Paul Statt Communications

Do higher taxes change behavior?

Generally speaking, yes. The laws of economics are pretty strict about this stuff: raise the price of booze, butts or junk food, and without even thinking about, we–that is, homo oeconomicus–cut back. But for public health law, the research question has to be: do we really get any healthier?

Alex C. Wagenaar, associate director of Public Health Law Research, just published a paper that found “significant reductions in mortality related to chronic heavy alcohol consumption following legislatively induced increases in alcohol taxes in Florida.” Raise alcohol taxes. Fewer drunks die.

This kind of research must be painstaking and methodical. Isn’t it odd: to support the obvious truth, you need to take special care. Wagenaar at al. needed data from 1969 through 2004, and “a time-series quasi-experimental research design…” “including nonalcohol deaths within Florida and other states’ rates of alcohol-related mortality for comparison. A total of 432 monthly observations of mortality in Florida were examined over the 36-year period. Analyses included ARIMA, fixed-effects, and random-effects models, including a noise model, tax independent variables, and structural covariates.”

It’s heavy. This is the kind of research that should be driving public policy,

Maldonado-Molina, M., & Wagenaar, A. (2010). Effects of Alcohol Taxes on Alcohol-Related Mortality in Florida: Time-Series Analyses From 1969 to 2004 Alcoholism: Clinical and Experimental Research DOI: 10.1111/j.1530-0277.2010.01280.x

In 97 Orchard: An Edible History of Five Immigrant Families in One New York Tenement ($25.99 New York, 2010) Jane Zieligman writes:

In the early 1920s a Boston dietitian named Bertha Wood conducted a multi-ethnic study of immigrant eating habits, eventually published as a book, Foods of the Foreign Born in Relation to Health. As the title suggests, the book was written for health-care professionals–visiting nurses, settlement workers, dispensary doctors–who served the immigrant community.

Wood’s “curious little book” in Zeiligman’s words, blames a single food for much of the difficulty Jewish immigrants faced: that “much-loved Jewish staple: the pickle.”

The briny garlicky sour cucumber was the gateway intoxicant for Jewish kids, according to Zeiligman: “The undernourished child was drawn to pickles the same way an adult was drawn to alcohol. More than a food, the pickle was a kind of drug for tenement children, who were still too young for whiskey.”

In Zeiligman’s mouthwatering tour of the kitchens of the Lower East Side, contemporary reformers saw many dangers lurking in the immigrants’ foodstuffs. To name only a few:

• Home candy manufacturing;
• The pushcart markets;
• Excessive consumption of greens;
• Highly seasoned foods.

The superannuated antics of old-time public health reformers are good for a laugh. But in the folk memory of many Americans, the Keystone Healthkare Kops are still at work, trying to “tell us what’s good for us.”

The difference between public health law then and now has to be research. If today’s reformers want to change the way Americans eat, they must be damned sure that there is solid empirical evidence that

• the proposed changes in diet are good for the public health, and,
• the proposed changes in laws and regulations will change the public’s behavior.

A recent paper does shows how to do that. “A Framework for Public Health Law Research,” defines this emerging scientific discipline and explores the promise and challenges of studying the impact of laws on health.

Public health experts, legal scholars and policy makers are increasingly recognizing that laws can keep people safe and healthy; for example, by encouraging the use of seat belts and by keeping the environment safe from toxins. This growing recognition has led to the emergence of “public health law research”, a developing field aimed at studying the intended and unintended consequences of laws on public health as a way to support evidence-based policy making.

Scott Burris, director of Public Health Law Research, a national program of the Robert Wood Johnson Foundation administered through Temple University, wrote the paper with Michelle Mello of the Harvard School of Public Health, Alexander Wagenaar of the University of Florida College of Medicine, Jeffery Swanson of Duke University School of Medicine, Jennifer Ibrahim of Temple University, and Jennifer Wood of Temple University.

