Thursday 31 August 2017

Get your story straight

Philip Morris (PMI) are in the process of rolling out their heat-not-burn product IQOS around the world. The company has famously said that it wants to stop selling cigarettes once it has converted existing smokers to the reduced-harm device. On Tuesday they announced that three million smokers have already switched, mostly in Asia.

Nothing happens in the world of tobacco without anti-smoking campaigners trawling through the archives to find a shaky historical parallel. Last week, Stanton Glantz tried to poison the well of harm reduction with a bizarre article about PMI being in favour of nicotine gum (or something).

This week, Ruth Malone, the gormless editor of Tobacco Control, has piped up with an article titled '“It doesn’t seem to make sense for a company that sells cigarettes to help smokers stop using them”: A case study of Philip Morris’s involvement in smoking cessation'. The quote comes from a focus group member talking to a consultancy, but it may also reflect American anti-smoking zealots' view of IQOS.

The article is open access so you can read it here if you're bored, but there isn't much in it. The gist is that PMI's smoking cessation service QuitAssist was not to Malone's liking (apparently they resisted using 'anti-industry themes'. Well, duh.) My only reason for mentioning it is to flag up the following quote that was spotted by Sarah Jakes on Twitter.

A particularly notable absence [from PMI's QuitAssist program] was the lack of financial support to help smokers purchase NRT, the very action that consultants Bain and Company had argued would allow PM to have the largest impact on quit rates.

Do try to keep up, Ruth. You're behind the times. In the newly revised history of tobacco, PMI secretly approved of NRT (nicotine replacement therapy) from the early 1990s onwards because they knew it didn't work and it kept people smoking. We know this because Stanton Glantz said so in a peer-reviewed journal.

So if PMI wanted to undermine its own stop-smoking efforts, they should have been shovelling money at nicotine gum and patches. If they had done that, they would have been applauded by the tobacco control lobby while (supposedly) boosting cigarette consumption. Then they could have gone back to their underground lair to laugh demonically like the cartoon villains that they are.

But as you so rightly say, Ruth, they didn't do that. They chose not to hand out NRT as part of their smoking-cessation program which means that either Glantz's theory or your theory is a load of old toot.

Or, quite possibly, both.

Wednesday 30 August 2017

Alcohol policy in the real world

Neo-temperance dogma says that the best way of reducing alcohol-related harm is to tackle the Three A's: advertising, affordability and availability.

The current available scientific evidence supports prioritization of multiple cost-effective policy actions – the so-called three alcohol policy best buys:

  • Increasing alcohol beverage excise taxes,
  • Restricting access to retailed alcohol beverages and
  • Comprehensive advertising, promotion and sponsorship bans

These policies will supposedly reduce per capita consumption which will supposedly reduce harmful consumption and therefore reduce alcohol mortality. By the same token, relaxing licensing laws, permitting advertising and making alcohol more affordable will have the opposite effect.

The Three A's are the Holy Trinity of alcohol policy, endorsed by the WHO and every 'public health' organisation you can think of. For example, in Health First: An Evidence-Based Alcohol Strategy for the UK, it says categorically...

Long-term success in minimising the harm from alcohol will only be achieved by population measures that reduce the affordability and availability of alcohol products for all drinkers. The research evidence is unequivocal: such population measures are the most effective in reducing alcohol consumption and alcohol-related harm. [My italics]

As neat and tidy as this theory is, drinkers have conspicuously failed to comply with it. In Britain, for example, campaigners claim that alcohol has become 60 per cent more affordable since 1980 and yet per capita consumption of alcohol is no higher today than it was then. Alcohol has become more widely available thanks to the Licensing Act and yet per capita consumption has fallen by nearly a fifth since it was introduced in 2005.

An interesting little study was published last week with some similarly awkward facts, this time from Denmark. The researchers looked at various factors that could influence the Danish drinking culture and looked for evidence of an impact on consumption and harm.

The first thing they noticed was that there was decline in alcohol consumption between 2003 and 2013 which was accompanied by a decline in alcohol-related mortality. So far, so good (although, interestingly, they found evidence of a rise in problem drinking at the same time).

Was this due to alcohol becoming less affordable? Far from it. There was a large cut in the tax on spirits in October 2003 of 45 per cent. Since then, the authors say, 'prices have either remained stable or have decreased'. Since incomes have increased in Denmark since 2003, this means that...

... purchasing power has made alcohol more affordable, along with lower prices through decreased taxes, theoretically this should have enabled, if not encouraged, Danes to buy and consume more alcohol.

But it didn't.

What about advertising? Unlike other Scandinavian countries, Denmark allows alcohol advertising to be published in the print media with relatively few restrictions and it can be broadcast on television and radio at any time. As in the UK, the content of drinks advertisements is self-regulated.

The only substantive change to the advertising environment identified by the researchers in Denmark was a tightening up of the industry's voluntary code in 2010. They conclude that 'advertising has become more restricted over our study period, even if it has been accomplished by self-regulatory measures of the alcohol industry.' These voluntary restrictions emphasised a commitment to avoid advertising to children, but this was already part of the self-regulatory code before 2010 so it is doubtful whether it made much difference to the content of the advertisements. (Incidentally, 'public health' campaigners claim that self-regulation is ineffective and therefore cannot argue that these minor changes reduced alcohol mortality).

Thirdly and finally, there is availability. Did alcohol become harder to obtain? No. On the contrary, the researchers note that...
Two laws affecting the physical availability of alcohol in Denmark were lifted on 1 July 2005. Both concerned off-premise sales of alcohol and point towards liberalising previous restrictions (Danish Health Authority, 2014). One of these was the elimination of a law which had set the closing of sales at 8 PM in grocery stores and a partitioning off of the display area after alcohol sales hours. Additionally, the ‘‘restaurant law’’ was lifted. Previously sales of alcohol to take away from a restaurant had to take place in a room separate from the eating establishment.

Taken together, the situation in Denmark is very much like that of the UK. Licensing laws have been relaxed, alcohol has become more affordable, and advertising appears in all media under a system of self-regulation. According to the wisdom of 'public health', this should have led to a rise in alcohol consumption and a rise in alcohol-related mortality. It has done neither.

The study's authors acknowledge that this is hardly an isolated example and refer to this study from Italy where alcohol consumption fell from 16 litres per person in 1971 to 7 litres in 2005. Over the same period, deaths from liver cirrhosis fell by around two-thirds.

Which of the Three A's accomplished this miracle? The answer, again, is none of them. The authors note that 'there have been very few implemented policies, and these have often been weak and generic'. The most popular drink in Italy is wine but wine duty was 'zero throughout this period.' Although there were some increases in the tax rate of spirits, they were not introduced until the 1990s by which time alcohol consumption had already fallen to less than 9 litres per person. Advertising continued to be largely unrestricted and the only significant change to licensing laws was a ban on the sale of alcohol after 3am, but that did not happen until 2010.

In conclusion, the Italian researchers say:

The ineffectiveness of the preventive policies on the alcohol consumption trends is striking... Alcohol policies, which are usually considered to be the main contributor to changes in consumption and alcohol-related harm, are not able to explain the changes in alcohol consumption which have occurred in Italy during the last decades.

Neither the authors of the Danish study nor the authors of the Italian study are able to explain why alcohol consumption and associated harms declined in their respective countries. The Italian study is even titled 'The puzzle of Italian drinking'. Given that the outcomes seen in these countries are exactly what 'public health' campaigners claim to want, you would think there would be a concerted effort to find out what caused them. Reducing harm without infringing on the rights of drinkers should be the Holy Grail of alcohol policy and yet there does not seem to be much eagerness to learn from real world case studies.

If the 'public health' lobby took evidence seriously, they would want to understand why there is no correlation between supply-side alcohol policies and alcohol consumption. Instead, they ignore what real people do in real countries and focus on computer models which repeat back whatever assumptions they have programmed into them.

