Evidence-based decriminalisation and evidence-based prohibition

The BBC led the news yesterday with a government report which found "no obvious" link between enforcement of drug laws and the number of people who take drugs. As somebody who wants to abolish drug laws, I have every incentive to applaud this report and use it as evidence for my position even though, like nearly everybody else, I haven't read it.

Nevertheless, I couldn't help feel some sympathy for the prohibitionists after watching Newsnight, which treated the issue of decriminalisation as such a no-brainer that they decided to have a general discussion about "why don't governments just follow the evidence?" instead of discussing the arguments about drugs specifically.

Remarkably, none of the guests gave the obvious answer which is that politicians have to get re-elected and voters might want drug users prosecuted regardless of whether it reduces the prevalence of drug use. (Clare Fox did, however, argue that the logical conclusion of evidence-based policy is the abolition of democracy in favour of a technocratic elite.)

The three guests didn't disagree as much as Walk might have wanted them to. They all agreed that evidence couldn't dictate political objectives and they didn't disagree enormously on whether evidence could help politicians to discover whether their policies actually work.

The examples that Kirsty Walk used to illustrate good and bad evidence-based policy could not have been more Newsnight. The smoking ban was obviously good, the Iraq War was obviously bad. I have always been opposed to both of them, but leaving aside the fact that the SCOTH report on secondhand smoke was every bit as sexed up and politically driven as the infamous 'dodgy dossier' on Iraq's weapons capability, sincere and reasonable arguments can be made for and against both policies without resorting to the specific evidence that Newsnight implied was all important.

In the case of Iraq, interventionists could make a decent case for regime change by pointing out the indisputable fact that Saddam Hussein had used WMDs in the past, had invaded his neighbours in the past and was treating his own subjects in an appalling manner. If the Iraqi people had embraced Western troops as liberators and created a peaceful and thriving democracy, the silly claims about rockets being fired at Cyprus within 45 minutes would have been forgotten. The real question should have been whether the war was winnable and whether it would do more harm than good. This question could not easily be answered with evidence until after the fact. An additional moral question—whether it is worth sacrificing the lives of British soldiers to liberate a foreign country—cannot be answered with evidence at all.

In the case of the smoking ban, Clare Fox rightly pointed out that the epidemiological evidence on passive smoking (even if it was more robust) cannot, in itself, justify the extensive and uncompromising smoking ban in force in the UK. It could just as easily justify a notice on the door of pubs saying 'People smoke in here. If that bothers you, go elsewhere.'

Walk also used the example of seat belt legislation. It is probably no coincidence that seat belt laws and the smoking ban were cited as instances of sound evidence-based policy. They are often used as precedents for the 'public health' lobby to force people to do thing (or not do things) for their own good (some MPs predicted this slippery slope in 1979 when the seat belt law was debated). In both cases, evidence relating to one narrow aspect of life was used to trump other considerations such as property rights, self-determination and the economic prospects of the pub trade. As Clare Fox said, evidence is often used as a way of overwhelming legitimate objections that fall outside of the narrow view of campaigners.

Ben Goldacre was also on the panel and he made the reasonable point that although evidence can be distorted, the solution is to find better evidence, not dismiss evidence altogether. He would like to see something closer to randomised control trials for public policy, such as trying something out in one region and comparing the results to a 'control' region. (A personal idea: There are constant, annoying announcements on British trains urging people to remember to take their belongings with them when they leave. It would be a simple matter to turn these announcements off for a few weeks and see if there is more lost luggage as a result. If not, switch them off forever.) There is some scope for Goldacre's idea, though probably limited, but he made a comment that inadvertently highlighted how the supposedly objective use of evidence depends on some very subjective prior beliefs:

"Everybody agrees what we want to do overall is reduce the prevalence of drug use, reduce the prevalence of harmful use"

Do they? I don't and a good many people who take drugs presumably don't think so either. There are several schools of thought on drugs which I have crudely split into four basic groups:

1. The libertarian/free market position.

View: We don't care how many people take drugs and we don't necessarily care how much net harm they cause so long as individuals have access to their drugs in the least hazardous forms and the costs are internalised. We also want to remove the criminality from their sale, manufacture and transport.

Solution: Legalisation, regulation and Pigouvian taxation.


2. The public health position

View: We want to reduce the net harm associated with drug use and we would like fewer people to take drugs. We don't want people who take drugs to go to prison. Drug use is a medical issue.

Solution: Decriminalisation, needle exchanges, prescription of pharmaceutical grade drugs to addicts, treatment.


3. The status quo prohibitionist position

View: Drugs are bad, m'kay? It is right that they are illegal and it is wrong to make laws which are not enforced.


4. The über-prohibitionist position

View: Drugs are inherently harmful and harm is directly linked to prevalence. The best way to reduce prevalence is to vigorously enforce drug laws. It is hypocritical to ban drugs whilst facilitating drug use at the taxpayers' expense with needle exchanges and safe injecting rooms.


I support the first position, the mood of the times favours the second position and the law reflects the third position. The fourth position is held by Peter Hitchens.

What does this week's evidence say? It says that enforcing drug laws doesn't make much difference to whether people take drugs or not. So where does that lead us? On the face of it, it suggests that we shouldn't bother hassling drug users and we should have some form of decriminalisation. From my perspective, three cheers for that. But the people who say that it is lame to ban drugs and then turn a blind eye to drug use have a point, don't they? And the people who say that giving people free needles is rank hypocrisy also have a point.

Even if "everybody agrees" that reducing the prevalence of harmful drug use is the goal, it is far from clear that a system of decriminalisation would be better than total legalisation. Decriminalisation, in my view, is a miserable little compromise that would do nothing whatsoever to make drugs safer, would do nothing about the criminal networks that produce and supply drugs (which is where most of the harm is caused) and would do nothing to internalise the costs (because drugs would remain untaxed).

So what is the evidence on legalisation versus prohibition? Obviously there isn't any in the modern era because legalisation hasn't been tried for a hundred years. In the early decades of drug prohibition, it does seem that opiate addiction generally declined. It is also clear that alcohol consumption—and some measures of alcohol-related harm—declined during Prohibition in the USA and elsewhere. Although some legalisers dispute it, logic dictates that drug legalisation would probably result in a rise in drug consumption (if only because prices would fall and availability would increase). Legalisation would almost certainly reduce the risk to individual drug users, but a reduction in net harm, though likely, is far from certain.

From the narrow perspective of health, then, prohibitionists are not without evidence (and you can expect to hear more from 'evidence-based' prohibitionists as the anti-smoking lobby moves towards its euphemistic 'endgame'). If you ignore the impact on crime, the economy and personal freedom, all sorts of prohibitions can be justified. But this is the problem with evidence-based policy: it depends on what you're measuring and many of the most important things in life cannot be quantified on a spreadsheet.

As Churchill said, scientists should be on tap, not on top.

The risks of drinking

There's a nice illustration of the gulf between 'public health' and reality in BMC Medicine this month in an essay entitled:

Why does society accept a higher risk for alcohol than for other voluntary or involuntary risks?

