Illicit Tobacco and Nicotine Markets

FDA authorizes Philip Morris to sell heat-not-burn cigarettes in the US. Philip Morris CEO: Smokeless “transformation” for the company is like no other. FDA authorizes smokeless IQOS cigarettes, restricts digital marketing to prevent youth exposure. IQOS exposure impairs human airway cell homeostasis: direct comparison with traditional cigarette and e-cigarette. FDA deals blow to IQOS. This should change everything: using the toxic profile of HNBs as a performance standard to phase out combustible cigarettes. Philip Morris shifts focus to heat-not-burn. Philip Morris rebuffed by World Health Organization as it tries to rewrite narrative. Philip Morris obtains a pan-EU injunction against an IQOS copycat from China. Philip Morris CEO lashes out at Hong Kong e-cigarette ban. Philip Morris CEO ridiculed for ‘staggeringly hypocritical’ campaign to ‘end smoking’—despite still selling cigarettes.

Big Tobacco is morphing into Big Vape. FDA chief accuses Juul, Altria of reneging on promise to combat teen vaping. A tale of two Juul pods: China‘s counterfeits pose a threat to US. Over 1,000 counterfeit Juul pods seized by border protection; there’s big profit in the fakes. Altria is paying a desperate price for Juul. Juul looks to Altria for more sway in DC. Altria-Juul deal worries anti-tobacco groups.

Strategies for eliminating smoked tobacco. Why tobacco product regulation is no magic bullet. UK tobacco companies are using e-cigs as a Trojan Horse, experts warn.

Analysis of tobacco industry pricing strategies in 23 European countries. Smoke Signals: Monitoring illicit cigarettes and smoking behavior in Colorado to support tobacco taxes. Decrease in the proportion of illicit cigarette use in Brazil: What does it really mean?

Medical Journal: 8/10/18

Talked to Dr. Weiss, the internist. He agrees with Dr. Sulica’s suggestion that the heart disease could be a side-effect of the previous radiation treatment. Likely diagnosis is atherosclerosis. Needs to be dealt with, but in the absence of current symptoms we can be patient. Suggested I go back on a statin, which I’d discontinued since my cholesterol numbers were OK and I was worried about short-term memory effects. Agreed with Dr. Bomback that I should cut back my allopurinol dosage from 300 mg. to 100 mg., to reduce the kidney load. I suggested that –since I hadn’t had a gout episode in more than a decade and was now on a low-meat diet –we consider dropping it entirely, but he thinks cutting back is enough until we see if those symptoms come back at the lower dose.

Next question was whether it’s possible to get the heart diagnosed without going on dialysis first. My friend Dr. Susie Lew, a nephrologist at GW, tells me there are ways of doing catheterization with little or no contrast, and with other preparations to minimize the kidney burden; in the best case, the kidney-function measurements don’t move.

That discussion led to my first health-care-policy insight of this episode. It turns out that New York State does very careful tracking of the outcomes of some surgical procedures. That sounds like a reasonable venture in quality assurance and consumer protection. However (there’s always a “however” in these things) that means that cardiologist who does a catheterization after which the patient needs dialysis gets a black mark on his or her record. On the other hand, if the patient is started on dialysis before the catheterization, then it doesn’t count as a bad outcome. Conclusion: We should look for a cardiologist in New York willing to run the risk, but be open to the possibility of going out-of-state.

Footnote: Some of the responses to my first email –for which I’m grateful –suggested to me that the medical picture I’d painted was overly grim. There’s no doubt that I’m what’s called an “interesting” case, but as far as I can tell I’m more likely than not to be alive and reasonably healthy ten years from now.

Illicit Tobacco and Nicotine Markets

UK and Dubai Customs seize 450 metric tons of illicit tobacco. Criminal gangs supplying illegal tobacco in Norfolk, UK. More than 1 million euros of smuggled cigarettes seized by Irish Revenue officials. Danish police arrest seven in raid on smuggling network. UK fake cigarettes: how to tell what’s real.

Malaysia is world’s largest consumer of illegal cigarettes. Malaysian man jailed for trying to smuggle millions of cigarettes into Australia. Australian authorities stub out illegal cigarette market. Policing the illicit trade of tobacco in Australia. Super big data and multi-stage information spatial system estimates of coastal tobacco smuggling in Taiwan. Philippines government cracks down on cigarette smuggling, counterfeiting.