When all you have is a hammer, everything looks like a nail.

Monday 28 August 2017

Anti-vaping agitprop at the Guardian

An article in the Australian edition of the Guardian has been annoying vapers but the person responsible says she can't understand why.

We have come across Melissa Davey before. Simon Chapman was quick to take her under his wing when she took a Masters in 'Public Health' at Sydney University a few years ago. She has since got a job at the Guardian writing blatantly partisan articles about health policy from the Chapman perspective.

Her latest effort is all the more pernicious for its pretense of balance. On its face, it is about the split in the 'public health' movement over e-cigarettes. Davey implies that this split is somewhere in the region of 50/50 whereas Chapman's prohibitionist stance is extreme and increasingly marginal.

Davey quotes liberally from vaping opponents Miranda Ween, Simon Chapman ('world-renowned tobacco control expert') and Chapman's protégé Becky Freeman. She also quotes from submissions to the government's recent consultation from Cancer Council Australia and the Australian Medical Association, both of which are also in the prohibitionist camp. 

On the pro-vaping side, she quotes Alex Wodak and Colin Mendelsohn. She fails to mention any of the health organisations, such as Public Health England or the Royal College of Physicians, that support vaping but she does quote from Philip Morris's submission to the consultation.

The Philip Morris reference is part of a narrative that portrays e-cigarettes as a tobacco industry plot. Never mind that PMI's focus is on its heat-not-burn product IQOS rather than e-cigarettes. Never mind, too, that the consultation was inundated with responses from ex-smoking vapers, none of which are quoted or even acknowledged in the article. Instead, the phrase 'big tobacco' appears nine times and she ends the piece by writing...

The question of how harmful these products are and whether they can save significant numbers of smokers from a lifelong addiction may still be up for debate. But there is no doubt if the products take off in Australia and become more widely available, big tobacco’s under-pressure profit margins will have some relief.

In fact, there is a great deal of doubt about this. In the UK, where vaping has taken off under a free market, cigarette sales have fallen dramatically and the main beneficiaries have been independent vape shops, such as Totally Wicked. The market is dominated by second and third generation e-cigarettes which tobacco companies have been slow to embrace. Tobacco companies would have a much easier time if the smoking rate had flat-lined, as it has in Australia.

In terms of pure column inches, Davey's article is far from balanced. The image below shows the anti-vaping content versus the pro-vaping content. There is at least twice as much of the former, even if you exclude Davey's own editorialising and focus on quotes from other people.

But there is more to Davey's bias that sheer volume of words. Every claim in support of e-cigarettes is challenged and every fact that goes against her view is given a caveat. For example, she writes:

There are smokers who credit e-cigarettes with having help them quit. The scientific literature, however, suggests they are not all that effective...

The link is dead so who knows what her source is for this claim, but there is ample scientific evidence from clinical trials and observational epidemiology that e-cigarettes work much better than placebos in helping people quit smoking. Davey's implication that the evidence for vaping is purely anecdotal is deeply misleading.

Elsewhere she writes:

A statistic often cited is they are 95% safer than cigarettes, but this has been disputed.

The statistic comes from a Public Health England report but Davey doesn't mention that, presumably because it would confer a degree of credibility upon it. Her source for it being 'disputed' is a Guardian article about a scurrilous Lancet editorial in 2015 which attempted to portray David Nutt and his colleagues as tobacco industry stooges. Aside from this ad hominem attack, neither the Lancet editorial nor the Guardian report offered any reasons to think that the 95 per cent figure was wrong. A subsequent report from the Royal College of Physicians concluded that the risks of vaping ‘are unlikely to exceed 5% of those associated with smoked tobacco’.

There are no such caveats when claims are made by the other side. The reader is told that '[m]any e-cigarette brands are owned by tobacco companies' without been given the context of how many brands available (ie. thousands) or how many are owned by tobacco companies (ie. a handful). Both the 'gateway hypothesis' and the 'dual user 'theory go unchallenged. Davey says that Freeman 'believes e-cigarettes are part of a ploy by tobacco companies to get children used to the idea of smoking'. This is a ridiculous and ahistorical claim and should be treated as such. At the very least, a decent journalist would have pointed out that tobacco companies did not so much as dabble in the vaping market until 2012 - and youth smoking rates have nose-dived in countries where vaping has become popular.

None of this is mentioned in Davey's article. Given this partial and misleading propaganda from one of her former students, it is hardly surprising that Freeman has been one of the few people to commend it.

Nuff said.

Saturday 26 August 2017

Healthy new towns for a healthy new breed of man

This week, NHS England announced its plans to build 'healthy towns' and pay people to go jogging. I had a bit of fun writing about this for Spiked.

There is something about new towns that excites the type of person that Adam Smith called ‘the man of system’. The idea of starting a living space from scratch, without regard to the untidy preferences of human beings, has been like catnip to every top-down organiser of society from Nero to Corbusier. The resulting settlements in such places as Brasilia, Milton Keynes and Canberra must have looked smashing when they were models on an architect’s desk but they are notoriously soulless when experienced in full scale.

They nevertheless retain their allure for dreamers and bureaucrats – new towns for a new breed of man – and it is no surprise that they feature prominently in the NHS’s Five Year Forward View. The five-year plan includes proposals for ‘Healthy New Towns’ which were unveiled on Tuesday and made frontpage news, largely thanks to the suggestion that people be paid to go jogging.

One of the NHS’s mantras is ‘health in all policies’, a phrase that probably sounds better in the original German, and its wonks are salivating at the idea of ‘designing in’ physical activity to the handful of housing developments that the Campaign to Protect Rural England has somehow failed to obstruct.

How do you design a town to encourage physical activity without banning cars and chairs? I don’t know, and neither does NHS England, so it held a ‘design for life’ competition to get some ideas. When the winners were announced this week, the chief executive of the NHS, Simon Stevens, said: ‘The NHS makes no apologies for weighing in with good ideas on how the built environment can encourage healthy towns’. There was no need to apologise because the ideas were not good. On the contrary, they were so fantastically bad that the mind boggles at the thought of what the losers came up with.

Click here to read the whole thing.

Friday 25 August 2017

Groundhog Day forever with the problem gambling statistics

The Guardian, 2012:

There are an estimated 450,000 "problem gamblers" in the UK, according to the most recent British Gambling Prevalence Survey. And the numbers are rising – up from 0.6% of the population in 2007 to 0.9% in 2010, according to one measure. A further 3.5 million people were categorised as "at-risk" gamblers.

The Guardian, 2015: 

The British Gambling Prevalence Survey 2010 (the last one before its funding was cut) said 900,000 adults were at risk of becoming problem gamblers and 450,000 people admitted they already had a problem.

The Guardian, 2016:

The British gambling prevalence survey indicates that there are around 450,000 pathological gamblers in the country – about 0.9% of the population.

Got that? Is that figure of 450,000 clear enough? That's the official mid-point estimate from the official UK-wide survey of problem gambling in 2010, as repeatedly cited by The Guardian (and other newspapers) for years. (If you are also interested in the more questionable number of 'at-risk' gamblers - see below - that figure is either 900,000 or 3.5 million depending on which hack you ask. Quite a spread, there.)

Now, I'm no Carol Vorderman but if the number of problem gamblers was to rise, it would have to be a bigger number than 450,000, right?

So how do you explain this in today's Guardian?

Number of problem gamblers in the UK rises to more than 400,000

More than 2 million people in the UK are either problem gamblers or at risk of addiction, according to the industry regulator, which warned that the government and industry were not doing enough to tackle the problem.

The report by the Gambling Commission estimated that the number of British over-16s deemed to be problem gamblers had grown by a third in three years, suggesting that about 430,000 people suffer from a serious habit.

