Annually, the Shorenstein Center on Media, Politics and Public Policy awards the Goldsmith Prize for Investigative Reporting to a stellar investigative report that has had a direct impact on government, politics and policy at the national, state or local levels. Six reporting teams were chosen as finalists for the 2020 prize, which carries a $10,000 award for finalists and $25,000 for the winner. This year, as we did last year, Journalist’s Resource is publishing a series of interviews with the finalists, in the interest of giving a behind-the-scenes explanation of the process, tools, and legwork it takes to create an important piece of investigative journalism. Journalist’s Resource is a project of the Shorenstein Center, but was not involved in the judging process for the Goldsmith Prize finalists or winner.  “Copy, Paste, Legislate” — a collaboration among The Arizona Republic, USA TODAY and the Center for Public Integrity — was named the winner on March 23.

Despite multiple U.S. federal government agencies recommending that homes have functioning carbon monoxide detectors, a 2019  NBC News investigation found that federally funded housing was held to a lower standard.

Journalists Suzy Khimm and Laura Strickler analyzed thousands of pages of federal regulations to determine that carbon monoxide detectors were not required in any of the 4.6 million homes that receive federal rental subsidies from the Department of Housing and Urban Development.

They also compiled and verified a national tally of carbon monoxide deaths in HUD housing, using lease documents, Freedom of Information Act requests for police reports and federal housing contracts, searches in HUD property databases, and interviews with retired housing officials and family members of the deceased. They found that at least 13 residents of HUD housing have died from carbon monoxide poisoning since 2003; carbon monoxide poising poses a higher risk to HUD housing residents than the general population.

The count was the first of its kind. Carbon monoxide deaths in federally funded housing were not being tracked by federal agencies, local housing authorities, academics or public health researchers.

After the first part of the investigation was published on March 1, 2019, the U.S. Senate and House of Representatives took swift action in the following weeks, introducing bills to require carbon monoxide detectors in public housing. In April, HUD announced that it would draft a federal requirement for carbon monoxide detectors in public housing.

Khimm says she began the investigation on a tip from a source, who alerted her to two deaths from carbon monoxide poisoning that occurred in a South Carolina public housing complex.

“I’m based in DC, and I focus on investigating federal agencies and the impact that their policies have on ordinary people,” Khimm says. “The first question that occurred to me when I first heard about the carbon monoxide deaths in South Carolina: Was there an oversight failure that put these residents at risk? What are the federal protections? Are there any federal protections, surrounding carbon monoxide issues in federally assisted properties? What is the federal role in all this?

“A lot of people were asking questions, important questions, about the local oversight of the property for the local housing authority in South Carolina, their maintenance, their property management. But, at that point in time, no one was asking the questions about HUD, about the federal oversight of these properties. So that was really how this investigation got started.”

We asked Khimm over phone and email about how she and her reporting partner, Strickler, got the story. Khimm’s responses, which provide helpful suggestions and reporting tips for journalists, were edited for length and clarity.

Confirming the absence of something can be harder than confirming the presence of something.

“Sometimes in reporting, you’re not looking for the presence of something — you’re trying to confirm the absence of something. And sometimes that can be even more difficult, because we were basically trying to prove a negative; we were trying to prove that something doesn’t exist,” Khimm explains. “That really did take a lot of legwork. A lot of our prior knowledge, prior investigative reporting into housing inspection standards, really proved to be key in terms of learning how to decipher what HUD’s inspection regimen should have looked like with respect to carbon monoxide.

“The quality of a health and safety inspection begins with the underlying standards. What is really being measured? You have to examine the actual standards and protocol for conducting inspections. What about enforcement of those standards? If an inspector finds serious problems, what’s supposed to happen next — and what actually did happen next?

“The ownership, management and oversight of federally subsidized housing is really complex and opaque. Different types of properties are held to different federal health and safety standards depending on their financial structure and ownership — whether it’s traditional public housing or a privately owned property that accepts Section 8 vouchers, for instance. For each set of standards and inspection protocol, we homed in on the specific sections and subsection regarding air quality, regarding things like smoke detectors and the gas-fired appliances that can emit dangerous levels of carbon monoxide.

“… You do the initial reporting and deep dive into the research, then go back and confirm your findings with other documents and sources to understand what the health and safety standards are, how inspections actually work, and what inspectors are actually looking at. To help back up what we were finding, we looked at the actual inspection checklists and individual inspection reports, in order to examine the criteria that inspectors were actually using to gauge the health and safety of a federally subsidized home. And we talked to people actually doing this work in the field.”

When reporting on and evaluating government standards, compare them with other existing standards.

“In terms of thinking about standards, and how do you go about evaluating standards and especially standards for health and safety, whether or not they’re good enough or adequate — how do we answer that question?

“I think one way to go about doing that is to look at other examples.

“For example, there’s something called the International Fire Code, which a lot of not only countries, but individual states or municipalities, local governments, might use as a basis for their building codes.

“The International Fire Code requires carbon monoxide detectors for homes that have gas fired appliances, and there’s specific language that they use, specific things that they require. So that is one thing that that I looked at in terms of thinking about what could possibly be missing from federal regulations.

“The other thing that we found in our reporting was the fact that other government agencies, the major safety bodies of the U.S. government, the Consumer Product Safety Commission, and HUD’s own Department of Healthy Homes, both of those bodies recommend carbon monoxide detectors. So in other words, the U.S. government itself recommends that all residents, regardless of whether you live in federally subsidized housing or not, install corporate monoxide detectors in the home. Yet the standards that HUD uses for some of the most vulnerable and poorest families in the country do not include that standard.”

Make multiple requests through different sources for the same documents.

“Every time I file a federal FOIA request, I always think about other ways in which I could get the same documents from somewhere else, because more likely than not, I will be able to get a faster response if I go outside the federal government than going to the federal government.

“If you’re looking for HUD records, that could mean going to the person who owns that property, so that could be a local housing authority, it could be a private landlord. There could be various other folks who’ve seen that information, and try to go through them. That could be going through local or state governments, which also tend to be more responsive and quicker than the federal government or could just be a private individual, people that you just have to find some way to appeal to and to talk to them.”

When trying to find specific information, consider all the forms it might take. And create Google Alerts. 

“I create Google Alerts for every project that I’m working on and keep checking them for weeks, months or even years later, just in case something pops up. I had a Google Alert for ‘carbon monoxide’ that pulled up any kind of related news stories.

“The couple that had died in Michigan, the initial local news on that did not say anything about them living in a federal assisted property. There was no mention of HUD, there was no mention that they had received rental subsidies, there was nothing there. There was also no mention of whether there were carbon monoxide detectors or not in their home.

“So basically, it took my going through their family and their lawyer and then going through the piles of legal documents and other financial paperwork and other things that the couple had left behind after they had died to determine whether or not they had actually received rental subsidies and that their unit was specifically under HUD’s oversight.”

…

“A lot of times, there might have been initial reports that there was a carbon monoxide incident. [But] it might not have been verified, at the time, that that was actually the cause of death. So it entailed us going to the coroner’s office, asking for and trying to confirm the cause of death, going through the local housing authority, asking them about this death that had happened years and years ago, what the residents’ names were, and then getting the details from the specific properties where these deaths might have happened.

“In some cases, we had to appeal to individual family members to confirm that their relatives had in fact been living in federally subsidized housing at the time of their death; there are privately owned properties that are subject to federal oversight and safety inspections, but which are not immediately identifiable as ‘public housing.’ This could be very challenging as family members did not always want to relive the circumstances of their loved ones’ deaths; carbon monoxide poisoning typically happens very suddenly and without warning.

…

“It was a combination of shoe-leather reporting, digging through public records and looking through archives. Early on, we did an extensive Nexis search that provided clues to help guide our reporting into individual carbon monoxide incidents, but that was just the beginning of our process.

“I did a very broad canvas of folks in the advocacy world, in academia, at HUD, trying to see whether anyone was keeping track of these deaths. It turns out that they were not, but some of them did have some helpful leads into cases that they’d heard about in the past.”

Convey the potential impact of your reporting to reluctant sources, like family members of victims.

“I think it helps to be patient, to make an appeal without expecting an immediate response — telling folks, please take all the time you need to think about this, please discuss it with your family. Also, be willing to talk to them off the record or on background first, being open-ended about the form in which you are willing to talk to them.

…

“I do think it’s a mixture of just being respectful and tactful, but persistent, reaching out to folks, and also just being honest with them about why you’re doing this reporting, you know, why are you telling this story? What are the bigger questions you’re trying to answer? And why do they matter? And what are you hoping to get out of the story?”

Humanize a wonky story.

“When you’re reporting on something that involves a lot of bureaucracy, and confusing policy details and complex issues, I think that means that the storytelling piece is even more important.

…

“I think especially for these kinds of wonkier issues, I think it’s even more important to convey a sense of the community, the people being affected, a sense of the place and the human stakes. I think that was a really critical component for our story in terms of telling it in a compelling way that really explained the human impact of these federal policies.”

Realize the potential to nationalize a local story.

“One thing that has surprised me in terms of reporting on an agency like HUD and an issue like housing is how often social policies that affect some of the most vulnerable people in the country, and that have federal dollars and oversight attached to them, are treated as strictly local issues rather than national ones.

“If you can find the chain of accountability and follow that through as thoroughly as possible, that’s really important, whether you’re a local reporter or a national reporter.

“It’s another way of following the money — there are federal rules, regulations, and oversight that are often attached to federal funding. It’s really important and will make sure that everyone who is responsible for some degree of oversight is being actually held responsible.”

The post How they did it: Reporters investigate carbon monoxide deaths, regulations in HUD housing appeared first on The Journalist's Resource.

Annually, the Shorenstein Center on Media, Politics and Public Policy awards the Goldsmith Prize for Investigative Reporting to a stellar investigative report that has had a direct impact on government, politics and policy at the national, state or local levels. Six reporting teams were chosen as finalists for the 2020 prize, which carries a $10,000 award for finalists and $25,000 for the winner. This year, as we did last year, Journalist’s Resource is publishing a series of interviews with the finalists, in the interest of giving a behind-the-scenes explanation of the process, tools, and legwork it takes to create an important piece of investigative journalism. Journalist’s Resource is a project of the Shorenstein Center, but was not involved in the judging process for the Goldsmith Prize finalists or winner.  “Copy, Paste, Legislate” — a collaboration among The Arizona Republic, USA TODAY and the Center for Public Integrity — was named the winner on March 23.

Christina Jewett’s “Hidden Harm” series for Kaiser Health News revealed a hidden U.S. Food and Drug Administration database that concealed millions of medical device malfunction and injury reports from public view.

Malfunction and injury reports associated with medical devices are typically reported to the FDA and made public in a database known as MAUDE, short for Manufacturer and User Facility Device Experience.

But starting in 2000, medical device manufacturers began taking advantage of reporting exemptions, which were created to cut down on extraneous paperwork, Jewett reports. Companies with exemptions could batch hundreds of injury reports into a single “alternative summary” filed in an internal repository.

“Many reports were so similar that reviewing them individually was ‘mind-numbing,’” Jewett writes, quoting an FDA official. “The manufacturers would instead send the FDA a spreadsheet of injury or malfunctions each quarter, half-year or year.”

At first, in 2000, the list of exempted devices was public, though at an unspecified later date and for unknown reasons that subsequently changed.

Jewett’s reporting uncovered half a million reports of injuries or malfunctions tied to breast implants; some 66,000 surgical stapler malfunctions and more than 50,000 deadly incidents tied to an implantable heart defibrillator, which corrects abnormal heart rhythms.

Her big story was published in March, 2019. Two months later, the FDA announced it was ending the “alternative summary” program.

And it all started with one tip.

“I had it on my story list for months, maybe more than a year, to look into medical device oversight,” Jewett explains. “And so I called a woman who had previously worked at the FDA, and she’d been quoted in the media, various stories, and I just kind of was fishing — you know, what’s interesting, what’s going on, what’s going wrong, who’s doing what, trying to figure out where I could plant my shovel and find a good story.”

The source mentioned the existence of “alternative summary reports,” in which medical device manufacturers batched injury reports associated with a particular device into one report that was not made accessible to the public. Jewett found this interesting, knowing that the FDA plays a key role in compelling medical device manufacturers to publicly report injuries, deaths and malfunctions associated with their projects. “I realized that there was a pretty big blind spot in the data,” she said.

The story took about six months to report.

“It was a lot of just, working the fundamentals,” Jewett says. “Just kind of the basic things you do as an investigative journalist. And persistence, and also just narrowing the scope and being pretty laser-like about what do I need to get the story out there in a way that’s going to really have an impact?”

We asked Jewett – a reporting team of one – how she did it. Her responses, which provide great tips for journalists, were edited for length and clarity.

1. Get the minimum story.

In investigative journalism lingo, the so-called “minimum story” is basically the core story you can promise to deliver to your editor – even if some of the reporting fails to yield certain juicy details and other elements you’re seeking.

Initially, “I had no minimum story,” Jewett says. “I just knew it was happening. I didn’t know how much, I didn’t know to what degree and for which devices.

“So I went to the FDA really early and started asking questions. I would send a link [to an FDA document referencing an ‘alternate summary report’] and say, ‘Hey, it looks like the makers of this device have some kind of exemption to report. Can I get the records or get some kind of explanation of why they got an exemption and how many reports they filed that way? And the answer was always, ‘File a FOIA [a Freedom of Information Act request].’ And that was turning out to be kind of a dead end, because I did file FOIAs, and then I would seek to get expedited processing. They refused to grant me expedited processing. In one of the letters I got back, they said, ‘You’re here at the end of the regular line, you can expect your records in 22 months.’ To which I said, ‘Oh, boy, this is not good.’

“I did a lot of Googling, terms and quotes, and I found some PowerPoint presentation from some industry conference where an expert was presenting to device companies. A lot of people who are former device executives or FDA employees go into consulting, and I worked the daisy chain of consultants who knew about this, and I found the one who said, ‘Yeah, I don’t know how many [alternative summary reports] there are; I think I read about it a couple of years ago,’ and she noodled around and sent me the link [to an analysis in Medtech Insight] and I was like, “that’s significant.” That really kept me going because I’m starting to see the shape of a minimum story. I’m like, okay, this is a thing, and here’s how much this happens.

“And so I sent a link to the FDA press office and said, ‘Hey, this [story] shows the number of these reports… do you mind just updating these numbers for me?’ And so that was kind of an easy ask, the kind of thing this press office probably handles all the time. And that got me an early break in terms of figuring out there were more than a million of these reports, and just a couple years show that.”

2. Focus on humanizing the story.

“The next step was, what device am I going to focus on to really turn the story from an abstract data story to a more human story? I was starting to look up litigation related to some of the devices I was finding, to see the types of things that can go wrong when there are malfunctions or injuries. And I ran across the surgical stapler.

