Public health expert at work

It's been a bad few days for SAGE's Theresa Marteau. Regular readers may recall that she is obsessed with the size of wine glasses. She thinks people drink more if they use large glasses and she'd quite like to regulate their size as a result. 

Alas, the evidence for this theory is mixed, at best. Last year, she cobbled together a 'mega-analysis' of studies which didn't really show much but she made the best of it and put out a press release calling for wine glass regulation anyway. She was back again yesterday with a new study co-authored with eleven fellow 'public health' researchers who apparently have nothing better to do during a pandemic. 

This time she was looking at beer and cider glasses but she came up empty-handed once again...

This study provides no clear evidence that using straight-sided glasses, compared with usual, predominantly curved glasses, reduces the volume of draught beer and cider sold for on-site consumption in bars.

 

This followed a study published on Friday in which she and eight other 'public health' people conducted an experiment in a 'commercial-standard naturalistic shopping laboratory' to see if putting warning labels on alcoholic beverages would put people off buying them.

It didn't.

In a naturalistic shopping laboratory, there was no evidence that health warning labels describing the adverse health consequences of excessive alcohol consumption changed selection behaviour. 

 

Not only did it not work, but the researchers found "extreme evidence in favour of the null hypothesis". A nice phrase. 

 

There was no clear evidence of a difference in the HWL groups for the percentage of drinks selected that were alcoholic compared to no HWL (44%): image-and-text HWL: 46% (OR=1.08, 95%CI=0.82,1.42); text-only HWL: 41% (OR=0.87, 95%CI=0.67,1.14). Concordant with there being no difference between groups, there was extreme evidence in favour of the null hypothesis (Bayes factor [BF] < 0.01).

It looks like being a long wait for that Nobel Prize, but at least we know she's not fabricating the data.

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Last Orders with Clare Fox

A new episode of Last Orders came out at the start of the month but I forget to mention it here. Our guest was Baroness Fox of Buckley. You may know her better as Clare Fox. 

We discussed vaccine passports, the controversy over pictures of Muhammed at Batley Grammar School and the nanny state post-Covid.

Have a listen.

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Less drinking, more problems - the lockdown alcohol "paradox"

I was on the Irish radio station Today FM yesterday talking about alcohol policy and lockdown drinking habits. I was up against someone from the Alcohol Health Alliance, an organisation that was specifically set up by the state-funded pressure group Alcohol Action Ireland "to support the Public Health (Alcohol) Bill". Sockpuppetry doesn't get much more blatant than that.

The Public Health (Alcohol) Act, as it now is, includes a number of hardline temperance policies including various advertising bans, minimum pricing, and a retail display ban (the latter is the first in Europe and is know in Ireland as the 'Booze Burka'). 

Minimum pricing still hasn't been introduced because the government doesn't want even more drinkers flocking over the border for cheaper alcohol, so it's been waiting for Northern Ireland to introduce it first. They've been waiting a while and may have to wait a lot longer.

A report was published by the Health Research Board this week calling for various other temperance laws, taxes and regulations. It reported that alcohol consumption fell by 6 per cent last year, largely due to the pubs being closed most of the time. It also reported that the Irish are still drinking more than the 9.1 litres per capita that the government has set as its target. Don't ask me why the government has a target for this, nor why it picked such a specific figure.

That was the background of the interview. I pointed out that England also saw a fall in alcohol consumption during lockdown but that alcohol-related deaths spiked at the same time. My opponent from the Alcohol Health Alliance was so wedded to the whole population approach that he couldn't get his around that, but I wouldn't be surprised if Ireland doesn't see the same combination of lower consumption and more harm when its figures are published.

You can listen to the interview here.

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Calorie labels on alcohol

The government is considering mandating calorie labels on alcoholic beverages. This is an anti-obesity push rather than an anti-drinking initiative. It is an extension of the plan to force food outlets to put calorie counts on their food menus. 

 

That policy is unworkable for smaller establishments who frequently change their menu and has already been watered down by the government. It will now only apply to businesses that have more than 250 employees. The same caveat will apply to the alcohol labelling policy, so it will only be the big chains that have to put calorie information on their beer pumps and/or menus.