The Western Balkan region is notorious for tobacco smuggling. Time to Quit: Tobacco tax increase and household welfare in Bosnia and Herzegovina.

South African Revenue Service seeks to track illegal cigarettes to their source. Tackling South Africa illegal tobacco trade could bring in 55% of recent tax shortfall.

A decade of cigarette taxation in Bangladesh: Lessons learnt for tobacco control. The myth of Pakistan‘s illicit cigarette trade. Philip Morris Pakistan closes factory due to rising illicit trade.

Menthol cigarette smokers react to Ontario‘s menthol cigarette ban. Ontario is finally ready to bust contraband tobacco. Here’s how Quebec did it. Japan Tobacco wins court protection in Canada over $1.32 billion smoking suit.

Economic determinants of smoking prevalence and regulation in high- to low-income countries: is corporate power the smoking gun?

Hong Kong Customs haul of illicit electronic smoking devices jumps 32% after announcement of ban.

Jordan charges 29 in fake smokes scandal.

Decision Overturning Ohio’s Political Gerrymandering

I have uploaded the decision of a three-judge district court overturning the political gerrymandering of Congressional districts in Ohio engineered by Republican legislators.

The opinion is 301 pages and, no, I have not read it from beginning to end. However, due to the length of this opinion, the Court provided the reader with a more concise summary which states, in part:

“Partisan gerrymandering” occurs when the dominant party in government draws district lines to entrench itself in power and to disadvantage the disfavored party’s voters. Plaintiffs in this action are individual Democratic voters from each of Ohio’s sixteen congressional districts, two non-partisan pro-democracy organizations, and three Democratic-aligned organizations. They challenge the constitutionality of Ohio’s 2012 redistricting map. Defendants are Ohio officials, and Intervenors are Ohio Republican Congressmen; Defendants and Intervenors both argue that the Plaintiffs’ claims are not properly before this Court and defend the map’s constitutionality on the merits.

* * * * *

We join the other federal courts that have held partisan gerrymandering unconstitutional and developed substantially similar standards for adjudicating such claims. We are convinced by the evidence that this partisan gerrymander was intentional and effective and that no legitimate justification accounts for its extremity. Performing our analysis district by district, we conclude that the 2012 map dilutes the votes of Democratic voters by packing and cracking them into districts that are so skewed toward one party that the electoral outcome is predetermined. We conclude that the map unconstitutionally burdens associational rights by making it more difficult for voters and certain organizations to advance their aims, be they pro-Democratic or pro-democracy. We conclude that by creating such a map, the State exceeded its powers under Article I of the Constitution. Accordingly, we declare Ohio’s 2012 map an unconstitutional partisan gerrymander, enjoin its use in the 2020 election, and order the enactment of a constitutionally viable replacement.

This raises a significant question. For me, this might even be characterized as an existential question. I went to law school. I then went to graduate law school. I’ve always believed that there are, roughly speaking, neutral principles of law that I can master. While there are close cases, at some point, one can discern an authoritative answer to legal questions.

There are currently pending two political gerrymandering cases before the Supreme Court: Rucho v. Common Cause, from North Carolina, and Lamone v. Benisek, from Maryland. Assume that the Court holds that courts cannot address claims that political gerrymandering violates the Constitution. That would mean that the various judges in the numerous cases that have all held to contrary have misinterpreted the law. And, of course, their actions were not off-the-cuff. Every case was well-briefed both by the litigants and by numerous amici curiae. The opinions were detailed and scholarly.

At some level, if so many judges with such a mammoth amount of legal resources at their fingertips cannot reach a “correct” conclusion, the concept of law based upon principles comes into question. In other words, I have simply been fooling myself for the last 45 years?

Medical Journal: 8/9/18

Mostly good news.

Dr. Sanfilippo, the radiation oncologist, looked at my radiation history. I had a cumulative dose of only 25 gray of radiation (that’s 2500 rads, if you’re old-fashioned), which he considered modest. No need to spread out the treatment series to reduce side-effects. Yesterday they made the mask I’ll be wearing for the treatments; it looks like a cross between a fencing mask and a death-mask from a medieval tomb sculpture. Also got a tiny tattoo mark so they can aim the beam; remind me never to get an actual tattoo.