“I’d never even heard of it, never thought about, I’d never even had any idea what it was. But after reading some of the lawsuits, I realized that when they malfunction, it can be devastating, even deadly for patients. And so, I started digging into those cases where the stapler would sever a vessel, but then failed to actually fire and close it, and people were just bleeding out. They’re horrible, upsetting cases to read. I found a case in Toledo where the attorney gave me access to the family, and flew out there and spent some time with the family of Mark Lovering. He had a liver surgery and had such a massive bleed that he had extensive brain damage, and could no longer walk, came out of the coma just barely able to function at all.”

3. Persistence pays.

“In 2016, publicly, I think there were 84 stapler injuries reported, whereas in the alternative summary data that year, there were nearly 10,000. That’s a powerful enough stat. But that came after asking [the FDA] for all the data for 20 years, and the justification for the exemption. ‘No, go away.’ Asking for three years [of data]. ‘No, sorry, go away.’ And then finally saying, ‘Please just give me one year, one year.’ And then I got one year. So, it was kind of enough that it gives you a sense that there’s something up there.

“This story kind of runs counter to my typical advice, which is to sometimes try digging into several different stories and then just go down the path where the doors are starting to open. I mean, this one, the doors were not opening but I still continued down the path. Just because I felt like it was such an interesting, important topic.”

4. Review past notes as the story develops.

“I talked to a lot of experts in the field. And I was really frustrated that I was just getting so many people saying, ‘I’ve never heard of that. I don’t know what that is, I have no idea.’ I reflexively take notes, and it felt like just like throwaway material, useless, but then when I did find out it was a thing, really a big, big thing, suddenly that material seems relevant, like, this could actually be something I use in the story to show that the people who dedicate their career to studying medical device malfunctions don’t even know this exists.”

5. Industry consultants can be valuable sources, actually.

“An investigative reporter might see a consultant for industry who’s always been part of that corporate club as kind of a boogeyman, but I approached the consultants for the medical device companies as humans. The ones I talked to, I asked all of them, put on your hat as a mother or a sister or a father or an uncle. And, when you’re approaching the medical system and trying to find out about a device, just the fact that so many of these reports are somewhere else, does that bother you? That really brought down some walls where they were like, ‘Yeah, I mean, you can’t trust this data.’”

6. Think about how framing a question to sources can compel answers.

“Medtronic, which owns Covidien [a surgical stapler manufacturer], I’m sure didn’t want to talk to me. But I framed my question in a way that would to compel them to answer.

“Their exemption ended in 2017. And so in 2018, it looked like there was this huge spike in surgical staple injuries. So I just asked them, I already knew the answer, but I just put it to them in a way that would compel them to answer, which is basically, ‘Did your surgical staplers suddenly become incredibly dangerous in 2018? Is this a public health concern?’

“It put them in a position to say, ‘No, our reporting exemption ended,’ when their first instinct would be to just blow me off or not really answer directly.”

7. You don’t always have to hold your cards close.

“There’s always a debate over, when do you go to the ‘target,’ you know, like the government agency that’s the architect of something you’re investigating. And there’s often an impulse to hide what you’re doing until the very end, and then you have this list of 15 penetrating questions and you give them one week to answer and then your investigation comes out. That’s just not always the right approach.

“With this story, I didn’t know [at first] if I had a minimum story, if I should just move on to something else. There was almost no choice. They knew everything about this, and I knew nothing about this. I really had to go early and just start asking questions about what these exemptions were.

“This was a really good case study for when it’s helpful to go to the agency early to just help them unpack: What is this? And those are often the kinds of questions that press offices are good at answering. What’s this program? How does it work?

“Sometimes it’s helpful to forward a message from a government agency to a doctor, or a lawyer or someone to you want to talk to about this, when no one’s heard of it.

“The impulse is to be really protective of that kind of material, but when you’re doing a story where nobody knows what you’re talking about, at some point, you have to cut some things loose and say, ‘This is what I’m talking about.’ It’s kind of counterintuitive and hard to do. But when you really need to get people to comment on something they’ve never heard of, it can be helpful.”

The post How she did it: Reporter finds millions of hidden reports of medical device injuries appeared first on The Journalist's Resource.

On April 30, 2018 the U.S. Environmental Protection Agency came out with a proposed rule titled “Strengthening Transparency in Regulatory Science.”

The new rule would limit the kinds of scientific studies the agency could use in support of future regulations. In short, in order for EPA to take a study’s finding into account when developing a regulation, the researchers would need to have made all the data in that study available to the public.

“The proposed regulation provides that when EPA develops regulations, including regulations for which the public is likely to bear the cost of compliance, with regard to those scientific studies that are pivotal to the action being taken, EPA should ensure that the data underlying those are publicly available in a manner sufficient for independent validation,” the summary of the proposed rule states. “This proposed rule is designed to increase transparency in the preparation, identification, and use of science in policymaking.”

While gaining access to data may sound appealing — especially to journalists — the policy could end up discounting many high-quality studies from EPA rulemaking.

Veena Singla, associate director of science and policy at the University of California, San Francisco’s Program on Reproductive Health and the Environment, explains that many studies rely on confidential data — for example, health studies involving human subjects.

Generally, institutional review boards — independent ethics committees housed at research institutions — mandate that data collected from human subjects remain confidential.

The proposed rule has faced strong opposition from scientists.

It’s one thing to make a study available to the public, but quite another to make all the related data publicly available, Singla says.

“What this rule is going after is actual, individual measurements,” Singla explains. “So, for example, a study might publish the results of average blood lead levels of this population of children that we looked at. The study will publish the number of children in the study, all kinds of information about the data in aggregate. And what the EPA will want is an individual child measurement, along with all the information about that individual child that the researchers used to calculate anything in their study. That’s pretty different … having all of that individual-level data publicly available is very different than having the study and its results publicly available.”

Journalist’s Resource interviewed Singla about a recent panel discussion she participated in during the American Public Health Association’s annual meeting in Philadelphia.

For additional insights, we also spoke with Joseph Goffman, a former EPA administrator who is now the executive director of Harvard Law School’s Environmental & Energy Law Program. During his tenure at EPA, Goffman was a chief architect of the Clean Power Plan of 2015. He helped craft many other rules, including the Mercury and Air Toxics Standards and the Cross State Air Pollution Rule, both established in 2011.

Singla and Goffman offered expert tips for understanding and reporting on the proposed rule along with other key changes occurring at EPA. Both consider “Strengthening Transparency in Regulatory Science” a misleading title.

1: Note the difference between making a study available to the public and making all the data publicly available.

Academic debates over open access scholarship are not the issue here, Singla notes.  “It’s about the underlying individual data points that went into the study,” she says.

2: Explain to audiences how the title of a proposed rule might mislead.

“The conundrum that reporters have is that the agency gets to choose its own titles,” Goffman says. “And up until this point, it’s been a universally observed convention that everybody who talks about a particular rule or proposal goes with the caption or title that the agency chose. A more accurate title would be, this is a ‘Narrowing Rule.’ Instead of a transparency-in-science rule, this is a narrowing science rule.”

Adds Singla: “It’s very contradictory because ‘transparency’ sounds like a good thing. The evidence and facts show that more transparency is not going to be the outcome of this policy approach. This is not going to be effective at increasing transparency. The end result is going to be, actually, limiting science. I think that’s the crux of it is [journalists] being able to explain why and how this rule is not going to achieve that result.”

For example, in an editorial published in PLoS Medicine, John P.A. Ioannidis, a professor and co-director of the Meta-Research Innovation Center at Stanford University, highlights potential effects of the rule. “In a random sample of the biomedical literature (2000–2014), none of 268 papers shared all of their raw data,” he writes. “Only one shared a full research protocol. If the proposed rule is approved, science will be practically eliminated from all decision-making processes. Regulation would then depend uniquely on opinion and whim.”

3: Find out how far along the rule is in the administrative rulemaking process.

EPA accepted public comments on the proposed rule between April 30, 2018 and Aug. 16, 2018. The agency received over 590,000 comments and is reviewing them. The next step in the rulemaking process is to issue a supplemental proposal to the rule. A supplemental proposal is essentially a revised draft of a rule. EPA had indicated the supplemental proposal would be issued in January 2020; however, to date, the draft is still in process.

“The agency rulemaking process goes through many, many steps,” Goffman explains. “And the steps often take the form of drafts or a succession of discrete, revised drafts of preambles and regulatory text. And that goes on. You know, usually those texts fall under the pen — either the drafting or editorial pen — of maybe two dozen people in the agency, located in different offices, including, but not limited to, the General Counsel’s Office. And so at any one time, any one document may or may not be representative of the document that ultimately goes out of the agency, formally, to the Office of Management and Budget for review.”

On Nov. 11, 2019, The New York Times published a leaked version of the supplemental proposal. The following day, the EPA’s press office issued a statement saying the accompanying article “is based on leaked preliminary, draft documents that are not accurate and do not include the final text submitted to the Office of Management and Budget (OMB) for interagency review.”

“This was a necessarily incomplete document in the way that a snapshot of a moving object is incomplete,” Goffman says. “But it doesn’t mean that the snapshot was inaccurate. In its typical, disingenuous fashion, the agency misused the term, [saying] that the Times’ reporting was inaccurate because the Times said, “Here’s what the document we got looks like.”’

In its statement, the EPA says the agency intends to issue a final rule in 2020. What that means, procedurally, is that after the supplemental proposal is released, there will be a public comment period, and then the EPA will review and respond to substantive comments before finalizing the rule.

“If they do indeed finalize the rule in 2020, they would have needed to respond to all of those substantive public comments in an adequate way,” Singla says. “And if they don’t, that can be the basis for legal challenges. In terms of the process, those next steps are important for journalists to understand.”

While the supplemental proposal hasn’t been released, Singla says witness testimony from Dr. Jennifer Orme-Zavaleta, principal deputy assistant administrator for science in the EPA’s Office of Research and Development (ORD), offers hints of what the supplemental proposal might entail. Orme-Zavaleta answered questions during the House Committee on Science, Space and Technology’s hearing on the rule on Nov. 13.

A key question, and an issue raised by The New York Times’ reporting, was whether the rule will apply retroactively.

“Her answer to that was ‘no’ and ‘yes,’ in a way,” Singla explains.

Orme-Zavaleta indicated that the policy will not apply to existing rules and regulations, only prospective, or new, regulation. However, when past rules and regulations come under review, all science involved will be subject to the “transparency” rule.

Singla continues, “Past science would be subject to the transparency rule as it comes up during any new rulemaking, and any review of existing standards or rules. So, like I said, it’s a no and a yes, and the yes portion of it is concerning because there are ongoing reviews mandated under many laws, and that would open up any of those past decisions and the past science to the rule.”

4: When deciding whether to report on leaked documents, consider why they were leaked.

“In seven years-plus that I worked at the agency, the many, many rules and comparable documents that I worked on, I don’t remember a non-final version draft leaking,” Goffman says. “I believe that the agency was managed by the politicals such that there was a kind of unquestioned mutual trust between the experts and the political managers. When I see a document like this leaking, the first thing I hypothesize is that there was not only a substantive disagreement between the political leadership and the expert staff, but that whoever leaked it must have had a reason not to trust that the subsequent process would be an honest one.”

Other EPA issues to watch for:

While the proposed “transparency” rule is getting a lot of media attention, there are many EPA issues getting less attention that are worth keeping an eye on.

“There’s a broader point. I think the political leadership, and the coalition they represent, have a good understanding of their own project, in the sense that they don’t just want to roll back a series of individual rules. They really want to decommission important components of the regulatory apparatus itself,” Goffman says. “And so it’s well advised for journalists, and other interested parties, to be attentive to parallels and patterns in these different enterprises.”

Singla offers an example: the EPA’s Toxic Substances Control Act (TSCA) systematic review method.

“The US Environmental Protection Agency (EPA) is responsible for making evidence-based policies to limit exposure to dangerous chemicals,” Singla writes in a commentary published in the American Journal of Public Health. “To inform potential chemical regulations, a core component of the EPA’s duty is to evaluate data on the hazards and risks of industrial chemicals under the 1976 Toxic Substances Control Act. Congress reformed the TSCA after widespread recognition of fatal flaws in the 1976 law. Under it, the EPA could not even restrict asbestos, a known human carcinogen. In 2016, President Barack Obama signed the Frank R. Lautenberg Chemical Safety for the 21st Century Act (Pub L No. 114-182), overhauling TSCA after 40 years.”

The overhaul includes a new methodology for collecting, evaluating and interpreting scientific evidence about chemicals.

“The EPA officially calls the method a ‘systematic review’ framework for TSCA, but it is systematic in name only, as it falls far short of best practices for systematic reviews,” Singla writes. “Application of the TSCA method will exclude relevant research from chemical assessments, leading to underestimation of health risks and resulting in inadequate policies that allow unsafe chemical exposures, thus harming public health.”

A main concern is that it lacks key elements of a systematic review such as a pre-established protocol for the review prior to conducting it. Having a pre-established protocol would “minimize bias and ensure transparency in decision making,” Singla writes. Another concern is that the EPA uses a flawed approach to evaluate study quality.

“The TSCA systematic review method is a lot more arcane, in the weeds,” Singla says. “It hasn’t gotten that much attention, but it has the potential to do the same thing as this ‘transparency’ rule, which is ultimately to limit the science and information that the agency is relying on.”

In addition to TSCA, Singla suggests journalists keep an eye on the EPA’s efforts to revise its guidelines for cost-benefit analysis and risk assessment.

“What Administrator [Andrew R.] Wheeler has said is that they’re going to go back, statute by statute, starting with the Clean Air Act, to revise the way that EPA looks at benefits and costs,” Sigla says.  “So again, this is one step back from particular rules and regulations, trying to change the fundamental way that the agency conducts its evaluations and analyses, to really bias them or stack them in a certain way, such as by limiting the kinds of evidence that’s used or changing the way that the agency considers the benefits of reducing pollutants.”

Goffman agrees: “What they started to try to do with their cost-benefit analysis represents a similar project, of weakening the impetus to regulate, or weakening the development of analysis that then triggers a statutory obligation to do additional regulation.”

Another issue to watch: Potential changes to the EPA’s cancer risk assessment guidelines.

“There’s also an effort underway for EPA to revise some of its risk assessment guidelines,” Singla says. “That’s looking at the risk of a chemical or pollutant — what are the health effects — and looking at the amount of the pollutant in the environment, or the amount that people eat, breathe or take in, [and] what are the health risks to people. That’s all done through EPA’s risk assessment process, and the agency has very clear guidelines on how chemical health effects are considered within that evaluation of risk, for cancer-causing chemicals and pollutants specifically. And there is an effort underway to revise those risk assessment guidelines and change the way that the agency is considering cancer-causing agents.”

She continues, “That’s something for journalists to watch, because it will change, across the board, the way that the agency looks at cancer-causing substances. It’s not related to any one specific chemical or substance, at this time. But it’s the underlying way the agency would look at the science, evaluate it and then come up with the risk. And the kinds of revisions they want to do would end up resulting in saying something’s less risky.”