When the authors (some Canadian folk who credit temperance stalwarts Ian Gilmore and Tim Stockwell for providing 'helpful comments') say 'society' they really mean 'the government', but their question becomes much easier to answer if it is framed properly as:

Why do people accept a higher risk for alcohol than for other voluntary or involuntary risks?

The answer, quite obviously, is that drinking is highly enjoyable, the benefits are large and the risks are small to non-existent for moderate drinkers and tolerable for heavier drinkers.

Remarkably, this answer barely occurs to the authors. Instead they point the finger at things like alcohol's "cultural acceptance among elites in most western societies". They suggest that "the risks of alcohol may not be fully understood by the general public" and that "the addictive properties of alcohol cloud the consumers’ ability to assess information and make a free choice" And, inevitably, they blame "the strong political influence of global alcohol producers".

The methodology employed in this paper is rather odd. The whole article seems designed to revive the old temperance belief that there is no such thing as a safe drink and it hinges on this graph, which purports to show the absolute risk of dying as a result of alcohol consumption before the age of 70.

This graph bears no resemblance to the actual relationship between alcohol and all-cause mortality which, as regular readers will know, is a J-curve. (Note that one drink is about 15 grammes of alcohol.)

Their assertion that drinking just over one drink a day gives you a one in 100 chance of dying from an alcohol-related disease before the age of 70 flies in the face of so much evidence that there is little point in continuing. Nevertheless, this is how they proceed:

How do these risks compare to other acceptable risks in society? Many of the fully involuntary risks, such as unsafe water provided to a household, have risk thresholds set at one in one million. Indeed, the one in one million has become something of a gold standard of acceptable risk for involuntary exposure and has been used in different areas such as water safety in Australia and the US, or for increases of exposure to carcinogens in air, sediment or soil. 

Fine. It makes sense to be highly risk averse when it comes to water pollution or carcinogen exposure so long as there are low-cost ways to eliminate risk and there are no benefits lost by doing so. Nobody wants to drink unclean water. Lots of people want to drink alcohol.

Involuntary risks are associated with activities, conditions or events to which individuals might be exposed without their consent. Examples of involuntary risks include the risks of natural disasters (earthquakes, floods, and so on), or technology-related risks such as bad air quality or contaminated water.  

People who live on fault-lines and flood plains are exposed to earthquakes and flood with their consent. Millions of people live in California with the sure knowledge that the Big One will come sooner or later. The benefits they enjoy from living in California (God knows what they are) outweigh the risk of having their home razed to the ground and the possibility of being killed.

It should be noted that other standards have been used, and sometimes we see ranges, such as one in a million to one in 100,000. Starr found that the public seems to be willing to accept voluntary risks roughly 1,000 times greater than involuntary risks. By this standard, an acceptable risk for voluntary risks experienced by the drinkers themselves is one in 1,000 deaths for the pattern of behaviour over a lifetime. 

Do you know what else Starr said in his classic 1969 essay? He said this:

In the case of "voluntary" activities, the individual uses his own value system to evaluate his experiences. Although his eventual trade-off may not be consciously or analytically determined, or based upon objective knowledge, it nevertheless is likely to represent, for that individual, a crude optimization appropriate to his value system...

"Involuntary" activities differ in that the criteria and options are determined not by the individuals affected but by a controlling body.  

He was right. Involuntary risks that affect whole populations may require action by 'a controlling body'. Voluntary risks, like drinking, don't.

They continue:

If we accept the stated acceptable risk of one in 1,000 deaths, drinking 20 g pure alcohol per day (equivalent to 1.5 to 2.5 standard drinks dependent on the national standard drink: 8 g pure alcohol per drink in the UK, between 10 and 14 g in other European countries) exceeds this threshold ... drinking 20 g pure alcohol per day seems to exceed a threshold of one in 100 for death on a lifetime basis

Firstly, drinking 20g of alcohol per day does not exceed that 'threshold'.

Secondly, drinking 20g of alcohol every day for decades is not a single action. It is many thousands of individual actions over a course of a lifetime.

Thirdly, insofar as the one in a thousand shot is a meaningful threshold, it applies to voluntary behaviour and is therefore a matter for individuals, not 'a controlling body'.

To put this in perspective, the average level of daily consumption in EU countries in 2012 was about 31 g pure alcohol per day among drinkers, entailing a mortality risk beyond this threshold. This level of drinking has led to a situation where every seventh death in men and every 13th death in women before age 65 in the EU is caused by alcohol. Clearly, this level of risk is not acceptable by usual standards. 

This is willfully misleading. Aside from the fact that the statistics are questionable, the reference to average consumption of 31g of alcohol clearly aims to reinforce the false impression that this is a dangerous amount to be drinking. In fact, alcohol-related deaths before the age of 65 are dominated by liver cirrhosis—which requires a much, much larger alcohol intake than that—and various causes such as suicide, drink-driving and violence which tend to be the result of acute intoxication, not persistent but moderate consumption.
 
Only at the very end of the article do we get this brief, bewildered acknowledgement:

Or may the actual or perceived pleasurable effects of alcohol consumption (that is, benefits) be so high that the informed choice of a mortality risk in the 1:100 range is seen as “reasonable risk”, so that there is no pressure from the public for government action, and governments are dissuaded from effective alcohol policies such as raising taxes?

That's exactly what it is. Well done. Even if drinking at that level led to a 1 in 100 risk of premature death rather than - as is actually the case - a reduction in the risk of premature death, it would be entirely reasonable for people to do it if they enjoy it. See also driving a motorbike, going skiing, climbing mountains, eating cream buns or any of the other comparable activities that are brought into these debates.

If, however, someone doesn't feel that the benefits are worth it—either because they don't really enjoy drinking or because they are particularly neurotic about their health—then they are free to abstain. What they don't do, unless they work in public health, is demand "government action" and higher taxes for people who don't share their preferences.

Dead rock stars

Chuck Berry: fading away, not burning out

As covered in the Daily Mail and elsewhere, a study has come out of the University of Sydney which concludes that rock stars tend to die younger than the general population.

Well, duh, you might say. And rightly so. A cursory knowledge of music history tells us that rock stars are more likely to die from drug overdoses, plane crashes, suicide etc. and this is confirmed in the study.

But I was startled to find that the author has also attempted to compare rock stars' longevity to the average.

Longevity was determined by calculating the average age of death for each musician by sex and decade of death. These averages were then compared with population averages by sex and decade for the US population (per 100,000).

And she has come up with this graph...

You see the problem here, I expect. Rock stars didn't exist until the 1950s and since many of them are still alive, we don't know what their average age of death is. It wouldn't be at all surprising if they die earlier on average, but the graph above tells us very little about whether this is so. When Chuck Berry (aged 88), Jerry Lee Lewis (aged 79) and Little Richard (aged 81) pop their clogs, the average is going to go up, especially if they keep breathing for another twenty years.

And, who knows? They might. Perhaps the higher risk when young is counter-balanced by the boost to longevity of having lots of money and the best healthcare in old age?

Be that as it may, you clearly can't work out the average lifespan of a rock star until at least the first generation of rock stars are dead.

I can't find the study, so I apologise to the author if I am misrepresenting her work, but somebody raised this question with her in the comments and her reply was not very convincing.

