"Mandated lifestyle modification"

I'm not sure if this is a real blog or very elaborate satire, but its author appears to be taking the latest heart miracle reports very seriously indeed.

Do Smoking Bans Reduce Heart Attacks?

Apparently not - certainly not in the short term, otherwise we would have seen evidence of it in the United Kingdom.

The impressive data keeps on coming. Back in January I commented on the 41% reduction in heart attacks in a Colorado county after a smoking ban went into affect.

That would be the study that Dr Michael Siegel criticised for using inappropriate methodology and for making conclusions that were "biased and invalid."

The data "keeps on coming" because, as I have said before, repetition is being used as a substitute for evidence. The latest study does not contain any new evidence and is the third meta-analysis to be published in as many years. All of them have come from the pen of Stanton Glantz, founder of the hardline anti-smoking group Americans for Nonsmokers' Rights.

Now comes a report out of the journal Circulation (abstract) that continues to confirm the dramatic reduction on acute coronary events in districts that legislate public smoking bans.

The report is a meta-analysis of 13 studies in which researchers examined changes in heart attack rates after smoking bans were enacted in communities in the United States, Canada and Europe. The researchers found that heart attack rates started to drop immediately following implementation of the law, reaching 17 percent after one year, then continuing to decline over time, with about a 36 percent drop three years after enacting the restrictions.

A 36 percent reduction in heart attacks after three years is a phenomenal outcome. There isn't a single medical intervention I know of that has that immediate and profound effect on outcomes.

Indeed not. And the very fact that it is so unprecedented, "phenomenal" and - how to put it? - miraculous should, in itself, be enough to make anyone in possession of their critical faculties wonder whether if it is actually true. 

There isn't a quality initiative or payment initiative the feds could come up with to save the kind of money that lifestyle modification could do.

And it is 'lifestyle modification' that the Happy Hospitalist blog is all about, as you will see from the author's five point plan:

1. A nationwide ban on smoking in public needs to be enacted by Congress. That means all public places, indoors and outdoors. It's time that smokers are banned to their homes where they expose nobody but themselves and their family to the dangers of first, second, third and fourth hand smoke. [My emphasis]

I was fascinated to find out what the source for fourth hand smoke was, so I took a look.

Fourth-hand smoke: You see through the window somebody smoking.

The fourth and last exposure to smoke was added as a joke

A joke. Okay. So is this whole post a joke or does the author just link to the first Google link that comes up?

2. If Congress does not have the political will to ban public smoking in this country, they should immediately give a proportionate percentage increase in Medicaid funds to states that have instituted such a ban based on the actuarial dollar savings generated by the reduction in health care costs and ongoing morbidity related to acute MI and its associated heart failure diagnosis.

But acute MI (myocardial infarction - ie. heart attacks) have not been shown to fall significantly in any US state that has enacted a smoking ban. That's why heart miracle studies focus on places like Pueblo, Colorado and Bowling Green, Ohio. The smaller the area, the greater the chance of a dramatic fall (or rise) in the heart attack rate. They're fluke results blown out of all proportion by anti-smoking activists and credulous journalists. 

3. The tax on a pack of cigarettes should be raised immediately to $20.

That sounds a little, er, high. Wouldn't there be massive problems with smuggling and organised crime, as is the case in Canada? And since this tax hike is necessary to pay for the treatment of smoking-related diseases, those with private healthcare will presumably be exempt from paying the $20? 

No? Oh.

4. Medicare cost sharing arrangements should increase by 100% starting in calendar year 2011 for all beneficiaries abusing tobacco who fail to comply to a strict tobacco free compliance policy.

I don't fully understand the US healthcare system, but isn't this saying that smokers should pay twice as much than nonsmokers? Please correct me if I'm wrong.

5. All Medicaid beneficiaries will be required to go tobacco free to maintain their benefits or be subjected to the same cost sharing arrangements as their Medicare counterparts, regardless of their ability to pay, or lose their benefits entirely.

So smokers should have to pay an extra tax of $20 (plus existing tax) for every pack of cigarettes but they won't get any treatment unless they quit smoking. Bear in mind that all this is deemed necessary purely on the basis of bogus studies purporting to show miraculous drops in heart attacks as a result of smoking bans.

The data is compelling.

The data - the real data, as published by the hospitals - certainly is compelling. It shows no discernible change in heart attack admissions since the smoking ban.

As long as the government mandates health care as an entitled right and forces the burden onto the tax payer, they have an obligation to force the populace into mandated lifestyle modification.

Now we're getting down to business. And if the smoker refuses to have his lifestyle modified, he is refused treatment. And if he does not receive treatment then surely the government has an "obligation" to refund all those taxes he has paid. Otherwise the whole business amounts to extortion, no? 

Mandated lifestyle modification. Blimey. Has a more sinister piece of jargon ever been coined?

Banning flavoured cigarettes

If you are looking for a brief explanation of why banning flavoured cigarettes is a pointless exercise, Steve Chapman's article at Reason is highly recommend.

At least since 1994, when seven tobacco executives testified before Congress that they didn't think cigarettes were addictive, the public has not put great trust in those who sell carcinogens for a living. What Americans may not realize is that they also shouldn't believe the people who are supposed to protect us from tobacco.

Chapman also explains why the claim that 3,600 American children start smoking every day is disingenuous and misleading. Do go read it all...

Flogging a dead horse

The Sunday Times is showing no signs of backing down from last week's voodoo science regarding the English heart attack miracle. Quite the reverse, in fact, as the paper has now provided a forum for Prof. John Britton (Director of the UK Centre for Tobacco Control Studies) to perpetuate the smoking ban/heart attack myth.

Under the fanciful headline 'Why are smoking bans so good at cutting heart attack rates?', Britton makes the explicit claim that...

