New review of Velvet Glove, Iron Fist

I'm honoured that Dr Michael Fitzpatrick has given Velvet Glove, Iron Fist a warm review for Spiked today. I've been telling anyone who'll listen to read Dr Fitzpatrick's The Tyranny of Health for several years now so it means a lot to me that he likes my book.

Fitzpatrick also reviews Geoffrey Kabat's Hyping Health Risks. Many readers will know Kabat as one half of the Enstrom/Kabat team who were subject to the most virulent abuse when the BMJ published their study showing that passive smoking "may not" increase lung cancer or heart disease risk. The personal attacks were so vicious (and unfounded) that they were more in keeping with a religious cult than a serious scientific debate. Kabat gives further examples of debased epidemiology and policy-based-evidence in his book and concludes that... 

The result of what Kabat dubs ‘the new McCarthyism in science’ is that epidemiology is reduced to propaganda.

Dr Fitzpatrick begins his review of my own book thus:

In his fascinating history of anti-smoking, Velvet Glove, Iron Fist, Christopher Snowdon (who was previously interviewed for the spiked review of books here) provides the wider context for the witch-hunt against Kabat and Enstrom. He shows how the campaign against passive smoking took off in the 1970s, long before the first studies that claimed to show its ill-effects.

An early campaigner’s statement that ‘we were just waiting for science to tell us what we already knew’ accurately reveals the subordinate role of science in the anti-tobacco cause. Snowdon also shows that the campaign against passive smoking has grown more strident and more influential in inverse proportion to the scientific evidence. Though large studies in the 1990s had shown all ‘those who had eyes to see that the passive smoking theory had unravelled’, the anti-smoking bandwagon rolled on regardless.

Please do read the rest...

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Fresh nonsense

From the print edition of The Sun today:

ONE CIG IS DEADLY

Smoking one cigarette in your 20s can send heart attack risk soaring, researchers claim. Just one fag's fumes can stiffen arteries by 25 per cent, restricting blood flow and damaging the heart.

How many readers will interpret this as a clear warning that smoking just one cigarette in your youth makes your heart attack risk "soar"? How many readers will then think one of the following:

(1) They might as well keep on smoking if they've started. The damage has been done.

(2) People in their 20s have heart attacks as a result of smoking.

(3) The Sun doesn't know what its talking about.

Only one of these statements is correct. See if you can guess which one. 

As per usual, the "research" in question has not been published but it appears to confirm the less-than-earth-shattering fact that smoking increases arterial stiffness. The press release which The Sun reworded gives us enough of the facts for us to see that its news report is tremendously misleading. What the research actually says is:

The study compared the arterial stiffness of young smokers -- five to six cigarettes a day -- to non-smokers. Arterial measurements were taken in the radial artery in the wrist, the carotid artery in the neck and in the femoral artery in the groin, at rest and after exercise.

Clearly then, this was a study of regular smokers, not of people who had just one cigarette in a lifetime. The readings were taken after the participants smoked one cigarette, but that's hardly the same thing. 

So what are the implications of this unpublished research? As the lead researcher says:

"In effect, this means that even light smoking in otherwise young healthy people can damage the arteries, compromising the ability of their bodies to cope with physical stress, such as climbing a set of stairs, or catching a bus," Daskalopoulou said.

Ho-hum. This isn't particularly news-worthy information, which explains why most newspapers haven't reported it. Maybe if the study had shown that "smoking one cigarette in your 20s can send heart attack risk soaring" other journalists would have picked up on it. 

But it didn't. 

[The article has been substantially rewritten in The Sun's online edition, with a slightly less hysterical headline and with some of the more blatant mistakes removed (including the whole first paragraph).]

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A little light reading

Some good articles around the web today. Patrick Basham and John Luik have a fine overview of the anti-smoking crusade at Spiked, in which they explain that science has never really been the issue.

Thanks to some unusual candour on the part of the anti-tobacco brigade in New York City, we now have official confirmation that banning smoking in public has absolutely nothing to do with protecting the health of non-smokers from second-hand smoke, but everything to do with stigmatising both smoking and smokers.

This is a reference to last month's proposed ban on smoking in parks, something that was demanded on the hideously Orwellian grounds that...

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

Basham and Luik see such puritanical authoritarianism as an inevitable and intended consequence of 30 years of militant activism.

What the evolution of the debate over public smoking shows is how little science has to do with the anti-tobacco crusade, how disingenuous that crusade is about its real motives and goals, how easily the crusade on tobacco can be extended to other causes (most notably the war on obesity), and how fundamentally dangerous it is to a society both free and democratic.

I can only concur (I made similar points to the NY newspaper Westside Spirit last month).

You may have read this weekend about a World Health Organisation study that has found an association between mobile phones and brain cancer. I haven't had time to look into these claims in any depth but Dave Hitt has and it seems to be another case of 'if you torture the data it will confess to anything'.

As Dave says at the Quick Hitts blog, it has all the hall-marks of junk science - it's unpublished, it's a meta-analysis, it cherry picks the data and, finally, comes up with a barely significant risk ratio of 1.18 (and 18% increase in risk). 

They start with 465 articles and cherry pick 23 studies, but were still unable to extract any scary numbers. Their odds ratio was .98. (1.0 signifies no effect.) But then they cherry picked it even more, down to 13 studies, and were able to concoct an 18% risk.

This sounds remarkably similar to the Environmental Protection Agency's notorious meta-analysis of secondhand smoke studies (which I discussed in The Untouchables). Please do read the rest of Dave's article, and if you haven't subscribed to his excellent podcast yet, you really should.

Last but not least, Dr Michael Siegel discusses the Australian heart attack data that I recently dug up over at the Rest of the Story blog.

These results are in accordance with the observations of several tobacco researchers in Australia who have previously told me that they failed to see any significant effect of smoking bans there on heart attack trends...

It pains me to see the scientific integrity of the tobacco control movement imploding like this.

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People who liked that, liked this...

From Digg, I thought this was an interesting juxtaposition of articles.

For those who like a bit of science fiction to go with their fictitious science.

Speaking of fictitious science, I'll be on Free Radio Santa Cruz today (7 pm GMT, noon PDT) talking to Robert Norse about the justification for outdoor smoking bans. You can listen live here.

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No heart miracle in any Australian state

Yesterday I discussed Australia's hospital admissions data which show that a series of smoking bans have done nothing to reduce that nation's heart attack rate. Far from resulting in a 40% fall - as claimed by the infamous Helena study - rates of acute myocardial infarction have continued to rise. 

