Highlight HEALTH

The ABC television drama Boston Legal is one of my favorite programs. The show features quick, intelligent dialogue and great performances. Producer David E. Kelly has used Boston Legal as a platform to speak out on a number of issues over the last four seasons. Each installment walks a fine line between entertainment and political/social issues such as the Iraq War, global warming and Hurricane Katrina. Tuesday night’s season premier titled “Smoke Signals” was no exception. In this episode, Kelly tackles big tobacco.

Attorney Alan Shore represents a client who is suing a large tobacco company; her father smoked cigarettes for over 50 years and died of lung cancer. Testifying before the jury, the tobacco company CEO maintained that “we also some good along the way”, asking, “how many industries actually spend money to discourage people from buying their products?” He claimed that “spending billions of dollars on anti-smoking campaigns and youth prevention efforts” is an “unprecedented display of corporate conscience.” In their closing arguments, the defense maintained that there wasn’t conclusive evidence that the tobacco company caused the death of the plaintiff.

Shore delivered powerful closing arguments in the case as only the incomparable James Spader could present. Throughout his closing, he cited research findings and statistics that seemed “made for TV” but are, in fact, very real. In quintessential Highlight HEALTH fashion, I have referenced the studies throughout his closing arguments below. There will only be 12 episodes in this, the fifth and final season of Boston Legal. Enjoy it while you can.

Closing arguments

Michael Rhodes smoked cigarettes for 50 years, got lung cancer and died; we all know what happened here. We also all know this death. Everybody in this room knows somebody who has fought this same battle and dies … agonizing, brutal, excruciating …

But … emotion has no play here. Michael Rhodes was eleven years old when he started smoking, it was 1948. At that time, there was no known risk, and even if there were, at eleven he certainly lacked the capacity to assume it. And after that, he was addicted. They manufacture them to be addictive.

In just the last few years, they’ve increased the amount of nicotine in the average cigarette by 11.6% to make them even more addictive [1]. Recently, we learned that tobacco companies have been adding an ammonia-based compound to cigarettes for years to increase absorption of nicotine [2]. It’s basically the same principle used in crack cocaine.

And let’s look at the obscene strategy they’ve employed here. Smoking may cause cancer, but it didn’t cause this particular cancer. It wasn’t our cigarettes, or it was genetic, or asbestos or a paper mill. Never do they take responsibility ever. And God forbid, if you sue them, they’ll bury you and your lawyer. They might even depose your doctor to death, for good measure. All their insidious methods and cunning corporate tactics aren’t just history, it’s what they continue to do now, today. Because the tobacco industry is like a nest of cockroaches, they will always find a way to survive.

They still go after kids with one strategy after another. They put up brightly colored ads at kid’s eye level in convenience stores. They hire gorgeous twenty-somethings to frequent popular venues and seduce young adults into attending lavish corporate-sponsored parties. Cockroaches will always find a way.

They can’t advertise on TV but they’ve hired PR agencies to hook them up with the film industry. And it’s worked. Researchers estimate that smoking in movies delivers nearly 400,000 adolescent smokers every year [3]. Every time you try to kill the cockroach, it finds another way. It has to, because when you make a product that kills off your consumers, you have to find a way to recruit new customers.

They’ve now got a new feminized version of the macho Camel brand using slogans like “lite” and “luscious” with hot pink packaging. Virginia Slims advertised their “thin cigarette”. Allure Magazine did a whole spread on the cigarette diet [4]. They use social and psychological profiling [5], targeting potential smokers by gender, ethnicity, sexual preference, socioeconomic groups … cockroaches don’t discriminate.

Their CEO comes into this courtroom gloating over their anti-smoking campaign, which is designed to get kids to smoke. In 2003, they spent more than 15 billion on advertising and promotion [6]. That’s a 225% increase from 1998, and they have the audacity to declare they’re trying to discourage smoking. This is not how corporations with a conscience behave.

How in God’s name are cigarettes even legal, can anybody tell me that? They are a deadly concoction of carcinogens that damage every single organ in your body. Why do we not ban them? Because it’s a free country, because freedom of choice is an American ideal worth somebody dying every six seconds? How can any company, especially one with such a conscience no less, knowingly manufacture a product that poisons its users? … and make that product look cool and hip and sexy and fun, so they can get children. How can any attorney defend a company that would do such a thing and how could any society tolerate it, but we do.

There is no conscience at big tobacco. There is no conscience in Washington, which has been bought and paid for by this industry. Conscience has to come from you, the jury. If real regulation is to happen, it has to come from you. People are smoking day after day after day and dying and dying and dying and the tobacco companies keep getting richer and richer. Last year alone, they made 12 billion dollars in profits [7]. How can that be?

How can that be?