[A]voiding tobacco smoke cuts the risk of a heart attack almost immediately – and it is this that has led to the marked reductions in hospital admissions and deaths.

Except that we know that there was no 'marked reduction in hospital admissions' in England, Scotland and Wales.

I won't go over the facts of this again, but my eye was drawn to this sentence:

In fact the smoke-free legislation, along with the tobacco advertising ban, media campaigns, NHS stop smoking services, and many other initiatives have all contributed to a near 30% reduction in UK smoking prevalence since 1997.

1997 is a rather odd year to use as the start date here, because there is no smoking prevalence data for 1997. I wonder if anything else happened in 1997 that would make Prof. Britton want to use it as the beginning of a great national revival? 

Labour routs Tories in historic election

Oh yeah, that. Aren't people like Prof. Britton supposed to avoid playing party politics?

For the record, there has not been a 'near 30%' fall in smoking prevalence since 1997. The most recent figures* from the Office of National Statistics show:

Prevalence of cigarette smoking amongst adults (Table 2.1)

1996: 28%

1998: 28%

2000: 27%

2002: 26%

2004: 25%

2006: 22%

This shows that smoking prevalence fell by 21.4%, so it would be truer to say there was a 'near 20% reduction in UK smoking prevalence since 1997.'

Is it too much to ask for the Director of the UK Centre for Tobacco Control Studies to get these basic facts right?

* Official stats for 2008 are not yet available. The government's target is to reduce smoking prevalence to 21% by 2010. Even if that happens - and there is no evidence that it will - it will still not represent a 30% drop since 1997.

The Goerlitz interview in full

FORCES have been good enough to combine all 11 parts of my interview with David Goerlitz (former cigarette model/current tobacco prevention speaker). This makes it easier to listen to in one chunk, so just press 'start'. Dave has an interesting story to tell, and he tells it well.

A voice of reason

Dr Christian Jessen

Is the penny starting to drop? On the day Spiked publish my article on heart miracles, a doctor writes (in The Evening Standard):

Some good has come from the smoking ban: researchers in Italy found that it resulted in a significant fall in hospital admissions for heart disease. In England, a similar trend has been noted. The Department of Health found a 10 per cent reduction in the number of hospital admissions for heart attacks in England in the year after the ban on public smoking was imposed in July 2007. This is good news as Britain is among the worst countries for deaths from heart disease — smoking, poor diet and lack of exercise being the main culprits.

As a doctor I should be delighted, but I do question if those results are indeed a true interpretation of the facts. The largest recent study (still ongoing) in the US has so far shown that smoking bans have no effect on heart attacks at all, and the main studies quoted in the press have been shown to be flawed, either in their methods of data collection, or in how their data was statistically analysed. I find it hard to believe that, given that smoking is claimed to increase the heart attack risk of lifelong passive smokers by 20 per cent, any noticeable drop in heart attacks as a result of the ban is yet to be seen. The numbers are just too small and the timescales too short.

Covering this story on their website, ASH once again strike a note of caution. Although they refer to a "growing body of evidence" in other countries, they also say:

Editorial comment: The reference to England is inaccurate as no data has yet been published.

This is the third time ASH have advised caution about the 10% claim which, according to reports, comes directly from the Department of Health. We know that ASH work very, very closely with the DoH, so what's the story? Perhaps if the DoH went on the record with this claim, instead of whispering rumours to journalists, we might have some clarity.

Heart miracle article in Spiked

In today's issue of Spiked, I have returned to the topic of smoking ban/heart attack miracles. 

The myth of the smoking ban ‘miracle’

Restrictions on smoking around the world are claimed to have had a dramatic effect on heart attack rates. It's not true.

Please read the rest...

It is also worth mentioning that the new 'study' which inspired the latest wave of media hysteria (the funniest headline being The Scotsman's 'Smoking ban slashes heart attacks by up to a third across world') was not a new study, but a meta-analysis (a study of studies). It was co-authored by Stanton Glantz, founder of Americans for Nonsmokers' Rights, director of TobaccoScam, director of SmokeFree Movies etc.

It is remarkable how few key people are responsible for so many theories, studies, facts and figures in the world of anti-smoking research (and how many of them started out as anti-smoking activists). Glantz has built up the heart miracle hypothesis almost single-handedly. His input so far has included:

Writing the meta-analysis which 'proved' that secondhand smoke causes heart disease (1991).

Coming up with the estimate that 50,000 Americans die from secondhand smoke each year (never independently verified and rejected by the EPA) (1991).

Writing 'Even a little secondhand smoke is dangerous', which claimed that brief exposure to smoke causes heart attacks, thereby paving the way for the heart miracle studies (2001).

Writing the Helena heart attack study (with 2 other anti-smoking activists) (2004).

Writing 'Cardiovascular effects of secondhand smoke; nearly as large as smoking' (2005).

Writing the first meta-analysis of heart miracles (2007).

Writing the second meta-analysis of heart miracles (2008).

Writing the third meta-analysis of heart miracles (2009).

Snowdo in New York

I was recently interviewed by a New York journalist, regarding the proposed outdoor smoking ban there. The resulting article (which I believe is on the front page of Westside Spirit) has now gone online and is well worth a read. My only quibble would be that the misspelling of my name makes me sounds like a character from the Lord of the Rings...

“This is almost a prohibitionist crusade now,” said Christopher Snowdo, one of the leading experts on the anti-smoking movement and author of Velvet Glove, Iron Fist: A History of Anti-Smoking.

Like hard-core pornography he said, “We are getting very, very close to it being prohibited without it being illegal.”

Do read the rest.

Government to encourage smoking

Not the smoking of tobacco, of course, but the smoking of heroin...