A few days ago I issued a plea to people to stop lying about problem gambling being on the rise. I don't know why I bother. See this article from last year if you want to know why this keeps happening.

Instead of checking the facts, the Guardian handed the mic to some anonymous clown from the Campaign for Casino Fairer Gambling - an organisation created and funded by multi-millionaire casino tycoon Derek Webb - to tell its readers what they want to hear:

“The bookies have claimed that because the overall population rate of problem gambling is static, FOBTs are not harmful. The data published today, which shows a rate increase, has totally undermined the bookies’ argument.”

In fact, the Gambling Commission's press release explicitly says that 'overall problem gambling rates in Britain have remained statistically stable' and that the latest estimate of Britain's problem gambling rate is 'similar to the rate published in the 2012 report'.

The Campaign for Fairer Gambling has got nothing to do with making gambling fairer and everything to do with Derek Webb's grudge against the bookies after they put the game he invented onto fixed odds terminal (FOBTs) without giving him a share of the profits ('rather than sue I backed a campaign to make my point'). He will be giggling with glee to see journalists at the Guardian acting as his useful idiots.

But FOBTs are uniquely addictive, right? Not really, not according to today's report from the Gambling Commission:

The lowest rates of problem gambling were found among those who gambled on the National Lottery (1.3%) and the highest were among those who spread bet (20.1%), bet with a betting exchange (16.2%), played poker in pubs or clubs (15.9%), bet on other events with bookmaker (not online) (15.5%) and played machines in bookmakers (11.5%).

The Guardian report didn't mention any of this. Weird, huh?


The Guardian story underwent a a bit of a rewrite before it appeared in print on today's front page. The lie about problem gambling rates rising is still there but it is less prominent and the headline focuses on 'at-risk' gamblers instead.

'At-risk gambler' is one of those terms like 'hazardous drinker', 'overweight' or 'pre-diabetic' which sounds scary but has no clinical significance. Its main purpose is to help campaigners come up with a LARGE NUMBER. (The Sun deserves a dishonourable mention here for interpreting this as 'More than two million people may be problem gamblers'. They're not, otherwise the test would have identified them as such.)

Problem gambling surveys give you a bunch of questions and if you say yes to a certain number of them you are defined as a problem gambler (3 out of 10 for the DSM-IV test and a score of 8 out 27 for the PGSI test - click on the links if you want to do them yourself).

If you say yes to just one of these questions you are defined as a 'low risk' gambler, and being a 'low risk gambler' makes you an 'at-risk' gambler. Say yes to a couple more and you are a 'moderate risk' gambler. Moderate risk gamblers are also at-risk gamblers.

The Guardian tells us that there are two million 'at risk' gamblers in the UK. The implication is that this is a lot (why else would it be on the front page?). In fact, it is a significantly smaller number than has been reported in previous surveys.

In the last UK-wide survey of 2010, 7.3 per cent of respondents were classified as at-risk gamblers. That's about 3.5 million people.

Overall, 5.5% of adults were low risk gamblers (a PGSI score of 1-2) and a further 1.8% were moderate risk gamblers (a PGSI score of 3-7), meaning that overall 7.3% of adults had a PGSI score which categorised them as an ‘at-risk’ gambler. These estimates were similar to those observed in 2007.  

If the report released yesterday is to believed, the percentage has since fallen to 3.9 per cent. That's about two million people.

Overall 2.8% of adults were classed as low risk gamblers (PGSI score of 1 or 2) and a further 1.1% were classed as moderate risk gamblers (PGSI score of 3 to 7). In total, 3.9% of adults had a PGSI score that categorised them as being at-risk gamblers (PGS I score of 1 to 7).

So, in conclusion, we have no change in the number of problem gamblers and a near-halving in the number of at-risk gamblers. Can someone please explain to me why this is front page news?

(Oh yeah, that.)


The Times has managed to outdo the Guardian with its (fairy) story:

Problem gambling grows by 50% in three years

The scale of the gambling epidemic sweeping Britain was laid bare yesterday by official figures showing that 430,000 people in the UK have a serious gambling problem, up from 280,000 in 2012.

A 50 per cent increase in three years has raised pressure on the government to place curbs on the betting industry.

 Times readers with good memories will be confused by this news. In 2011, the paper told them:

It is estimated that there are now between 360,000 and 450,000 problem gamblers in the UK.

 And in February last year they were told:

The last gambling prevalence survey in 2010 found there were 450,000 problem gamblers in Britain but experts at GamCare say the number of addicts is likely to grow in proportion to the size of the industry, which suggests there are now 562,000.

But by October of last year, the 450,000 had doubled to, er, 336,000.

The proportion of people with a severe gambling problem has almost doubled in three years from 0.4 per cent of the population to 0.7 per cent, the equivalent of 336,000 people, according to the Gambling Commission. 

And now it's doubled [sic] again to 430,000. How many times can a number be doubled without getting any bigger?

Thursday 24 August 2017

That shady link between Big Tobacco and nicotine gum

Just when you think the world of tobacco control can't get any crazier we get headlines like this:

The Shady Link Between Big Tobacco and Nicotine Gum

This represents a new narrative opening up. The story now is that Nicotine Replacement Therapies (NRT - gums, patches, etc.) are not very effective and this somehow the fault of the tobacco industry, rather than the pharmaceutical industry.

Stanton Glantz - for it is he - jumped the shark a long time ago so I am reluctant to say that this is a turning point for him. Nevertheless, this is quite a pivot. Not only does he say that NRT doesn't work, he says that it keeps people smoking.

“The problem is, without the behavioral support, they actually inhibit quitting,” he said. “Unfortunately, a lot of people think they are making progress and quitting when that’s not so. That’s what tobacco companies have known for decades. They’re developing products under the guise of nicotine replacement therapy.”

Glantz's co-author on this occasion is one Dorie Apollonio from San Francisco's bonkers Center for Tobacco Control and Research.

“It was surprising to discover the industry came to view NRT (nicotine replacement therapy) as just another product,” said Dorie Apollonio, an associate professor in clinical pharmacy at UCSF and lead author of the study. “The tobacco companies want people to get nicotine — and they’re open-minded about how they get it.”

Are they really though, Dorie? Do they really not prefer you to get nicotine from tobacco products that they sell for a profit rather than from pharmaceutical products made by the pharmaceutical industry? Or, for that matter, e-cigarette products made by the vaping industry? If you can't see the difference, you should probably keep your views about business to yourself.

In the press release, she says:

“Tobacco companies put out these products as a way to sidestep policies, by giving people a way to ‘smoke without smoking’. 

The tobacco industry - I knew it was them! Even when it was Big Pharma, I knew it was them!

It is unclear which policies are being 'sidestepped'. If they are anti-smoking policies then it should be considered a success that people are 'smoking without smoking' (ie. not smoking).

It is also unclear which products they are talking about. NRT is almost entirely manufactured and sold by Big Pharma. Always has been. Glantz and Apollonio suggest that FDA regulation of tobacco under the 2009 Family Smoking Prevention and Tobacco Control Act has opened the door to Big Tobacco selling NRT on a grand scale, but their only example is Zonnic, an obscure nicotine gum company that RJ Reynolds bought before the Family Smoking Prevention and Tobacco Control Act was passed.

To shore up their hypothesis, they also mention a nicotine lozenge called Verve but this is not marketed as a stop-smoking product and is only sold in the state of Virginia. They have no other examples and they ignore the rest of the world where FDA regulation does not apply.

Have tobacco companies gone wild with NRT outside the USA? No they haven't. The only 'therapeutic' product from a tobacco company that springs to mind is BAT's e-cigarette (sort of) Voke, which was licensed as a medicine in the UK a few years ago when it looked like the government was going to demand that all e-cigs be medically licensed. When the government changed its mind about this, BAT gave up on Voke and it never came to market. So much for the tobacco industry riding the NRT bandwagon. 