There is a small amount of survivor bias at work here, ie. the rock stars have to live to be in their twenties (generally) before they become rock stars. That probably isn't a big issue when so few people die before the age of 20. The real problem here is a sort of reverse survivor bias, sort of like immortal time bias, but not quite either of those.

So, my question is: does this fallacy have a name?

Health über alles

During the closing overs of the farcical WHO conference in Moscow (COP6) delegates agreed to something called the Moscow Declaration. In keeping with the fog of secrecy that surrounded this covert meeting of unelected tax-spongers, the text of this declaration has not been released, but I've seen a draft. It contains some delusional prohibitionism (eg. "The desired goal of tobacco control measures at the international and national levels is complete victory over tobacco"), but there is also this striking assertion:

The right to enjoyment of the highest attainable standard of health, guaranteed by international law and national legislation of the vast majority of States, takes precedence over any laws related to tobacco use. There is no fundamental right to tobacco use.

Leave aside the question of whether it is really a fundamental right to have ‘the highest attainable standard of health’ in the sense that such a right could ever be asserted in court. Leave aside the fact that in a free society you don’t need a specific right to smoke; if it hasn’t been explicitly forbidden you have the right to do so. Leave aside the fact that this 'right' can, it seems, not be revoked by smokers even though it's their body; the WHO wants to enforce it without their consent. And leave aside the fact that the WHO has no democratic legitimacy and that this quote comes from a meeting held in Russia from which the public and the media were banned.

Instead, look at what is being said here, namely that the supposed right to perfect health takes precedence over democratically decided laws and other written or unwritten rights; that the pursuit of health is the highest priority, trumping all other concerns.

This is obviously untrue. Obvious, because not a single person lives their life as if longevity was the only, or even main, goal. If people wanted to attain the highest standard of health at the expense for all else, they would behave as if they did. They would sacrifice earthly pleasures and there would be no need for a public health movement. The very fact that a public health movement exists is proof that people don’t want it. What is not true for the individual cannot be true for the collective.

Faced with the awkward fact that people are free to live a life of purity but prefer to make trade-offs between health and other goals, the 'public health' lobby has come up with a range of ad hoc explanations which amount to a revival of the concept of false consciousness: that people buy products because they’re too cheap, or advertised too much, or too readily available.

These arguments cannot be supported by empirical evidence, personal experience or logical deduction. In reality, people offset costs against benefits, risk against pleasure, quality of life for longevity. The fatal conceit of the public health movement is it portrays one important, but narrow, goal as if it were the only thing that matters.

Carl Philips explained this very nicely in a blog post that should be read in full:

I recall a conversation with a fellow economics-trained assistant professor of public health. I forget the specific trigger for our observation, but it came after a meeting of faculty, when we both realized that we were surrounded by idiots. The issue was public-health-based policy recommendations and their absurd implicit objective function. Our observation was that in economics we often lean on the convenient myth that people’s goal is to maximize their lifecycle welfare, and that social policies should be based on that. It is easy to demonstrate that this is an oversimplification of behavior, and to argue from an ethical standpoint that there should be some departures from this in policy. But at least our simplified fiction is basically sound, both practically and ethically: Trying to maximize their welfare is roughly what people do, and there is an obviously defensible case to be made that trying to assist with such maximization is an important ethical goal — if not the ethical goal — of public policy.

We observed how sharply this contrasted with the implicit objective function in almost every public health policy discussion, which is basically “maximize longevity at any expense, and everything else be damned.” The economists who study medical care at least interject into this the caveat that some financial expenditures are too much to pay for the tiny bit of extra longevity they provide. But to the public health people, all other costs and benefits are trumped by the one objective. Economists’ objective function, we agreed, was not quite right, but at least it was generally defensible. The public health view, on the other hand, was utterly absurd. No one wants to live their life according to such an objective. Not even close. And therefore there is no possible way to justify it as an ethical goal for public policy.

The core belief behind 'public health' movement, as it is today, is so ridiculous that it can never be said out loud. Even the Moscow Declaration only hints at it.

As Carl points out in his post, the public healthists are not always consistent with their 'health über alles' mentality. They do not recommend that women have as many children as they can from a young age to reduce their risk of breast cancer, despite childlessness being a risk factor. They will not tell teetotallers to start drinking, despite teetotallism being a risk factor for heart disease. With some exceptions, they won’t support the use of e-cigarettes. But this only demonstrates how many moral zealots work in public health industry.

The public health industry is not a single entity. It is partly made up of those who have a connection with the medical establishment but who have taken the whole thing too far by ignoring trade-offs between longevity and other goals. And it is partly made up of moral entrepreneurs, puritans, and other single-issue cranks who, in the absence of a 'public health' movement to latch on to, would be campaigning under a placard outside some town hall or other.

It is hardly surprising that old school fanatics have been drawn to a movement that has more credibility and—crucially—more money than the impecunious moral reform groups of earlier eras. Once the public health lobby decided that a single objective trumps all other concerns, they became fanatics by definition and other fanatics were drawn in like moths to a headlight.

The great British booze rip off

From the Morning Advertiser:

UK consumers currently pay about 40% of the entire level of alcohol duty across the whole European Union.

This is a striking claim. I had heard that the British pay 40 per cent of all the beer tax in the EU, but I didn't realise that the same was true of all other alcoholic drinks.

Nevertheless, a check of the numbers in this EU document shows that it is true. The figures break down like this:

Spirits

EU total: €14.5 billion
UK total: €3.7 billion
UK percentage: 25%

Wine

EU total: €6 billion
UK total: €4 billion
UK percentage: 67%

Beer

EU total: €10
UK total: €4 billion
UK percentage: 40%

Sparkling wine

EU total: €1 billion
UK total: €460 million
UK percentage: 43%

Intermediate ('alcopops')

EU total: €700 million
UK total: €406 million
UK percentage: 58%

All alcohol

EU total: €31.2 billion
UK total: €12.5 billion
UK percentage: 40%


This is a rip off of British drinkers on an epic scale. The UK—which drinks less than the EU average—has 12 per cent of the EU population but pays 40 per cent of alcohol taxes. Pound for pound, we are paying more than three times as much alcohol duty than the EU average.

The exploitation of wine drinkers is particularly ruthless (most EU countries don't levy alcohol duty on wine at all), but every type of drink is subject to exceptionally high rates of tax. No wonder the European Commission thinks the British government can afford to give it another £1.7 billion.

Couch potatoes

From the Telegraph:

Couch potato lifestyles could kill the welfare state, landmark report warns

Couch potato lifestyles have left the UK with one of the lowest levels of activity in the western world, and without change, the welfare state could collapse, health officials have warned.

If the welfare state is so fragile that it can be brought down by people sitting about, perhaps we need a better system?

The welfare state won't be brought down under the weight of couch potatoes, however. This is just the latest scare story about obesity/smoking/drinking etc. bringing the NHS to "the brink of collapse". As I'm sure you know by now, obese people have lower heathcare costs than non-obese people.

At least Public Health England—for it is they—are talking about physical inactivity.

Officials warned that the UK population is now 20 per cent less active than it was in the 1960s...