Also from the APHA annual meeting: Research-based tips for reporting on science research. Also on Trump’s EPA: Formaldehyde and leukemia: What research reveals about the risks.

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Randomized, controlled clinical trials are studies in which a new intervention, such as a medical device, is randomly assigned to some participants and tested against a control group, which receives a standard treatment or a placebo to determine its effects. They often are considered the gold standard of medical studies because they can provide evidence of causation.

Even so, these trials can be designed such that the deck is stacked in favor of the new treatment, so journalists can’t assume a study is reliable just because it’s randomized, according to Dr. Joanna Chikwe, professor and chair of cardiac surgery at the Smidt Heart Institute at Cedars-Sinai Medical Center in Los Angeles.

There’s a financial incentive for health care industry players to bring their expensive-to-create-and-test devices to market, Chikwe told journalists gathered recently for a fellowship on cardiovascular health, “Covering the Heart Beat,” organized by the National Press Foundation.

The cost of hospital cardiac care has jumped from $200 billion in 2015 to around $250 billion today, and is projected to increase to $400 billion by 2035, Chikwe said, citing a March 2019 paper in Circulation.

“Innovation is one of the biggest cost drivers,” she said. “It will take you, on average, between $7 [million] and $19 million just to go from concept to [a medical device] that’s ready to put into a person. And that’s the cheap bit … one randomized trial is required for FDA [U.S. Food & Drug Administration] approval, and that will cost you somewhere between $31 [million] and $95 million.”

During her talk, which focused on medical device development, Chikwe explained how the cost of industry innovation can influence the results of clinical trials. Chikwe also highlighted a few strategies that trials might employ in hopes of securing favorable results — and questions journalists can ask to help them detect when these strategies are being used.

Tips for detecting bias

In the pre-study phase, trials can build in bias toward one treatment through its design. With that in mind, journalists might want to ask questions about which endpoints, or outcomes, the researchers have chosen to study.

Chikwe noted that a study can be designed to deliberately avoid endpoints that indicate a new device is inferior. For example, let’s say a manufacturer has created a new device that’s inserted through a minimally invasive procedure. Compare this with an invasive surgical treatment that’s the current standard. If the endpoints the researchers select are hospitalization after treatment or blood transfusions, it will be difficult to truly gauge effectiveness, especially considering both hospitalizations and blood transfusions are more likely to occur after surgery. What the researchers should test is whether the new device prolongs a patient’s life or improves their condition.

Another way to bias the results of a study is to choose a “non-inferiority” design. In a non-inferiority study, as long as outcomes associated with the new intervention aren’t inferior to the comparison treatment, the results can be seen as favorable for the new treatment. If there’s a wide margin for determining whether or not a treatment is inferior, the new intervention could actually have worse results but still be technically considered “non-inferior.”

For some studies, the bias might be in the pool of patients selected, Chikwe said. For example, does the study test an intervention using relatively healthy patients, compared with patients who have a much more severe disease?

Studies might be designed with a short follow-up period, Chikwe said. That way, researchers can get their results out sooner, and the results might be biased in the short-term in favor of the new treatment. For example, Chikwe said that early results almost never favor heart surgery over a non-surgical intervention, because heart surgery tends to offer survival benefits only in the longer term.

In the execution and analysis phase of a study, a number of factors can bias results:

• Physicians might break the randomization of the study, Chikwe said. A patient might be randomly assigned to receive the new treatment, but physicians sometimes deem a new treatment too risky or otherwise unsuitable for a particular patient. In that case, the results are based on an “as-treated analysis;” they allow researchers to compare how the patients fared as they were treated, but not necessarily as they were supposed to be treated had treatments been randomly assigned. As-treated analyses can be used to seek FDA approval for new medical treatments.
• Researchers might change the study design while it is underway — perhaps because preliminary results are unfavorable, or because of feasibility concerns.
• In the analysis phase, individuals running a study might analyze only a subset of the recorded outcomes to demonstrate a benefit or avoid showing harms.

After the study is completed, Chikwe said, there are yet more opportunities for bias to creep in:

• When readying a study for publication, authors may choose to report some outcomes but not others.
• They could underreport negative results, or spin neutral or negative results favorably.
• Chikwe suggested that conflicts of interest at high-impact medical journals might lead them to publish methodologically flawed trials. A 2010 study of conflicts of interest at medical journals found that pharmaceutical companies’ purchase of reprints accounts for a large share of journal revenue. If the companies’ trials aren’t published in medical journals, they might have less reason to purchase reprints, which would hurt journal revenue, Chikwe said.

What’s a journalist to make of all this — especially one who doesn’t have the time or knowledge to spot all the pitfalls of a study? Chikwe’s main tip is to enlist the opinion of a third-party expert in clinical trials or study design to evaluate claims made in favor of a new medical device.

“I spend a huge amount of time thinking about this kind of research and reading it,” she said. “And I can read a paper and pick up maybe a third of the issues with it, because some of them are so subtle, but so important. You really need to work with somebody whose whole interest is that … Have a relationship with somebody who is a trialist, somebody who’s got genuine interest in and knowledge of methodology.”

While you’re here, check out our tip sheet that dispels five widespread myths about women’s heart health and our summary of new research on the cardiovascular risks of marijuana use.

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In January, Journalist’s Resource attended a four-day fellowship on cardiovascular health, “Covering the Heart Beat,” organized by the National Press Foundation. Researchers, physicians and journalists gathered with the goal of improving news coverage of cardiovascular health.

At the training, Dr. Noel Bairey Merz and Dr. Martha Gulati delivered presentations on women’s heart health. Bairey Merz is director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai Medical Center in Los Angeles, and chairs the National Institutes of Health-sponsored Women’s Ischemic Syndrome Evaluation (WISE) initiative, a project aimed at better understanding heart disease in women. Gulati is chief of cardiology at the University of Arizona College of Medicine-Phoenix and co-author of the book Saving Women’s Hearts.

They broke down oft-repeated myths about cardiovascular disease in women and shared the facts of the matter. This tip sheet summarizes a few of their key points.

Myth: Cardiovascular disease is a man’s disease.

Reality: Women and men have similar rates of cardiovascular disease.

Nearly half of all women in the U.S. — 60 million — have cardiovascular disease, which includes coronary heart disease, heart failure, stroke and hypertension, according to the most recent statistics from the American Heart Association. A similar number of men — 61.5 million — have cardiovascular disease. For comparison, about 3.5 million U.S. women have breast cancer.

Myth: Women don’t die from cardiovascular disease nearly as often as men do.

Reality: Cardiovascular disease is the leading cause of death for both sexes. In 2017, 418,655 women and 440,460 men died of cardiovascular disease.

Myth: Heart disease looks the same in men and women.

Reality: Bairey Merz said research has found that heart disease in women often looks different, quite literally, than it does in men. For example, plaque on the walls of women’s arteries looks different from the plaque on men’s. It also affects their arteries differently.

Diagnosing a heart attack in women requires more sensitive blood testing, Bairey Merz added, because their hearts are generally smaller and release smaller amounts of troponin, a protein the body releases when the heart muscle has been damaged.

These differences might explain why heart disease in women isn’t always diagnosed and treated promptly. But researchers haven’t always considered men and women separately enough, Bairey Merz said.

She described a consequential 1991 letter to the editor in the New England Journal of Medicine written by Dr. Bernadine Healy, then director of the National Institutes of Health. “Yentl, the 19th-century heroine of Isaac Bashevis Singer’s short story, had to disguise herself as a man to attend school and study the Talmud. Being ‘just like a man’ has historically been a price women have had to pay for equality. Being different from men has meant being second-class and less than equal for most of recorded time and throughout most of the world,” Healy writes.

Healy applies the story of Yentl to heart disease. She argues that only recognizing heart disease in women when it presents similarly to men’s heart disease, and treating women’s heart disease as the same as men’s, leads to inferior diagnosis and treatment of heart disease in women.

“The problem is to convince both the lay and the medical sectors that coronary heart disease is also a woman’s disease, not a man’s disease in disguise,” she writes. “Decades of sex-exclusive research have reinforced the myth that coronary artery disease is a uniquely male affliction and have generated data sets in which men are the normative standard. The extrapolation of these male-generated findings to women has led in some cases to biased standards of care and has prevented the full consideration of several important aspects of coronary disease in women.”

Bairey Merz added that the “Yentl syndrome” still afflicts the field today: “The health care establishment still, I think, has these gendered ideas of not doing research in women.”

Myth: Men and women both receive the standard of care for cardiovascular disease.

Reality: Men often are more likely to receive care that follows established guidelines for treating cardiovascular disease than women.

“When a woman has a heart attack, do we even treat women equally?” Gulati asked. The short answer, she said, is: no.

The long answer: A 2012 paper in the American Journal of Medicine found that women were less likely to receive care concordant with established guidelines for heart attack — and were more likely to die from the condition — than men. The study looked at a sample of 31,544 patients from 369 hospitals across the U.S. between 2002 and 2008.

A few of the differences highlighted in the study:

• Women were less likely to get aspirin or a beta blocker within 24 hours of a heart attack, which is the standard of care.
• They were less likely to undergo any type of invasive procedure to treat the heart attack.
• They also were less likely to receive anti-blood clotting therapy within 30 minutes of going to the hospital, another standard of care.
• In addition, women were less likely to receive timely coronary angioplasty – the insertion of a tiny balloon into the artery to clear a blockage, which is recommended within 90 minutes of being admitted to the hospital.
• Younger women experiencing heart attacks suffered worse outcomes than older women — higher mortality rates and lower-quality care.

“The only thing women do better is die,” Gulati said. “Even when we don’t have all the answers about the [sex-related cardiovascular disease] differences… if we just followed the guidelines, we would save lives.”

Differences in care aren’t limited just to the clinical setting. Gulati said that in out-of-hospital cases of cardiac arrest, women are less likely to receive bystander-initiated cardiopulmonary resuscitation (CPR) than men. “We know the sooner we initiate CPR, the more likely we are to save lives,” she said. As it stands, women are less likely to survive cardiac arrest than men.

Gulati suggested the reasons why CPR is not performed as often on women might have to do with concerns about touching women, or the fact that people are trained to perform CPR on male mannequins rather than female figures. That might lead individuals to believe they do not know how to perform CPR appropriately on a woman, Gulati said.

Myth: Women experiencing heart attacks report so-called “atypical” symptoms such as stomach pain, pain in the jaw and heart palpitations, rather than “typical” symptoms like chest pain, pressure or tightness.

Reality: Research shows that women are actually more likely than men to report typical symptoms, but are also more likely to list a greater number of symptoms.

“The public health message has really somehow gone out there as if every woman will present atypically rather than most people will present with the typical symptoms,” Gulati said.

A 2018 study in Circulation finds that a similar percentage of men and women reported chest pain when seeking help for a heart attack — 89.5% and 87%, respectively. Women, however, were also more likely to report three or more additional symptoms than men. Additionally, both women and their healthcare providers were less likely to consider women’s symptoms heart-related than men and their providers. For example, women were more likely to consider their symptoms related to stress or anxiety, and 53% of women reported that their provider did not think their symptoms were heart-related, compared with 37% of men.

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Over two million U.S. adults with cardiovascular disease have smoked marijuana, and the substance may carry increased cardiovascular risks, new research indicates.

The study informs questions about the health impacts of policy changes on marijuana. Marijuana use remains illegal federally, but is legal medically in 33 states and the District of Columbia and recreationally in 11 states and D.C. It also makes the case for more research on the effects of marijuana, especially among people with heart disease.

The paper was published this week in the Journal of the American College of Cardiology. It combines a review of the research on cardiovascular risks linked to marijuana use with an analysis of national survey data on use of marijuana in the U.S.

Using data collected through the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2016, the researchers estimate that of the 89.6 million adults in the U.S. who had at some point used marijuana, about 2 million of them had cardiovascular disease – including congestive heart failure, coronary heart disease, or a heart attack.

“That’s an incredible number of people, and even since that time, we know that marijuana use has increased dramatically in the United States,” says Ersilia M. DeFilippis, MD, lead author of the paper and cardiology fellow at Columbia University Irving Medical Center.

“What’s more, there may be many people who are at risk for cardiovascular disease but may not be diagnosed,” she adds. “That just highlights how important it is for us to get good data in this area.”

Currently there is a dearth of controlled research on the subject because marijuana remains classified federally as a Schedule I substance, a Drug Enforcement Administration categorization that indicates these substances have “no currently accepted medical use in the United States,” and a high potential for abuse.

“We know from at least epidemiological studies that marijuana use has been associated with a variety of cardiovascular conditions, including abnormal heart rhythms, weakening of the heart muscle, heart attacks, as well as stroke,” DeFilippis says. Her paper highlights a meta-analysis that finds smoking marijuana was one of the top three triggers of heart attack. Another highlighted study finds that among 334 patients younger than 45 who had experienced a stroke, 17% were cannabis users.

“We have data that suggests these associations,” DeFilippis says. “But we really need to have better controlled studies, to be able to better inform people.”

While research on the health effects of marijuana by delivery method — smoking, ingestion, topical application — is also scarce, DeFilippis points out research finds that inhaled marijuana smoke is, chemically, quite similar to tobacco smoke.

“Although the active ingredients of the cannabis plant differ from those of the tobacco plant, each produces about 4,000 chemicals when smoked and these are largely identical,” finds a 2003 study in The BMJ comparing marijuana and tobacco.

“Given how we accept that smoking is a well-known risk factor for cardiovascular disease, what does that mean for marijuana? And how do we counsel patients?” DeFilippis says.

The research review also highlights known interactions between marijuana and heart medications. Statins, for example, which are prescribed to lower cholesterol levels, can be affected by marijuana use. Levels of statins in the blood may increase when used with marijuana because of how the body metabolizes those substances. Levels of blood thinners, which are used to prevent stroke, and beta blockers, which lower blood pressure, can also increase due to marijuana use.

Further, because marijuana’s chemical composition varies between different strains, medication interactions are “unpredictable,” DeFilippis says.

Given that cardiovascular disease is the leading cause of death in the U.S., DeFilippis urges people who have or are at risk for heart disease to talk with their doctors about their marijuana use, whether it’s recreational or medical.

“Hopefully, with more data, we can help to provide more guidelines for doctors,” she says. “But we do know that for people who are using marijuana and on cardiovascular medications, it will be important for cardiologists as well as our pharmacy colleagues to be aware of potential drug interactions in that setting.”

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A federal government database of doctors who provide medication-assisted treatment for opioid use disorder is rife with inaccurate information, making it difficult for people seeking help to schedule appointments, shows new research in the Journal of Psychiatric Practice.