Obviously, it is Big Pharma that sells NRT and it is an open secret that they make the most money when people use patches and gum indefinitely, rather than for the six months that are recommended on the pack. I know at least two people who have been using Nicorette gum for twenty years. The problem with NRT is clear to anyone who has tried it: it is good enough to relieve cravings a little, but not enjoyable enough to make you want to switch full-time and give up smoking (this is one of the big differences between NRT and vaping - and vaping doesn't require counselling to work).

Rather sweetly, the authors claim to only have just realised this:

Now, a new study conducted by scientists at UC San Francisco reports that tobacco companies have known for decades that, without counseling, NRT hardly ever works and that consumers often use it to complement smoking. 

You don't say! If you've got a problem with this - and you would be justified in complaining - take it up with the pharmaceutical industry (who make them) or the FDA (who approved them as efficacious stop-smoking medicines) or the anti-smoking groups (who have ceaselessly touted NRT to consumers and governments). And if Glantz and Apollonio are alleging fraud, misconduct and deceit, they should encourage the tobacco control community to reject any further funding from Big Pharma.

(Incidentally, the best explanation for the failure of NRT seems to be Carl Phillips and colleagues' observations about second-order preferences: It is marketed to people who want to smoke but want to not want to smoke, with the message that it will indeed change their preference to smoke. It doesn't, and so they start smoking again. In so far as it works better in the presence of counseling, this is probably just self-selection: smokers who are inclined to volunteer to be in studies of cessation counseling are an odd subset of all smokers who want to quit more than average.)

This insight [!!! - CJS] from the formerly secret industry documents known as the “Tobacco Papers” reveals why companies that once viewed nicotine patches and gum as a threat to their cigarette sales now embrace them as a business opportunity, the researchers said.

One tobacco company buying up one small nicotine gum company hardly represents the tobacco industry 'embracing' nicotine replacement therapy. But even if it did embrace them, so what? Tobacco companies have bought up food and drink companies in the past, why shouldn't they invest in the alternative nicotine market?

And what are these 'insights' are whence did they come? You won't be surprised that they came from yet another cherry-picking trawl through the archives...

Apollonio’s researchers analyzed 90 million pages of documents from seven tobacco companies dating back as far as 1960, obtained in litigation against the tobacco industry.

Obviously they didn't actually analyse 90 million pages of documents. That would take several lifetimes. What they did was do a word search of the chaotically assembled industry documents hosted at UCSF, of which there are reputed to be 90 million pages, and hoped for the best. As they explain in the study, it's the kind of 'analysis' that anybody could do.

We used a snowball strategy, beginning with the keywords “nicotine patch,” “NRT,” and “nicotine gum,” and then we refined search terms and dates using named individuals, organizations, and products and adjacent (by Bates numbers) documents. 

The Legacy Documents archive is actually a very good resource. I used it a lot when I was writing Velvet Glove, Iron Fist. It is massive, however, which means that (a) no one can read enough to get the full picture, and (b) it lends itself to cherry-picking in the wrong hands. 90 million documents written by countless individuals from rival companies over seventy years cannot easily be distilled into a handful of quotes giving the definitive view of the whole industry. Some will be statements of official policy, others will be ideas brought up for debate and others will be random musings of individuals. Quotes can be illustrative, but they need to be supported by a substantial amount of other evidence before we use them to make generalisations.

The historian Virginia Berridge has something to say about the way the tobacco archives have been used in her book Marketing Health:

The enthusiasm for online industry archives is an interesting phenomenon. We are seeing a new type of family history, a Whig history revived and a rediscovery of 'the document' whose main role is to play to the policy objectives of the anti-tobacco field.  

So what does the study by Glantz and Apollonio say?

Firstly, it says that American tobacco companies began looking at alternative nicotine delivery devices in the 1950s. Glantz and Apollonio claim that they did not take any of them to market because they wanted to avoid regulation by the FDA. This is true, although they do not ask why tobacco companies outside the USA also failed to pursue them.

Secondly, they say that the tobacco industry had concluded that NRT didn't work as early as 1992. Life is too short for me to trawl the archives to see whether this is a fair judgement, but here are all of the quotes Glantz and Apollonio use in their study to prove that Big Tobacco 'knew' that NRT was a non-starter. All of them come from 1992 and all but one of them were written by the same person (Doran Stern of PMI):

'Clinical results indicate the nicotine patch was more effective against placebos. . . . It is important to keep in mind, however, that in objectively validated tests (1 full year after quitting) nicotine patch scores were less impressive vs placebos. . . . Some sort of behavior modification was administered during the clinical tests. Without some degree of psychological therapy, many experts warn that the nicotine patch is powerless [as a method of smoking cessation]... The explosive growth of nicotine patch sales has not seemed to increase rate[s] of quitting (currently holding at 6.7% for 12 [month period] ending June [1992]).'
'301 past two year quitters (out of a sample of 551 quitters identified in January–February) were reinterviewed . . . to determine their usage of and reactions to the Nicotine Patch. . . . Roper [the polling organization Philip Morris hired to track smoking trends] data through December indicate that quitting rates on a 12 [month] basis have been roughly flat.'
'Studies of the efficacy of nicotine gum or transdermal patches on smoking cessation invariably show a significant benefit in the short term, but only a small advantage (if any) over placebo in the long term (6+ months). . . .'
'Monthly and 12 [month] quitting rates have been roughly flat through April. The use of Nicotine Patch as a way to stop smoking jumped dramatically in April (8% - 26%). . . . The results seem to suggest that Nicotine Patch [use for quit attempts] evidenced growth at the expense of ‘stopped all at once’ quitting.'
'Based on the attached results from our Continuous Tracking Study [Roper polls of smokers], it appears that usage of the nicotine patch has dropped steadily since it peaked in June. . . . [A] possible explanation for the patch’s loss in popularity may relate to the difficulty quitter’s [sic] experience in adhering to the strict, but necessary, regimen prescribed for the patch treatment.'
'Almost all the men we spoke to [who used NRT patches] went back to smoking... Some believe that the novelty [of the nicotine patch] has started to wear off.'

It is reasonable to assume that other industry insiders have commented on NRT since 1992. Did they take a different view? Did they see NRT as a threat? Glantz and Appollonio do not tell us, but I reckon I could write a paper showing that tobacco companies were terrified of NRT if I spent a couple of days searching the archives and set my threshold of proof as low as they do. Nevertheless, the press release for this study baldly states that 'by 1992, the industry had determined that patches and gum by themselves do not help smokers quit.'

Even if this were true, so what? According to one newspaper, working from the press release:

They discovered that as companies knew in 1992 that patches and gum alone did not help people quit smoking but did not act on that information.

Where to begin? There is no evidence that these companies had any information about NRT that couldn't be acquired by regulators or 'public health' professionals. They certainly didn't have information in 1992 that the rest of us didn't have by, say, 2002. But let's suppose they did. What were they supposed to do about it? Imagine what would have happened if cigarette companies had launched a campaign to deter people from using smoking-cessation drugs in the 1990s. Imagine if they had accused the pharmaceutical industry of pushing junk science to support their claims of efficacy. How do you think the anti-smoking lobby - which was by then heavily funded by the pharmaceutical industry - would have reacted if Philip Morris had come out and said 'these stop-smoking products are worthless, don't use them'? They had no incentive to do this and they would have been vilified if they had.

Isn't it the job of the 'public health lobby' to do due diligence on these products? Or the pharmaceutical industry? Or the regulators? If it was so obvious that these products don't help people quit - indeed, that they reduce quit rates, as Glantz now claims - why have the 'experts' of tobacco control been sitting on their hands for the last 25 years? Why have so many studies, such as this one in the anti-smoking lobby's house journal Tobacco Control, concluded that over-the-counter NRT works if it doesn't? And why does Glantz have more faith in the opinion of two random tobacco company employees than in the 'public health' lobby's finest minds?