Heroin addicts could be given free aluminium foil to encourage them to smoke rather than inject the class A drug under plans being considered by government advisers.

Few would disagree that injecting heroin is more dangerous than smoking it. As a harm reduction strategy, this proposal has a certain superficial logic to it, but as a practical matter it is - surely - a pointless waste of time. Heroin users inject the drug because it is the most efficient way of taking it, not because they can't afford a bit of tin foil.

But what I find particularly interesting about this story is the contrast between harm reduction policies with heroin, which is completely illegal, and tobacco, which isn't. In the field of tobacco there are various alternatives - snuff, snus, e-cigarettes or even pipes and hookah - which are known to reduce or eliminate the health risks associated with cigarettes, and yet it is fashionable to pretend that this is not so.

The article goes on to explain that health professionals are already able to give away free syringes to heroin addicts. Government policy regarding hard drugs has an element of realism. There is an acceptance that not all users will simply give up. There is an acceptance that there will never be a drug-free world and so we should minimise the health risks associated with them. In the field of tobacco, however, the quit-or-die approach still reigns supreme. It is a smoke-free world or nothing.

It is now almost 60 years since Doll and Hill published their first study showing the link between lung cancer and smoking and yet there are more smokers in the world than ever before. It is safe to say there will be more smokers in the world next year than there are now.

Despite this, the public health community acts as if the eradication of tobacco is just around the corner. Any attempt to reduce the risks from tobacco is verbatim verboten because it might 'encourage' people to keep smoking. They don't appear to worry that handing out free foil and syringes might 'encourage' people to keep taking heroin.

We accept that the war on drugs can never be won and we spend public money helping heroin addicts to take their drug more safely. At the same time, e-cigarettes are being banned, snus is illegal throughout most of Europe, smokeless tobacco is being unfairly maligned and hookah is the subject of hysterical news stories. 

Does tobacco have to be illegal before we look at sensible harm reduction policies?

Very old rope

Various newspapers, including the The Scotsman, have been reporting this:

A doctor's letter written more than 400 years ago has revealed the medical profession were even then concerned about the risks of smoking to young people. The letter, by Dr Eleazar Duncon, was unearthed by librarians at the Royal College of Physicians of Edinburgh (RCPE) as they prepared for an exhibition.

Professor Sir Neil Douglas, the president of the RCPE, said it gave a "fascinating insight into historical concerns" about smoking and young people.

The amount of attention this little story has been receiving is rather puzzling. As readers of Velvet Glove, Iron Fist will know, various people warned about the health effects of tobacco, almost from the moment it arrived on European shores. 

More puzzling, though, is the suggestion that this particular example has only just been "unearthed". The letter has been on the National Library of Australia's database since 1999, and has long since been known by various academic institutions. 

One could argue that the RCPE has only just become aware of it, but that defence is undermined by the fact that the letter has been on the RCPE website for at least a year. I know, because that's where I first saw it. If you need proof that it's been there a while, see Michael Siegel's blog, where a reader mentioned it in this comment last December. 

In light of this, the idea of Scottish librarians happening upon this "fascinating" letter by chance whilst rifling through dusty old files lacks all credibility. Quite obviously, this was a well-prepared PR exercise directed at newspapers with column inches to fill. And it's been a successful one. The Sunday Express reported it with the headline 'Doctors wanted smoking ban in 1600s', which is not what the letter says at all.

So why has this fairly inconsequential snippet of history suddenly appeared now? The Scotsman provides the answer:

Its existence emerged just days before MSPs at Holyrood consider the principles behind a Scottish government plan to curb the sale of cigarettes and tobacco to youngsters. The matter is due for discussion on Thursday.

Truly, no stone goes unturned in the publicity drive for this campaign.

Censoring reality

Mark Lawson has written an interesting article at The Guardian in which he discusses some recent examples of photos being ditched from promotional material because they show a celebrity smoking.

A quiz question: what is the link between ex-President Jacques Chirac, the composer Rachmaninov and interviewer Lynn Barber? If this were a picture round, you'd get it immediately, from the little angled strip of white on their hand. The answer is that attempts have been made to ban photographs of them on the grounds that they were shown smoking.

The publication of Chirac's latest volume of memoirs has mysteriously been delayed, allegedly because of concerns over a dustjacket image which shows him having a puff. This matches the experience of Barber – who withdrew from the Richmond Literature Festival when objections were raised to the inclusion in the brochure of a publicity shot in which she palms a gasper – and, posthumously, of the Russian composer. When the pianist Stephen Hough chose to illustrate a recording with a snap of Rach toting an elegant cigarette holder at the keyboard, his US distributor asked for this dissonant health and safety note to be taken out.

It should be said that these were all decisions taken by private companies. I am not aware of any anti-smoking groups calling for photos of celebrities who smoke to be banned (let me know if I am wrong). They are, however, calling for smoking to be banned in films, and so this could be seen as just another "logical step" in the "denormalisation" of smoking.

The argument of the censorious forces in the above cases is that the shocking ciggy pics might encourage those seeing them to light up at home or outside the office door; could, in the terrible official lingo, "normalise" the activity.

Which just serves to highlight the central problem with the denormalisation programme. As much as those in Tobacco Control would like it otherwise, there are well over a billion smokers on the planet. Presenting a picture of the world that doesn't include them requires, by necessity, a certain degree of deceit.

And once photos of smokers have been banished, the next logical step - surely - is to banish the sight of smokers themselves. That, incredibly, was the argument used this week to justify an outdoor smoking ban by New York City Health Commissioner Dr Thomas Farley:

"We don't think children should have to watch someone smoking."

Dr Michael Siegel has more on the New York story, and Mark Lawson's article is well worth reading.

