Stakeholder Actions and Their Impact on the Organizational Cultures of Two Tobacco Companies

We link the behaviors of executives and lawyers in two tobacco companies, in defending their tobacco products to the actions of stakeholders (e.g., the U.S. Government and Congress, medical researchers, consumers, public‐health organizations, tobacco‐control advocates, and insiders who have spoken out). Included in our analysis, which is based on publicly available documents spanning over a period of almost six decades, are critical incidents in which moral disengagement tactics were applied in the decision‐making process. We infer that the disengagement tactics applied by tobacco decision makers are indicative of what Schein and other organizational scientists describe as organizational culture. We equate the critical incidents to the espoused beliefs and values and underlying assumptions which comprise organizational culture and explain that the cultures of these two tobacco companies are not consistent with the stakeholder theory of management. We conclude that the critical incidents we analyze were immoral and the representatives were indeed accountable for these behaviors. From an organizational change perspective, we discuss how analyzing these critical incidents can serve to assess the extent to which an organizational culture is ethical. Furthermore, these critical incidents can be fed back to organizational decision makers and can then be used to initiate organizational changes.     

Sometimes we're our own worst enemies

There is a sense of frustration among physicians involved in the decision and policy making processes within health care institutions. Because the endpoint is reached at glacial speed, too much time, money, and opportunity is lost. The decision making process can be repetitious and tedious because of unnecessary steps. By eliminating certain tactics and strategies employed by upper-level management in many health care institutions, the decision making process becomes more effective. This article focuses on the medical staff's role in the decision making process; explains why tactics to involve the medical staff are ineffective and why eliminating the medical staff from certain aspects of the process does not jeopardize the institution; and concludes that the hospital board and its delegates should be autonomous in the decision making process.     

Designing Referral Network Structures and Decision Rules to Streamline Provision of Urgent Health and Human Services*

This study uses fully factorial computer simulation to identify referral network attributes and referral decision rules that streamline the routing of people to urgent, limited services. As an example of a scenario, the model represents vaccine delivery in a city of 100,000 people during the first 30 days of a pandemic. By modeling patterns of communication among health care providers and daily routing of overflow clients to affiliated organizations, the simulations determine cumulative effects of referral network designs and decision rules on citywide delivery of available vaccines. Referral networks generally improve delivery rates when compared with random local search by clients. Increasing the health care organizations’ tendencies to form referral partnerships from zero to about four partners per organization sharply increases vaccine delivery under most conditions, but further increases in partnering yield little or no gain in system performance. When making referrals, probabilistic selection among partner organizations that have any capacity to deliver vaccines is more effective than selection of the highest‐capacity partner, except when tendencies to form partnerships are very low. Implications for designing health and human service referral networks and helping practitioners optimize their use of the networks are discussed. Suggestions for using simulations to model comparable systems are provided.     

Environmental Tobacco Smoke: Science vs. Rhetoric

After an extensive review and analysis of the scientific evidence on the respiratory health effects of passive smoking, the U.S. Environmental Protection Agency concluded that environmental tobacco smoke causes lung cancer in adult nonsmokers and increases the risk of a variety of non-cancer respiratory disorders, especially in children. This article is a response to claims in Dr. Gio Gori's article "Policy Against Science: The Case of Environmental Tobacco Smoke," appearing in the same issue of this journal, that such conclusions are unwarranted. This response focuses only on the respiratory health effects of environmental tobacco smoke.     

Canada's Health Status: A Public Health Perspective1

Health status assessment and disease surveillance are essential to identify and priorize health issues, to evaluate intervention programs and to plan to meet future needs for health services. Canadians currently benefit by having among the highest life expectancies at birth in the world (81 for females, 74 for males). Disability-free life expectancies for females and males, respectively, were 10.1 and 11.3 years lower for the lowest income quintile compared to the highest. Canada's infant mortality rate in 1990 (7/1000 live births) was one of the lowest in the world but within Canada, the rate in the lowest income quintile (10.5/1000 live births) was almost double that in the highest income quintile (5.8/1000 live births). Fair or poor health was reported by 36% of adult Canadians in the lowest income category in 1990 compared to only 5% in the highest income group. The leading causes of premature death for females in 1991 were breast cancer, coronary heart disease, lung cancer, car crashes, birth defects and suicide; those for males were coronary heart disease, suicide, car crashes, lung cancer, birth defects, and AIDS. Lowest income quintile males had mortality rates at least double those for the highest income quintile for alcohol-related conditions, violence, injuries and emphysema. Cardiovascular diseases, cancer, musculoskeletal diseases, injuries and respiratory diseases imposed the highest direct and indirect economic costs in Canada in 1986. For all of these conditions, improved prevention is possible. For example, the forecasted tobacco-related deaths before age 70 among current male smokers age 15 will far exceed those due to car crashes, suicide, murder, AIDS, and drug abuse combined. Population aging will aggravate trends for many chronic conditions especially those with increasing incidence rates; there will be large increases in the numbers of persons with aging-related cancers, dementias and other conditions. There is an urgent need for Canadian health jurisdictions to ensure that rational priorities, goals/objectives, strategies, and programs are in place to enhance prevention and disease control.     

