Thursday, 13 May 2021

The 2021 Nanny State Index

Europe's hall of shame

The latest edition of the Epicenter Nanny State Index, which I've spent the last few months putting together, is published today. Regular readers will know that it's a biennial league table of the best and worst places in the Europe to eat, drink, smoke and vape.

Since the last edition was published in 2019, the COVID-19 pandemic has led governments around the world to impose coercive controls on an almost unprecedented scale. As the world slowly returns to normal, it is crucial that all liberties are restored.

The pandemic was a reminder of the difference between a genuine public health problem that requires collective action and self-regarding private behaviours which do not. Outbreaks of serious infectious disease are thankfully rare in the developed world and COVID-19 required an effective public health response. In Europe, too many public health agencies had been distracted by the nanny state agenda and were ill equipped to carry out their core function of protecting the public from infectious disease. Even the World Health Organisation seemed more interested in banning e-cigarettes and taxing sugary drinks than in controlling the coronavirus.

When lockdowns were introduced in the spring of 2020, paternalists seized the opportunity to impose the kind of lifestyle regulation they had hitherto only been able to dream about. At one point, one in five people worldwide were living in a country where the sale of cigarettes and e-cigarettes was illegal. For a while, a quarter of the world’s population lived under alcohol prohibition. As more people were forced to socialise outdoors, anti-smoking campaigners demanded outdoor smoking bans. Campaigners in the USA and elsewhere claimed (falsely) that vaping increased the risks of people catching the virus. E-cigarette shops and alcohol retailers were deemed ‘non-essential’ in many countries. When lockdown ended, bars reopened but some countries did not allow them to serve alcohol.

It is an ill wind that blows no good and the pandemic response also led to modest liberalisation in some places. A few countries legalised home delivery for alcoholic drinks. Some countries, such as the UK, allowed more bars to serve drinks on the street. But, overall, the pandemic gave the nanny statists an opportunity to ruthlessly exploit.

This edition of the index reflects the situation as of March 2021, but we have not included legislation that is expected to be a genuinely temporary response to the pandemic. The outlook is bleak nonetheless. Almost without exception, governments across Europe are adopting higher sin taxes and more prohibitions.

This year, the index has been expanded to thirty countries - the EU plus Iceland, Norway and the United Kingdom. Norway tops the league table although that could change once it legalises e-cigarettes. Lithuania, with its heavy temperance legislation, is again in second place while Finland drops to third.

The top of the table is dominated by Scandinavia, Eastern Europe and the British Isles. Greece is the only country from southern Europe in the top half, largely thanks to its very high sin taxes on alcohol and tobacco. At the more liberal end of the table, the best countries are a mixed bag. Germany has performed the extraordinary feat of having the lowest score in all four categories of the index. Hovering above it we find Czechia, Luxembourg, Spain and Italy, all of which have done well in previous editions. Denmark is just above this group and is the only Scandinavian country not in the top ten. That seems likely to change in the future, however. Like the Netherlands, Denmark has a slew of hardcore nanny state policies in the pipeline.

Twelve countries now have taxes on sugary drinks, ranging from five eurocents per litre in Hungary to 30 eurocents in Ireland. Several countries also tax artificially sweetened drinks. And thirteen countries tax e-cigarette fluid (up from eleven in 2019), with tax rates ranging from six eurocents per ml in Hungary to 30 eurocents in Finland and Portugal.

Germany is now the only country in the EU that could be described as smoker-friendly. Previous contenders Austria and Czechia have both introduced draconian smoking bans in recent years. The number of vaper-friendly countries is also dwindling. Seventeen of the thirty countries in the index have made it illegal to use an e-cigarette wherever smoking is prohibited. Sixteen countries have a total or near-total ban on e-cigarette advertising.

We have made a few changes to the index since the 2019 edition was published. As heated tobacco products have become popular, taxes on heated tobacco have inevitably become attractive to politicians. A new subcategory has therefore been included in the tobacco section, worth up to five points. Countries that have been foolish enough to ban these products (Malta and Norway) are given maximum points.

Ireland has pioneered the alcohol display ban (otherwise known as the booze curtain) and so a new subcategory has been added to take that into account. It is also worth five points. A subcategory for minimum alcohol pricing, which is now in force in Wales and Scotland and may soon be in place in Ireland, was added in the 2019 edition.

All taxes are adjusted for affordability in the Nanny State Index. This year, in a change to the previous methodology, we use median incomes rather than per capita GDP for this calculation. Median incomes are a better guide to the spending power of individuals, particularly in corporate tax havens where GDP does not accurately reflect average incomes.

