Saturday, 23 May 2020

Fergus's coronavirus conundrum

Fergus Walsh

I've been chuckling about this all day so I had to share it with you.

Fergus Walsh, the BBC's medical correspondent, has written about how he was 'gobsmacked' to repeatedly test positive for the coronavirus antibody (meaning, obviously, that he has had the virus).

Imperial College London are testing these finger-prick home antibody tests for accuracy and ease of use. One of the team there calculated that my repeated positive tests made it incredibly unlikely that I was continually producing a false result. In other words, it seems I have definitely had coronavirus.

 In retrospect, this should not have come as such a shock.

I've not had any symptoms in recent months. I'm rarely ill, but I did have a bout of pneumonia in early January. I was off sick for about 10 days and had a cough and a high temperature. I couldn't shake it off. My GP in Windsor diagnosed a bacterial infection and gave me antibiotics. These helped a bit, but in late January I needed another course of antibiotics. These seem to have done the trick. Was it really Covid-19? 

Given that he had the two main symptoms and has tested positive, it does rather sound like it, doesn't it? 

I don't think so. 

What?

The first confirmed case of coronavirus in the UK was in late January when two people from China fell ill in York. It wasn't until a month later that the first cases of domestic transmission occurred. Note that although I'd been reporting on the outbreak in China by mid-January, the farthest afield I'd been in recent months was Christmas in Brussels.

But it has since been established that the coronavirus was spreading in Europe in December, if not earlier. We have a confirmed case in France was who treated on 27 December. This is accepted by the WHO (who said it was 'not surprising') and was widely reported earlier this month, including by the BBC.

So I don't think I missed a story here - the first coronavirus case in the UK was not me. But after that I've had no symptoms at all. Not a cough, not a high temperature, smell and taste normal, and no aches and pains, headaches, diarrhoea, conjunctivitis, skin rash or any of the other possible warning signs listed by the World Health Organization.

So, apart from that time when he was really ill for ten days with the classic symptoms of coronavirus, he hasn't any coronavirus symptoms. What a lucky escape!

Fergus goes on to say that 'having a positive test did not change my mindset' and that he still assumes 'that everybody I meet has coronavirus, and that I have it.'

And he welcomes the government's roll out of extensive antibody testing because...

It will also give us the first really accurate picture of how many people have had coronavirus without knowing it, so-called asymptomatic cases - people, it seems, like me.

Asymptomatic!

I don't know what's more funny. The fact that the BBC's medical correspondent didn't realise - even with hindsight - that he was personally involved in the biggest health story of his lifetime. Or that a journalist is so trusting of claims from authorities that nothing - not personal experience, not repeated diagnostic testing, not even the fact that the claims have been made obsolete by subsequent evidence - will stop him believing them.

Friday, 22 May 2020

Prohibition and the pandemic

Governments around the world have been gold-plating their lockdowns with prohibition. I've written about it for Spiked...

Here are some fun statistics for you. Last month, a quarter of the world’s population lived under alcohol prohibition. More than a fifth lived in a country where the sale of cigarettes was illegal and an even greater proportion still live in countries where the sale of e-cigarette fluid is prohibited.

These startling figures are mostly due to the vast population of India, where an existing ban on vape juice was accompanied by full prohibition of alcohol and cigarettes when it went into lockdown on 24 March. After 40 days and 40 long nights, the ban was rescinded in much of the country two weeks ago, but ‘emergency’ alcohol prohibition remains in place in South Africa, the Philippines, Greenland, Panama, Zimbabwe, most of Argentina, and parts of Thailand and Mexico. Peru, Malaysia and Mexico have all banned brewing, with the latter suffering from a severe beer drought. Drinkers in Delhi, the Indian capital, now face a 70 per cent tax on alcohol, supposedly to discourage long queues at liquor stores.

This is the future nanny statists want. When asked to justify these sweeping prohibitions, politicians mutter something about relieving pressure on the health service – the catch-all excuse for draconian laws in this foul year of 2020 – but it is difficult to avoid the suspicion that overzealous officials have used the lockdown to introduce the kind of heavy-handed paternalism that has only now become politically possible. 

Do read it all.


Thursday, 21 May 2020

Nanny state pressure groups on the make

Last month I wrote about the plight of 'public health' groups being overshadowed by a genuine public health problem...

If you’ve spent your career believing that drinking, smoking and obesity are the real epidemics, a potentially fatal virus forcing billions of people into hiding could make you question your priorities. But if the nanny state lobby was disoriented at first, it has quickly learnt to adapt.

And so it has. With the Prime Minister reputed to be in the mood to fight the war on obesity with renewed vigour, the anti-smoking and anti-drinking lobbies sniff an opportunity.

Let's start with the temperance lobby. Its de facto leader in Britain, Ian Gilmore, has written a short editorial for the BMJ in which he promotes his 'Commission on Alcohol Harm', a rigged consultation that will no doubt be confused with a Royal Commission or a Select Committee when it publishes its predictable conclusions later this year.

To get the media interested, he starts the editorial with an outlandish claim... 
 
As the UK and most other countries went into lockdown, the need to save lives from covid-19 rightly took priority over longer term health concerns. Many people reacted to the closure of pubs and restaurants by stocking up to drink at home in isolation, and alcohol, along with household items and storecupboard food, disappeared from supermarket shelves. In the week to 21 March, alcohol sales were up 67%. In comparison, overall supermarket sales increased by only 43%. Now, as signs emerge of some control over new cases of covid-19, it is increasingly clear that if we don’t prepare for emerging from the pandemic, we will see the toll of increased alcohol harm for a generation.