Researchers combed the Substance Abuse and Mental Health Services Administration’s database of buprenorphine providers to verify the accuracy of phone numbers and confirm whether the provider was in fact prescribing buprenorphine and accepting new patients. SAMHSA is an agency of the U.S. Department of Health and Human Services.

Buprenorphine, sold under the brand name Subutex, and a component of the drug sold under the brand name Suboxone, is a drug commonly prescribed to treat opioid use disorder.

Researchers called SAMHSA-listed buprenorphine providers in the 10 states with the highest drug overdose death rates according to 2015 Centers for Disease Control and Prevention (CDC) drug overdose death data — West Virginia, New Hampshire, Kentucky, Ohio, Rhode Island, Pennsylvania, Massachusetts, New Mexico, Utah and Tennessee. They then focused on providers listed as practicing within a 25-mile radius of the county with the highest drug-related death rates in 2017, narrowing down the list to 505 providers.

The researchers secured appointments with just 28% — 140 — of providers contacted. In most cases, nobody answered the phone or returned the call, or the phone number listed was incorrect.

Over one quarter — 27.1% — of the numbers listed were incorrect, the researchers report. A similar percentage — 25.9% — of phone numbers corresponded to providers who did not offer buprenorphine.

“Someone who has opioid use disorder, if they try to use the federal database to locate someone to get medication-assisted treatment from, they’re going to find out that the database is full of wrong numbers and practices that aren’t even prescribing buprenorphine,” says author J. Wesley Boyd, an associate professor of psychiatry at Harvard Medical School.

Researchers made two attempts at contact during normal weekday business hours and left voice messages with a callback phone number when given the option. Calls were made over the span of two months. If the researchers made contact with the provider or office staff, they asked whether the provider currently prescribed buprenorphine. If yes, the researchers followed up by asking which insurance they accepted, including Medicaid, whether they were accepting new patients, and when their first available appointment was.

“One of the clinics that I called said to me, ‘Oh, Dr. Wartenberg hasn’t been in this clinic for over 12 years,’” Boyd recalls.

An evidence-based approach

Medication-assisted treatment is an evidence-based treatment for opioid use disorder. It has been shown to reduce the risk of overdose death for people who use opioids. These medications reduce symptoms of craving and withdrawal.

A study of 151,983 adults in England treated for opioid dependence between 2005 and 2009, published in Addiction, found the risk of fatal drug overdose more than doubled for individuals who received only psychotherapy compared with those who received medication-assisted treatment.

An April 2017 systematic review and meta-analysis published in The BMJ found that people receiving medication-assisted treatment were less likely to die of an overdose or other causes than peers with opioid use disorder who did not receive such treatment.

And a March 2015 review of randomized controlled trials in the Harvard Review of Psychiatry compared medication-assisted treatment of opioid use disorder with placebo or no medication and found that medication-assisted treatment “at least doubles rates of opioid-abstinence outcomes.”

Long waits and potential solutions

The researchers of the new paper verified that 310 of the 505 phone listings in their sample — 61.4% — listed correct numbers. Of all the providers who supposedly offered buprenorphine according to the database, only 195, or 38.6% actually did.

The researchers were able to ask 173 of these providers whether they accepted private insurance, and most — 75.7% — did. And more than half of the buprenorphine providers who were asked about whether they accepted Medicaid did — 62.9%.

“To me it was the one pleasant surprise of our findings, namely, that a decent chunk of the practices or individuals that we called did accept Medicaid,” Boyd notes.

But appointments typically required a wait — the average wait was 16.8 days, and the range spanned from 1 to 120 days. “Sixteen days is obviously a dangerous amount of time. Because as far as I’m concerned, every single time you use [opioids], you’re putting your life in jeopardy,” Boyd says.

Boyd notes that an underlying contributor to issues of access to buprenorphine is the relative scarcity of buprenorphine providers due to prescribing restrictions. Under the Drug Addiction Treatment Act of 2000, physicians must complete a training program if they want to prescribe medication-assisted therapy outside of an opioid treatment program.

“In order for people to be able to prescribe buprenorphine, the requirement for them to do additional training is, I think, obsolete and not necessary,” Boyd says. “So one thing is just to eliminate the requirement for specialized training over and above the training that one gets in order to be able to prescribe medications generally.”

Boyd suggests that SAMHSA might shore up the database through mass mailings to listed providers. He acknowledges that people can find medication-assisted treatment other than through the SAMHSA database, but as a provider listed in the database himself, he says he gets calls “infrequently, but regularly” about buprenorphine that likely stem from the listing.

“We were trying to replicate the experience of an opioid user looking for help,” Boyd says. “And this was the best way we thought that we could explore that issue.”

Boyd has conducted similar research on the issue of availability of mental health care. For more on the opioid epidemic, check out our long read.

The image on this page, obtained from Wikimedia Commons, is being used under a Creative Commons license. No changes were made.

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On Jan. 2, the Trump administration announced a ban on most flavored e-cigarette cartridges, except for menthol and tobacco flavors. The ban is aimed at reducing the uptake of vaping among young people.

Whether it will prove effective remains to be seen. History, however, may provide some insight.

The new policy banning most flavored e-cigarette cartridges echoes prior regulation of the tobacco industry. The Family Smoking Prevention and Tobacco Control Act, passed by Congress in 2009, banned the sale of flavored cigarette products — except for menthol.

The menthol exemption has garnered heavy criticism from public health advocates. They argue that any flavored product may encourage smoking and vaping among youth. Research shows that menthol cigarette use is disproportionately high among young smokers.

“Menthol – which is an ingredient in both mint and menthol flavored products – provides a cooling sensation that masks the harsh taste of nicotine, making it easier for children to get hooked,” said American Academy of Pediatrics President Sally Goza, in a statement following last week’s partial flavored vape ban. “The idea that menthol is an adult flavor is just plain wrong.”

In fact, compared with all other age groups, youth between the ages of 12 and 17 are the most likely to use menthol cigarettes, according to a 2016 study in Tobacco Control, which tracked the prevalence of the product in the U.S. over the course of a decade. While overall smoking rates among youth declined from 2004 through 2014, the proportion of youth smokers who use menthol cigarettes increased. Nearly 40% of surveyed youth smokers reported using menthol cigarettes from 2012 to 2014, compared with 35% from 2008 to 2010.

A 2006 study in Nicotine and Tobacco Research finds that menthol cigarettes are a “starter product” for youth smokers; data from the National Youth Tobacco Survey indicate that menthol cigarette use “was significantly more common among newer, younger smokers.”

“There’s been a lot of research done on correlates and consequences of menthol cigarette smoking, particularly among younger individuals,” says Amy Cohn, associate professor in the department of pediatrics at the University of Oklahoma College of Medicine, who studies tobacco use and regulation. “It’s been linked to progression to regular smoking among younger individuals. It’s been linked to greater nicotine dependence compared to non-menthol cigarette smoking, and greater difficulty quitting smoking among adult smokers.”

A 2019 study published in the American Journal of Preventive Medicine provides further detail on these trends. The study looks at data collected in 2013 and 2014 through the Population Assessment of Tobacco and Health Study, a nationally representative study of smoking habits that includes a sample of 13,651 U.S. kids between the ages of 12 and 17.

Of the respondents who had ever smoked a cigarette, more than 2 out of 5 — 43.2% — said the first cigarette they smoked was menthol. And 42% of respondents named a menthol brand as their regular brand. Youth who smoked menthol cigarettes in the past month were more likely to report that those cigarettes were easier to smoke than youth who smoked non-menthol cigarettes in the past month.

“It’s not as if only five or 10 percent of young people who started smoking start with a menthol cigarette, it’s almost half of them,” says Cohn, who was lead author of the study. “One of the reasons hypothesized for why menthol is so appealing to young people is that it’s been proposed to, quote-unquote, ‘help the medicine go down.’ The minty cooling sensation is supposed to mask the harshness of inhaled cigarette smoke.”

Additionally, kids who reported smoking menthols in the past month were more likely to have smoked six to ten cigarettes per day and less likely to have smoked between one and five cigarettes per day than kids who reported smoking non-menthol cigarettes in the past month.

Breaking the findings down further, the researchers found that youth respondents who began smoking with a menthol cigarette and who stated a preference for a menthol cigarette brand were more likely to be black, to have started smoking at a relatively older age and to have smoked menthol cigarettes in the past month.

Targeted marketing

Research shows that menthol cigarettes in particular have been marketed toward black youth.

“A lot of research suggests that this marketing has something to do with the uptake of menthol [cigarettes], specifically in this group of individuals,” Cohn says.

For example, a 2012 study published in Nicotine and Tobacco Research examined cigarette advertising in 407 stores within walking distance of 91 California schools, located in neighborhoods of varying racial demographics. Among the findings: “For each 10 percentage point increase in the proportion of black students, the proportion of menthol advertising increased by 5.9 percentage points.”

A 2011 study in Tobacco Control examined 953 tobacco industry documents from the 1930s through 2000s to examine various research questions, including whether menthol cigarettes were marketed to specific populations. The study finds that menthol cigarettes “were marketed as, and are perceived by consumers to be, healthier than non-menthol cigarettes. Menthol cigarettes are also marketed toward specific social and demographic groups, including African Americans, young people and women, and are perceived by consumers to signal social group belonging.”

About 80% of African American smokers smoke menthol cigarettes, Cohn notes, suggesting that peer use may also influence on why menthol cigarette smoking is higher among African Americans.

The patterns, she says, raise concerns about health equity. For this reason, and others, Cohn says it’s important to keep combustible tobacco products in the public eye even as e-cigarettes draw increasing media attention.

“I think that there’s a lot of focus on e-cigarettes and vaporized products. And what I think that does for the tobacco industry is that it takes the focus off of cigarettes and things like menthol cigarettes that have been around for a long time. And I think it’s important that we keep the focus on menthol cigarettes,” Cohn says. “The FDA has been saying we need more information, we need more data on the impact of menthol cigarettes on smoking and indicators of abuse liability…. I think there’s a lot of research to make the decision.”

The image on this page, obtained from Wikimedia Commons, is being used under a Creative Commons license. No changes were made.

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This post has been updated with new research since it first ran in January 2019.

New Year’s resolve flagging? Academic research can bolster your ambitions. We’ve collected peer-reviewed behavioral science research that might help you successfully achieve some common resolutions: spending less time on your smartphone, saving money, exercising more, drinking less, quitting smoking, eating fewer treats, getting over your procrastination habit, and yes, even flossing. Read on to become a better you.

If you’ve resolved to SLASH YOUR SCREEN TIME … try reading: “Batching Smartphone Notifications Can Improve Well-Being”
Fitz, Nicholas; et al. Computers in Human Behavior, December 2019.

If you’re chained to your phone and unhappy about it, you might consider receiving smartphone notifications at set intervals throughout the day rather than as they come. Researchers at Duke University and Georgetown University found that study participants who received notifications batched to arrive only three times a day reported better moods, higher productivity, and greater feelings of control over their phones. They also unlocked their phones less often in comparison with participants who received notifications as usual and another group of participants who received no notifications at all.

In total, 237 smartphone owners living in India participated in the study. Participants downloaded an Android app developed by the researchers that regulated the delivery of phone notifications. Respondents also were asked to report in a daily diary various measures including: “concentration, distraction, stress, anxiety, mood, productivity, social connectedness, and work enjoyment—as well as phone-specific outcomes: feeling of being interrupted by notifications, sense of missing out on notifications, sense of control over phone, social pressure to respond to others, phone overuse, and intentional phone checking.” Participants were informed that they could always access their notifications by opening individual apps. “In other words, we only manipulated the delivery of notifications (e.g., to the lock screen), rather than preventing messages from being accessed at all,” the authors explain. The researchers also gathered data on how often the participants checked their phones as reported by the phone’s operating system.

“Compared to those in the control condition [notifications as usual], participants whose notifications were batched three-times-a-day felt more attentive, productive, in a better mood, and in greater control of their phones,” the researchers write, noting that the batched group also reported lower stress levels.  “In contrast, participants who did not receive notifications at all reaped few of those benefits, but experienced higher levels of anxiety and ‘fear of missing out’ (FoMO).” They’ve released the app, called Daywise, for personal use through Google Play. But sorry, iPhone users. So far Daywise is only available on the Android platform. “Daywise for iOS is one of the most requested queries from iOS users, so much so that a few iOS users have moved to Android just so they can use Daywise! But unlike Android, iOS doesn’t allow third party developers [to] control notifications to a degree we’d like for batching to work in a nuanced manner,” author and DayWise creator Ranjan Jagannathan told us in an email. “Till we’re able to do this flexibly enough, we will not be able to build a powerful version of Daywise for iOS.”

If you’ve resolved to CUT BACK ON DRINKING… try reading: “Young Adults Do Not Catch up Missed Drinks When Starting Later at Night—An Ecological Momentary Assessment Study”
Groefsema, Martine; et al. Experimental and Clinical Psychopharmacology, November 2018.

Trying to drink less? Consider starting your night out later. The party will be in full swing and you might avoid the hangover the next day. Researchers in the Netherlands conducted a study of 197 young adults’ drinking habits. They sent out surveys to participants’ smartphones every hour between 9 pm and 1 am on Thursday, Friday and Saturday for five consecutive weeks to record drink consumption. Here’s what they found: “no differences in drinking pace (i.e., slope) were found across the subsequent hours between evenings on which individuals started at different times; individuals do not catch up on missed drinks. Moreover, when individuals start drinking later, they consume less alcohol in total during the evening and showed less binge drinking.”

If you’ve resolved to QUIT SMOKING… try reading: “A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation” 
Halpern, Scott D.; et al. The New England Journal of Medicine, May 2018.

If you want to quit smoking, try paying yourself to do so. Research shows that cash incentives are more effective than other cessation strategies – including the strategy of trying to replace smoking with vaping. Researchers at the University of Pennsylvania looked at the outcomes of five different strategies for workplace smoking-cessation programs. Just over 6,000 participants were included in the study and randomized into five groups. The groups received one of the following:  usual care (informational materials and text messages with advice and encouragement); free cessation aids (including nicotine-replacement therapy, prescription medications to help quit and, in the event that those strategies failed, e-cigarettes); free e-cigarettes; a reward of up to $600 plus the free cessation aids detailed above; or a redeemable deposit account of up to $600 plus the free cessation aids. The deposit group differed from the reward group in that money was removed from the deposit account if abstinence goals were not met. This framed the deposit account in terms of potential losses, in contrast to the incentive framing of the reward group, in which additional money was added to the reward for each goal met. The success rates of the five strategies, ranked from highest to lowest, are as follows: redeemable deposit (2.9 percent); reward (2 percent); e-cigarettes (1 percent); free cessation aids (0.5 percent); usual care (0.1 percent). In sum: Put your money where your smoke is.

If you’ve resolved to FLOSS YOUR TEETH… try reading: “Translating Dental Flossing Intentions into Behavior: A Longitudinal Investigation of the Mediating Effect of Planning and Self-Efficacy on Young Adults”
Hamilton, Kyra; et al. International Journal of Behavioral Medicine, June 2017.