References

1. Connolly et al. Trends in nicotine yield in smoke and its relationship with design characteristics among popular US cigarette brands, 1997-2005. Tob Control. 2007 Oct;16(5):e5.
   View abstract
2. How an Unregulated Industry Experiments on America’s Kids and Consumers. American Cancer Society Cancer Action Network, American Heart Association, American Lung Association and Campaign for Tobacco-Free Kids. 2008 Feb 20.
3. Sargent, J. AAP Handout, October 2006. News release, American Academy of Pediatrics.
4. Morris, L. “The Cigarette Diet.” Allure Magazine. 2000 Mar.
5. Ling and Glantz. Using tobacco-industry marketing research to design more effective tobacco-control campaigns. JAMA. 2002 Jun 12;287(22):2983-9.
   View abstract
6. Federal Trade Commission Cigarette Report For 2004 and 2005. United States Federal Trade Commission. 2007
7. Fortune Global 500 2007: Altria Group.

Everyone knows that a good education is important for getting a good job. Now researchers are finding that being well-educated can lengthen your life. The study, published earlier this month in the journal PLoS ONE, finds that socioeconomic inequalities in the U.S. death rate between people with less than a high school education and college graduates increased from 1993 to 2001 [1]. The widening gap is due to (i) significant decreases in mortality from all causes, heart disease, cancer, stroke and other conditions, in the most educated and (ii) unchanged or increasing death rates in the least educated.

Epidemiologists at the American Cancer Society (ACS) worked with scientists from the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) to analyze over 3.5 million deaths from 1993 to 2001. They used data from the National Vital Statistics System (NVSS) and death certificate information to calculate annual age-standardized death rates for 25 — 64 year olds by level of education for all causes of death as well as for the seven most common causes of death (heart disease, cancer, stroke, HIV infection, diabetes, chronic lung disease, accidents).

The study restricted the analyses to deaths among non-Hispanic whites and blacks. It also excluded deaths that occurred in seven states (Georgia, Kentucky, New York, Oklahoma, Rhode Island, South Dakota and West Virginia) because completeness of education on death certificates in these states was less than 80% in at least one of years considered in the study.

The study found that between 1993 and 2001, the ratio of the all cause death rate in people with less than 12 years versus greater than or equal to 16 years of education significantly increased in white and black men, and in white women, indicating that those with a college education or better had an increased life expectancy. Contributing to the inequality was significant reductions in mortality for the most educated men (36% in black men and 25% in white men), largely due to decreases in death rates from HIV infection, cancer and heart disease.

Interestingly, the decrease in all cause death rates among men became larger with each additional increment of educational attainment (i.e. 12 years of education vs. 13 — 15 years vs. greater than or equal to 16 years). In women, this affect was only observed with greater than or equal to 16 years of education.

The study results support a previous investigation of county-level mortality published last month showing a steady increase in mortality inequality across the U.S. [2]. In that study, death rates between 1983 and 1999 increased for women in a large number of counties, principally due to chronic diseases related to smoking, overweight and diabetes, and high blood pressure. Most counties that showed a worsening of life expectancy were in the deep South, along the Mississippi River and in the Appalachia, extending into the southern portion of the Midwest and into Texas.

Between 1961 and 1983, counties with increased or decreased life expectancy improvements had relatively similar levels of income. However, after 1983, gain in life expectancy was positively associated with county income. Thus, those who were disadvantaged did not benefit from the increase in life expectancy experienced by the advantaged, demonstrating a large health inequality.

What does all this mean? It means those with less education are getting left behind and literally dying earlier as a result. ACS chief executive officer Dr. Otis W. Brawley, M.D. said that [3]:

People [in the U.S.] with less education have fewer financial resources, less access to health insurance or stable employment, and less health literacy. As a result, while the death rate among the most educated Americans is dropping dramatically, we’re seeing a real lack of progress or even worsening trends in the least educated persons. The gap between the best and worst off in the country is actually getting wider.

Last year, the American Cancer Society launched the Access to Health Care campaign, a national initiative to raise awareness about the problem of true access to health care. The website shows what is being done to help those uninsured and underinsured and how you can help.

Education is a marker of socioeconomic position. Lower educational attainment and thus a poorer socioeconomic position is associated with a variety of factors that affect health, including decreased financial resources, reduced access to health insurance and health literacy. Given that one of the CDC’s strategic imperatives is “all people, and especially those at greater risk of health disparities, will achieve their optimal lifespan with the best possible quality of health in every stage of life” [4], these results are troubling and highlight the growing problem with the U.S. healthcare system.

