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Public Health

All articles with the "Public Health" tag.

Published: Mon, 22 Jan 2018 00:00:00 -0500

Last Build Date: Mon, 22 Jan 2018 15:13:19 -0500


Good Samaritans in Southern California Cited for Feeding the Homeless

Tue, 16 Jan 2018 11:45:00 -0500

Police in the City of El Cajon (near San Diego) spent part of the Martin Luther King holiday weekend citing people for feeding the homeless. Now those people are fighting back. On Sunday, police cited about a dozen people—including one 14-year-old girl—with misdemeanor charges for feeding homeless people in a public park. El Cajon passed this law as an "emergency" in October, claiming it was needed due to a rise in Hepatitis A in Southern California last year, an outbreak that has hit the homeless especially hard. Hepatitis A can be spread quite a few ways among those who live unsanitary lives (as the homeless typically do), but it seems unlikely that it's a result of non-homeless people giving homeless people food. El Cajon's City Council is abusing a health scare to make it harder for the public to provide assistance to homeless people because they want them off the streets and into managed shelters and churches. This "solution" then criminalizes voluntary charitable interactions between citizens for not fitting into the model of how the city wants people to behave. High school teacher Matthew Schneck shared his citation on Twitter: Today I got arrested for feeding the homeless in Wells Park in El Cajon. The City of El Cajon has made it illegal to share food with homeless people. "...One has a moral responsibility to disobey unjust laws" —Martin Luther King Jr. — Matthew Schneck (@matthew_schneck) January 15, 2018 Listen to El Cajon City Council member Bob McClellan complain about people finding their own ways of helping the homeless and not complying with the city's master plan (via the San Diego Union Tribune): Councilman Bob McClellan said the city has published a list of churches where people can get food and where activists can help serve food, in an effort to contain food sharing to closed and sanitary environments. "They don't have to feed them in the park where it could cause a problem according to the health authorities," McClellan said. "If they want to help the homeless, look at the list of places. All they have to do is read the list." The group responsible for the event on Sunday knew full well what was going to happen. The group—named Break the Ban—is defying the ordinance on purpose. They and their lawyers are now going to use the citations to challenge the constitutionality of the law itself. This was their fourth event feeding the homeless in defiance of the law. They're planning another event for January 27. The American Civil Liberties Union (ACLU) describes the ban as "unconstitutional and unnecessarily cruel." They're claiming the sharing ban violates freedom of speech. It may seem strange to say that giving food is a form of speech, but the ACLU argues that the city is picking and choosing who can express charitable attitudes toward the homeless and the circumstances of how they may do so: "By prohibiting food sharing only when done for 'charitable purposes,' El Cajon is regulating food sharing because of its expressive content, punishing only those who share food to express their religious or political beliefs in ministry or charity but not those who share food for other purposes," said David Loy, ACLU SDIC's legal director. "If charitable appeals for funds are within the protection of the First Amendment, the same is true for charitable giving, whether of money or food." El Cajon is hardly alone here. Atlanta has targeted good Samaritans for feeding the homeless in public spaces, as have such cities as Orlando, Tampa, Houston, and Philadelphia, among others. Watch ReasonTV's video from 2012 about Philadelphia's attempt to stop people from feeding the homeless: src="" allowfullscreen="allowfullscreen" width="560" height="340" frameborder="0">[...]

Adolescent Smoking Rates Reach Historic Lows, Despite Vaping's Popularity

Thu, 14 Dec 2017 14:30:00 -0500

Survey data released today show that cigarette consumption by teenagers has reached "historic lows," nothwithstanding warnings that the rising popularity of vaping would make smoking cool again. In an interview with The New York Times, Thomas Glynn, former cancer science director at the American Cancer Society, called the dramatic decline in adolescent smoking since the late 1990s "an astounding accomplishment in public health." But he added that "I think we have to have alarms out" about adolescent vaping, which may yet lead to a surge in smoking. Don't give up fear!

The share of high school seniors reporting past-month cigarette use in the Monitoring the Future Study has fallen from 36.5 percent in 1997 to 9.7 percent this year—a 73 percent drop. The declines among younger students have been even more dramatic: from 30.4 percent in 1996 to 5 percent this year among 10th-graders (an 84 percent drop) and from 21 percent in 1996 to 1.9 percent this year among eighth-graders (a 91 percent drop). These downward trends have continued even as adolescent experimentation with e-cigarettes has become increasingly common.

(image) The survey puts past-month vaping this year at 16.6 percent among 12th-graders, 13.1 percent among 10th-graders, and 6.6 percent among eighth-graders. Those rates are up significantly since last year but about the same as in 2015 and lower than they were in 2014, when the survey first asked about vaping. Earlier data from the CDC's National Youth Tobacco Survey indicate that past-month e-cigarette use by teenagers tripled between 2011 and 2013.

One reason that teenagers who vape have not gotten hooked on nicotine and graduated to combustible cigarettes is that most of them are not consuming nicotine. In the Monitoring the Future Study, 58 percent of 12th-graders who reported vaping in the previous month said their e-liquid contained "just flavoring." Even those who vape nicotine rarely do it often enough to develop a habit. The Monitoring the Future Study does not report numbers for daily vaping. But in the National Youth Tobacco Survey, less than 1 percent of middle school students and less than 3 percent of high school students report vaping on 20 or more days in the previous month.