You what? One week of stockpiling to compensate for a period of self-isolation when the pubs are shut does not remotely imply that there will be a 'toll of increased alcohol harm for a generation'. This is gibberish, for which he provides no evidence in the rest of the editorial.

Nevertheless, the BBC and Sky both fell for it. Here's the Beeb...

Tackling harmful drinking during the lockdown will be "an integral part of the nation's recovery", an editorial in the BMJ says.
With supermarket sales of alcohol having risen, it warns cases of alcoholic liver disease could increase too.

But have alcohol sales risen overall? It doesn't look like it. And, as I argued last week, temperance doctrine dictates that a dramatic decline in alcohol advertising and availability should lead to a substantial improvement in alcohol-related health outcomes. Surely temperance doctrine couldn't be wrong?!

And the writers fear drinking could be fuelling a rise in calls to domestic violence charities.

It's the lockdown, rather than the drinking, that is the problem there.

Sales of alcohol in supermarkets and corner shops jumped by 22% in March.

Because people were stockpiling! They were also stockpiling toilet paper, but they weren't using more of it.

Sales of alcohol in off-licences rose by 31% in the same month - but this accounts for just 1% of alcohol sales.

I don't know what this is supposed to mean. Suggestions in the comments please.

And with the lockdown starting on 23 March, figures for the whole of April are likely to be much higher.

Er, why? The stockpiling had eased off by April, had it not?

"It is increasingly clear that if we don't prepare for emerging from the pandemic, we will see the toll of increased alcohol harm for a generation," the editorial says.

This is a stupid opinion which goes unchallenged by the BBC.

Nanny state lobbyists are in the fortunate position of having their every word turned into a news story by the credulous media. Action on Smoking and Health (ASH) get the same privileged treatment, especially from the Guardian.

Earlier this month, ASH made some wild extrapolations from a survey to claim that...

More than 300,000 UK smokers may have quit owing to Covid-19 fears

Today, they are singing a rather different tune. Based on another survey they commissioned, they have fashioned a new narrative...

Millions in UK smoking more amid coronavirus crisis, study suggests

Whilst these two claims are not mutually incompatible, the change of emphasis can be explained by ASH's desire to squeeze more money out of the taxpayer. The article contains some of the most blatant grifting I have ever seen from them.

News of the survey came as the campaign group Action on Smoking and Health (Ash) accused the government of taking an unreasonably long time to make a decision over the release of £350,000 in funding it was asked to apply for by the Department of Health and Social Care (DHSC) for a “quit smoking for coronavirus” campaign, while a unique “window of opportunity” to encourage smokers amidst the pandemic closes.

A unique window of opportunity to shore up their finances, more like. Does the Department of Health normally approach private organisations and actively encourage them to apply for funding? Or does it only do it with their close chums?

“Quit for Covid is being run on a shoestring, and without adequate funding can only have a limited impact,” said Deborah Arnott, the chief executive of Ash – which receives a £140,000 annual government grant along with funding from large charities.

“The Department of Health and Social Care and Public Health England are supportive and even asked us to apply for funding from the government’s charity scheme when it opened in April. We were told there would be a decision within a week, so the project could start in May and run till October.

“Since then there has been radio silence and we understand the decision now rests with No 10. There is a window of opportunity to provide the support and encouragement smokers need to Quit for Covid, but it is closing fast.”

Oh dear, what a shame.

Taking Liberties has more details on Quit for Covid. It looks like just the kind of ineffective lame duck that the Department of Health would lavish money on.

Tuesday, 19 May 2020

Prohibition webinars

You can never have too many webinars, can you? So here's one my colleague Kristian and I did yesterday for Oxford University's Conservative Association.


 
Don't forget the Forest webinar tonight and the big prohibition event on Thursday.

Speaking of prohibition, if you smoke menthol cigarettes you have until midnight to stock up for the rest of your life, Helmut Schmidt style.

Monday, 18 May 2020

The failings of Public Health England and the WHO

Having spent years saying Public Health England should be closed down and the WHO should be defunded, it's pleasing to see so many people coming round to my point of view. All it took was for these organisations to get a bit of scrutiny.

There's a damning article in the Economist this week about PHE... 

The pandemic has exposed flaws in Public Health England

After the pandemic, the government is likely to rethink the executive agency’s role

Let's hope so.

While the failure to raise [Covid testing] capacity spreads well beyond PHE, there is concern across the health system—in the NHS, government and local authorities—that PHE has failed to rise to the challenge. 

It's difficult to keep up with all of PHE's shortcomings this year, but they include failing to work with the private sector to ramp up testing capacity, advising people against wearing face masks, assuring the public that it is 'very unlikely that people receiving care in a care home or the community will become infected' and failing to use local public health teams in contact tracing. It has now emerged that PHE knew about an outbreak of the virus at a Nike conference in February and did not tell the public.

Still, menthol cigarettes are being banned this week, so at least PHE's fat cats have got one thing to celebrate.

Before the pandemic, PHE was well regarded. 

By other people in the 'public health' racket, perhaps.

A review by the international association of public-health bodies concluded that it rivalled any in the world. 

It might be time to revise that now.