References

1. Jemal et al. Widening of socioeconomic inequalities in U.S. death rates, 1993-2001. PLoS ONE. 2008 May 14;3(5):e2181. DOI: 10.1371/journal.pone.0002181
   View abstract
2. Ezzati et al. The reversal of fortunes: trends in county mortality and cross-county mortality disparities in the United States. PLoS Med. 2008 Apr 22;5(4):e66.
   View abstract
3. Worsening Health Trends Among Least Educated. American Cancer Society News Center. 2008 May 14.
4. Center for Disease Control and Prevention’s Health Protection Goals. Accessed 2008 Jun 2.

There are a lot of good reasons for people to lose weight and to quit smoking. However, according to a new study published in PLoS Medicine, saving money on lifetime healthcare costs isn’t one of them [1].

Researchers at the Netherlands’ National Institute for Public Health and the Environment used a simulation model to estimate lifetime healthcare costs for a hypothetical group of 1000 healthy-living people from age 20 until the time when the model predicted all had died. They made similar estimations for a group of people who were either obese (i.e. BMI > 30) or lifetime smokers with healthy weight. Healthcare costs from each group were then compared to the healthy-living cohort. Data from the Netherlands on the costs of illness was used by the mathematical model to estimate healthcare expenditures.

Perhaps not surprisingly, the model predicted that, until age 56, yearly healthcare costs were lowest for healthy people and highest for people who were obese. At older ages, smokers incurred the highest yearly costs of healthcare. However, due to differences in life expectancy (at age 20, life expectancy was 5 years less for people who were obese and 8 years less for people who were smokers), total lifetime healthcare spending was greatest for healthy people. The cost of nursing home care was the principle factor increasing the cost of care for healthy-living people.

Thus, strictly in terms of healthcare costs, prevention of obesity and smoking does not result in a cost savings, since people who are obese or are lifetime smokers are more likely to die earlier than healthy-living people.

It’s important to stress that the study focused exclusively on healthcare costs related to obesity and smoking. The study didn’t take into account other associated economic costs, such as reduced productivity or prescription drugs. Indeed, the authors suggest that, in the case of obesity and smoking, indirect costs and could be higher than direct medical expenses.

More to the point however, does the prevention of obesity and smoking require an economic savings in order to be appealing?

Not necessarily. The goal of healthcare isn’t to save money, but to reduce suffering and death. The Netherlands’ study concludes by stating that:

Prevention may therefore not be a cure for increasing expenditures — instead it may well be a cost-effective cure for much morbidity and mortality and, importantly, contribute to the health of nations.

To be cost effective, prevention has to produce optimum results for the expenditure. Specifically in healthcare, cost effectiveness is defined as the costs incurred as a result of a service divided by the health outcomes achieved [2].

Thus, review of cost-effectiveness is very useful for assessing value. Cost-effectiveness analysis should help improve the delivery of those preventive services that will lead to the greatest improvements in population health and the most efficient distribution of resources.

A 2006 study by the National Commission on Prevention Priorities identified the most valuable clinical preventative services that can be offered in medical practice [3]. The highest ranking services in terms of clinically preventable burden and cost effectiveness were:

• Discussing the benefits/harms of daily aspirin use for the prevention of cardiovascular events with men ≥40, women ≥50, and others at increased risk.
• Immunizing children against diphtheria, tetanus, pertussis, measles, mumps, rubella, inactivated polio virus, Haemophilus influenzae type b, hepatitis B, varicella, pneumococcal conjugate and influenza.
• Screening adults for tobacco use, providing brief counseling and offering pharmacotherapy.
• Immunizing adults aged ≥50 against influenza annually.
• Immunizing adults aged ≥65 against pneumococcal disease.
• Screening women who have been sexually active and have a cervix within 3 years of onset of sexual activity or age 21 routinely with Pap smears.
• Screening adults aged ≥50 years routinely with colonoscopy.
• Screening adults aged ≥65 routinely for diminished sharpness of vision.
• Measuring blood pressure routinely in all adults (hypertension screening) and treating with antihypertensive medication to prevent incidence of cardiovascular disease.
• Screening routinely for lipid disorders among men aged ≥35 and women aged ≥45 (cholesterol screening) and treating with lipid-lowering drugs to prevent the incidence of cardiovascular disease.
• Screening adults routinely to identify those whose alcohol use places them at increased risk and providing brief counseling with follow-up.

The take-home message? Very few preventive healthcare services save more money than the cost incurred. The value of healthy-living is reduced yearly healthcare costs earlier in life and increased life expectancy. Isn’t that what it’s all about?

References

1. van Baal et al. Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure. PLoS Med. 2008 Feb;5(2):e29. DOI: 10.1371/journal.pmed.0050029
   View abstract
2. Haddix A, Teutsch SM, Corso PS. Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation. 2nd ed. New York: Oxford University Press; 2003.
3. Maciosek et al. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med. 2006 Jul;31(1):52-61.
   View abstract