Since each Australian state acted independently, it is useful to look at them individually. The graphs below show rates of heart attack admissions in Australian public hospitals between 2000 and 2008. The date of the smoking ban is shown with an arrow in each case.

Of most interest is the data from Western Australia, Tasmania and Queensland. These three states were the first to introduce comprehensive smoking bans (in January 2005, January 2006 and July 2006 respectively) and so have the longest follow-up time in which a fall in heart attack incidence could manifest itself. As you can see from the graphs below, that did not happen.

Western Australia

Tasmania

Queensland

In every case, heart attack admissions rose over time and there was no positive effect from each state's smoking ban. If one adopted the post hoc ergo proptor hoc rationale of Stanton Glantz and the other "smoking bans slash heart attacks" advocates, one might even say that the smoking bans of Western Australia and Queensland resulted in even more lives being lost. This would be abject nonsense, but no more so than the conclusions of studies from out-of-the-way places like Helena, Pueblo and Bowling Green (which, incidentally, have far fewer people living in them).

Hospital admissions statistics from the other Australian regions follow much the same pattern. Again, there is a long-term rise and, again, the introduction of smoking bans had no discernible effect on the year-on-year fluctuations that are inevitable in such data. In fact, if one were feeling uncharitable, it would (again) be technically true to say that 3 of these 4 regions saw the heart attack rate rise more sharply after the ban than before it. Of all the Australian states, only South Australia saw a fall in the rate, albeit by only 1.5%.

Australian Capital Territory

New South Wales

Victoria

South Australia

These figures, I think, speak for themselves. The arrows might as well have been placed there in a game of pin the tail on the donkey for all the relevance they have to the number of people suffering heart attacks. There is no correlation whatsoever. In this respect they are entirely in keeping with the data from England, Scotland and Wales. 

It is not inconceivable that in the next few months we shall see some researcher come forth clutching a study showing that heart attacks fell by 30 or 40 per cent in Eucla or Katoomba or God knows where after the smoking ban. It is even conceivable that news of this miracle would sweep around the world like the notorious Helena and Scotland studies did. 

It would, however, be nice to think that journalists might ask themselves whether data collected by professional tobacco control advocates from obscure towns really trumps genuine hospital admissions data collected by professional statisticians from entire nations.

But that, I fear, may be too much to hope for.

[All figures come from the Australian government's 'Australian hospital statistics' series]

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Smoking bans have not reduced heart attacks in Australia

Hospital admissions statistics from Denmark recently confirmed evidence from England, Scotland, Wales and the USA that smoking bans do not significantly reduce rates of acute myocardial infarction (heart attacks). This contradicts several widely reported epidemiological studies which have claimed a dramatic reduction in the heart attack rate as a result of smokefree legislation.

I have recently been looking at hospital admissions data from Australia to see if there is any evidence to support the "smoking ban slashes heart attacks" hypothesis. With the exception of the sparsely populated Northern Territory, the whole of Australia has now adopted comprehensive indoor smoking bans and so, if the hypothesis is correct, we should see signs of rates of acute myocardial infarction declining.

Unlike much of Europe and the US, there is a long-term upward trend in heart attack admissions in Australian hospitals. The reasons for this are not clear. Australia's rising population (of around 1.5% a year) will have been one factor and there will have been changes in methods of diagnosis. Whatever the cause, it is quite obvious from the graph below that smoking bans in Australia have done nothing to change that upward trend.

All the data is shown as financial years (April to March). Australia's states introduced their bans independently between January 2005 and November 2007. The coloured arrows indicate when each ban was implemented.

Black: Western Australia (population: 2.22m)

Yellow: Tasmania (population: 0.5m)

Blue: Queensland (population: 4.18m)

Green: Australian Capital Territory (population: 0.34m)

Red: New South Wales and Victoria (population: 6.89m and 5.40m)

White: South Australia (population: 1.16m)

Although a third of Australia's population was covered by smoking bans by the end of 2006, the two most heavily populated states introduced their bans in July 2007. South Australia was the last to follow suit in November 2007.

There is no hospital admissions data yet available beyond March 2008. The statistics for 2008/09 will complete the picture, but what we can see from the data already available is that there was no decline in the heart attack rate, nor was there even a decline in the rate of increase. Indeed, the rate of increase accelerated slightly in 2007/08, despite this coinciding with bans covering the densely populated states of New South Wales and Victoria.

The Australian data lacks the simplicity of Wales and Scotland, where the authorities helpfully introduced their bans at the start of the financial year. Nevertheless, if the Helena hypothesis is correct, some positive effect on the heart attack rate should be visible, and there should be a cumulative effect as more and more states implemented their bans. There is absolutely no evidence of any such effect. 

Note that the Helena hypothesis specifically claimed a drop in heart attacks of 40% within the first six months of the ban. Although Victoria and New South Wales introduced their bans towards the end of the time-frame, there was still nine months between July 2007 and March 2008 for a drop in heart attacks to occur. Instead, the rate rose from 51,667 to 55,676 between 2006/07 and 2007/08.

Australia's hospital records provide further evidence that the "smoking bans slash heart attacks" hypothesis is incorrect.

This data comes from the Australian Institute of Health and Welfare website (click 'Diseases of the Circulatory System', then 'Ischaemic heart diseases'). There is also a report (Australian hospital statistics 2007-08) which breaks the admissions down by public and private hospitals (page 218).

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A race against time

I mentioned in a recent post the extraordinary influence of San Francisco-based tobacco control advocate Dr Stanton Glantz in all areas of tobacco control, and particularly with regards to the smoking ban/heart attack hypothesis.

Glantz is the founder of Americans for Nonsmokers' Rights, the director of SmokeFree Movies, the director of TobaccoScam and director of the Center for Tobacco Control Research and Education. I doubt that even he would describe himself as wholly impartial on the smoking issue.

He co-authored the original "heart miracle" study and has co-authored no fewer than three meta-analyses at a rate of one a year, all of which concluded that smoking bans immediately brought about a dramatic - if implausible - reduction in heart attack rates. 

Aside from a discredited study from Iceland, there has been no fresh evidence to support the smoking ban/heart attack hypothesis for some time and yet it is rarely out of the news. It has been kept there purely on the basis of press releases which promote new reviews and meta-analyses which, in turn, rely on old data, none of which stands up to scrutiny on its own merits.

