Smoking and COVID-19 - the evidence gets stronger

I've found it impossible to keep up with all the research on smoking and COVID-19 recently. The tireless @phil_w888 has now catalogued over 700 studies of COVID-19 patients that have data on smoking prevalence. 

In the last week, the largest observational study yet conducted found that smokers (in Mexico) were 23 per cent less likely to test positive for COVID-19. This is in line with the results of an ongoing meta-analysis by some researchers who would clearly prefer the hypothesis to be disproved but who nevertheless have found a 26 per cent reduction in infection risk for current smokers. 

A study published in the Lancet a couple of weeks ago looked at the factors associated with COVID-19 caseloads at the national level. It found that countries with higher rates of smoking tended to have lower rates of Covid infection.

And a newly published prospective study of nearly 20,000 Covid cases tells a familiar story. Your chances of ending up in intensive care with the virus are increased if you are male, non-white, from a low income area, obese ... or a nonsmoker. 

Note the telltale dose-response relationship. The heaviest smokers are an incredible 88 per cent less likely to end up in ICU with COVID-19.

The same rules apply to your chances of testing positive for COVID-19. Indeed, it seems increasingly clear that smokers are less likely to end up in intensive care with COVID-19 because they are less likely to catch it in the first place.

Factors such as obesity, deprivation and being BAME are now universally acknowledged as risks for COVID-19. The UK government, in particular, has gone to town on the obesity finding. 

The smoking finding, by contrast, continues to be ignored, although the evidence for a protective effect is about as a strong as the evidence for obesity being a risk factor. 

And yet the association with smoking is not even mentioned in the abstract of the latest study (above), nor is it mentioned in the abstract of the Lancet study. The authors of the latter describe it as an 'unexpected finding' which 'requires further investigation'. The authors of the other study describe it as a 'counterintuitive finding' , although they do acknowledge that it is 'consistent with very low rates of smoking seen in patients presenting with COVID-19 in Wuhan and similar data from the USA and with the findings of a more limited analysis of patients with COVID-19 in France.

They also propose several possible causal mechanisms: 

This may reflect a general immunomodulatory effect, a mechanism that is thought to explain the lower incidence of sarcoidosis, extrinsic allergic alveolitis and ulcerative colitis in current smokers. Alternatively, smoking may cause increased ACE2 mRNA expression in human lung much as ACE inhibitors or ARBs are believed to, suggesting a possible common protective mechanism for severe COVID-19 disease. Additional possible mechanisms include a direct protective effect of nicotinic receptor stimulation or an association of smoking with another protective factor. This finding arose when including smoking status as a confounder and should be interpreted cautiously. Further studies are required to verify the apparent protective association, determine whether it is independent of other risk factors, and investigate potential mechanisms. 

The 'public health' lobby has done a good job of ignoring these findings so far, but how long can it continue? With the world economy crippled by lockdowns and social distancing - not to mention the human cost of the virus - is it ethical for them to overlook a possible solution? That solution may not involve smoking per se. It is likely to merely involve harmless nicotine. 

These findings get stronger by the day and are extremely interesting, and yet I do not see much interest in them from the people who are supposed to be protecting our health. It could be a fatal oversight.

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Remain (Inside) vs. Leave (the House) - the faultline in British politics

It's not a novel observation to say that the debate about lockdown measures is a rerun of Brexi, with the same people lining up on each side. But why should that be? In this article for the Telegraph, I throw a few theories around...

On the face of it, the two issues have nothing in common. It may be that Brexiteers are less risk averse. No Deal Brexiteers, in particular, embrace risk almost by definition. Remainers, by contrast, feel safer with the status quo, and once lockdown became the status quo, any loosening of it felt like a risk.

Or it could be about settling old scores. Some pro-lockdown campaigners are more or less explicitly anti-Tory activists who oppose any relaxation so they can say ‘I told you so’ in the future when there is a second wave of (hello, ‘Independent SAGE’).

Others are still smarting from the referendum. I swear there are political journalists in this country who will go to their graves convinced that the biggest news story of 2020 was Dominic Cummings driving to Barnard Castle. It is difficult to imagine them getting quite so upset about a special adviser possibly committing a minor breach of a regulation if he had not run the Leave campaign. 

Similarly, it is hard to imagine Sir Ed Davey reporting someone to the police for going to the pub two weeks after travelling to America - and therefore possibly not having quite done the full fourteen day quarantine - if his name wasn’t Nigel Farage (or as Carole Cadwalladr dubbed him, in typically understated fashion, ‘Typhoid Nigel’). Farage’s response was to tell Davey, not unreasonably, to ‘get a life.’

Do read it all.

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Alcohol doesn't cause cancer?

There was much excitement in 'public health' circles last year when a study failed to find an association between moderate drinking and lower rates of heart disease. The study used conventional epidemiology and Mendelian Randomisation (MR) to look at a Chinese population in which a gene that is associated with alcohol avoidance is relatively common (it is very uncommon in the West). The authors found a protective effect for heart disease when they used epidemiology but not when they used MR. It was not the first MR study to come to this conclusion.