Another possible reason why adolescent vaping and smoking rates have been moving in opposite directions, of course, is that teenagers who otherwise would be smoking are vaping instead. Since the hazards of vaping pale beside the hazards of smoking, such substitution also should count as an "accomplishment in public health."

Goat Yoga Gets Baaaaaa-nned

Fri, 01 Dec 2017 16:12:00 -0500

Good, old-fashioned goats and the ancient Hindu practice of yoga are two things that don't seem to go together.

(image) And yet, last year, a small farm in Corvallis, Oregon started offering classes that combined the two. Goat yoga is exactly what it sounds like: the practice of yoga in the presence of goats.

Soon these classes had a 900-person waiting list for an hour of ritual calisthenics with a bunch of horned ruminants. Within a year, the unlikely trend had spread across the nation.

"We would go through the different asanas and the different flows," explains Amanda Bowen, a goat-yoga instructor with GoatToBeZen in Maryland, "and the goats will come around and interact with people as we're doing the class."

And then the unstoppable force of goat yoga locked horns with the immovable object of the Washington, D.C. Department of Health. When Congressional Cemetery Director Paul Williams applied for a livestock permit in the District of Columbia, he was greeted by four lawyers "ready to throw every curve ball they possibly could at me to prevent goat yoga."

But goat springs eternal. Since Manchester, CT. reversed its ban late last summer, the only place in the country where risk-averse municipal bureaucracies are undermining this fitness-to-farm trend threat is the nation's capital.

Produced, shot, narrated, and edited by Todd Krainin.

J.S. Bach, BWV 536 Prelude and Fugue in A Major, performed by James Kibbie
J.S. Bach, BWV 546 Prelude and Fugue in C Minor, performed by James Kibbie
Front Porch Sitter, by Audionautix

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Public Health Nannies Want to Stop You From Boozing. Why? Because Cancer

Thu, 09 Nov 2017 15:45:00 -0500

The great thing about modern epidemiology is that you can find multiple studies to justify just about any public health policy you happen to favor. If you have a bias, there is plenty of confirming evidence from which to cherry pick. Now come the doyens of the American Society of Clinical Oncology (ASCO) with their statement on alcohol and cancer. ASCO cites research estimating "3.5 percent of all cancer deaths are attributable to drinking alcohol" in the United States. That would mean some 21,000 of the 596,000 Americans who died of cancer in 2016 were killed by cancers associated with alcohol consumption. In comparison, smoking tobacco is estimated to cause 32 percent of all cancer deaths (about 120,000 deaths). Drinking booze is specifically associated with oropharyngeal and larynx cancer, esophageal cancer, hepatocellular carcinoma, breast cancer, and colon cancer. The group treats consuming alcohol as a pure public health problem to which the only solutions are various forms of prohibition. They recommend regulating alcohol outlet density; increasing alcohol taxes and prices; maintaining limits on days and hours of sale; enhancing enforcement of laws prohibiting sales to minors; restricting youth exposure to advertising of alcoholic beverages; and resisting further privatization of retail alcohol sales in communities with current government control. ASCO tells only part of the story about the health effects of drinking beer, wine, and spirits. There appear to be plenty of studies that find hard drinking increases an individual's risk of cancer. But the devil is in the cherry picking. Lots of research finds light to moderate drinking involves a trade-off between a slightly higher risk of cancer and significantly lower risk of cardiovascular disease. Of course, the folks at ASCO are aware of this issue. In an attempt to deal with it, the ASCO statement cites a line of research that argues that "the benefit of alcohol consumption on cardiovascular health likely has been overstated." For example, one 2005 study referenced by ASCO warned that due to confounding effects, "nonrandomized studies about the health effects of moderate drinking should be interpreted with caution." As far as I can tell, the ASCO statement itself cites meta-analyses of mostly nonrandomized studies in support of its claims that drinking alcohol causes cancer. Gander, meet sauce. Claims for the cardiovascular benefits of moderate alcohol consumption remain somewhat controversial. That being said, a huge new meta-analysis in the Journal of the American College of Cardiology (JACC) probing the relationship of alcohol consumption to all-cause, cardiovascular, and cancer-related mortality in U.S. adults finds significant health benefits from light to moderate drinking. To some extent there is a trade-off between reduced cardiovascular risks and higher cancer risks. The JACC researchers subdivided drinkers into six groups: lifetime abstainers, lifetime infrequent drinkers, former drinkers, and light drinkers (fewer than 3 drinks per week), moderate drinkers (more than 3 and less than 14 drinks per week for men and less than 7 for women), or heavy drinkers (more than 14 per week for men and more than7 for women). Binge drinking was defined as five or more drinks on one or more days per week. ASCO asserted that "even modest use of alcohol may increase cancer risk." However, Medscape reports of the JACC study that "light and moderate alcohol intake predicted reduced all-cause, cardiovascular, and cancer mortalities in both men and women." That's right, light to moderate drinkers not only had lower risks of dying from any cause or from cardiovascular diseases, but also lower risks of dying from cancer. On the other hand, the JACC researchers found "the highest levels of alcohol intake were associated with increased all-cause and cancer mortality in men but not women." Interestingly, even heavy drinkers had a lower risk of dying from cardiovascular diseases than did abstainers,[...]