The "smoking bans slash heart attacks" story was in the newspapers last month as a result of another of Stanton Glantz's meta-analyses. It was in the newspapers again this month as a result of a review from the Institute of Medicine. This latest paper, somewhat unusually, does not credit Glantz as a co-author but, as Michael Siegel has revealed today, he once again played a key part in the process.

The Committee held a public meeting in which it heard presentations by experts in the field covering various topics. According to the report, the topic of smoking bans was only presented by one expert: Dr. Stan Glantz.

And, as Dr Siegel, points out:

Dr. Glantz has a very particular view of the smoking ban studies

This is putting it mildly. In fact it would be true to say that the whole hypothesis is Glantz's baby. He, more than anyone, has a great deal invested in seeing the idea lodge in the public consciousness. Not only does it help in the campaign for more smoking bans in public places, but it implicitly suggests that passive smoking is even more dangerous than advocates like Glantz have previously claimed. It supports the notion that, as one of Glantz's research papers once stated, "even a little secondhand smoke is dangerous".

If, on the other hand, the public saw that the heart attack rate has not fallen dramatically as a result of smoking bans in England, Scotland or Wales, and that there has been considerable cherry-picking in the studies that suggest otherwise, it would damage Glantz's reputation considerably. It may even put the whole tobacco control movement under the spotlight.

Sure enough, the Institute of Medicine's study did not include the hospital data from the UK, nor did it include a study of the entire US which showed no association between the introduction of smoking bans and declines in heart attack rates. 

The absence of this data from the IoM's report is troubling, since Dr Siegel had made the committee aware of this contradictory evidence:

The report claims to have reviewed unpublished data and to have attempted to identify unpublished studies that might have found no effect of smoking bans on heart attacks. The report states that "no such studies were identified." 

I find this difficult to believe, especially since I was a reviewer of the report and I made the committee aware of several unpublished analyses which documented no significant effect of smoking bans on heart attacks.

The fact that this data was omitted, and that Stanton Glantz was given another starring role in the creation of the IoM's report, should be of concern to anyone who expects impartial research from such organisations. 

What I think we are seeing now is a frenzy of activity to establish the smoking ban/heart attack hypothesis in the public's mind before more national hospital data exposes it as a myth. 

In my view, the anti-smoking movement has bitten off more than it can chew by creating a hypothesis that can so easily be disproved. Junk science thrives in the darkness. So long as the raw data cannot be viewed, it is difficult to comprehensively debunk it. But that is not the case here.

Perhaps they did not realise that hospital admissions data was publicly available when they set out with this hypothesis. Perhaps they thought that nobody would check it. Whatever the case, it is crucial that they make the public believe that the evidence for their hypothesis is "overwhelming". Once it takes hold in the public's mind, any evidence to the contrary can be dismissed as the work of the tobacco industry, "flat-earthers" or "tobacco harm deniers".

And it's working. Thanks to a well-drilled PR machine and an unquestioning media, the latest report - based on no new data at all - has been picked up worldwide (517 articles, according to Google). Last month's report - also based on no new data at all - generated around 300 articles. 

And yet, new data keeps coming along - complete data from whole nations, rather than selected data from small communities. In the last few days, the Danish Health Department has released a comprehensive report [PDF] using data from the National Hospital Register showing that there was no decline in the heart attack rate after the smoking ban was introduced in August 2007. It concludes:

In none of the four studies was there an effect from the law for men and women in the two age groups. We could not detect any difference in hospitalization rates after the Act came into force. The expected greater effect among younger than among older people could not be found.

The graph below shows the heart attack rate amongst the two age groups (35-49 and 50-64). As usual there is a gradual decline over time which is not accelerated at all by the smoking ban (marked by the black line):



Number of news articles on Google about these findings (at the time of writing): zero.

(Thanks to Klaus K for the tip and for the English translation)

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When the lie's so big

I think I'm starting to know how Bill Murray felt in Groundhog Day...

Bans on smoking in restaurants and bars reduces [sic] the risk of heart attacks among non smokers, according to [sic] hard hitting report.

The research, by the U.S. Institute of Medicine reviewed 11 key studies of smoking bans in Scotland, Italy, the U.S and Canada.

They [sic] found drops in the number of heart attacks across the board, ranging from six per cent to an impressive 47 per cent.

Since the idea of smoking bans dramatically reducing the heart attack rate is yet again being circulated by lazy (and illiterate) journalists, I don't feel so bad about publishing yet again the facts which show this to be complete and utter rhubarb. Not only has it not happened, but it could never happen. The smoking bans of England, Scotland and Wales had no effect whatsoever on Britain's heart attack rate. 

And no, before you ask, the figures shown below have not been peer-reviewed. There is no need to peer-review complete hospital admissions statistics. They represent the complete data set. They are painstakingly reviewed by professional statisticians before they are published. These statisticians have no agenda and no a priori hypothesis to support. These are the facts.

Epidemiological studies require peer-review because they use a sample of the population to make claims about the entire population. They could, and do, get it wrong. The hospital data of England, Scotland and Wales are the evidence for the entire population. Complaining that these statistics are not peer-reviewed is like MORI complaining about an election result because they failed to predict the result.

And, unlike Jill Pell, Stan Glantz and all the other authors of the heart attack miracles, I can show you the raw data behind the facts. They are here, here and here. 

The myth of the smoking ban ‘miracle’

‘Heart attacks plummet after smoking ban’ declared The Sunday Times earlier this month, as it reported that England’s smoking ban has ‘caused a fall in heart attack rates of about 10 per cent’ (1). A few days later, The Scotsman upped the ante, informing its readers that ‘Smoking ban slashes heart attacks by up to a third across world’ (2).

Tales of heart attacks being ‘slashed’ by smoking bans have appeared with such regularity in recent years that it is easy to forget that there is a conspicuous lack of reliable evidence to support them. It is almost as if the sheer number of column inches is a substitute for proof.

The most recent reports are a case in point. Although The Sunday Times claimed a 10 per cent drop in heart attacks, nowhere in the 500 word article was a source mentioned and no one was quoted giving this figure. The ‘study’ the newspaper referred to does not exist, and the anti-smoking pressure group Action on Smoking and Health (ASH) – not renowned for downplaying the risks of passive smoking – went to the unusual lengths of posting a notice on its website the following day to point out that ‘the figures reported in The Sunday Times yesterday (and now circulating elsewhere) are not based on any research conducted to date’ (3).

Although the story quickly went around the globe, no one seems to know where the figure came from. It’s all rather strange. Basing journalism on anonymous sources is commonplace in the world of politics, but it is surely not necessary in the realms of science.

