Friday, 3 July 2015

Making sense of alcohol-related hospital admissions

The latest figures for alcohol-related hospital admissions were published last month and, over at the Alcohol Policy blog, James Morris lamented the fact that such announcements ‘no longer appear to generate significant media attention following changes to the reporting of the data’. This, he argues, is because the Department of Health prefers to use a narrow measure of ‘alcohol-related’ rather than the previous broad measure. The broad measure helped to push the number of alcohol-related hospital admissions over the (newsworthy) threshold of one million some time ago, but it was never credible. Here’s why.

The first thing to understand about alcohol-related hospital admissions is that there is no nurse on the door to judge whether your condition is due to drink. It is simply assumed that a certain proportion of each medical condition is caused by alcohol. So, for example, 15 per cent of breast cancer cases amongst women aged 45 to 54 are assumed to be caused by alcohol consumption, 23 per cent of hypertensive diseases amongst men aged 65 to 74 are assumed to be caused by alcohol, and so on, through every disease, injury and death that could possibly be due to drinking.

If this seems somewhat arbitrary, it is, but there is some science behind it. Alcohol really is a contributor to some chronic diseases and it is right that this be acknowledged in the data, however imperfectly. The problems only really arise when you start counting secondary diagnoses as alcohol-related. That is what the old ‘broad’ measure did.

Imagine that you have hypertension and you go to hospital because you have a virus. The virus is your primary diagnosis and your hypertension is your secondary diagnosis. The hypertension has nothing to do with your virus, but it is recorded in the data anyway. Although your visit to hospital was not alcohol-related in any meaningful way, hypertension is considered to be an alcohol-related condition and because you have it as your secondary diagnosis, your admission is officially alcohol-related. You have contributed to the alcohol stats without touching a drop.

Not only is this absurd, it also guarantees that the numbers will keep rising over time because the population is growing, people are getting older and, above all, clinicians are more likely to record a secondary diagnosis than they were in the past. If you ever wondered how alcohol-related hospital admissions could double in the space of a decade despite alcohol consumption falling, this is a large part of the reason.

Since many alcohol-related conditions are diseases of old age, it is a mathematical certainty that they will continue to generate more and more hospital admissions as the population expands and ages. A year-on-year increase in the number of admissions for alcohol-related pneumonia, for example, only really tells us that there has been a general rise in admissions for pneumonia. We have no idea what role alcohol played, it is just assumed that a set proportion of them were alcohol-related. We could all stop drinking tomorrow and the number of ‘alcohol-related’ admissions for heart disease and cancer would continue to rise for many years, or until the underlying assumptions were updated.

Nevertheless, even under the narrow measure, there has been a rise in admissions, from 253,000 to 333,000 since 2004, but this needs to be put in the context of a massive increase in the use of hospitals in general. In 2001, there were 12 million finished consultant episodes in English hospitals.

Last year there were 18 million. Alcohol is a factor in less than two per cent of them and most involve longterm conditions rather than acute intoxication. I mention this only because newspapers like to illustrate their stories about alcohol-related hospital admissions with photos of drunks on the pavement but, as the Office for National Statistics noted last week, only ‘950 (less than 1 per cent) of admissions were for the toxic effects of alcohol’.

In any case, the ‘public health’ lobby has no reason to worry about the Department of Health switching to a more accurate definition of an alcohol-related admission. The latest figures may not have made the front page this year, but the Mirror still reported that ‘Hospital admissions caused by alcohol have soared to one million a year’. The Express ran the news under the headline ‘Booze Britain: Drink-related hospital admissions double in a decade’. So long as the Office for National Statistics keeps publishing figures for the broad measure, we can expect them to continue being newspaper fodder for many years to come.

[Cross-posted from Spectator Health]

Wednesday, 1 July 2015

The anti-smoking lobby is burning our money

Harry Phibbs has written an important post about the little known issue of the Local Declaration on Tobacco Control (LDTC). This is an ASH initiative to get local authorities to sign up to an agreement to ostracise the tobacco industry in everything they do. Essentially, it is Article 5.3 of the Framework Convention on Tobacco Control gold-plated to a ludicrous degree.

Article 5.3 says, very simply...

In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law.

Fair enough, perhaps, but ASH is not content with keeping the tobacco industry away from 'public health policies', it wants the government to have nothing to do with them even when local authorities and the industry have mutual interests, such as tackling counterfeit tobacco. And so they have gone around the local councils and got them to sign up to an agreement that includes a promise to...

