Are moderate drinkers responsible for the majority of alcohol-related harm?

You can't understand modern 'public health' ideology without understanding the arguments made in Geoffrey Rose's Strategy of Preventive Medicine. It is from this book that we get the 'prevention paradox' and the idea that 'a large number of people exposed to a small risk may generate many more cases than a small number exposed to a high risk'.

If heavy exposure to Risk Factor X increases risk of Disease Y by 200%, and moderate exposure increases risk by 10%, a layman might decide to focus on those who are mostly heavily exposed because they are at greatest risk.

Not so fast, says the 'public health' expert. Only 1% of the population are heavily exposed whereas 60% of the population are moderately exposed (the other 39% avoiding exposure altogether). This means that moderate exposure accounts for more cases than does heavy exposure. Efforts should be focused on those who are moderately exposed.

This makes a certain amount of sense in the theoretical example above, but it is not a principle that can be universally applied. Rose tried to apply it to all sorts of risk factors and his successors have applied it to more, including gambling and salt consumption. 

Doctors tend to deal with people on the extremes: alcoholics, the morbidly obese, people with very high blood pressure, etc. Rose's version of preventive health focused on the (median) average person. There are a lot of people at or around the average and not so many at the extremes. His view that you save more lives if you focus on the apparently 'normal' than on the high-risk 'deviants' gave licence to the 'whole population approach' of government imposing broad-brush policies on everybody.

Leaving aside the negative consequences of these policies, the theory only works when the average person is at genuine risk. Take blood pressure, for example. The first graph in Rose's book shows the bell curve of systolic blood pressure. The y-axis is the percentage of population.

From this we can see that the median adult has a reading of around 130/80mmHg. On the right-hand tail of the distribution we can see the people who have high blood pressure.

In Rose's view, you would save more lives by lowering the blood pressure of people who had a reading of 120 or 130mmHg than by treating the people whose blood pressure exceeded 160mmHg. Why? Because there are so many more of them.

He complained that doctors only considered giving statins to people whose blood pressure exceeded 100mmHg - thus 'encouraging the belief that those who do not qualify for the high-risk group, because they are "normal", have no cause for concern.' (p. 47).

But is there cause for concern? What reason was there to think that the blood pressure of an average person was unhealthy? One of Rose's own graphs shows that the risk of heart disease does not increase until blood pressure exceeds 130mmHg.

Weirdly, Rose claims that this graph shows 'a continuum of associated risk which increases progressively over the whole observed range'. It does not. It shows that the baseline rise is about 6% and that risk only begins to increase from around 130mmHg.

Of course, there are occasions when being 'normal' or average is not healthy or, at least, not optimally healthy. Rose gives the example of average cholesterol levels in Finland, which are (or were) a lot higher than levels in Japan. The former is probably less healthy than the latter.

But it cannot be assumed that the average person everywhere is always at elevated risk, nor that their health would invariably benefit from doing less of whatever it is that carries risk to people on the extremes.

Take alcohol. The physical harms of alcohol overwhelmingly affect (a) people who get very drunk and suffer acute harms, and (b) people who drink a great deal for many years and suffer chronic harms.

The average drinker does neither. Even if we leave aside the J-Curve showing significant health benefits from moderate consumption, it is clear that alcohol consumption by the median drinker contributes only a very small part to alcohol-related ill health.

This is a challenge to Rose's theory and therefore to the whole population approach. This is awkward because it is in the field of alcohol that the whole population approach has been most warmly embraced. It is officially endorsed by the Scottish government and is at the heart of Ireland's Public Health (Alcohol) Act which will restrict advertising, introduce minimum pricing, put alcohol behind shutters, etc.

How can this be justified? Step forward Claire O'Dwyer and her colleagues from Ireland's Health Research Board. Last week they published a paper title 'Drinking patterns and the distribution of alcohol-related harms in Ireland: evidence for the prevention paradox' which includes a passage that is hilariously and shamelessly political, even by the standards of 'public health' activist-academia:

Policy implications

Research indicates that the most effective approaches to reducing alcohol consumption are those which target the entire population, such as increasing the price and reducing the availability of alcohol. In Ireland, the Public Health (Alcohol) Act (2018) has recently (October, 2018) been passed and will introduce a number of population-based strategies to reduce alcohol consumption, including a minimum unit price for alcohol sales and restrictions on advertising and marketing. This policy represents one of the most progressive alcohol policies in the world. It was fiercely contested by the alcohol industry and the interval between the publication of the Bill and the passage of the Act at 3 years was the longest ever in Ireland. None of the provisions in the Act have yet been implemented. The findings in this study demonstrate that alcohol-related harms in Ireland are distributed across the population, providing support for a population-based strategy to reducing alcohol consumption. The findings thus indicate a need for the rapid implementation of measures outlined in the Public Health (Alcohol) Act (2018).

Subtle, eh?

The study itself purports to show that most alcohol-related harms 'are accounted for by low- and moderate-risk drinkers' and not, as some might expect, heavy and dependent drinkers.

The authors surveyed 4,338 drinkers and asked them if they had suffered any harm in the last twelve months.

The eight harms covered were harm to finances, harm to health, harm to work or study, harm to friendships or social life, harm to home life or marriage, been in a physical fight, been in an accident, and stopped by the police. E.g., “Have you experienced harms to your finances in the last 12 months due to your own drinking?”

You will notice that only three of the eight relate to physical harm, including two (physical fights and accidents) which may not have necessarily resulted in any significant harm to health.

Indeed, even 'harm to health' does not necessarily imply significant harm to health. The journal that published the study, BMC Public Healthy, has open peer review so we can see that one reviewer asked the obvious question:

Question: how is 'harm to health' determined by the survey take? Does this refer to blacking out, or falling, or experiencing a hangover, or does this refer to receiving a clinical diagnosis, such as fatty liver disease?

The answer came back:

"Harm to health" was not further defined in the survey and was left up to participants’ interpretation.

So it could be anything from having a champagne cork fly in your face to being put in a wheelchair for life. It seems likely that most of these harms were relatively trivial because most accidents and illnesses are relatively trivial, but we have no way of knowing.

This runs the risk of producing apples and oranges comparisons. A dependent drinker developing acute pancreatitis counts for the same as a light drinker tripping over in a pub.

The results are below. Click to enlarge.

As the first and third columns show, dependent drinkers are much more likely to suffer 'harm' than the other drinkers. But only 6.9% of those surveyed were classified as dependent drinkers, so only a minority of the harmful incidents could be attributed to them (see the second and fourth columns).