The big picture is one of a constantly expanding nanny state raising prices and trampling freedom. The blame for this lies overwhelmingly with domestic governments, not with the European Union. The EU banned menthol cigarettes in May 2020, but it cannot be held responsible for regressive taxation, draconian smoking bans and excessive regulation of alcohol and food. The gulf between the freest countries at the bottom of the table and the least liberal countries at the top is almost entirely the result of decisions made by their own governments. Change is possible.

The Nanny State Index is a huge collaborative project which involves gathering and checking over a thousand pieces of data. As always, we thank our friends and partners across Europe who make it possible.

Download the publication here and visit the website here. If you spot anything that you think is an error, let me know. 

And you can watch the launch event live on YouTube at 1pm tomorrow.

Wednesday, 12 May 2021

On the Pin Factory podcast

I was on the Adam Smith Institute's Pin Factory podcast recently talking about tobacco harm reduction, unlocking the economy and the prospects for the UK economy. Check it out. 

Tomorrow's a big day for me, with the new Nanny State Index published in the morning and a very special guest on The Swift Half with Snowdon at 5pm. Watch this space.

Tuesday, 11 May 2021

A public health expert speaks

However, one or two people have told me that he is respected as an expert in real public health issues, such as infectious disease control. 

Imagine my surprise, then, when I stumbled across this article published last October in which he praises Hungary's response to COVID-19. Hungary's authoritarian leader Victor Orban was widely criticised for his 'Coronavirus Coup' in the early days of the pandemic when he seized even more power in the name of defeating COVID-19. McKee didn't worry about this so much, although he did acknowledge that "aspects of the government’s response have featured in the increasingly polarised Hungarian political scene". 
Instead, he asks why Orban's regime has done so well. is clear that Hungary has fared much better than many other European countries. Why?
McKee comes up with three reasons. Firstly, spending money on public health...
Hungary, in common with several of its neighbours, is fortunate in having a relatively well-developed laboratory system, linked closely to the public health system.
Secondly, spending money on public health...
Hungary was a pioneer in developing public health training in central Europe and has benefited from the capacity that this developed
And thirdly, in a self-referencing paragraph, following the science and acting quickly...

The dangers are all too apparent when looking at the countries that have performed worst, with the USA and Brazil led by politicians that have rejected the evidence, instead putting forward a series of often bizarre proposals that defy the basic laws of science, or even any sense of logic (McKee et al., ). This has undoubtedly cost tens of thousands of lives. Again, Hungary was fortunate as the government acted extremely quickly, at a time when closing down even a few days earlier could make an enormous difference.
In conclusion...
So Hungary seems to have done very well.
But has it? Fast forward to May 2021 and Hungary has the highest per capita Covid death toll on the entire planet.

If this is how hot McKee is in his area of alleged expertise, no wonder he gets everything else so wrong.

Monday, 10 May 2021

Presumed consent could lead to fewer organ donations

First published by Spectator Health in October 2018

So much political folly could be avoided if we focused on outcomes rather than intentions. The passing of legislation in the Commons last week to introduce presumed consent for organ donation will probably not result in disaster but the law is likely to be a flop and the campaign for its introduction should concern anybody who hopes for evidence in policy-making.

The idea is simple. Hundreds of people die every year for want of an organ donor. If the government switches from the current system, in which have to people opt in to the organ donor register, to a system in which people have to opt out, there will be more organ donors, more organs donated and more lives saved.

This being the case, the only challenge for politicians is to persuade or overwhelm those who have an ethical or religious objection to doctors harvesting their organs without permission. I respect the views of such people but I do not share them. The idea of the state implicitly owning my corpse makes me feel slightly uncomfortable, but people dying needlessly because of beliefs which are essentially irrational is worse. Proponents of presumed consent rightly argue that there is no coercion because it is easy to opt out.

If you have no moral objections to presumed consent, the only question is whether it works. And that is where it falls down.

When Wales introduced an opt-out system in 2015, Health Minister Mark Drakeford called it a ‘ground-breaking step which will save lives’. The First Minister Carwyn Jones described it as ‘law making in Wales at its best’. It was left to the Bishop of Swansea and Brecon to be the ghost at the feast, warning that ‘in the deeming of consent, there is always the risk that that idea of gift might vanish.’

