What? What?

Ripped from the headlines of the New England Journal of Medicine:

“Results. In 5,063,622 person-years of follow-up, 10,235 men and 4318 women for whom childhood BMI data were available received a diagnosis of CHD or died of CHD as adults. The risk of any CHD event, a nonfatal event, and a fatal event among adults was positively associated with BMI at 7 to 13 years of age for boys and 10 to 13 years of age for girls. The associations were linear for each age, and the risk increased across the entire BMI distribution. Furthermore, the risk increased as the age of the child increased. Adjustment for birth weight strengthened the results.

Conclusions. Higher BMI during childhood is associated with an increased risk of CHD in adulthood. The associations are stronger in boys than in girls and increase with the age of the child in both sexes. Our findings suggest that as children are becoming heavier worldwide, greater numbers of them are at risk of having CHD in adulthood.”

This is from an article entitled, “Childhood Body-Mass Index and the Risk of Coronary Heart Disease in Adulthood,” authored by Jennifer Baker and colleagues. (You can read the entire article here.)

First, let me congratulate Dr. Baker who is listed as a post doc researcher at the Institute for Preventative Health in Copenhagen. She must be bouncing off the walls right now because a NEJM vita hit as a post doc is a major accomplishment. Lots of joy and happiness with the Baker people and her colleagues.

Second, let me sharply disagree with just about everyone connected to this research. The abstract notably omits any quantitative values in the Results portion which is fishy given that this is an epidemological study which means it’s only about numbers. Instead we get the rhetorical weasel word, “significant,” as the standard by which we understand the outcomes. See, kids who are heavy have “significantly” more heart disease as adults compared to kids who are lighter.

Sounds signficant, doesn’t it? Certainly the reviewers and editors at the New England Journal of Medicine thought it must be . . . significant. So what are the numbers? I mean, we’re all adults here, the children are in bed, so we can speak frankly.

The relative risk for heavy kids is 1.10.

That means, for example, if light kids have a rate of 10 per 100,000 for heart disease, then heavy kids will have a rate of 11 per 100,000. I’d give you the actual numbers from the study, except that the researchers did not provide the absolute rates or if they did they described them so poorly that I cannot tell for sure what’s going on. They do provide a lot of Tables with various relative risk ratios none of which exceed 1.10.

This is an absurb study and it is absurd that the NEJM published it and it is absurd how it is presented.

As I’ve noted much earlier, based on my forceful, relentless, and unique method of analysis, I’m predicting that Hillary Clinton and Rudy Giuliani will win the nominations of their respective parties and that Senator Clinton will win the general election. Until everyone in the race wakes up to this unavoidable persuasion truth, we continue the charade that these primaries actually matter. Sigh. Onward.

Currently, Clinton hammers away at her nearest competition, Barack Obama, and based on results in Nevada and New Hampshire, the attacks are working. The interesting persuasion question here is: What is Senator Obama’s method of defense? Here’s a quote from the New York Times that seems to be (from my general reading of many sources) the basic tactic.

Mr. Obama, asked in a brief interview whether his rivals had distracted him from making a positive case to voters, snapped: “Why would that rattle me? My suspicion is the other side must be rattled if they’re continually saying false things about us.”

The key phrase here is “saying false things.” Obama seems to think that when the Other Side makes arguments against you, the best persuasion response is to relabel those arguments as “false.” This has been a consistent line with Mr. Obama since Mrs. Clinton began to argumentatively dispute Obama’s issues and positions. When the Other Side makes a negative claim about me, respond by saying the negative claim is false.

As a persuasion expert extraordinaire, I must admit to being perplexed at this tactic. I’ve noted in the past with great embarassment, I did not attend Harvard or Law School, and maybe in my 30 year career as a persuasion maven, I missed the line of research that supports the “it’s false” line of defense against attacks. Nothing in my vast, deep, and complex reservoir of persuasion wisdom suggests, nay, whispers that when the Other Side is raising negative arguments about you that the best persuasion tactic is to, in essence, throw a yellow flag, and call the play, “false.” My sports metaphor is most apt in this instance as Mr. Obama seems to think that in politics there is an official referee and that he can play that role, too. Hey, that claim is out of bounds, 15 yard personal foul, play on.