Want to develop a habit of flossing your teeth? Planning and believing in yourself (a.k.a. “self-efficacy” in psychology circles) are key, finds this study of 629 Australian university students. “Controlling for baseline flossing, the effect of intentions on behavior was mediated via self-efficacy and planning, with 64 percent of the flossing variance accounted for by this set of predictors,” the authors write. Self-efficacy was measured by participants’ belief in their ability to floss their teeth daily on a long-term basis, “even when I cannot see any positive changes immediately,” “even when I am in a hurry,” and “even when it takes a long time to become part of my daily routine.” Planning was measured by responses to questions about when, where, and how to floss, as well as responses to potential setbacks. Better oral hygiene, this study suggests, requires commitment and intention, but it is within reach (just like those pesky molars – try harder!).

If you’ve resolved to SPEND LESS and SAVE MORE… try reading: “The Interactive Effects of Bitter Flavor and Mood on the Decision to Spend or Save Money”
Cai, Fengyan; et al. Journal of Experimental Social Psychology, May 2017.

Getting a handle on your spending can be a bitter pill to swallow. But a bitter beverage might be just the thing to keep your finances on track, according to this study. Researchers looked at the effects of mood and flavor on participants’ proclivities to spend or save. They hypothesized that happy participants would be more likely to spend and less likely to save, and that these inclinations could change depending on shifts in mood. They also thought that moods might shift based on particularly pungent tastes. The researchers put all this to the test by measuring participants’ mood measuring participants’ moods before and after randomly assigning them to drink either bitter-melon-flavored, salty or plain water. After consuming the water, the participants completed an exercise in which they indicated the likelihood that they would save an extra allowance received each month. Researchers also asked questions that got at the participants’ moods after consuming the drink. They found that baseline happy participants who consumed the bitter drink were more likely to save compared with those who drank pure water or salty water, and also expressed more worry about the future than these other groups. On the other hand, participants who were unhappy at the outset were less likely to spend money after consuming the bitter drink. “As we noted earlier, unhappy individuals are generally motivated to engage in behavior that can decrease or eliminate their negative feelings they are experiencing,” the authors explain. “If tasting a bitter drink activates thoughts about the adversity of their present life situation, it could increase their desire to spend money for this reason.” Two field experiments that involved consuming bitter melon water or pure water and comparing actual savings and spending decisions lent further support to the findings.

If you’ve resolved to STOP PROCRASTINATING… try reading: “Acceptance and Commitment Therapy and Cognitive–Behavioral Therapy as Treatments for Academic Procrastination: A Randomized Controlled Group Session”
Wang, Shuo; et al. Research on Social Work Practice, January 2017.

On deadline and doing everything but working on your assignment? We’ve all been there. The key to overcoming procrastination, one study suggests, is changing the way you think about your work. The research involved 60 undergraduates struggling with academic procrastination who received either Cognitive Behavioral Therapy (CBT) or Acceptance and Commitment Therapy (ACT). Participants who received CBT were encourage to challenge their thoughts, set goals and work on time management skills. The ACT group “introduced acceptance by experiential exercises, which helped members to realize that not only are efforts to manage and control our thoughts and emotions futile, but they also prevent us from doing valued life activities.” The participants in the ACT group were led through mindfulness activities and worked to “explore and clarify life values, make plans to pursue life goals, and make commitments to actions.” The good news: both methods worked. “Both therapies showed remarkable short-term effects in decreasing procrastination, but ACT had a better long-term effect,” the authors write. “While ACT significantly decreased negative affect and improved neuroticism, CBT had a stronger effect on time management.”

If you’ve resolved to EXERCISE… try reading: “Goals and Social Comparisons Promote Walking Behavior”
Chapman, Gretchen B.; et al. Medical Decision Making, May 2016.

Not meeting your goals can be demoralizing, but aiming high might have its benefits regardless. In a study that lends support to the old cliché about shooting for the moon, researchers found that participants who were assigned higher goals for daily step counts walked more than those who had medium or low goals, even if they didn’t quite reach their target. The experiment involved 148 university employees. Another experiment involving 64 individuals compared steps walked when participants received individual versus social comparison feedback. The control group simply logged their steps and received emails reminding them to input their data. When the social comparison group logged their steps, they learned how they performed relative to the other participants. They also received emails with similar information. The social comparison group walked more than those who received only individual feedback. The researchers suggest that these findings indicate the importance of reference points, either established through goals or comparison between peers, in changing behavior.

If you’ve resolved to EAT LESS JUNK FOOD… try reading: “The Taming of Desire: Unspecific Postponement Reduces Desire for and Consumption of Postponed Temptations”
Mead, Nicole L.; Patrick, Vanessa M. Journal of Personality and Social Psychology, January 2016.

Whatever you’re trying to cut down on, consider putting it off for another time rather than vowing to quit it entirely. The key is not to care too much about when you will indulge again. This study features four different experiments testing “unspecific postponement.” The authors write, “We hypothesized that people interpret unspecific postponement (‘I can have it some other time’) as a signal that they do not strongly value the postponed temptation. In this way, unspecific postponement may reduce desire for and consumption of postponed temptation, both in the present moment and over time.” The findings indicate that this is in fact the case. When participants freely decided to postpone their selected (edible) temptation, they desired it less and consumed it less (they both delayed consumption and ate a smaller quantity of it). Two of the other experiments found that postponing a temptation to a specific date, in comparison to unspecific postponement, did not reduce desire or consumption. Lastly, participants presented with M&Ms who were encouraged to tell themselves that they could have them some other time ate less than those who were encouraged to tell themselves not to eat them at all.

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It has been a productive and exciting year at Journalist’s Resource. We welcomed a new team member, economic research reporter extraordinaire Clark Merrefield. We established a great collaborative relationship with The Burlington Free Press. We created a series of behind-the-scenes stories featuring journalists who were finalists for the 2019 Goldsmith Prize for Investigative Reporting. We delved deep into the 2020 census. And we began to look at what the research says about some of the Democratic presidential candidates’ policy proposals. So far in 2019, our small team has published or significantly updated 159 tip sheets, research roundups and other resources aimed at helping journalists cover the policy topics they needed to explain to the public.

Next week, we’ll reveal the 10 most-read pieces that we published over the past year. But today we’re sharing some of the JR team’s favorite pieces. Here are our 2019 staff picks.

Chloe Reichel, health research reporter:

8 tips on how to cover drinking responsibly

With holiday festivities in full swing, I thought I’d feature 8 tips on how to cover drinking responsibly as a reminder: Each year in the U.S. more people die from alcohol-related causes than overdoses from all other drugs, combined. Research suggests that there is no safe level of alcohol consumption, which has been causally linked to over 200 disease and injury conditions. And yet media coverage of alcohol tends not to focus on the risks of drinking, instead highlighting benefits in lighthearted lifestyle coverage. Which is why I think this tip sheet is so important — the media can and should do a better job of covering alcohol as a public health issue.

Carbon taxes + cap and trade = Tackling climate change like an economist

I’d like to call 2019 the year of Clark Merrefield, at least for Journalist’s Resource. I’m so glad for the humor, creativity and expertise our new colleague has brought to the project. Carbon taxes + cap and trade = Tackling climate change like an economist is the perfect example. Clark pitched the idea to participate in Covering Climate Now, an international journalism campaign to strengthen coverage of climate change; wrote this informative, accessible piece as one of his contributions; annotated it using Genius; and made me literally LOL in the process. Here’s the line, see for yourself: “In Washington circles, a lot of people think carbon taxes are going to be much more politically feasible,” Harvard University economist Robert Stavins says. “My view is, if it was possible to demonize cap-and-trade as a tax, it is highly likely that it will be possible to demonize a carbon tax as a tax.”  

Denise-Marie Ordway, managing editor:

10 tips for covering white supremacy and far-right extremists

This is one of my favorite JR tip sheets because it does two things well: It educates journalists about a national and local problem that tends to be misunderstood and it offers practical tips they can use immediately to do their jobs better. The tip sheet also introduces journalists to two top scholars who’ve thought a lot about how journalists portray white supremacy and help white supremacists spread their message.

What happens to a community when a rural school closes?

I chose this piece because I’m personally interested in this topic, and because it’s a great example of how our team can work with a newsroom to help it ground and frame its coverage using academic research. The studies of rural schools that Clark found add a lot to this Burlington Free Press article by helping us better understand the role schools play in small communities and what these communities experience when their only school closes.

Clark Merrefield, economic research reporter:

Data journalism at two elite news outlets lacked transparency: Research

Whether elementary or in-depth statistical analysis, data plays a huge role in the work of many journalists. This paper Denise covered has so many important reminders and tips that can help reporters live up to their own standards for transparency. It’s a must-read for new and veteran journalists alike.

The opioid prescribing problem: A JR long read

It would be impossible for any reporter covering addiction in America not to find something thought-provoking in this long-read from Chloe. She’s been covering research on opioid addiction for years and brought together the most consequential current research on how opioid prescribing helped fuel the opioid epidemic, in this incredibly informative and readable piece.

New economic research resurfaces debate about the link between legalized abortion and crime reduction

This story I wrote offers an interesting juxtaposition between pop-economics and traditional academic economics. The paper at the center of the article is an update of an original paper that helped launch the Freakonomics franchise. This piece offers some interesting looks behind the academic curtain, of how academics who disagree interact with each other.

Carmen Nobel, program director:

Prince Harry in Afghanistan: Miguel Head shares the story of a historic media blackout

For 10 weeks in late 2007 and early 2008, hundreds of news organizations agreed to embargo a big story: Prince Harry had been deployed to Helmand, Afghanistan, serving with the British Army. Miguel Head served as the chief press officer for the United Kingdom Ministry of Defence at the time. Last April, he sat down with me to share the inside story of how and why a cutthroat press decided to keep a major secret about a beloved public figure. The resultant oral history garnered attention from several popular lifestyle publications. Town and Country wrote its own article about our piece. So did The Frisky. So did Lainey Gossip. And the popular fashion blog Go Fug Yourself featured us in their weekly “Royals Roundup.”

A graphic guide to the 2020 US census

We hired the brilliant Josh Neufeld to create our first piece of graphic nonfiction, which explains the risk of undercounts, the potential ramifications of an inaccurate count, the threat of misinformation and disinformation campaigns, and important dates on the census calendar. It also includes cartoon cameo appearances by Supreme Court Chief Justice John Roberts and Secretary of Commerce Wilbur Ross — donning a New Year’s Eve party hat.

Happy holidays, readers. Come back next week to see JR’s most-read features of 2019.

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Efforts to shape public perceptions of a given issue — also known as agenda-setting — are a mainstay of the tobacco industry, researchers show. Robert Proctor, a professor of the history of science at Stanford University, details the tactics industry executives deployed over more than a century to promote their products and cast doubt on the science documenting tobacco-related health risks in his 2011 book Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition.

“What kinds of strategies are used to manufacture doubt?” Proctor writes in the book. A few tactics used: “Hire journalists to write industry-sympathetic articles in the popular press and pressure media organs to ignore or suppress reports unfavorable to the industry. Threaten to withhold advertising from magazines that give too much attention to tobacco-disease links.” Other strategies: Divert. Distract. Deny.

“People tend to include or exclude from their cognitions what the media include or exclude from their content,” writes media scholar Donald L. Shaw in an influential 1979 paper on agenda-setting in mass communication. “People also tend to assign an importance to what they [the news media] include that closely resembles the emphasis given to events, issues and persons from the mass media.” Accordingly, the tobacco industry’s influence on the media in turn shapes public perceptions of the issues.

One example of agenda-setting that plays out through the media is found in its coverage of corporate social responsibility (CSR) initiatives. Tobacco industry CSR initiatives are projects — philanthropic or otherwise — undertaken “to shape public and policymaker understandings about tobacco control and the industry,” according to the authors of a 2018 study on the topic.

The study looks at 649 U.S. news reports about tobacco industry CSR initiatives published in newspapers, online and in television and radio broadcasts between 1998 and 2014. The news coverage was predominately positive, and rarely quoted tobacco control advocates, researchers found.

To what extent does news coverage still reflect tobacco industry efforts to agenda-set? How has the introduction of e-cigarettes complicated the issue? How has agenda-setting influenced public perceptions of tobacco control and, more recently, vaping?

This research roundup aims to answer those questions by examining studies published in the past five years on media coverage of tobacco and e-cigarettes. We hope to help journalists understand some of the forces that might shape their coverage as well as raise awareness about how the nature and tone of news stories have affected public perception and public policy.

Vaping in the news

Content Analysis of US News Stories About E-Cigarettes in 2015
Wackowski, Olivia A.; et al. Nicotine & Tobacco Research, August 2018.

This paper analyzes news coverage of e-cigarettes provided in 2015 by a variety of U.S. news organizations — four newswires, four online news outlets and the 30 newspapers with the largest circulations. In total, the researchers analyzed 295 articles. They found that 45.1% of stories focused on policy or regulatory issues around vaping. The next most common topics were health effects (appearing in 21.7% of studied articles) and e-cigarette prevalence (featured in 21% of articles). Articles frequently mentioned the following concerns: youth e-cigarette use (45.4%), e-cigarettes as a potential gateway to smoking (33.9%) and the appeal of flavors (22.9%). Articles that focused on Food and Drug Administration regulation of e-cigarettes more frequently mentioned youth prevalence of vaping (61%) than adult prevalence (13.5%).

“News articles more frequently discussed potential e-cigarette risks or concerns (80%) than benefits (45.4%), such as smoking harm-reduction,” the authors write. Similarly, when expert sources such as doctors, researchers and government officials were quoted, they were more likely to cite risks associated with e-cigarettes than benefits, such as avoiding the tar in traditional cigarettes. The researchers conclude, “While such coverage may inform the public about potential e-cigarette risks, they may also contribute to increasing perceptions that e-cigarettes are as harmful as tobacco cigarettes.” 

Youth and Young Adult Exposure to and Perceptions of News Media Coverage about E-Cigarettes in the United States, Canada and England
Wackowski, Olivia A.; Sontag, Jennah M.; Hammond, David. Preventive Medicine, April 2019.

This study analyzes what teens think about e-cigarettes. It looks at online survey data collected from 12,064 teenagers ages 16 to 19 in the U.S., Canada and England. The survey was conducted in July and August of 2017. It asked respondents about their exposure to news about e-cigarettes and their beliefs about the content of these stories. Respondents also answered questions about their perceptions of the harmfulness of e-cigarettes and their intention to use or stop using them. Nearly one-fifth, or 17.1% of respondents, reported encountering e-cigarette news at least “sometimes” over the past month. Most respondents thought the content was either mostly negative (35.7%) or mixed (34.8%). Only 19% viewed the coverage as mostly positive. White respondents were more likely to see negative e-cigarette news than their non-white peers.