Treating Drug Overdoses As Homicides May Be Deadly

Tue, 07 Nov 2017 17:30:00 -0500

Because prompt medical attention is crucial in saving people from potentially fatal opioid overdoses, 40 states and the District Columbia have enacted "911 Good Samaritan" laws that shield bystanders from some drug-related charges when they call for help. But as a new report from the Drug Policy Alliance (DPA) notes, a countervailing legal trend undermines efforts to keep drug users alive by encouraging homicide prosecutions when they die. "The most common reason people cite for not calling 911 in the event of an overdose is fear of police involvement," says the report, which was written by DPA senior staff attorney Lindsay LaSalle. "The only behavior that is deterred by drug-induced homicide prosecutions is the seeking of life-saving medical assistance." Treating fatal overdoses as homicides therefore makes them more likely. DPA found that 20 states have laws that specifically address drug-induced homicide, while others "charge the offense of drug delivery resulting in death under various felony-murder, depraved heart, or involuntary or voluntary manslaughter laws." Possible sentences range from two years to life, which is the minimum penalty in six states. Under federal law, drug distribution resulting in death or serious injury is punishable by 20 years to life in prison. These laws have been on the books since the 1980s, but prosecutions seem to have risen sharply in recent years, judging from mentions in news stories, which by DPA's count more than tripled between 2011 and 2016, from 363 to 1,178. Prosecutions were reported in all but four states and were especially common in the Midwest. The highest counts during this period were in Wisconsin (882), Ohio (577), Illinois (486), and Minnesota (433). The surge in prosecutions looks like a reaction to the dramatic increase in heroin-related deaths since 2010, a trend fostered by the crackdown on prescription narcotics and the increasingly common use of fentanyl, a highly potent synthetic opioid, as a heroin adulterant or substitute. Although politicians may claim that drug-induced homicide prosecutions are aimed at high-level dealers, the targets are usually people close to the decedent. Their role in "distributing" the drug may be limited to buying it for someone else or sharing a stash. When money changes hands, the dealers are often selling just enough to finance their own habits. "The vast majority of charges," LaSalle writes, "are sought against those in the best positions to seek medical assistance for overdose victims—family, friends, acquaintances, and people who sell small amounts of drugs, often to support their own drug dependence." LaSalle cites several studies to support that conclusion. A 2002 analysis of 32 drug-induced homicide prosecutions, published in the New Jersey Law Journal, found that "25 involved prosecution of friends of the decedent who did not sell drugs in any significant manner." According to a 2017 report by a Wisconsin TV station that looked at the 100 most recent prosecutions for drug-induced homicide in that state, "nearly 90% of those charged were friends or relatives of the person who died, or the lowest people in the drug supply chain." When the Chicago Tribune examined drug-induced homicide cases filed between 2011 and 2014, it found "the defendant was typically the last person who was with the person who overdosed." These trends make sense when you consider the practical challenges of tying a defendant to a batch of drugs that figured in someone's fatal overdose. The last link in the supply chain or a fellow drug user is an easier target than someone who never met the decedent. But prosecuting those closest to people who die from overdoses (or, more typically, from combinations of drugs) is perverse as a strategy for minimizing fatalities, since the legal exposure discourages bystanders from calling 911. This legal strategy is also unjust, treating accidents as if they were deliberate. LaSalle notes the case of Michael M[...]

Brickbat: The Tick

Fri, 15 Sep 2017 04:00:00 -0400

(image) Members of Japan's Miyazaki prefectural government say that in retrospect it was a bad idea to bring a deadly tick with them to a press conference to warn about the dangers of a tick-borne disease. The tick got away, and even with help from the reporters at the press conference, officials were unable to find it.

Fixating on Adolescent Vaping Could Be Deadly for Adult Smokers

Thu, 07 Sep 2017 14:50:00 -0400

The first surgeon general's report on e-cigarettes, published last December, could have highlighted the enormous harm-reducing potential of products that simulate smoking but do not contain tobacco or burn anything. Instead Surgeon General Vivek Murthy sounded the alarm about adolescent vaping, which he called "a major public health concern." A critique of Murthy's report, published online yesterday by Harm Reduction Journal, shows how dangerously misguided his concerns were. "The majority of e-cigarette use among US youth is infrequent and experimental, and minimal among never-smoking youth," note Italian internist and tobacco researcher Riccardo Polosa and his co-authors. "Additionally, the majority of the very small proportion of US youth who do use an e-cigarette frequently are actually using e-cigarettes that do not contain nicotine." Polosa et al. also point out that "the increasing prevalence of e-cigarette use between 2010 and 2015 has coincided with the sharpest declines in the smoking rate among US youth and young adults on record." Murthy, who was removed from his post in April but has not been permanently replaced yet, focused on the share of teenagers who report using an e-cigarette in the previous month, which rose "an astounding 900 percent" (from 1.5 percent to 16 percent) between 2011 and 2015, as measured by the National Youth Tobacco Survey (NYTS). Digging more deeply into the survey data, Polosa et al. show that relatively few teenagers vape frequently and almost all of those who do are current or former smokers. In the 2015 NYTS, for example, just 0.6 percent of middle school students and 2.5 percent of high school students reported vaping on 20 or more days in the previous month. According to the 2014 Monitoring the Future Study (MTF), less than 1 percent of teenagers who vape that often are never-smokers. The MTF data also indicate that most adolescents who vape use nicotine-free e-liquids, which makes Murthy's fear that they will get hooked on the drug and later graduate to smoking seem even more fanciful. On the face of it, nothing like that seems to be happening. As Polosa and his colleagues point out, "the increasing rate of ever-use of e-cigarettes among US youth has coincided with the sharpest declines in youth smoking rates in many decades." That is true for young adults as well as teenagers. The coincidence of these opposing trends does not necessarily mean that e-cigarettes have hastened the decline in smoking. But it is a plausible possibility that should not be overlooked by public health officials who want to reduce smoking-related morbidity and mortality, since e-cigarettes are far less hazardous than the conventional kind. Even in the rare instances where teenagers who have never tried tobacco take up vaping, they are far better off in terms of health risks if they otherwise would be smoking. As Polosa et al. note, "e-cigarettes may have the potential to reduce the likelihood of smoking initiation among youth who may be especially at risk for initiating smoking in the absence of e-cigarettes." The studies that Murthy cited as evidence that vaping leads to smoking show only that teenagers who try the former are more likely to try the latter. "There was no evidence that adolescents were regular e-cigarette users at baseline," Polosa et al. note, "and no evidence that they were smoking cigarettes regularly at follow-up." Even if some teenagers go through a vaping phase before becoming regular smokers, that does not necessarily mean the experience of vaping makes them more inclined to smoke. An attraction to both forms of nicotine consumption could be a function of personality and circumstance. If e-cigarettes are a gateway to the real thing, that gateway is so tiny that its impact cannot be seen in smoking trends. "At the very least," Polosa et al. observe, "available data appear reassuring that e-cigarettes are not decelerati[...]

