Wednesday, February 26, 2014

Anti-Smoking Advertisements

A few days ago, I posted about a handful of recent smoking policies that have come up in discussions with friends and family, in new campus rules, and in laws around town. As promised, today I want to talk about some interesting anti-smoking advertisements.

In my "theories of health and social behavior" class last semester, we talked about various advertising campaigns and what has made them successful (or not). Interestingly enough, studies show that some anti-smoking (and anti-drug, anti-drinking, etc.) campaigns actually increase propensities for engaging in those activities, while others effectively work to reduce them.

For example, after a major industry lawsuit in 1998/1999, some cigarette companies agreed to run anti-teen smoking advertising campaigns. The messaging in these ads may have conveyed with words that smoking was bad for you on the one hand, but the way that was done was often ineffective or even subversively promotional of smoking. Whether this was intentional or simply misguided, I cannot say, but it is definitely interesting. For example, by showing a single brave student resisting the peer pressure of everyone else smoking, the real messages interpreted by teens may have been, "You're the only one who doesn't smoke," and, "Your parents are trying to tell you what to do." Or by directly mentioning companies' brand names as the funders of the messages, the companies may have actually built more positive brand association. Especially for a target audience like teenagers, perceptions about how many other people are doing an activity, how cool/desirable those other people are, how trustworthy an industry is, and whether the teen is being "told what to do" by an adult (as compared to being given greater independence), can actively affect decisions to start or continue a behavior. This is an important reminder as a public health professional that we need to be careful with our interventions and take as much precaution as possible to prevent unintended harm. Here is an example of an ad that was evaluated to have actually produced an increase in intention to smoke among teens:

A totally different type of advertisement that we studied, which was evaluated to be more effective, involved off-beat messaging that cast the tobacco industry in a negative light. This was without ever directly telling people what to do or even mentioning the negative consequences of smoking. Check out this innovative ad:

The reason I started thinking about this topic again so recently is that I saw a series of newer anti-smoking advertisements circulating online. For example, this one has gone viral and boasts the YouTube tagline, "perhaps one of the best anti-smoking ads ever created." I am still skeptical, but it is definitely interesting. Judge for yourself:

And then there is this super  hilarious new series about people who self identify as "social smokers," comparing them to social farters, social nibblers, and social ear wax pickers. To see all three videos, click here, and to check out the campaign's facebook page, click here. Below is one of the videos:

Click here for some other creative anti-smoking print advertisements. What do you think? Will these latest ads achieve their goals to decrease smoking? Are there any unintended messages here? What are your opinions on any of the policies mentioned in my last post, or the anti-smoking movement in general?

Friday, February 21, 2014

Smoking Policies

For whatever reason, smoking has been the topic of many conversations, viral videos, and policies popping up in my life lately, and I wanted to share some of the interesting things that have been coming up. Feel free to leave a comment letting me know what you think about any or all of these issues!

Berkeley Campus Smoking Ban

U.C. Berkeley recently became a smoke-free campus, meaning that you have to physically leave campus to smoke a cigarette. My prior workplace implemented a similar policy during my first year there, while at the same time offering increased smoking cessation support. As an asthmatic with lots of allergies who does not smoke, I personally feel in favor of the ban. Cigarette smoke has often been a trigger for me. 

At the same time, I know that some of my peers have expressed "feeling judged" by the campus administration and fellow students. Whether you believe this judgment is ultimately a bad thing or not, they obviously perceive it as injurious in some way. Having never been a smoker, I cannot say that I personally know how hard it is to quit. Based on what I do understand, however, it seems that for many people, the relaxation associated with smoking, the reflexive association of cigarettes with certain experiences, the reduced appetite that makes weight management easier for some smokers, and especially the addictive power of nicotine, make it difficult for many to stop. In my prior work place, the smoking ban did serve as an added motivation for some people who were on the verge of deciding to quit, and I heard many stories of people who had made the change through smoking cessation programs shortly after the ban went into effect. On the flip side, I also recall that as a result of that smoking ban, instead of smoking in front of our building, many people simply crossed the street and smoked in front of other businesses, thus exposing other employees and customers to more second hand smoke. And since our company no longer provided ash trays on site, many people threw their cigarette butts in the street outside of said other businesses. Suffice it to say, we received some complaints. I am not sure if this will be the case near our campus or not. It seems that only time will tell. All in all, I appreciate and support the policy, but I recognize that for some, it remains controversial.