Generally speaking the evidence strongly indicates that politics is like a knife fight - you know you are going to get cut, so just expect it and deal with it. The most common response is, therefore, cut back in response. (The theatrical sigh of unsophisticated observors about “going negative” is the mark of someone who’s never been in knife fight.)

The newest tactic is inoculation and you can read all about it. Basically, you use inoculation in advance of the knife fight and the anticipated cuts you’re going to receive. The tactic aims at reducing the damage or deflecting the attack. Perhaps the greatest example of inoculation comes from none other than former President Bill Clinton in 1992 and his infamous “woman problem,” then with Gennifer Flowers (how about that for a flashback?). Ms. Flowers let it be known privately that she was about to go public with allegations of an adulterous relationship with Candidate Bill Clinton early in the 1992 primaries. The Clinton campaign used this private knowledge to make a hasty appearance on the TV show, “60 Minutes,” literally the night before Ms. Flowers called her press conference. We know how it all worked out. Inoculation works.

Yet, Senator Obama appears to have superior persuasion knowledge and the “it’s false” defense. I wonder if he picked it up while watching “Cops” on TV. Doesn’t it seem that most of the suspects try to use the “it’s false” defense?

Past the bad kidding here, this looks like the response of an unexperienced, untrained, and unschooled persuader. Mr. Obama has been noted as a compelling speaker, but he clearly lacks basic persuasion skill. He orates effectively, but he can’t take a punch very well. Stated another, old fashioned way (with a tip of the hat to Aristotle) Senator Obama is good at ceremonial speaking, but not at political speaking.

I’m probably more than a little biased here because of my predictions, so take this with a grain of salt and a little patience.  If Mr. Obama doesn’t come up with some besides “Hillary is lying about me and so is her husband” then he should be giving a speech something like Fred Thompson did today.  And if Obama defies persuasion gravity (and my expert prognostication) and wins, well then, maybe I’m applying to Harvard.  Go Crimson!  Rah! Rah! Rah!

The most recent issue of the Journal of the American Medical Association reports a study that is shocking and I’ll bet you dollars to donuts that it won’t get much attention. Just read the abstract:

Persistence of Contradicted Claims in the Literature

Athina Tatsioni, MD; Nikolaos G. Bonitsis, MD; John P. A. Ioannidis, MD
JAMA. 2007;298(21):2517-2526.

Context Some research findings based on observational epidemiology are contradicted by randomized trials, but may nevertheless still be supported in some scientific circles.

Objectives To evaluate the change over time in the content of citations for 2 highly cited epidemiological studies that proposed major cardiovascular benefits associated with vitamin E in 1993; and to understand how these benefits continued being defended in the literature, despite strong contradicting evidence from large randomized clinical trials (RCTs). To examine the generalizability of these findings, we also examined the extent of persistence of supporting citations for the highly cited and contradicted protective effects of beta-carotene on cancer and of estrogen on Alzheimer disease.

Data Sources For vitamin E, we sampled articles published in 1997, 2001, and 2005 (before, early, and late after publication of refuting evidence) that referenced the highly cited epidemiological studies and separately sampled articles published in 2005 and referencing the major contradicting RCT (HOPE trial). We also sampled articles published in 2006 that referenced highly cited articles proposing benefits associated with beta-carotene for cancer (published in 1981 and contradicted long ago by RCTs in 1994-1996) and estrogen for Alzheimer disease (published in 1996 and contradicted recently by RCTs in 2004).

Data Extraction The stance of the citing articles was rated as favorable, equivocal, and unfavorable to the intervention. We also recorded the range of counterarguments raised to defend effectiveness against contradicting evidence.