FDA Lies About Vaping While the CDC Inches Toward the Truth

Thu, 31 Aug 2017 14:15:00 -0400

Between 2011 and 2016, according to survey data from the U.S. Centers for Disease Control and Prevention, cigarette smoking by teenagers fell by half, cigar smoking fell by a third, pipe smoking fell by two-thirds, and smokeless tobacco use fell by a quarter. Yet according to the Food and Drug Administration, there were "no significant declines in overall high school tobacco use" during that period. How is that possible? Let me answer that riddle by posing another one. If you call an e-cigarette a tobacco product, and the incidence of past-month vaping among high school students more than sextupled from 2011 to 2016, how does that affect the trend in overall tobacco use? The answer is that it does not affect the trend in overall tobacco use at all, because calling an e-cigarette a tobacco product does not make it a tobacco product. Yet that is what FDA does, partly for regulatory reasons. E-cigarette fluid often contains nicotine derived from tobacco, which supposedly transforms a tobacco-free product into a tobacco product, giving the FDA authority to regulate it. The FDA maintains that pretense even when reporting what is happening in the real world. The result, as Boston University public health professor Michael Siegel notes on his tobacco policy blog, is an alternative reality where dramatic declines in adolescent tobacco consumption never happened. The CDC plays the same game, falsely claiming "current use of any tobacco product did not change significantly" among high school students from 2011 to 2016. This blatant misrepresentation magnifies a problem (underage tobacco use) that the FDA and the CDC are charged with addressing, making their work seem more urgent and more worthy of funding. It also conflates e-cigarettes, a noncombustible, tobacco-free alternative to conventional cigarettes, with products that are far more dangerous, obscuring the enormous harm-reducing potential of this innovation. By lumping e-cigarettes in with tobacco products, the FDA and CDC may hope to scare kids away from them. But the message to current smokers—that they might as well keep puffing away, since all these nicotine sources are essentially the same—is potentially deadly. A new CDC webpage about e-cigarettes gives some ground on that score, conceding that "e-cigarettes have the potential to benefit adult smokers who are not pregnant if used as a complete substitute for regular cigarettes and other smoked tobacco products." But by insisting that e-cigarettes be a "complete substitute," the CDC dismisses the health benefits of smoking less, even if the number of cigarettes per day does not fall to zero. "Dual use is not an effective way to safeguard your health," the CDC says. "Because smoking even a few cigarettes a day can be dangerous, quitting smoking completely is very important to protect your health." This slippery formulation deliberately obscures the fact that smoking a few cigarettes a day is less dangerous than smoking a pack or two a day. If e-cigarettes help smokers make that change, they are reducing tobacco-related harm. The CDC's discussion of how the health hazards of vaping compare to those of smoking is similarly misleading. "Are e-cigarettes less harmful than regular cigarettes?" it asks. "Yes—but that doesn't mean e-cigarettes are safe. E-cigarette aerosol generally contains fewer toxic chemicals than the deadly mix of 7,000 chemicals in smoke from regular cigarettes. However, e-cigarette aerosol is not harmless. It can contain harmful and potentially harmful substances, including nicotine, heavy metals like lead, volatile organic compounds, and cancer-causing agents." Sadly, it counts as an improvement that the CDC is willing to explicitly say e-cigarettes are less harmful than regular cigarettes instead of dodging the question entirely. But you would not guess from its gloss that vaping is something like 95 percen[...]

