Medical Journal: 10/28/18

Had a moderately rough time in Prague, but suddenly today I’m feeling better: not normal, but better. As of this morning, I seem to be able to croak rather than whisper reliably, which makes a huge difference. And I just spent an hour on my feet in the Rijksmuseum without undue strain. Was going to cut my trip short by two days; now I’m shooting for one.

Illicit Tobacco and Nicotine Markets

FDA seeks ban on menthol cigarettes. FDA’s proposed flavored tobacco policy draws mixed reaction. Is it racist to ban menthol cigarettes—or not to? FDA tobacco crackdown draws fire from the right. Black advocacy groups cheer FDA’s push to ban menthol cigarettes.

Can a menthol ban survive lawsuits? Why an FDA ban on menthol is likely to survive a tobacco industry lawsuit. British American Tobacco sets out defense of menthols.

Flavored vapes draw FDA ire, with some exceptions: Mint, menthol, and tobacco flavors will stay on shelves. E-cig users are already searching for ways around coming sales restrictions.

Reps. Pallone and Shalala introduce comprehensive legislation to address youth tobacco use.
Prohibits all characterizing flavors of tobacco products, including menthol, and provides FDA with authority to collect user fees from all classes of tobacco, including e-cigarettes.

Ban on menthol tobacco products predicts cigarette cessation at one year.
The study found higher rates of quitting among menthol smokers compared with non-menthol smokers.

Evaluating a real world ban on menthol cigarettes: an interrupted time series analysis of sales.
Implementation of a menthol ban was associated with significant reduction of menthol cigarette sales and total cigarettes sales.

Statement from FDA Commissioner on advancing new policies aimed at preventing youth access to flavored tobacco products.
“Recent evidence indicates that mint- and menthol-flavored products are preferred more by adults than minors. We’re also aware that some adults may be using mint- and menthol-flavored products with the goal of ceasing combusted tobacco use, seeking health benefits at the individual level, and may be at risk of migrating back to cigarettes.”

Effect of menthol bans on tobacco purchases in the RTI iShoppe virtual convenience store.

NYC Council ignoring “unintended consequences” in discussing menthol ban.

Consumption of legal and illegal cigarettes in the Gambia. Policy makers’ views on the implementation of the Framework Convention on Tobacco Control in the Gambia.

Strategies and barriers to achieving Finland tobacco endgame. Trends in UK use of roll-your-own cigarettes, 2008–2017.

Economics of tobacco control, part three: evidence from the ITC Project.


Medical Journal: 10/20/18

Nothing really new to report. If any of the symptoms are improving, it’s not noticeable to me. I would have expected to be in better shape two weeks-plus after the last treatment I’m coughing up occasional tiny bits of what appear to be tissue from the throat. Climbing three steps up to a train with my luggage, then hoisting my suitcase to the rack above the seats, left me seriously panting.

As of Thursday morning, my voice had progressed from a whisper to a croak, which seemed like important progress. But two days of talking too much at a meeting set me back again. This weekend I’m planning to be silent except for a few short phone calls; I’ll see if that helps.

Off to Prague and Amsterdam Tuesday night. That’s not seeming nearly as good an idea now as it did when I planned it, but I still expect to have a good time.

Cannabis News Round-Up

Former anti-pot politicians are lining up to profit off the end of their war on drugs. Marijuana industry wants Los Angeles to crack down on illegal pot shops. Democrats urge tougher penalties for black-market sales in New York marijuana legalization bill. The $160 billion cannabis industry, much of it still illegal, makes for a “beautiful opportunity”. Behind Oregon’s blockbuster marijuana deal: a Russian billionaire, cannabis consolidation. Marijuana industry could surpass NFL in revenue by 2020. Could Big Cannabis overrun California?

New study: Making medical marijuana legal does not prevent fatal opioid overdoses.