“Participants exposed to mostly negative e-cigarette news were more likely to perceive that e-cigarettes cause at least some harm and, among past 30 day users, have intentions to quit e-cigarettes in the next month,” the authors write. Teens who reported seeing mostly positive news were more likely to report curiosity about trying e-cigarettes than peers who encountered mixed or mostly negative coverage. “E-cigarette news exposure may shape e-cigarette harm perceptions and use intentions, as well as reflect existing beliefs and product interest,” the authors conclude. 

To Vape or Not to Vape? Effects of Exposure to Conflicting News Headlines on Beliefs about Harms and Benefits of Electronic Cigarette Use: Results from a Randomized Controlled Experiment
Tan, Andy S. L.; et al. Preventive Medicine, December 2017.

This randomized, controlled experiment provides a complementary perspective to the more common observational research on the topic of news coverage of tobacco products. In this study, 2,056 U.S. adults between the ages of 18 and 85 responded to an online survey after viewing headlines about the safety of e-cigarettes. Each was assigned to one of four groups, reading headlines reflecting one of four of the following messages about the safety e-cigarettes: positive, negative, conflicting, or no message. Participants focused solely on the headlines and then answered questions about their beliefs about the harms and benefits of using e-cigarettes. The researchers found that participants who read negative headlines reported increased beliefs about harms and decreased beliefs of benefits, compared with participants who viewed positive headlines. These differences held when the researchers further analyzed the responses of only participants who had never used e-cigarettes. Adults who had never used e-cigarettes and read headlines with conflicting messages about e-cigarettes reported lower belief in the benefits of e-cigarettes than those who viewed positive headlines. The researchers suggest these findings demonstrate the link between the tone of news coverage of e-cigarettes and public beliefs about the product.

Tobacco control and industry in the news

A Multi-Year Study of Tobacco Control in Newspaper Editorials Using Community Characteristic Data and Content Analysis Findings
Stanfield, Kellie; Rodgers, Shelly. Health Communication, July 2018.

This study looks at the content of 1,473 editorials published in all Missouri newspapers between 2005 and 2011. Researchers chose Missouri because it has one of the lowest tobacco excise taxes in the country and does not have a statewide indoor smoking ban. At the community level, however, there have been successful initiatives to adopt smoke-free policies, the authors explain.

The researchers found that most editorials were about tobacco restrictions or ordinances, used neutral language and were factual in nature. However, they discovered that most of the editorials that took a position against tobacco control were published in cities with no clean air ordinances and the highest rates of smoking. On the other hand, cities that had low smoking rates and smoke-free policies had the highest percentage of editorials with a positive slant toward tobacco control. “The results show an agenda-setting function at the editorial level and a potential selection bias in selecting editorials according to topic, slant, and tone,” the authors conclude. “Not only were positive tones nearly non-existent in editorials, the majority of negatively slanted editorials were published in cities with the highest rates of smoking and no ordinance.”

Characteristics of Community Newspaper Coverage of Tobacco Control and Its Relationship to the Passage of Tobacco Ordinances
Eckler, Petya; Rodgers, Shelly; Everett, Kevin. Journal of Community Health, October 2016.

This study also looks at Missouri newspaper coverage of tobacco issues, but focuses on articles and editorials. The researchers looked at content published by all 381 Missouri newspapers between September 2006 and November 2011. In total, they analyzed 4,711 tobacco news stories. The researchers found that most were about tobacco control and were positively slanted toward it. “Stories with a positive tobacco control slant had information about enforcement, emphasized the lack of negative economic consequences or the health and economic benefits of policies or worker protection,” the authors write. However, editorials tended to be more negative in tone — in both the headline and text — than news stories.

Newspapers in towns that had smoke-free ordinances ran more stories about tobacco control than those located in towns without smoke-free ordinances. The authors write that this implies a connection between media coverage of tobacco control and the passage of tobacco control policies. Towns without smoke-free ordinances had more “non-tobacco control stories,” including news stories about youth smoking.

“We conclude that the tobacco industry may have had success in impacting news stories in no-ordinance cities by diverting attention from tobacco control to secondary topics, such as youth smoking, which meant stories had fewer public health facts and fewer positive health benefits in towns that may have needed these details most,” the authors write.

Setting the Agenda for a Healthy Retail Environment: Content Analysis of US Newspaper Coverage of Tobacco Control Policies Affecting the Point of Sale, 2007–2014
Myers, Allison E.; et al. Tobacco Control, July 2017.

This study looks at media coverage of point-of-sale tobacco control policies — interventions targeted at the place where people purchase tobacco products. Some examples are requirements for tobacco retailers to acquire licenses, prohibitions on the redemption of coupons for tobacco purchases and restrictions on the sale of tobacco in pharmacies.

This study looked at 917 news articles on point-of-sale tobacco control policies published in 268 regional newspapers and five national newspapers between 2007 and 2014. Nearly half of these articles focused on tobacco retailer licensing. Just over half had a mixed, neutral or anti-tobacco control slant. Articles that were framed in terms of politics, rights, or regulation, or that quoted anti-tobacco control sources (e.g., tobacco industry sources, tobacco retailers or tobacco users) were much less likely to have a pro-tobacco-control slant.

Tobacco retailers were cited in 39.6% of the stories studied, second only to government sources (52.3%) and followed by tobacco industry sources (22.0%). On the other hand, stories that focused on health issues and featured research and sources in favor of tobacco control tended to support tobacco control.

Trends in US Newspaper and Television Coverage of Tobacco
Nelson, David E.; et al. Tobacco Control, January 2015.

This study looks at newspaper, newswire and television coverage of tobacco issues in the U.S. between 2004 and 2010. The researchers looked at data from the U.S. Centers for Disease Control and Prevention’s Office on Smoking and Health’s news media surveillance system. The CDC created this system in 2004 to track tobacco stories in the news. The system identifies tobacco news stories in 10 major newspapers, two major newswires and six national television networks. They found that, on average, there were three newspaper stories, four newswire stories and one television story on tobacco each day. Television stories tended to focus on addiction or health effects and were less likely to focus on secondhand smoke or tobacco regulation than newspaper and newswire stories. Newspaper and newswire coverage of tobacco issues varied more than television coverage. “Newspaper editors and television producers have an important agenda-setting role, serving as gatekeepers who make decisions about whether a topic or event is ‘newsworthy,’ and thus, reported at all,” the authors write. “Differences in tobacco themes among individual newspapers and newswire services also strongly suggest that news editors differ in whether and how they choose to report tobacco stories.”

US Media Coverage of Tobacco Industry Corporate Social Responsibility Initiatives
McDaniel, Patricia A.; Lown, E. Anne; Malone, Ruth E. Journal of Community Health, February 2018.

The tobacco industry’s corporate social responsibility (CSR) initiatives are projects meant “to shape public and policymaker understandings about tobacco control and the industry.” They include food aid, arts funding, youth smoking prevention programs, disaster relief, employee volunteer programs and research efforts.

This study looks at 649 U.S. news reports about tobacco industry CSR initiatives — including newspaper articles, online news stories and transcripts of television broadcasts and NPR broadcasts — available through online media databases. Publication dates ranged from 1998 through 2014. Tobacco industry CSR coverage was predominately positive, and rarely quoted tobacco control advocates. Local newspapers provided most of the coverage of tobacco industry CSR.

The most common initiatives featured were unrelated to tobacco and aided “non-controversial” beneficiaries such as students, the elderly and arts organizations. Positive coverage was more common in the South — where many tobacco companies are headquartered — than in the West. When tobacco control advocates were quoted, news coverage was less likely to have a positive slant.

“The absence of tobacco control advocates from media coverage represents a missed opportunity to influence opinion regarding the negative public health implications of tobacco industry CSR,” the authors conclude. “Countering the media narrative of virtuous companies doing good deeds could be particularly beneficial in the South, where the burdens of tobacco-caused disease are greatest, and coverage of tobacco companies more positive.”

Read more: Teen vaping: Is it really a gateway to cigarette smoking?; ‘Causes’ vs. ‘contributes to’: Strong causal language on product warning labels more effective; E-cigarettes aren’t better at helping smokers quit than other strategies

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In the lead-up to the 2020 elections, the Journalist’s Resource team is combing through the Democratic presidential candidates’ platforms and reporting what the research says about their policy proposals. We want to encourage deep coverage of these proposals — and to do our part to help deter horse race journalism, which research suggests can lead to inaccurate reporting and an uninformed electorate. Our criteria for the proposals we’re covering is simple: We’re focusing on proposals that have a reasonable chance of becoming policy, and for us that means at least 3 of the 5 top-polling candidates say they intend to tackle the issue. Here we look at candidates’ proposals to address the opioid epidemic. Candidates are divided in their approaches; while nearly all favor increasing funding for and access to treatment for opioid use disorder, fewer candidates support harm reduction policy interventions, such as safe injection sites and needle exchanges. A few candidates incorporate broader criminal justice-level changes or physician-level interventions into their policy proposals.

Candidates favoring increased funding for and access to treatment

Michael Bennet*, Joe Biden, Cory Booker*, Pete Buttigieg*, John Delaney*, Amy Klobuchar*, Bernie Sanders*, Tom Steyer*, Elizabeth Warren*, Marianne Williamson*, Andrew Yang*

Candidates favoring harm reduction interventions

Michael Bennet, Cory Booker, Pete Buttigieg, Amy Klobuchar, Bernie Sanders, Elizabeth Warren

Candidates favoring action against pharmaceutical companies

Michael Bennet, Cory Booker, Pete Buttigieg, John Delaney, Tulsi Gabbard, Amy Klobuchar, Bernie Sanders, Elizabeth Warren, Andrew Yang

Candidates favoring interventions that target physician prescribing behavior

John Delaney, Amy Klobuchar, Andrew Yang

Candidates favoring decriminalization of possession of opioids

Pete Buttigieg, Andrew Yang

What the research says

Access to treatment: Medication-assisted treatment is an evidence-based treatment for opioid use disorder; it has been shown to reduce the risk of overdose death for people who use opioids. Methadone, buprenorphine and naltrexone are types of medication-assisted therapy for opioid use disorder. These medications reduce symptoms of craving and withdrawal. A systematic review and meta-analysis of medication-assisted treatment find that people receiving such treatment were less likely to die of an overdose or other causes than their peers with opioid use disorder who did not receive medication-assisted treatment.

Harm reduction: Harm reduction initiatives attempt to reduce the risks associated with using drugs. Such initiatives include needle exchange programs, widespread distribution of the opioid overdose antidote naloxone and supervised injection facilities. Supervised injection facilities, also known as safe injection sites or supervised consumption facilities, are not legal in the U.S. They exist legally in other countries, such as Canada and Australia, however.

Several studies have demonstrated a positive link between safe injection site use and entry into treatment. Safe injection sites also provide benefits to people who use drugs in the form of sterilized equipment and supervision to mitigate the dangers of overdose.

Over a dozen studies have linked needle exchanges with lower rates of hepatitis C and HIV infection among people who inject drugs.

A systematic review of research on take-home naloxone programs, which provide people at risk of opioid overdose with kits including the antidote, concludes that “there is overwhelming support of take-home naloxone programs being effective in preventing fatal opioid overdoses.”

The pharmaceutical industry: Big Pharma’s role in marketing opioids spurred physicians to prescribe more opioids, research shows. This, in turn, fueled the opioid epidemic the country faces today. Policies targeted toward Big Pharma include proposals to hold industry players liable for their role in the opioid epidemic with criminal penalties and fines.

Decriminalization: The rationale behind decriminalization of the personal use of narcotics is that criminal penalties essentially criminalize substance use disorder. Proponents of decriminalization argue that such drug use should, instead, be met with evidence-based treatment. There is not much research on the effects of decriminalization because it’s rare. However, in 2001, Portugal decriminalized personal acquisition, possession and use of illicit drugs. Research indicates that drug-related deaths have fallen since the southwestern European country decriminalized illicit drugs.

Physician-level interventions: These interventions target prescriber behavior. Examples include physician education programs, guidelines or restrictions on the quantity of opioids physicians can prescribe, and prescription monitoring programs that allow physicians to view patients’ prescription history to avoid overprescribing or illegitimate prescribing. While education and prescribing policies have curtailed prescribing habits, prescription monitoring programs have been less successful, studies indicate.

Key context

In late 2017, the U.S. Department of Health and Human Services declared the nation’s opioid crisis a “public health emergency.” The problem has been building for over a decade, spurred by sharp increases in prescriptions for opioids, commonly used to treat both short-term and chronic pain.

About 233.7 million opioid prescriptions were filled each year, on average, from 2006 to 2017, according to a March 2019 study in JAMA Network Open that looks at opioid prescriptions filled in retail pharmacies across the U.S.

Prescription painkillers have a high risk of abuse — across the academic literature, rates of misuse among patients taking opioids for chronic non-cancer pain average between 21% and 29%. Research indicates that as of 2013, more than 2 million people in the U.S. had prescription opioid-related opioid use disorder.

Prescription opioids can also pave the way for illegal drugs like heroin. Eighty percent of people who have used heroin have previously misused prescription opioids, according to an August 2013 analysis of national survey data collected from 2002 to 2011.

As opioid use and misuse has increased, deaths linked to the drugs have increased. In 2017, opioids were involved in 47,600 drug overdose deaths, accounting for nearly 70% of all overdose deaths nationwide that year.

Recent research

Access to treatment:

A review of randomized controlled trials comparing medication-assisted treatment of opioid use disorder to placebo or no medication finds that medication-assisted treatment “at least doubles rates of opioid-abstinence outcomes.”

A study of 151,983 adults in England treated for opioid dependence between 2005 and 2009 finds that the risk of fatal drug overdose more than doubled for individuals who received only psychotherapy compared with those who received medication-assisted treatment.

Harm reduction:

Two reviews — one published in Drug and Alcohol Dependence in 2014, and one published in Current HIV/AIDS Reports in 2017 — indicate that supervised consumption facilities promote help people access treatment. The more recent review looks at 47 studies published between 2003 and 2017 on supervised drug consumption facilities. The authors find a handful of studies that demonstrate a positive link between safe injection site use and starting treatment.

One of these studies compared enrollment in detoxification programs among those who used Vancouver’s supervised injection facility the year before and after it opened in 2003. Researchers find the facility’s opening was linked to a 30% increase in detox program use, which, in turn, was linked to pursuing long-term treatment and injecting at the facility less often. A later study of the injection facility focused on use of detox services located at the facility. It finds that 11.2% (147 people) used these services at least once over the two years studied. The authors conclude that supervised injection facilities might serve as a “point of access to detoxification services.”

A 2006 study of 871 people who injected drugs finds no substantial increase in rates of relapse among former users before and after the Vancouver site opened. However, the researchers also find no substantial decrease in the rate of stopping drug use among current users before and after the site opened. Another study of 1,065 people at this facility published in 2007 finds that only one individual performed his or her first injection at the site.