Estimating the Health Impacts of Tobacco Harm Reduction Policies: A Simulation Modeling Approach

With adult smoking prevalence rates declining too slowly to reach national objectives, opinion leaders are considering policies to improve tobacco-related outcomes by regulating the composition of cigarettes to be (1) less harmful and/or (2) less addictive. Because harm reduction efforts may actually encourage higher cigarette consumption by promoting a safer image, and addictiveness reduction may increase the harmfulness of cigarettes by encouraging compensatory smoking behaviors, policymakers must consider the tradeoffs between these two approaches when proposing legislation to control cigarette content. To estimate health impacts, we developed a dynamic computer model simulating changes in the age- and gender-specific smoking behaviors of the U.S. population over time. Secondary data for model parameters were obtained from publicly available sources. Population health impacts were measured as change in smoking prevalence and the change in cumulative quality-adjusted life-years (QALYs) in the U.S. population over 75 years. According to the risk-use threshold matrix generated by the simulation, modifying cigarettes to reduce their harmfulness and/or addictiveness could result in important gains to the nation's health. Addictiveness reduction efforts producing a 60% improvement in smoking behavior change probabilities would produce a net gain in population health at every plausible level of increase of smoking-related harm that was modeled. A 40% reduction in smoking-related harm would produce a net QALY gain at every level of behavior change considered. This research should prove useful to policymakers as they contemplate giving the FDA the authority to regulate the composition of cigarettes.     

一种基于区间直觉梯形模糊数偏好的大群体决策冲突测度研究

针对决策偏好为区间直觉梯形模糊数的大群体决策冲突测度问题,首先给出了两个区间直觉梯形模糊数的距离,提出了群体成员冲突函数,基于该函数对大群体成员偏好进行聚类形成若干聚集,以此为基础提出了聚集冲突测度模型并集结为群体冲突测度模型,然后应用于大群体偏好集结。最后通过一个算例对模型进行了验证。该模型便于大群体意见的分析与协调,适用于群决策支持系统,在应急决策中具有实际应用价值。     

Chemical and biological agent incident response and decision process for civilian and public sector facilities.

In the event of a terrorist attack or catastrophic release involving potential chemical and/or biological warfare agents, decisionmakers will need to make timely and informed choices about whether, or how, to respond. The objective of this article is to provide a decision framework to specify initial and follow-up actions, including possible decontamination, and to address long-term health and environmental issues. This decision framework consists of four phases, beginning with the identification of an incident and ending with verification that cleanup and remediation criteria have been met. The flowchart takes into account both differences and similarities among potential agents or toxins at key points in the decision-making process. Risk evaluation and communication of information to the public must be done throughout the process to ensure a successful effort.     

A Dynamic Model to Assess Microbial Health Risks Associated with Beneficial Uses of Biosolids

There is increasing interest in the development of a microbial risk assessment methodology for regulatory and operational decision making. This document presents a methodology for assessing risks to human health from pathogen exposure using a population-based model that explicitly accounts for properties unique to an infectious disease process, specifically secondary transmission and immunity. To demonstrate the applicability of this risk-based method, numerical simulations were carried out for a case study example in which the route of exposure was direct consumption of biosolids-amended soil and the pathogen present in the soil was enterovirus. The output from the case study yielded a decision tree that differentiates between conditions in which the relative risk from biosolids exposure is high and those conditions in which the relative risk from biosolids is low. This decision tree illustrates the interaction among the important factors in quantifying risk. For the case study example, these factors include biosolids treatment processes, the pathogen shedding rate of infectious individuals, secondary transmission, and immunity. Further refinement in methods for determining biosolids exposures under field conditions would certainly increase the utility of these approaches.     

Decision Style in British and Swedish Organizations: A Comparative Examination of Strategic Decision Making

In this paper results from parallel large scale studies of strategic decision making in Sweden and the United Kingdom are reported. Swedish decision makers are found to employ a decision making style which emphasizes negotiation within a restricted group. This style, which involves considerable information search, leads to very long decision times. Strategic decisions in Britain are made among groups which include fewer strongly committed participants. Delays are common and often serious, but do not lengthen the process unduly. Decision styles in both countries include contrasting tendencies which produce a dynamic tension in the decision arena.     