Results For the 2 vitamin E epidemiological studies, even in 2005, 50% of citing articles remained favorable. A favorable stance was independently less likely in more recent articles, specifically in articles that also cited the HOPE trial (odds ratio for 2001, 0.05 [95% confidence interval, 0.01-0.19; P < .001] and the odds ratio for 2005, 0.06 [95% confidence interval, 0.02-0.24; P < .001], as compared with 1997), and in general/internal medicine vs specialty journals. Among articles citing the HOPE trial in 2005, 41.4% were unfavorable. In 2006, 62.5% of articles referencing the highly cited article that had proposed beta-carotene and 61.7% of those referencing the highly cited article on estrogen effectiveness were still favorable; 100% and 96%, respectively, of the citations appeared in specialty journals; and citations were significantly less favorable (P = .001 and P = .009, respectively) when the major contradicting trials were also mentioned. Counterarguments defending vitamin E or estrogen included diverse selection and information biases and genuine differences across studies in participants, interventions, cointerventions, and outcomes. Favorable citations to beta-carotene, long after evidence contradicted its effectiveness, did not consider the contradicting evidence.

Conclusion Claims from highly cited observational studies persist and continue to be supported in the medical literature despite strong contradictory evidence from randomized trials.

Author Affiliations: Department of Hygiene and Epidemiology, (Drs Tatsioni, Bonitsis, and Ioannidis) and the Department of Dermatology (Dr Bonitsis), University of Ioannina School of Medicine; and the Biomedical Research Institute, Foundation for Research and Technology-Hellas (Dr Ioannidis), Ioannina, Greece; Institute for Clinical Research and Health Policy Studies, Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts (Drs Tatsioni and Ioannidis).

Even if you are not trained as a statistician you get the drift from the article title. Doctors persist in believing disproven claims. Let’s drill down a bit here.

The researchers in this article draw a distinction between information generated from “epidemiological” studies versus information generated from “randomized controlled trials (RCT).” These researchers put forth the claim that RCTs are the gold standard and if epi studies conflict with the experiments, science goes with the experiments. (If you want all the pain and glory of learning about these things you can start with this chapter from Steve’s Primer on research methods. You’ll like it. Really. It won’t hurt a bit.)

To demonstrate their point, the researchers use the example of Vitamin E studies. The initial findings of a positive effect for using Vitamin E came from a couple of epi studies published in the early 1990s. (I remember reading the NEJM one and using it in, of all things, a large lecture introductory media effects class - the kids were bedazzled.) An epi study is a type of survey where you ask a lot of people (millions sometimes), “Do you take Vitamin E?” and then wait 10 years and ask all the same people, “Are you still alive?” Now, of course, you ask a lot more than the Vitamin E question and you also ask for other interesting outcomes besides mortality, but you get the point.

Experimenters, by contrast, take a slightly different approach. They will get a smaller group of people (sometimes less than one hundred), give everyone a pill, but some folks are randomly assigned a real Vitamin E pill while the others get sugar pill, a placebo. The researchers then watch everyone for awhile and see if anyone dies or gets sick or files a lawsuit.

Experimenters typically mistrust epi researchers while epi researchers tend to view themselves as the true Children of Science. Let’s just say that there is a tension between the RCP folks and those epi mavens. Oddly enough, I am an experimentalist and I can also play statistics like chords on a guitar, so guess where my biases lie. Back to the opera.

We have frightening evidence that medical researchers and physicians and nurses and all those people who went to Schools of Medicine or Public Health, keep on believing things that are untrue. And not just believing, they keep on citing them, teaching them, defending them.

There is likely to be a brief debate about this article, especially from the epi community. Please make sure I’m not on the jury for this one because I’ve already tangled with the epi folks. They require budgets slightly larger than the national debt, typically find piddling effect sizes expressed in those lame 1.1 relative risk ratios, and then they think they’ve discovered blue sky, white snow, and a free lunch . . . not to be harsh or judgmental or unfair or wicked or even accurate about it.

Now, the thoughtful among you might be wondering what all of this has to do with persuasion besides Steve whaling away on some group of people you’ve never met.