The majority of incidents were accounted for by the other groups.

...these findings imply that most alcohol-related-harms are due to periods of acute intoxication, and because these occasions are most numerous among low and moderate drinkers, they account for the majority of alcohol-related harms.

There is sleight of hand at work here. The study does not look at moderate drinkers. It looks at moderate risk drinkers.

What is a moderate risk drinker? In this study, it is a non-dependent drinker who engages in Heavy Episodic Drinking (HED). Heavy drinking is immoderate by definition, I would have thought, and is defined here as the consumption of at least 60 grams of alcohol in one session (7.5 UK units, or about four pints of beer). The individuals could, of course, be drinking much more than that.

Moreover, they could be drinking much more than that very often. The survey asks how often the participant engages in HED. Regardless of whether they say  “everyday”, “5–6 times a week”, “4 times a week”, “3 times a week”, “twice a week”, “once a week”, “2–3 times a month” or “once a month”, they are lumped together (see the black bar in the charts above) and considered to be 'moderate-risk'.

Common sense tells you that somebody who gets drunk most days is at high risk of all the 'harms' mentioned in this study, not least because the 'harms' in question relate to the consequences of drunkenness rather than the long-term effects on health. Somebody who only gets drunk once a month is clearly at lower risk and might be considered a low- to moderate-risk drinker by a layman (although not necessarily by a 'public health' academic). In this study, they are all grouped together as Heavy Episodic Drinkers.

It seems almost inconceivable that the survey didn't ask people how many units of alcohol they consumed, but if the authors have this information they don't use it. Why not? Units per week is the measure of choice in 'public health' for classifying risk. Many of the heavy episodic drinkers will be drinking enough for them to be classified as hazardous drinkers (more than 14 units a week) or harmful drinkers (more than 35 units a week for a woman or 50 for a man). It would be very useful to have this information.

The most cynical explanation for the authors' reluctance to show us how much these people are drinking is probably the correct one. If the statistics were broken down into subgroups, we would likely see a close association between heavy consumption and harm. Instead, the authors devised a methodology which allows people to consume vast quantities of alcohol and still be classified as 'moderate-risk' so long as they don't meet the DSM-IV criteria for alcohol dependence.

The study has another peculiar feature. For each of the harms, respondents...

...were assigned a score of 0 (“never”) 1 (“yes, once”) or 2 (“yes, more than once”) on each of the eight questions depending on their response. Scores on each of the eight harm questions were summed to give each participant a total score of harms that ranged from 0 to 16.

It is not clear how these scores were used in the final analysis, if at all. The results section only shows how many people had suffered each 'harm' at least once in the last year. This means that incidence of harm by, say, a dependent drinker who is habitually arrested and hospitalised will be greatly underestimated.

The authors are aware of this issue, saying...

This score is likely to be an under-estimation of harms, as “more than once” could equate to a number greater than 2. 

But they justify it, saying...

However, the purpose of obtaining the total harm experienced by the survey population was not to provide a precise estimate of the number of alcohol-related harms in the population but was to estimate how the harms were distributed across each drinker type. Hence the scoring of the scale in this way was appropriate to the aim of the study.

Focusing on prevalence, rather than quantity, would be OK if the authors stuck to talking about prevalence. But they don't. On the contrary, they repeatedly insist that their findings show the proportion of incidents that are caused by each group. The abstract of the study says...

The majority of the harms in the population were accounted for by drinkers who were not dependent on alcohol... the majority of alcohol consumption and related harms in the Irish population are accounted for by low- and moderate-risk drinkers

This is wrong. The authors cannot make any claims about the number of harms. They can only make claims about the number of people involved.

This misrepresentation occurs again and again...

In line with previous findings on the prevention paradox, the majority of harms occurred to low-risk or moderate-risk drinkers...

...the majority of the harms were accounted for by people who engaged in HED...

...our findings indicate that the majority of harms in the Irish population were not accounted for by dependent drinkers...

The majority of alcohol-related harms in Ireland occurred among drinkers who engage in heavy episodic drinking.

When the study was picked up by the media, journalists naturally made the same mistake...

Binge drinking among low to moderate risk drinkers is responsible for most of the alcohol-related harm that occurs in Ireland.

None of these claims is supported by the study's results. The authors simply do not have the data to make such assertions. Under their methodology, a drinker who got into a fight at the Christmas party is responsible for the same amount of harm as an alcoholic who gets into fight every night.

This is a critical flaw because we know that a tiny minority of drinkers are responsible for a huge number of incidents. It should have been picked up in peer review, but neither of the reviewers even mentioned it.

In conclusion, let us return to the central claim of the study which I have already quoted above...

...these findings imply that most alcohol-related-harms are due to periods of acute intoxication, and because these occasions are most numerous among low and moderate drinkers, they account for the majority of alcohol-related harms.

It should now be clear that this is untrue for three reasons.

Firstly, the study barely examines the long-term health harms which are the cause of most alcohol-related mortality. At best, it shows that people who get drunk are more likely to be involved in situations that are associated with drunkenness than people who do not get drunk.

Secondly, the study does not look at 'low and moderate drinkers'. It looks at a poorly defined cohort of low and moderate risk drinkers, many of whom are neither moderate drinkers nor at moderate risk.

Thirdly, the authors can make no claims about 'most' or 'the majority' of alcohol-related harms because their study makes no attempt to quantify them.

So what does this study tell us about the prevention paradox? Nothing, because the prevention paradox is about death and disease, neither of which are measured here. Are moderate drinkers responsible for the majority of a broader range of harms? The data in this study is insufficient to tell us that either, but probably not.

Are cigarette filters useless?

Richard Kluger memorably equated twentieth century efforts to make a safer cigarette to breeding a one-fanged rattle-snake. It has become dogma in tobacco control that neither filters nor low-tar cigarettes make any difference to the risks of smoking. Low tar (or 'light') cigarettes, in particular, have been portrayed as a tobacco industry scam, with the role of government and public health scientists written out of the story.

Regulators send out mixed messages. The EU's Tobacco Products Directive bans companies from putting nicotine and tar yields on cigarette packs to prevent consumers getting the idea that lower yields are less dangerous. At the same, it banned companies from selling cigarettes with more than 15 mg of tar in them in 1993 and has since lowered the limit to 12 mg and then 10 mg, presumably because it thinks higher yields are more dangerous.