Protect our tobacco control work from the commercial and vested interests of the tobacco industry by not accepting any partnerships, payments, gifts and services, monetary or in kind or research funding offered by the tobacco industry to officials or employees

This is Article 5.3 on steroids. Does it matter? Well, yes, it matters quite a bit because the tobacco industry has traditionally given local authorities rather a lot of financial support to tackle illicit tobacco, but because of ASH's ideological intransigence that money is now coming from taxpayers. As Phibbs says...

What is the practical relevance of such a gesture? Most significantly, it is preventing the industry from working with signatory councils (trading standards) on the issue of the illegal trade in tobacco products, which cost the Exchequer £2.1 billion in 2014 alone, imposed significant costs on retailers as a result of lost sales, and brought organised criminal gangs into local communities.

Several local authorities have rejected funding for sniffer dogs from tobacco manufacturers, which are used to locate illegal products. They have decided to fund this activity themselves and are redirecting funds from the public health budget in order to do so.

Okay, in this instance the money is coming from the public health budget so it probably would have been wasted anyway, but ASH's little treaty is also hindering the fight against tobacco smuggling...

There have been examples where the trading standards officers, believing that LGDTC stops them from dealing with the industry, have refused to work with the industry on counterfeit tobacco – this includes refusing local, on-the-ground, intelligence.

And it is not just illicit tobacco. Money is also been turned away to deal with littering...

Due to LGDTC, councils and the Keep Britain Tidy campaign will no longer work with the tobacco industry on anti-litter measures or campaigns such as making bins smoker friendly.

This is lunacy. If the industry wants to pay for these services, taxpayers should be thankful. Aside for tobacco smugglers, who benefits from councils rejecting contributions towards sniffer dogs? Where is the conflict of interest? When it comes to counterfeit tobacco, the only conflict is between the tobacco industry, who would like to see less of it, and the anti-smoking fanatics who want to pretend it doesn't exist.

Local councils have been sold a bill of goods by ASH about what they can and cannot do. I've been reading a document entitled 'Guidance for Trading Standards on engaging with the tobacco industry' which is endorsed by ASH and Public Health England. ASH has its own list of tips entitled 'Developing Policy on Contact with the Tobacco Industry'. Both of them offer highly misleading advice to local authorities based on a misrepresentation of Article 5.3. The first of them says:

This document articulates the legal obligations placed on public authorities by the Treaty and illustrates established best practice for those working in the sector.

The 'Treaty' has never been enshrined in law in Britain or the EU, so this is wibble from the outset. There are no 'legal obligations'. From a legal perspective, the FCTC is nothing more than a bunch of aspirations, but even if Article 5.3 was the law, it clearly refers to health policy, not trade policy, smuggling or waste disposal.

None of this stops ASH from making thinly veiled threats like this...

[Article 5.3] could be relied upon in legal proceedings brought by an individual or other non-state body against a public authority. An authority that does not act in compliance with the convention may be exposed to risk of judicial review. If a local authority decides to diverge from the guidelines it is suggested the reasons for doing so should be documented.

This is intimidation, plain and simple. It raises the spectre of lawsuits (that will never been filed) to coerce councils into taking an extreme position to suit ASH's comic book worldview.

The document goes on to say that local authorities should only deal with the industry if they need written confirmation that a counterfeit product is indeed counterfeit. If offers of money and support are made, the councils are told to run a mile. In a section about what to do if the industry 'approaches your local authority with offers to support to tackle illicit tobacco', the guidance reads:

Decline the offer citing conflict with the guidelines on the implementation of Article 5.3 and the Local Government Declaration if your local authority has signed it

The Local Government Declaration obviously has no legal standing, and nor do the guidelines about how Article 5.3 should be implemented which, being guidelines, are even less binding than Article 5.3 itself.

The document even makes this paranoid plea:

Let public health colleagues know about any approaches from the tobacco industry

Needless to say, all of this goes far beyond anything in Article 5.3, but with the bogus threat of legal action hovering over their heads, it is little wonder that local authorities have chosen to unnecessarily milk the taxpayer for bills that have traditionally been paid by industry. The result is worse local services where other budgets are depleted and a less effective response to organised crime.

Taxpayers are not only being forced to pay for ASH, they are being forced to pay for their collateral damage.

Tuesday, 30 June 2015

There's a riot going on

Published 8 hours ago...

Victorian prison system 'very ready' for smoking ban, Corrections Commissioner Jan Shuard says

Victoria's prison system is "very ready" for a smoking ban which comes into effect on Wednesday, Corrections Commissioner Jan Shuard says.

The Victorian Government flagged a ban would be put in place about a year ago and since then the Corrections Department has been working with Quit Victoria to tailor programs specifically for the inmate population.

About 84 per cent of people going into the state's 14 prisons smoke, and about 1,300 prisoners or 20 per cent of the prison population, have attended quit programs up until the end of May.