MR studies featured prominently in the Sheffield Alcohol Research Group's report for the Australian government last year (Australia has since lowered its drinking guidelines). They also feature prominently in the US Dietary Guideline Advisory Committee's report (the US is also pondering a lowering of the guidelines). You can see the appeal to the anti-alcohol lobby.

The hype around MR studies says that they are 'nature's RCTs' and can prove causation. Neither of these claims is true, at least as far as identifying behavioural risk factors is concerned. Observational epidemiology is far from perfect but MR studies have enormous problems of their own. Self-reported alcohol consumption data might not always entirely reliable, but MR often does not involve alcohol consumption being reported at all. It is merely assumed that people with certain genes will drink less than other people.

But just as someone whose genes make them more likely to smoke is not necessarily a smoker, someone who has genes that make them more prone to alcohol avoidance is not necessarily a non-drinker (or even a light drinker). A few genes have been identified, particularly in Asian populations, which make people react badly with alcohol, but this is no guarantee that they will not drink heavily. In situations and cultures in which drinking is expected - networking among Japanese businessmen, for example - any genetic predisposition towards light drinking or teetotallism may soon evaporate.

In a commentary in the European Journal of Epidemiology, Kenneth Mukamal and colleagues argue that MR “is subject to all of the limitations of instrumental variable analysis and to several limitations specific to its genetic underpinnings, including confounding, weak instrument bias, pleiotropy, adaptation, and failure of replication.” MR studies on alcohol consumption and cardiovascular disease, they write, “demonstrate that it must be treated with all of the circumspection that should accompany all forms of observational epidemiology”.

Two new MR studies were published recently, neither of which attracted much attention. In June, an MR study published in Cancer Genetics found no association between inferred alcohol consumption and breast cancer. It also found no association with ovarian cancer.

And then last week, an MR study published in PLOS Medicine failed to find an association between inferred alcohol consumption and any form of cancer except - using one of the two databases - lung cancer.

The PLOS study is particularly interesting because it also looks at smokers - or, more accurately, people with a genetic predisposition to smoking. If it hadn't found an association with lung cancer, it would have raised serious questions about MR's credibility in this area. Fortunately it did, but it only found a doubling in risk, whereas epidemiological studies suggest that risk increases by anything from five to fifty-fold depending on smoking intensity. The study also found associations with several other cancers, but the risk ratios were quite low. For most of the cancers studies, there was no statistically significant association.

The results for inferred smoking therefore point broadly in the right direction, but it seems that the risk has to be rather large for MR to show a statistically significant result.

The results for alcohol, however, would require the textbooks to be rewritten if they were true. The epidemiological evidence linking alcohol to several forms of cancer is nearly as strong as the evidence linking moderate drinking to lower rates of heart disease. Lung cancer isn't one of them, but that is the only cancer with which the MR study found a statistically significant elevation in risk, albeit in only one or the two datasets used.

What are we to conclude? That MR has 'proven' that moderate drinking does not reduce heart disease risk, but that drinking in general does not increase cancer risk? Or that MR studies are too crude to find the kind of associations identified by observational epidemiology - including the link with breast cancer which is the basis of the 'no safe level' meme?

If we are to allow MR studies to override epidemiological findings about alcohol, several babies will have to be thrown out with the bathwater.

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E-cigarette regulation - money talks

An interesting article in the Economist tells us a lot about e-cigarettes. In China, the world's biggest cigarette market, smokers are increasingly switching to e-cigarettes. The state-owned tobacco monopoly is not happy about it.

Investor optimism derives in large part from the prospect of rapid growth in China, where just 10m people were regular users of e-cigarettes at the end of last year. But dig a little deeper and the outlook darkens. A powerful state-owned cigarette monopoly, China Tobacco, will not cede ground to a rival product without a fight.

Regulators have already intervened on behalf of China Tobacco, which paid 1.2trn yuan in taxes last year, accounting for 6% of government revenues. In November the authorities banned online sales of e-cigarettes (ostensibly to prevent minors from buying them). Now they can be bought only at physical outlets like convenience stores and karaoke bars. In recent months editorials in state-owned newspapers have claimed (falsely) that vaping is more harmful than conventional cigarettes. A spokesman for the Electronic Cigarette Industry Committee of China, a trade body, blames the online ban for a wave of bankruptcies among smaller firms.

It is obvious what China Tobacco's motivation is. They fear missing out on cigarette sales if people switch to vaping. The Chinese government, insofar as it can be distinguished from the tobacco monopoly, doesn't want to miss out on tax revenue. More vapers means fewer smokers, hence the online sales ban and scare stories.

Does this sound familiar? The United States has been awash with scare stories about e-cigarettes for several years, culminating in the 'EVALI' panic last year. A ban on online sales (disingenuously titled the Preventing Online Sales of E-Cigarettes to Children Act) passed the Senate earlier this month and will be voted on in the House any day now.

The only difference is that China Tobacco doesn't have the 'public health' lobby cheering it on.

American 'public health' campaigners argue that e-cigarettes don't help smokers quit and act as a gateway to tobacco for young people. China Tobacco obviously doesn't agree.