Created as part of controversial reforms to the health system in 2013, it emerged from 129 organisations, including those responsible for health protection (watching for infectious diseases) and for health promotion (campaigning against smoking). The inspiration was America’s Centres for Disease Control and Prevention. In Britain the model seems unlikely to survive the crisis.

Good.

The fragmented system that has resulted has its own problems, particularly in data collection. The health department has brought in Dido Harding, the head of an NHS regulator, to sort things out, and to link the testing programme with contact tracing, which is still run by PHE. The Office for National Statistics is leading serological studies to see how widespread covid-19 is in the British population. It is an all-hands-on-deck-situation for the government. Yet effective organisations tend to accumulate responsibilities. Instead, some in the NHS joke that PHE is enjoying a period of “self-isolation”.

One of the problems, as Matthew Syed argued in the Sunday Times yesterday, is that PHE had been preparing for an influenza outbreak, not a coronavirus outbreak, despite two near-misses in the recent past - SARS and MERS - being coronaviruses.

Once country that did not make that mistake is Taiwan, whose response to the epidemic has been exemplary. Alas, the WHO is not likely to learn many lessons from Taiwan because it barely acknowledges its existence. The reason is China. The video below has become an infamous reminder of the WHO's attitude towards Taiwan, and the Economist, in a different article, looks at how China keeps the Taiwanese out of the room. Worth a read.







Boris Johnson's war on obesity

Boris Johnson is reputed to be launching a war on obesity, both his and other people's, when this is all over. The Times covered this gossip on its front page last week, perhaps feeling vindicated for publishing so many anti-sugar editorials over the years.

More cynically, this looks like an attempt to shift the blame for the government's handling of COVID-19: "Don't blame us, blame the fatties." This doesn't stack up as an excuse, however, as I wrote in an article for the Spectator.

Leaving aside the total failure of every anti-obesity policy to date, let us consider the government’s political motivation for finding a scapegoat for Britain’s relatively high Covid death rate. How convenient it would be if people believed that South Korea handled the crisis better because of its low rate of obesity and not because of its contact tracing capability and widespread use of face masks.

However...

If Britain had fewer obese people it would have more old people. If it had more old people, it would have more deaths from Covid-19. Italy’s relatively low rate of obesity may have contributed to it having an unusually large elderly population, but this did not prevent it from having an unusually high death rate from Covid-19. Quite the reverse. 

This is the lesson from health economics that refuses to be learned. We all have to die from something. If you avoid a ‘lifestyle-related’ disease, you will die from something else at a later date. Blame the obese if you must, but don’t fool yourself into believing that you would benefit personally if, by some miracle, Boris Johnson’s forthcoming interventions succeed.



Sunday, 17 May 2020

Prohibition produces the usual results in South Africa

The BBC has made a short video about South Africa's lockdown ban on alcohol and tobacco. Aside from making the dubious claim that the prohibition was based on logic and reason, it gives an accurate picture of what's been happening. It is the usual story of crime, corruption, tax loss and financial ruin.


A hundred years after the the 'noble [sic] experiment' began in the USA, it seems that every generation has to learn this lesson for itself.

Speaking of which, menthol cigarettes are being banned in the EU and UK on Wednesday for no good reason. I'll be talking about this in a webinar for Forest on Tuesday to which you are warmly invited.

I'll also be chairing 'Prohibition and the Pandemic' on Thursday for the IEA. This will be an online panel discussion with some very distinguished guests talking about prohibition past and present. You can see the line up and register for it here.



Friday, 15 May 2020

Has anybody heard from Public Health England?

I had an article in the Yorkshire Post this week. It's not payywalled so do have a read of it.

Has anybody heard from Public Health England recently? When the agency was set up in 2013, its ‘primary duty’ was ‘to protect the public from infectious diseases and other environmental hazards’ and yet the fight against coronavirus has been led by the Department of Health and the NHS.

While the Chief Medical Officer and his deputy have become household names, the head of PHE (can you name him?) has been nowhere to be seen.
The quango’s main contributions to date have been hindering the roll out of testing with its overly centralised bureaucracy and assuring the public that it is ‘very unlikely that people receiving care in a care home or the community will become infected’.

Public Health England gets £4bn from the taxpayer each year. Of this, more than three-quarters goes to local authorities in ring-fenced grants.

Each local authority has Director of Public Health on a six-figure salary. With PHE gone AWOL, the Directors of Public Health have spent the crisis complaining about being left out of the loop.

If there was ever a time for the public health establishment to shine it is now. PHE’s budget for ‘protection from infectious diseases’ has risen from £52m to £86.9m in the last few years.

The latter is, admittedly, only two per cent of the public health budget, but how the money is divvied up is a political choice. If a fraction of the £4bn available had been spent stockpiling personal protective equipment, we would be in a much stronger position than we are now.






Thursday, 14 May 2020

Clive Bates on the banter hypothesis

I've just been watching Clive Bates talking to Brent Stafford on Regulator Watch. Clive is always good value and he has some interesting thoughts on the theory that smoking/nicotine reduces COVID-19 risk. He also mentions this recent study which found - comprehensively - that smoking significantly reduces the risk of Parkinson's Disease.

Check it out.



Smoking and COVID-19 - what's new?

Forgive me for boasting, but I reached a personal milestone last month when an article of mine was classified as fake news by Facebook. The article discussed some of the many studies that have emerged in the last two months showing smokers to be significantly under-represented in the coronavirus wards of Europe, America and China. Those who stumble across on it on Facebook are now warned that it is ‘misleading’.