On the howling wilderness of Planet Glantz, the tobacco industry should have been promoting nicotine gum and the 'public health' lobby should have been calling bullshit on it. The reality, of course, was pretty much the opposite. The industry quietly recognised that NRT was an unwelcome competitor but was unlikely to be an existential threat while the 'public health' lobby went around touting it despite mounting evidence that it didn't work as advertised.

It is true that NRT is largely ineffective (Glantz's study does not actually show this, but it happens to be true) and so it is the self-appointed experts of tobacco control who have to explain themselves, as do Big Pharma, the FDA, the WHO and all the governments that have been using taxpayers' money to dish out patches and gums for decades.

But Glantz does not point the finger at any of them. Instead, he comes up with an excuse that is quite something:

"The tobacco companies are generally 20 or 30 years ahead of the public health community in their thinking about their issues," Glantz says. "They have much more resources [sic] than the health community does to study their products."

This is the David and Goliath delusion on crystal meth. The 'health community' has had vastly more resources with which to research NRT than would have been available to a couple of analysts in 1992. All these guys seem to have done is look at published research, monitor smoking rates and used some common sense. The idea that the tobacco companies knew something about NRT in the early 1990s that nobody else could have known until Glantz and Apollonio published their 'insights' is laughable.

The implication of Glantz's paper is that the debate over how well NRT works has been settled by a handful of comments in some tobacco industry briefings a quarter of a century ago. It suggests that a couple of dudes working in commerce had a better understanding of nicotine, addiction and smoking cessation in 1992 than the entire global tobacco control movement has acquired in the years since. This does not reflect well on him or his colleagues and yet he seems happy to admit it.

He also seems happy to admit that NRT is not much good. Indeed, his condemnation of NRT - and over-the-counter NRT in particular - is arguably more fierce than the scientific literature justifies (that literature may be junk, but it is his colleagues' junk and he normally treats it as gospel). This is surprising, not only because so much pharmaceutical money swishes around in tobacco control, but because it makes his previous support of NRT look rather foolish. In 2005, for example, he wrote:

Individual smoking cessation is a highly cost-effective clinical medical intervention for individual smokers; nicotine replacement therapy (NRT) is a key element of this approach to combating nicotine addiction... NRT should be recommended in both clinical practice and public health practice.

When a study suggested that over-the-counter NRT didn't work in 2012, he said 'this is just one study, and it's not terribly huge', adding that 'we don't necessarily want to throw out the baby with the bathwater'.

He has now thrown the baby halfway across the bathroom. Why? What has possessed him to do a screeching U-turn on NRT which will embarrass his colleagues and upset Big Pharma?

As with most of his activity these days, it can be explained by his fanatical opposition to e-cigarettes. He insists that e-cigarettes do not help smokers quit and now he is saying the same about NRT. He says that 'dual users' of e-cigarettes are less likely to quit and now he is saying the same about dual users of NRT. He claims that the tobacco industry likes e-cigarettes because they sustain smoking rates and nicotine addiction - now he is saying the same about NRT.

The purpose of the study is to draw a parallel between the tobacco industry's supposed attitude to NRT in the 1990s and its supposed attitude to e-cigarettes and other alternative nicotine devices today. Never mind that it was the pharmaceutical industry that brought NRT to market and his own colleagues who hawked it. Never mind that the tobacco industry has never supported NRT and has never made any serious effort to take an NRT product to market.

When Glanz and Apollonio make the (dubious) assertion in the conclusion of their study that 'NRT can expand nicotine use while maintaining smoking rates' it is done with a nod and a wink to the FDA. What they are really saying is that e-cigarettes and any other safer nicotine device that smokers might switch to can expand nicotine use while maintaining smoking rates.

The purpose of the study becomes clear in the final line when they write:

These findings suggest that the least harmful way to sell nicotine delivery products is to restrict them to smokers whose quit attempts are medically supervised, consistent with the original studies of NRT for smoking cessation. 

This is a complete non-sequitur. Nothing in what has come before leads to this conclusion. Nowhere in the study do they discuss the vastly different risk profiles of the various nicotine products. There is no reason to think that the 'least harmful way' of regulating the nicotine market is to restrict access to the least harmful products. Quite the reverse.

This is just another thinly-disguised, puritanical attack on harm reduction approaches. It is a nonsensical conclusion, but it is whole purpose of the study from Glantz and Apollonio's perspective and they hammer the point home again in the press release, saying: 

“Our study shows that by not regulating nicotine in all tobacco products, including NRT, the FDA could be walking into a trap.”

There is method in Glantz's apparent madness of severing of relations with the pharmaceutical industry. By turning on NRT, he can be consistent in his opposition to all alternative nicotine products and demand consistent regulation, ie. medical licensing and a ban on over-the-counter sales.

If I may speculate for a moment, it has another possible consequence. By rejecting all nicotine products, it opens the door to the full demonisation of nicotine. Nicotine underwent an image change when Big Pharma started selling it. The public had often assumed that it was carcinogenic because of its connection with smoking, but this myth had to be debunked once it was being sold as medicine. The scientific consensus is that nicotine is addictive and can be toxic in large doses but is basically harmless when consumed at the levels found in recreational tobacco products. Smokers smoke for the nicotine but die from the tar, as Michael Russell said back in 1976.

Opponents of vaping have an incentive to resurrect the old myths. Lacking evidence that vaping kills, bottom feeders such as Simon Chapman have been scrambling around for any crumb of evidence implicating nicotine as a health threat. The existence of medically licensed NRT is a problem for these fanatics, but if Glantz's bizarre new narrative takes hold, it will be less of an obstacle. If you can do the mental gymnastics required to believe that the tobacco industry loves the pharmaceutical industry's stop-smoking products because they make people smoke, you can easily believe that same is true of e-cigarettes, snus, lozenges etc.

These people do not just want a tobacco-free world, they want a nicotine-free world, and this extraordinary rewriting of history is another step towards it.

Tuesday 22 August 2017

Stop lying about problem gambling

If the case against fixed odds betting terminals (FOBTs) is so strong, why does everybody who campaigns against them resort to demonstrable lies?

I was going to blog about this article from Victoria Coren in The Observer. It pains me to have a pop at her because she is one of Britain's better writers and one of our finest poker players. Her article centres around a statistic that I have not been able to verify and which she is only able to support with a link to a Daily Mail story. It also contains the false claim that people can lose £500 a minute on FOBTs (which she has tried to justify on Twitter by saying it could happen if you played two machines at once!), but this is chicken feed compared to the outrageous lies that are usually made by anti-FOBT campaigners. Mainly, however, she relies on an argument that is so overtly snobbish that I'm going to pretend it was made tongue-in-cheek and pass over it.

I cannot be so generous towards Iain Duncan Smith and his Centre for Social Justice, however. Last week he was talking through his hat at Conservative Home under the headline 'Problem gambling is soaring – it’s time to cap the stakes on betting machines'. In the article, he claims:

The British Gambling Prevalence Survey identified 450,000 problem gamblers in 2010 with an average debt of £17,500. The number of problem gamblers has now increased to 593,000 in 2015.

IDS was promoting a report from the Centre for Social Justice, which begins by claiming...

In 2006, the Centre for Social Justice (CSJ) published its Breakthrough Britain report on addiction, which outlined the systemic issue of gambling and its pervasive effects on individuals and communities. At the time of publication, there were 250,000 problem gamblers in the UK, whereas estimates now exceed 593,000. [My italics]

Note the word 'exceed' there. The report cites the NHS Choices website as its source, but when you visit it you will see that it says:

There may be as many as 593,000 problem gamblers in Great Britain.[My italics]

Straight away, we have a problem. The NHS website says that 593,000 is the upper limit whereas as CSJ says it is the lower limit and IDS says it is the exact figure.