City of Berkeley Residential Smoking Bans

Then there have been even more controversial smoking bans, such as the City of Berkeley's law against smoking in apartments or condos, where neighbors may presumably suffer the effects of second hand smoke. And more recently, there is a more restrictive proposal on the table to ban smoking inside single family homes where children, seniors, or lodgers are present. (I'm not sure what the law says about seniors who are smokers.) When I first learned of the latest proposal, I felt outraged at the heavy-handedness and immediately concluded it was going too far. But after sitting on it for a couple months, I cannot help but wonder why I jump to so adamantly defend the "right" to expose others to potent known toxins, including allowing a person to expose their kids, just because they are their kids. We do have plenty of laws in place mandating that you send your kids to school, seek medical care when your child has a serious illness, and do not abuse your child, so it is not as if our society as a whole believes parents can simply raise their kids in literally any fashion. While these cigarette laws are certainly paternalistic, I believe there is room for debate about where we draw the line between necessary paternalism and going too far, especially when it comes to exposing kids to things we know to be poisonous carcinogens. Right now, I find myself in the void on this particular issue and still trying to make up my mind.

Hiring Practices

Also related to the topic of smoking, I recently had a conversation about employers who do not hire smokers at all (e.g. Cleveland Clinic). On the one hand, I always found it hypocritical for healthcare professionals to smoke while telling their patients to quit. On the other hand, as a general hiring policy, one could argue that this is discriminatory, especially as we were discussing whether this standard might be applied to other fields not directly related to health. The other people with whom I was discussing the policy emphasized that smoking is a choice, unlike many other personal characteristics that should not be used as reasons for not hiring. I am personally not swayed to their side and will cautiously say that I still see this policy as discriminatory. However, I was clearly in the minority in the discussion I was having, and I am open to having my opinion changed by a compelling argument in future.

CVS to Stop Selling Cigarettes

CVS Caremark recently announced that it will stop selling cigarettes in retail locations by October 14. The CEO stated, "The sale of tobacco products is inconsistent with our purpose." (See this article on the CVS site.) As pharmacies are playing a greater role in not only dispensing drugs, but also providing a certain level of patient care (such as walk-in clinic sites), it seems to be even more off-mission to continue to sell a product known to cause so many illnesses and deaths. CVS Caremark specifically is branding itself as a "pharmacy innovation company" that is "working to make health care better." According to their website, they also aim to exercise ethics, abide by principles of corporate social responsibility, and influence health policy. With regards to this latest decision, I have to say that I am impressed at their willingness to lose a portion of their revenue to maintain integrity. Bold move, CVS Caremark. Bold move!

In my next post, I plan to share about some interesting anti-smoking commercials, both old and new. In the meantime, what do you think about the above policies? Which ones are good ideas and which ones go too far?

Thursday, February 13, 2014

Reusing Plastic Baggies (I Mean Ziploc!)

Where I live in San Mateo County, single use plastic bags, like those you may be accustomed to receiving in grocery stores, are now taxed ten cents. In nearby San Francisco, the bags are banned altogether, but stores have the legal option of providing a paper bag, compostable plastic bag, or reusable bag for at least ten cents per bag. Apparently, San Francisco became the first U.S city to ban plastic bags in grocery stores in 2007. Then in 2013, they expanded the ban to include all stores and restaurants.