Admittedly, the headline was ‘Smoke fags, save lives’ and I did call on doctors to start prescribing Lucky Strikes. Perhaps I overstepped the line when I called for the British public to clap for cigarettes every Thursday evening. But surely the intelligent reader could tell these comments were tongue-in-cheek?

Joking aside, the hypothesis that smokers are at less risk of contracting COVID-19 has a growing weight of evidence behind it and is being taken seriously by serious people. There are now more than twenty studies pointing in that direction. In the last week, two meta-analyses combining findings from the scientific literature have been published. One of them suggested that smokers are 78 per cent less likely to ‘have an adverse outcome’ from COVID-19. The other suggested that smokers are 82 per cent less likely to be hospitalised with the disease in the first place. 

This is an enormous protective effect, if true. But is it? As you might expect, the medical establishment is not exactly punching the air with joy at this news and every alternative explanation is being thoroughly explored. There are certainly reasons to be sceptical. Some of the studies have not yet been peer-reviewed and most of them rely on crude comparisons between the number of smokers with COVID-19 and the number of smokers in the general population. A large study from the UK last week found that only 6.9 per cent of the people who died from the virus were smokers, but this translated into a slight reduction in risk, a slight increase in risk or no significant effect at all, depending on how the figures were adjusted for other factors.

It is also likely that the unfashionable habit of smoking is under-reported by people attending hospital with an acute respiratory disease, and yet it is difficult to believe that ‘shy smokers’ fully explain the exceptionally low rates of smoking recorded among COVID-19 cases. The percentage of smokers with the virus is typically around five per cent in countries where the smoking rate is between 15 and 30 per cent. Since COVID-19 attacks the lungs and preys on those with underlying health conditions, one would expect smokers to be over-represented in these studies. Instead, they are heavily under-represented.

It is natural to approach counter-intuitive findings with caution, but there is a difference between scepticism and blind denial. When asked about the smoking-coronavirus link on television recently, the celebrity doctor Xand van Tulleken said: ‘I haven't looked into this particular piece of research but I would discount it completely. It is definitely wrong.’ Public Health England’s only contribution has been to assert that smokers who contract COVID-19 are fourteen times more likely to die from it, based on a tiny Chinese study which included just five smokers. It is notable that those who are so eager to point out the potential flaws in the epidemiological evidence on smoking and coronavirus happily cite exactly the same kind of evidence when talking about obesity and coronavirus.

In any case, not all the studies have relied on a crude comparison with the national smoking rate. Studies from the USA and France have adjusted for other factors - including, crucially, age - and found that the significant protective effect still holds.

The working hypothesis is that nicotine is responsible. This is assumed because there are plausible biological mechanisms by which nicotine could confound the virus and because the prospect of smoking per se being the prophylactic is too terrible for doctors to contemplate. But it remains only an assumption. The French neuroscientist Jean-Pierre Changeux is currently carrying out experiments with nicotine patches, but he has yet to publish his findings. Other than that, the only real crumb of evidence comes from a study based on an online survey which concluded that vapers were 55 per cent less likely to get COVID-19.

Although smokers are less likely to be hospitalised with COVID-19, several studies have found them to have worse outcomes once admitted. With smoking banned in and around hospitals, this leaves open the intriguing possibility that smokers are less able to fight the virus once they are deprived of nicotine. This idea was raised by doctors at the Royal Glamorgan Hospital back in mid-March, before the lockdown began. They suggested that ‘the simple use of nicotine patches should be be urgently considered and discussed’. This advice fell on deaf ears, but perhaps giving nicotine patches to COVID-19 patients is not such a bad idea - and not just to smokers.


Previously published in the Telegraph

I have updated my list of smoking/coronavirus studies here.

Wednesday, 13 May 2020

Alcohol consumption in the lockdown

Cards on the table, folks. I don't know what's happened to per capita alcohol consumption during lockdown. Aside from the drinks industry and possibly HMRC, I doubt anyone has much of an idea.

The media keeps repeating the line that alcohol sales in the off-trade rose by 31 per cent at the start of lockdown, with the implication that alcohol consumption has soared. This is wrong, of course. Not only were people stockpiling it to consume over several weeks, but sales in the on-trade have fallen by 100 per cent.

If I had to guess, I'd say that overall alcohol consumption has fallen. People who only drink when they go out can no longer do so and whilst there will be plenty of people who drink more out of boredom, there may be more who don't want to or cannot afford to.

If you work in 'public health' you must think that alcohol consumption - and therefore alcohol-related harm - has definitely gone down. In neo-temperance ideology, consumption is driven by advertising, affordability and availability - and harm is driven by per capita consumption (or so they believe). I don't know what's happened with affordability, but advertising has all but disappeared (as it has in most industries) and availability has shrunk enormously as a result of 100,000 licensed premises closing.

Good news for the health of the nation, then? Not really, because neo-temperance ideology is bunkum. Per capita alcohol consumption is a distraction. We are bound to see a fall in the harms associated with the night-time economy, albeit at huge economic and human cost, but I'd be surprised to see a fall in self-inflicted health harms.

Figures published last month by Alcohol Change UK (formerly Alcohol Concern and Alcohol Research UK) seem to bear this out.

While much media coverage has focused on people’s drinking increasing, more than one in three of the 1,555 drinkers surveyed told us that they have either stopped drinking or reduced how often they drink, since the lockdown. Six per cent have stopped drinking entirely.