The report by Public Health England says the typical lifestyle in Britain, with long hours spent in desk jobs, high levels of car travel and evenings spent watching TV or playing computer games is endangering the health of most of its population.

It warns: “Social, cultural and economic trends have removed physical activity from daily life. Fewer of us have manual jobs. Technology dominates at home and work, the two places where we spend most of our time. It encourages us to sit for long periods – watching TV, at the computer, playing games or using mobile phones and tablets. Over-reliance on cars and other motorised transport is also a factor.”

Indeed. I have been saying this recently on this blog and in an IEA report. If Public Health England conceded that calorie consumption has also been falling, we might get closer to understanding the real cause of the obesity 'epidemic'.

Michael Blastland gave a superb talk at the Battle of Ideas on Sunday in which he questioned why 'public health' folk tend to focus on diet, but not on exercise. He concluded that it is because there is no industry to attack and no legislation to campaign for. This, I think, is absolutely true. The public health lobby are one club golfers. If they can't blame industry for all the troubles of the world, they don't know what to do.

On a slightly related note, I am reminded of an anecdote in the great Petr Skrabanek's The Death of Humane Medicine which illustrates the yearning of epidemiologists to explain every premature death by reference to lifestyle.

When death strikes 'before its time', the victim's lifestyle becomes the subject of scrutiny. Death does not just happen. Something or somebody must be blamed. Obituarists casually search for snippets from the dead person's way of life which would 'explain' the timing and the mode of death.

When a 33-year-old friend of an epidemiologist suddenly died of a heart attack, without having any 'risk factors', the epidemiologist was greatly puzzled and so were his medical colleagues. 'The heart attack should not have occurred in this patient', was the verdict of experts. But it did. It was not fair. Was he a secret smoker? Had he used too much salt at home, even though he appeared to be shunning it in the hospital canteen? Then, finally, one doctor solved the mystery - the young man was a 'couch potato'.

All of Skrabanek's excellent books can be downloaded free here.

Good cop/bad cop - how the BBC frames the debate on sugar

The BBC wants to know when if you've stopped beating your wife.

Last night the BBC broadcast Trust Me, I'm a Doctor. It featured a segment about sugar that was a nice example of how the media can narrow the terms of a debate while pretending to be neutral.

It started by showing some of the hysterical claims about sugar being 'the new tobacco' before declaring that it would be presenting the views of two scientists who held wildly differing opinions about the subject.

"To find out more, I've invited a couple of leading experts whose research has led to contradictory headlines..."

One of these experts was Simon Capewell of the anti-sugar pressure group Action on Sugar.

The other was Mike Rayner from the, er, anti-sugar pressure group Action on Sugar.

Only Capewell (bad cop) was introduced as being from Action on Sugar and it is simply not true that their research "has led to contradictory headlines". Both of them think that sugar is the leading cause of obesity, both of them think that the government should intervene in people's diets and both of them want sugar taxes. Rayner's research focuses on what a jolly good thing it would be if we taxed sugar and fizzy drinks. Capewell entirely agrees.

The main differences between the two is that Rayner (good cop) believes he is doing the Lord's work and he would like to broaden food taxation to go beyond sugar to deal with the whole diet:

"I don't care whether it's hot or cold, whether you got it from a takeaway or a shop - I'd like us to tax all unhealthy foods from butter to biscuits."

You can watch extended interviews of Capewell and Rayner by clicking on the links. Rayner certainly comes across as the saner and more thoughtful of the pair—and so he is—but this is because he rejects the garbage about sugar being addictive and/or toxic (which Capewell virtually admits he has to spout in order to get the attention of politicians).

Only in the fruity world of 'public health' can this be considered a meaningful difference. From Rayner's perspective, it is more reasonable to tax calories as calories rather than demonise sugar per se, but that is still a patently extreme point of view. And yet this guy is being wheeled out as the voice of reason!

I won't fisk Capewell's interview, although I am tempted. I hope that anyone who watches it will spot his duplicity and evasiveness when answering questions, as well as the eagerness of the presenter to help him out (to a laughable degree when the topic turns to addiction). Rayner got a slightly rougher ride, but there was no acknowledgement of the role of physical inactivity in causing obesity, nor was there any recognition of the fact that per capita sugar consumption is the same today as it was a hundred years ago. Both sides agree that sugar is the villain and the government needs to act, preferably with taxes.

By only showing us the devil and the deep blue sea, the BBC managed to make Rayner look like the good cop and Capewell the bad cop, but it was like a debate between a Marxist-Leninist and a Maoist, or a Hayekian against a Friedmanite. The shades of disagreement might seem significant to those who have already picked a side, but they are meaningless for those who want to see the bigger picture.

The effect—and, I assume, the intention—was to shift the debate from 'what's going on?' to 'what shall the government do?'

Heart miracles: Is the truth emerging?

If there is one pseudo-scientific claim that illustrates the credulity of the media and the duplicity of the public health movement better than any other, it is the idea that smoking bans lead to dramatic reductions in heart attack incidence.

It is now ten years since the British Medical Journal published Stanton Glantz's notorious 'Helena Miracle' study which claimed that the heart attack rate fell by 40 per cent after a small town in Montana banned smoking in pubs and restaurants. Numerous copycat studies followed, typically involving thinly populated towns and regions which, because of the small number of heart attacks that take place each month, are given to large fluctuations in hospital admissions.

From the outset, the most plausible explanation for the heart miracle phenomenon was that activist-researchers were scouring hospital records for unusual declines in heart attack admissions that roughly coincided with 'smokefree' laws. With so many smoking bans being enacted, it was inevitable that they would coincide with a blip in admissions now and again.

But when whole nations bring in smoking bans, the rate of decline has typically been zero or in the low single digits, ie. in line with the long term trend. (The most notable exception was a study of Scotland which claimed a 17% decline—a finding that is totally inconsistent with official NHS data.)

Having written about this for the five years, I was pleased to see some sanity rear its head in the American Journal of Medicine in January. A study by Basel et al.—which I have only just become aware of it thanks to Klaus in Denmark—looks at rates of acute myocardial infarction (heart attacks) in Colorado after a statewide smoking ban went into effect in 2006. This is of particular interest since two widely touted heart miracle studies have involved small pockets of Colorado. A 2006 study of Pueblo, Colorado claimed that there was a 27% decline in heart attacks when it went 'smokefree' in 2003 and a 2006 study of Greeley, a small town in Colorado, also claimed a 27% decline.

The researchers looked at the data for the whole of Colorado before and after its strict statewide smoking ban came into force. They looked first at total admissions for acute myocardial infarction and then they excluded the eleven towns and counties that already had smoking bans in place. In both instances, they found no effect from the ban.

We did not observe a significant decrease in acute myocardial infarction hospitalization rates in Colorado after enactment of a comprehensive statewide smoking ordinance. Even after removal of geographic regions where preexisting smoking ordinances were under enforcement, no statistically significant reduction in acute myocardial infarction hospitalizations was detectable. This contrasts with a number of prior studies, including local smoking ordinance studies in Pueblo and Greeley, Colorado, and adds to a growing literature that the cardioprotective effect of smoking bans may be less than initially suggested.