Despite the inconvenience (as I am still working on the habit of remembering to actually bring my pile of reusable bags with me), I appreciate the move to spare our landfills, streets, and oceans from some of the 500 billion to one trillion plastic bags produced per year. I definitely see a significantly higher number of people bringing their own reusable bags to the store after the tax started, even though it is only ten cents! I love how such small things can really change our habits! And I am excited to see that a lawmaker in my home state of Connecticut is now proposing a similar tax.


On a related note, I thought it would be fun to share a small plastic bag idea you can implement in your own home to spare the environment (and your wallet). Full disclosure: this idea comes entirely from my mother-in-law!

I am no longer talking about the big plastic grocery bags here, but about the small ones you buy in a box, like Ziploc storage bags. Growing up, I often used plastic sandwich bags, freezer bags, etc. to store food or other items. After I was done with them once, I threw them in the garbage. But did you ever consider that these bags can actually be washed and re-used?

In our home now, after we use a plastic baggie to bring carrots in our lunch, we turn it inside out and wash it with a sponge when we get home. The next day, it is dry, and we can bring our fruit in it. A few days later, we can send a friend home with some leftovers in the cleaned bag. The bags hold up well over two or three hand washes.

I do have some "rules" about the bags that I try to follow. For me, once a bag has had raw meat in it (like when we freeze chicken breasts in plastic freezer bags), I do not feel comfortable washing and reusing it, as I personally feel concerned that bacteria may still linger in the corner nooks. Also, once a bag gets a little wear (I am not talking about holes, but just a bit less smooth and shiny), I no longer use it for anything that requires an air-tight seal, like liquids, fresh produce, or frozen things. But I can still use it a few more times for less demanding purposes, like bringing almonds in my lunch or storing pens and pencils. After many many uses, it does eventually wear out completely, but at least I feel like it has served its time before going to the landfill.
Plastic baggies drying with some other dishes on our counter.

Of course, there are other containers we use regularly that are even more durable and long-lasting than bags and that spare the environment even further. These would be containers like Tupperware or the now-trendy and environmentally friendly alternative - glass jars. I highly recommend using these types of alternatives as often as possible. But for now, I still use baggies for some things, and I definitely feel better about using them more than once, as opposed to tossing a perfectly good container in the trash.

Do you have any simple things you do in your household to spare the environment and/or your wallet?

Saturday, February 1, 2014

Some Ethical Limits of Statistics

My piece titled "Some Benefits and Limits of Statistics" has been in the top five of my all-time most viewed posts for a while now. I have no clue why this is so, but in any case, I am glad people like to learn! (Or there are some very zealous cyber bots searching for posts about statistics in the United States and Russia.)

Either way, an observation that my latest statistics professor, Nicholas Jewell, made on the first day of class this semester (yes, I am taking more statistics) really stuck with my heart, and I thought it a good time to share. In so many ways, I am preaching to myself in this post, as I have had many a moment of poor character in my thoughts and words over the years, many times as a result of my numbers bent, and it is something I am constantly praying for God to redeem in me. So here goes.

In statistics, we typically do not have information about every single person or thing we want to understand. Instead, we take samples from a study population and try to generalize what we find in the sample to the whole population. Think of this like asking one hundred random strangers in your town whether they like your hair do. If 80 of the 100 people you stop all over your town tell you it's a bad hair do, you might reasonably guess that about 80% of people in the whole town would think the same, regardless of whether you have actually asked every single one of them. If you care much about what others think, you go get a new hair cut, or if not, you pride yourself on being a hair rebel.

Intuitively, we generally prefer larger sample sizes, because, all other things being equal, they make our results more credible. For example, if you stopped 5 random strangers some place in your town, and 4 of them did not like your hair do, you might chalk it up to bad luck in your stranger selection. You might figure, hey, if I had asked five other people across the street or across town, they might have said something different. But if you ask 1,000 random strangers, and 800 say you look like Medusa, you would be less likely to assume it was an "unlucky 800." As it turns out, this intuitive understanding is also mathematically true in statistics, although I won't get into too many details here.