Though supervised injection sites are illegal in the U.S., one opened underground in 2014. Researchers interviewed those who used the underground site during its first two years of operation and their findings were published in 2017 in the American Journal of Preventive Medicine. The site’s users were asked the same set of questions about their use patterns every time they injected drugs at the site. The authors conclude that the site offered several benefits, including safe disposal of equipment, unrushed injections and immediate medical response to overdoses. The authors add that if the site were sanctioned, it might be able to offer additional benefits, including health care and other services.

Big Pharma:

Research suggests that physicians targeted with marketing from pharmaceutical companies prescribe opioids at higher rates than doctors not exposed to their marketing.

Several studies use data from the Centers for Medicare and Medicaid Services’ Open Payments database, which tracks payments made by drug and medical device companies to physicians. That information is used to analyze how relationships between physicians and drug companies are linked to prescriptions written.

These studies define opioid-related payments as cash payments — for example, speaking fees associated with promoting a drug — and payments-in-kind — free meals pharmaceutical representatives provide to doctors’ offices, for instance. These studies find that physicians who receive opioid-related payments tend to prescribe more opioids.

A study in PLoS One from December 2018 looks at physicians who received opioid-related payments, some in 2014 and some in 2015, compared with doctors who never received such payments. The authors find that physicians who received opioid-related payments had a larger increase in the number of daily doses of opioids dispensed, as well as in total opioid expenditures, prescribing pricier opioids per dose.

Another study looking at the same data offers further detail. The study, published in Addiction in June 2019, focuses on 865,347 physicians across the country who filled prescriptions for Medicare patients from 2014 to 2016. “Prescribers who received opioid-specific payments prescribed 8,784 opioid daily doses per year more than their peers who did not receive any such payments,” the authors write.

Other research geographically links opioid marketing and opioid-related overdose mortality. The paper, published in JAMA Network Open in January 2019, analyzes county-level prescription opioid overdose deaths and county-level opioid marketing payments.

The authors find that deaths from prescription opioid overdoses increased with each standard deviation increase in opioid marketing as measured by dollars spent per capita, number of payments to physicians per capita and number of physicians receiving payments per capita. Standard deviation indicates the variation of a given value from the average. “Opioid prescribing rates also increased with marketing,” the authors write. They note that the higher prescription rate might be why overdose deaths increased.

Physician-level interventions:

An August 2018 study published in Science highlights the role physician education might play in addressing the nation’s opioid crisis. The intervention was simple: When a patient died of an opioid overdose, the county medical examiner sent the prescribing physicians a letter notifying them. The authors conducted a randomized trial of 861 physicians whose patients overdosed. The intervention group received the letter, which included a safe prescribing warning consisting of these recommendations:

• Avoid co-prescribing an opioid and a benzodiazepine.
• Minimize opioid prescribing for acute pain.
• Taper long-term users off opioids.
• Avoid prescriptions lasting for three consecutive months or longer and prescribe naloxone, an opioid overdose antidote.

The control group received no communication.

Physicians in the intervention group cut their opioid prescribing by 9.7% — as measured by milligram morphine equivalents in prescriptions filled — in the three months after the letter was sent. These physicians also started fewer patients on opioids and wrote fewer high-dose prescriptions than the control group.

Prescribing policies and guidelines also have successfully curbed physicians’ distribution of opioids.

In October 2017, the Michigan Opioid Prescribing Engagement Network released opioid prescribing guidelines for nine surgical procedures to clinicians participating in the Michigan Surgical Quality Collaborative, a statewide initiative to improve surgical care.

Researchers compared opioid prescribing before and after these guidelines were released, analyzing data from 11,716 patients across 43 hospitals collected from February 2017 to May 2018. They find that prescriptions declined, on average, from 26 pills to 18 pills per month after the guidelines were released.

Patients also took fewer of the pills they were prescribed. As measured by patient-reported survey data, opioid consumption following surgery dropped from 12 pills to nine, “possibly as a result of patients anchoring and adjusting their expectations for opioid use to smaller prescriptions,” explain the authors of the August 2019 New England Journal of Medicine study. Although patients received smaller prescriptions and used fewer pills after the guidelines were published, there were no substantial changes in the patients’ satisfaction and pain scores.

Similar to the study of Michigan’s opioid prescribing guidelines is a February 2018 study in the American Journal of Emergency Medicine that tracks the effects of an emergency department opioid prescribing policy. The policy resulted in declines in opioid prescriptions. Compared with the control emergency department, the two intervention hospitals had a more pronounced decline in opioid prescribing. The authors conclude that emergency department-based policies might help reduce opioid prescribing.

Prescription drug monitoring programs, which allow physicians to view patients’ prescription history to avoid overprescribing or prescribing opioids to people who don’t actually need them, have been shown to be less effective. A January 2018 study of national data published in Addictive Behaviors finds that there were not statistically significant differences in the likelihood that physicians would prescribe opioids for chronic pain when comparing states with prescription drug monitoring programs with those without.

Further reading

General overview

Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic

Allison L. Pitt, Keith Humphreys and Margaret L. Brandeau. American Journal of Public Health, October 2019.

The gist: “Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.”

Safe injection sites

Attendance at Supervised Injecting Facilities and Use of Detoxification Services

Evan Wood, Mark W. Tyndall, Ruth Zhang, Jo-Anne Stoltz, Calvin Lai, Julio S.G. Montaner and Thomas Kerr. New England Journal of Medicine, June 2006.

The gist: A study of Vancouver’s supervised injection facility finds “an average of at least weekly use of the supervised injecting facility and any contact with the facility’s addictions counselor were both independently associated with more rapid entry into a detoxification program.”

Injection Drug Use Cessation and Use of North America’s First Medically Supervised Safer Injecting Facility

Kora DeBeck, Thomas Kerr, Lorna Bird, Ruth Zhang, David Marsh, Mark Tyndall, Julio Montaner and Evan Wood. Drug and Alcohol Dependence, January 2011.

The gist: “These data indicate a potential role of SIF [supervised injecting facilities] in promoting increased uptake of addiction treatment and subsequent injection cessation.”

“A Little Heaven in Hell”: The Role of a Supervised Injection Facility in Transforming Place

Ehsan Jozaghi. Urban Geography, May 2013.

The gist: “Participants’ narratives indicate that attending InSite [Vancouver’s supervised injection facility] has had numerous positive effects in their lives, including changes in sharing behavior, improving health, establishing social support and saving their lives.”

Process and Predictors of Drug Treatment Referral and Referral Uptake at the Sydney Medically Supervised Injecting Centre

Jo Kimber, Richard P. Mattick, John Kaldor, Ingrid Van Beek, Stuart Gilmour and Jake A. Rance. Drug and Alcohol Review, May 2009.

The gist: Researchers conducted 1.5-year study at a supervised injection site in Sydney. They find that 16% of clients at the site referred to treatment by health and social welfare professionals went on to receive it, leading the authors to conclude that the center “engaged injecting drug users successfully in drug treatment referral and this was associated with presentation for drug treatment assessment and other health and psychosocial services.”

Inability to Access Addiction Treatment and Risk of HIV Infection Among Injection Drug Users Recruited from a Supervised Injection Facility

M.-J.S. Milloy, Thomas Kerr, Ruth Zhang, Mark Tyndall, Julio Montaner and Evan Wood. Journal of Public Health, September 2012.

The gist: Many who use supervised injection facilities have the desire to access treatment. This study surveyed 889 people who were randomly selected to be surveyed at Vancouver’s supervised injection facility. “At each interview, ∼20 percent of respondents reported trying but being unable to access any type of drug or alcohol treatment in the previous 6 months,” the authors write. The main barrier to access, respondents said, was waiting lists for treatment.

Big Pharma

The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy

Art Van Zee. American Journal of Public Health, February 2009.

The gist: In the first six years it was on the market, Purdue Pharma spent about six to 12 times more to promote OxyContin than it had to promote another long-lasting opioid. The paper describes various marketing strategies including promotional giveaways and Pharma-funded medical education programs.

Industry Payments to Physicians for Opioid Products, 2013-2015

Scott E. Hadland, Maxwell S. Krieger and Brandon D. L. Marshall. American Journal of Public Health, September 2017.

The gist: This study examines payments pharmaceutical companies make to physicians to market opioid products. The authors find that 375,266 opioid-related payments that weren’t related to research work were made to 68,177 physicians over the study period. The authors estimate that about 1 in 12 physicians in the U.S. received a payment from a pharmaceutical company to promote their opioid medications during the 29-month study period. The bulk of the money went toward speaking fees or honoraria, but the most common expense was food and beverages – 352,298 payments totaling $7,872,581.

Association of Pharmaceutical Industry Marketing of Opioid Products to Physicians with Subsequent Opioid Prescribing

Scott E. Hadland, Magdalena Cerdá, Yu Li, Maxwell S. Krieger and Brandon D. L. Marshall. JAMA Internal Medicine, June 2018.

The gist: “Whereas physicians receiving no opioid-related payments had fewer opioid claims in 2015 than in 2014, physicians receiving such payments had more opioid claims,” the authors write.

Physician-level interventions

Differences in Opioid Prescribing Practices among Plastic Surgery Trainees in the United States and Canada

David W. Grant, Hollie A. Power, Linh N. Vuong, Colin W. McInnes, Katherine B. Santosa, Jennifer F. Waljee and Susan E. Mackinnon. Plastic and Reconstructive Surgery, July 2019.

The gist: Plastic surgery trainees were asked about their opioid prescribing education, factors contributing to their prescribing practices and what they would prescribe for eight different procedures. The authors find that, of the 162 respondents, 25% of U.S. plastic surgery trainees received opioid-prescriber education, compared with 53% of Canadian trainees. For all but one of the eight procedures, U.S. physicians prescribed significantly more morphine milligram equivalents than their Canadian counterparts.

Subject experts

Caleb Alexander, professor and co-director of the Center for Drug Safety and Effectiveness, Johns Hopkins University.

Michael L. Barnett, assistant professor, Harvard T.H. Chan School of Public Health.

Chinazo Cunningham, professor, Albert Einstein College of Medicine.

Scott Hadland, assistant professor, Boston University School of Medicine

David N. Juurlink, scientist, Sunnybrook Research Institute.

Thomas Kerr, associate professor, The University of British Columbia.

For more, check out JR’s long read on the opioid prescribing problem, our summary of research on where opioids are prescribed the most and our tip sheet for reporting on fentanyl and synthetic opioids.

This piece adheres to suggestions offered by the National Institute on Drug Abuse’s media guide, which recommends language that avoids the potentially stigmatizing term “addict” in the context of substance use. It states: “In the past, people who used drugs were called ‘addicts.’ Current appropriate terms are people who use drugs and drug users.”

*Dropped out of race since publication date.

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When journalists cover academic research, they often face the challenge of explaining complex scientific findings in a way the public trusts and understands.

Fittingly enough, there are researchers dedicated to the study of just that, producing knowledge that may help journalists better communicate other research findings.

Dietram A. Scheufele, the Taylor-Bascom Chair in Science Communication at the University of Wisconsin-Madison, studies this topic.

His recent paper, “Science Audiences, Misinformation, and Fake News,” published in Proceedings of the National Academy of Sciences in April 2019, highlights some of the biggest challenges in science communication, including declining public trust in the news media.

Earlier this month, Scheufele, who’s also an affiliate at the Morgridge Institute for Research and who served as a fellow at Journalist’s Resource’s academic home, the Shorenstein Center, in fall 2010, spoke about ways to communicate science effectively as part of a panel discussion at the American Public Health Association’s annual meeting in Philadelphia.

Afterward, I followed up with him to ask how the media can help improve the public’s understanding of scientific research. The following interview has been edited for length and clarity.

Some of Scheufele’s main takeaways:

• Understand that terms that are now part of the common lexicon, such as “climate change,” or “gun control,” are the product of strategic framing. Framing is a tool used to explain complex topics by connecting them to already existent modes of thought and interpretation, for example through metaphor or specific vocabulary.
• Be mindful of how the media’s repetition of these terms might influence readers’ interpretation of an issue. For example, Scheufele explained that some people might associate the term “gun control” with a threat to their rights, whereas they might interpret “gun safety” differently — as the broad concept of avoiding gun accidents or mass shootings.
• Journalists should explain how policy makers and communications experts frame — and counter-frame — issues to provide context and perspective to readers.
• Consider reporting what the larger body of academic research indicates rather than a single study. Journalists, university communications offices and scientists all have been known to contribute to the so-called “single study” problem, prioritizing exceptional individual studies over larger patterns of findings.
• Beware that excessive press coverage of attacks against the media might exacerbate the issue, making the public less trusting of journalism.

Chloe Reichel: To get started, I want to pick up back where we left off at the APHA session. So you talked a bit about framing and how it’s so important because it influences how we interpret facts… I’m wondering what your tips are for journalists, on how to frame scientific research in a way that promotes science but also doesn’t land them in a spot of being accused of bias.

Dietram Scheufele: Framing… allows all of us to constantly make sense of the world, explain issues effectively, by basically making a complex topic applicable to a mental schema — call it a mental shelf, to use a different metaphor.

So it allows us to put it on one shelf that we already know and we interpret it in a particular way.

…

So, what does that mean for journalists? It means on the one hand, it’s really important to understand how carefully framed many of the messages are that come from different players in the policy arena, and that’s not any different for politics than it is for scientific issues. And really not blindly following a particular terminology.

CR: I’m wondering what you would say to the people who continue to push back when they hear the Guardian use “climate crisis,” or when they see “gun control” and they automatically assume that the writer just wants to abolish the Second Amendment.

DS: “Climate change” is a really good one. When [scientist and environmental policy professor] John Holdren … joined the [then-President Barack] Obama Office of Science and Technology Policy, he pushed somewhat for changing the wording and talking about “global climate disruption.” Also, to get away from this idea that this is either about warming or about just change but that is really going to disrupt everything from airplane travel to everything else. And Fox News pushed back pretty quickly and said, look you’re basically reframing the topic in order to push certain policy stances.

And I think this is where journalists have to be very careful, in terms of endorsing one term or the other. And you know that’s not any different for “gun control” and “gun safety,” than it is for the “death tax” or the “estate tax,” or for “exploring for energy” or “drilling for oil.” These are all intentionally-chosen terms.

…

Now if I start changing the language as a journalist, and I change it intentionally, I need to ask myself, why am I doing this? Am I doing this in order to raise awareness about an issue? And am I doing this to draw attention from readers to this issue — which I think is a very important purpose of journalism — or am I doing this in order to promote certain policy outcomes, because I think that we need to have certain types of policy proposals passed? And then I think, journalists leave themselves a little bit more vulnerable to partisan attacks if they do the latter.

…

I think, ultimately, the solution is twofold. One is to be very careful in what frames we end up adopting, especially if it means a change to the common vernacular.

