Thursday, 2 February 2023

Public health comic investigates the Beano

There's a laughable investigation into the Beano's website, of all things, in the British Medical Journal today. The Beano has responded, saying that the authors had chosen “to cite selective examples out of context”.

If you're familiar with the world of 'public health' academia, this will be enough of a clue for you to guess that Mark Petticrew is one of the authors, and you would be right.

I've written about  it for the Spectator

One of the regular characters in Viz is an old woman called Meddlesome Ratbag who goes to great lengths to engineer situations in which she can be offended so she can complain to the authorities. I was reminded of her this morning when I read the British Medical Journal‘s investigation into the Beano. Yes, you did read that correctly. One of the world’s leading medical journals has been devoting its attention to a children’s comic.

It turns out the Beano has a popular website that has been visited by nearly 48 million kids since its launch in 2016, according to the investigators. It stands accused of mentioning the brand names of various sweets, treats and fast food companies. These products are not advertised on the website and no money has changed hands. The owners of the comic have clarified that on occasions when they work with companies, this is ‘always clearly marked’ on their website and ‘would never include’ brands deemed by the government to be ‘high in fat, sugar or salt’ (HFSS).

The Beano is nevertheless accused on ‘exposing children to HFSS content’ by acknowledging the existence of the likes of Skittles and Greggs. In an overwrought editorial accompanying the investigation, the BMJ says:

Todays innocent fun” is tomorrows health crisis.

Read the rest here.

Prohibition failing everywhere

After the fall of the Islamic State, Bhutan was left as the only country in the world where tobacco sales were banned. Prohibition did not go well (who could have predicted that?)

The Bhutanese government legalised tobacco in July 2021 as a response to the COVID-19 pandemic. This was not because the government recognised the potential of smoking to reduce infections, but because so many tobacco smugglers were coming over the border carrying the virus.

The Tobacco Control blog has finally accepted that Bhutan has no plan to bring prohibition back. This makes it sad.

Bhutan reverses sales ban on tobacco

In 2010, Bhutan was lauded globally for being the first country to ban tobacco sales and smoking in public places. The ban lasted for over a decade until the circumstances posed by the COVID-19 pandemic compelled policy makers to change course, legalising the sale of tobacco within the country.

The Bhutanese legislation essentially banned everything except bringing a bit of tobacco in from abroad for personal consumption.

Building on the nationwide sales ban in 2004, the Tobacco Control Act, 2010 imposed a comprehensive ban on all tobacco products in Bhutan. The law prohibited cultivation, manufacture, supply and sale of tobacco products; imposed bans on advertisements, promotion and sponsorship of tobacco products along with restrictions in films; declared smoke-free public places or zones; and also prescribed a labelling requirement for display of country of origin and health warnings on tobacco products. Tobacco consumption, however, was not banned. Import of tobacco products for personal consumption was permitted, but taxed. The law also levied a sales tax of 100% for imported tobacco products from India and an additional custom duty of 100% for tobacco products from other countries. The Tobacco Control Regulations, 2013 and the Tobacco Control (Amendment) Act, 2014 imposed limitations on the quantities that could be purchased for personal consumption and required declarations of importer’s identity. The law also prohibited the illegal sale of tobacco and the use tobacco products in public places, punishable under the Penal Code Act of Bhutan, 2004

Despite the existence of a robust legal and regulatory framework for tobacco control, smuggling and a black market for tobacco was rampant in Bhutan.

Incredible use of the word 'despite' there. Here in the real world, we would say 'because of'.

Tobacco use in Bhutan has not decreased significantly, with a tobacco use prevalence of 24.8% and 23.9% as per the STEPS 2014 and 2019 respectively.
'Not decreased significantly' is one way of putting it. Another way of putting it would be 'increased exponentially'. In 2003, Bhutan had a smoking rate of just one per cent!
So that's tobacco prohibition gone for now. Over to you, New Zealand!
These politicians banned alcohol – now poisonous hooch is killing thousands

The world’s largest prohibition experiment since the 1920s pushed liquor production underground. The consequences have been disastrous.

 You don't say.

Wednesday, 1 February 2023

Learning lessons from Scotland?