BURRIS, S., WAGENAAR, A., SWANSON, J., IBRAHIM, J., WOOD, J., & MELLO, M. (2010). Making the Case for Laws That Improve Health: A Framework for Public Health Law Research Milbank Quarterly, 88 (2), 169-210 DOI: 10.1111/j.1468-0009.2010.00595.x

How can you measure the impact of a law? The Obama administration, for example, recently called for an “evidence-based” approach to the writing of laws and policies that affect the public’s health in matters of drug abuse. But applying the scientific method to an evaluation of a law’s impact requires a rigorous approach to measurement. In “Measuring Law for Public HealthEvaluation Research,” published in the June 2010 Evaluation Review, Charles Tremper, Sue Thomas and Alexander C. Wagenaar provide researchers good guidance for legal researchers.

The authors write that in order to measure effectively the effectiveness of a law, one must “focus on the “is” rather than the “ought” ” of the legal environment, taking such into account such variables such as enforcement policies, financial appropriations and even the simple question of law’s effective date. The suggestions and procedures offered in this paper will improve “the utility and accuracy of research that uses legal data, ultimately improving public policy and its effectiveness in achieving important goals in advancing population health and well-being,” the authors conclude. “By blending the knowledge and skills of social scientists with that of legal experts, scholars can produce more accurate and more useful policy evaluations.”

Tremper, C., Thomas, S., & Wagenaar, A. (2010). Measuring Law for Evaluation Research Evaluation Review, 34 (3), 242-266 DOI: 10.1177/0193841X10370018

There’s a legitimate argument against “crying wolf,” that is, frightening children with scary stories about what might happen to their health if they don’t wash their hands properly. Jeffrey Hall Dobken, M.D., a professor of pediatrics at Weill Cornell School of Medicine in New York and a N.J. bioethicist, makes the argument in MedPage Today: Columns – And Now a Word … – About Crying Wolf.

We live in a society of fear. “Terrorism” is its most visible manifestation, but “health” is also hard to miss. But rather than moving to either pole–fearing that anything might kill us, or ignoring all possible dangers–I wish that we could respond to solid mathematical and scientific evidence, and not to our reptilian instincts.

China instituted quarantines and strict immigration rules earlier this year, in response to the H1N1 virus. According to a front-page story in The New York Times (Nov. 12, 2009) “Chinese and foreign health officials say that some of those contested measures — more easily adopted by an authoritarian state — may have helped slow the spread of the disease in the world’s most populous country. ”

Unfortunately, no research is cited.

The best that reporter Edward Wong can offer as evidence: ““I think there were a variety of measures put in place by different countries, and it’s difficult to say what worked best and what didn’t, but China’s has worked very well,” said Dr. Michael O’Leary, the director of the Beijing office of the World Health Organization.”

I was struck by the deft analogy Shannon Brownlee and Jeanne Lenzer used to describe the experts who question the research behind the H1N1 vaccine.

” Like the engineers who warned for years about the levees of New Orleans, these experts caution that our defenses may be flawed, and quite possibly useless against a truly lethal flu. And that unless we are willing to ask fundamental questions about the science behind flu vaccines and antiviral drugs, we could find ourselves, in a bad epidemic, as helpless as the citizens of New Orleans during Hurricane Katrina.”

Granted. But no sane engineer looking at flood control before Katrina was arguing we should “tear down this levee.” That’s in effect what people opposed to flu vaccination are saying .

New York Times July 19, 2009

“How dangerous is driving while texting?” That question raises important issues for public health law and research. How much do we really know about the danger, and does the issue call for a legislative solution? Political resistance to such a ban is strong, as evidenced by the reaction of the Department of Transportation earlier this year to its own research, and more convincing data will be needed to overcome it. An analysis of the research and researchers mentioned in the Times demonstrates that pubic health professionals still need the support of further research as they convince governments to ban this dangerous multi-tasking practice.

The research presented in the Times series “Driven to Distraction” points to the importance of accumulating enough data to effect changes to laws. The best data available, it seems, are about the dangers of trying to do many things at once. Such “multi-tasking” does include texting while driving, but much research deals with the larger question, “How much distraction can the human brain handle?” This research is neither explicitly about driving, nor explicitly about texting. David Strayer and his University of Utah Applied Cognition Laboratory, featured in the Times story, are the only group doing such explicit research.