"This has been 18 months in the making. We've had a very long-term project in place to work with both our staff and the prisoners in preparing for [the ban]," Ms Shuard told 774 ABC Melbourne.

Published 2 hours ago...

Massive riot breaks out at maximum security prison over smoking ban

A huge riot has broken out at a prison in Australia over a smoking ban.

Inmates at Ravenhall prison span out of control today and prison staff were evacuated at the maximum security facility.

Television footage from the prison in Ravenhall, a suburb of Melbourne, showed prisoners with their faces covered, carrying sticks as makeshift weapons, while smoke was also seen. As many as 300 inmates were involved, the Australian Broadcasting Corporation said.

And it's not even Wednesday yet.

Send the cleaning up bill to the anti-smoking fanatics who lobbied for this (indoor and outdoor) ban.

What's the point of changing the drinking advice?

Why do campaigners get so excited about drinking and eating guidelines being lowered? Surely they don't expect people to change their behaviour as a result?

They don't, but guidelines are very useful for problem inflation and activist rhetoric, or so I argue today at Spectator Health. Do have a read.

Monday, 29 June 2015

More minimum pricing junk science

The Observer is probably the most gullible newspaper when it comes to 'public health' quackery so it's no surprise to see it reporting this...

Imposing a minimum unit price for alcohol leads to a dramatic fall in drink-related crime, including murders, sexual assaults and drink-driving, a new study shows.

Crimes perpetrated against people, including violent assaults, fell by 9.17% when the price of alcohol was increased by 10% over nine years in the Canadian province of British Columbia.

This is based on a feeble correlation and correlation almost certainly doesn't imply causation in this instance. Tim Stockwell—for it is he—doesn't bother to find a control group to so I have done it for him at The Spectator. It turns out that minimum pricing in British Columbia correlates better with crime in Britain than it does in British Columbia. Now that's magic.

Do have a read.

Friday, 26 June 2015

R. Room with a view

Every time a 'public health' group loses its taxpayer funding an angel gets it wings, so it is with a glad heart that I give you the week's second best news from Australia (see here for the best)...

The Centre for Alcohol Policy Research in Melbourne, which explored research areas such as the cost and harms of "passive drinking", has lost its $170,000 annual government funding, about 10 per cent of its funding base.

I'm amazed it's only 10 per cent, to be honest.

Spokesman Michael Thorn said the funding cut meant the centre would no longer be able to pay its international expert Professor Robin Room.

Mr Thorn said that without Professor Room, the centre would be forced to close.

Eh, what? You've still got 90 per cent of your funding left - or so you claim.

"An academic research centre of this standing requires a world-class researcher. Without a world-class researcher there is no centre," he said.

Far be it from me to suggest a way to keep this ghastly organisation going, but surely sacking somebody else is the obvious alternative?

There has been much wailing and gnashing of teeth in the public health racket about the departure of Robin Room (whom we have encountered before on this blog). He is regarded as something of an pioneer and if you read his scintillating memoir A Book of Letters for Robin Room, you can see why...

‘Alcohol Control Policies in a Public Health Perspective' broke so many areas of new ground. We called it the Purple Book and I worked on it in 1974–75. The authors came from five countries and were a motley bunch of sociologists dressing ourselves up as public health experts.

Something of a godfather to the modern movement, clearly.

Temperance tricks of the trade

A new study of the neo-temperance lobby's tricks of the trade was published this week. It is paywalled but can be read here. In it Alfred Uhl from the Austrian Public Health Institute looks at several examples of wishful thinking, faulty logic and statistical foul play by people who want to more and more taxes and restrictions on alcohol.

Put simply, the activist/academics who dominate the discussion of alcohol policy in the most prominent 'public health' groups have decided that tobacco-style bans and taxes are the way to deal with alcohol-related health problems and no amount of evidence is going to deter them.

Take Peter Anderson, for instance, a temperance academic who wears many hats, including that of project leader at the EU-funded ALICE-RAP project...

The fact that Anderson et al. (2012) present tax increases and bans on alcohol advertising as two of the most effective measures does not only contradict the conclusions that Anderson and Baumberg (2006) had drawn a few years earlier: ‘Looking across Europe more thoroughly there is no apparent correlation between the revenue from alcohol-specific taxes and per capita consumption’, but also those of Babor et al. (2003), who had rated advertising bans as rather ineffective. It is interesting to observe here, regarding the relationship between alcohol taxes and per capita consumption, that real alcohol prices in Austria dropped by around 50% over the past four decades, while per capita alcohol consumption did not increase; rather, it fell by 20%.