Now Martin McKee and his chums have called for filters to be banned entirely, the effect of which would be to greatly increase yields of both nicotine and tar. This is not a new idea. In Velvet Glove, Iron Fist, I wrote about anti-smoking fanatic John Slade who wished the government had banned cigarette innovation in 1950 so that 'the only cigarettes on the market would be unfiltered 70 mm smokes, and far fewer people would be smoking.'

McKee et al. make their argument on the basis of litter, but perhaps they share Slade's hope. If so, I'm not sure it will work. Smoking was never more popular than it was in 1950 and I would far rather smoke an unfiltered Lucky Strike than a modern 'light' cigarette. Most people today don't know what a decent cigarette tastes like.

McKee et al. assert that the benefits of filters are a 'myth', but the only sources they cite as evidence are an article from the New York Times Magazine and an article in the pseudo-journal Tobacco Control.

Studies looking at the issue are few and far between, so it is a weird coincidence that one was published on Monday in JAMA Internal Medicine. Awkwardly for McKee, it found that...

After adjustment, unfiltered cigarette smokers were nearly 40% (hazard ratio, 1.37; 95% CI, 1.10-1.17) more likely to develop lung cancer and nearly twice (hazard ratio, 1.96; 95%CI, 1.46-2.64) as likely to die of lung cancer compared with those who smoked filtered cigarettes. Additionally, all-cause mortality was nearly 30% (hazard ratio, 1.28; 95% CI, 1.09-1.50) higher.

.. This study confirms that smoking any type of cigarette conveys serious health risks. Within the context of this study, unfiltered cigarettes are the most dangerous, and individuals who smoke them should be targeted for aggressive tobacco treatment interventions. 

This is in line with previous epidemiological studies such as this and this. The idea that filters confer no benefit whatsoever is unproven, to put it mildly. But we already knew that McKee doesn't approve of harm reduction.

Getting advertising wrong

Last week we saw Mark Petticrew and friends make fools of themselves claiming that the booze industry encourages pregnant women to drink. Today they're back with a study proving that they don't know the first thing about advertising. The study has not been covered by the media, which must have come as a disappointment, but you can read it here.

It is obvious from the first line that this is not a serious piece of research:

Alcohol advertising is an important influence on alcohol consumption, and the evidence supports the restriction of advertising and marketing as a cost-effective intervention for reducing alcohol harms.

Having begged the question, they trawl through case studies published by the Institute of Practitioners in Advertising, mostly from between 1981 and 2003, looking for evidence that alcohol advertising is aimed at increasing alcohol consumption.

In a way, of course, it is. The aim of a Stella Artois campaign is to sell more Stella Artois. The aim is not to increase beer sales per se, let alone alcohol sales in general.

It doesn't seem to matter how much evidence shows that advertising does not increase aggregate consumption, 'public health' people still insist that it does - because they think (wrongly) that it would justify a ban.

Overall, 30/39 (approximately 77%) of the case studies explicitly mentioned increasing or maintaining market share as an objective or use this as a measure of campaign effectiveness.

Yes, that's the whole point.

There is consistent evidence from these case studies to support the industry claim that growing or defending market share is an important advertising objective.

Aye, there is.

They then move onto the 'alcohol industry claim' that 'Advertising Does not, and Is not Intended to, Stimulate Consumption'. This is where they come unstuck.

If sales and volume sales can be taken as a proxy for consumption, then all of the 39 case studies present evidence that advertising affects this outcome.

Er, no. Each of the case studies is for a specific brand. A rise in market share for one brand does not imply a rise in overall consumption. It is much more likely to lead to a fall in market share for another brand. Indeed, the case studies offer a reminder of several brands that were once very familiar but are not anymore, eg. Boddington's, Hofmeister, Murphy's.

Here are the authors' first two examples of advertising being used (supposedly) to increase consumption...

“We did not want to just sell Magners in the warm summer months: we wanted it to be drunk throughout the year”.

(Magners Cider, 2008)

The same campaign also: “…amplified Magner’s relaxed timeless brand values and drove winter consumption".

But even Petticrew et al. seem able to grasp that Magner's was trying to get people to drink their cider in winter instead of drinking, say, lager, not in addition to drinking the same quantity of lager...

Arguably, these examples show attempts to increase market share, rather than overall consumption. 

No kidding. But just when you think they have seen the light...

Other examples are more likely to reflect increases in consumption, such as this example where Foster’s lager used a humour-based campaign. The evaluation describes how it

“…gave permission for a ‘drinking occasion’… Blokes were lapping up the ads, but most importantly, they were lapping up Foster’s lager too…as the ads ran, sales rose, and they have continued to do so”.

(Foster’s Lager, 2015)

This campaign did not aim to increase overall consumption, and nothing in the quote suggests otherwise.

As noted above, the fact that all campaigns had increasing sales as an objective and/or main outcome is also an indirect indicator of the intended effects on consumption.

As noted above, it is nothing of the sort. The authors seem unable to distinguish 'consumption of Brand X' with 'consumption of alcohol'.

...one common way of measuring the effectiveness of the campaigns is in terms of willingness to purchase. The Grolsch lager campaign provides one example of this:

“The most concrete measure of increased consumer demand is rate of purchase. Grolsch’s rate has more than trebled since campaign launch…Put simply, consumers are demanding the brand more than ever”.

(Grolsch, 2003)

It would be tedious to repeat all the examples cited by the authors. Suffice to say, they are all like this. First, the authors claim that the company is trying to increase overall demand for alcohol, then they produce a quote that clearly shows the company is only interested in increasing market share.

When they take on the 'industry claim' that 'Any Observed Relationship between Advertising and Consumption is not Causal', they say...

...these case studies often have the stated aim of demonstrating a causal relationship. This is sometimes made explicit, as in these examples from the Campari and Archers Schnapps case studies:

“This case history will show the vital role that an integrated advertising strategy, in terms of planning input, media choice and creative content, played in that growth. It will seek to demonstrate a causal relationship between advertising and Campari sales performance…”

(Campari, 1981)

No doubt there was a causal relationship between the Campari advertising campaign and Campari sales performance, but that has got nothing to do with the question of whether the advertising campaign increased the number of units of alcohol sold. The distinction is blindingly obvious. Are the authors really too thick to see it or are they playing dumb?

...it has been claimed that advertising benefits the consumer by keeping product prices down [47]. However, there is considerable evidence from these data that the opposite is the case, with advertising helping to maintain or increase prices.