However, some people are drinking more often. Around one in five drinkers (21%) told us that they have been drinking more frequently since the lockdown. This suggests that around 8.6 million UK adults are drinking more frequently under lockdown. 

So more people are drinking less than are drinking more. However...

It is the people who were already drinking the least often who have cut down in the greatest number. Nearly half (47%) of people who drank once a week or less have cut down or stopped drinking, compared to just over a quarter (27%) of people who drank two to six times a week, and just one in five (17%) daily drinkers. Worryingly, nearly one in five (18%) daily drinkers have further increased the amount they drink since lockdown.

There is also anecdotal evidence from people who work with problem drinkers that the situation is getting worse. So much for the whole population approach.

In the BMJ, Harry Rutter and Adam Briggs, a pair of one club golfers from the 'public health' industry who called for lower speed limits, minimum pricing and more tobacco control as a response to the lockdown, are calling for exactly the same policies as a response to easing the lockdown. Fancy that!

They seem to accept that any decline in alcohol consumption in the last two months has not been accompanied by health improvements, and may have been accompanied by a worsening, but they have a predictable solution for that...

Drinking habits have also changed. A survey from the charity, Alcohol Change UK, suggests that up to a third of UK adults have reduced how much they drink compared to a fifth that have increased consumption. Whilst welcome, closer reading of the data tell us that those who drink most often are the least likely to have cut back—those dependent drinkers who are most likely to respond to policies such as minimum unit pricing

It was unfortunate timing for them that their blog post was published on the same day as the latest nugget from the official minimum pricing evaluation was published. Based on focus groups with social workers and health practitioners, it found that these professionals quite liked the idea in theory but didn't see any evidence of it working on dependent drinkers in practice.

Within this context, participants were, however, broadly supportive of MUP as a policy to address hazardous and harmful drinking at a population level. Participants felt that the increase in price may encourage people to reflect on, and possibly reduce their consumption, with positive implications for children and young people.

Participants, however, also suggested that MUP may have little positive impact on those who they described as having a possible dependency; for this group the view was that MUP would not be sufficient to address the perceived dependency. Contingent on whether and how someone’s preferred alcohol was affected by MUP, participants suggested this could mean increasing financial strain on families who may already be experiencing financial hardship. It could also mean people changing what they consume to get a better ‘return on the price’, for example, switching from strong white cider to vodka.

Anyone could have told the government this before it went ahead with the stupid, regressive policy. Indeed, many of us did.

Tuesday, 12 May 2020

Reforming Public Health England

The IEA's Definite Article show is a live interview every Monday at 6pm in which someone discusses an article they have written.

This week it was me talking about this article about public health funding. In the interview I give my thoughts about the recent changes to the lockdown laws, such as they are, and explain what I would do to Public Health England if I got the chance.



You can download False Economies: Myths about public health spending here.

Thursday, 7 May 2020

Myths about public health spending

I've got a paper out with the IEA today about public health spending. It starts with a discussion about whether cuts in public health spending left the UK unable cope with COVID-19. You can read more about that, plus some views on Public Health England, in an article I've written for the Spectator...

No country can prepare perfectly for a new viral pandemic, but Britain’s public health system has fallen conspicuously short. Why? The stock answer from many is ‘under-funding’ – but the NHS budget has continued to rise since 2010, albeit not at the unsustainable pace seen during the New Labour splurge.

Public Health England (PHE), whose ‘primary duty is to protect the public from infectious diseases’, was created in 2013 and spent over £4 billion in 2018/19, of which around £3 billion was handed to local authorities in ring-fenced grants. Local authorities have seen their budgets cut in recent years, but this has little bearing on Covid-19 since the responsibility for dealing with pandemics lies with PHE, the NHS and the Department of Health.

PHE’s budget for ‘protection from infectious diseases’ rose from £52 million in 2014/15 to £86.9 million in 2018/19. There have been no cuts in this crucial area. Still, £86.9 million is only 2 per cent of the public health budget. If you include routine vaccination programmes, the amount spent protecting the public from infectious diseases rises to 13 per cent. With the benefit of hindsight – and arguably without it – it could be argued that this was not enough, but that does not necessarily imply that the overall public health budget was too small. The real question is what happened to the other 87 per cent.


The paper goes on to talk about the cost-effectiveness of public health spending. It is often claimed that 'prevention is worth a pound a cure' and that cuts to public health spending are a 'false economy'. Leaving those clichés aside, it is possible to evaluate the return on investment. It's difficult to tell whether the UK spends too much, not enough or the right amount on public health, but it is far from certain that it would be better to increase the budget rather than spend more on healthcare. Either way, spending decisions shouldn't be based on pseudo-economics.

There's a taster of what I say in this blog post for the IEA.

Many of the arguments made for increased spending on public health are based on a misunderstanding of economics. A study published in the Journal of Epidemiology & Community Health in 2017 is often cited as evidence that ‘[e]very £1 spent on public health in UK saves average of £14’. This implies a direct saving to taxpayers through the prevention of future healthcare costs, but that is not what the study looked at. It reviewed 52 pieces of research from around the world, covering a range of public health interventions, and concluded that, on average, they produced a return on investment to ‘the wider health and social care economy’ equivalent to £14 for every £1 spent. This is neither a cash sum nor a saving. The bulk of it comes from putting a monetary value on a year of life and multiplying it by the number of life years expected to be saved by the interventions.