Treatments start a week from Monday and run five days a week for a total of 28 sessions, so into late September. Met with the nutritionist who works with the radiation folks; she wanted to make sure I got lots of different nutrients and at least 80gm./day of protein. She had a different theory than Dr. Bomback, the nephrologist; she thinks that to the kidneys all proteins are equally burdensome, while he specified red meat, shellfish, and poutry as much more work for the kidneys than other protein sources. (The fact that different medical experts, especially in different fields, can’t agree on reasonably basic questions, and that there’s no strong drive to resolve those disagreements experimentally, is something I got used to the last time I went through this.) Also met with a skin-care nurse who told me all the things I needed to do and not do to prevent skin problems at the radiation site. Not too burdensome.

This morning I saw Dr. Sulica, the ENT surgeon. Given that there was some risk that the tumor couldn’t be excised surgically because of its positioning, he agreed with the view I had already formed that, even without the heart issue, it looked like a better bet overall. He’s not entirely confident that killing the tumor will cure the cough, but that’s an inconvenience rather than a real problem. He scoped the throat again and reports that the tumor still looks well-contained “not at all likely to be a bad actor.” Perhaps unsurprisingly, Dr. Sulica is somewhat less sanguine about radiation side-effects than the radiation oncologists are; he thinks there is some risk of damage to the voice. He pointed out that most of the bad stuff happens months or years after the radiation treatment, so the radiation folks never see the damage and continue to think they aren’t doing any. For example –and this was complete news to me –he thinks it very likely that the heart problem is a side-effect of the previous set of radiation treatments; apparently that’s now a known risk, though it may not have been in 2000. On the other hand, interventional radiology has gotten more precise, he said, “less like a sledge-hammer.” On the other hand, all of the risks are fairly low probability, and most of them arrive only with some delay. So, all things considered, radiation seems like the better course.

Dr. Sulica agreed with my observation that it’s strange that that expensive piece of radiation equipment works the day shift weekdays only. It would be much less disruptive to my life if I could get some of my treatment evenings and weekends. He pointed out something I hadn’t considered, which is that in addition to the economic question there’s a clinical question. “Tumor biology must be highly unusual if it respects not only weekends but holidays.” I’d assumed the idea was to spread out the dose to minimize side-effects, but apparently there isn’t any actual science supporting the idea of five-day-a-week treatment as opposed to seven days. The first time I heard the phrase “evidence-base medicine” I wondered what other sort of medicine there might be; now I understand that many of the healing rituals of our tribe are based on folk-wisdom rather than anything resembling science.

One advantage of radiation over surgery is that I don’t have to hurry about getting the cardiac issue diagnosed and treated, because I don’t need to be cleared for anaesthesia in the short run. Of course it has to be dealt with eventually, if only because I’ll need a strong enough heart to handle a general anaesthetic for the kidney transplant. A nephrologist friend I talked to suggested a couple of options for doing cardiac catheterization with little or no contrast, which in the best case would mean no additional kidney damage at all, and wouldn’t involve starting on dialysis before the catheterization (and then being committed to dialysis from then on). I’m going to ask Dr. Weiss, the internist, to find a cardiologist willing to take that approach. Still cheerful and –to all appearances –healthy.It’s terminally weird to be dealing with all this heavy-duty medical stuff without actually feeling sick, but for now I’d rather have the weirdness than the symptoms.

Cannabis News Round-Up 5/3/19

Helping banks play SAFE while serving the cannabis industry. Congress can open banks to legal cannabis industry with SAFE Act. D.C. mayor Muriel Bowser unveils bill to legalize recreational marijuana sales.

Jackson County, Oregon black market bust: $15M in pot & stockpile of firearms. Seattle mayor Jenny Durkan calls for nationwide evaluation on marijuana legalization.

Connecticut pot tax clears committee, setting the stage for final legalization bill. Pot tax proposal in Connecticut similar to Massachusetts model. Contentious hearing in Hartford on Connecticut marijuana legalization. Connecticut Republican lawmakers to discuss implications of legal recreational marijuana. With time running short, Vermont House struggles with full legalization. Vermont governor Phil Scott‘s three wishes. Recreational marijuana delivery could soon become the norm in Massachusetts.