The second story – reported by a host of news organisations, including the BBC – also had no new data to report. Instead, it took its cue from an article in the journal Circulation which examined previous smoking ban/heart attack studies. If nothing else, the Circulation paper offers an opportunity to reflect on just how feeble the collected evidence is on this issue (4).

The first study to make the claim that smoking bans ‘slash’ heart attacks was met with howls of derision when it was published in the British Medical Journal in 2004 (5). Studying the modest population of Helena, Montana – where the number of monthly heart attacks seldom strayed into double digits – the study’s authors made the astounding claim that the town’s smoking ban had led to the rate of acute myocardial infarction (heart attacks) plummeting by 40 per cent.

Dubbed the ‘Helena miracle’ by a legion of sceptics, the 40 per cent finding was damned by its very enormity. Since the authors were adamant that the drop was due to secondhand smoke (rather than smokers quitting), the finding required the reader to believe that 40 per cent of heart attacks in pre-ban Helena had been solely caused by passive smoking in bars and restaurants. To understand quite how miraculous the Helena miracle was, one must bear in mind that around 10 to 15 per cent of coronary heart disease cases are attributed to active smoking. That passive smoking could be responsible for a further 40 per cent strains all credibility.

Despite the inherent implausibility of the hypothesis, further studies were swiftly commissioned. If smoking bans could be shown to immediately save lives, it would be a compelling reason to implement bans elsewhere and expand those already in place. And since all that was required to ‘prove’ the hypothesis was a rough correlation between a declining heart attack rate and the start of a smoking ban, the prospects were good. Heart attack rates had been falling for years in most countries and there were plenty of smoking bans to choose from. The law of averages dictated that another heart miracle would soon come to light.

Flawed though it may have been, the Helena research was followed by several studies that displayed such a cavalier approach to the scientific process that they bordered on the comical. Researchers in Bowling Green, Ohio, for example, saw a large rise in heart attacks during the first year of the smoking ban. Side-stepping this awkward fact, they simply redefined year two of the ban as the ‘real’ post-ban period and, since that year followed an abnormal peak, there was naturally a decline in the heart attack rate. As a consequence, the researchers could triumphantly declare that the smoking ban had led to a 47 per cent reduction in heart attacks (6).

In the Piedmont region of Italy, there was an inconvenient rise in heart attacks amongst those over the age of 60 after the ban, and so those people were simply ignored. In a study that was trailed by the BBC (‘Smoking ban reduces heart risk’), the researchers focused entirely on those under 60, thereby recording an 11 per cent drop in cases (7).

Studies such as these form the basis for the recent reports of smoking bans slashing heart attacks by ‘up to a third’. The Circulation paper gathers them together and concludes that, on average, smoking bans cause rates of acute myocardial infarction to fall by 17 per cent. It includes the studies from Ohio and Italy, as well as three studies that have never been published and have only been ‘reported at meetings’.

The paper does not, however, include a mammoth (published) study of the entire United States, which concluded: ‘In contrast with smaller regional studies, we find that workplace bans are not associated with statistically significant short-term declines in mortality or hospital admissions for myocardial infarction or other diseases.’ (8)

Nor does it include an (unpublished) paper which found no statistically significant fall in heart attacks amongst the entire populations of California, Florida, New York and Oregon (9).

Perhaps the most remarkable aspect of the ongoing heart-miracle farrago is the eagerness to focus on small studies when complete hospital data is so freely available. It is extraordinary that no BBC journalist, for example, has thought of taking a few minutes to see how many people were rushed to hospital with acute myocardial infarction before and after the smoking bans of England, Scotland and Wales. If they did so, they would see that smokefree legislation has had no tangible influence on heart attack rates at all.

The graphs below show the number of emergency admissions for acute myocardial infarction, with the arrow indicating the start of the smoking ban. What is abundantly clear in each case is that the number of heart attack admissions has been falling for some time. Far from causing further dramatic cuts in heart attack rates, the bans had no discernible effect.

Scotland

The press said: ‘Heart attacks drop by 17 per cent after smoking ban’ ( Telegraph)

The data says:



Wales

The press said: ‘The number of patients suffering a heart attack in Wales has fallen dramatically following the ban on smoking. (Wales Online)

The data says:



England

The press said: ‘Heart attacks plummet after smoking ban’ (The Sunday Times)

The data says:



Publicly accessible hospital admissions data is like kryptonite to those who are so eager to believe in miracles. In most epidemiological studies pertaining to secondhand smoke, the raw data is not published. Here, it is open to all and shows quite clearly that the long-term downward trend in heart attacks has not been affected in any way by the implementation of smoking bans. It provides such a simple and straightforward rebuttal to the heart attack ‘slashing’ hypothesis that one wonders what level of hubris drives those who still espouse it.

The three graphs above cover a population larger than the sample groups in all the studies reviewed in Circulation combined, but no matter how much empirical evidence exposes the fantasy of the Helena miracle, it may be too late for the anti-smoking lobby to back down on this issue. Too many reputations are at stake.

After five years of covering these stories so uncritically, the same may be true of the media. One can scarcely blame newspapers for covering stories that offer such dramatic conclusions as the heart miracles. The irony is that if they dug just a little deeper, they might find a more interesting, and more believable, tale of human folly.

(1) Heart attacks plummet after smoking ban, The Sunday Times, 13 September 2009

(2) Smoking ban slashes heart attacks by up to a third across world, Scotsman, 22 September 2009

(3) ASH Daily News for 15 September 2009, Action on Smoking and Health, 15 September 2009

(4) Declines in Acute Myocardial Infarction After Smoke-Free Laws and Individual Risk Attributable to Secondhand Smoke, Circulation, 21 September 2009

(5) Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study, British Medical Journal, 2004;328:977-980

(6) The impact of a smoking ban on hospital admissions for coronary heart disease, Preventative Medicine, 2007 Jul;45(1):3-8. Epub 2007 Apr 4

(7) Short-term effects of Italian smoking regulation on rates of hospital admission for acute myocardial infarction, 29 August 2006

(8) Changes in U.S. Hospitalization and Mortality Rates Following Smoking Bans, National Bureau of Economic Research, March 2009

(9) Do Smoking Bans cause a 27 to 40% drop in admissions for myocardial infarction in hospitals?, The Smoker’s Club

(10) Coronary heart disease: hospital activity, ISD Scotland

(11) Hospital admissions date online, Health Solutions Wales

(12) Hospital Episode Statistics, HES Online

Originally published by Spiked (24/9/09)

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This is really happening

Quote of the week comes from Dick Puddlecote, writing about the World Health Organisation's plans to copy the anti-smoking blueprint to the letter when they launch the war on alcohol in January:

I once suggested to some beardy tossbag from CAMRA that he should throw his weight behind objecting to tobacco prohibition because his vice was next. He piffled that drinkers were too numerous to be subject to the same denormalisation.