Bloomberg gets down to brass tacks

It looks as if the proposed smoking ban in New York parks is to be abandoned, not because it would be draconian but because, as Mayor Bloomberg has conceded, it would be unenforceable:

"Our Police Department has enough to do. They can't be going around giving tickets."

No one should interpret this as an indication that Bloomberg's war on smoking has reached its logical conclusion. Far from it, as the New York Post reports:

Bloomberg sounded tougher than ever toward smokers.

"Make no mistake about it," he said. "This city is not walking away from our commitment to make it as difficult and as expensive to smoke as we possibly can."

This is a revealing comment. In the past, smoking bans have nearly always been justified on the basis of non-smokers' rights and secondhand smoke. Tax rises have been justified on the basis that smoking-related diseases cost society billions. 

But with so many indoor smoking bans now in force, the secondhand smoke argument is running out of steam. Similarly, tobacco taxes are now so high that it is difficult to pretend that all that money is needed to treat smokers (even Julian Le Grand has admitted that nonsmokers cost the NHS more than smokers) .

In Velvet Glove, Iron Fist, I suggest that as the passive smoking and tax arguments become less credible, the anti-smoking movement will need fresh rhetoric. I think they have three options:

a) move on to other causes

b) convince the public that secondhand smoke is deadly in the tiniest quantities, even outdoors

c) become overtly paternalistic; tell smokers it is for their own good

We are currently seeing a move towards all three of these. Many health professionals and epidemiologists are finding rich pickings in the emerging campaigns against food and drink. A few others are trying desperately hard to gather some evidence against 'third-hand smoke'. Many more are beginning to openly admit that they simply don't like people smoking and will use whatever force is necessary to stop them. 

Bloomberg falls into this last category and probably always has. He may not have intended to express his true feelings so explicitly on this occasion, but it's no bad thing for the standard of public discourse that he did. Whether you agree with him or not, a serious debate about the state's role in legislating private behaviour can only be had when both sides speak openly about their intentions.

 

Science without press release. Or science.

From the ASH website today:

Correction: Heart attacks plummet after smoking ban

We have heard that the figures reported in the Sunday Times yesterday (and now circulating elsewhere) are not based on any research conducted to date.

You read that correctly. The figures are not based on any research. So they are, in fact, completely groundless.

The impact of the smokefree legislation on heart attacks is being analysed by Anna Gilmore and team at Bath but they have no final results yet.

And, to be fair to Gilmore and her team, they were not quoted as saying the heart rate fell by 10%. In fact, no figures were quoted by anyone at all.

So what's going on here? Has Sunday Times' journalist Jonathan Leake made the whole thing up? Is the 10% a figment of his imagination or is it a case of whispered conversations with an anonymous source? Leakes' article explicitly states:

The ban on public smoking has caused a fall in heart attack rates of about 10%, a study has found.

But, as Dr Siegel* has pointed out, there is no study and will not be for quite some time. No one is prepared to go on record with this mysterious 10% figure. Now it transpires that the research has not even been conducted yet!

Bear in mind that this article has gone around the world. It was copied virtually word for word by The Daily Mail, Metro and The Telegraph. It has appeared in The Australian and The Times of India. And yet the story is so shaky that even anti-smoking groups are distancing themselves from it.

Science by press release is bad enough. This story doesn't even seem to have a press release to back it up. 

This really is a new low.

* The good doctor has the low-down on yet another heart miracle here.

Why I don't believe in miracles

I mentioned yesterday that 'heart miracles' (studies that show the heart attack rate plunging by 10-40% after a smoking ban) are mathematically impossible. I would like to explain why.

The whole premise relies on a basic confusion between relative risk and absolute risk. Here is an example of a relative risk:

Drinking coffee whilst driving increases the risk of a fatal car crash by 80%

And here is an absolute risk:

U-boat crew in the Second World War had an 80% chance of dying at sea

The second example could also be phrased as '80% of U-boat crew died at sea during the Second World War'. It is the total risk for the individual, but it also tells us about the death rate amongst the whole group.

The first example is very different. It merely gives us the increased risk to the individual compared to that of the person who never drinks coffee whilst driving. 

A fallacious use of that first statistic would be to say that if motorists were banned from drinking coffee, the number of fatal car crashes would fall by 80%. A second's thought will tell you that that is obvious nonsense, because drinking coffee whilst driving is only one of many factors that increase risk whilst driving (and a fairly minor one, at that).

But it is precisely this fallacious reasoning that is used to justify the implausibly large drops in heart attacks reported in these smoking ban studies. The reasoning is:

Secondhand smoke exposure increases the risk of heart attack by 30%, therefore a smoking ban will reduce the number of heart attacks by 30%.

This could only be true if secondhand smoke was the only risk factor for heart disease and, of course, it isn't. According to the World Health Organisation there are 300 risk factors, including obesity, diabetes, physical inactivity, stress, high cholesterol, high blood pressure and a family history of heart disease - all of which increase risk more than passive smoking is said to.

It is a quite simple logical fallacy and yet it has been used from the very beginning with these heart miracle studies. Lest it be thought that I am putting words into anyone's mouth, here is how the authors of the Helena study (the first heart miracle study) explained a 40% drop in their 2004 paper (British Medical Journal).

[The study reported 40 heart attacks in the 6 months before the smoking ban and 24 after it]

The effect associated with the smoke-free law may seem large but is consistent with the observed effects of secondhand smoke on cardiac disease. 

Secondhand smoke increases the risk of a myocardial infarction by about 30%; if all this effect were to occur immediately, we would expect a fall of - 0.30 x 40.5 = - 12.2 in admissions during the six months the law was in effect, which is within the 95% confidence interval for the estimate of the effect (a drop of - 32.2 to - 0.8 admissions).