Reference 47 is none other than the 2014 reprint of the IEA's Advertising in a Free Society, which I abridged and wrote the foreword to. It does indeed say that advertising tends to lower prices. Advertising is a major lever of competition and competition tends to lower prices. There is plenty of evidence for this (see page 8, for example).

But what is true in general terms is not necessarily true in every case. Premium brands are more expensive because they have a good reputation. That reputation is often built on advertising, as I explain in the foreword...

But what if it could be shown that the more expensive branded good is identical to the unbranded budget good by objective criteria? Would this not be proof that the company is playing on consumers’ vanity and anxiety to exploit them? Harris and Seldon argue that the question is meaningless be-cause a product has no objective value. Even if the branded good is distinguishable from the unbranded good only by the advertising that portrays it as being of higher class, the consumer is justified in buying it. If he values it more highly be-cause he associates it with glamour, good taste or ethical living then he is right to pay more for it. Harris and Seldon argue that ‘if a bath soap, a fountain-pen, or a carpet gives more pleasure when the consumer thinks it is used by a duchess or a television performer, then he is making a logical decision in buying it: he is being more sensible than his critics’

In the whole history of British marketing, one brand has used advertising to justify higher prices more blatantly than any other: Stella Artois. With the slogan 'reassuringly expensive', it turned a bog standard Belgian lager into a premium drink. It is therefore no surprise that Petticrew et al. use it as evidence...

Several case studies also describe the mechanisms by which higher prices are maintained, e.g.,

“The premium price ideally pays for the advertising which tells the consumer the product costs more in the first place”. (Stella Artois, 1993)

Nobody has ever claimed otherwise, but note the contradiction in their logic. If, as they claim, alcohol advertising leads to higher prices in general, they should be in favour of it because higher prices lead to less consumption. 

In reality, the aims of alcohol advertising vary with regards to price. Premium brands use advertising to justify higher prices while retail advertising tends to focus on lower prices. Mid-range brands simply do what most advertising does - remind people that they are still there.

In conclusion:

These data suggest that advertising both aims to change attitudes, expectancies and consumption behaviour, and is effective in doing so.

And so it is. That is the proper purpose of advertising. What is doesn't do is increase per capita alcohol consumption or rates of alcohol-related harm - and nothing in the study shows otherwise.

Irn-Bru's reverse ferret

Some fun news was reported yesterday. I have written about it for Spiked...

In July, still insisting that it ‘made the right decision to reduce the sugar in Irn-Bru and the vast majority of drinkers agree’, the company announced a profit warning. Its share price fell by 30 per cent in a day and has fallen further since.

How serendipitous, then, that Robin Barr – great-grandson of the eponymous AG – recently stumbled across a dusty book buried deep in the company’s archives which contains the original recipe written out in longhand. As luck would have it, the 1901 version of Irn-Bru contained even more sugar than the fabulously popular version that Barr took off the shelves last year.

Having made such a remarkable discovery, the company decided that it would be rude not to share this ‘authentic piece of Scottish history’ with the public. Irn-Bru 1901 will be available in the shops from 2 December, supposedly as a limited edition. Just in case you haven’t got the message, it will be explicitly marketed as ‘old and unimproved’. 

Do read it all.

Somebody should measure childhood obesity

The government has set up a National Food Strategy, led by Henry Dimbleby, and has launched a call for evidence which closes on Friday.

The National Food Strategy will examine activity across several departments of state, building on the flagship Agriculture Bill and Fisheries Bill currently before Parliament, the Industrial Strategy, the Childhood Obesity Plan and the upcoming Environment Bill.

With regards to the Childhood Obesity Plan, I have just submitted a proposal suggesting that maybe, just maybe, somebody should make an attempt to measure childhood obesity.

Here's what I wrote...

The NFS call for evidence mentions the government’s Childhood Obesity Plan. The Childhood Obesity Plan opens with the assertion that ‘more than one in three children are obese or overweight by the time they leave primary school’. The claim that more than a third of eleven year olds are overweight or obese is routinely made by the Department of Health, Public Health England and single-issue campaigners, and is used to justify a wide range of interventions in the food market.

This factoid is rarely challenged, but it should be. We have no idea what the rate of childhood obesity is in the UK because nobody has made a serious effort to measure it. All we can say with confidence is that it is far lower than the government claims. For reasons that have never been explained, the government refuses to use the clinical definition of childhood obesity (based on the BMI of the 98th percentile in 1990). The clinical definition sets an unrealistically low threshold and therefore allows many false positives, but the government’s definition (based on the BMI of the 95th percentile in 1990) allows the category to consist mostly of false positives. Most of the children who are classified as obese by the government’s definition would not be classified as such by a clinician - or, indeed, by a lay person.

If the UK government used the clinical definition, it would find that the rate of obesity among eleven year olds was well under five per cent. If a representative sample was examined by a clinician, the rate would likely be lower still. It is bizarre that so much time and money is directed at the problem of childhood obesity without any serious attempt to measure its prevalence. Politically, it is easy to see why campaigners prefer a large number to a smaller number, but this does not justify fiddling the figures.

The inflation of the childhood obesity figures leads to demonstrable absurdities. For instance, it is well understood that the risk of obesity rises with age. If taken at face value, the government’s statistics show that the prevalence of obesity among 13-15 year olds is 25 per cent, but falls sharply to 15 per cent for 16-24 year olds. Children do not suddenly lose weight when they leave school. The discrepancy is explained by adult obesity being measured objectively while childhood obesity is not.

Given the Department of Health’s apparent lack of interest in getting to the truth of this matter, it would be a suitable target for fresh thinking from the National Food Strategy. Creating realistic BMI charts to measure childhood obesity is an achievable and important goal.

It is extraordinary to consider that the definition of childhood obesity was made without any child ever being examined or diagnosed (instead, the rate of obesity among children was extrapolated from the rate of obesity among 18 year olds!). A more rational approach, which would cost a tiny fraction of Public Health England’s £4 billion budget, would involve clinicians examining children of various ages and recording the BMI of those who are at the lower end of the obese range, based on adiposity and visible excess weight. These records could then be used in perpetuity as thresholds for childhood obesity at different ages.

Aside from being truthful with the public, a realistic measure of childhood obesity would have two benefits. Firstly, it would allow policy to be targeted towards children who are genuinely obese, as opposed to statistically obese, by giving us accurate information about their profile (socio-economic characteristics, region, race, etc.).