Writing in the Times on July 19 , Matt Richtel, formerly a reporter on the video gaming industry, cited many other research studies. But the key document, and the news “hook” for this story, was an unpublished U.S. Department of Transportation National Highway Traffic Safety Administration study commissioned in 2003, to assess the safety risk of cellphone use while driving. This study and its suppression by the Department of Transportation was the main topic of Richtel’s follow-up story in the Times on July 21.

Richtel’s story claims that the NTSB chose not to publish the results, under political pressure not to upset the telecommunications industry with a call to ban driver cellphone use. Transportation department officials claim that they chose not to publish the research because the data was too inconclusive. One way or the other, more research–and more research that explicitly addresses the safety of texting while driving–is needed.

Research and researchers mentioned:

The suppressed National Highway Traffic Safety Administration study did produce an extensive bibliography in 2008 that cites NHTSA studies (6), journal articles (78), conference proceedings (42), technical reports (39) and other research (9) from the mid-1990s until 2005.

Another key quotation in Richtel’s July 19 story is this: “A 2003 Harvard study estimated that cellphone distractions caused 2,600 traffic deaths every year, and 330,000 accidents that result in moderate or severe injuries.” Lacking a citation, the reader might turn to the Harvard Center for Risk Analysis. (http://www.hcra.harvard.edu/). The only relevant publication is a paper by J. T. Cohen and J. D. Graham, “A revised economic analysis of restrictions on the use of cell phones while driving,” in Risk Analysis. This cost-benefit analysis “raises substantial uncertainty in the estimates of several important inputs, including the extent to which cell phone use increases a driver’s risk of being involved in a crash, the amount of time drivers spend using cell phones (and hence their aggregate contribution to crashes, injuries, and fatalities), and the incremental value to users of being able to make calls while driving.”

Nationwide Mutual Insurance, a car insurance company, surveys drivers annually about cell-phone use, and also about other distractions while driving. NMI is an advocate of a cellphone ban, and its surveys indicate broad public support for it. The most recent data are from August 2009. This publication also provides several links to academic studies.

Robert D. Foss, the director of the Highway Safety Research Center, University of North Carolina, is quoted saying that laws alone will not change behavior–a subject in which he speaks with authority. His research interests include the role of alcohol in auto accidents and the high crash risks of teen drivers.

The most pertinent research cited in the Times is the work of David Strayer and his University of Utah Applied Cognition Laboratory. Strayer’s group investigates “the impact of using advanced in-car technologies on driving performance and traffic safety. Our research addresses three specific goals limited to the most prominent communication technology, the cellular phone.” They claim to provide unambiguous scientific evidence demonstrating that cell phone conversations disrupt driving performance, to compare the increased risk of cell phone use to other activities, and to provide a theoretical account of the disruption.

Steven Yantis, Johns Hopkins University, psychological and brain sciences also investigates the broader topics of human visual attention and cognitive control.

David E. Meyer, who directs the University of Michigan Brain Cognition and Action Laboratory, is also interested in fundamental aspects of human perception, attention, movement production, reaction time, multitasking, executive mental control and human-computer interaction.

John Ratey, a professor of clinical psychiatry at Harvard Medical School, is not quoted for his research, which has been mainly in autism and ADHD. His contribution to the story is perhaps his Harvard connection or the title of a 2008 book he co-authored, “Driven to Distraction.

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This study is worth considering just because it calls Facebook a “nonymous online environment.”

Isn’t that a great word? Sherri Grasmuck, a Temple University sociologist, analyzed the contents of 63 Facebook accounts, and found ” that the identities produced in this nonymous environment differ from those constructed in the anonymous online environments previously reported.”

“Facebook users predominantly claim their identities implicitly rather than explicitly; they “show rather than tell” and stress group and consumer identities over personally narrated ones.”

Enough said.

ZHAO, S., GRASMUCK, S., & MARTIN, J. (2008). Identity construction on Facebook: Digital empowerment in anchored relationships Computers in Human Behavior, 24 (5), 1816-1836 DOI: 10.1016/j.chb.2008.02.012

Potti, S., Milli, M., Jeronis, S., Gaughan, J., & Rose, M. (2009). Self-perceptions of body size in women at an inner-city family-planning clinic American Journal of Obstetrics and Gynecology, 200 (5) DOI: 10.1016/j.ajog.2008.11.027