I have highlighted the key calculation. They are saying that 30% of heart attacks before the smoking ban were caused by secondhand smoke (12 of the 40 cases). Therefore, the smoking ban would be expected to save 12 lives. Their study actually found 16 fewer cases but, as they say, that is within the margin of error.

This is a fundamental error of logic. The 30% is the relative risk. It tells you nothing about the absolute risk to the population. 

So what is the absolute risk? I am not going to argue about the true effects of secondhand smoke here. For the purposes of this argument, let us go along with the Helena study authors and say that it increases risk by 30%. One of those authors was Stanton Glantz, a prominent and somewhat fanatical anti-smoking activist who has never been accused of underestimating the risks from secondhand smoke. I will use his figures so that I am not accused of cherry-picking. 

The US has around 630,000 deaths from heart disease each year. According to Stanton Glantz, 37,000 of these - or 5.9% - are caused by secondhand smoke. Even taking these figures, then, it should be self-evident that eliminating secondhand smoke could not possibly reduce heart attacks by more than 5.9%.

But smoking bans don't eliminate secondhand smoke. They eliminate it in bars, restaurants and other "public" places, but people continue to smoke in their homes and elsewhere. A smoking ban might perhaps halve secondhand smoke exposure, in which case it might - at the uppermost limit - reduce heart attacks by 3%.

I stress that I am not attempting to come up with my own estimate of how many lives are "saved" by smoking bans. Apply your own figures, by all means. The end result will be the same. It is mathematically impossible for a smoking ban to reduce the heart attack rate by 10-40% because even the most hyperbolic estimates indicate that secondhand smoke causes far fewer than 10% of heart attacks.

There is one other possibility - that smoking bans result in people giving up smoking and therefore suffer fewer heart attacks. On the face of it, this is a more plausible option. However, there is scant evidence that smoking bans actually do increase the quit rate, as Mark Wadsworth has been pointing out. 

It has been estimated that smoking is responsible for 11% of total cardiovascular deaths (PDF). Therefore, even if tobacco was banned and everybody stopped smoking, deaths from heart disease would not - could not - fall by more than 11%. The idea that banning smoking in bars and restaurants can reduce the heart attack rate more effectively than the total abolition of tobacco is plainly ludicrous.

Tricks of the trade

Over the last few years I have spent an inordinate amount of time picking through 'heart miracle'  studies - ie. those which claim a dramatic fall in the heart attack rate as a result of a smoking ban. What I find fascinating about them is that you know, from the very offset, that the conclusion it going to be wrong. 

It is not a question of having a closed mind or being unduly suspicious. Smoking bans cannot bring about huge reductions in the heart attack rate of 10, 20 or 30 per cent because it is a mathematical impossibility. Only someone who does not understand the difference between absolute risk and relative risk would think otherwise (I have tried to explain this before, and will do so again on this blog soon).

And so it is like watching David Copperfield doing his flying trick. It might look impressive but you know it's just a trick. With magic, the fun is in trying to work out how it's done. And just as the flying trick is always going to involve some form of industrial strength wire, the explanation to a heart attack miracle is always going to involve some form of cherry-picking.

In America, there is no national smoking ban. Instead, individual towns often bring in their own smokefree legislation. This provides a perfect hunting ground for the cherry-picker because hundreds of individual bans mean hundreds of chances to find an unusual drop in hospital admissions. As Michael McFadden points out in the comments to this post, who knows how many places they examine before they find a place which gives the "right" result?

One of the great mysteries of antismoking research that we'll probably never know the true data for is just how many studies like this have been started and then aborted when the early answers didn't come out right.

The smaller the community, the greater the chances of large random variations. It is no great surprise, then, that the first heart miracle was seen in the small town of Helena, Montana (population 66,000). The 40% drop seen there was possible because there were so few people being hospitalised (as few as 4 per month), therefore a small variation in actual cases created a huge variation in the percentage.

But as the size of the study populations grows, the opportunity for spotting big variations in the heart attack rate declines. This can be seen if you compare the supposed drop in heart attacks to the size of the study populations:

Bowling Green, Ohio (30,000) : 47%

Helena, Montana (66,000) : 40%

Pueblo, Colorado (105,000) : 33%

Piedmont, Italy (4.4 million) : 11%

Scotland (5 million) : 17%

England (51 million) : 10%

There is, of course, no reason why a smoking ban should be more effective in preventing heart attacks in Helena, Montana than in the whole of England, so right away we have reason to be suspicious. And it is when whole nations are studied that the heart miracle theory really falls apart. 

There are two key reasons why a cherry-picker is going to find it difficult to use British data to sustain the heart miracle hypothesis. Firstly, the UK's population is too large to ever see random variations of 30 or 40%. Secondly, the NHS publishes hospital admissions data, so we can easily check what we are being told.

This was the problem for Jill Pell and her Scottish study. No sooner had she claimed a 17% fall in heart attacks than the NHS published hospital admissions data that showed that the real decline was less than half of that.

Anna Gilmore is the person charged with showing that England saw a heart miracle after the ban. Her position is even worse than Pell's. Not only has England got a much larger population than Scotland (and therefore even less chance of a fluke result), but the hospital admissions data has already been published. 

We know that the heart attack rate fell by between 2 and 4% before the ban and by between 2 and 4% after the ban (see the HES website). To date, we only have the data for the first 9 months following the smoking ban, but that it is enough to go on. After all, if smoking bans immediately save lives, the first 9 months is where we would see the biggest drop.

If the claims being made in recent news reports are to be vindicated, Gilmore needs to turn this 2 to 4% drop into a 10% drop. It sounds a tall order but it is not impossible.