May God rot his middle class pompous paunch if he doesn't now realise that he was disastrously wrong.

Please read Dick's whole piece, as well as both New Scientist articles, because I find the whole thing too wearying, depressing and predictable to write about right now. Suffice to say, the phrase "passive drinking" is going to enter common parlance over the next few months and years. The WHO intends to challenge the "neoliberal ideology which promotes the drinker's freedom to choose his or her own behaviour" (since when was the freedom to choose one's own behaviour a "neoliberal ideology"?)

And, this being the World Health Organisation, the policies they come up with will apply not just to individuals, nor even to individual countries, but to the whole of the human race. There is no escape.

Those of us who have been warning against this for the last few years get no pleasure from being proven right. And yet still there will be those who say it won't really happen. That they'll be happy with a little extra tax on alcohol. That they'll stop once they've banned drinks advertising. Meanwhile, the tee-totallers will assure themselves that food isn't the next thing on the list.

Why am I reminded of Charlie Brown running up to kick that football again and again and again?

And all they wanted was non-smoking sections on aeroplanes...

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E-cigarettes - safe for now

Last month I posed the question of whether British anti-smoking groups would follow in the foot-steps of their American cousins and call for e-cigarettes to be banned. 

As I mentioned, ASH (UK) has a remit of encouraging safer forms of nicotine use (they support the legalisation of snus, for example). Furthermore, the amount of money British anti-smoking groups receive from pharmaceutical companies is a trickle compared to the river of cash spent in the US by GlaxoSmithKline, Pfizer and Johnson & Johnson (the latter, via the RWJF).

This question has now been partly answered by an ASH (UK) fact-sheet [PDF] which states the organisation's position:

ASH supports a harm reduction approach to tobacco, that is, we recognise that whilst efforts to help people stop smoking should remain a priority, many people either do not wish to stop smoking or find it very hard to do so. For this group, we believe that products should be made available that deliver nicotine in a safe way, without the harmful components found in tobacco.

Most of the diseases associated with smoking are caused by inhaling smoke which contains thousands of toxic chemicals. By contrast, nicotine is relatively safe.

Therefore, e-cigarettes, which deliver nicotine without the harmful toxins found in tobacco smoke, are likely to be a safer alternative to smoking. In addition, e-cigarettes reduce secondhand smoke exposure since they do not produce smoke.

This is level-headed stuff and is good news for smokers who wish to quit. There is an abundance of evidence (albeit anecdotal) that the e-cigarette is the most effective smoking-cessation device yet invented. Banning it would be madness from a public health point of view. 

ASH (UK)'s assertion that e-cigarettes do not create secondhand smoke is a statement of the obvious, but is nonetheless welcome since their American namesakes have been making laughably hysterical claims to the contrary, such as this, from the ASH (US) website:

A new device for addicted smokers who want to be able to get their nicotine fix by “smoking” in places where smoking is prohibited, and do so by exhaling a cloud of “smoke” made up of a chemical which is both toxic and addictive.

This new product, already being sold and used in many U.S. cities, is called an e-cigarette...

If you don’t want people sitting next to you – in a waiting room, restaurant, bar, or any other area where smoking is now prohibited – using one of these devices to get around smoking bans, and forcing you and your loved ones to inhale deadly nicotine – please help now!

We should be thankful that ASH (UK) haven't sunk to this level of fear-mongering. Nonetheless, they have three reservations about e-cigarettes.

1. Most deliver a low dose of nicotine which may not give a typical smoker a sufficient ‘hit’ to satisfy cravings, discouraging smokers from continuing to use them.

2. Because the products are unregulated there are some concerns about their safety since few manufacturers disclose the ingredients of their products.

3. So far, there have been no clinical trials to prove that they can help people to stop smoking. In the absence of such evidence, ASH therefore recommends that people who want to quit smoking should use nicotine replacement therapy or other proven pharmacological aids such as Champix (varenicline) or Zyban (bupropion).

I don't believe that the first point is valid. E-cigarettes offer high, medium, low and zero nicotine cartridges and I haven't heard users complain that the high nicotine cartridges are insufficient. Besides, users can take as many drags as they need to increase the dose. ASH's criticism could more accurately be aimed at pharmaceutical nicotine devices like patches and gum.

The second point is moot. Already, we are getting a clear indication that there are very few ingredients in the devices and that none of them - nicotine included - are harmful at the doses found. Nevertheless, regulation is required and is welcomed by the e-cigarette industry. As ASH points out: 

...e-cigarettes are subject to general consumer protection laws and it is the responsibility of trading standards officers to rule on their safety.

That should be sufficient regulation.

The third point is also questionable. It is true that clinical trials have not yet shown e-cigarettes to be effective as smoking-cessation devices, but then they are not being marketed as such. On the other hand, they have not been shown to be harmful. The same cannot be said for Champix and Zyban which, between them, have been linked to 317 suicides or attempted suicides. 

In July, the FDA ruled that black-box warnings must be put on both these products:

FDA: Boxed Warning on Serious Mental Health Events to be Required for Chantix and Zyban 

The U.S. Food and Drug Administration today announced that it is requiring manufacturers to put a Boxed Warning on the prescribing information for the smoking cessation drugs Chantix (varenicline) and Zyban (bupropion). The warning will highlight the risk of serious mental health events including changes in behavior, depressed mood, hostility, and suicidal thoughts when taking these drugs.

This leaves consumers with a choice between a product that has not been clinically proven as a stop-smoking device but is safe, and two products that have been proven to cause psychotic disorders. That ASH (UK) is recommending the latter may seem perverse, but at least they are still allowing a choice.

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Inevitable consequences

If I linked to Frank Davis every time he wrote an eloquent and thought-provoking post it would become a daily task, but this short article is well worth reading. Frank's point is that - as an enthusiastic smoker - his tolerance towards others has declined as tolerance towards his own pleasures has diminished. 

Of course, many people would argue that smoking is an irrational habit, but that is hardly the point, for the same can be said of many other lifestyle choices:

[A]part from the fact that they both voted for the smoking ban, one of the reasons I don't like Kerry McCarthy and Paul Flynn is because he's a druid and she's a vegan. And that means that they're both profoundly irrational people, who also happen to be MPs, unfortunately. 