"The top portion of this graphic depicts probability densities that show the relative likelihood that the "true" percentage is in a particular area given a reported percentage of 50%. The bottom portion shows the 95% confidence intervals (horizontal line segments), the corresponding margins of error (on the left), and sample sizes (on the right). In other words, for each sample size, one is 95% confident that the 'true' percentage is in the region indicated by the corresponding segment. The larger the sample is, the smaller the margin of error is."

As Professor Jewell reminded us during our first class, in public health in particular, we are often using epidemiological methods to compare people who experience a certain health outcome with people who do not. For example, we might study the characteristics of people who get pancreatic cancer in their lifetime versus people who do not get pancreatic cancer in their lifetime, in the hopes of figuring out what those who get cancer share in common and how they are different from those who do not get cancer. If we conduct a study of 1,000 people, where we compare 999 individuals who did not get the cancer with one person who did, we are not likely to feel confident that the one person who got cancer in our sample is statistically representative of the multitude of people who get pancreatic cancer around the world. (This is just like the hair-do example above, where we believe the results more when we ask more people.) Let's assume that the single cancer patient in our study is also the only one of the 1,000 people we study who has ever visited the North Pole - so our one cancer patient has visited the North Pole, but our 999 non-cancer patients have never visited the North Pole. Do we then have evidence that the North Pole is associated with pancreatic cancer? Most of us would say no, because we intuitively sense that we cannot draw a conclusion based solely on a single person's experience. On the other hand, if we compare 500 people who did not get cancer with 500 people who did and find that a history of North Pole vacations is much more common among the cancer patients, we are more likely to believe and perhaps further investigate an association between cancer and the North Pole.

In the above example, more cases of disease in our study population gives us more confidence in our conclusions. We are more likely to learn something and believe it could be true more generally by studying 500 cancer patients than by studying only one cancer patient. As statisticians, then, we may find ourselves in the position of wishing for more cases of disease in our sample size in order to have greater confidence in our results. And this is where I really appreciated the insight of Professor Jewell. In moments like those, when we are wrapped up in data and numbers, we should take a moment to step back and realize exactly what we have just thought. Should anyone really wish for more cases of a disease, just for the sake of analytic rigor? The obvious answer should be no. We may wish that we had crafted a better study design to interview more individuals who already have the disease, but it is very easy to forget that each of those data points is a real person.

Every single cancer patient enrolled in a study represents a person and family and community who had to go through an agonizing experience. Participating in a study in and of itself is often no walk in the park, either. Furthermore, the results of a study into what causes a given outcome may benefit future patients, but are often too late to benefit the ones under study at the time. This pain and trial are not to be so callously wished on anyone.

And it is in this sense that as students, teachers, researchers, etc., those who use statistics have an ethical responsibility to consider the human costs of what we quantify. Professor Jewell said he reminds himself of this by watching one particularly compelling and emotionally complex movie about human subjects research every year, which helps re-center him on the human aspects of his work. You may find your own unique ways to heighten your awareness. I believe this need applies not only to public health, but also to many fields that utilize mathematical inquiry beyond public health - education, public policy, social work, and business, just to name a few. It is not that our methods will necessarily be changed in any concrete way by exercising compassion in our thoughts (although they might, in some cases); rather, we can seek an attitude of empathy and a posture of humility as acts of internal integrity. It is not that we should neglect the study of disease or other negative life outcomes, as our numerical inquiry is typically not the cause of such outcomes, and is often ultimately aimed at improving health. But even as we work for these good causes, we should take time to reflect, empathize, and get outside our little boxes to just be human - to appreciate the lived experiences of those studied or affected, and to stop ourselves from so recklessly throwing around words and cold thoughts about those who it is all too easy to see as data point number 732.