 

The British Beer and Pub Association is said to be 'furious' about this idea and Matt Kilcoyne of the Adam Smith Institute is also unhappy...

 

‘Brits backing their locals are well aware that too many pints makes beer belly more likely. We don’t need government enforced calorie counts to tell us something we already know.’

‘Ministers thinking up this madness should stop and drop the policy. Let the publicans and the punters do what they want in the pubs without Mr Hancock wagging his finger each time a pint is pulled.’

I can't really share this outrage and I'm not convinced that everybody does know how many calories there are in a glass of wine or a pint of beer. Perhaps the government should conduct a survey to find out if there is really an information deficit worth addressing?

 

I wrote about this kind of thing in Killjoys...

 

It is not paternalistic to require a seller to provide accurate information about his wares. Manufacturers and retailers usually know more about their products than do consumers, leading to information asymmetries. If they deliberately withhold important facts from consumers in order to make more sales it is arguably a form of fraud and is certainly a form of market failure. Free-market economists are therefore in favour of buyers being given the facts. Once equipped with adequate information, some people may decide not to buy, but that is not the economist’s intention. The aim is only to give the consumer sufficient information upon which to make his decisions. Information asymmetries due to consumer ignorance are a conventional market failure for which there is a simple solution: education. 

The state can have a hand in this by broadcasting information to the public, or mandating certain lessons in schools, or forcing manufacturers and retailers to impart certain facts to customers. Even John Stuart Mill approved of the use of coercion if a person was ignorant of the risks. In a much discussed analogy in On Liberty, Mill argues that it is right to stop a man crossing an unsafe bridge if there is no time to warn him of the danger, but that no one should intervene if he is aware of the risks. When there is ‘not a certainty, but only a danger of mischief ’, he wrote, ‘no one but the person himself can judge of the sufficiency of the motive which may prompt him to incur the risk’ and so the person should ‘be only warned of the danger; not forcibly prevented from exposing himself to it’. 

 

In a country where people are increasingly health conscious, calorie counts on alcohol don't strike me as any more controversial than putting the volume of alcohol on a beer pump. I can't say that I feel like Tim Martin is wagging his finger at me when I see the calorie counts in Wetherspoons' menus (although I was taken aback to see that their Full English Breakfast contains 1,200 calories).

The problem with mandatory calorie counts in restaurants is that it would be expensive for small businesses and would lead to pubs, cafés and restaurants restricting their range of food. There is no practical or libertarian objection to calorie counts on packaged food in shops, nor is there a problem with Starbucks and McDonalds putting calorie information on the board. It's useful information, not coercive paternalism.

 

Apparently, the government reckons it's going to cost the licensed trade £92 million to change their pumps and menus. That sounds a bit steep for a basic graphic design job. Perhaps the answer is to have a long lead-in time so labels and menus can be changed when they are due an update. 

I've yet to hear a good reason why calorie counts should be on food but not alcohol. Some say it could encourage eating disorders, but that applies to all calorie labelling and isn't sufficient reason to conceal important information. Some have said that hard liquor will become more appealing to weight-conscious drinkers, but if people's response to being given accurate information is to drink more vodka and less beer, that's their business.

As I see it, the only problem with the idea is that it will give the capricious 'public health' lobby a foot in the door to demand paternalistic and misleading health warnings in pubs. It's bad enough that the booze industry has capitulated to government pressure and put the fake drinking guidelines on bottles and cans. 

From Killjoys again...

 

An informative warning for alcohol might explain that 11 million British adults drink at a ‘risky’ level, according to government statistics, and that there are 9,000 alcohol-related deaths a year, meaning that risky drinkers have a roughly 0.08 per cent chance of dying of an alcohol-related cause each year. If given this information, most consumers might conclude that a ‘risky’ level of drinking is not very risky at all. For that reason, such warnings are never issued. Instead, the public is told that alcohol has been ‘linked to’ more than 60 diseases and that there is ‘no safe level of drinking’.