Why Handwashing Is Key to Ballpark Food Safety

Sat, 19 Aug 2017 08:00:00 -0400

In an interesting before-you-reach-for-that-hot-dog style report released last week, Sports Illustrated compared and ranked the food-safety climate at every Major League Baseball park in the United States. Seattle's Safeco Field came in first, while Tampa Bay's Tropicana Field brought up the rear. My favorite (and hometown) ballpark, Boston's Fenway, ranked second. Among its conclusions, the report found "almost a third of the league's stadiums had over 100 total violations, including both Los Angeles clubs. One Chicago stadium failed its routine inspection for the second summer in a row. Eighteen ballparks had critical violations in at least a quarter of their concession stands." Some of the violations reported are objectively gross: "Camden Yards had evidence of rodent infestation at eight different food entities and Yankee Stadium had 14 stands overrun with filth flies." The SI report updates the first such study, published by ESPN in 2009. Food safety at sporting events has long intrigued me. The first time I ever really thought about food safety is intimately tied to sports. The year was 1980. I was seven years old. As I watched an episode of Quincy, M.E.—titled "Deadly Arena"—I saw the title character engage in what IMDB characterizes as "a race against time to find the source of" a botulism outbreak at a sports stadium "before the field becomes littered with bodies." Some of the best stadium food I've eaten in the years since has been the Ichiroll (an Ichiro Suzuki-themed sushi roll) and the grasshoppers at Safeco. The worst food I've ever eaten at a sporting event—football, rather than baseball—was a crab and cheese pretzel at FedEx Field in Maryland. But the relative tastiness of a stadium's food doesn't have much if anything to do with the safety of that food. "The real risk, it seems to me at the ballpark, is the handling of food," said UCLA Prof. Michael Roberts—with whom I serve on the board of the Academy of Food Law & Policy—in comments to SI. "That's where you've got handlers cooking the food, handing it out, managing refrigeration and heating. … So it seems that the most important players in this would be local level, the county inspectors, the folks that are there to ensure quality and safety measures are being followed." Others SI spoke with echoed Roberts. And I will, too. He's exactly right. Data back him up. Nearly six out of every ten cases of foodborne illness in this country are caused by norovirus, which is transmitted most often from person to person due to poor handwashing after using a restroom. According to a 2016 article published in the Journal of Food Protection, every state requires workers to wash their hands after using a restroom. Requiring foodservice employees to wash their hands after using a restroom is—in a bubble—smart lawmaking. But other rules may offset the handwashing rule. For example, fire-safety laws requiring that bathroom doors open inward, rather than outward, means in most cases that a person must touch a door handle before they leave a restroom. So a foodservice worker may do everything they're supposed to—washing their hands before leaving a restroom—but their best efforts may be foiled by having to share a bathroom-door handle (and the associated germs) with people who don't wash their hands. The FDA's model food code recognizes the potential for re-contamination after washing one's hands. "TO avoid recontaminating their hands ... FOOD EMPLOYEES may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a HANDWASHING SINK or the handle of a restroom door," it states. But many foodservice establishments are swapping out environmentally unsound disposable paper towels for efficient, modern air dryers. As more and more restaurants move to fancy Dyson-style air driers[...]

Researchers Highlight the Government's Complicity in Heroin Deaths

Fri, 04 Aug 2017 17:01:00 -0400

This week a presidential commission and the Justice Department sounded the alarm about recent increases in opioid-related deaths. One of the most striking features of this problem is that heroin-related deaths have been rising faster than heroin use since 2010, which means heroin use is becoming more dangerous, thanks partly to adulteration with fentanyl, a synthetic narcotic that is roughly 40 times as potent. Drug warriors claim that development is driven by consumer demand because addicts are always looking for a better high. New research reported in The International Journal of Drug Policy (IJDP), which recently devoted a special section to "U.S. Heroin in Transition," tells a different story. The IJDP articles implicate the war on drugs in making heroin more hazardous, but they also provide reasons to hope that harm-reduction policies can mitigate that effect. According to the official narrative, intravenous drug users seek out fentanyl-fortified heroin, notwithstanding the substantial risk of a fatal overdose, because they prefer its psychoactive effects. "The users know they could die," a DEA official told the Worcester Telegram & Gazette in 2014. "They're chasing the dragon. They're looking for the ultimate high." Last year a vice cop in East Providence, Rhode Island, told a local paper "heroin cut with fentanyl gives the user a more intense high," and addicts "want that ultimate high, taking them right to the edge." A few months later, a DEA agent told the New Haven Register "the users know that they could die from taking this heroin," but "they want the ultimate high," so they ignore the risk. Brown University medical anthropologist Jennifer J. Carroll and her collaborators interviewed 149 opioid users in Rhode Island and found very little support for such claims. "Our findings directly contradict this narrative," they report in their IJDP article. "Interviewed heroin users overwhelmingly indicated that they prefer to avoid fentanyl-contaminated heroin whenever possible....When they do encounter fentanyl-contaminated heroin, many users report greatly disliking and often fearing the unpredictability of its effects." The initial effects of fentanyl are more intense than heroin's, but not necessarily in a good way. The interviewees described the experience as overwhelming and incapacitating, and "a general consensus emerged that the effects of fentanyl are distinctly uncomfortable or distressing," with many users describing an unpleasant "pins and needles" sensation in their faces and limbs. Another drawback of injected fentanyl is that its effects last only a half-hour to an hour, compared to four to five hours for heroin. And then there is the risk of sudden death. "The high potency of fentanyl means that only a minuscule amount (less than 2 mg, the equivalent of two grains of salt) can lead to overdose and death," Brown epidemiologist Brandon Marshall and his co-authors note elsewhere in the same issue of the IJDP. They add that "fentanyl causes rapid and more profound respiratory depression than other opioid analgesics, which significantly narrows the window of opportunity for reversal with naloxone," an opioid antagonist used to treat overdoses. An Australian study found that "the overall risk for fentanyl-related overdose was nearly 4.5 times higher than risk for overdose with other opioids." Contrary to the accounts of cops and DEA agents, the Rhode Island opioid users interviewed by Carroll and her colleagues did not blithely dismiss this risk. "Participants who were aware of fentanyl universally described it as dangerous and potentially deadly," Carroll et al. write. "People are dropping like flies," one heroin user said. "I don't want to die," said another, explaining why he buys heroin only from a dealer he trusts not to sell him fentanyl-laced powder. Others sa[...]