Zero Covid enthusiast Devi Sridhar is in the Guardian today telling the English to learn some lessons from the Scots if they want to reduce alcohol-related mortality. Scotland has a far the highest rate of alcohol-specific death, so I'm not sure anybody is knocking on Nicola Sturgeon's door begging for advice, but let's roll with it.

Over the past 15 years, its devolved government has attempted to reduce alcohol-related harm through a ban on multi-buy price promotions on alcohol, minimum unit pricing, reducing the drink-driving limit and restricting alcohol marketing on TV. And partly due to these efforts, alcohol harm fell in Scotland between 2003 and 2012, before plateauing. The emphasis in Scotland continues to be on high-risk groups.


She is right to say there was a fall in alcohol harm, as measured by alcohol-related deaths, between 2003 and 2012, although the rate is still far higher than in England. 


So which policies does she think achieved this? As you can see, she names four.

1. Ban on multi-buy discounts. 

Introduced in October 2011. When it was evaluated in 2014 it was found to have had no effect on alcohol consumption.

2. Minimum pricing. 

Introduced in May 2018, long after the decline in mortality. Regular readers will be aware that this policy died on its arse. All the evidence to date suggests it reduced alcohol consumption slightly but not among heavy drinkers who are consuming more. There is no evidence of health benefits and some suggestion of harm.

3. Reducing the drink drive limit. Introduced in 2014, after the fall in alcohol-related deaths. It has been evaluated twice. Both studies concluded that it had no effect.

Firstly, this study in 2018 found that lowering the limit "was not associated with a reduction in RTAs [road traffic accidents]" but it did damage the pub trade.

Secondly, this study in 2021 found that lowering the limit "had no effect on drink driving and road collisions".

4. Restricting alcohol marketing on TV. 

This hasn't happened and the Scottish government doesn't have the power to make it happen. It is a figment of her imagination.

So, we have four policy changes, one of which is imaginary. The three that are real didn't work and two of them took place after the period in question. Top work from a public health PhD!

Devi doesn't ask why heavy drinking went up so much in 2020 and 2021 despite overall drinking going down, but if she gave it some thought she might find some useful lessons for how to reduce alcohol-related deaths in the future. 

Tuesday, 31 January 2023

Scots buying more alcohol from England

Further to this morning's post about minimum pricing, Public Health Scotland put out another report today. Based on survey data, it found that the proportion of Scots who have bought alcohol in England to bring back to Scotland rose from 13% in 2021 to 19% in 2022.

The report downplays this somewhat...

In 2022, a majority of 81% of 1,014 respondents did not report ever purchasing alcohol from across the border with England in person. Only 5% (54 respondents) reported travelling for the sole purpose of buying alcohol to bring back to Scotland. A larger proportion of 19% (191 respondents) reported bringing alcohol back to Scotland that they had purchased on a visit for another purpose because it is cheaper there than in Scotland.

"Only" 5%?! If the survey is representative, that's well over 200,000 people going over the English border purely to buy booze to bring back to Scotland. Considering how far most Scots live from the border, that's an incredible statistic. Off licence owners in the north of England should drink a toast to Nicola Sturgeon.

A further 14% are taking the opportunity of travelling to England to bring back some relatively cheap alcohol. It shows how much minim pricing is hitting drinkers in the pocket.

I'd love to see the same stats for Wales, where England is a stone's throw away for large numbers of people. If the Public Health Scotland report is any guide, a lot of them will have been heading over the Severn Bridge to get to an English Asda. 

Among the minority of 10% of panel members in Scotland who reported living within 60 minutes’ travel from the border with England (n=102) it was more common to report buying alcohol across the border, with 22% having travelled for the sole purpose of buying alcohol and 27% having bought alcohol while travelling for another purpose.

The Scottish government's claim that minimum pricing has worked rests solely on alcohol sales dropping slightly in Scotland while they rose slightly in England. I wonder how much of that is due to cross-border shopping?

Minimum pricing had a negligible impact on the booze industry

Public Health Scotland has produced the latest part of its minimum pricing evaluation.

To appreciate the full chutzpah of this tweet, you need to know that Colin Angus is a stalwart of the Sheffield University team responsible for the dire modelling that persuaded the Scottish government to go ahead with minimum pricing. (Not that they needed much persuading - they were committed to the policy before there was any evidence for it.)
It's a bit rich for Angus to have a pop at people for making inaccurate predictions about this policy. You only need to scroll to the bottom of the BBC article to be reminded of how bad his own track record is. 