Secondly, it would allow progress to be measured. At it stands, the government’s target of reducing childhood obesity by 50 per cent by 2030 can only be achieved if large numbers of healthy children lose weight. This is neither realistic nor desirable. Officially, the proportion of children who are obese has remained more or less unchanged since 1999. Thanks to the large number of false positives, it is impossible to tell from the official dataset whether the number of genuinely obese children has risen, fallen or remained the same. 

I have written about this at greater length (with links to sources) in these two articles:

https://life.spectator.co.uk/articles/no-one-in-three-children-arent-obese-this-headline-grabbing-figure-is-a-statistical-invention

https://life.spectator.co.uk/articles/childhood-obesity-figures-vastly-exaggerate-the-scale-of-the-problem/

The use of children in the sockpuppet state

It's our old friend, the slippery slope again.

Call to hide alcohol from view in shops, just like cigarettes

Shops should be required to screen alcohol from public view just like cigarettes, Edinburgh’s deputy council leader Cammy Day has said.

This can't be true, can it? After all, 'the “domino theory” i.e. that once a measure has been applied to tobacco it will be applied to other products is patently false'.

So why is it happening?

His call follows a report by the Children’s Parliament in which children as young as nine voiced concern about the high visibility of alcohol in everyday life.

I wrote about this cynical PR exercise last month:

So the Scottish government has a public consultation on alcohol on the way. The government funds its own anti-alcohol lobby groups, of which Alcohol Focus Scotland is one. It convenes a group of children who are, aparently, too young to be exposed to the sight of beer in shops but are old enough to make detailed policy proposals. And their policy proposals are going to be fed into the consultation as not only the views of the public but of the chiiiiiildren.

If this was happening in some benighted dictatorship overseas, we would not hesitate to mock it as the brazzen parody of democracy it is.

Regardless of what you think about this particular issue, this is not the way to make policy.

The Children’s Parliament report published last month called for alcohol to be made less visible in shops and on TV and the removal of adverts from billboards and an end to alcohol firms sponsoring events where children are present.

Wow, the young children have exactly the same view as the adults (from Alcohol Focus Scotland) who primed them. What are the chances?

Councillor Day said he had been shocked by the youngsters’ report. “This was young people aged 9-11 who have fears at that age about the impact of alcohol on their life.

“I’ve written to Ash Denham asking her to work with local government to review alcohol licensing and how we can make it safer for young people. If cigarettes are bad for you and we have them hidden behind a screens, why are we not doing the same for alcohol?”

Well, Councillor Day, the traditional answer from anti-smoking groups is that cigarettes are a unique product, the only consumer product that kills when used as directed by the manufacturer, etc. But that bit of rhetoric tends to be forgotten once the door has been wedged open and it becomes open season on any product that displeases the nanny statists.

The Scottish Government published an Alcohol Framework document last year which promised a consultation on potential measures, including mandatory restrictions on alcohol marketing, to protect children and young people.

And that is exactly why the Scottish Government funded the Children's Parliament to look at the issue, with a temperance group brought in to ensure the children said the right thing. They could hardly have been any more blatant about it.

A government spokeswoman said: “We are all too aware of the impact of alcohol advertising and agree that there is more we can do to protect children and young people from alcohol harm. A key part of this is restricting alcohol marketing which is why we will be consulting on options for mandatory restrictions in Scotland in Spring 2020.”

Thus, the circle is complete. Government decides on the policy. Government funds pressure group to lobby for the policy. Government convenes a bunch of kids to support the policy. Government tells the media that it is under pressure from concerned children to introduce the policy. The media play along with the charade.

Pretending to cave in to state-funded lobby groups has been the defining feature of the sockpuppet state for years, but exploiting children in this way is a new and sinister development.

Last Orders with Martin Durkin

A new Last Orders podcast came out recently. I forgot to mention it here at the time, but here it is.

This month's guest is the wonderful film maker Martin Durkin. We talk about the US vape panic (again), the lies about minimum pricing and whether it's OK to spray smokers in the face with fire extinguishers.

Have a listen.

A year of cannabis legalisation

Yesterday was the first anniversary of cannabis re-legalisation in Canada. I made a short video for VolteFace (see below) with a few thoughts about what needs to be done to wipe out the black market. My view hasn't really changed since I wrote this because the statistics haven't really changed. At the last count, two-thirds of recreational cannabis was still being bought on the black market thanks to the high price and lack of availability of legal product.

Speaking of statistics, the available data do not strongly show any increase in the number of Canadians consuming cannabis. In the first three quarters of 2018, the prevalence rate was 14%, 15.6% and 15.2% respectively.

In the last quarter of 2018, when cannabis was legalised, the rate was 15.4%. In the first quarter of 2019 it was 17.5%, and in the second quarter it was 16.1%. The confidence intervals of these estimates are about 1.5% either way. All figures relate to use in the last three months.

At most, legalisation has led to a one percentage point increase in use, mainly thanks to people aged over 55. Use amongst 15-24 year olds has certainly not gone up.

🇨🇦🎂🌿 Canada, 1 year on🌿🎂🇨🇦@cjsnowdon of @iealondon takes issue with a few fundamentals of the Canadian model but accepts its a work in progress

Issues:

1⃣Rife illicit market

2⃣Lack of competition+shops

3⃣Level of taxation

Verdict:

✅Room for improvement pic.twitter.com/IRNQoo6GMZ

— Volteface (@VoltefaceHub) October 17, 2019

The lack of competition and availability is confirmed in this Reuters report which I worth reading if you're interested in the topic. It seems that the cannabis companies are losing money hand over fist at the moment.

Pubs hit hard by the smoking ban - new study

Taken from Closing Time

There's a nice study in Health Policy looking at the impact of the English smoking ban on alcohol sales. It is of particular interest because it provides data for smokers and nonsmokers in the on-trade and off-trade.

The results will come as no surprise to anyone who has watched the collapse of pub industry since 2007.

The data show that before the smoking ban, smokers spent nearly twice as much money in pubs as nonsmokers - and nearly 50 per cent more on alcohol overall.

After the ban, average weekly expenditure in pubs by smoking households fell by 45 per cent, from £10.06 to £5.68.

Was this made up for by nonsmokers flocking to smoke-free pubs, as anti-smoking campaigners - and the useful idiots at CAMRA - promised? Not a bit of it. Expenditure by nonsmoking households also fell, from £5.70 to £4.42 a week.