Years of life clearly have value and there is nothing wrong with framing them in financial terms for the purpose of economic analysis, but the benefits that come from better health are largely intangible and are principally bestowed on individuals. For the most part, the ‘social value’ created does not yield a financial return on investment.

By way of analogy, a local council might decide to erect a statue to a revered character at a cost of £10,000. An economist could estimate its social value by finding out how much the residents are prepared to pay to keep the statue. If a thousand residents are prepared to pay £20 each, the social value of the statue is £20,000. This shows us that the statue has value, but it would be an obvious mistake to claim that the statue has boosted the local economy by £20,000 or has saved taxpayers £10,000.

You can download the whole report here.

Wednesday, 6 May 2020

Have 300,000 smokers quit because of COVID-19?


On Monday, I mentioned the claim from Action on Smoking and Health that 300,000 smokers have quit as a result of coronavirus fears. I said that it seemed unlikely that such a figure could be confidently derived from a survey of 1,000 people.

Simon Clark has got hold of the YouGov survey and my suspicions have been confirmed. As he explains...

Of the 1,004 people polled, 56% (562) were never smokers; 31% (307) used to smoke but have given up; 9% (90) smoke every day; and 4% (40) smoke but not every day.

In other words, only 13% of the sample (130) were current smokers, significantly less than the national smoking rate.

The most important group however were the 310 people (or 307 according to the data) who used to smoke because it's from their responses that ASH extrapolated the headline figure of 300,000 smokers who have allegedly been driven to quit 'over Covid-19 fears'.

I'm no mathematician and I've been struggling to get my head round the figures, but with a bit of outside help this is how I think they did it.

First, let's round up the figures so the sample size is 1,000 people of whom 130 were smokers, and 310 ex-smokers.

Two per cent of the 310 ex-smokers cited concerns about Covid-19 being the reason they quit smoking in the last four months.

That's six people, or 0.6% of the 1,000 people polled.

The adult population of the UK is approximately 50 million and 0.6% of 50 million is ... 300,000.
The bad news therefore is that the headline-grabbing figure of 300k appears to be based on the responses of just SIX (6) smokers who have quit in the last four months.

ASH's maths are roughly correct, but it is a massive stretch to convert six people into 300,000 people. It is very risky to form any conclusions based on a tiny proportion of people responding to a survey because, as I have said before..

...there are always going to be some respondents to surveys who don't read the question, don't understand the question, don't tick the right box or are having a laugh.

In total, the survey found 28 people who claimed to have quit in the last four months, of whom six said that they had quit 'solely or partly due to COVID-19 (e.g. because of; the health risk, not going to the shops to buy tobacco, no social smoking)' - ie. not solely because of 'coronavirus fears'.

Extrapolated across the whole country, this suggests that 1,350,000 people have quit smoking this year. Does that sound remotely plausible in a country which has 6.5 million smokers? At best, there is going to be a huge relapse rate.

As with most ASH research, the factoid about 300,000 Covid quitters deserves to go in the bin.

The dog that didn't bark

Here's a novelty. In this study, non-smoking is listed as a co-morbidity.


Why? Because it is a study of coronavirus patients in the New York City area and the last study from NYC showed that non-smokers were more likely to be hospitalised with COVID-19 than smokers.

The smoking rate in New York is 14 per cent, and 19 per cent of Americans are ex-smokers (this figure rate is probably higher in NYC). You might therefore expect at least 33 per cent of patients in this study to be ever-smokers. Indeed, given smokers' increased risk of underlying health conditions, you might expect that number to be a good deal larger.

In fact, only 16 per cent of the patients were ever-smokers. On the face of it, ever-smokers are around half as likely to be hospitalised with COVID-19 than never-smokers.

What do the authors of the study make of this? Nothing. Smoking is never mentioned, except in the table, and there is no attempt to produce risk ratios.

I suspect that the authors ran the numbers and didn't like what they found. I also suspect that they had the figures for current and former smokers separately but combined them (as the authors of the previous NYC study did).

We're not going to get anywhere if we leave stones unturned. Maybe there is nothing in the smoking/nicotine hypothesis - I certainly have my doubts - but we can't just ignore evidence we don't like. As Dr Ruth Propper says in the current issue of Nicotine and Tobacco Research...

“Whether we approve of the results from a societal or public policy perspective is beside the point.”

In science, that should really go without saying. 

Tuesday, 5 May 2020

Liberty versus the lockdown

I've written a short briefing paper about the UK lockdown for the IEA, explaining what you're allowed to do (not much) and the risks of any of these massive restrictions on civil liberties being retained a minute longer than they need to be.

I have been dismayed by the government's eagerness to extend the lockdown for a second time despite its having achieved its original objectives. On this, it seems to be responding more to public opinion than to its scientific strategy. Nothing wrong with that in a democracy except that public opinion has been formed by the government's daily insistence that the only way of tackling the virus is by staying at home.

I discussed my concerns on Sky News yesterday.



Deadly agency nominated for award

Having written about the 'public health' racket for well over a decade, I am not easily shocked by lies and corruption, but some stories still have the capacity to knock me for six.

Yesterday, Peter A. Briss of the Centers for Disease Control and Prevention (CDC) was nominated for a Service to America medal in the Science and Environment category. He is a finalist, and may yet win it, because he supposedly...

Identified the chemical compound in vaping products that caused life-threatening lung injuries among young adults, communicating the danger to public health and saving lives. 