No one’s in a hurry to legalize recreational marijuana in New York. New York marijuana: What to know about minority ownership, social equity and pot arrests. Advocates oversell how New York legal weed will eliminate the black market. Will New Jersey legalize marijuana in May? Top Democrat says it’s fifty-fifty. New Jersey medical marijuana could move on without recreational legal weed, expungement plan.

Illinois is prioritizing legalization. Full, 300-page pot legalization bill could be introduced in Illinois within days. Legalizing marijuana in Illinois: A good or bad idea? Small Illinois towns hope legalized marijuana bring more jobs.

Twin Cities business leaders to discuss potential impact of recreational marijuana legalization in Minnesota. Las Vegas ordinance on weed lounges could overstep authority.

A marijuana brand with loads of street cred. Winners and losers of American pot stocks so far this year. A small marijuana company wants to sell spliffs. It won’t be easy. Scalia Law Schools symposium on the law & economics of legalization. How living near a marijuana dispensary affects your home’s price.

Taiwan resists as activists launch campaign to legalize marijuana. Canada pot exchange gets some competition.

We’re All Human

In early April of this year, a class action complaint captioned Richard Cole v United Health Insurance Company was filed in the United States District Court for the Southern District of Florida. The complaint alleges that:

Instead of acting solely in the interests of the participants and beneficiaries of its health insurance plans, upon information and belief, UHC denied coverage for [Proton Beam Radiation Therapy (“PBRT”)] to treat prostate cancer because, on average, PBRT is significantly more expensive than traditional Intensity Modulated Radiotherapy (“IMRT”) or other treatments.

The case was assigned to Judge Robert N. Scola, Jr. Earlier this week, Judge Scola recused himself. The substance of the recusal order should be read in full:

In early 2017, the Court was diagnosed with prostate cancer. In
determining the best course of treatment, the Court consulted with top medical experts throughout the country. All the experts opined that if I opted for radiation treatment, proton radiation was by far the wiser course of action. Although the Court opted for surgery, rather than radiation, those opinions still resonant.

Further, a very close friend of the Court was diagnosed with cancer in 2015. He opted to have proton radiation treatment at M.D. Anderson in Houston. His health care provider, United Healthcare, refused to pay for the treatment. Fortunately, he had the resources to pay $150,000 for the treatment and only upon threat of litigation did United Healthcare agree to reimburse him.

It is undisputed among legitimate medical experts that proton radiation therapy is not experimental and causes much less collateral damage than traditional radiation. To deny a patient this treatment, if it is available, is immoral and barbaric.

The Court’s opinions in this matter prevent it from deciding this case fairly and impartially.

Medical Journal: 8/6/18

All sorts of developments. Kidney function is heading south rapidly. Now down to about 14% of normal. Estimated to need either transplant or dialysis within a year, possibly sooner.

That now seems like the most likely explanation for my loss of appetite, which I’d thought was caused by whatever was causing my persistent cough. I’m down 25 pounds; could stand to lose another 20, but I’m told that’s not advisable right now. Hard to express how liberating it’s been to have what for normal people is a normal appetite. I thoroughly enjoy my food, but I don’t feel the need to eat very much of it. Set up for a transplant evaluation at NYU Langone with a top transplant team. Three (!) donors have already volunteered, which leaves me gratefully stunned. Prognosis favorable: >95% that the organ will still be working five years from now, with an expected useful life of about 20 years. (As the nephrologist put it, “The kidney is a good bet to outlast you.” First year will involve a lot of immunosuppressives; after then it will just be twice-a-day doses of two drugs, and some increased susceptibility to colds (which I almost never get). I’m also told I need to get all my immunizations up to date before I go on immunosuppressives.

I’ve had a severe and persistent cough for almost two years now; that finally got diagnosed last month. I was scheduled for surgery to excise a small (1 cm) and apparently localized squamous-cell carcinoma on the left vocal fold. (Unfortunately, that’s the one that still works; the other has been paralyzed since my bout of Hodgkins.) That prognosis, too, was favorable, and the procedure not too drastic. But I needed cardiac clearance before any anaesthesiologist would put me under. (Apparently quite deep under for this sort of surgery.) A left bundle-branch block (no, I don’t know what that means, either) prevents an EKG from being interpretable, so they tried a chemical stress test. That test was negative, but I reacted abnormally strongly to the chemical stressor. My internist wanted to do an angiogram just to confirm that the heart was OK and would handle the surgery, but the nephrologist said that with my current numbers an angiogram had about a 30% chance of putting me in frank kidney failure.