Spending on alcohol from the off-trade remained pretty similar for both groups.

The study's author, Rob Pryce, does a separate analysis comparing the post-ban period with the two years before the ban (rather than six years). The results are similar for smokers, but the decline in spend by nonsmokers is smaller.

Click to enlarge

Whichever way you look at it, the evidence is clear: pubs' best customers spent a lot less in them after they were banned from smoking. Who'd have thought?

... smoking households significantly reduced their on-premise expenditure following the smoking ban, and non-smoking households did not significantly change their expenditure...

Apologists for the smoking ban sometimes claim that it cannot have done so much damage to pubs because smokers were in the minority. It is true that only 21 per cent of UK adults were smokers when the ban came in, but they were spending a lot more money in pubs. As anyone who remembers those halcyon days will recall, there were plenty of pubs where at least half the regulars were smokers. In some pubs, it could be 80 per cent.

The idea that nonsmokers would make up for this lost business was always a cynical fantasy. Most nonsmokers didn't care about secondhand smoke and most of those who did were never going to become regular pubgoers anyway.

This study only confirms the bleeding obvious, but it is still nice to have some firm figures.

Does the alcohol industry encourage pregnant women to drink? Four idiots investigate.

It is with a heavy heart that I must inform that Mark Petticrew is at it again...

Alcohol industry 'puts pregnant women at risk', researchers say

Alcohol firms and bodies they fund are encouraging women to drink in pregnancy – putting their unborn child in danger – by publishing false and misleading information about the risks involved, new research claims.

The study is here. It is a follow-up to this discredited effort by Petticrew and three colleagues who claimed that the booze industry 'appears to be engaged in the extensive misrepresentation of evidence about the alcohol-related risk of cancer.' Ironically, that study was based on some extensive misrepresentation, not to mention shameless cherry-picking and selective quotation.

Now he and three fellow cultists are back with a study that makes the unlikely claim that the alcohol industry is actively encouraging pregnant women to drink because (don't laugh)...

...women are a crucial part of the alcohol market, as has been pointed out in relation to alcohol consumption and breast cancer risk (Connor, 2017). Pregnancy, therefore, may represent a significant commercial threat...

Hmm. So what's the evidence that alcohol companies are encouraging pregnant women to drink?

Several alcohol industry–funded websites appear to emphasize the scientific uncertainties regarding safe levels of drinking.

There is a great deal of uncertainty about safe levels of drinking during pregnancy. A few years ago, the UK government amended its advice. Having previously advised woman to avoid alcohol in the first trimester, it now advises pregnant women 'to not to drink alcohol at all to keep risks to your baby to a minimum.'

This is the precautionary principle in action, however. It does not reflect any solid evidence showing risk to the baby from light drinking.

As a recent systematic review concluded...

This review demonstrates the paucity and poor quality of evidence addressing this important public health question... In conclusion, we found limited evidence for a causal role of light drinking in pregnancy, compared with abstaining, on most of the outcomes examined. Despite the distinction between light drinking and abstinence being the point of most tension and confusion for health professionals and pregnant women and contributing to inconsistent guidance and advice now and in the past, our extensive review shows that this specific question is not being researched thoroughly enough, if at all. In addition, there has been no evidence regarding possible benefits of light alcohol consumption versus absence.

And even Petticrew admits at the end of his new study that....

...we emphasize that there are indeed uncertainties and complexities in the area of alcohol and health, not the least in defining the benefits of risks and harms from “light” drinking

It is perfectly acceptable for the authors of the systematic review to 'emphasize the scientific uncertainties regarding safe levels of drinking', but when organisations that get funding from the alcohol industry do it, they are supposedly encouraging pregnant women to drink.

But do they even do that? This is the first example Petticrew cites to make his case:

The International Alliance for Responsible Drinking (IARD), an alcohol producers’ “responsible drinking” body, appears to emphasize uncertainty regarding “safe” limits by publishing a table that details “drinking guidelines for alcohol consumption by women who may become pregnant, are pregnant and are breastfeeding issued by government bodies in various countries.” The table shows national guidelines from Albania to Vietnam, with no accompanying explanation.

You can visit the webpage here. It is literally just a list of the advice given by various governments worldwide, presumably so people who live in those countries can find out what their government recommends. What kind of 'accompanying explanation' is required? Alas, Petticrew et al. don't tell us because they move on to their next killer example...

Lack of consensus is also highlighted by Brown-Forman, which references the “ongoing debate about whether there is a ‘safe’ level of consumption during pregnancy, or during certain time frames of a woman’s pregnancy.”

So what?

The word debate is commonly used elsewhere in alcohol and tobacco industry narratives to imply that scientific evidence is simply a matter of debate or opinion among scientists

Are you kidding me? 'Debate' is commonly used to describe a debate, of which there are many in science and none in the dogmatic world of 'public health' activism.

DrinkWise also states that there is “confusion about how much one can safely drink during pregnancy”—with the added apparent implication that such a safe level exists.

A fevered mind might infer that. Most people would not. I doubt anyone of sound mind could look at the DrinkWise webpage and see anything other than unequivocal advice to avoid alcohol when pregnant or when trying to conceive.

In any case, the statement above does not come directly from DrinkWise. They are quoting Alec Welsh, a professor of fetal-maternal medicine, who I dare say knows a bit more about the subject than Mark Petticrew and his 'public health' pals.

Some wording appears to imply that alcohol is safe—but has not yet been proven to be so. For example, Diageo’s DrinkiQ website states that “research has yet [emphasis added] to establish a ‘safe’ amount to drink during pregnancy,”.. The language in the first clause of this sentence implies that there is a completely safe limit, which simply has not yet been identified.

Wibble.

They then quote Quebec's Educ’alcool Canada...

"The scientific community believes [emphasis added] that abstaining from drinking is the safest choice.” This appears to be an example of industry “mixed messages.” The word believe (like the word debate) may also imply that that this message is based not on evidence but on ideology.

The evidence is clearly insufficient to say that the case either way is proven beyond doubt. This applies to all claims based on observational epidemiology, incidentally. Evidence is built up until the case is made beyond reasonable doubt, but that still requires interpretation and, yes, belief. Causation can never be proven in epidemiology, and in this instance we don't even have good correlations. That doesn't make it a matter of ideology - whatever that is supposed to mean - it makes it a matter of opinion. Or, if you will, belief.