The obvious way of conducting this study would be to use the NHS's hospital admissions data from July 2007 to June 2009 and compare the number of heart attack admissions in that period to the two years prior to the smoking ban. However, that is unlikely to yield a 10% fall, so a more creative approach may be required. 

Here are some tricks she could use...

Possibility no. 1

Pick an unrepresentative time-frame

There will some degree of seasonal variation in the hospital admissions figures. If, for example, there was an unusual decline in admissions between October and December 2008 compared with October to December 2006, Gilmore could focus entirely on those months and ignore the rest.

Tried and tested in: Wales, where Chris Franks ignored inconvenient months to 'prove' there was heart miracle. And in France, where a single month was used to show the same.

Possibility no. 2

Change the definition of a heart attack

'Heart attack' is a general term, usually equated with the medical condition of acute myocardial infarction (AMI). This is what the Helena researchers studied and it is what the Scottish researchers initially set out to study. Somewhere along the way, however, the Scottish researchers decided to focus on acute coronary syndrome (ACS). Nothing wrong with that per se, since ACS can also be reasonably classed as a heart attack. 

But there is a difference between AMI and ACS, and there are different figures for the two. Gilmore could decide to use whichever set of figures shows the biggest drop. She could even do what Jill Pell did, and use the troponin test to diagnose ACS cases. This would have the advantage of meaning that no-one would ever be able to disprove her study, since the NHS does not use the troponin test to diagnose ACS cases.

Tried and tested in: Scotland, by Dr Jill Pell and her team

Possibility no. 3

Pretend the smoking  ban started in a different year

If the data for 2007 and 2008 doesn't fit, why not make out the smoking ban started in a different year?

Tried and tested in: Bowling Green, Ohio, where -  incredibly - researchers used a drop in heart attacks between 2002 and 2003 to 'prove' there was a heart attack miracle. 2002 did indeed see an unusual peak in heart attacks, and the rate fell in 2003. This was taken as proof that the smoking ban "slashed" heart attacks. The inconvenient truth was that the smoking ban actually started in early 2002.

Possibility no. 4

Ignore the whole population 

This is a variation on No. 1, but with the region being cherry-picked rather than the time-frame. There is bound to be regional variation in the hospital data, so why not concentrate on the areas with the biggest heart attack decline and ignore the rest? 

Tried and tested in: Piedmont, Italy, and by the Daily Mail who reported that the heart attack rate had fallen by 40% in "some hospitals" in England, based on data from the Shrewsbury and Telford Hospitals NHS Trust which saw a large but unrepresentative fall in cases. 

Of the latter case, even ASH felt compelled to add a disclaimer when it reported the Mail's story:

Please note: Although it was reported by some newspapers that hospitals saw a 40% decline in heart attacks the overall figure was 3%.

Having made that clear, it will be interesting to see how ASH responds to the 10% claim.

I confess that I know very little about Anna Gilmore, other than that she is a Board & Council member of ASH and has worked with Stanton Glantz. I'm sure she is not the type of person who would use any of the tricks above.

I'm just saying that if an unscrupulous researcher did want to manipulate the evidence for political ends, these are the kind of tricks they could use. That's all I'm saying.

Incidentally, Dr Michael Siegel has, as usual, some interesting things to say about the 10% claim. He concludes his analysis by saying:

The scientific integrity of the tobacco control movement is imploding before my very eyes.

Do go read the rest.

The worst junk stat of 2010?

It was with some incredulity that I read the following in The Sunday Times.

THE ban on public smoking has caused a fall in heart attack rates of about 10%, a study has found.

Researchers commissioned by the Department of Health have found a far sharper fall than they had expected in the number of heart attacks in England in the year after the ban was imposed in July 2007.

In Scotland, where the ban was introduced a year earlier, heart attack rates have fallen by about 14% because of the ban, separate research has shown. Similar results are expected in Wales where a third study is still under way.

It is quite astonishing to see the 'Scottish heart miracle' make its way into the pages of The Times again, since they are well aware that the study did not reflect the true rate of hospital admissions. 

Having reported the Dr Jill Pell's Scottish study in 2007 under the headline 'Non-smokers suffer fewer heart attacks after ban', the newspaper later included it as one of the Worst Junk Stats of 2007:

“Smoking ban cut heart attacks in Scotland by 17 per cent”, researchers and politicians trumpeted to the world in September through press releases, a conference and interviews, all faithfully reported. 

It was the ban what done it, they said... until six weeks later when official data halved the drop — to 8 per cent — against a trend immediately before the ban of a 5 or 6 per cent drop, and a fall a few years ago of 11. All of which makes it hard to be sure what, if any, effect the ban really had. The researchers went strangely silent.

Harsh reality made things worse for Dr Pell and her Scottish miracle the following year when the full hospital data was published by the NHS. Anyone who has followed this story will be aware that the heart attack rate did not fall by anywhere near 14% (this is a new figure, by the way, previously it was always 17%) and that the rate rose in year 2 of the ban. This seemed to be the final nail in the coffin of the theory that smoking bans immediately slashed the heart attack rate, as I wrote in Sp!ked earlier this year:

The Scottish ‘miracle’ has ceased to be. It is no more. It has gone up to join the choir invisible. If Pell hadn’t nailed it to its perch, it would be pushing up the daisies.

It is extraordinary - truly extraordinary - that a newspaper that has already had its fingers burnt with these silly heart attack stories is so willing to do so again. This is all the more so since the study will not be published until next year and is, in the researchers' own words, "incomplete". 

This is yet more - to use Michael Siegel's words - 'science by press release'. Dr Siegel has shown time and again that these heart attack studies are deeply flawed. The tricks used change from study to study but tricks they are. Not one of them can be considered to be serious science.

