Sunday, April 17, 2016

Tobacco control vs AIDS prevention

I just finished Chris Snowdon's excellent book Velvet Glove, Iron Fist. One of the points Snowdon emphasizes repeatedly throughout the book is that the anti-smoking lobby is actually more of an anti-tobacco industry lobby. The primary concern is not the health of smokers, it's bringing down the cigarette companies.

Over the years, this mindset has led public health crusaders to demonize anything that may shed a positive light on smoking or the tobacco industry, whether it deserves such treatment or not. Big public health's reaction to the advent of e-cigarettes is a great example of this. But this unwavering disdain for anything perceived as pro-smoking extends even to genuinely good deeds the tobacco industry may do. And as if on cue a "study"* released just this week gives me a perfect example to dissect.

On Monday researchers writing in the Journal of Social Aspects of HIV/AIDS pointed out that the tobacco industry's extensive funding of AIDS groups, often called AIDS service organizations (ASOs), is part of a conspiracy to stave off further regulation of tobacco:
A new paper claims the historical involvement of tobacco companies during the early days of the response to the AIDS epidemic was just a cynical marketing ploy to distract the public from the dangers of smoking.
On this point there is little to debate. The tobacco industry has tried everything to shift the state's attention away from cigarettes; funding the fight against AIDS and other infectious diseases fits perfectly within that strategy. Indeed it was a brilliant move, and big public health rightly saw it as an attempt to co-opt their fundraising efforts. This "study," therefore, is just an example of one public health cause attempting to muscle another one out of funding, and using the tobacco industry's dishonesty as a justification.

Health writer and filmmaker Tom Naughton notes in his documentary Fathead that disparate public health groups, anti-smoking and anti-obesity groups in this case, have to lobby for government funding. They campaign incessantly for sin taxes and research grants, both of which sustain their efforts to fight smoking or obesity. But another way they secure funding is by attacking each others causes, claiming that their own cause is far more serious a threat to the public.

This makes sense, too. If tobacco isn't public enemy number 1, the government will be less enthusiastic about taxing cigarettes and funding anti-tobacco initiatives and research. Every dollar spent on obesity or infectious diseases is a dollar not spent on tobacco control, after all. The authors of the "study" expend a lot words dancing around this point in hopes of dismissing it. They write that following the outbreak of the AIDS epidemic
there were arguably more pressing health matters [than infectious diseases in the third world] as the majority of child and adult deaths continued to be caused by non-communicable diseases, many of which were related to the growing use of tobacco products.

Arguable indeed. According to Baylor College of Medicine,

"three infectious diseases were ranked in the top ten causes of death globally in the most recent survey by the World Health Organization ... lower respiratory infections (3.1 million deaths), HIV/AIDS (1.5 million deaths), and diarrheal diseases (1.5 million deaths)." 

These numbers slightly outpace the deaths WHO attributes to smoking-related illnesses, so the claim that smoking is the greatest threat to health worldwide is incorrect. And when we add in the fact that infectious diseases aren't lifestyle choices (nobody chooses to get AIDS, people choose to smoke), we have a pretty solid case that the tobacco industry was serving the greater good by channeling resources towards AIDS prevention and awareness, whatever their motivations.

But I urge you to make note of that sneaky dependent clause at the end of that quote: "...the majority of ... deaths continued to be caused by non-communicable diseases, many of which were related to the growing use of tobacco products." Smoking certainly contributes to this category of disease, but the WHO also admits that lack of exercise, excessive drinking and poor diet kill more people than smoking.

The problem is further compounded because all of these behaviors are risk factors for many of the same diseases. For example, high blood pressure can kill you, but globally how do we know which risk factor led to the most cases of high blood pressure? The WHO fact sheet doesn't say, probably because it's impossible to separate them out accurately.

But assume the "study" is right that money shouldn't be diverted from tobacco control. Who funds ASOs? Anybody but tobacco companies. The "study" vaguely refers to "alternative resources" and "other donors." My guess is that those donors will ultimately be taxpayers in first world countries, since few other private enterprises have an incentive to fund AIDS prevention. Whoever ends up footing the bill, though, the point of the "study" is that there should be more funding for public health all around: "... there is a need for more collaborative, rather than competitive, approaches to increase societal resources for health needs overall."

Such a conclusion ignores the economic reality that governments have only so much money to throw into the black hole of public health, and what they do spend is influenced by a host of political concerns. Ultimately this is why ASOs are willing to take tobacco money, and it also explains why big public health feels the need to stop them.

*I put "study" in quotes because anti-smoking crusaders have made a habit of copying and pasting content from internal tobacco industry documents into medical journals, adding a bit of commentary and calling it original research. That sounds more like an 8th grade book report to me than a scientific study, but I figured it was worth pointing out.


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