A Cap on Nicotine in Cigarettes Would Be Hazardous to Health

Wed, 02 Aug 2017 15:20:00 -0400

Robert Proctor, the historian of science who wrote the fascinating 1999 book The Nazi War on Cancer, loves the Food and Drug Administration's idea of "reducing the nicotine in cigarettes to a nonaddictive level." Writing in The New York Times, Proctor, now a professor at Stanford, calls the FDA's proposal "exceptionally good news for tobacco control, and for human health." In fact, he says, "a legal cap on the nicotine in cigarettes could be one of the most important interventions in human health history." I don't think this intervention would work out the way Proctor imagines. His op-ed piece is an excellent example of expecting good intentions to ensure good outcomes, even when experience tells us the policy is bound to backfire. "Cigarettes with nonaddictive nicotine levels would be radically different from what used to be known as 'low tar' or 'light' cigarettes, marketing gimmicks now barred by law," Proctor assures us. "Those cigarettes were advertised as delivering less nicotine and tar into the lungs, even though there was no actual reduction." Although it is by no means clear that "there was no actual reduction," it's true that "light" cigarettes were at best only slightly less harmful than regular cigarettes. But the reason for that casts doubt on the logic of the proposal Proctor is championing. It turned out that smokers who switched to "light" cigarettes tended to engage in "compensatory behavior" that boosted nicotine delivery and moved them closer to their usual dose. They smoked more cigarettes, took more puffs from each one, took bigger puffs, or held the smoke deeper and longer. They even subconsciously covered the tiny filter holes that helped reduce a cigarette's machine-measured tar and nicotine yields. The upshot is that "light" cigarettes did not offer anything like the health advantage implied by those official, government-certified numbers. The problem was that tobacco companies reduced nicotine along with tar, when what they should have done was reduce tar while keeping nicotine the same. E-cigarettes embody the latter approach taken to its logical conclusion: They deliver nicotine with no tar at all, since they do not contain tobacco and do not rely on combustion. To its credit, the FDA has finally begun to recognize the huge potential health benefit of reducing the toxins and carcinogens that smokers absorb along with nicotine. In the case of conventional cigarettes, however, the agency is considering the opposite approach: forcing smokers to absorb more toxins and carcinogens for any given dose of nicotine. The aim, as Proctor says, is to "make addiction virtually impossible," so that "kids might start smoking, but they wouldn't have trouble quitting." But what about the 30 million or so Americans who already smoke cigarettes? Deliberately increasing their exposure to the dangerous compounds generated by burning tobacco is neither ethical nor sensible, even (or especially) from a "public health" perspective. There are other problems with the FDA's proposal, aside from its health-damaging paternalism. Proctor notes that "sales were disappointing" when Philip Morris introduced three brands of nicotine-free cigarettes in the 1980s, "in part because high-nicotine cigarettes remained on the market." But forcing cigarette manufacturers to dramatically reduce nicotine levels would stimulate a black market supplied by smuggled imports and illicitly manufactured smokes. Smokers could dodge the cap on nicotine by turning to the black market, spiking their cigarettes with liquid nicotine, or rolling their own using full-strength tobacco. As longtime British anti-smoking activist Clive Bates notes, it is not even clear that the FDA has the authority to mandate the nearly complete removal of nicotine from cigarettes. The Family Smoking [...]

The FDA Warms to Vaping

Wed, 02 Aug 2017 00:01:00 -0400

On the face of it, the decision that the Food and Drug Administration (FDA) announced on Friday, extending by four years a crucial deadline for e-cigarette manufacturers to seek approval of their products, was no more than a stay of execution. But the FDA also signaled a new receptiveness to vaping as a harm-reducing alternative to smoking, which suggests this reprieve could turn into a commutation. That would be good news for smokers who want to quit and for anyone sincerely interested in helping them. For too long American public health officials have been unreasonably hostile to e-cigarettes, which are far less hazardous than the conventional kind and offer a closer simulation of the real thing than nicotine gum or patches do. Scott Gottlieb, the new FDA commissioner, seems to appreciate the public health potential of this innovation. "The overwhelming amount of death and disease attributable to tobacco is caused by addiction to cigarettes," he says. "Envisioning a world where cigarettes would no longer create or sustain addiction, and where adults who still need or want nicotine could get it from alternative and less harmful sources, needs to be the cornerstone of our efforts—and we believe it's vital that we pursue this common ground." Gottlieb's vision of nonaddictive cigarettes involves mandating a gradual reduction in nicotine content, which would increase the risks that smokers face by forcing them to absorb more toxins and carcinogens for the same dose of nicotine. But his interest in less dangerous alternatives to cigarettes is encouraging. The FDA says "a key piece" of its new approach is "demonstrating a greater awareness that nicotine—while highly addictive—is delivered through products that represent a continuum of risk and is most harmful when delivered through smoke particles in combustible cigarettes." The agency wants to strike "an appropriate balance between regulation and encouraging development of innovative tobacco products that may be less dangerous than cigarettes." Toward that end, the FDA is giving e-cigarette companies until August 8, 2022, to apply for permission to keep their products on the market under regulations published last year, rather than the original deadline of November 8, 2018. The agency says it will use the extra time to seek additional public comment and develop clearer guidance for the industry. The 2016 regulations require manufacturers of vaping equipment and e-liquids to demonstrate that approval of their products "would be appropriate for the protection of the public health." It is not clear what that means in practice, but the FDA projected that applications would cost hundreds of thousands of dollars per product, and many observers thought that was an underestimate. To give you a sense of how expensive and burdensome the process was expected to be, the FDA anticipated that it would receive applications for just a tiny percentage of existing products. The implication was that the regulations would drive the vast majority of companies out of business. If the FDA is serious about making "less harmful sources" of nicotine "the cornerstone of our efforts," it will develop transparent, straightforward, and practical criteria for approval of current and new vaping products. Standing between smokers and products that can save their lives is surely not "appropriate for the protection of the public health." Nor is making those products less appealing by arbitrarily restricting flavors. Since supposedly "kid-friendly" e-liquids are very popular among adults who switch from smoking to vaping, it's a bit worrisome that the FDA plans to solicit public comment on regulation of flavors, which it acknowledges may be "helping some smokers switch to potentially less harmful forms of nic[...]