Smokers are not always in the minority. A non-vegan smoker is in the majority if the debate turns to veganism. A non-druid smoker is in the majority if the debate turns to paganism. The protection offered by numbers swiftly disappears when the tables are turned. If we cannot find any higher reason to be tolerant, simple self-protection should suffice.

Philosophically speaking, tolerance should probably not be contingent on others being tolerant back. Turn the other cheek and all that. But in terms of human behaviour, it is inevitable that the creation of divisions is going to generate resentment on both sides.

This is the aspect that most worries me about the "denormalisation" crusade. The creation of divisions - or, let's put it more bluntly, hatred - is not a side-effect of denormalisation, it is the pre-meditated intention of the whole endeavour. It deliberately creates divisions where there was once tolerance. There is a fine line between denormalisation and stigmatisation. There is an even finer line between stigmatisation and hate-mongering. 

Stanton Glantz, one of the architects of "denormalisation" once described it as “implicitly defining smoking as an anti-social act.” It is, quite explicitly, a top-down approach designed to get people to pressure their peers into not smoking, but it does not account for the more thuggish and tribal part of the human psyche. The result has been that we now have high-profile millionaires calling for children to report their own parents to the police.

But, as Frank's post shows, the antipathy works both ways:

Before the ban I was a left-leaning liberal, and a Lib Dem voter. And I vaguely looked upon Greenpeace and Friends of the Earth and the green movement and environmentalism in a friendly, approving sort of way. And although I didn't do it myself, I really wasn't bothered if friends of mine stopped smoking, and started eating organic vegetarian food and going to yoga classes and Buddhist retreats. I was tolerant to the point of super-tolerance. Lesbians, are you? Pleased to meet you.

That's all over now. It all ended around about 1 July 2007.

It was an inevitable and intended consequence of denormalisation that nonsmokers would become less tolerant of smokers. Less anticipated, perhaps, was the fact that this would also work in reverse. The result has been the creation of another little pocket of hate in the world. Try as I might, it's difficult to think of any social problem that's ever been solved by the creation of more hate.

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That's one way of putting it

Under the headline 'Early introduction of ban does little to reduce smoking rates', The Irish Times has reported that... 

More people continue to smoke in the Republic than in Northern Ireland, despite the earlier introduction of the smoking ban here, according to new research.

The One Island – One Lifestyle? report, which compares the health of individuals living on both sides of the Border, shows the introduction of the workplace smoking ban in the Republic in 2004 has done little to reduce overall smoking rates.

Done little? That's one way of putting it. A more accurate way of putting it would be to say that smoking rates have increased since the ban, as the same newspaper reported last year:

The number of people who said they were smokers fell from 33 per cent in 1998 to 27 per cent in 2002 but increased to 29 per cent last year

Using the post hoc ergo propter hoc logic so beloved of researchers when heart attacks are being counted, one might even say that the smoking ban "caused" more people to smoke. I wouldn't subscribe to that logic, but it is clear that the smoking rate was falling significantly before the smoking ban and has risen since.

It is interesting to note that there was also a significant fall in the smoking rate in Northern Ireland before the ban as well.

The effects of the workplace ban in the North have yet to be assessed, but the percentage of smokers there fell 6 per cent from 32 per cent in 2003 to 26 per cent in 2005.

We shall see whether this fall continues after 2007 or whether the curse of the smoking ban will hit the Irish North of the border too.

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Muck-spreading

From the pen of Gavin Hewitt, the BBC's Europe editor:

In politics it is often true that you are judged by your friends and associations. I was reminded of this when I read the British Foreign Secretary's attack on the Tories and their European allies. David Miliband's allegation is that the Conservatives have linked themselves to the far right in Europe, to neo-Nazis and anti-Semites.

I've heard this too and I'd be interested to know what the truth is. Let's read on, shall we?

Its leader is Michael Kaminski from Poland. The allegation against him is that he opposed an unconditional apology for the massacre of 41 Jews by Poles in the village of Jebwadne during World War II.

Ooh!

He says he has been mis-represented.

Oh.

His party is accused of being homophobic.

Ooh!

Again there have been denials.

Oh.

Another target has been Robert Zile of Latvia's Fatherland and Freedom Party. His party is accused of commemorating those
who served in the Waffen SS.

Right...

The Tories have said that they would never do business with anyone who they thought glorified the SS.

Okay. So what's the truth? Read on for 400 words and you get this...

I have not investigated these allegations of far-right connections myself and I do not know their strength...

I haven't investigated these allegations either, Gavin, but then I'm not the BBC's Europe editor. Any chance you could shine some light on them rather than repeating gossip and hearsay?

...but I know that as the British election gets closer they will gain more attention not less; that it will be difficult to close down this story and that in the dog-fight of an election campaign you can be judged, fairly or not, by your friends and associations.

No smoke without fire, eh?

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On the fringes (2) - Labour and Five Live

[Reflections on the party political conference season - part two]

I popped along to the Labour fringe meeting partly because I live nearby and partly because Iain Dale had mentioned it on his blog. The debate was called Can Labour Win? The two Labour MPs present claimed - naturellement - that Labour could win, but the '200 days of power' posters hung all around the room hinted at a more defeatist attitude.

Iain Dale aside, the line-up was distinctly off-putting, consisting as it did Caroline Flint and Caroline Lucas - neither of whom would get my vote in a thousand life-times - and that obnoxious heap of lard Ed Balls.

If Ed Balls is the future of the Labour party, they really are in trouble. The man is a perpetual undergraduate, stuck in the 1980s, who does nothing but attack the Tories and knock down straw men. After 12 years in power, he still acts as if he is in opposition which - if the polls are to be believed - he soon will be. 

It was a forgettable event at the start of a downbeat conference. Neither Ed Balls here, nor Gordon Brown in the main hall, seemed capable of grasping the fact that it was saving, rather than spending, money that is now the priority. Mumbling rhetoric about 'social justice' and 'equality' is no substitute for an economic plan, even if played well to the Fabian Society's audience.

A refusal to face reality was on display again the following day, when I was in the audience for Victoria Derbyshire's live debate on Radio Five. I seldom listen to Victoria's show (it's nothing personal) but, to give her her due, she is a very capable broadcaster and watching her control a three-hour debate where anything could go wrong made me appreciate the calm head required for live radio.