If tobacco regulation is any guide, future labelling in the name of ‘public health’ will not lead to consumers being better informed. Graphic health warnings are less about education than they are about shock and disgust. Studies have shown that pictorial warnings are less effective in transmitting facts than written warnings because they literally repel the consumer. Cass Sunstein supports graphic warnings as a way ‘to persuade, not merely inform’, but when the evidence was independently reviewed, it found that ‘the impact of picture health warnings was negligible’ among young people in the UK and had ‘no discernible impact on smoking prevalence’ in Canada. The obvious explanation for this is that ‘individuals are very well informed about the consequences of smoking, and therefore benefit little from further messaging'. Once again, we have a legitimate market failure (or potential market failure) which paternalists have failed to solve – and may have exacerbated – because their intention is not to inform but to deter.

The threat of the slippery slope is always there, but there is a fundamental difference between simple information and a 'warning'. We should embrace the former but rarely the latter. Unless you want to get rid of calorie counts and ingredient lists on food products and hide the strength of beer from pubgoers, I can see no logic in opposing simple, discreet calorie labelling on booze in chain pubs.

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A swift half with Freddie Sayers

The second episode of The Swift Half came out last week and has proved remarkably popular. Freddie is the executive editor of Unherd and has been interviewing most of the major players on every side of the lockdown debate since last spring. Check it out.

I'll be interviewing the Sunday Times' Matthew Syed live at 6pm, also for the IEA but not for The Swift Half. Catch it here.

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Another awkward study about smoking and COVID-19

A study in pre-print from Germany looks at a particularly deadly outbreak of COVID-19 in the county of Tirschenreuth in spring 2020. The researchers took blood samples from 4,203 residents to see who had antibodies (and therefore who had contracted COVID-19). All the participants filled in a questionnaire with various questions about their lifestyle, e.g. alcohol consumption, how much TV they watch, physical activity, etc. 

 

Overall, 8.6% of those tested had antibodies. To the surprise of the researchers - but perhaps not to regular readers of this blog - only one lifestyle factor was associated with having antibodies for SARS-CoV-2 - and it was a negative association.

 

We were also interested whether seropositivity was associated with factors capturing a less healthy lifestyle (low physical activity, current or ex-smoking, drinking alcohol, or increased body-mass-index as a marker for excess calorie intake). We found no association with any lifestyle factor, except for current smoking. Remarkably, the odds of being seropositive was substantially decreased for current smokers compared to never-smokers (OR=0.36, 95%-CI: 0.24-0.53), while there was no association for ex-smokers (Supplemental Table 8). This would correspond to a 2.8-fold increase in the odds of being seropositive among never-smokers or ex-smokers compared to current smokers (Figure 5).

 

The researchers went to great lengths to find an explanation for smokers having a third of the risk of getting COVID-19, preferably one which didn't involve smoking.

The finding that current smoking was associated with a smaller probability of being seropositive is counter-intuitive under a hypothesis that smoking was associated with a less healthy attitude and more risky behavior. 

 

We conducted several sensitivity analyses in the search for potential confounding effects: first, we found stable associations across age groups and sex (unadjusted OR of seropositivity for current smokers vs. ex-/never smokers = 0.43, 0.34, and 0.47 for age groups 14-39 (young), 40-59 (mid), 60+ (old), respectively; 0.32 for men and 0.51 for women) (Supplemental Table 9). 

 

Second, we considered the possibility that the association of current smoking with reduced probability of seropositivity was due to an impaired ability of smokers to raise antibodies based on a previous report [20,21]. However, among the 74 individuals reporting a positive SARS-CoV-2 PCR test, we observed only 5 individuals without antibodies and these included 1 current smoker and 4 never-smokers (20% smoker as in the full sample). 

 

Furthermore, the association persisted when restricting to individuals having reported a previous PCR test: current smoking was associated with a positive test report versus negative test report (among the n=501 tested: OR=0.35), which is in line with a hypothesis that current smoking was associated with a lower risk of infection (Supplemental Table 10). This finding was not compromised by a higher proportion of current smokers among those tested, as previously reported by others [22]: 21.0% of those tested and 20.2% of those not tested were smokers (OR=1.07 adjusted for age, sex). Of note, we observed more women than men tested (14.4% and 9.4%, respectively), but no difference across age groups (9.7%, 12.2%, 11.5%, for age 14-19, 20-69, 70+, respectively). 