Will the English study be flawed? We can be sure of it if, as is claimed, it is going to make out that heart attacks fell by 10%. We know this because routine hospital data has (again) long-since been available. It shows no discernible difference in the heart attack rate before and after the smoking ban. This data was made available in February and I discussed it then. Dr Siegel showed English heart attack admissions in a graph (reproduced below), and wrote:

As one can see visually, there is absolutely no change in the trend of declining heart attack admissions in England during the first nine months during which the ban was in effect. There appears to be a relatively steady decline in heart attack admissions from 2002-2008, with no change associated with the smoking ban.

The decline in heart attack admissions from 2006-2007 to 2007-2008 was 3.7%, compared to declines of 3.7% in the preceding year and 3.8% in the year before that.

Thus, this analysis confirms that no matter how you look at it, there was no change in the rate of declines in heart attack admissions in England associated with the first nine months of the smoking ban.

It will be fascinating to see how the authors of this new study manage to turn 2% into 10%, but we shall have to wait several months. When it is finally published, I suspect that The Times will have a strong contender for its Worst Junk Stats of 2010 list.

Britain versus the rest of the world

When I was in California a few years ago, I was surprised by how much smoking went on in certain bars. I assumed that the owners were turning a blind eye to the state's famous smoking ban (the first in the world). 

In fact, as Simon Eldon-Edington explains, even fiercely anti-smoking California has allowed various exemptions. His article in The Publican is well worth reading, as it speaks of a rarely heard truth - that the UK and Ireland have smoking bans that are more unforgiving than almost anywhere else on earth. 

Most of us think that the UK smoking legislation is pretty much the same as the rest of the world's. But in reality, it’s not. All US states (even New York), and most of Europe, have some exemptions to permit cigarette smoking inside certain bars, under certain conditions. The UK has zero.

All US states, and most of Europe, permit fully-enclosed outside smoking areas. The UK permits a roof, and two sides. Less than a pig sty.

The current UK smoking legislation therefore gives us the dubious honor of having the most draconian smoking legislation in the world. Should we be proud that we’re still the best in the world at something?

Meanwhile - in related news - Croatia has substantially amended its smoking ban, just a few months after implementing it. The reasons are familiar:

Since the law banning smoking in all public places was introduced in May, managers of cafes and restaurants say their businesses are being ruined.

Earlier this week, the Netherlands also "repaired" its smoking ban. With almost every other European country allowing significant exemptions and designated smoking rooms, is there any chance of the UK following Holland and Croatia and amending the smoking ban?

A full list of European smoking bans, and there exemptions can be read here.

The Guardian reports the Dark Market story

Last month, I wrote an article ('The Dark Market') which showed how ASH, Cancer Research, Lord Darzi and the Department of Health managed to convince the House of Lords that the cost of converting a shop to comply with the 'dark market' (ie. removing tobacco products from sight) was unrealistically low. 

I looked at e-mails released under the Freedom of Information Act which showed how a quote from a Canadian shop-fitter was misinterpreted, manipulated and recalculated to come up with the lowest possible price. The intention, clearly, was to persuade politicians that the new law would not damage the thousands of businesses that would have to comply with it. 

When the shop-fitter saw what ASH and the DoH had done, he repeatedly told them that their price (a mere £120 per shop) was far too low. Both organisations ignored him and the quote was cited as gospel both in the press and in the House of Lords debate (which passed it without amendment). Even today, the incorrect figure continues to appear on literature from groups like Smokefree Action and Cancer Research.

The whole affair is extremely revealing as an example of how "official" figures are constructed and contorted for political ends. As such, it is good to see that The Guardian has now covered the story:

The government has been accused of misleading parliament over the cost for retailers of implementing the controversial tobacco display ban.

Internal documents obtained under the Freedom of Information Act show that officials at the Department of Health (DoH) were warned by manufacturers that they had dramatically underestimated how much it would cost retailers to modify their shops to comply with the ban.

Indeed they were. The man dragged into this farce was Canadian shop-fitter Phil Beder of 4 Solutions Displays, who told ASH's Deborah Arnott quite explicitly:

“Hi Deborah,

I want to reiterate that the last e-mail I sent to you (April 28) was a complete clarification of all costs associated with covering of tobacco.

I also want to make sure you are not making additional assumptions on costs to suit your internal needs...

4 Solutions Displays cannot produce, deliver and install for the minimal dollars you are publishing...

We would ask that you remove 4 Solutions Displays from any of your promotional materials as the numbers are misrepresenting the actual costs to a wide base of retailers in the UK...

I trust your organization will insure the entire financial story is told to all and not choose a single number that doesn’t represent the actual facts.”

Beder also told her that the tobacco display ban in Canada had damaged small businesses and had not led to a reduction in youth smoking (which was the reason given for bringing in the ban in the first place). None of this was ever relayed to the public or mentioned in the House of Lords debate.

Instead, as The Guardian reports:

Ash responded by telling 4 Solutions that it was confident its figures were correct.

The Canadian manufacturer also wrote to the National Federation of Retail Newsagents, which is opposed to the ban, confirming that the full cost would be far higher than the figure quoted by the DoH. When the federation emailed the DoH on 15 May to highlight the discrepancy, an official replied saying: "We are confident of the validity of the estimates that ministers have been quoting."

The Department of Health has responded to The Guardian's investigation, saying:

"Point-of-sale displays have already been removed in a number of countries, including Canada, [where] removing point-of-sale display has coincided with a fall in smoking prevalence rates among 15 to 19-year-olds from 29% in 2002 to 19% in 2007."