This finding is important and telling, but the study is also worth reading for its discussion of the existing literature. It is clear that heart miracles are confined to small, obscure towns in a way that can only be described as suspicious. (I have inserted hyperlinks to each study mentioned below.)

Overall, a review of published research shows that acute myocardial infarction RR reduction appears inversely related to sample size. For example, small studies in Bowling Green, Ohio, and Helena, Montana, found dramatic RR reductions (39% and 40%, respectively) but also had few acute myocardial infarction counts (58 acute myocardial infarctions in Bowling Green, 64 acute myocardial infarctions in Helena) and relatively small study populations (30,052 and 68,140, respectively). Studies in Greeley and Pueblo, Colorado, and Graubünden, Switzerland, found less dramatic RR reductions (27%, 27%, and 22%, respectively), corresponding to somewhat larger study populations (∼86,000, 147,751, and 188,000, respectively).

As the authors note, these large declines in small communities (which are not just implausible, but mathematically impossible), contrast sharply with evidence from large communities and whole nations.

...one national study used Medicare Provider Analysis and Review files and national death records; a nonsignificant reduction in acute myocardial infarction-related (RR, −4.1; 95% CI, −9.4 to 1.3) and all-cause (RR, −0.7, 95% CI, −2 to 0.6) mortality was observed 1 year after smoking ordinance enactment. In this study, researchers evaluated all possible pairs of ordinance and nonordinance hospitals and recorded the change in acute myocardial infarction incidence post-ordinance. They found that RR reductions of 10% or greater were common, but that RR increases of 10% or greater were equally as common; taken in aggregate, the mean was near zero.

Another study examined 74 cities geographically distributed across the United States that were affected by smoke-free legislation. Individual cities showed wide variation in acute myocardial infarction incidence after ordinance enactment, with risk ratios ranging from −36% to +54%; however, the mean risk ratio for the 74 cities was 0.97 (95% CI, 0.96-1.02).

... A study performed in Christchurch, New Zealand after a countrywide smoke-free ordinance, found a 0% RR reduction in acute myocardial infarction with an approximate population size of 350,000. Countrywide studies with larger population bases provide concordant findings. In England, a 2.4% RR reduction was observed (population of 50 million). In Italy, a 4% RR reduction was observed (population of 58 million). In France, a 0% RR reduction was observed (population of 63 million). Finally, in a study examining the US Medicare population in states with a smoke-free ordinance versus those without, a 0% RR reduction was demonstrated (population of 30 million).

In the case of the English study, the heart attack rate fell at exactly the same rate after the smoking ban as it had been doing before the smoking ban. After dressing this up with some superficial computer modelling, Anna Gilmore—for it was her—relied on nothing more than a post hoc ergo propter hoc assumption. A similar claim, though never published, was made about Wales.

The authors attribute much of the heart miracle phenomenon to publication bias. That is likely to be a part of it, although I think that researcher bias and selection bias played more of a part.

These analyses support the hypothesis that small study populations may be more likely to find dramatic changes in acute myocardial infarction incidence, whereas increasing the study sample size attenuates the magnitude of the reduction. Also, review of the studies in aggregate reveals data asymmetry that suggests the potential for publication bias or heterogeneity not entirely explained by a random-effects meta-analysis. The presence of publication bias may explain why small sample size studies have tended to report large decreases in acute myocardial infarction incidence, whereas relatively few small sample studies have shown no effect.

The whole heart miracle scam has, in my view, been built on two simple tricks:

Firstly, dredging the data for any town that saw a large decline (in percentage terms) in heart attacks at around the time of a smoking ban. Nobody decided to do a study of Helena, Montana or Bowling Green, Ohio before the bans took place. The decision to focus on such obscure places came about only once it was clear that they were anomalous (not unlike Derren Brown's horse-racing trick). They were then presented to the media with the implication that they had been randomly selected.

Secondly, although less frequent, studies of larger populations have portrayed rather small declines in the heart attack rate as being the result of a smoking ban, without acknowledging that that there had been a secular decline of the same magnitude long before the ban was enacted. As the authors of the above study note, the secular decline is simply ignored in such cases.

That's really all there is to it. The 'public health' lobby has been selling this lemon to the public for ten years while describing sceptics, such as Michael Blastland (the creator of BBC's excellent More or Less series), as 'denialists' and 'dissidents'. The American Journal of Medicine study won't be enough to set the record straight in the public's mind—it received no media coverage, naturally—but it is further ammunition for those who do not believe in the 'noble lie'.

Henry Hill on public health

This, from Henry Hill at Conservative Home, is well worth reading...

The most important thing to bear in mind is that public health has no regard for individual choice. As a movement which measures its success largely in averaged outcomes and national statistics, its focus is not on minimising harm to third parties or helping individuals to make informed choices – although it will employ those arguments – but on controlling people to force its desired outcomes.

Boris’ quaint notion that there is no justification in preventing him lying on the grass with a cigar because he was harming nobody but himself will cut no ice with the public health movement. It’s bad for his health, so it should be stopped. Many, probably most, public health activists make no secret of their intention to prohibit tobacco.

But their ambitions are not limited to tobacco. Some months ago there was an outbreak of press hysterics about sugar, the ‘new nicotine’. This should have surprised nobody. There was always going to be a ‘new nicotine’, just as when sugar taxes have tripled the price of a Yorkie bar and we’re drinking cola from olive-green ‘plain cans’ with pictures of clogged arteries on them there would be a ‘new sugar’.

For years it has suited both sides of the public health debate to pick on cigarettes. Lovers of booze, food, or idleness could pretend that there was some particular wickedness in tobacco that warranted making a special case of it, whilst public health activists could establish useful precedents to wield against fresh targets when the time came.

Come that time has.

Do read the rest.

Were there really 9.6 million alcohol-related hospital admissions last year?

Mark Wadsworth has spotted that the number of alcohol-related hospital admissions have risen rather sharply in the last couple of years. In fact 'risen sharply' is an understatement. 'Rocketed into the stratosphere' might be a better way of putting it.

BBC, 26 May 2011: The number of alcohol-related hospital admissions in England has topped 1m for the first time, according to official statistics.

From The Daily Mirror, yesterday:

Heavy boozers are putting the NHS under “intolerable strain” and risk sparking a health crisis which will cost the country billions, a charity claimed yesterday. Alcohol Concern said 9.9 million NHS admissions in England – including hospital patients and clinic and A&E visits – were related to alcohol last year...

The Office for National Statistics is the usual port of call when looking up alcohol-related hospital data. Their latest figures for England tell us the following:

In 2012/13, there were an estimated 1,008,850 admissions related to alcohol consumption where an alcohol-related disease, injury or condition was the primary reason for hospital admission or a secondary diagnosis. Of the estimated 1,008,850 alcohol related admissions:

65% (651,010) were due to conditions which were categorised as partly attributable chronic conditions

6% (60,830) were for conditions categorised as partly attributable acute conditions

The figure of 1,008,850 admissions is considerably higher than it was a decade ago for various reasons, but it is lower than it was in 2011/12, 2010/11 and 2009/10.