 

Finally, we also found a significant dose-response between the number of daily smoked cigarettes and seropositivity among all participants (zero cigarettes for never and ex-smokers OR=0.50 per 10 cigs/day, 95%-CI: 0.37-0.65, modelling reported # cigarettes smoked daily in a linear fashion, adjusted for age and sex) and a similar association restricting to current smokers (OR=0.69 per 10cigs/day, 95%-CI: 0.43- 1.07, Supplemental Table 11). Allowing for non-linear dose-response supported this finding (Supplemental Figure 2). 

 

A reverse epidemiology effect could induce a bias here, when individuals being current smokers at the height of the outbreak included severely ill individuals (e.g. cancer, severe heart disease) that prevented individuals from going outside or primed individuals to be particularly careful avoiding infection. However, the smoking- associated severe diseases would affect more likely older individuals and are less likely among younger individuals; therefore, the stable effect estimates across age groups provide evidence against such bias that would fully explain the strong association across age groups. 

 

Another potential bias needs to be considered when smokers who were infected were less likely to participate in the study. However, most individuals have not known their seropositivity at the time of questionnaire completion and participation.

Having come up empty-handed, they are forced to concede that smokers really are significantly less likely to be infected, as many other studies have shown. 

Particularly important to discuss is the finding that current smoking compared to never smoking, but not ex-smoking, was associated with a decreased risk of being seropositive and for reported infection. The association is strong, stable across age groups and sex, and exhibited a dose-response-effect. While the sample size of smokers among individuals with reported PCR-test was limited, the stable risk estimates and the few individuals with reported infection not showing antibodies suggests that the finding was not due to a lack of antibody building, but due to lower infection probability.

 

But here comes the cope...

 

This does not allow for the conclusion that smoking per se was protective. 

 

It does though, doesn't it? 

While smoking is generally linked to a less healthy and more risky behavior, a behavior associated with smoking that guards against infection could result in the same observation, e.g. gathering socially more outside or less frequently.

 

Hmm. It's a stretch.

 

And finally...

 

Any conclusion that smoking was preventive for SARS-Cov-2 infection needs to be rigorously challenged and, if substantiated, conclusions made need to weigh in the adverse public health impact due to the severe other implications of smoking like lung cancer.

 

It goes without saying that all conclusions in science should be "rigorously challenged", but it is difficult to imagine quite so much rigour being called for if the study had found smokers to be at greater risk of infection.

Hat top to Phil for bringing this to my attention.

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Behavioural economics and flawed paternalism

I've been reading a very interesting paper by Charles J. Delmotte and Malte F. Dold who discuss the problem with using sin taxes to tackle so-called internalities. Paternalists argue that taxes are not only needed to address negative externalities - costs and harm to others - but negative internalities - ie. costs that people impose on their own future selves which they are not always fully aware of. Classic examples include teenagers taking up smoking without realising how addicted they are going to get and students taking on debt without realising how little their degree is going to be worth.

 

The latter example is a fairly recent problem largely created by government policy and it doesn't lend itself to sin taxes, but nicotine products, alcohol, food and cannabis do. 

Economists want resources to be distributed efficiently and this requires people to make rational choices. Behavioural economics has shown that people do not always make rational choices (although we already knew that). But much of the paternalist argument relies on the paternalist making assumptions about what people's 'true' preferences are and then showing that people do not always follow them. A lot of this is based on comparing stated preferences with revealed preferences. Delmotte and Dold give an example:

Consider for instance alcohol consumption: a hyperbolically discounting drinker might promise today not to drink at the party on Saturday but then she reverses that decision once Saturday has become today. In such a scenario, following a behavioral welfarist logic, sin taxes on alcohol would help as a commitment device to align individual choice with one’s ‘true’, long-term preferences.

 

I have always found this kind of reasoning problematic. It seems weird to assume that what people say they want in the future is their true preference, but the choices people actually make in the present are illegitimate. I discussed an example from the behavioural economics literature in Killjoys... 