Nevada becomes first state to ban pre-employment marijuana drug testing. Nevada to try limited banking for cash-heavy pot industry. Nevada US Attorney says marijuana prosecutions possible. Oregon hopes to be an interstate marijuana supplier. Portland, Oregon invests cannabis tax dollars into black-owned businesses. California prisoners can legally possess marijuana, appeals court rules.

Colorado touts reaching $1 billion in cannabis taxes but the industry is stagnating. Colorado still exporting black-market cannabis because it makes tons of money in other states. Colorado hard seltzers want to take over legal weed, too. Can Colorado micro-business licenses diversify the marijuana industry?

Why Illinois legalization law is different from all others. The economic impact of recreational marijuana in Illinois. What’s legal weed gonna cost in Illinois? A lot. Legal weed could send millions of dollars to Illinois violence prevention groups. Illinoisresidents see benefits in legalization, but concerns persist. Legal pot in Illinois means concerns in Iowa. Want to work in the Illinois legal pot industry? Here’s who’s hiring right now.

New York Farm Bureau backs marijuana legalization. Majority in New York back use of recreational marijuana. So many reasons to legalize cannabis in New York. Will New York legal marijuana go up in smoke before June adjournment? Chairman to New York Senate Democrats: Don’t vote on marijuana this year.

Washington DC is one step closer to recreational marijuana dispensaries. Will Delaware legalize marijuana this year? New Jersey medical marijuana expansion stalls, expungement reform advances amid legal weed protest.

Maine can have say about new recreational marijuana rules. Maine marijuana rules up for important committee vote. Rhode Island marijuana legalization probably dead this year.

In Michigan‘s Upper Penninsula, weed is a lonely pursuit for its one and only dispensary.

Democratic presidential candidates mostly agree on marijuana legalization. The exception? Joe Biden.

Canada blew its chance to be the world’s pot leader. Veteran cannabis company Harborside joins wave of US firms listing on Canadian exchange.

Why legal weed in United Kingdom may be a pipe dream.

Medical Journal: 10/13/18

Sorry for the long silence. I thought I’d posted something Wednesday, but apparently it didn’t take.”Getting up slowly,” as the football announcers say when someone’s had his chimes rung. But I should have the worst of it behind me now.

Those two nights of sleep without chemical assistance were the exception, and tolerance is starting to build; last night, even with 50 mg. of Tramadol, I didn’t sleep at all, though I got up at 4am Pacific time (7am Eastern) and didn’t get to bed until 11pm. I think my energy is a little bit better, but the sore throat is persistent. Whatever I take to deal with it causes me to cough, which tears up the throat again. It’s a losing proposition. The pain is never severe, but it’s enough to interfere with sleep.

Got the latest lab work back; Dr. Bomback reports that the creatinine number (which measures kidney function, with higher numbers reflecting diminished function) is up a little bit, presumably as a side-effect of the Entresto. He thinks it’s ok to stay on my current dose, but doesn’t want to boost it any. That leaves me with some cardiac insufficiency, enough to make a one-mile walk a significant problem. I’m going to ask Dr. Weiss if adding one or the other of the previous heard meds to the current dose of Entresto is an option; the one time I took all three on the same day (not knowing that the Entresto was supposed to replace the others) was the one day I could walk some distance at a normal pace.

Waiting to get my voice back; Dr. Sanfilippo thought three weeks or a month from a week ago. I hope that’s right, but so far there’s no progress

Medical Journal: 10/6/18

Last treatment Thursday. Dr. Sanfilippo says the coming week may be the worst; then expects me to feel better “from week to week, not from day to day.” Likely to have a voice about three weeks from now. He suggests having Dr. Sulica scope me about a month from now, when the inflammation has died down. Predicts that the tumor mass will have disappeared entirely, leaving nothing to biopsy.

Indeed, I’ve felt fairly rotten the last couple of days. I seem to be feverish, and yesterday when I took too many pills too quickly they came back up. On the other hand, I’ve now had two nights of undrugged sleep, the first time I haven’t needed sedatives in nearly a month. Got a good night’s sleep last night, woke up, had breakfast, checked my email and Twitter … and went right back to bed for another few hours of sleep. The deficit must have been profound, but right now I’m fully alert and comfortable. Tomorrow may be the time I try some exercise.