So who is right? The answer is none of them, although the NHS is slightly closely to the truth. The 593,000 figure is the upper limit of the higher of two estimates from the 2010 British Gambling Prevalence Survey, which reported:

This [problem gambling percentage estimate] equates to somewhere between 342,000 and 593,000 adults according to the DSM-IV and between 254,000 and 507,000 adults according to the PGSI.

That was seven years ago and there have been several more surveys since then, but none has reported an estimate as high as that found in the 2010 report. As I explained a few months ago:

The first three reports in 1999, 2007 and 2010 used two different methodologies and came up with the following estimates:

1999: 0.6 per cent (DSM-IV), N/A (PGSI)

2007: 0.6 per cent (DSM-IV), 0.6 per cent (PGSI)

2010: 0.9 per cent (DSM-IV), 0.7 per cent  (PGSI)

Responsibility for collecting the data was then handed to public health bodies who came up with the following estimate for England and Scotland (combined) for 2012:

2012: 0.5 per cent (DSM-IV), 0.4 per cent  (PGSI)

Since 2013, the figures have been collected by the Gambling Commission which only uses the PGSI methodology. Results are as follows:

2013: 0.5 per cent

2014: 0.5 per cent

2015: 0.5 per cent

2016: 0.7 per cent

Quite clearly, the estimates fall within a narrow range of 0.4% to 0.9% and have not risen over time. It is difficult to explain why the Centre for Social Justice would focus on figures from seven years ago and present them as current. A cynic might say that they are deliberately misleading the reader in their pursuit of a narrative that is not supported by the facts. Naughty cynics.

CSJ's Breakthrough Britain report on gambling (which was actually published in 2007, not 2006) is no longer online and I don't have a copy of it so I don't know whether it claimed that there were 250,000 problem gamblers. However, I am familiar with all the possible sources and the 250,000 figure seems to be plucked out of thin air. The British Gambling Prevalence Survey of 2007 reported:

Taking into account the 95% confidence intervals around the prevalence estimates, one can conclude that the number of adult problem gamblers in Britain is somewhere between 236,500 and 378,000 according to the DSM IV, and 189,000 and 378,000 according to the PGSI.

250,000 fits within these confidence intervals, albeit towards the lower end. It seems that CSJ is happy to take a (roughly) mid-point estimate for 2007 while taking the top end of the highest estimate for 2010 - and then claiming that the real figure exceeds even that!

At the very least, this is extremely sloppy. Now let's return to what IDS claimed at Conservative Home, because he uses a different number:

The British Gambling Prevalence Survey identified 450,000 problem gamblers in 2010 with an average debt of £17,500. The number of problem gamblers has now increased to 593,000 in 2015.

Where does the 450,000 figure come from? It is a mid-point estimate from the 2010 survey.

Where does the 593,000 figure come from? It is the top-end estimate from the 2010 survey.

In other words, IDS has taken two figures from the same estimate in the same survey in the same year and pretended that one is from 2010 and the other is from 2015! This is a squalid misuse of statistics.

In fact, the estimate of problem gambling prevalence in 2015 was 0.5 per cent, considerably lower than the 0.9 per cent IDS is relying on for 2010.

Neither IDS nor CSJ have bothered to look at any of the figures since 2010. The Gambling Commission's most recent mid-point estimate of the number of problem gamblers is 320,000. This is in line with estimates published back in 2000 when the population was smaller (and there were no FOBTs in the UK):

The likely number of problem gamblers in Britain is thus 370,000 according to the SOGS, and 275,000 according to the DSM-IV.

Of the 11 estimates made since 1999, the 0.9 per cent figure is the only one that exceeds 0.7 per cent. It is plainly an outlier, but if you took it as gospel you would have to conclude that problem gambling prevalence has fallen significantly since 2010.

A more reasonable interpretation is that problem gambling rates have been essentially static for as long as anyone in Britain has been measuring them, totally unaffected by FOBTs, advertising, casino deregulation and all the other bogeymen of anti-gambling crusaders.

These statistics are not difficult to find so can people please stop lying about them?

Monday 21 August 2017

Disingenuous puritans

It is my contention that many 'public health' campaigners do not believe their own arguments and do not care about the things they claim to care about. There are two nice illustrations of this today.

Firstly, The Times (which is strangely obsessed with gambling) gives its front cover to some whining from GambleAware about children seeing gambling advertisements. The UK gambling industry's marketing spend was £312 million last year, according to the article, and this is 62 per cent more than it was five years ago.

Kate Lampard, the chairwoman of GambleAware, warns of a 'possible public health crisis in gambling addiction' but presents no evidence that gambling advertising has a negative effect on adults or children. Gambling advertising was largely illegal until 2005 but rates of problem gambling have not risen in the years since.

Gambling advertising is already tightly regulated on television, only permitted after the 9pm watershed or during sporting events.

Not only is it illegal for children to gamble, it is generally difficult for them to do so.

Moreover, it is not obvious that the increase in gambling spend means that children have been 'exposed to [a] huge rise in gambling adverts', as the headline claims. The article notes that the biggest increase in advertising spend has been online, which may or may not be seen by children, and whilst TV advertising has risen by 43 per cent in the last five years, it tends to be spent late at night.

Finally, gambling has nothing to do with 'public health' unless you stretch the definition of 'public health' to the point of meaninglessness.

But what really piqued my interest was this line in The Times article, in which Lampard says:

'With the average age at which children start to watch post-watershed TV unsupervised being 11¾, restrictions based on a 9pm watershed may offer little protection.'

You can expect to hear this kind of argument a lot if the obesity warriors succeed in getting 'junk food' ads banned before 9pm. Unless you ban all forms of advertising everywhere, it will always be possible to claim that somebody under the age of 18 will see them from time to time.

But the watershed is not principally designed for advertising regulation. It exists to reassure parents that programmes shown before 9pm will be reasonably family-friendly. 'Unsuitable material' cannot be broadcast until after the watershed, as Ofcom explains:

Unsuitable material can include everything from sexual content to violence, graphic or distressing imagery and swearing. For example, the most offensive language must not be broadcast before the watershed on TV or, on radio, when children are particularly likely to be listening. 

If Kate Lampard is concerned about 11¾ year old children seeing gambling adverts, she must also be concerned about them seeing 'sexual content', 'violence', 'graphic or distressing imagery' and, perhaps, 'swearing'. And since she thinks it is the job of politicians, not parents, to control what minors see on television, the logical conclusion is that the watershed should be moved back to 10pm, 11pm, midnight, or whatever time children do not watch TV unsupervised.

But she is not calling for this. Instead, she wants to get rid of gambling advertisements after 9pm while keeping all the other 'unsuitable material' on air. Therefore, I don't believe her when she claims to be concerned about protecting children's fragile little minds. I think she just wants to stop adults seeing gambling adverts.

As a second example, take this from the state of Victoria in Australia where a ban on smoking in outdoor places where food is served has effectively turned into a ban on people eating in smoking areas.

Victoria’s new anti-smoking laws could actually mean food is making way for cigarettes in many of the state’s pubs, bars and restaurants, a move anti-smoking campaigners have warned against.

In so far as this legislation had a rationale, it was to 'protect' people who are dining out from smelling tiny wisps of tobacco smoke. That dubious policy goal has been achieved. It doesn't make any difference whether business owners allow smoking and ban food sales or ban smoking and allow food sales. In both cases, the smoking and the eating are separated. 

But guess what? The anti-smoking zealots still aren't happy:

Quit Victoria policy manager Kylie Lindorff said venues that chose food over smoking areas would be making a smart business decision, because more than 85 per cent of Victorians do not smoke.

“We would encourage venues to provide smoke-free outdoor dining as a priority. We believe that it’s really good for business and it’s what the majority of Victorians support,” Ms Lindorff said.