Here: if scientists get it wrong and persist in getting it wrong, what explains their beliefs and behavior?

Persuasion theory and research.

Not health theory and research.

This research study demonstrates a common finding in persuasion research on biased, central route processing. Smart, thoughtful people will try to make the data fit their hypothesis even when it is apparent that the data don’t fit.

This is another way of saying that scientists and physicians and their ilk are human after all and behave according to the same rules of psychology that all us mere mortals obey. We tend to believe we are smart, consistent, and justified and we tend to make data fit our key beliefs more often than we make our beliefs fit “scientific reality.”

As I mentioned at the top of this post, it’s unlikely that this JAMA story will get much attention despite its critical importance. Here’s a quick illustration.

On the same day that JAMA published this research article, the New England Journal of Medicine published a study on childhood obesity and adult heart disease. Using the Googe news aggregator, I found that in the two days following these publications the childhood obesity study has been picked up in 350 different web sources, the majority of which are standard news sites like the New York Times or the Washington Post. By contrast, in the two days since the publication of this scientific bias study, the Google news aggregator lists fewer than a dozen sites carrying a story about it.

What’s interesting to me about this comparison is that the childhood obesity study is an epi-style method that finds about the same effect size as the Vitamin E studies. As we’ve seen with those epi studies on Vitamin E, we need to be extremely careful in accepting the conclusions until we get stronger evidence from experimental studies (RCTs).

I’m developing my persuasion scripts idea into a commercial website. I’ve purchased the domain name: www.PersuasionScripts.com. And, I’m developing the site content even as you read this. While I have a comfortable grasp of the content, I’m not exactly sure how to market this idea.

See, part of my motivation goes beyond profit and into a deeper form of self benefit. Every day I encounter incompetent interactions with various commercial and nonprofit groups. I’m sure you experience the same thing. You call a business about an immediate need you have (for example, our dishwasher just dropped dead and I want a new one while Melanie really needs it) and the interaction with various repair and sales folks has been clumsy, inept, and silly. The person who answers the phone isn’t the one you need. The one you need isn’t here. Or is here, but when they pick up the phone you can tell they are distracted with another task. I can think of many instances where I was literally trying to give my money away for some product or service and I made that clear, yet the people I was talking with couldn’t figure it out and lost the sale. This can happen over the phone or over the Internet or face to face. People are generally lousy at communication, particularly persuasive communication.

Scripts would help a bit. If everyone had a good basic script for standard encounters (initial contact, maintanence, growth, conflict, termination, etc.) and always used them, sales, service, and satisfaction would improve faster than the addition of computers caused. If you think about it, a persuasion script is a bit like using computers for your work. A computer requires a kind of script before it can be effectively employed. But once you understand that computer script and use it, you accrue serious advantages. With a computer in the system you can bring inventory control to the cash register. With a computer you bring accounting to the cash register. With a computer you bring your catalog to the telephone marketer. A persuasion script provides the same kind of connection and efficiency.

Okay, so if everyone used my persuasion scripts I can make some money and better still, I might get better service in my commercial and noncommercial interactions. So if I sell scripts I get a lot of benefits besides the obvious one.

The trick is how to market this. I can’t decide whether to write up a bunch of fairly detailed scripts with those fill-in-the-blank variables (e.g. INSERT YOUR BUSINESS NAME HERE) for very little customization and sell them like little books or whether this idea more of a consulting service that requires some interaction between me and them to create a truly custom script. I know that I can do both, but then that creates some tension in the potential buyer (should I go simple and buy a vanilla script or go complicated and get the consulting service) and you don’t want to make a buying decision complicated.

I’m toying now with the idea of making this rather like Amazon where the scripts are like books. I’ll write up a bunch of vanilla scripts, then give each one a page and price, just click and buy. The marketing is interesting.

You’ll recall that workers with the guerilla marketing firm, Interference, Inc., managed to get themselves arrested under terrorism-related charges for their activities in Boston as they put up bomb-like devices around town aimed at getting an audience for a new cable TV cartoon show. Under the premise that all publicity is good publicity, did this persuasion and influence stunt work? We now have some tentative evidence.