But this, too, is a gross distortion of the facts, as I have explained before:

Since only four of Canada's thirteen territories had enacted any sort of a tobacco display ban prior to 2007, it makes it extremely unlikely that the decline in teen smoking between 2002 and 2007 could have been due to such legislation.

If tobacco display bans were effective in reducing the smoking rate, only Saskatchewan (which was the first to pass such a law) has had enough time to see the benefit. As it happens, Saskatchewan has the highest smoking rate of any Canadian territory. One cannot blame the anti-smoking advocates for looking for evidence to support their latest ban, but it seems - once again - that the myth does not fit the reality.

Sometimes, if you're in a hole, it is best to just stop digging. For the Department of Health and ASH, that time has surely come.

(Thanks to Belinda for spotting the article. The whole 'dark market' article can be read here [PDF])

It's a small world

I recently mentioned a study that is being cited as evidence to support the case for the plain packaging of cigarettes. It suggested, to no one's great surprise, that some people could still recognise low tar cigarettes from the colour of the packs.

The study was warmly welcomed by ASH, who have been lobbying for the plain packaging policy for some time. In September 2008, ASH's Chief Executive Deborah Arnott described plain packaging as "an idea whose time has come". In March this year, she said: "the ultimate challenge is to get rid of tobacco advertising completely by requiring tobacco products to be sold in plain packaging"

Martin Dockrell, ASH's campaigns manager, is also a long-time fan of this idea. He was advocating it in July of last year and was promoting it again in February this year, saying:

"The health community is only beginning to understand what tobacco manufacturers have known for decades: the package matters more than the product, especially when you are pitching to children."

No wonder, then, that ASH were so quick to endorse the new study. Deborah Arnott was quoted by various news sources, including the BBC, saying: 

"This research shows that the only sure way of putting an end to this misleading marketing is to require all tobacco products to be sold in plain packaging," said Deborah Arnott, chief executive of Ash, an anti-smoking group.

"That would remove false beliefs about different brands and communicate the message that all cigarettes are dangerous.

"This matter has been discussed by parliament and there is now a perfect opportunity to include a requirement for plain packaging of tobacco products to be included in the health bill."

ASH's Deborah Arnott and Martin Dockrell clearly have much to thank the authors of the new study for. So who are they? Step forward...er...Deborah Arnott and Martin Dockrell.

No one in the media saw fit to mention that the person welcoming the report (Arnott) also happened to be one of its authors. Nor did they mention that she is the Chief Executive of one of the organisations that paid for it:

Surely, it is in the public interest to mention these little facts?

Thirdhand smoke: the lie that won't die

Bizarrely, the Daily Mail has today decided to resurrect the thirdhand smoke myth...

Is that nasty ash-tray tang that lingers on car-seat fabric, curtains in homes and the clothes of the nicotine addict strong enough to damage other people's health?

No.

According to some experts, third-hand smoke, as it is known, is as dangerous to health as the fumes billowing directly from a pipe or cigarette, particularly for babies and children.

Actually, no experts have ever said that because there is no evidence whatsoever for it. They have only surmised that people might be less inclined to smoke in their house if they believed that 'thirdhand smoke' killed.

The warning came from a paper produced in the respected journal Paediatrics earlier this year.

Much, much earlier this year. At the start of January in fact, and it was thoroughly debunked at the time, even by the Mail's own columnists, so why on earth is the Mail reporting it nine months later?

I won't go into the reasons why 'thirdhand smoke' is such a silly scare, as I have done so before. See Beyond Belief.

It must be a very slow news day.

(Note for those outside the UK: The Daily Mail is notorious for peddling health scares. A full list of all the things it says cause cancer can be seen at the excellent Kill or Cure? website.)

Stylish minimalism

Today sees the release of The Beatles' back catalogue on remastered CD. For what it's worth, my favourite Beatles album is The Beatles, AKA The White Album. Not only do I think it's the best Beatles album, I happen to think it's the best album by anyone. 

There's a long-running argument amongst fans of the Fabs over how The White Album would have been as a single-record set. Personally, I think it's more than fine as a double album, but to get in the spirit of things, here's how my track-listing would have looked if it was distilled down to a 45 minute LP (and, yes, it does include Revolution 9):

SIDE A

1. Everybody's got something to hide except for me and my monkey

2. Dear Prudence

3. I'm so tired

4. While my guitar gently weeps

5. I will

6. Julia

7. Martha my dear

8. Happiness is a warm gun

SIDE B:

9. Back in the USSR

10. Sexy Sadie

11. Revolution 1

12. Cry baby cry

13. Revolution 9

14. Savoy Truffle

15. Blackbird

16. Long, long, long

But let's leave the music aside for a moment and consider the sleeve. Rolling Stone described the all-white cover as "stylish minimalism." Its designer, Richard Hamilton, said that:

"Pop Art should be popular, transient, expendable, low-cost, mass-produced, young, witty, sexy, gimmicky, glamorous, and big business."

David Quantick, Revolution: The making of the Beatles' White Album, p. 163

It will be interesting to see how the album sells this time around because, if the anti-smoking groups are correct, the plain cover should be a major deterrent to consumers, especially the young (PDF).

The research showed that smokers would associate smoking from a plain pack as being less stylish, less sociable and less mature than smoking cigarettes from packs with full branding, and also that the product would be less satisfying and of lower quality tobacco.

Or, worse still...

Indeed, plain packaging would create negative imagery. Instead of being a badge product to be proudly displayed, the ugly pack would be a source of embarrassment.

Ugly? That's a bit strong. The plain pack above (from ASH promotional material) actually looks quite smart and attractive. But the anti-smoking groups say that people will definitely be put off from buying something with a plain white cover. I wonder.

The White Album went platinum 19 times and is the tenth biggest selling album of all time. Just think what it could have done without that "ugly" sleeve.