Similar data from Scotland show that there were 35,926 alcohol-related discharges in 2012/13. Feel free to look up the figures for Wales and Northern Ireland, but it's quite obvious that the total number for the UK is nowhere near 9 or 10 million. It is an order of magnitude lower at just over one million. To put that in context, England's NHS deals with 125 million hospital admissions every year and alcohol-related admissions make up 1.4 per cent of the total.

There are various ways of inflating the number of alcohol-related admissions, such as widening the range of 'alcohol-related' illnesses and including admissions which are only partially related to alcohol. However, these techniques have all been exhausted and the ONS figures includes the widest range of admissions that can conceivably be described as alcohol-related.

The majority of admissions are not wholly, or even necessarily mainly, attributed to alcohol use. Most relate to chronic diseases such as hypertension and breast cancer. These figures are not calculated by doctors and nurses making assessments of patients. Instead, the system of alcohol-attributable fractions is used. This assumes that a certain percentage of admissions for each disease were caused by drinking. Chronic illnesses (which typically require many visits to hospital to treat) make up the majority:

Of the 1,008,850 admissions in 2012/13,

- around 711,840 admissions were for reasons that are partly attributable to alcohol consumption (i.e. the attributable fraction associated with the diagnosis (either primary or secondary) most strongly associated with alcohol consumption was less than 1)

- over half (57%) of these partly attributable admissions were for hypertensive diseases (ICD-10 codes I10 – I15), accounting for approximately 404,650 admissions. Admissions with other partly attributable diseases, injuries or conditions were much lower in comparison

- second highest condition in this category was cancer (ICD-10 codes C00 – C15, C18 – C22, C32 and C50 ) with 83,510 admissions (Table 4.1).

It is worth noting the various conditions that people are admitted for and the way they are categorised because the unwary newspaper reader might assume that all, or most, of the alcohol-related admissions are injuries, accidents and overdoses that take place on a Friday or Saturday night in 'Binge Britain'. That's hardly surprising when even the Morning Advertiser uses photos like this to illustrate the story.

But where does the 9.6 million (some papers reported 9.9 million) figure come from? The source is the temperance group Alcohol Concern who have been working their buddies in the pharmaceutical industry to produce a nifty website which supposedly allows users to see how many alcohol-related admissions there are each year in each area of the country.

They explain their methodology as follows:

The inpatient admissions and A&E attendances data in this map are for 2012/13. Estimates for outpatient attendances are based on benchmarks from the Birmingham Heavy Drinkers Project (1997 to 2004), The General Lifestyle Survey (2009) and the number of high risk drinkers taken from Local Alcohol Profiles (LAPE) (2005) estimates.

No more details are available but they have clearly derived estimates based on some (fairly old) data and some unexplained assumptions.

You would only bother coming up with estimates from a computer model if the real figures were not available. But here's the thing. The ONS has detailed hospital admission data for exactly the same areas that Alcohol Concern make guesstimates for. And what a difference there is between the ONS's figures and Alcohol Concern's estimates.

In Barnsley in 2012/13, for example, the ONS says there were 900 alcohol-related hospital admissions (600 were partly attributed to alcohol, 300 were wholly attributed to alcohol). Alcohol Concern says there were 46,992.

The difference between 900 and 46,992 is non-trivial to put it mildly.

To take another example from my neck of the woods, Alcohol Concern reckons there were 128,922 alcohol-related hospital admissions in West Sussex in 2012/13. The ONS says there were 14,210.

Alcohol Concern reckons there were 52,092 admissions in Brighton and Hove. The ONS says there were 4,640.

Alcohol Concern says there were 48,745 alcohol-related hospital admissions in Westminster. The ONS says there were 3,360.

These are massive discrepancies and Alcohol Concern make no attempt to explain why their figures are ten to fifty times higher than the ONS's. On the contrary, their press release implies that theirs are the official figures.

Since the ONS is a reputable organisation using official NHS records and a transparent methodology, I am inclined to think that their figures are much closer to the truth than those of a partisan pressure group.

Still, it got an enormous amount of newspaper coverage so well done Alcohol Concern. But be careful—one day a journalist might actually bother doing some basic fact-checking.

Leaked document shows WHO's hard line on e-cigarettes

I've received what appears to be the WHO's draft text about e-cigarette regulation (from this week's top secret FCTC meeting in Moscow).

Apologies for the poor quality of the image. You can click to enlarge, but this is what it says (all strikes and underlines are in the original. ENDs are 'Electronic Nicotine Delivery Systems', a daft term that only 'public health' people use for e-cigarettes):

(a) [preventing the initiation of ENDS by non-smokers and youth]

(b) minimize as far as possible potential health risks to ENDS users and protecting non-users from exposure to their emissions; non-users

(c) prohibit prevent unproven health claims from being made about ENDS the promotion of ENDS by any means that are false, misleading, deceptive or likely to create an erroneous impression about their characteristics, health effects, hazards or emissions; and

(d) protect existing tobacco control efforts activities from all commercial and other vested interests of the tobacco industry that produces and sells related to ENDS, including interests of the tobacco industry with measures similar to those considered in Article 5.3.

3. The Parties are invited to consider banning or regulating ENDS including as tobacco products, medicinal products or consumer products [or other categories as appropriate] taking into account a high level of protection for human health with special attention to vulnerable groups such as pregnant women.

Urges Parties to consider banning or restricting advertising, promotion and sponsorship of ENDs.

5. Invites Parties and WHO to comprehensively monitor the use of ENDS among smokers and non-smokers especially among youth including the relevant questions in all appropriate surveys on risk factors for non-communicable diseases...

The various deletions suggest that this may not be the finished article. Nevertheless, assuming that it is genuine and current, it is important to note that the WHO's position is to urge countries to ban the marketing of e-cigarettes. It would also like them to ban them entirely or regulate them as tobacco or medicinal products (which, of course, they are not).

Moreover, the WHO is also considering rolling out Article 5.3 to e-cigarette companies. Article 5.3 says that tobacco companies shouldn't be involved in setting public health policy. Anti-smoking cranks like to pretend that (a) it is a law (it isn't in most, if not all, countries), and (b) that it stops governments having any meetings with the tobacco industry or anyone who is vaguely connected to the tobacco industry. Some politicians have fallen for this lie. Extending Article 5.3 to e-cigarette companies would be a very bad idea as governments urgently need to hear from people who know what they're talking about with this emerging technology.

Finally, you will note the reference to 'protecting non-users from exposure' to e-cigarette vapour. This assumes that there is something in the vapour that non-users need to be protecting from, but there is no credible evidence for this. Clearly, the aim here is to encourage bans on e-cigarette use indoors (and, if pocket dictators like Lord Darzi have their way, outdoors too).

I stress again that the above may not be the final text, but if it bears any resemblance to the finished draft, it looks like the WHO will be recommending advertising bans, inappropriate regulation (up to and including prohibition), indoor bans on use and the exclusion of e-cigarette companies from the dialogue. Not quite the light touch we were led to believe would be the outcome of COP6. 

A perfect hatred

What can you say about the proposal to ban smoking in the—ahem—beautiful, pristine, pure air of London town? Perhaps the first thing to say is that it is only a proposal from a revolting left-wing doctor-cum-politician. Boris Johnson has distanced himself from it:

"This idea in my view, as a libertarian conservative, comes down too much on the side of bossiness and nannying.