Embracing Harm Reduction, FDA Gives E-Cigarette Industry a Regulatory Reprieve

Fri, 28 Jul 2017 13:15:00 -0400

Today the Food and Drug Administration (FDA) said it is giving manufacturers of electronic cigarettes until August 8, 2022, to apply for approval of their products under regulations announced last year, which were widely expected to drive most companies out of business. The original deadline was November 8, 2018, and the four-year extension is supposed to provide more time for public comment and industry guidance as part of a "comprehensive regulatory plan" that aims to strike "an appropriate balance between regulation and encouraging development of innovative tobacco products that may be less dangerous than cigarettes." The agency says "a key piece of the FDA's approach is demonstrating a greater awareness that nicotine—while highly addictive—is delivered through products that represent a continuum of risk and is most harmful when delivered through smoke particles in combustible cigarettes." That is music to the ears of harm-reduction advocates who see vaping as a life-saving alternative to smoking and viewed the original FDA rules as misguided, heavy-handed, and potentially deadly meddling that effectively gave conventional cigarettes an advantage over competing sources of nicotine that are much less dangerous. In addition to providing regulatory relief for the e-cigarette industry, the FDA will be investigating the possibility of mandating a gradual reduction in the nicotine levels of combustible cigarettes. The idea is to make cigarettes less addictive for new smokers, but the policy is apt to hurt current smokers by forcing them to absorb more toxins and carcinogens along with their usual dose of nicotine. The FDA "intends to issue an Advance Notice of Proposed Rulemaking (ANPRM) to seek input on the potential public health benefits and any possible adverse effects of lowering nicotine in cigarettes." The FDA's new commissioner, Scott Gottlieb, sees a nicotine-reduction mandate as complementing the agency's new receptivity to harm-reducing cigarette alternatives. "The overwhelming amount of death and disease attributable to tobacco is caused by addiction to cigarettes," Gottlieb says. "Envisioning a world where cigarettes would no longer create or sustain addiction, and where adults who still need or want nicotine could get it from alternative and less harmful sources, needs to be the cornerstone of our efforts—and we believe it's vital that we pursue this common ground." The FDA also seems to be contemplating flavor regulations that might favor e-cigarettes over the real thing. It says it will "seek public comment on the role that flavors (including menthol) in tobacco products play in attracting youth and may play in helping some smokers switch to potentially less harmful forms of nicotine delivery." The Family Smoking Prevention and Tobacco Control Act, the law that gave the FDA authority to regulate tobacco products, banned most "characterizing flavors" from cigarettes but made an exception for menthol, by far the most popular one (and, not coincidentally, a big moneymaker for Philip Morris, which supported the law). It sounds like the FDA might be reconsidering that exception, while at the same time recognizing that so-called kid-friendly e-cigarette flavors are in fact very popular with adults who switch from smoking to vaping. The FDA says it will use the reprieve it is giving e-cigarette companies to clarify what will be required to keep their products on the market. The agency also plans to develop product standards that address battery hazards and help keep e-cigarette liquids away from children. Over all, it looks like the FDA under Gottlieb will be taking a much more practical approach to e-cigarette regulation that recognizes the realities of the existing market and the relat[...]