Selecting human health metrics for environmental decision-support tools.

Environmental decision‐support tools often predict a multitude of different human health effects due to environmental stressors. The accounting and aggregating of these morbidity and mortality outcomes is key to support decision making and can be accomplished by different methods that we call human health metrics. This article attempts to answer two questions: Does it matter which metric is chosen? and What are the relevant characteristics of these metrics in environmental applications? Three metrics (quality adjusted life years (QALYs), disability adjusted life years (DALYs), and willingness to pay (WTP)) have been applied to the same diverse set of health effects due to environmental impacts. In this example, the choice of metric mattered for the ranking of these environmental impacts and it was found for this example that WTP was dominated by mortality outcomes. Further, QALYs and DALYs are sensitive to mild illnesses that affect large numbers of people and the severity of these mild illnesses are difficult to assess. Eight guiding questions are provided in order to help select human health metrics for environmental decision‐support tools. Since health metrics tend to follow the paradigm of utility maximization, these metrics may be supplemented with a semi‐quantitative discussion of distributional and ethical aspects. Finally, the magnitude of age‐dependent disutility due to mortality for both monetary and nonmonetary metrics may bear the largest practical relevance for future research.     

A NOTE ON THE RELATIONSHIPS AMONG FINENESS,GARBLING, AND SUFFICIENCY FOR THE COMPARISON OF INFORMATION SYSTEMS*

Choice among competing information systems is an important problem for both the providers and users of information. When the attributes of the decision makers and decision problems for which information is produced are unknown or heterogeneous, it is difficult to choose among alternative information sources. Three criteria for such comparisons of information systems are available in the theory of information economics. These criteria may be distinguished by the differing restrictions that they impose on the generality of the studies in which they are used. This note explicates the relationships among these criteria and discusses the various limitations that they impose on generality.     

Risk Perception in Context: The Savannah River Site Stakeholder Study

Environmental managers are increasingly charged with involving the public in the development and modification of policies regarding risks to human health and the environment. Involving the public in environmental decision making first requires a broad understanding of how and why the public perceives various risks. The Savannah River Stakeholder Study was conducted with the purpose of investigating individual, economic, and social characteristics of risk perceptions among those living near the Savannah River Nuclear Weapons Site. A number of factors were found to impact risk perceptions among those living near the site. One's estimated proximity to the site and relative river location surfaced as strong determinants of risk perceptions among SRS residents. Additionally, living in a quality neighborhood and demonstrating a willingness to accept health risks for economic gain strongly abated heightened risk perceptions.The Consortium for Risk Evaluation with Stakeholder Participation (CRESP)The Consortium for Risk Evaluation with Stakeholder Participation (CRESP)The Consortium for Risk Evaluation with Stakeholder Participation (CRESP)     

Is the Precautionary Principle Really Incoherent?

The Precautionary Principle has been an increasingly important principle in international treaties since the 1980s. Through varying formulations, it states that when an activity can lead to a catastrophe for human health or the environment, measures should be taken to prevent it even if the cause‐and‐effect relationship is not fully established scientifically. The Precautionary Principle has been critically discussed from many sides. This article concentrates on a theoretical argument by Peterson (2006) according to which the Precautionary Principle is incoherent with other desiderata of rational decision making, and thus cannot be used as a decision rule that selects an action among several ones. I claim here that Peterson's argument fails to establish the incoherence of the Precautionary Principle, by attacking three of its premises. I argue (i) that Peterson's treatment of uncertainties lacks generality, (ii) that his Archimedian condition is problematic for incommensurability reasons, and (iii) that his explication of the Precautionary Principle is not adequate. This leads me to conjecture that the Precautionary Principle can be envisaged as a coherent decision rule, again.     

Integrated Uncertainty Analysis for Ambient Pollutant Health Risk Assessment: A Case Study of Ozone Mortality Risk

The U.S. Environmental Protection Agency (EPA) uses health risk assessment to help inform its decisions in setting national ambient air quality standards (NAAQS). EPA's standard approach is to make epidemiologically‐based risk estimates based on a single statistical model selected from the scientific literature, called the “core” model. The uncertainty presented for “core” risk estimates reflects only the statistical uncertainty associated with that one model's concentration‐response function parameter estimate(s). However, epidemiologically‐based risk estimates are also subject to “model uncertainty,” which is a lack of knowledge about which of many plausible model specifications and data sets best reflects the true relationship between health and ambient pollutant concentrations. In 2002, a National Academies of Sciences (NAS) committee recommended that model uncertainty be integrated into EPA's standard risk analysis approach. This article discusses how model uncertainty can be taken into account with an integrated uncertainty analysis (IUA) of health risk estimates. It provides an illustrative numerical example based on risk of premature death from respiratory mortality due to long‐term exposures to ambient ozone, which is a health risk considered in the 2015 ozone NAAQS decision. This example demonstrates that use of IUA to quantitatively incorporate key model uncertainties into risk estimates produces a substantially altered understanding of the potential public health gain of a NAAQS policy decision, and that IUA can also produce more helpful insights to guide that decision, such as evidence of decreasing incremental health gains from progressive tightening of a NAAQS.     