We noted that on some websites the positioning of the information on the webpage appears to dilute its importance and/or present mixed messages. For example, on the Drinkaware website, the sections on pregnancy appear on the webpage titled “Health effects of alcohol.” The page has 45 sections, of which the last four are sections on pregnancy, breastfeeding, FAS, and fertility, requiring the user to scroll down approximately nine pages to access the information

This is desperate stuff. Firstly, who measures a single webpage in terms of pages? You scroll down to find what you need (try it).

Secondly, it is perfectly reasonable to put information that is only relevant to half the population for a fraction of their lifetime towards the bottom.

Thirdly, Drinkaware has a whole webpage dedicated to alcohol and pregnancy which comes up in the first page of listings when you Google 'alcohol pregnancy'. On that page you are told...

Not drinking alcohol is the safest approach

Drinking alcohol at any stage during pregnancy can cause harm to your baby and the more you drink, the greater the risk. This is why the low risk drinking guidelines advise pregnant women that the safest approach is to not drink alcohol at all during pregnancy.

If you’re pregnant or think you may become pregnant, you’re also advised not to drink.

This, apparently, is the alcohol industry [sic] encouraging pregnant women to drink. It's laughable.

Organisations affiliated with the drinks industry cannot win, no matter what they do. If they don't provide information, Petticrew accuses them of using a 'strategy' which is...

.. part of a wider set of industry tactics that includes manipulating the evidence base, lobbying, and constituency building (forming alliances with other sectors, organizations, or the public to give the impression of larger support for the industry’s position)

But if they do provide information, he says...

More generally, the alcohol industry involves itself in providing health information because it can then can portray itself as “part of the solution” and therefore play a greater role in the regulatory landscape. This echoes strategies adopted by the tobacco industry when it was faced with the growing, unequivocal evidence of the harms of smoking.

I really don't know how this rubbish gets published, even in a low quality journal.

The radicalisation of Dame Sally

Sally Davies stepped down as Chief Medical Officer last month, but she refuses to go away. In the last week alone she has called for a raft of extreme anti-food policies and a ban on flavoured e-cigarettes.

She was not always like this. As I argue in this article for Spiked, Davies' time in 'public health' is a cautionary tale of radicalisation.

Just when you thought she had gone away, Sally Davies is back – and louder than ever. When she finally stepped down as the UK’s chief medical officer last month, after a long farewell tour, I naively thought we had seen the back of her. But then that’s what I thought about John Major and Gary Barlow in the 1990s, so I should be used to disappointment by now. Some people just don’t know when they’re not wanted.

Dame Sally seemed to revel in her reputation as a bossy, nanny-state scold in her nine years as Britain’s ‘top doctor’. So it’s been a shock to discover that she was self-censoring all that time. Freed from the constraints of her £205,000-a-year government job, she is now able to say what she really thinks, and it’s scary stuff.

Last week, she called for a ban on eating and drinking on public transport (with a generous exemption for ‘fresh water’ and breastfeeding). This week, she jumped on America’s anti-vaping bandwagon and demanded a ban on flavoured e-cigarette fluids (ie, nearly all of them). At this rate, she will be proposing full rationing and mandatory marathons by Christmas.

Do read it all.

Dame Sally and plain packaging for food

Former Chief Medical Officer Sally Davies treated us to her mad parting shot last week with a report on childhood obesity. Most of the media coverage focused on the idea of banning eating and drinking on public transport (because it normalises snacking or something), but that was only one of a number of lunatic proposals.

Also included was...

Accelerate the [food] reformulation programme (PHE), If sufficient progress is not made, the government should apply either:

a. A fiscal lever or

b. Standardised packaging, (as for tobacco).

This is not the first time we have seen calls for plain packaging to be extended to food. In addition to several studies pushing the idea, the IPPR think tank wants plain packaging for all sweets, crisps and sugary drinks (as 'a challenge to the power of corporate manufacturers').

The idea also surfaced two weeks ago when the Food Ethics Council held an event called 'Food policy on trial: in the dock - plain packaging' in which four people debated whether to put 'unhealthy' food in 'standardised' packaging.

Whoever was on the 'jury' had a penchant for state intervention because they concluded that...

• Much stronger regulation is needed on packaging and on food and drink claims, both in what is allowed and how strictly that is enforced. ‘Fake farms’ and cartoon animations shown on pack to market unhealthy products to children were two examples of where the jury agreed that bans were needed.

• The jury called for honesty to become a central tenet of any food strategy. It proposed a citizens’ assembly [oh, God - CJS] to decide on which claims about food and drink should and should not be allowed, on packaging and more broadly. It also recommended incorporating that into the National Food Strategy (England) process.

• There are problems with the idea of introducing plain packaging on worst-offending food and drink categories, not least setting boundaries about what should and should not be included. However, the threat of such a radical idea opens up the space for other interventions to be brought in.

The mere fact that plain packaging hasn't had any measurable impact on anything when tried on tobacco hasn't held this bandwagon back one inch. As I said of plain packaging when it was first mooted in the UK, when all you have is a hammer, everything looks like a nail.

Amusingly, one of the people speaking in favour of plain packaging for 'junk food' at the Food Ethics Council debate was Ben Pugh of Farmdrop. You may recall Farmdrop as the company that got caught out advertising cheese, jam and other everyday groceries that are classified as High in Fat, Sugar or Salt under the government's puritanical definition. It's great to see that his faith in Big Government hasn't been shaken!

By the way, did you see the cover of Sally Davies' report? It tells you a lot about how little grasp she (or whoever writes her nonsense) has of the evidence. The implication is that childhood obesity has risen because food has got bigger. It suggests that a bag of crisps weighed 100g in 1990 and weighs 150g today. The average pack of crisps actually weighs 25g today and weighed 30-35g in 1990. Sally Davies is comparing a modern multi-pack of crisps with, er, something.

The graph also shows childhood 'obesity' rising between 2006 and 2018, which it didn't, and the x-axis is totally mental, going up in increments of 16 years, 4 years, 5 years, and then 3 years.

Apart from that, rigorous stuff! Dame Sally was worth her £205,000 a year, wasn't she?.

The Lancet explained

I've just come across this press release from earlier in the year which helps explain how so much unscientific, non-medical, political dross gets published in the alleged medical journal the Lancet.