Who is most likely to be right - a bunch of moral entrepreneurs who have never seen a ban they didn't like, or some hard-nosed businessman who have skin the game?

Meanwhile...

Americans are smoking more during the coronavirus pandemic because they are spending less on travel and entertainment and have more opportunities to light up. They are also switching back to traditional cigarettes from vaping devices in the wake of federal restrictions on e-cigarette flavors.

Malice, corruption or unbelievable incompetence? You decide.

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Life and liberty webinar tonight at 6pm

I'm chairing an online panel discussion today at 6pm to discuss risk, wellbeing, health and wealth. The trade-off between life and liberty has been brought into stark relief by the pandemic. What lessons have we learned?

We have a great line up of speakers, so join us on YouTube at 6pm.

Julian Jessop, IEA Fellow and former IEA Chief Economist

Timandra Harkness, Broadcaster, Mathematician and Author

Professor Robin Dunbar, Emeritus Professor of Evolutionary Psychology at Oxford University

Otto Brøns-Petersen, Head of Analysis at the Danish Free Market Think Tank, Centre of Political Studies (CEPOS).

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Whatever happened to plain packaging?

With the government set to introduce all the Theresa May (previously David Cameron) nanny state policies on food, no one in government seems able to predict what success looks like. How much will obesity fall back as a result of these costly interventions? Will the government repeal the laws if obesity hasn't dropped by 2025?

You won't get any answers from MPs or 'public health'. They know and we know that the policies won't make any difference and there will be no desire to seriously evaluate them in the future. As I have said many times, 'public health' is not a results-driven business.

Take plain packaging, for example. The battle for this stupid policy involved years of screeching and millions of pounds of taxpayers money spent on self-lobbying. What happened? Where is the audit?

Australia has had plain packaging since December 2012. Anti-smoking clown Simon Chapman said it was "almost like finding a vaccine that works very well against lung cancer." But what really happened?

National smoking figures are only published every three years Down Under and this month saw the latest set of figures. Over three years, the smoking rate had fallen by just one percentage point. Since 2012, the smoking rate has fallen at half the longterm average, as Jo Furnival explains:

The Australian Institute of Health and Welfare (AIHW) released the 2019 National Drug Strategy Household Survey (NDSHS) this week. This survey has become a vital indicator of the performance of government health policies, including tobacco control. Previous surveys were carried out in 2010 before plain packaging for tobacco products was introduced, in 2013, the year following its introduction (along with other measures, including tax increases), and again in 2016.

The data shows that, prior to 2012, the per centage of daily smokers in Australia was in long-term, steady decline (a rate of 0.46 per cent annually for 20+ years). After plain packaging was introduced, this annual rate of decline slowed by almost a half to just 0.26 per cent between 2013 and 2019.

Moreover, the proportion of smokers planning to quit has not changed since plain packaging was introduced. Three in 10 smokers have no interest in quitting, the same percentage (30 per cent) as in 2010. Rather than this costly eight-year experiment, the Australian government would have been better off doing nothing at all.

Trebles all round! And it gets better...

The proportion of smokers using illicit, unbranded loose tobacco has increased by 37 per cent (10.5 per cent in 2010 to 14.4 per cent in 2019). Meanwhile, overall consumption of illegal tobacco products (including unbranded loose tobacco, along with contraband and counterfeit items) has risen by a whopping 80 per cent (from 11.5 per cent in 2012 to 20.7 per cent in 2019) and is now at a record level, according to a recent KPMG study.

Tremendous work, and all as predicted by those who opposed the policy.

Australia shows what happens when nanny state fanatics run the show. Ban e-cigarettes, introduce plain packaging and set taxes so high that buying from the black market is almost a moral duty. What could go wrong?

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A no deal Brexit is no good for smokers

An interesting piece at 1828 by Dan Pryor about an issue I had missed.

The UK is facing a tobacco tariff timebomb. Britain’s black market in cigarettes is set to boom if trade talks with the European Union fail to bear fruit by the end of the year.

The damage can be easily avoided easily if the department of international trade makes some minor changes to its post-transition period tariff regime. But so far, there is no sign that politicians are aware of the problem.

The issue stems from the UK Global Tariff – our post-Brexit replacement for the EU’s Common External Tariff. In the absence of a trade agreement, the UKGT will apply to all imported goods from 1 January 2021. At present, cigarettes imported from the EU for sale in the UK (which make up the overwhelming majority of our market) are liable for tobacco duty and VAT but are not subject to any tariff.

Presumably, though, in an unfortunate oversight (since there’s virtually no domestic tobacco industry to “protect”) the UKGT in its current form will slap an eye-watering 50 per cent tariff on cigarettes and a 70 per cent tariff on roll-your-own tobacco. That’s on top of existing charges. Even with an EU-UK trade deal, if we get our rules of origin requirements wrong, the tariff could still end up applying.

Do read it all.

The government could adjust tobacco duty downwards so that prices remain unchanged (it would get the same amount of revenue), but the anti-smokers would doubtless scream blue murder.

Or it could get a trade deal with the EU, which it should do anyway.

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