In a staggering rewriting of history, we are told that the source of the disease was a 'mystery' until the CDC got to the bottom of it in November 2019:

All of these individuals vaped, inhaling an aerosol via an e-cigarette or other device, but it was a mystery to medical professionals why they suddenly were getting sick with what they would later call E-Cigarette or Vaping Use-Associated Lung Injury.

At the helm of the response was Dr. Peter Briss and a large Centers for Disease Control and Prevention team that, alongside federal and state scientists, conducted hundreds of labor-intensive studies and tests searching for clues. Within months, they discovered direct evidence that a chemical compound, vitamin E acetate, used in some vaping products, was the likely culprit in the disease. Since this discovery in November 2019, emergency room visits and deaths have decreased sharply.

And what was this discovery?

The team had a breakthrough in November 2019 when they found vitamin E acetate in vaping products containing THC, the active agent in marijuana, and, crucially, in the lungs of sick patients. Vitamin E acetate is an oily substance that was being added to THC products, and it was interfering with normal lung function in otherwise healthy people.

Indeed it was, but if the CDC discovered this in November, how could it be that a non-scientist like me, watching from the other side of the Atlantic, was writing this in early September?

The most likely culprit is Vitamin E acetate, an additive that has been used as a thickening agent on the black market since late last year. Vitamin E acetate is not safe to inhale and has been linked to lipoid pneumonia, which can be fatal. Whatever the killer chemical turns out to be, it is not nicotine.

The answer is that it was already common knowledge to anybody who was paying attention. The New York State Department of Health identified Vitamin E acetate as the problem in August.

"Our laboratory was the first to identify vitamin E acetate in vaporizer fluids recovered from pulmonary injury patients, which we promptly reported to officials of the U.S. Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA) and public health officials from numerous states via conference call and via e-mail on August 19, 2019," said David C. Spink, Ph.D., Chief of the Laboratory of Organic Analytical Chemistry at Wadsworth and corresponding author of the study.

 "Based on our work, the New York State Department of Health issued a press release on September 5, 2019 indicating that vitamin E acetate was a key focus of the Department's investigation of potential causes of vaping-associated pulmonary illnesses."

On 24 September, journalists at Leafly had discovered everything that needed to be known about the 'epidemic'. If awards are going to be dished out, there should be a Pulitzer Prize for this article telling the full story of how Vitamin E acetate got into the THC black market.

What was the CDC doing while all of this was going on? They were doing their best to shield the truth from the American public, telling them in so many words that conventional nicotine vaping was deadly. As I wrote in September...

The CDC has been the worst offender, using weasel words such as ‘e-cigarette product use’ and ‘vaping or e-cigarette use’ to describe the behavior which led to the recent deaths. When asked in a press conference how a product that has been around for a decade could suddenly cause an acute epidemic, the CDC’s Brian King suggested that the problem had been around the whole time but was only becoming visible thanks to ‘increased diligence’. He put the blame squarely on conventional e-cigarettes, saying: ’We do know that e-cigarettes do not emit a harmless aerosol. They can include a variety of potential harmful ingredients, including ingredients that are harmful in terms of pulmonary illness… we know there’s a variety of constituents in e-cigarette aerosol that could be problematic in terms of illness.’ Again, not a complete lie, but far from the truth.

The FDA was slow to wake up to the real causes of the ‘mysterious lung illness linked to vaping’, but it got there in the end. On Friday, it published a sensible warning on its website, telling Americans to ‘avoid buying vaping products on the street, and to refrain from using THC oil’. The CDC, however, simply reiterated its advice that people shouldn’t vape anything, ever.

The CDC is playing a dangerous game. When a bad batch of drugs appears on the streets of Britain, the police do not issue a general warning against taking drugs. Instead, they describe what the bad batch looks like so that drug users can avoid it. Why? Because telling people not to take drugs doesn’t work. Telling people to avoid a particular bunch of green Ecstasy pills does. By the same token, the CDC’s policy of telling people not to vape is not only a tacit instruction to smokers to keep smoking, but is a less effective way of tackling the current spate of hospitalizations than telling people to steer clear of black market THC cartridges.

It wasn't until January 2020 that the agency finally withdrew its advice for everyone to stop vaping and accepted that illegal THC cartridges were the problem.

The CDC's misinformation last autumn almost certainly killed people. The idea that anyone at the agency be rewarded for their response is a sick joke.


 


Monday, 4 May 2020

Smoking and COVID-19: evidence update

UPDATE 16 May

A UK study in Lancet Infectious Diseases found that smokers were half as likely to test positive for the coronavirus. The unadjusted odds ratio was 0.59. After adjustments it was 0.49. This is important because it suggests that smokers are under-represented in coronavirus wards because they are less likely to contract the disease in the first place (and not necessarily because they are less likely to develop severe symptoms). A French prevalence study published last month suggested the same thing.

Chinese study of 202 COVID-19 patients finds that only 7.9 per cent had any smoking history. The authors don't comment on this finding. (The Chinese smoking rate is 27 per cent.)

Study from Kuwait finds that only 4 per cent of COVID-19 patients were smokers, but finds that smokers were more likely to progress to intensive care and die.

Swiss study finds only 4.5% of COVID-19 patients are active smokers. The authors don't mention this in the text.

Study from Mexico finds a smoking prevalence among patients of 9%. If admitted, smokers were somewhat more likely to need ICU and less likely to survive.