New Study Provides Strong Evidence That E-Cigarettes Boost Smoking Cessation

Thu, 27 Jul 2017 17:15:00 -0400

A new study, based on data from a large survey of current and former smokers in the United States, provides some of the strongest evidence yet that electronic cigarettes are helping Americans move from the first group to the second. The study, reported this month in the BMJ, finds that quit attempt and smoking cessation rates both increased significantly during the period when e-cigarette sales took off. Furthermore, these changes were entirely attributable to increased quitting among e-cigarette users, who were more likely to try and more likely to succeed than smokers who did not vape. The researchers, led by University of California at San Diego public health professor Shu-Hong Zhu, found that 45.9 percent of smokers reported quit attempts in the 2014-15 Current Population Survey, up from 41.4 percent in 2010-11. The percentage who stopped smoking for at least three months also rose, from 4.5 percent to 5.6 percent. "This is the first time in almost a quarter of a century that the smoking cessation rate in the US has increased at the population level," Zhu and his colleagues write. "The 1.1 percentage point increase in cessation rate...might appear small, but it represents approximately 350 000 additional US smokers who quit in 2014-15." What happened during this period that might account for the change? Zhu et al. note that e-cigarette use in the U.S. "became noticeable around 2010 and increased dramatically by 2014." That correlation is reinforced by the researchers' subgroup analysis of the 2014-15 data, which found that 65 percent of smokers who had used e-cigarettes in the previous year had tried quitting, compared to 40 percent of the other smokers. "Numerically speaking," the authors say, "it was this e-cigarette user subgroup that raised the overall quit attempt rate for 2014-15, and thus the rate was statistically significantly higher than in all previous survey years." Vapers also had a higher cessation rate than nonvapers in 2014-15: 8.2 percent vs. 4.8 percent. "Again," Zhu et al. write, "the 2014-15 survey had a noticeably higher overall cessation rate because the e-cigarette user subgroup had a higher cessation rate than those who did not report e-cigarette use in the past year." Since this is an observational study rather than a randomized, controlled experiment, alternative explanations are possible. But the researchers persuasively argue that neither the 2009 increase in the federal tobacco tax nor the TIPS From Former Smokers ad campaign that began in 2012 can adequately explain the increase in smoking cessation, especially in light of the stark subgroup differences. The impact of the tax hike was relatively small and short-lived, Zhu et al. say, while it is hard to see why the anti-smoking ads would have had an impact only on smokers "who happened to use e-cigarettes in 2014-15." Still, smokers who try vaping may differ from those who do not in ways that make them more likely to quit. "Given that the e-cigarette user subgroup was the only group that had statistically significantly higher rates in 2014-15," Zhu et al. say, "it is tempting to attribute the increase in the overall smoking cessation rate in 2014-15 solely to e-cigarette use. However, e-cigarette use itself could be an indicator of motivation to quit smoking, which would predict a higher quit rate. Thus, attributing the full 73% relative difference to e-cigarettes is likely an overestimate of their effect." These results nevertheless should allay fears that e-cigarettes might somehow make smoking more common than it would otherwise be. To the contrary, the vaping alternative seems to be accelerating the downward trend in the smoking rate, which in this survey fell from 21 percent in 2001[...]

Curbing Traffic Stops Would Save Lives

Thu, 20 Jul 2017 00:15:00 -0400

Last weekend, in the wee hours of the night, Chicago police stopped a car carrying four people. When officers approached it, they saw a passenger holding a gun. The outcome was a familiar one: an 18-year-old man was shot by police. Too often, traffic stops lead to tragedy. Philando Castile was shot to death in his car by a police officer in Minnesota. Last week, a mistrial was declared for a University of Cincinnati officer prosecuted for killing 43-year-old Samuel DuBose, whose car had a missing front license plate. Sandra Bland, yanked out of her car by a Texas state trooper after allegedly failing to signal a lane change, died in jail. All three victims were black. Cops are also at risk. In March, a police officer died in a shootout with a passenger who ran from a car that had been pulled over in Tecumseh, Okla. In June, a police lieutenant was fatally gunned down after a stop in Newport, Arkansas. When an officer stops and approaches a vehicle, both the cop and the driver are vulnerable. Any wrong move or misjudgment can turn the encounter deadly. "Traffic stops and domestic violence are the highest-risk calls—you have no idea what you're walking into," John Gnagey, executive director of the National Tactical Officers Association, told the Orlando Sentinel in 2010. Even when motorists get off unharmed, the experience can be frightening, infuriating or humiliating. Stops breed fear and distrust of law enforcement, particularly among minorities. So why do cops rely so much on the practice? Enforcing traffic laws is a large share of what they do. Ignoring motorists who drive too fast or ignore signals could foster chaos on the road. But there are other ways to combat bad driving. University of California, Berkeley law professor Christopher Kutz points out that police in France do traffic stops at less than one-third the rate that American cops do. In England and Wales, it's one-fourth. The obvious alternative is using cameras. Speeders and red-light runners can be detected and ticketed by electronic means. Upon paying the fine, says Kutz, the offenders could be required to show that they are licensed and insured. I've gotten citations from red-light and speed cameras, and while I resented the fines, I was grateful that I wasn't detained on the roadside by an armed officer. The time I got a mere warning for (barely) failing to come to a complete stop on an empty suburban street after midnight was considerably less pleasant. Being a gray-haired white male, I've been pulled over only three times in my adult life. Castile, 32, had been through that experience 49 times—and "was rarely ticketed for the reason he was stopped," according to the StarTribune of Minneapolis-St. Paul. Joel Anderson, an African-American reporter for BuzzFeed, said on Twitter last month that he's been stopped more than 30 times since he started driving—including five times for seatbelt violations when he was wearing his seatbelt. Traffic stops are often an excuse for cops to search a car for drugs and guns. Curtailing police reliance on this pretext would free motorists from being dragooned to "consent" to searches for which the cops lack probable cause. True, the change would let criminals operate at less risk. But hassling the innocent to catch the guilty is an abuse of our constitutional principles. In Illinois last year, police conducted 2.17 million traffic stops. Just 8,938 yielded contraband—one bust for every 242 stops. The rare instances when police find evidence of a crime, Kutz told me, "don't justify the enormous social costs of widespread police interventions." This is an extremely inefficient way of detecting drug and gun crimes. It's also often discrim[...]