A quick Google of Kylie Lindorff reveals that she is a career nanny statist who has never had a proper job in her life, so the pubs and restaurants of Victoria could be forgiven for ignoring her business advice. But what's it to her? She wanted to separate smokers from diners, right? She was delighted when the law was passed in 2014, saying: 'Victorians can all breathe a little easier today knowing that Victoria has committed to putting public health first by creating smoke-free drinking and dining areas'.

Now she wants a total ban on smoking outdoors in the state. The only conclusion one can draw from this is that smoke-free dining was never her real concern, just as children's exposure to unsuitable material on television are not Kate Lampard's real concern. These people are insincere, opportunistic puritans.

Tuesday 15 August 2017

Teetotallers still dropping like flies

Another day, another large cohort study confirming the benefits of moderate drinking. This time it's a 14 year study involving 333,247 Americans which concludes:

Compared with lifetime abstainers, those who were light or moderate alcohol consumers were at a reduced risk of mortality for all causes (light—hazard ratio [HR]: 0.79; 95% confidence interval [CI]: 0.76 to 0.82; moderate—HR: 0.78; 95% CI: 0.74 to 0.82) and CVD (light—HR: 0.74; 95% CI: 0.69 to 0.80; moderate—HR: 0.71; 95% CI: 0.64 to 0.78), respectively. In contrast, there was a significantly increased risk of mortality for all causes (HR: 1.11; 95% CI: 1.04 to 1.19) and cancer (HR: 1.27; 95% CI: 1.13 to 1.42) in adults with heavy alcohol consumption.

So that's a reduction in mortality risk of more than a fifth for both light and moderate drinkers compared to teetotallers. A similar magnitude of risk reduction was found in a BMJ study earlier this year. Numerous studies have been showing the same thing since the benefits of moderate drinking were first noticed (and covered up) 45 years ago.

The usual alcohol policy tweeps from the 'public health' lobby have been quiet today - perhaps because they are on holiday - and so the task of muddying he water has fallen to Buzzfeed. Its article, by Tom Chivers, mentions the usual excuse that non-drinkers are all terribly ill because they used to be alcoholics. Although Chivers acknowledges that this study only looked at lifetime abstainers, he implies that most studies of this kind do not. In fact, most studies conducted in the last fifteen year have only looked at lifetime abstainers. The 'sick quitter' hypothesis is a thoroughly debunked zombie argument that should have been dropped long ago.

With the sick quitters put to one side, he takes the fall back position of suggesting that there is something else about teetotallers that makes them less healthy:

But people who've never drunk in their lives are fairly unusual, in Western society, as well. So there may be some other factor that we haven't thought of.

There are several problems with this line of argument.

Firstly, saying 'teetotallers are less healthy because, er, reasons' isn't much of an argument to begin with.

Secondly, if it is an argument, it is an argument against all epidemiology. Different groups are usually different in several ways. That is why epidemiologists adjust for confounding factors. Of confounding factors, Chivers says: 'You can try to avoid these problems, but you can never do it perfectly.' This is trivially true, but there is a hint of the Nirvana fallacy about it. Perfection is impossible in observational epidemiology. The question is not whether it is perfect, but whether it is good enough. In this study, the researchers took account of a wide range of factors, including physical activity, smoking, race, body weight and education. They also adjusted for the prevalence of various diseases. The association between teetotalism and death remained.

Thirdly, it is not at all clear that teetotalism correlates with unhealthy behaviour. On the contrary, it often correlates with healthy behaviour (whereas heavy drinking correlates with unhealthy behaviour).

Fourthly, teetotallers are not 'fairly unusual' in the United States. A third of Americans are teetotal. Forty per cent of the people in this study did not drink and 23 per cent of them had never drunk. By contrast, only 5 per cent were heavy drinkers. It is therefore heavy drinking that is fairly unusual, but Chivers doesn't fault the evidence on alcohol harm from heavy drinking on the basis that there might be something weird about heavy drinkers.

A few other points are worth mentioning because they have been generally absent from the news reports about this study:

Firstly, the authors found a reduction in risk for cancer mortality among light drinkers, and no increase in cancer mortality risk for moderate drinkers. So much for there being 'no safe level'.

Secondly, they found no increased risk of heart disease mortality among heavy drinkers (but a large reduction among the other drinkers).

Thirdly, moderate drinking was defined as up to 14 drinks per week for men and up to 7 drinks a week for women. A 'drink' is not a unit, however. In this study, a drink is 14 grams of alcohol whereas a British unit is 8 grams of alcohol. The male moderate drinkers were therefore consuming up to 24.5 units and the female moderate drinkers were consuming up to 12.25 units.

The Buzzfeed piece claims that the statistician David Spiegelhalter 'says [the study is] a vindication for the new, low-risk NHS guidelines'. It's hard to see how. The authors clearly define moderate drinking differently to the NHS and there was a reduction in mortality in the group that included men who drink much more than the 14 units now recommended by the government. (NB. the only change to the guidelines was the reduction in the male limit.)

Spiegelhalter (who was on the guidelines committee) is quoted as saying: 'Once you get above the NHS guidelines of 14 units a week, that's when risk starts taking off.' Nothing in this study supports that statement. Is he getting confused between a US 'drink' and a UK 'unit'?

Fourthly, the health outcomes for light drinkers and moderate drinkers were virtually identical across the board, so there is no evidence for the claim that is sometimes made about the benefits of drinking only existing for people who drink tiny amounts.

Finally, an accompanying editorial notes that...

For most older persons, the overall benefits of light drinking, especially the reduced cardiovascular disease risk, clearly outweigh possible cancer risk.

Can we expect the 'public health' lobby to recommend that teetotallers start having a few drinks? Don't hold your breath.

Tuesday 8 August 2017

Public Health England's shrinkflation

The British government's underhand manipulation of the food supply should be a major news story. So far it has been largely ignored so I was pleased to see Blair Spowart get to grips with it at Spectator Health today...

Don’t expect PHE to stop its interference when its targets are inevitably not met. It’s already tackling salt in much the same way as sugar. Next on their naughty list is saturated fat. Because PHE needs perpetual public health crises to justify its existence, it is always sure to find one – to the detriment of consumers. This wide-ranging food reformulation programme is all happening, moreover, without even the pretence of public consultation.

More needs to be done to show consumers who’s really ripping them off. The first step is moving beyond our kneejerk reaction to shrinkflation and related phenomena – ‘blame it on Brexit’ – and looking more closely at the subtle but powerful impact of our economically illiterate public health lobby.

Monday 7 August 2017

The economic consequences of clean living

I'm pleased to announce the publication of the third part of the IEA's Public Purse trilogy looking at the net cost of bad habits to the nation's finances. We have previously looked at alcohol and obesity. We now turn our attention to smoking which is often said to impose a cost of £13.7 billion per annum on UK taxpayers. That figure comes from a risible Policy Exchange report from 2010 and is overwhelmingly made up of dubious lost productivity costs.

The question we ask in this series of reports is simple and important: what would be the impact on government revenues and spending if the 'public health' lobby won the war on drinking, smoking and obesity? Campaigners often claim, or strongly imply, that costs would fall but this is based on an economic calculation that exaggerates and misrepresents costs while ignoring savings.

Written with Mark Tovey (author of Obesity and the Public Purse), Smoking and the Public Purse takes a full account of the costs, savings and tax revenues associated with smoking and finds that the government would be spending £14.7 billion more per annum if nobody smoked.

In the absence of smoking, the government would spend an extra £9.8 billion annually in pension, healthcare and other benefit payments (less taxes forgone). Duty paid on tobacco products is £9.5 billion a year. In total, the gross financial benefit to the government from smoking therefore amounts to £19.3 billion. Subtracting the £4.6 billion of costs (above) produces an overall net benefit of £14.7 billion per annum.