"One feature of life in London is that we are a city that allows people to get on with their lives within the law provided they are not harming anyone else.

"I think smoking is a scourge and it's right to discourage it (but) I am very sceptical at the moment."

He drew on personal experience as he described his opposition: "I have to think back to my own life two decades ago when my wife and I had a baby.

"It came to that point when everybody was asleep and I was in such a mood of absolute elation I wondered out into a park in Islington and it was in the middle of winter but I laid on the ground and had a cigar.

"I don't want to be in a city where somebody can stand over me and say you've got to pay £115 for doing something that is of no harm to anybody except me."

I would have preferred it if Johnson had openly mocked Lord Darzi's plan (of which an outdoors smoking ban is only one element). Nevertheless, he has made it quite plain that he will not be acting on it.

But, oh!, what a nest of vipers came to life when the idea was unfurled. How quickly the bottom feeding prohibitionist slime rose to the surface at the thought that the Overton window had moved in their direction. Deborah Arnott, Alan Maryon-Davis, John Britton, Alex Cunningham and Sally Davis went into spasms of delight, bewitched as they were by the prospect of smokers being further harassed and humiliated. As Dick Puddlecote notes, proposals like this are a wonderful way to smoke out the lurking sadists in society.

...the period of time between the press release going out in the early hours and Boris's statement at lunchtime was open season for every irrational smoker-hating whacko, psychopath, and berserker to spew their bile on every possible platform. Lord Narzi and Sally Davies effectively signalled to thousands of society's most vile that hyperbolic hatred was officially sanctioned by the authorities.

Seemingly terrified that their crown of health fascism might be slipping from their heads, the Labour party showed its true colours (which they have never really tried to hide, even in opposition) by pledging to turn the idea into law at the first opportunity:

Dame Tessa, the former Olympics minister, seized the initiative to promise action if she makes it to City Hall in 2016.

She told the Standard: “If you are asking somebody of Ara Darzi’s eminence and reputation to conduct an investigation like this, you have got to have a pretty good reason for not accepting it if you want to improve the health of Londoners.

“The recommendations are all grounded in evidence and have public support - 59 per cent are in favour of a ban [as far as I can tell, this is a made-up statistic—CJS].

“Lord Darzi has looked at the very radical proposals that Mayor Bloomberg introduced in New York. These have been tried and tested. Similar protections should be offered to Londoners.

“If I were Mayor of London, promoting the health of Londoners would be one of the key areas I would want to act on.”

To be clear, the proposal is to ban grown adult human beings from smoking in 20,000 acres of outdoor space in London, including the city's large parks (Darzi wants to turn parks into "beacons of health"—a phrase that probably sounds better in the original German). Why? Few had the nerve to evoke the phantom of passive smoking. Instead, they said that people have a duty to be "role models" and that children might see somebody smoking and seek to emulate them.

Words almost fail me. Most of the remaining words are expletives. I was in Brussels when the news was announced and I was in no mood to suffer fools gladly when I did a couple of interviews I did over a mobile phone (Voice of Russia and BBC Suffolk, the latter starts 14 minutes in). Is it necessary to give a reasoned response to arguments that are so obviously made with no sincerity? Are we really supposed to deal with ad hoc bans as if they were stand-alone measures rather than pieces of a mounting prohibition?

It hardly needs to be said that smokers, like nonsmokers, have never volunteered to be role models for other people's children. The claim that adult activity should be criminalised if it can be witnessed by minors does not have to be taken to its logical extreme for it to be exposed as absurd and totalitarian. It is plainly not a serious argument. And yet, if I did feel the need to act as a role model to children, I would, first and foremost, impress upon them the importance of ignoring and despising unjust laws. I would hope to teach them that there is, in any society, a minority of bigots who resent liberal values and who will do whatever they can to impose their own lifestyles upon them. If flouting a draconian law will help a child realise that the state is not its friend, then I will cheerfully light a cigarette in any street or park.

Even if the argument wasn't bogus, it would have no bearing on the law. But it is bogus. The proposal—like most anti-smoking policies—is really about belittling, stigmatising and hassling smokers because a certain class of people despise smokers and are keen to encourage the public to share their contempt. But, as I have discussed at length elsewhere, it is the hateful, authoritarian bigots who should be denormalised.

This issue is beautifully clear-cut. If you have any sympathy at all for the idea that smoking in the open air should be a criminal offence, you are the enemy. To call you a 'nanny' would imply a level of compassion and concern that doesn't exist.You are a cancer in the body of society, spreading fear and hatred. You sow misery and division where none existed before. To quote the Book of Psalms (later appropriated by the prohibitionist Billy Sunday) I hate you with a perfect hatred. You do not deserve to live in a free society and, therefore, I don't think you would miss living in a free society. Perhaps, then, you should leave.


Postscript

I can't leave this topic without highlighting a shameless and obvious lie that appeared in the Evening Standard yesterday. Don't these people have editors?

Regressive, illiberal soda taxes

I have an article up at Spiked that looks at how the words 'liberal' and 'progressive' have become so debased that they are used by proponents of patently illiberal and regressive soda taxes.

Please read it.

The trivial impact of Mexico's soda tax

There was much rejoicing amongst 'public health' campaigners when Mexico brought in a soda tax at the start of the year. A tax of one peso per litre—about 5p—might not sound much, but in a country where the minimum wage is $5 per day, it is significant and will increase the price of fizzy drinks by about ten per cent.

The usual hyperbolic claims were made for this tax in advance. It was predicted (by advocates) to reduce consumption by 10 to 13 per cent. They said it would prevent "up to" 630,000 cases of diabetes by 2030.

Obviously, we can't yet measure the effects on diabetes (if any), but can see what effect the tax is having on consumption. Via Jon Fell, I see that the PepsiCo quarterly results have been published. They show a small rise in sales since the start of the year. Regarding their soft drink sales in Latin America in the 12 weeks up to the 6th September 2014, they say this:

Volume increased 1%, which included a contribution of nearly 1 percentage point from certain of our bottler’s brands relating to our new joint venture in Chile. Latin America volume increased 5%, primarily reflecting a mid-single-digit increase in Venezuela and a low-single-digit increase in Mexico, partially offset by a low-single-digit decline in Brazil.

And in the 36 weeks up to the 6th September...

Volume increased 0.5%, which included a slight contribution from certain of our bottler’s brands relating to our new joint venture in Chile. Latin America volume increased 3.5%, reflecting nearly 2 percentage points from certain of our bottler’s brands in Chile, a mid- single-digit increase in Brazil and a slight increase in Mexico.

Coca-Cola will release its latest results later this month, but its quarterly statements for the first half of the year have already been published. In contrast to Pepsi, they show a small decline in sales. In the first quarter of the year:

Volume in our Latin Center (+5%) and South Latin (+2%) business units continued to grow, partially offset by a low single-digit volume decline in Mexico given the new excise tax that impacted the beverage industry and our business.

And in the second quarter:

Latin America’s volume was even in the quarter, as strong 8% volume growth in our Latin Center business unit was offset by a 3% volume decline in Mexico.

