Assessing Evidence in Public

Health
GCH 380
  In this class, you’ve learned some tools
to critique the strengths and weaknesses
of a single research study
 How do we go about weighing a body of
Questions research evidence?
 Do we have time to do this for everything
we care about in our lives?
 So then, how do we make decisions in these
instances?
  How many of you believe that smoking causes lung cancer?
 Cause vs. increases risk? What do we mean by causes?
Smoking and  Does something have to happen every time for it to have
Lung Cancer caused a specific time?
 Necessary and/or sufficient
  Strength
 Biological Gradient
 Consistency
 Specificity
Hill’s
Guidelines for  Temporality

Causation  Plausibility
 Coherence
 Experiment
 Analogy
  When looking through the following
slides, think about:
 When was there sufficient evidence that
Smoking & tobacco use caused cancer, and what actions
should have been taken at what point in
Lung Cancer time?
 Were we too slow to respond? Could we have
saved millions more lives? What lessons can we
bring to addressing other issues?
  1938: Smokers don’t
live as long as non-
smokers
 1939: Strong dose-
response association
between smoking &
lung cancer
Tobacco
  1950: 3 case-control studies
(retrospective)
 Levin: smoking & lung cancer
A turning point  Doll & Hill: heavy smokers 50x more
likely to get lung cancer
 Wynder & Graham: 95.5% lung
cancer patients were smokers
  1953: Wynder, painting tobacco on backs of mice
produced tumors
 1956: Doll & Hill: Cohort study providing evidence that
tobacco smoking increased risk of LC (among male
physicians)
 1956: Tobacco industry forms “scientific” committee to
Evidence of create controversy in research findings regarding adverse
Harm health effects
 Voluntary warning labels on cigarettes
 1964 US surgeon general:
 Cause of lung & laryngeal cancer in men
 Probable cause of lung cancer in women
 Most important cause of chronic bronchitis
 Habituating like marijuana (not addictive)
  1970: Start of nonsmokers’ right movement
 1970: cigarette ads banned from TV
 1983: Increase in Federal tax on cigarettes (8 cents)
 Surgeon General Everett Koop (1982-9)
 Released 8 reports on health consequences of
Actions Taken tobacco use
 1986: report on involuntary smoking
 1988: addiction: same way as heroine &
cocaine
 Smoking rates in the U.S. declined (38% to
27%)
  Hirayama 1990: Cohort study of Japanese
women
 Compared LC rates of (1) nonsmoking wives of
nonsmoking husbands (2) nonsmoking wives of
smoking husbands (3) women who smoke

Secondhand  Risk of LC about 2x as high in women who were

wives of smokers compared to non-smokers
Smoke  Both nonsmoking groups lower LC rates than
smoking women

 1992: US EPA report on respiratory health

effects of passive smoking: lung cancer and
other disorders
  US Tobacco Industry Sued by 46 States
 1998 a MSA was signed
 Required yearly payments by tobacco
companies to States (>$200 billion over first
25 years)
Master  Placed restrictions on the advertising and
Settlement marketing of tobacco products
Agreement  US tobacco companies ordered to publish their
internal documents produced for the case
 Physical repository in England until grant in
2002 made them available UCSF library
 Tobacco Institute was dissolved
  ”How tobacco smoke causes disease”
 Biological Harm
2010 Surgeon’s
 7,000 chemicals – 100’s of these are
General Report hazardous and 69 are known to cause
cancer
  There are no RCT’s … this would be unethical
 At what point was there sufficient evidence that
we should better begin regulating smoking (to
reduce harm)? What scientific evidence is
So… Does enough to warrant what types of actions?
smoking cause  Remember: All products/behaviors are different, and
lung cancer? have different levels of risk
 We want to get it right the first time – crafting
legislation is tricky
 This is all time sensitive!
  The moral limits of markets
 If we don’t decide as a society when to act and what
should be done, the free market will decide, and the
public health outcome isn’t good...

Lessons with  Industries should not be considered trusted

stakeholders in prevention of health issues
Tobacco  Is vaping bad for you? What lessons can we apply?
 Do we necessarily need RCTs?
 No. However, we need to be careful with
observational studies
  Think about other public health issues that we
are trying to reduce by building scientific
evidence and strong research skill sets
 Climate Change
 COVID-19 and vaccinations
Other public  Antibiotic resistance

health issues  Vaping

 It is important to remain pragmatically skeptical

of research findings
 However, be aware of logical fallacies and
propaganda used to undermine scientific findings
  Based on available evidence, it is not always easy to
know when to take action and what actions are
warranted
 Beyond knowing what is “good” and “bad” for us, we
need to know how to get people to act differently
 Behavior change not always motivated by knowledge
Considerations  In most cases: necessary but insufficient first step

 Single study should usually not inform decisions (need a

body of research evidence)
 Most research concludes that we need more research
 Associational studies may overreach by providing
suggestions for practice (need to weigh benefits and risks)
  A necessary (but often insufficient) first step may be
coming to consensus about what is healthy/safe
 We don’t always “know” “the truth”; we estimate it
 “All models are wrong; some are useful”
 Weighing the evidence in conflicting research (understanding
which models are more useful) may require advanced
understanding of research methods but is very important

Considerations  Political agendas may make this difficult

 Time wasted may often be lives lost
 Maintaining credibility is important, but can slow info

 Stronger scientific evidence is slow & expensive to obtain

 Time wasted may often be lives lost
 Can be unethical; what do we do when we lack this
evidence?
 Need to weigh all the benefits and risks of action
  There are ways to synthesize the findings of
numerous studies:
 Systematic reviews
 Meta-analyses
 This type of writing is very time consuming when
done well
Considerations  Ideally, as studies are published the important
literature building up to the study are synthesized to a
lesser degree (in the background/discussion sections)
 Practitioners’ guides/handbooks are available
 To help public health practitioners identify evidence-
based practices