On the selective omission of facts:

An illustration of how it is possible to present statistical findings in a way that best supports the policy conclusion desired is that of Edwards et al. (1994) using data from an article by Hurst (1973), who had reanalysed data stemming from the influential Grand Rapids Study. In a well-planned roadside study, Borkenstein, Crowther, Shumate, Ziel, and Zylman (1964) had shown that drivers with moderate alcohol levels around 0.3 g/l blood alcohol concentration (BAC) had a significantly lower risk of committing an accident than completely sober drivers, an effect referred to as the ‘Grand Rapids dip’. When Hurst reanalysed these data separately for groups with similar drinking habits, he could show that the Grand Rapids dip was an artefact due to a Simpson paradox (where heterogeneous samples are analysed, the overall effects can be the opposite of the effects in all homogenous subsamples), leading to erroneous interpretations. In effect, the risk of committing an accident rises almost linearly with the amount of alcohol consumed, which is a positive result for those who support Zero-BAC-limits for drivers. However, Hurst also found that the risk of committing an accident in a completely sober state is four-fold for abstainers compared to daily drinkers, with daily drinkers reaching the risk level of abstainers after they exceed a BAC level of 1.0 g/l, which is twice the legal limit for drivers in most European countries. This finding about the ‘dangerous abstainers’ is hard to explain and is certainly an unwanted result for alcohol control activists. Edwards et al. (1994) chose to document the pleasant effect and hide the unwelcome effect by standardising the risk at Zero BAC level to 1 for every group. They could thus demonstrate the linear increase of risk with increasing BAC-levels, but hide the differences at Zero BAC levels: a brilliant trick for an advocate, but hardly excusable for a scientist.

On the deliberately misleading cost-of-alcohol studies...

A popular argument raised to support a strict alcohol control policy is the high social cost of alcohol use for society. Anderson and Baumberg (2006) stated the loss to be 1.3% of GDP. It can easily be shown that the logic of such cost calculations is systematically flawed, since the costs are, to a large extent, not paid for by the non-involved others or from the public purse. Alcohol-induced premature death undoubtedly causes high intangible costs for the persons drinking excessively (internal costs) and their near environment, but dead persons – similarly to children not born due to contraception or young immigrants not allowed to enter the country due to strict immigration laws – neither produce nor consume any goods... These figures are a perfect advocacy tool for alcohol control activists, and they help preventionists, therapists and researchers justify funding for their activities.

On presenting correlation as causation...

An illustrative example by Anderson and Baumberg (2006, p. 147) is the way in which the relationship between heavy drinking and suicide is presented in the following terms: ‘Heavy drinking is a major risk factor for suicide and suicidal behaviour among both young people and adults’. Knowing that heavy alcohol consumption is commonly a consequence of psychiatric problems such as depression, an adequate causal interpretation would be that persons with a tendency to heavy alcohol use have an increased suicide risk, and that it is likely that drinking excessively increases the suicide risk even further. There is also little doubt that some suicides are a consequence of depression caused by drinking alcohol in individuals who otherwise would not have killed themselves, but what fraction of suicides is due to the primary disease and what fraction is due to alcohol problems cannot be answered properly if only the association is recorded. A certain percentage of depressed persons who eventually commit suicide and use alcohol to self-medicate their depression may even have lived longer since this form of self-medication made them postpone their suicide. It cannot be denied that excessive alcohol may cause depression and suicide, but to interpret and present associations in the usual way, without considering widely known facts and cultural contextual factors and without presenting different explanations is misleading.

Finally, some wise words about the bluff of 'evidence-based policy' which really just means 'evidence that the policy we propose will do the thing we want it to'...

Examples from key publications supporting evidence-based alcohol policy show that much of it should more realistically be labelled ‘policy-based evidence’... By taking a stand against certain value-driven positions which unjustly claim a degree of proof that is not factually justified, the present article argues for greater modesty and not at all for moving back to well before the age of enlightenment, when relying uncritically on authority, experience and intuition was the name of the game.

To demand that political decision-makers should implement evidence-based policies is particularly misleading, since it suggests that policy (what should be done) can be derived from empirical research (what is), which is a popular misconception, labelled a ‘naturalistic fallacy’ by Moore (1960). All empirical claims raised in discussions about policy should correspond as closely as possible to reality, but practical decisions are always rooted in ethical–political value decisions related to the image of humanity, society and the world (Uhl, 2007). This aspect is camouflaged by the term ‘evidence-based policy’. The question of how paternalistic an administration should be, or how far the views of the majority of the population in a democratic society should prevail (that is how far it is legitimate to coerce individuals in a society to behave in a healthy way) is an ethical–political decision to be decided very carefully and is not simply factual–scientific.

Well said, and that's without even mentioning the cesspool of minimum pricing 'research'.