Still no results reported from my blood and urine test. Definitely crossing LabCorp off my list. I’m told they specialize in workplace drug testing.

As promised, the radiation oncology team let me keep the custom-made mask that was used to keep my head from moving during the treatments. Having a genuine North American piece on my wall will diversify my collection, which otherwise is entirely West and Central African. For a people with a relatively limited tradition of ritual mask-making,the North Americans show a great deal of promise. I greatly admire the combination of portraiture with high abstraction, reminiscent of the best Lobi work,or the early Cycladic figurines.

Ritual Healing MaskN. American, early c. XXI.

Medical Journal: 10/3/18

Next-to-last treatment today. See Dr. Sanfilippo for my last status check after the final treatment tomorrow. Not feeling horrible, but the sedatives I’m taking every night to sleep –or just to rest comfortably –leave me draggy during the day. And yes, rotating chemicals seems to work –at least, Ambien worked again after three days off. Sore throat has been annoying but not unbearable. Loss of voice very inconvenient. Exercise tolerance quite low.

On the other hand, on Sunday I graduated from “Obese” to “Overweight” on the standard BMI chart, and the one 46L suit I kept around now fits perfectly.

Went to a for-profit stand-alone lab (Labcorp) today for routine blood and urine tests. Pretty grimy. I think I’ll go back to Columbia, though it’s more of a schlep. If the results look good in terms of kidney function, I’ll be able to raise the dose of Entresto and –with luck –feel reasonably normal again.

Today’s treatment involved an unnecessary scare. The technicians said that today was my weekly X-ray. (I’m not sure what it’s supposed to show; surely a 1cm soft-tissue tumor can’t be visible?) After they put the mask on and clamped me in –which means I can’t see anything –I heard the sound of what I guess was he X-ray machine and then the brilliant flash. Then I waited. And waited. And waited. Usual treatment takes about 2 min. from being clamped in to being released; this must have been close to 15 minutes, and the treatment still hadn’t happened. I started imagining all sorts of things that could have gone wrong, but no one was saying anything.

Finally I heard the sound of the treatment and was unclamped. As I got up, I said to one of the technicians, “What the hell just happened.” Answer? Nothing. The M.D. had to look at the X-ray before the treatment went ahead, and he was busy.

Since I don’t have any clear idea which of my symptoms relate to the cancer, which to the radiation (except the sore throat, the sleep problem that comes from the sore throat, and the sunburned neck), which to the cardiomyopathy, and which to the renal insufficiency, I’m not sure how much better I’ll feel a month from now. Fingers crossed.

Illicit Tobacco and Nicotine Markets

Colombia loses iconic cigarette as Philip Morris International packs up and goes.
PMI blamed the closing of its factories and the end of Pielroja on another iconic element of Colombian culture: contraband.

New report exposes continued impact of illicit tobacco trade in the European Union. The trade in black market cigarettes cost member states a total of €10 billion ($11.23 billion) in lost tax revenues in 2018.

Illicit cigarette factory discovered in Belgium.
The packaging indicated that the products were destined for Greek, Turkish and British markets. The number of cigarettes found was equivalent to over a million packs and the worth of the scheme was estimated at €6 million.

Manitoba man caught with thousands of contraband cigarettes.
In relation to the seized tobacco, Manitoba stood to lose $37,130.72 in tax revenue if these products had been sold. If convicted, the accused is subject to a triple tax penalty of $111,392.16.


Where Is Blaise Pascal When You Really Need Him?

Both the Washington Post and the New York Times have reported that the Trump White House refused to approve the written testimony of Dr. Rod Schoonover for entry into the permanent Congressional Record. Dr. Schoonover had testified on Wednesday before the House Permanent Select Committee on Intelligence on the dangers that climate change poses to the security of the US.