I'm not sure which 'opponents' he's referring to. Perhaps the Scotch Whisky Association? Among economists, the only question was whether minimum pricing would make more profits for the drinks industry. Economic theory suggested that they wouldn't, but it was always a possibility since people are not fully rational and competition is not always perfect.

In the IEA monograph Flaws and Ceilings (2015), I predicted that minimum pricing would increase revenues but have little overall effect on profits.
Drinkers who prefer to purchase budget brands with low production costs will have to buy mid-range brands which have higher production costs. The impact on industry profits is negligible; it is consumers who are denied their first choice preference who lose out.
This seems to have been borne out by today's report which combines sales data with interviews with industry 'stakeholders' and finds that there have been some winners and losers, but no clear trend for the industry in either a negative or positive direction.
  • Overall effects on retailer profits were felt to be small with increased margins compensating for decreased volumes, with the effects depending on the mix of alcoholic drinks sold pre-MUP.

This should not be surprising since the impact of overall sales volumes has been pretty marginal. A Public Health Scotland report published last November found that per-unit alcohol sales only fell by 1.1% in the first three years of minimum pricing. Scottish consumers are spending more money on drink and consuming nearly as much as they did before. Some heavier drinkers are consuming more.
I can't remember what the Sheffield mob predicted would happen to industry profits after minimum pricing. I don't think they modelled it, but if Colin Angus wants to take it as a win that the booze industry has done fine out of the policy, we should let him. He hasn't had many wins in his career as a soothsayer.  

There's only a few months to go before minimum pricing has its fifth birthday and the sunset clause kicks in. After that, the Scottish government has twelve months to prove that it has worked. Objectively, it will be unable to do that because the evidence clearly indicates that it has been a flop, but this is politics so I'm sure they will find a way. I wouldn't be surprised if activist-academics pull a dodgy counterfactual out of their hat at the last minute and claim success, as has just happened with the sugar tax. In fact, I'd put money on it.

Friday, 27 January 2023

'Public health' academics apply lipstick to a pig

Re-posted from my Substack...

Just before Britain’s sugar tax was introduced in April 2018, various advocates of the policy were handed £1.5 million of taxpayers’ money to evaluate it. Marking your own homework is considered perfectly normal in ‘public health’.

They had their work cut out because what the government classifies as child obesity (but actually isn’t) rose in 2018/19, rose again in 2019/20 and then rose dramatically in 2020/21; the latter doubtless being lockdown-related.

Clearly unable to claim that childhood obesity declined after the tax was introduced, the evaluation team settled for arguing that there was less sugar in soft drinks as a result of the tax.

On average, this is probably true, although much depends on how much you trust the counter-factuals above. The effect certainly wasn’t very large and sugar consumption from soft drinks had been dropping for many years anyway.

Since soft drinks only provide around 2% of the nation’s calories and there had been no decline in obesity in previous years when sugar consumption from soft drinks had been in freefall, it was unlikely that the sugar tax would have any measurable impact on obesity rates. This seemed to be confirmed by obesity rates for both children and adults being higher in every year since the tax was implemented.

Today, however, the evaluation team is claiming victory based on an extremely sketchy model. They created a counterfactual based on trends between 2013 and 2016 and then compared it to what actually happened. Child obesity didn’t actually decline among any groups. Even relative to the counterfactual, it didn’t decline among boys of reception age or girls of reception age. It didn’t decline among Year 6 boys either. But there was, supposedly, a 8% decline among Year 6 girls. This, again, was only a relative decline. Even among this subgroup of the population, rates of obesity actually rose.

Even the strongest association of the SDIL [Soft Drinks Industry Levy] among the most levy-responsive groups (e.g., year 6 girls) reflected only a dampening of the rate of increase in obesity prevalence compared to the counterfactual rather than a reversal in trends.

When the researchers produced a counterfactual based on data from 2013 to 2018 - when the tax was actually implemented - it found that obesity was higher than expected among reception age kids and about the same as expected among Year 6 kids. This finding is filed away in the supplementary material and the authors barely mention it.

The authors conclude that…

Our results suggest that the SDIL was associated with decreased prevalence of obesity in year 6 girls, with the greatest differences in those living in the most deprived areas.