And, it appears that all publicity is good publicity. Various indicators of viewership show favorable changes. For example, hits on the cable TV website were up 77% following the media uproar and actual viewership of the new program also rose 20%. Whether any of these increases will hold remains to be seen, of course, and the point of the Interference activity was to get new eyeballs and not necessarily to hold them. As a result, I’d have to say that Interference did its job.

Remember, all bad persuasion is sincere and Interference is sincerely insincere.

Did you hear about it?

Two applied persuasion researchers are in jail for terrorist activities, arrested by Boston Police for planting suspicious bomblike devices in and around Boston. Authorities initially set bail at $100,000 for each perpetrator. Man, and you thought persuasion was easy?

Yeah, there is a catch to all of this. See, the two guys were doing guerilla marketing for the launch of a new cable cartoon show on the Cartoon Network. The Network hired the guerilla marketing firm, Interference, Inc., to handle the promotion. Guerilla marketing aims at gaining attention through street level, face to face, and sometimes in your face activities. It is, in essence, smartly done street theater that attracts a crowd and promotes a simple message. The crew at Interference, Inc. (a great company name, huh?) got the contract to promote the new cartoon show that features the adventures of a talking milkshake, so Inteference Inc. created a boxlike device with blinking lights and wires coming out of it, then stationed these devices across Boston and many other large cities in the US over the past couple of weeks.

So far, this is just fun guerilla marketing, but apparently the authorities in Boston got freaked out over these mysterious, bomblike devices popping up on freeways and in tunnels and managed to arrest two Interference workers. There is a lot more to this story than we currently know. This promotion has been going on for at least a couple of weeks across the US and yesterday, the Boston Police get nervous and arrest two young men. What scares me is that if the Boston Police genuinely saw these devices as potential security threats, why the hell did it take them over two weeks to notice them?

Everyone involved is apologizing (Interference, the Cartoon Network, and Turner Broadcasting which owns the Cartoon Network), but I don’t take it too seriously. I’m guessing that some cop or prosecuting attorney got honked off for some silly reason and wildly over-reacted here. For example, when the two Interference workers were first arrested, their bail was set at $100,000. It’s already been reduced to $2500. That would seem to indicate that adults are now getting involved in this case.

Meanwhile, the “bad guys” in this case (Interference, Cartoons, Turner) have got to be crying crocodile tears over this. They are getting a phenomenal amount of free media coverage today over this event and everyone is getting their name in the paper big time. Under the assumption that there is no such thing as bad media attention, it appears that the applied persuasion guys are the big winners right now.

For me, well done guerilla marketing demonstrates by contrast one of the Rules: All bad persuasion is sincere. This attempt by Interference Inc. is good persuasion because it definitely achieved its persuasion goal: It got attention to its message. And it did so in a most insincere way. The initial actions of the Boston authorities illustrates the exact problem when you are sincere in your efforts to “persuade” others. Boston police sincerely believed they had a problem on their hands and sincerely charged Interference guys. And they look sincerely foolish doing so.

Over the Christmas holidays a commonplace event occurred that provides me with a metaphor for understanding how to do persuasion. See, a neighbor called a couple of weeks before Christmas to request our help in putting up their tree. They had gotten a very large tree that hadn’t looked so large at the tree farm or even on top of the truck, but now was looking like something you’d use as a replacement telephone pole. So, they called in the hill reinforcements.

When I arrived at their house I, too, was immediately struck at just how big the thing was, easily 12 feet with beautiful, symetric branches. An adult could not grasp the trunk without having to stick your face deep in the needles. And while it would fit in the great room with cathedral ceilings, it was going to be a monster to install. My mind turned at the engineering possibilities. I talked with the neighbor, Dwayne, for his ideas. Now, Dwayne is a very bright physical scientist with an international reputation and while my background in quantum or mechanical physics is a bit light, I know enough about his field to know that he’s got some serious smarts in his head. (And, practical smarts, too; he had enough sense to get his wife to rally the troops to fight this tree.)