The report also looks at the impact on the treasury if all three of the most discussed 'lifestyle factors' - obesity, alcohol and smoking - miraculously disappeared.

Alcohol and tobacco duty provide £10.7 billion and £9.5 billion to the government respectively, with an additional £4 billion of VAT charged on this duty. If, as expected, the forthcoming sugar levy raises £500 million per annum, the government will be in receipt of £24.7 billion of ‘sin tax’ revenue by 2018.

Taken together, the net benefit to the government from the three most hotly discussed ‘lifestyle factors’ - alcohol, obesity and smoking - is £22.8 billion.

You can download Smoking and the Public Purse here.

There is some news coverage here, here, here and here.

You can read my blog post for the IEA here.

And you can see Mark Littlewood talking about the findings on Sky News below:

Smoking and the Public Purse brings this series to an end. You can read all the relevant publications below. Nothing in them should be particularly controversial (see Death and Taxes for a review of the literature). It is obvious that a cost-benefit analysis requires benefits to be included alongside costs. Unfortunately, including benefits and savings doesn't suit single issue campaigners because it shrinks their estimates of the 'burden on taxpayers'. With the exception of obesity, which incurs a relatively small overall cost to the health service, doing the job properly turns a cost into a net saving.

I don't suppose this body of research will make much difference because it doesn't confirm what people want to believe (contrast that with the wafer-thin Policy Exchange document which has been cited hundreds of times in public debate), but I will keep banging this drum because it happens to be true.

 Alcohol and the Public Purse - Christopher Snowdon (2015)

Obesity and the Public Purse - Mark Tovey (2017)
Smoking and the Public Purse - Christopher Snowdon and Mark Tovey (2017)

Death and Taxes - Christopher Snowdon (2016)

Saturday 5 August 2017

Chlorine, chickens and Brexit

I was on the Spiked podcast this week talking about the chlorinated chicken thing and why Remainers briefly became obsessed with it. Have a listen.

Thursday 3 August 2017

Fast food, obesity and junk science

I was on the radio yesterday debating with some busybody from the NHS who wants to limit the number of takeaway shops in Britain's high streets. The feeble hook for this story was the news that the number of takeaway outlets in the country has increased by eight per cent in the last three years, according to a pearl-clutching Guardian analysis.

This would seem to reflect the resurgent economy and population growth but for the 'public health' lobby it is a crisis. Why? Because fast food causes obesity, dunnit?

But does it? Leaving aside the fact that takeaway food shops do not necessarily sell 'junk' or 'fast' food, the assumption that takeaways cause obesity has always been just that: an assumption.

What empirical basis does it have? A 2010 evidence review identified 12 studies looking at fast food outlet availability and obesity. Six found a positive association, five found no association and two found a negative association.

It also looked at six studies of fast food consumption and obesity. Three found an association, the other three didn't.

This is hardly compelling and I recommend reading this post by Mike Gibney in which he discusses some of the more recent evidence, starting with a 2017 study from the USA which concluded:

Our a priori prediction that FFRs [fast food restaurants] and FSRs [full service restaurants] would be positively linked to obesity prevalence was not supported

He also mentions a study of Europeans which found:

Our results suggest, contrary to normative views, that away from home food expenditures negatively affect BMI and that BMI is negatively related to the percentage of the food budget spent away from home.

And he mentions another recent study from the USA which found that...

Neighbourhood convenience stores and fast-food restaurants were not associated with BMI in any model.

The authors of that study argued that 'weak findings in the literature [which report an association between fast food and obesity] may be due to residual confounding'.

If you want to get an idea of how weak the evidence is for the fast food/obesity link, take a look at this study from the British Medical Journal. This is the one that campaigners like to cite because it concluded:

Exposure to takeaway food outlets in home, work, and commuting environments combined was associated with marginally higher consumption of takeaway food, greater body mass index, and greater odds of obesity.

The study looked at people's 'exposure' to takeaway food in Cambridgeshire and claimed that people who were heavily 'exposed' were 80 per cent more likely to be obese. The study concludes with a call for 'policies designed to improve diets through restricting takeaway food availability' which is a bit of a red flag for activist-driven research. This response from a statistician (which the authors never addressed) is devastating. It reveals that the finding was entirely dependent on adjustments to the data.

After reading the interesting article by Burgoine et al. I was at first irritated by the lack of a table to compare the characteristics (as shown in Table 1) of participants grouped according to quarters of take-away environment. Further, I missed a simple presentation of outcome variables (mean take-away consumption, mean BMI, percentage overweight and obese) grouped according to these same quarters. Usually one would expect such tables in order to assess the comparability of the groups with respect to possible confounders and for a direct, unadjusted comparison of outcomes, respectively.

Then I discovered this information in Web table 3 of the online appendix. Here, we see systematic differences between quarters with respect to education, smoking and car ownership. I think the authors should have presented these tables and drawn attention to these differences in the main printed article, even if the multiple linear regression models adjusted for the covariables concerned.

What surprised me even more in Web table 3 was the fact that mean take-away consumption was slightly inversely correlated with combined take-away availability, varying between 36.3 g/day in Q1 and 34.2 g/day in Q4. This contrasts completely with the results of the multivariate analysis (Fig. 1) in which a significant positive correlation between take-away availability and consumption was obtained. Moreover, In Web table 3 mean BMI is almost constant in all quarters of take-away availability, contrasting with the significant positive correlation between take-away availability and BMI derived from the multiple linear model (Fig. 2). While I accept that the multivariate analysis adjusting for potential confounders is the analysis of choice for such an observational study, the complete lack of agreement with the simple univariate analysis is worrying and should be presented and discussed.

A hint on the possible explanation for these inconsistencies is given under ‘sensitivity analyses’. ‘In models that omitted supermarket exposure as a covariate, the associations between combined take-away food outlet exposure, consumption of take-away food and body mass index were attenuated towards the null…’. These sensitivity results are given in Web figures 5 and 6. The expression ‘attenuated towards the null’ is an understatement: no association remains at all, in agreement with the simple univariate comparison.

If you look at the supplementary data, you can see that he is correct. There is no difference in average weight between those who have the greatest exposure to takeaways (4) and those who have the least (1). Moreover, the people who had the easiest access to takeaway food ate less of it than those who had the least access.

Your faith in the authors' conclusion therefore depends on how much faith you have in their numerous adjustments to the data. To my mind, it is junk science, but whatever you think of it, it is simply untrue to claim that the people in this study who were most 'exposed' to takeaways were fatter than other groups.

It brings to mind a study I wrote about five years ago which looked at fast food consumption among teenagers in Tower Hamlets. It concluded:

This study revealed a very high frequency of fast food consumption among the schoolchildren. Taste, quick access and peer influence were major contributing factors. These schoolchildren are exposed to an obesogenic environment, and it is not surprising that in this situation, many of these children are already overweight and will likely become obese as adults.

Notice how the authors beg the question. It is assumed that those who eat the most fast food will be most likely to be obese. They say that 'many of these children' are already overweight or obese but they do not say how many, nor do they compare obesity rates between those who eat a lot of it and those who do not.

You have to dig into the study to discover why they are so coy about this. It goes unmentioned in the text of the study, but we can see in Table 2 that there is an inverse relationship between frequency of takeaway consumption and body weight. The children who ate the most of it weighed the least and those who ate the least of it weighed the most.

This was clearly not what the authors were hoping to find so they ignored it and editorialised with a blatantly activist conclusion:

Clearly, actions need to be taken to either limit the ability of these children to access fast food outlets or to change the foods they purchased at these outlets (eg, less calorie dense, with more fruit and vegetables, with less fat and salt) and to have a ban on the sale of sweetened soft drinks at these outlets.

 Ever get the feeling you're being cheated?