And, inevitably…

Additional strategies beyond SSB taxation will be needed to reduce obesity prevalence overall, and particularly in older boys and younger children.

This study will doubtless be cited as evidence that the sugar tax ‘worked’, but it is extremely thin gruel. Apart from requiring some very obvious cherry-picking to find evidence of success, it requires us to believe that the mere announcement of the sugar in 2016 reduced obesity among one very specific demographic, while the introduction of the sugar tax did not.

The authors argue that the announcement of the sugar tax incentivised soft drink companies to reformulate their drinks. Indeed it did, but not straight away and not in huge numbers. Lucozade and Ribena took the sugar out in 2017 and Irn-Bru halved the sugar content in 2018. It seems unlikely that this would be enough to reduce obesity among 10-11 year old girls by 8%, especially since it mysteriously had no effect on anyone else.

The counterfactual for those girls is shown below in red. The real obesity figures are shown in blue. You can see that the trend in obesity was essentially flat from 2015 to 2018 - i.e. before the sugar tax - but the counterfactual keeps on rising. Voila! The gap between the two lines is your 8% reduction in obesity. The evidence for the sugar tax being even a partial success starts and ends with this chart.

Even if you have faith in the highly suspect counterfactual scenario, why on earth would the sugar tax drive a significant reduction in obesity among Year 6 girls but not Year 6 boys? The authors confess themselves to be baffled...

‘it is unclear why this might be the case, especially since boys were higher baseline consumers of SSBs [sugar sweetened beverages]’

So they take the opportunity to splutter something about their current policy objective, advertising bans.

One explanation is that there were factors (e.g., in food advertising and marketing) at work around the time of the announcement and implementation of the levy that worked against any associations of the SDIL among boys.

There is no evidence for this whatsoever.

And why would Year 6 children be affected and not reception age children? Apparently, it was never likely to benefit younger children…

This result is congruous with findings from a cohort of British children showing that SSB consumption at ages 5 or 7 are not related to adiposity at age 9 years

Now they tell us! I don’t remember Jamie Oliver saying that, do you?

The lack of impact on young children gives the authors an excuse to once again push for more action from government…

Fruit juices, which are not included in the levy, are thought to contribute similar amounts of sugar in young children’s diets as SSBs and may explain why the levy alone is not sufficient to reduce weight-related outcomes in reception age children. In addition to drinks, confectionery, biscuits, desserts, and cakes are also important high-added sugar items, which are regularly consumed by young children and could be a target of additional obesity reduction strategies.

With the case for sugary drink taxes now ‘proven’ in the fairytale world of ‘public health’ academia, taxes on ‘confectionery, biscuits, desserts, and cakes’ will no doubt be next. And when those taxes also patently fail to reduce obesity, we can expect a lavishly funded evaluation team to turn up wielding the carefully selected findings from another dodgy model to prove that those, too, have been a triumph.

To date, the sugar tax has cost consumers well over a billion pounds.

Tuesday, 24 January 2023

Food reformulation folly - the zombie twitches

The food reformulation wheeze seemed to fade away once Public Health England was killed off, but state-funded charity Nesta resurrected it this week and wants it to be mandatory. 

I wrote about it for Cap-X...

Public Health England (PHE) is dead but its terrible ideas live on. In 2015, PHE initiated a ruse in which it planned to remove 20% of the sugar from most processed food. The target was set for 2020 and the agency started working with its ‘stakeholders’ in the food industry to achieve ‘health by stealth’. 

The idea was that the companies would slyly remove sugar from their trusted brands and consumers would lose weight without having to make any effort. It was assumed that we wouldn’t notice the taste of artificial sweeteners because we are creatures of habit. So long as the packaging looks the same, we will mindlessly consume the same brands in the same quantities as we always do.

It didn’t quite work out like that. The food industry had to break it to PHE that you can’t take the sugar out of a cake or chocolate bar without compromising the size and texture, not to mention the taste. Some products, such as boiled sweets, consist of almost nothing but sugar and cannot be reformulated. Jam has to contain a certain amount of sugar otherwise it cannot legally be sold as jam. In any case, people will not buy artificially sweetened cakes, biscuits, spreads and confectionery because they taste horrible.