Dwayne’s idea was to haul the tree into the room and place it lying on its side on a couple of saw horses. “You mean, like we’re going to cut it up for firewood?” I asked. “Yep. And then we move the saw horse at the bottom end of the trunk up toward the top of the tree until it tips over, you know, a fulcrum.”

So, we dragged the tree into the house (perhaps another blog post someday – that tree did not go quietly into the house) and got it up on two saw horses. Then Dwayne brought out the tree stand. It was one of those big, green circular plastic jobs with the four pairs of long handled screws, but he’d customized it by nailing the stand into a 3 square foot piece of plywood for greater stability and strength. Dwayne eyeballed the tree trunk, then kicked the tree stand with his toe in line with some imaginary path he could see in his mind’s eye. “Okay, we’re set.”

Then his young son, Garrett, and I picked up the tree at the heavy end at the bottom of the tree while Dwayne moved the saw horse a bit closer to the top of the tree. We sat the tree back down. It still looked like it was ready for the chain saw. So, we lifted it again and Dwayne moved the saw horse up another couple of feet and we sat the tree down again. This time, however, the trunk of the tree was quivering like some weird wood magnet was pulling on it. Gravity had the tree in its grip and the tree was shaking just off its balance point. So, the kid and I lifted the tree one last time as Dwayne moved the saw horse, then, voila, the tree tipped effortlessly down, gravity drawing its weight and I just guided the fall of the trunk along that imaginary line Dwayne saw, the tree fell into the tree holder and we easily walked it upright while Melanie and Regina got under the tree and started turning the screws to secure the tree. It was literally the work of falling off a log.

The point of this fun story is the correct application of a scientific principle in a specific engineering circumstance. There were a lot of different ways to handle that tree, but when we put it in the thrall of scientific principles (gravity and the fulcrum), the whole process was shooting fish in a barrel. The trick, though, was not simply seeing the scientific principle, but also being able to construct an engineering solution that capitalized upon those principles.

We face the same kind of problem with applied persuasion. If you read the Primer, it’s fun to learn about things like dissonance or attribution or the different forms of conditioning and the two routes. But, how do you make it happen in the real world? I know many very bright and talented persuasion researchers who would starve as marketing experts or sales experts or politicians or anyone who uses persuasion and influence to make a living because they are good at science, but not so good at engineering. And the same pattern holds in reverse. Many people who try to make a living with persuasion and influence often have no idea why things work or don’t work and can’t predict very well their chances of success because they really do not understand the science behind their “engineering” attempts.

The basic trick is to know the science, then look for ways to get your receivers into an “engineering box” that capitalizes on that science. Dwayne knew the science of gravity and the fulcrum, but the trick was to get that damn big tree into an engineering box so that we could use gravity and the fulcrum. That’s why he got the saw horses and called the neighbors. The same holds with persuasion and influence. Once you understand the scientific principles, your applied engineering problem is learning how to manuever receivers into the ELM box or the CLARRCS cues box or the dissonance box and then let gravity and the fulcrum go to work. Alternatively, if you can’t figure out how to move people into a particular box, your applied engineering problem is to instead figure out what kind of box the situation naturally presents, then determine if there is a scientific persuasion principle that could be applied.

For example, it is difficult in the natural world to easily manipulate the WATTage of receivers. There’s simply so much going on and so many available sources of information out there that you can’t control them and grab the dimmer switch of a person’s WATT and turn it higher or lower. Therefore, since you can’t easily or automatically control the route of persuasion, you must have both strong arguments and strong cues available for either circumstance. Once you identify (not manipulate, just identify) the processing state of the receiver, you then move them into either the argument box or the cue box, deliver the persuasion tool and let science do what it does.

So, the next time you’re trying to do applied persuasion think with science and engineering. What are the principles and what is the box?

Merry Christmas! Happy Persuasion and Influence!