 

In Inside the Nudge Unit, David Halpern (2015: 139) details the results of two behavioural experiments that appear to show ‘time-inconsistency’, with people making different decisions in the here and now than they would make for their future selves::

‘Around three-quarters of (Danish) workers chose fruit over chocolate when the prize was due to be delivered the following week, yet the majority instead chose chocolate when offered the choice at the point of delivery. Similarly, most people choose a healthy snack option over an unhealthy one for later in the day - especially if they have just eaten - but the reverse is true when asked immediately before the snack is available. The same appears to be true for other forms of consumption: most people choose a ‘highbrow’ movie (such as Schindler’s List) over a ‘lowbrow’ one (such as Four Weddings and a Funeral) when deciding what to watch next week, but the reverse when thinking about the evening.’

What should we conclude from this? Halpern says it shows that we are ‘trapped in our present’ and links it to hyperbolic discounting in which ‘the further into the future a cost or benefit, the disproportionately smaller it becomes relative to immediate costs and benefits’. So it does, but it also shows something else. People have a tendency to think - or hope - that they will have a different outlook in the future. If you have ever agreed, months in advance, to do something in which you are not very interested - such as going to a conference that is likely to be dreary - you will be familiar with this cognitive bias. Like an elephant in the distance, it seems very small when it is only a date in the diary. You think that you will be eager and ready when the day comes, but when it does you wonder why you ever agreed to it. This is a cognitive bias, but it tells us more about second-order preferences than it does about being ‘trapped in the present’. You wish you were the kind of person who enjoyed going to tedious conferences, eating healthy food and watching highbrow films. You hope that in the near future you might become that person. But you are not.

In the experiments above, the participants were given a straight choice. They did not have to pay for their food and films. There was nothing to sway them in the choice architecture, no nudging, no default option. Given that they opted for chocolate and Sleepless in Seattle, it would take a leap of faith to conclude that what they really wanted was celery and The Piano. Yes, they chose healthy food and highbrow films for their future selves, but putting something off until tomorrow is only one step removed from not doing it at all. At best, these experiments show that people know what an idealised version of themselves ought to do. Awkwardly, though, they also show what people really want to do.

Stated preferences are fairly worthless because people don't have to balance any costs or benefits. They are not making a real decision. We are all familiar with the experience of going to the pub with the intention of having just one pint and ending up having significantly more. It is not obvious that one pint is the welfare-maximising amount, nor is it obvious that your wellbeing would have been enhanced by being kicked out off the pub before you could have the second. 

It seems to me that there is nothing special about the stated preferences of your past self and that paternalists only hold these preferences in high regard because they tend to be less hedonistic than people's revealed preferences. Sin taxes designed to tackle negative internalities are also going to reduce positive internalities, AKA benefits.

Moreover, people's preferences change over time. That is the point Delmotte and Dold make in their paper and it has significant implications.   

The idea of dynamic preferences surfaces prominently in chapter three of On Liberty, entitled “On Individuality as one of the Elements of Well-Being.” Therein, Mill ([1859]2003, 124) states that “(h)uman nature is not a machine to be built after a model, and set to do exactly the work prescribed for it, but a tree, which requires to grow and develop itself on all sides.”4 Mill uses the metaphor of a tree to describe the transformational nature of human choice: over time, individuals develop into a more mature version of themselves. What is required for such a personal growth path, Mill argues in reference to Wilhelm von Humboldt, is the exposure to “experiments in living” ([1859]2003, 122). 

 According to Mill, a person obtains individuality – they develop their own preferences – when they have been exposed to a variety of situations, they have been free to think about who they want to be and discuss freely with others what matters to them. Importantly, this process of individuation has to be an active process in which individuals pursue what they perceive to be their own good, in their own way. In other words, active choices on behalf of the individual are necessary for processes of individuation which are, in turn, the prerequisite for individual well-being.

And so, in conclusion...

 

Rather than choosing taxes that target specific lifestyles, individuals with dynamic preferences have a common interest in rules that secure an important degree of freedom for future preference development. Moreover, as individuals cannot predict their future preferences, we argue that they will opt for a tax code that is neutral with regard to today’s and tomorrow’s preferences.

The study is paywalled but you can read a pre-print version here. 

 

Reading that paper nudged me towards this video of Mario Rizzo talking about the flaws of behavioural paternalism. It's worth a watch. I don't know who kicks things off with the introduction but I like his style too.

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