature is as bad as he says it is, shouldn't the first cut prescription be to fix the publishing process in medicine? On the whole, I'm skeptical. But I do like Hanson's betting markets on scientific ideas.

On the other hand, today I also read this about Stephen Glantz's metastudies on smoking and heart attacks.

Sure enough, the Institute of Medicine's study did not include the hospital data from the UK, nor did it include a study of the entire US which showed no association between the introduction of smoking bans and declines in heart attack rates.

The absence of this data from the IoM's report is troubling, since Dr Siegel had made the committee aware of this contradictory evidence
...
The fact that this data was omitted, and that Stanton Glantz was given another starring role in the creation of the IoM's report, should be of concern to anyone who expects impartial research from such organisations.

You can get any result you like out of a metastudy if you're careful about which studies to include (among a host of other decisions about weighting data from various studies); that's why you really have to trust the guy who wrote the study, or, better, have several metastudies that all point in the same direction.

HT on WSJ piece: Book of Joe

Morning roundup

• Pfizer now marketing Champix, a stop-smoking aid, in NZ. Sounds like a milder form of Antabuse but for tobacco rather than alcohol. Now, will this mean that ASH, SFC and the public healthists worry less about tobacco because it's less addictive, or worry more about it because anything that makes quitting easier also makes starting more likely? HT: National Business Review.


• The public healthists at Otago School of Medicine at Wellilngton have been busy rummaging through your trash. They reckon about 3% of cigarettes consumed here come in from abroad, either through duty-free or smuggled. Wilson then bemoans the lost tax revenue. Never mind that duty free is in place mostly to avoid the transactions costs of having to collect minor amounts of tax (ie the cost of collecting the tax outweighs the tax collected). And never mind that even O'Dea's anti-tobacco commissioned study says that the currently collected excise taxes far outweigh any costs to the public health system in New Zealand.

  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.



• Good luck to Bradford and Scott who are fighting Canadian prostitution legislation, arguing that restrictions are unconstitutional. New Zealand's legalisation in 2003 has certainly not worsened outcomes and has arguably done a lot of good.


• Copyright increases both the rewards from producing new content and the costs of doing so.

Smoking, fiscal externalities, and harm minimization

Colby Cosh points me to still more examples of very bad analysis of the costs of drugs: in this case, smoking. The Canadian study seems to have tried to tally up the costs to government of tobacco, but didn't note that smokers' deaths reduce government pension costs and avoid the health system having to deal with the other ways they would otherwise have died (as we all do, eventually).

Two things worth noting.

First, Kip Viscusi and others have found that when the costs are tallied correctly, smokers save the government money: they die earlier of cheaper diseases.

Based on surveys of smokers in the United States and Spain, for instance, he demonstrates that smokers actually overestimate the dangers of smoking, indicating that they are well aware of the risks involved in their choice to smoke. And while smoking does increase medical costs to the states, Viscusi finds that these costs are more than financially balanced by the premature mortality of smokers, which reduces their demands on state pension and health programs, so that, on average, smoking either pays for itself or generates revenues for the states.

Second, it's unclear whether these "cost the health system money" effects really are inefficiencies. They're called fiscal externalities, and are of pretty dubious status regardless of the direction of the sign. If we take Buchanan and Stubblebine's (1962) categorization of pecuniary and technological externalities, fiscal externalities don't get to count as the kind that cause inefficiencies. In the Buchanan-Stubblebine framework, pecuniary externalities affect others via the budget constraint while technological externalities enter directly via the utility function: only the latter has efficiency consequences. In short, under that view, we should be no more worried about inefficiency caused by somebody smoking more and costing the health system money than we should be worried about inefficiency caused by somebody bidding against you at a house auction.

Even if you want to count fiscal externalities as technological, it's well-neigh impossible to tell where to stop. If the existence of a public health system induces me to smoke more than I otherwise would, imposing costs on you, the taxpayer, it will also have effects on all kinds of other things I might choose to do. Folks will take on more risks on many margins and will invest less in avoiding health costs. At what point does the State get to tell us we're forbidden from risky sexual practices because of the costs of STDs on the health care system? As Edgar Browning so nicely showed us, the full set of taxes and subsidies that would eliminate all of the incentive effects inherent in the public health system would have an incidence similar to an actuarily-fair private health insurance premium, but with massive transactions costs.

Finally, Reason points me to an FDA campaign against electric cigarettes, which deliver nicotine vapor to smokers. While these electronic delivery mechanisms are far safer than regular cigarettes, the anti-tobbac folks worry that they'll prove the gateway into regular tobacco for non-smokers. Or, at least that would be the rational version of the argument. Arguments against harm-minimization devices of this sort often seem more akin to the Pope's reaction to a campaign promoting masturbation over pre-marital sex. Consider the position of the anti-tobbac lobby here in New Zealand with respect to chewing tobacco, or snus, which here is banned.

Snus is an addictive tobacco product that contains nicotine. The risk of developing cancer is far less among snus users than it is among smokers. However, it cannot be said that snus is an entirely safe product nor can it be claimed that it has been proven to be an effective cessation aid for smokers who want to quit. ...Rather than deregulating the use of oral tobacco in New Zealand more substantial health gains are to be had from the regulation of all tobacco products.

In other words, even though it could well improve health outcomes for smokers, it's still tobacco, and tobacco is evil, and suffer not tobacco to live among you.

It's an empirical question around elasticities on the extensive and intensive margins, but I'd be extremely surprised if either electronic cigarettes or chewing tobacco proved net harm increasing. It's a shame that the onus isn't on the pro-ban folks to prove harm.