The results are now in. An evaluation published by the Welsh government last year found that the data ‘does not show any consistent change in deceased organ donations in Wales’ and that there has been ‘no rise in average quarterly donor levels’. These findings were reported by the BBC and the failure of presumed consent in Wales has been widely discussed in the medical media. Despite this, MPs have pushed through the legislation in England with the ludicrous assertion that it will save hundreds, or even thousands, of lives each year.

The reality is that not a single life will be saved if the outcomes seen in Wales are replicated in England and it is quite conceivable that lives will be lost. How can this be when so many more people are opted in? It’s because, as the Bishop of Swansea and Brecon feared, the gift has been vanishing.

Many people believe that the current system requires explicit consent. It does not. If you die without an organ donation card in your pocket, your next of kin can give consent on your behalf. It is wise to put yourself on the register and explain your wishes to your family, but it is not essential. If you haven’t registered, your next of kin can give permission. If you have registered, they have no legal right to veto.

If you do not want your organs to be given to somebody else, you can put your name on a separate register. Very few people do this at the moment – except in Wales. In 2016/17, there were 27,559 people in England who had explicitly opted out of the system, a mere 0.05 per cent of the population. In Wales the figure was 175,000, or 5.6 per cent. These are people who have been taken out of the system for good. Their decision cannot be overruled by the next of kin.

Presumed consent has therefore led to there being fewer potential organ donors and we should not be surprised that it has not led to more organs being donated.

Although counter-intuitive at first glance, this outcome seems perfectly logical once it is explained. The Welsh government can be forgiven for experimenting with the idea in 2015. It is not inconceivable that it could have worked. But now that we have the results from a near-perfect natural experiment, it is inexcusable for English MPs and a national newspaper to make grandstanding claims about the new legislation saving hundreds of lives. What is the point of evidence if it is disregarded in favour of good intentions?

It is far from impossible that presumed consent in England will lead to fewer organs being donated, but even if the Welsh experience is emulated and it merely has no impact either way, the policy is not cost-free. A significant minority will be very unhappy about the law being introduced and a good deal of money will have to be spent informing the public about it.

If we want to increase the number of donors, there are better options. Given the importance of the next of kin under the current system, efforts should be focused on asking the crucial question delicately and sensitively at this most difficult of times. As Katherine Wright of the Nuffield Centre on Bioethetics points out, using specialist nurses to handle the situation appropriately greatly increases the likelihood of the family giving consent. It is this, not presumed consent, that has helped Spain achieve such a high rate of donation.

More controversially, we could repeal the ban on people selling their organs while they are alive. A few countries provide some form of financial incentive for live organ donors and this seems to work. Less controversially, we could make organ donor cards more accessible to the public. In the 1980s, I recall them being a common sight on shop counters. What happened to them?

None of these solutions will give MPs the warm feeling of righteousness that they experienced last week but, unlike presumed consent, they might actually do some good.

Friday, 7 May 2021

Last Orders with Geoff Norcott

There's a new episode of Last Orders out with special guest Geoff Norcott. We talk about working class Tories, the state of Britain’s pubs and PC policing. It was recorded before the election results came through, btw.

You non-subscribers can listen here.

Jamie Oliver’s guilty sugar secret: his own recipes are full of the stuff

First published by Spectator Health in September 2015

Imagine a country in which state-subsidised television networks wheel out popular celebrities to scare the masses into supporting more taxes. Imagine no longer. This is not a dystopian future, this is Jamie’s Sugar Rush.

According to a Guardian journalist, Mr Oliver is ‘extremely well liked’. If so, I have drifted further from mainstream public opinion than I realised. In his guise as a TV evangelist on Channel 4 last night, he increasingly resembled a cadaver being zapped with electricity, all blank eyes and random facial expressions. ‘I’ve come here to get my head around it,’ he said with faux-naivety as he prepared to fire loaded questions at another sympathetic interviewee. In an hour of staged encounters and predictable factoids, it was the voyage-of-discovery charade that grated more than anything. It was always going to end with advertising bans, higher taxes and a new crusade for a celebrity chef. Channel 4 knew it, we knew it and Jamie knew it.

There were moments of propaganda in this programme that Kim Jong-Un would have rejected for being too crude. Towards the end, Oliver confronted a bunch of big-wigs to tell them about the revolutionary idea that had emerged from his awakening. The idea was a tax on sugar. Ooh, controversial. Jamie was nervous. How would they react?