So there we have it. Soft drink sales are up slightly for Pepsi and down slightly for Coca-Cola. Coca-Cola is twice as large as Pepsi in terms of sales in Latin America so we can surmise that overall sales are down, but only by about two per cent.

For the anti-soda crowd, this represents success. They deal in a world where there are no costs, only benefits (a defining characteristic of the fanatic) and so any decline in sales is a victory, no matter what economic burdens are placed on the population.

More objectively, however, this is a very feeble outcome from a major tax initiative in a low income country. Once again, the predictions have proven to be hopelessly optimistic. This natural experiment suggests that the elasticity of demand for soda in Mexico is in the region of -0.3, much more inelastic than the computer models assumed. (Soda consumption may continue to decline in Mexico—we shall see—but you would expect the biggest decline to take place in the first months of the tax.)

What effect will a decline of 2 or 3 per cent have on obesity and health? Even if we leave aside the substitution effects that tend to offset any effect on calorie consumption, it is hard to see it being anything other than negligible. Mexico has the highest per capita consumption of soda in the world, but soft drinks still only account for 5 per cent of calories consumed. A low single digit decline in a source of calories that only made up one twentieth of total energy consumption in the first place is so trivial that any impact on weight, let alone diabetes, is going to be too small to measure.

The Mexican soda tax should be seen as what it is: just another stealth tax.

Censorious fanatics

Further to last week's post about a production of Carmen being cancelled because its government sponsor didn't like the fact that the lead character works in a tobacco factory, The Australian reports that this was not an isolated incident:

When the Blue Room Theatre in Perth staged an acclaimed play about addiction several years ago, lurking in the opening night audience was a bureau­crat who demanded one scene be axed from future performances.

The man watching the first local production of British playwright Martin Crimp’s The Country was employed by the West Australian government’s health body Healthway, one of the theatre’s main sponsors.

“He came to us afterwards to tell us we had to remove one scene that featured smoking,” recalled Blue Room former executive director Jansis O’Hanlon.

“We weren’t allowed to have smoking or language about smoking, and we weren’t allowed to show any smoking paraphernalia ... The play was about addiction and there was also a scene with (heroin) needles, but they had no problem with us showing that.”

Ms O’Hanlon said the theatre withdrew from the sponsorship deal rather than compromise its artistic integrity. “It was a big gulp for us to say no,” she said, recalling that Healthway also had demanded to approve all scripts.

The extent of the sponsor's control over artistic expression revealed in this article reduces the credibility of Healthway's claim that they had not put any pressure on WA Opera to cancel Carmen and that it was "their choice" to do so. It was Healthway or the highway.

Healthway attempted this week to distance itself from censorship claims, but its 2013-14 annual report states: “Healthway will maintain a firm stance on not supporting arts organisations that portray smoking on stage during performances.”

Indeed, as Dick Puddlecote has shown, veteran anti-smoking zealot Mike Daube told WA Opera that they wouldn't get funding for performing Carmen. He later lied to the press when he said that they had been under no pressure to drop the play.

Premier Colin Barnett promised to examine Healthway’s sponsorship arrangements to exclude any censorship provisions. He said he was “highly embarrassed” by the ban, which Tony Abbott described as “political correctness gone crazy”.

“If that sponsorship arrangement through Healthway led to the cancellation of the opera, that is a serious mistake that smacks of basically art censorship,” Mr Barnett said.

There's a simple solution to this. Stop funding Healthway. Close it down. The taxpayer shouldn't be forced to fund entertainment, least of all entertainment that is largely the preserve of the rich. And the taxpayer certainly shouldn't be forced to the fund censorious puritans—what else can you call people who forbid not only smoking, but "language about smoking" and "smoking paraphernalia" from appearing in a theatrical production?

Good on the Blue Room Theatre for "taking the big gulp and saying no" to these state-sanctioned bullies despite the loss of subsidy. And good on WA health director Kim Hanes for telling Healthway to buck their ideas up. As the photos below show, too many people are prepared to rewrite history in an effort to appease fanatics (see here for more).

WHO starting to make Putin look good

"They did WHAT?!"

The WHO's COP6 tobacco summit has gone into full, paranoid meltdown. After ejecting the public yesterday, they have now barred the media from attending. Interpol were banned before the conference began. The event is not—and has never been—streamed on the internet. The official Twitter feed hasn't posted a message for 24 hours. It's a completely secret meeting now.

These people are starting to make Putin look like a namby-pamby, tree-hugging liberal. Here's a thought: if you're making political decisions without being elected, if your Director-General is lying to the world's media rather than admit that she's at your conference, and if you're worried that the police, the public and the press might hear what you're talking about, maybe you're not the good guys after all.

The WHO's tobacco convention voted to ban the public. To ban the press, they never voted - just put guards at the door to keep us out. #COP6
— Drew Johnson (@Drews_Views) October 14, 2014

Margaret Chan: fully occupied?

Margaret Chan: Fully occupied

Margaret Chan, the Director-General of the World Health Organisation, delivered a speech about the Ebola pandemic today.

Except she wasn't able to deliver it personally so an underling did it for her. He explained...

WHO Director-General’s speech to the Regional Committee for the Western Pacific

Dr Margaret Chan
Director-General of the World Health Organization
(delivered in her absence by Ian Smith, Executive Director of the Director-General's Office)

Keynote address to the Regional Committee for the Western Pacific, Sixty-fifth session Manila, Philippines 13 October 2014

Mr Chairman, Excellencies, honourable ministers, distinguished delegates, Dr Shin, ladies and gentlemen,

The Director-General sends you her best wishes for a productive session. She is fully occupied with coordinating the international response to what is unquestionably the most severe acute public health emergency in modern times.

I am delivering her messages to you, in the words she wanted to use.

"Fully occupied"?! She was in Moscow talking to anti-smoking zealots, praising the Russian government and blowing her own trumpet. Here she is...

WHO DG lauds Russia's efforts in tobacco control pic.twitter.com/0az4cGGKbt
— WHO FCTC (@FCTCofficial) October 13, 2014

This is the kind of thing that's been fully occupying her mind today...

Dr. Chan of @WHO: proud to be Big #Tobacco's no. 1 enemy: "I regard this as a badge of honor" - powerful opening remarks! #COP6 #FCTC
— Ari Rubenstein (@AriRubenstein) October 13, 2014

Tobacco industry is increasing its dominance over the market of #ecigarettes, says WHO DG at #COP6 pic.twitter.com/vRUKH1ehY3
— WHO FCTC (@FCTCofficial) October 13, 2014

Incidentally, her Ebola speech is quite a piece of work; full of self-justification and her usual political rhetoric about 'inequalities' and' profit-driven industry'. She doesn't sound particularly interested in Ebola and she certainly doesn't sound like she has a strategy. The terrible thought crosses my mind that when she talks about 'the most severe acute public health emergency in modern times' she wants people to think she means Ebola but she is actually thinking about tobacco. That way, in her own mind she wouldn't be telling a lie about her whereabouts.

Surely not, though. The entire media have assumed that it's a reference to Ebola. What do readers think: outright lie or mere deceit?