The show consisted of a stream of Labour politicians being wheeled into the room to be abused by the Sussex public. There were so many that I can't recall them all but I'm fairly sure that Caroline Flint, Charles Clarke, David Blunkett, Neil Kinnock, Tony McNulty, Jack Straw and Tessa Jowell all made appearances. All expressed loyalty to the Prime Minister and all stated that Labour could win the election but, in truth, few put their heart into it. In fact, only Neil Kinnock seemed to have any fight left in him and when he had to rush off during the news (presumably he had a gravy train to catch) he was given a spontaneous round of applause for being, at the least, entertaining.

More interesting than anything the politicians said was the way the show was orchestrated. It is not, of course, as spontaneous and chaotic as it might sound on the radio. Tea and coffee is served for an hour before the show begins, which gives half a dozen BBC staff a chance to go around chatting with their audience. Although casual, the purpose of these little chats is to see whether you follow politics, whether you can string a sentence together and - to put it bluntly - whether you're a weirdo whose going to ruin the show.

Mrs Snowdon and myself must have come across as reasonably sane because we were then seated in the first row, which was handy because it later allowed me to request Tony McNulty's resignation to his face (he was caught up in the expenses scandal). 

During the show itself, the same BBC workers who greeted us over hot drinks pace the floor taking whispered questions from the audience. If they think the question is relevant and will take the discussion in the right direction, they put their hand up to attract the attention of the producer who, in turn, attracts the attention of Victoria. This, again, weeds out the loony comments and keeps the show on track. As I recall, only one truly incoherent comment made it onto the air (from one of a hoard horde of students in the audience) and the glare that Victoria gave the producer afterwards was priceless. 

All in all, a decent way to spend a Monday morning but really it was just a warm up for Question Time, of which more in the next post.

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On the fringes (1) - Lib Dems in Bournemouth

[Reflections on the party political conference season - part one]

For me, the conference season began with a fringe meeting ('Politics and Prohibition') at the Lib Dem conference in sunny Bournemouth. The libertarian-minded Liberals who attended were, I'm sure, unrepresentative of the party as a whole, but the wide-ranging discussion (from drinking to prostitution) was entertaining and stimulating. 

Liverpool council's proposal to give films which depict smoking an 18 certificate was greeted with rather more contempt than would have been the case if it had been presented in the main conference hall. Bravely commending the policy to the house was Liverpool councillor Colin Eldridge who brandished research from the pen of the ubiquitous Stanton Glantz. 

Colin seemed sincere enough but he is naive if he really can't see the wider implications of the Orwellian smokefree movies policy. An ex-smoker himself, Colin blamed watching The A-Team as a youngster for his subsequent cigar habit so perhaps he is more impressionable than most and I did get the sense that he was being used by an anti-smoking lobby which has identified Liverpool as a potential San Francisco of Britain (the city was set to go it alone with a smoking ban as far back as 2004).

Colin claimed that the demand to reclassify films which 'exposed' children to the sight of people smoking came not from the council but from normal teenagers (as supposedly represented by the D-MYST group). This inspired the best comment of the day from someone on the floor:

We're doomed, aren't we? If children are demanding that films be classified 18 just because people are smoking in them, then what hope is there for the future? 

I must be getting terribly cynical because the idea that children really were the driving force behind this policy hadn't even occurred to me. (And they're not, of course. The Department of Health-funded D-MYST group is a classic example of astro-turfing).

It's hardly a novel observation to say that the Liberal Democrats are divided between the Classical Liberal right and the Social Democratic left. I don't know how the party will ever overcome this fundamental split but it does at least make for a lively debate. The panel at this particular event - hosted by Liberal Vision - was naturally slanted in favour of liberal Liberals, including Charlotte Gore, Mark Littlewood and Belinda Brookes-Gordon. I wish them well in their attempt to get their party back. Still, rather them than me. 

And like Dick Puddlecote, I'll be recalling the scenes inside and outside the Marriott Highcliff Hotel next time I hear the Lib Dems talking about cracking down on smoking and binge-drinking. 

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Anti-smoking trend turned in Denmark

[This is a guest post from Klaus K, whose Danish blog is here. Klaus provides news which acts as a further reminder that total smoking bans - with no exemptions and no amendments - remain rare in mainland Europe.]

Anti-smoking trend turned in Denmark

Despite two years of heavy media pressure from the anti-smoking lobby, Denmark's liberal prime minister Lars Løkke Rasmussen said this week that the government will not tighten the smoking ban in December, when the smoking law is to be re-evaluated.

The government planned to introduce a total ban in 2009, and this has been reported for two years by the media and the health community but when, in August, the anti-smoking lobby demanded a ban on smoking rooms in schools, the DF party (Dansk Folkeparti) said that they would not support a tightening of the ban.

DF health speaker Liselott Blixt told the media that "enough is enough". She said that smokers were being harassed, and she also expressed doubt about the validity of the popular claim that passive smoking is a killer. "Nobody is going to die, because they smell a little smoke. We must have places for the Danish smokers," Mrs Blixt said to Politiken. 

By September, most of the Danish political parties had agreed, leaving only the left-wing parties Socialdemokratiet, Socialistisk Folkeparti and Enhedslisten still wanting to tighten the ban.

The Danish ban currently allows designated smoking rooms in the hospitality sector - with free choice of smoking in all small bars and cafés below 40 m2 serving area. Many bigger bars and cafés have chosen to downscale their serving areas to get below the 40 m2 limit, thus allowing smoking.

In the sixth largest Danish city - Randers (in Jutland) - a handful of bar-owners said on national television that they break the law regularly and allow smoking. They said Randers is the "wild smoking west" - they put ashtrays on the tables, saying it is not ashtrays but "garbage trays". One bar-owner in Randers is going to court for allowing his guests to smoke in his 400 m2 pub. The suit was filed by the national "working-control" authority, which oversees the anti-smoking law. The court case starts in Randers on November 22nd.

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Alcohol - the new tobacco

[More political ramblings to follow but while I drive my van from Yorkshire to Brighton, here's something I wrote a few weeks ago and never got round to posting]

Ian Dunt at politics.co.uk has written a fine article which echoes one of the themes of Velvet Glove, Iron Fist - that the war on tobacco is a precursor to the war on other 'vices'.

And so it begins. The British Medical Association (BMA) is calling for Britain to become the first country to ban alcohol advertising, sponsorship and promotions. We know it won't end there. This line of attack was the first front in the war against smoking, and it appears alcohol is now in the health lobby's sights.

Indeed. I'm sure the reader does not need to be reminded that the campaign against cigarettes began with an advertising ban.