Lo and behold, they liked it! Graham MacGregor spoke at length about his support for the proposal. Tam Fry thought it was great. Mike Rayner was also keen. What are the chances? It so happens that MacGregor is the chairman of Action on Sugar, Mike Rayner is a member of Action on Sugar (although the programme did not credit him as such) and Tam Fry, head of the National Obesity Forum, has been going on about taxing food for as long as I can remember. How fortuitous that three of the country’s leading anti-sugar fanatics were in the room.

The millionaire chef is now doing his bit by putting a ‘tax’ on sugary drinks in his own restaurants. The money will go towards a fighting fund to campaign for higher taxes for all. This is Oliver’s contribution to the fight against a product that he says is ‘evil’, a strong word and yet a strangely weak response. People who run vegan restaurants think that killing animals is evil, but they don’t settle for increasing the price of a steak by 10p. They stop serving it. Oliver’s approach is rather different. He hikes the price of a glass of Coke from £2.60 to £2.70 while selling cookery books which are, to put it gently, not wholly consistent with his trenchant anti-sugar views.

Jamie says we shouldn’t be eating more than seven teaspoons of sugar a day. Will he therefore be apologising for his ‘chocolate love cake’ recipe that contains 21 teaspoons of the stuff? What about his sticky toffee pudding (12 teaspoons) or his tasty sundae (16 teaspoons)? Will he be recalling and pulping the cookery book that gave the world his recipe for gluten-free Christmas cake in which every slice had 28 teaspoons? (Jamie has not yet updated his website to include the new sugar guidelines, but that is now four times the recommended daily amount.)

‘Those are desserts!’, I hear you cry. ‘It’s the ‘hidden’ sugars in breakfasts, main courses and drinks that are the real problem.’ OK then. In Jamie’s Sugar Rush, the great man bemoaned the ‘added sugars’ in bread. His own loaf requires two tablespoons — that’s tablespoons, not teaspoons. His pancakes, which were recently promoted in the Sunday Times as a ‘healthy breakfast’, have 17 grammes of sugar per serving — more than a bowl of Frosties. His salmon dish has three teaspoons of sugar, as does his chicken garden soup. As for drinks, how about trying one of Jamie’s milkshakes, which contain more sugar than a can of Coke?

I could go on and on. The point is not that Jamie Oliver has double standards. The point is that any professional chef would appear hypocritical if he started demonising a staple ingredient. Oliver’s recipes don’t use sugar excessively or gratuitously. They are not toxic, addictive or evil. They use as much sugar as is needed to give them the right taste and texture.

If you believe that a teaspoon of sugar is intrinsically harmful, any cookery book will terrify you, even Mrs Beeton’s. ‘Hiding’ ingredients is what chefs do. They are the sellers of ‘empty calories’, the ‘spikers’ of food, the ones who add the ‘added sugar’. Bread is supposed to have a bit of sugar in it. It doesn’t suddenly become a crime when Tesco does it. Everybody, please, calm down.

Jamie Oliver may truly believe that sugar is evil. He may genuinely think that it is dangerous to eat more than seven teaspoons of sugar a day. But if he took his beliefs to their logical conclusion as a restaurateur he would have to become a full-time television presenter to make a living because he would have no restaurant business left. Surely nobody wants that.

Thursday, 6 May 2021

George Monbiot blames the government for rising obesity levels – there’s a simpler explanation

First published in Spectator Health in August 2018

George Monbiot has written a curate’s egg of an article for the Guardian on the subject of obesity. Struck by the near-total absence of fat people in a photo of Brighton beach in 1976, he wondered whether the rise of obesity in the intervening years was the result of more calories in or fewer calories out.

What he discovered came as a shock to him. His first revelation will be no surprise to readers of this blog: calorie consumption has fallen over time. Thanks to the National Food Surveys, we have a treasure trove of information going back to 1940. It shows that the average Briton was consuming more than the modern recommendation of 2,500 calories a day during the war. This rose after 1945, peaking in the 1960s, and falling thereafter. Average daily calorie consumption fell from 2,850 in 1970 to 2,560 in 1980. By 2011, it had dropped to 2,269. Figures from the National Diet and Nutrition Survey, which began in the 1980s, tell much the same story.

These surveys have raised concerns about mismeasurement. We know that people under-report what they eat and that fat people under-report more than thin people. In 2016, Public Health England hired the Behavioural Insights Team to look into this. Sure enough, they found evidence that people under-reported calorie intake and that the scale of under-reporting had risen over time, but even after correcting for this, they found that we are consuming fewer calories than we did in the 1970s.