'Activist Editor' Richard Horton of The Lancet receives $100,000 Roux Prize

.. "Richard has been an activist editor, relentlessly taking on issues beyond the traditional scope of 'public health,' including the accountability of the medical profession, as well as human rights," said IHME Director Dr. Christopher Murray. "He has demonstrated an uncompromising commitment to advance health internationally, and his vision for a healthier, safer, and more just world has made Richard one of the world's most sought-after population health speakers."

One of those issues beyond "traditional public health" has been "planetary health," a discipline Horton argues transcends incorporating public health and the environment, and examines "the unity of life and the forces that shape those lives," according to an editorial published last year.

"Planetary health was intended as an inquiry into our total world. Our political systems and the headwinds those systems face," he wrote. "The failure of technocratic liberalism, along with the populism, xenophobia, racism, and nationalism left in its wake. The intensification of market capitalism and the state's desire to sweep away all obstacles to those markets."

Okay.

Smoking literature

I'm off on holiday for a few days so I'll leave you with a bit of reading material from my favourite single-issue pressure group, FOREST.

Josie Appleton is always worth reading. Her book Officious is a modern libertarian classic and her recent polemic 40 Years of Hurt is worthy of your attention.

Rob Lyons is also a doughty fighter for smokers' rights. His recent FOREST publication, Nicotine Wars, calls for unity between vapers and smokers. It is naive to think that the puritans will leave vaping alone once they've finished with smoking, as events in the USA have shown.

I've also been reading Jacob Grier's Rediscovery of Tobacco which is excellent. I'll review it properly in a few weeks.

Mysterious vaping illness - latest

It's been over a month and there is still no sign of the USA coming to its senses about the 'mysterious vaping-related disease'. The media reporting has been generally abysmal, but the response of politicians and health agencies has been nothing short of reprehensible.

Here is the latest advert from the Illinois Department of Public Health, for example...

There's no denying where you'll end up if you keep vaping. Take the first step to quit today visit: https://t.co/n9u0OdtGIm #ILQuitVaping pic.twitter.com/6QycNirIEC

— IDPH (@IDPH) October 2, 2019

From the very outset, all the evidence pointed to cannabis oil cartridges being the problem. A strong warning about these products, particularly the black market variety, might have prevented the outbreak of death and disease continuing. We're up to a thousand hospitalisations now.

It is clear that these products are everywhere. As the New York Times reported yesterday...

.. As health officials grapple with a public health crisis they are struggling to understand, police departments are in the midst of a swift crackdown on vaping products containing THC, the psychoactive ingredient in marijuana. In the Phoenix area, the authorities recently raided three homes over eight days, seizing hundreds of THC cartridges at each. In Wisconsin, detectives arrested two young brothers accused of running a large-scale THC cartridge assembly operation inside a condo. And in Nebraska, sheriff’s deputies found a stash of cartridges in a car parked at a truck stop. 

.. The effort to crack down on illicit vaping products has been laden with complications. The police say they have been stunned by the growth in popularity and variety of vaping devices. Enforcement can be difficult because vaping THC is not accompanied by the distinctive — and often incriminating — smell of marijuana. And police officers have had to learn the difference between vaping cartridges for THC, which are illegal for recreational use in most states, and devices for vaping nicotine, which are legally sold at many drugstores and gas stations.

If only the media learned the difference. Last week, Ben Camerillo was hospitalised with acute lung pain after suffering the 'mysterious vaping-related illness'. The television news reported that he has PTSD and used 'both THC and flavored vaping products'. The news item ended with the words 'if you are vaping you need to stop.'

But as Camerillo explains in the video below, he has only ever vaped cannabis/THC oil. He has never smoked and never used nicotine e-cigarettes.

Interestingly, he says that he bought THC carts from (legal) dispensaries, so the most sensible public health message is: avoid vaping cannabis oil while scientists figure out what exactly is going on.

Instead, mendacious politicians have been ordering vape shops to pull their flavoured vape fluids off the shelves, thereby greatly expanding the black market. Look at the state of this...

DEVELOPING: We’re in Mr. Vapors smoke shop w/ Westland Police. Officers visiting NUMEROUS smoke shops, to make sure they are NOT selling banned, flavored E-cigarettes. Those who violate the order, can face as much as 6 months in prison & $200 fine. ⁦@wxyzdetroit⁩ #4PM #5PM pic.twitter.com/IoJ8P2GfTs

— Simon Shaykhet WXYZ (@simonshaykhet) October 2, 2019

Also of interest is the video from TRT in which Robert West, Deborah Arnott and Sarah Jakes discuss the attempt by 'public health' dinosaurs like Simon Capewell and Martin McKee to import the US vape panic to the UK. A man who died nine years ago after switching from cigarettes to vaping is being held up as the UK's first and only 'vaping-related' death.

The Sunday Times recently claimed that there have been 200 cases of 'health problems linked to vaping' since 2014. But, as Arnott points out below (17 minutes), the MHRA is obliged to make a note of any complaint related to any of the products it regulates, of which only 74 have actually mentioned vaping. None of them has been proven.



Anti-vaping crusaders in the UK know that this is the chance they have been waiting for. We shall see if they have anything else up their sleeve.

That teen vaping epidemic

All the data you need to debunk America's teen vaping panic is freely available on government websites. Martin Jarvis and colleagues have been looking at the National Youth Tobacco Survey and the number of high school students who regularly vape without having previously used tobacco is very small indeed.

Past-30-day e-cigarette use increased by 78% from 11.7% in 2017 to 20.8% in 2018. In both years, use was strongly associated with lifetime tobacco use history: it was seen in 8.4% of never tobacco users in 2018, in 29.0% of those who had tried a non-combustible, but never a combustible, product (OR 4.4 (CI 2.8-7.2) by comparison with never tobacco users), and in 71.0 % of those who had smoked more than 100 cigarettes in their lifetime (OR 26.8, CI 17.7-40.5)

Frequent use occurred in 0.1% of never tobacco users in 2017 and 1.0% in 2018. Findings from 2014 and 2015 showed that first product tried was overwhelmingly cigarettes among those with a substantial lifetime cigarette history. Among past-30-day e-cigarette users who had never tried tobacco products in 2018, 3.8% reported craving, 3.1% reported wanting to use within 30 minutes of waking, and 61.8% said they had used e-cigarettes on ≤10 days in their life.

They conclude:

We find a gaping chasm between the vision of an epidemic of e-cigarette use threatening to engulf a new generation in nicotine addiction and the reality of the evidence contained in the NYTS.

Meanwhile, cigarette used by this age group has just fallen to the lowest level on record.