As an organisation, the BMA only comprehends the world through the prism of physical harm. Harm is bad. Non-harm is good. Nothing else fits in the equation. Unfortunately for them - but fortunately for us - there's so much more to life than that.

Many things which cause harm are a fundamental part of a life worth living. Sex, for a start, has killed more humans throughout history than we could count, through sexually transmitted diseases, the act of giving birth and jealous husbands, to name but three.

Cigarettes are the same. They kill millions. But there is a certain beauty to the sensual, subtle – almost mystical – nature of smoking which isn't negated just because it is dangerous or addictive. Any rigorous exercise or extreme sport has killed humans in their thousands. On the other end of the scale, bacon butties - possibly the greatest invention in the history of man - will invariably end you if you enjoy them too often. Sometimes it's worth giving up some safety for a little pleasure. It is risk and excitement and uncertainty that make life worth living.

This is a value judgement, of course, but it is one that Ian Dunt is free to make as a sentient adult human being. We all make such judgements. For the individual, life is made up of many parts - wealth, health, sex, love, music, sport, food and so on - of which health is but one. The British Medical Association is naturally preoccupied with health. This is hardly surprising, and is as it should be. Equally, economists are preoccupied with wealth, the Football Association is preoccupied with sport and Cosmopolitan magazine is preoccupied with sex.

Every important aspect of our lives has its experts, advocates and specialists. They are so attached to their own aspect of life that they lose sight of the other priorities people have. They get tunnel vision.

Amongst historians, for instance, it is a running joke that specialists of one period of history will become convinced their era represented the turning point in history (try to find a consensus about when the medieval period really ended, for example). The same is true in real life. Business is accused of focusing too much on money, at the expense of the environment and quality of life. Environmentalists are accused of focusing on pollution and climate change at the expense of development and wealth generation.

'Healthists' (and I hate to use such a clumsy word) can be accused of being preoccupied with health at the expense of pleasure. The problem is compounded by the fact that pleasure cannot easily be quantified. Certainly, it cannot be quantified as easily as longevity, which is what public health statistics so often boil down to. And that, perhaps, is why the health argument wins through so frequently. Statistics are powerful.

Everyone, deep down, understands John Stuart Mill's central tenet of On Liberty; that we cannot take away someone's freedom unless they are oppressing the freedom of someone else.

I will freely admit that I view Mill's famous harm principle as being sacrosanct. I've written at length about what Mill would have made of the current anti-smoking movement.

Doctors must not become policy makers - any more than the drinks lobby should.

But doctors have become policy-makers (or, at least, their representatives have - the doctors I know have no will to legislate). And this is the crux of the matter. It is quite valid to have a health lobby and it is quite valid to have a drinks lobby. The problem comes when health is exalted to a supreme status above all other considerations and the "drinks lobby" is treated as a rogue industry. The balance has been lost.

In the real world, health is important and, to many of us, drinks are important too. The individual balances pleasure and risk, savings and expense, time with money, work with play. When the specialist loses sight of this, he risks becoming a myopic extremist.

Mill is famous for expressing the fear that the freedom of the individual was at risk when democracy turned into a tyranny of the majority, but it was Hayek who best expressed the danger posed by the specialist in The Road to Serfdom:

We all think that our personal order of values is not merely personal, but that in a free discussion among rational people we would convince the others that ours is the right one.

The lover of the country-side who wants above all that its traditional appearance should be preserved and that the blots already made by industry on its fair face should be removed, no less than the health enthusiast who wants all the picturesque but insanitary old cottages cleared away, or the motorist who wishes the country cut up by big motor roads, the efficiency fanatic who desires the maximum of specialisation and mechanisation no less than the idealist who for development of personality wants to preserve as many independent craftsmen as possible, all know that their aim can be fully achieved only by planning - and they all want planning for that reason.

But:

Though it is the resentment of the frustrated specialist which gives the demand for planning its strongest impetus, there could hardly be a more unbearable - and more irrational - world than one in which the most eminent specialists in each field were allowed to proceed unchecked with the realisation of their ideals."

The "planning" Hayek refers to is collectivism. Whether you call this planning communism or fascism, only totalitarianism is able to fully meet the needs of the specialist who sees nothing but the bee in his own bonnet.

The various kinds of collectivism, communism, fascism, etc., differ between themselves in the nature of the goal towards which they want to direct the efforts of society. But they all differ from liberalism and individualism in wanting to organise the whole of society and all its resources for this unitary end, and in refusing to recognise automonmous spheres in which the ends of the individuals are supreme. In short, they are totalitarian in the true sense...

A while ago I was interviewed by someone who told me that, as a keen gardener, she hated to see other people not weeding their gardens and that, if she had the power, she would pass a law to force people to do their weeding. What could be wrong with that? On the surface it seems such a small thing. A weeded garden, I suppose, looks better than an unweeded garden. Doing a spot of gardening isn't such a big chore and most people do it anyway. Her point was that she could not bring about this (to her) great improvement in the nation's gardens as a lone individual. Even if she hooked up with like-minded people, she would only see a moderate change through a campaign of persuasion. Only the state, with all its power, could eradicate this (to her) pressing problem.

We could all name similar minor annoyances which could be eliminated without any great hardship (to us), if only the might of the government was directed towards them. And it is this that gives the state its allure. I have long been of the opinion that most people do not want a smaller state. They are happy with a big state so long as they feel it is on their side and so long as it goes after the people they don't like. This is - to put it mildly - a problem for those who lean towards libertarianism.

But I digress. The drinks industry will continue to assume good faith on the part of those who oppose them. They will make concessions to the health specialists. They will go along with 'voluntary' agreements (which will soon become compulsory). They won't put up much of a fight to the ban on advertising. They will expect the specialists to stop at some point in the near future.

But the specialists won't stop. They see alcohol, quite explicitly, as a Group 1 carcinogen. This puts it in the same class as tobacco. Why, then, would they stop at an advertising ban?

The drinks industry hates to compare itself with the tobacco industry (understandably), but it really does not matter who they compare themselves with. It matters who the specialists are comparing them with.

The knives are out for alcohol, as they are for various types of food. As I argue in Velvet Glove, Iron Fist, the blue-print was drawn up by the anti-smoking lobby. If the drinks lobby took its head out of the sand it would see that its future lies not with a mere ban on broadcast advertising, but in plain packaging, pictures of diseased livers on their labels and under-the-counter sales. And more. We shall see what the next move against smoking is, before we predict the fate of drinkers a decade or more hence.

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