Both the Post and the Times had links to the MS Word document of
Dr. Schoonover’s comments complete with the editorial comments of the WH censors reviewers. I have posted a copy of that document here. (I have added the RBC “Seal” and OCR’d the document.) Reading the document is more alarming than the fact of the suppression of Dr. Schoonover’s comments. It reveals a White House or NSC staff that is dominated with climate-denier ideologues.

For instance, one comment reads:

[T]here is nothing exceptional about current climate and it is profoundly incorrect to say that ‘characteristics of global climate are moving outside the bounds experienced in human history.” There was faster and greater Medieval warming around the year 1000 when Norse settled southern Greenland and developed a thriving agricultural society.

BJME 3.

The blog Skeptical Science shoots a hole in that nonsense:

Firstly, evidence suggests that the Medieval Warm Period may have been warmer than today in many parts of the globe such as in the North Atlantic. This warming thereby allowed Vikings to travel further north than had been previously possible because of reductions in sea ice and land ice in the Arctic. However, evidence also suggests that some places were very much cooler than today including the tropical pacific. All in all, when the warm places are averaged out with the cool places, it becomes clear that the overall warmth was likely similar to early to mid 20th century warming.


Since that early century warming, temperatures have risen well-beyond those achieved during the Medieval Warm Period across most of the globe.  The National Academy of Sciences Report on Climate Reconstructions in 2006 found it plausible that current temperatures are hotter than during the Medieval Warm Period.  Further evidence obtained since 2006 suggests that even in the Northern Hemisphere where the Medieval Warm Period was the most visible, temperatures are now beyond those experienced during Medieval times  (Figure 1).  This was also confirmed by a major paper from 78 scientists representing 60 scientific institutions around the world in 2013.


Secondly, the Medieval Warm Period has known causes which explain both the scale of the warmth and the pattern. It has now become clear to scientists that the Medieval Warm Period occurred during a time which had higher than average solar radiation and less volcanic activity (both resulting in warming). New evidence is also suggesting that changes in ocean circulation patterns played a very important role in bringing warmer seawater into the North Atlantic. This explains much of the extraordinary warmth in that region. These causes of warming contrast significantly with today’s warming, which we know cannot be caused by the same mechanisms.

However, at the center of the WH attack is the “uncertainty principle.” That is, the proposition that we cannot act on the threat of global climate change because it is possible that our conclusions are not airtight. Thus, they include this quote from Syukuro “Suki” Manabe: “Don’t put your model in a race with nature. Your model will lose this race.” The quote is literally accurate but taken out of context. What Manabe did in his work was to simplify his models, taking out complexities and, thereby, isolating specific factors in climate change. See here. Manabe believes in the reality of CO2 driven climate change and the basic accuracy of climate models.

Finally, we get to Blaise Pascal and his famous wager. In its most simple form, Pascal posits that we cannot by human reason either prove or disprove whether God exists. He points out that if a wager was between the equal chance of gaining two lifetimes of happiness and gaining nothing, then a person would be a fool to bet on the latter. He then concludes that it is irrational to risk an eternal life of happiness for the possibility of gaining nothing. (“If you gain, you gain all; if you lose, you lose nothing.”) (I’m certain that many of the members of the RBC would jump on me if I did not point out that one of the flaws in the wager is that there are many competing gods and that one cannot, using human reasoning, prove which is the true god.)

But that’s not the choice we face in addressing global climate change.

First, modeling, while not perfect, allows us to fairly accurately compute the future temperature rise and rise in ocean acidity due to CO2 buildup. Thus, we are out of “coin flip” territory. The probabilities of a disastrous outcome are, if not certain, very high.

Second, we can assess our costs, but downside and upside, with some degree of accuracy. We have projections of populated areas that are threatened by sea rise, species that are at risk of extinction, and the geographic shift of areas that can be used in agriculture.

Basically, Pascal basic approach was correct. Weigh the upside against the downside. He was in error in assessing the upside (i.e., that there are many competing gods) and could not calculate the probabilities involved. We are not so limited. Except in the White House.