So the internist ordered a PET stress test (with a different chemical stressor) instead. That went very smoothly, with virtually no side effects. But the results were bad: something was seriously impeding blood flow in the heart when the veins were dilated. (Consistent with the reduced exercise tolerance I’d been attributing to the cancer.) So surgery isn’t an option without doing a cardiac catheterization first, which would require that I go on dialysis immediately (first hemodialysis, which is seriously disabling, then the less problematic peritoneal version you can do at home while you sleep). The ENT surgeon suggested that I check in with a radiation oncologist to see if the tumor could be handled that way, without using any sharp objects. Just saw him today, and the answer is “Yes.” He wants to see my previous radiation record, but even if I got a lot of it that just means he’d have to space out the dose. Base case is a painless fifteen-minute procedure five days a week for about five weeks, with no side effects at the beginning but likely hoarseness and some sore throat toward the end and in the following week. Unlike the surgical option, no risk of ongoing damage to the voice. I think if I’d known this up front, I would have chosen radiation over surgery; I thought there was significant cancer risk from radiation, but apparently not.

In the meantime, I got a call today from Columbia Presbyterian, telling me that I was scheduled to be admitted today to have a dialysis catheter put in tomorrow and a cardiac cath Wednesday. All of that was news to me; there seems to have been another breakdown in communication. Apparently HIPPA makes email unusable for medical stuff, and voicemail just isn’t an adequate substitute. Will still need a cardio workup in the fairly near future to figure out what that issue is; the PET results suggested to the internist that I’m at some significant near-term risk of a heart attack. (My father had a massive one at age 60, so this is dismaying but not entirely surprising.)

I remain hopeful and cheerful; for whatever reason, I don’t obsessively worry about medical stuff in the way I do about career stuff or politics. But we’re definitely in advance-directive, medical-power-of-attorney, do-you-have-your-will-in-order territory, and I’m doing some serious what-if planning to try to keep both the Marron Crime and Justice effort and BOTEC in operation even if I’m not.

The cost of the GND, or what’s the price of gopher wood?

“Make thee an ark of gopher wood”, Yahweh told Noah (Genesis 6:14). Gopher is just a transliteration of the otherwise unknown nonce word גפר . Nobody knows what this means; suggestions range from cypress to bulrushes. It isn’t even necessarily a kind of tree: could be “timber” or “any old wood”. The story claims that whatever he used, Noah got the job done. This makes the Ark a good analogy to the Green New Deal. Like the over-specified dimensions of the Ark, parts of the GND are specific, others studiously vague.

Probably not this sort of gopher

The GND in the United States (it’s not likely to work as a meme elsewhere) is a manifesto not a plan. Its promoters have not yet provided one; rational politics by AOC, as she wants to prod establishment Democrats on the committees into action, not engage in a suicidal death ride against them. The lack has created an inviting target for adversaries. However, the conservatives are missing the point about the GND by raising a scare about big numbers. The big numbers are a selling point. Think big! Go for it! Rosie the Riveter can do it! In this, AOC is authentically Rooseveltian.

A conservative think tank (American Action Forum, Holtz-Eakin et al) has charged in anyway and come up with a ridiculous “estimate” of the cost of the GND: $93 trillion. $36 trn of this is the “cost” of Medicare for All, conveniently forgetting the avoided health insurance. (The net cost if any depends on how much it is politically feasible to squeeze medical providers. Net zero cost is technically feasible, based on the universal experience of other OECD countries.) For the jobs guarantee, they put a useless range of “$6.8 trillion to $44.6 trillion”. The only function of this is to create the scary $93 trn total. I have nothing to offer on these areas. What I do know a little about is the energy side, where the GND is groundbreaking.

Continue reading “The cost of the GND, or what’s the price of gopher wood?”

Black De-Carceration

The imprisonment rate in the United States is down around 10% over the past decade, but this average trend hides a larger trend: African-American imprisonment is down substantially.

As Chuck Lane and I break it down in Washington Post, the African-American male rate is now at a 26.5 year low and the African-American female rate is now at a 30 year low. More details here.