Explaining Public Resistance to Genetically Modified Corn: An Analysis of the Distribution of Benefits and Risks

Genetically modified (GM) crops have met with widespread approval among scientists and policy makers in the United States, but public approval of GM crops, both domestically and abroad, is progressing much more slowly. An underlying cause of public wariness may be that both nations and individual consumers do not perceive significant benefits to themselves from GM crops, while fearing the risks they may incur. In this study, an economic analysis is conducted to determine whether the benefits of one type of GM corn, Bt corn (genetically modified to resist damage from the ECB and Southwestern corn borer), outweigh the potential risks; and who the "winners" and "losers" are among stakeholder groups that may be affected by Bt corn. It is found that Bt corn growers, consumers, and industry all benefit from Bt corn adoption, though the purported health and environmental benefits of reducing chemical pesticide usage through Bt corn are negligible. Though the aggregated public benefit is large, the welfare gain to individual consumers is small and may not make up for perceived risks. While environmental and health risks of Bt corn are unlikely, the potential market risks-impacting both the organic corn market and total U.S. corn exports-are found to be significant. Currently, distributional analysis is not a part of regulatory decision making of Bt corn in the United States; yet it may help to explain why decision makers at both the government and individual-consumer levels have failed to embrace Bt corn and other GM crops.     

A Method for Comparing the Impact on Carcinogenicity of Tobacco Products: A Case Study on Heated Tobacco Versus Cigarettes

Comparing the harmful health effects related to two different tobacco products by applying common risk assessment methods to each individual compound is problematic. We developed a method that circumvents some of these problems by focusing on the change in cumulative exposure (CCE) of the compounds emitted by the two products considered. The method consists of six steps. The first three steps encompass dose-response analysis of cancer data, resulting in relative potency factors with confidence intervals. The fourth step evaluates emission data, resulting in confidence intervals for the expected emission of each compound. The fifth step calculates the change in CCE, probabilistically, resulting in an uncertainty range for the CCE. The sixth step estimates the associated health impact by combining the CCE with relevant dose-response information. As an illustrative case study, we applied the method to eight carcinogens occurring both in the emissions of heated tobacco products (HTPs), a novel class of tobacco products, and tobacco smoke. The CCE was estimated to be 10- to 25-fold lower when using HTPs instead of cigarettes. Such a change indicates a substantially smaller reduction in expected life span, based on available dose-response information in smokers. However, this is a preliminary conclusion, as only eight carcinogens were considered so far. Furthermore, an unfavorable health impact related to HTPs remains as compared to complete abstinence. Our method results in useful information that may help policy makers in better understanding the potential health impact of new tobacco and related products. A similar approach can be used to compare the carcinogenicity of other mixtures.     

Physician and nonphysician managers as decision makers: are the differences justified or just an illusion?

If the cost of health care is to be curtailed, it is necessary to understand physician behavior and decision making. Not only is physician decision making critical from a clinical perspective, but, as the number of physician executives increases, they must be able to integrate their clinical expertise and management skills into the business context. This article explores differences in decision making methods between physician and nonphysician managers.     

The tobacco wars: back to the states

With the United States Senate's failure to pass comprehensive tobacco legislation, the fight to recover public health costs from big tobacco shifts back to the states. The question for those working to reduce youth smoking rates is whether that battle can be accomplished at the state level.     

The Informatics Institute: why do we need it?

Why should physician executives care about medical informatics? For that matter, what is medical informatics anyway? Broadly defined, medical informatics is the study of the collection, storage, retrieval, and analysis of data and information in health care to support clinical and administrative decision making. Informatics is important because, in the past 10 years, powerful computer, software, and information technologies have been developed to enable health care organizations to automate some of the work of decision making, for improved quality of care and cost control, and for successful managed care contracting. This new emphasis on informatics in health care was the impetus for the founding by ACPE earlier this year of The Informatics Institute, which will be involved in educational and research activities in the growing area of medical informatics. In this new column in Physician Executive, Dr. Marshall Ruffin, President and CEO of the Institute, will discuss the role of medical informatics in health care delivery and financing and its relation to physician executives.