But I think number two is, one tool that we’re underutilizing, if you look at most of the experiments on framing, they really depend on you only hearing one term versus the other. So some of the work that Daniel Kahneman had done back in the 70s that he won a Nobel Prize for in 2002 in economics, they depend on you not seeing the counter frame. You only see one of the two frames and most framing experiments actually show that very clearly. You know if you hear “gun control” all the time you have one view here and “gun safety” all the time you have another view. But we have very little data and I think this is where it’s good journalism comes in, it says, look, you’re being offered different interpretations with these different terms and engaging with the idea that different frames are designed from different political players, are designed to produce different outcomes, ultimately, is a matter of really helping citizens navigate public discourse.

CR: In your paper, you talk about how in surveys, only 1 in 10 Americans express a great deal of confidence in the press and about 3 in 4 think that the biggest problem with news about scientific research findings is the way news reporters cover it. And then you go on to discuss false balance and other ways that trust in the media is being undermined. But just getting back to reporting on scientific research findings, do you have suggestions for what journalists could do to communicate them in a way that audiences are more likely to find credible?

DS: This is as much of a problem with journalism as it is with how universities communicate about their research, and scientists themselves. The idea that we overemphasize individual studies over the larger patterns of findings that we have.

But we don’t believe in gravity because Newton dropped an apple. We believe in gravity because there have been hundreds and thousands of studies in I don’t know how many settings, at the planetary level and at the electron level, that have looked at the same principles. And so after those, now we’re pretty confident that this is a larger pattern.

…

As much as we can, we should focus in our coverage on what larger bodies of research tell us and not obsess too much about over what an individual study tells us. Because when that study gets retracted later, or when there’s another study that contradicts that study that says coffee’s good for you and says coffee is not good for you, that’s exactly when we potentially lose trust from readers.

I think the reason why the pattern is also important is because we’re going to be talking about things like replication. Questions about replication and reproducibility in psychology, for instance — how do we get across the idea that some of the processes of us constantly proving ourselves wrong is actually built into science?

Unless we’re able to communicate some of those internal self-corrective processes, we shouldn’t be surprised if there’s potentially some people in the public asking questions about, to which degree science is going the way it’s supposed to or not. And so I think it’s really important for scientists, public Information officers and science journalists to all pay attention to this issue.

The last thing that I’ll say about this, and I think it’s a really important one, especially for those of us in academia:  Science journalists, their job is not to be cheerleaders for science. Their job is not to translate and take the science that universities do and bring it to the public. Their job is to cover science as one democratic institution that we have; this is our best way of pushing frontiers of knowledge.

But their job is to cover that the way they would cover any other institution, meaning with a watchful eye toward what’s really going right, what’s exciting, and a watchful eye toward what sometimes may be going wrong, or, where the public should be paying attention. So I think part of our problem also comes from us — and by us meaning, various groups in the in the general public — having a warped understanding of what a science journalist’s job actually is.

CR: You also write in your paper that the media might be undermining itself through the discussion of “fake news” or mis- and disinformation. I thought that was an interesting point and spurs a number of questions, chief of mind wondering how the media could do a better job of covering attacks against the press.

DS: I think your assessment is totally right; it’s a Catch-22 to some degree. It’s not that you cannot write about it. But at the same time, the more you write about it, the more you amplify a message that’s ultimately designed to undermine your own work.

…

One of the things that the [Donald] Trump administration, in particular … has been really good at, is what in communications we call “agenda building,” so, influencing what ends up being covered by the press.

And, personally, I’ve seen very few Trump tweets talking about fake news on his Twitter feed, because I don’t follow it carefully enough; neither do most other people. But I’ve seen those tweets on CNN coverage, I’ve seen them on New York Times and Washington Post web pages. So I’ve basically seen the amplified effect through traditional news media. And the point that we’re making in the article is, it’s totally fine to acknowledge the fact that the Trump administration probably is not particularly fond of the news media, and is trying to undermine its credibility in order to be able to work around them or without them. But that doesn’t mean that I need to repeat and amplify and give a very broad forum to every tweet that keeps repeating that.

For more, check out our tip sheets on how to write about health research and viral nutrition research. We also have a resource on selecting and reporting on medical studies.

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At the American Public Health Association’s annual meeting in Philadelphia last week, researchers and public health leaders spoke on a range of topics affecting public health. In one session, Indivar Dutta-Gupta, co-executive director of the Center on Poverty and Inequality at Georgetown Law, explained the health implications of the 2020 census.

In the lead-up to the decennial population count, the Center is publishing a series of fact sheets, briefs and reports to outline the importance of a fair and accurate census.

Below, we summarize his most compelling points about why the census matters and what it will mean for public health in the United States.

Why the census matters

• It’s the country’s one shot at getting an accurate picture of who lives here, Dutta-Gupta explained. “The decennial census is the only attempt we make to count and collect information about everyone in the country. That’s it,” he said.
• The data gathered is used in a number of high-stakes applications. For example, it’s used to divide the 435 seats in the U.S. House of Representatives among the 50 states. It also guides an estimated $1.5 trillion dollars in federal funding, according to estimates from George Washington University’s Andrew Reamer. Dutta-Gupta continued, “A fair and accurate decennial census is essential to the equitable distribution of federal funding, and political power, and it’s essential for us to make smart decisions about how to solve social problems.”

What it will mean for health

• Shifts in political power, like the one that follows apportionment, can have health policy impacts. Consider, for example, how political shifts determined the fate of policies such as the Affordable Care Act.
• Census data influence a number of measures — the poverty level, for example — that guide the distribution of federal funds, Dutta-Gupta said. “Decennial data feed into other data that then are used to determine if [government] program providers are eligible for funding and which individuals are eligible for programs,” he explained.
• The $1.5 trillion in federal money guided by census data helps fund the following health-related programs:
  • the Children’s Health Insurance Program (CHIP)
  • Medicaid
  • Medicare
  • the Supplemental Nutrition Assistance Program (SNAP)
  • the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
  • community health centers funded through the Health Resources and Services Administration Health Center Program.
• Many national surveys rely on data collected through the decennial census. “One of the things that I’ve learned is that the decennial census really affects everything,” Dutta-Gupta said. “It affects basically every [national] survey that you can think of,” he said, explaining that Census data influences the sampling of subsequent surveys — it helps to establish what a representative population would look like on a smaller scale, and it helps to determine the “weighting,” or conversion between the sample population and general population. Dutta-Gupta cited the following surveys as influenced by census data: the U.S. Census Bureau-run Current Population Survey, the American Community Survey, and Survey of Income and Program Participation. These surveys are conducted at several timepoints throughout the year and measure labor participation, population and housing information, economic well-being, food security and rates of health insurance, among other things. Dutta-Gupta also mentioned that any survey that depends on inflation adjustments is in that way tied to census data. Additionally, the Healthcare Cost and Utilization Project, which also relies on census data, measures health-related factors such as income, educational attainment, housing, age, race, ethnicity, financial well-being, disability, fertility, health insurance coverage and costs, health care utilization and medical expenditures.
• Census data has a large impact on the assessment of certain health programs. Dutta-Gupta explained: “Decision-making, monitoring and assessment of program performance is also dependent on decennial data. For example, the Rural Health Program utilizes decennial census data to define non-urbanized areas and medically underserved community populations. These areas are classified basically entirely based on the counts of the decennial census initiative.”
• Some populations are often undercounted. “The Census Bureau aims to count everyone once, only once and in the right place. This commitment, however, is particularly tested when it comes to groups that we consider hard to count, like young children, people of color, people with low incomes, recent and undocumented immigrants, and people experiencing homelessness,” Dutta-Gupta noted. He later added in a phone interview, “The groups that tend to be omitted at the highest rate, unsurprisingly, are also the ones that would probably most benefit from greater access to and provision of health care and coverage.”
• Census data also can help researchers and government officials understand which communities are most vulnerable to the impacts of climate change. “People of color and low-income communities are some of the communities hit hardest by the climate crisis, and accurate decennial census data are needed to ensure environmental policies, practices and strategies are equitably developed and implemented,” Dutta-Gupta added.

Story ideas

For journalists looking for stories about what the decennial census means for public health, Dutta-Gupta suggested the following ideas:

• Dutta-Gupta explained in a phone interview that health-related coverage of the census rarely goes beyond the funding impacts it might have, and even when it does, this coverage typically is lacking in detail. He recommends asking state officials how state-run programs would be affected by potential funding cuts. For example, which benefits would they cut if they received less government funding?
• Dutta-Gupta also suggests looking at the role health-related institutions, like hospitals and doctors’ offices, might play in encouraging people to participate in the 2020 census. He advises journalists ask various health institutions whether and how they will assist with the count.
• Consider how public health could be affected if bad information about the census is shared with the public, whether intentionally or inadvertently. “We might start seeing tweets and all sorts of misinformation and disinformation around the census — just like we always see around voting,” he said in a phone interview. “I think that [mis- and disinformation] might have direct health implications itself,” such as psychological effects — fear and anxiety — which might in turn lead individuals to avoid using social programs such as Medicaid.

The post Why the 2020 census matters for public health: An explainer appeared first on The Journalist's Resource.

Print newspaper coverage of suicide falls short of expert recommendations suggested by the website Reporting on Suicide and the American Foundation for Suicide Prevention, new research in JAMA Network Open finds.

How the news media covers suicide matters. Research suggests that reports on celebrity suicides are linked to subsequent increases in suicides — a so-called “copycat” or contagion effect. Mental health advocates urge that thoughtful reporting — for example, stressing the preventable nature of suicide, working to destigmatize mental illness and avoiding the glamorization of a celebrity’s death — may prevent contagion and connect individuals with needed mental health resources.

Accordingly, projects such as Reporting on Suicide have enlisted the expertise of journalism and suicide prevention experts to develop guidelines for reporting on suicide. It’s worth noting here that these are recommendations, not rules. Individual newsrooms and news organizations may have their own guidelines for how to approach the topic of suicide — or have no guidelines at all. And individual journalists may have differing opinions about the media’s responsibility in covering the issue.

It’s also worth noting that the guidelines are largely based on peer-reviewed research. As the “About” page on the Reporting on Suicide website explains, “The recommendations are based on more than 50 international studies on suicide contagion.”

The new study scrutinizes 10 print newspapers’ coverage of two celebrities who recently died by suicide — designer Kate Spade on June 5, 2018 and chef Anthony Bourdain on June 8, 2018.

The newspapers included in the study represent all regions of the U.S. and had a minimum print circulation of 200,000.  The papers included were the Chicago Tribune, Denver Post, Houston Chronicle, Los Angeles Times, New York Times, Seattle Times, Tampa Bay Times, USA Today, Wall Street Journal and Washington Post.

The authors wanted to focus on papers with wide readership because of their larger impact and because they tend to feature original reporting and writing on suicide deaths instead of republishing wire stories, John P. Ackerman, senior author on the paper and the suicide prevention coordinator for the Center for Suicide Prevention and Research at Nationwide Children’s Hospital in Columbus, Ohio explains.

In coverage from the day after each of the deaths, researchers examined how closely the publications followed 14 guidelines gleaned from Reporting on Suicide and the American Foundation for Suicide Prevention on covering suicide responsibly. June 11 was used for reporting on Bourdain’s death in USA Today, because it publishes in print on weekdays only.

“A really unfortunate natural experiment arose with Kate Spade and Anthony Bourdain’s deaths that occurred closely together,” says Ackerman.

Some of the media coverage of Spade’s death was criticized by suicide prevention organizations and research organizations (such as the Annenberg Public Policy Center) for its sensationalist bent, including details such as the color of a scarf used as the lethal means.

He explains that his team was interested in whether coverage of Bourdain’s death just a few days after Spade’s followed more guidelines, perhaps in response to this criticism.

The researchers find that reports of Bourdain’s death adhered to more of the 14 guidelines than reports on Spade’s death. That, they note, indicates that criticism of the coverage of Spade’s death might have influenced how journalists covered Bourdain’s death.

However, none of the papers studied adhered to all 14 guidelines in their coverage of either death.

They all followed two of the guidelines, however: to avoid including “a single-cause explanation for suicide death” and avoid “referring to suicide as a growing problem, epidemic, or skyrocketing.”

None of the newspapers followed these two guidelines: to share a hopeful message that suicide is preventable and convey that suicidal behaviors can be reduced with mental health support.

For both deaths, most newspapers followed less than half the 14 guidelines.

Fewer than one-third followed six of them.

“Fairly consistently, [newspapers] weren’t doing the things that we know are pretty straightforward,” Ackerman says. He calls it “a missed opportunity to support those who are most vulnerable.”

He says the main goal of the study “is not to wag fingers at journalists.”

“It’s to say, not only can you reduce the harm of a story about a celebrity suicide, but there’s things that you can do that can potentially create a very positive impact,” he says. “There’s so many messages out there that could really be helpful.”

Ackerman says that effective journalistic practices include linking suicide to underlying mental health causes, stressing that suicidal crises are typically short-lived, providing details about resources available and reporting that most people who survive suicide attempts will not go on to die by suicide.

He suggests that training journalists early in their careers could help improve adherence to guidelines. He also recommends newsrooms use a checklist developed by Reportingonsuicide.org.

“It’s striking that we still treat the topic of suicide with a level of stigma and morbid curiosity that we don’t cover other forms of death with,” he says. “If a person died of a heart attack, would you be talking about the scarf that they were wearing? So I think we still have a ways to go in not sensationalizing this.”

But, he says, the groundwork is in place for positive change to occur.

“There are guidelines that are easily accessible,” he says “There are resources that can be added to any story, without too much additional effort or space.”

What to do (and what to avoid) when reporting on suicide

According to the 14 guidelines, responsible news coverage of suicide:

Shares a hopeful message that suicide is preventable.

Conveys that suicidal behaviors can be reduced with mental health support and treatment.

Provides helpful information, such as warning signs or risk factors of suicide.

Does not provide details about the location of the death.

Provides the National Suicide Prevention Lifeline phone number.

Does not include details or images of the lethal means or method used.

Is not prominently placed in the newspaper.

Does not describe suicide as inexplicable or without warning.

Does not report specific details concerning notes left behind.

Uses language preferred by mental health advocates, e.g., “died by suicide” rather than “committed suicide.”

Uses a photo that focuses on the individual’s life instead of his or her death.

Uses a non-sensational headline.

Avoids single-cause explanation for suicide death.

Avoids referring to suicide as a growing problem, epidemic or skyrocketing.

Per the guidelines above, we are including the number for the National Suicide Prevention Lifeline, a toll-free hotline available to people having thoughts of suicide. That number is 1-800-273-8255 (TALK). SpeakingOfSuicide.com/resources includes a list of additional resources for people having suicidal thoughts, as well as resources for their friends and families.

More research: Journalists perpetuate myth about suicide during winter holidays; Suicide prevention: Research on successful interventions; How the news media impacts suicide trends: Research roundup

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