All the evidence points in the same direction. Average calorie consumption – and, indeed, sugar consumption – is lower today than it was in the 1970s when obesity was relatively rare. The only way to deny this is to dismiss decades of research as worthless rubbish. That is not a good look for an empiricist and it is to Monbiot’s credit that he does not do so.

If we are not consuming more calories then the rise of obesity must be due to us burning fewer calories off, right? Not so fast, says Monbiot. He offers evidence that children are doing just as much exercise as ever and that people in poor countries burn the same number of calories as people in rich countries.

So what is the answer? Alas, this is where Monbiot’s article descends into gibberish. If you’re familiar with his oeuvre, you won’t be surprised to hear that the blame lies with those nasty corporations. They use advertising to ‘overcome our resistance’. They ’employ an army of food scientists and psychologists to trick us into eating more than we need’. They ‘discovered our weaknesses and ruthlessly exploit them.’

This is all standard Guardian banter but it doesn’t make any sense in the context of Monbiot’s article. It is almost as if – perish the thought – he decided what his conclusion was going to be before he began his research.

Even if everything Monbiot says about ‘Big Food’ is true, even if he is right when he says that ‘the opportunities to load our food with sugar have boomed’, we are still faced with the inescapable fact that we are consuming less sugar and fewer calories than we did in the glorious summer of 1976. As far as I can tell, Monbiot does not subscribe to magical thinking about particular types of calorie. His explanation therefore explains nothing.

So what is the real answer? There are factors that Monbiot does not mention, such as the rise of central heating and the decline of smoking, which are likely to have had some effect, albeit only on the margins. It is possible that future research will find that some unsuspected biological factor has also played a role. And it is important to remember that averages do not tell the whole story. It would be an ecological fallacy to assume that everybody is eating less just because average consumption has fallen.

Nevertheless, it is puzzling, to say the least, that the rate of obesity could rise so sharply if calorie consumption has fallen and people are as physically active as they have ever been. But this is where Monbiot makes his mistake. Physical activity has declined and his slivers of evidence to the contrary do not stack up against the facts. Public Health England says that levels of physical activity have dropped by a quarter since 1961. The World Health Organisation says that western countries have seen ‘decreased physical activity levels due to the increasingly sedentary nature of many forms of recreation time, changing modes of transportation, and increasing urbanization.’ Harvard School of Public Health says that: ‘Physical activity levels are declining’ and that ‘this decline in physical activity is a key contributor to the global obesity epidemic’.

Physical activity is not always easy to measure and it is often confused with leisure time exercise, but there should be little doubt that we are burning off fewer calories than ever in our day to day lives.
Britons are walking less (from 255 miles per year in 1976 to 179 miles in 2010) and cycling less (from 51 miles per year in 1976 to 42 miles in 2010). This is true of both adults and children.

Unsurprisingly, people who drive to work are fatter than those who go by foot or by bicycle. And when we get to work, we are more sedentary than ever, as Tim Olds notes:

In the 1960s, half the jobs in private industry in the United States required at least moderate-intensity physical activity, compared to less than 20% today.
Work in factories and farms has given way to office work, and that has amounted to over 400 kilojoules less each day that adults expend at work. This difference alone results in a weight increase of about 13 kilograms over 50 years, which pretty closely matches actual changes in weight.

Only 18 per cent of British adults report doing any moderate or vigorous physical activity at work while 63 per cent never climb stairs at work and 40 per cent spend no time walking at work. Outside of work, 63 per cent report spending less than ten minutes a day walking and 53 per cent do no sports or exercise whatsoever.

This trend is confirmed by the National Food Surveys, which occasionally allude to the fact that the rise of office work resulted in people not needing to eat so much. As early as 1962, they reported that:

 ‘energy requirements have decreased in all regions … The decrease in calorie requirements is greatest in Classes A2 and B, and is partly explained by the increasingly sedentary nature of their occupations’. In 1971, they mentioned the ‘continuing decline in energy needs as work becomes less strenuous.’

On average, declining energy needs have resulted in declining energy consumption, but not for everybody. Hence obesity. It is easier than ever to get fat, not because we are eating more but because physical activity has been engineered out our lives. It is trivially true to say that obesity is caused by eating too much, but in relation to what? If we want to understand what has changed at the macro level in the last fifty years to drive up rates of obesity, we must first acknowledge that ‘calories in’ have not gone up. And once we accept that, there is only one credible explanation left: ‘calories out’ have gone down.