Spanish study based on an online survey finds that vapers and tobacco users are half as likely to get the coronavirus. Odds ratios are (0.45 95% CI 0.28-0.71) and (0.52 95% CI 0.27-0.98) respectively. Not the strongest study but in line with the first study in this list and the first to look at e-cigarettes.



UPDATE 12 May

Two meta-analyses have been published in the last week. Farsalinos et al. suggests that smokers are 78 per cent less likely to ‘have an adverse outcome’ from COVID-19. Gonzalez-Rubio et al. suggests that smokers are 82 per cent less likely to be hospitalised with COVID-19.

Two new studies came from Italy. Colombi et al. found that only 2.5% of COVID-19 patients were current smokers. However, the same table appears to show that 7.6% were smokers. The authors don't produce odds ratios or comment on the smoking findings.

The other Italian study (Gaibazzi et al.) is titled 'Smoking Prevalence is Low in Symptomatic Patients Admitted for COVID-19.' It finds that only 4.8% of COVID-19 patients were smokers, despite the national smoking rate being 24%.

A large study from the UK (Williamson et al.) found that only 6.9 per cent of the people who died from COVID-19 were smokers. This translates into a 20% reduction in risk, a 20% increase in risk or no significant effect at all, depending on how the figures are adjusted for other factors.

Finally, a study from New York published last month that I had previously missed found that only 5.1% of COVID-19 patients were smokers. The authors do not comment on this.


ORIGINAL POST

ASH reckons that 300,000 people have given up smoking as a result of COVID-19 fears. I share Taking Liberties' suspicions about this figure. It is derived from a survey of 1,004 people which found that two per cent of smokers had quit in recent weeks. The poll isn't available online at the moment, but if it was representative of the UK population - as it is obviously supposed to be - there would be about 150 smokers in it. If two per cent of them quit, that is three people. It seems bold to take such tiny numbers and translate them into the claim that 300,000 smokers have quit.

Be that as it may, ASH say that there has never been a better time to quit. Given how few smokers are being hospitalised with COVID-19, one could argue the opposite. If the evidence continues to show smokers under-represented in coronavirus wards, the hashtag #QUITFORCOVID could take on a sinister double meaning.

How is the evidence looking? Last week didn't see as many new studies as the previous week, but there were a few worth mentioning.

The NEJM published a study of 8,910 COVID patients from '169 hospitals in Asia, Europe, and North America'. Unusually, it found that white people were more likely to die from the disease once admitted to hospital than other ethnic groups. It also found that smokers were more likely to die once admitted. However, although the authors didn't comment on it, it also showed that there were fewer smokers admitted to hospital than you would expect. Just 5.5% were current smokers, well below the average in almost any country.

After finding that only 1.3% of patients were smokers in its last report, the US Centers for Disease Control have stopped publishing data on smoking - which is, er, odd. However, a few states are still doing so. In Georgia, the rate is just 5.2%. In Oregon, albeit from a smallish sample, the rate is 1.4%. There must be some more statewide data. Let me know if you find it.

A large study of 16,749 COVID patients in the UK was published last week. The authors don't discuss smoking specifically, but one of their graphics suggests that the smoking rate was around five per cent. The smoking rate in the UK is around 15 per cent.

I have my doubts about this chart. The study is based on a massive dataset from ISARIC which holds information on 19,809 COVID patients, of whom 514 were smokers. That is a tiny proportion, but smoking status is only established for 5,924 of them so a better estimate is that 8.7% of the patients were smokers. That is still well below the national rate.

Also of possible interest, there was a study of 226 victims of a coronavirus (but not COVID-19) in Toronto, Canada which found that: 'Only 3.1 % of patients were current smokers'.

I'll use this blog post as a holding page for all relevant studies so, for the sake of completeness, here's the story so far:

The smoking rate of COVID-19 patients in Chinese hospitals was 10 per cent in Yang et al., 6.7% in Wan et al., 3.9% in Mo et al., 7% in Huang et al., 9% in Dong et al., 1.9% in Guan et al., 6% in Zhou et al., 1.4% in Zhang et al., 9.4% in Du et al. and in 6.4% in Liu et al. In Shi et al., only 8.2% of cases had any smoking history. The smoking rate in China is 27%.

The highest smoking rate recorded in any of the studies is 18.5% in Kim et al.'s study from South Korea and that is still well below the national smoking rate. In New York, it is 6.7%.

This study from the USA looked at 3,789 US military veterans aged between 54 and 75 who were tested for COVID-19, of whom 585 tested positive. Smokers were heavily under-represented with an odds ratio of 0.45 (95% CI 0.35-0.57), ie. they were 55 per cent less likely to test positive.

This study of 661 people tested for COVID-19 in a badly hit area of France reported that: 'Smoking was found to be associated with a lower risk of infection (7.2% versus 28.0% for smokers and non-smokers, respectively), and this association remained significant after adjustment for age (OR = 0.23; 95% CI = 0.09 –0.59) or occupation (OR = 0.27; 95% CI = 0.10 –0.71).'

This suggested that smokers were 70-80 per cent less likely to test positive for COVID-19, in line with a previous study from France.

Finally, there is some evidence that smokers are more likely to suffer complications and/or die once hospitalised with COVID-19. Then again, there is evidence that they don't. See this post for a discussion of that.

Let me know if I've missed any studies (note that I am not including reviews, meta-analysis or commentaries).

Sunday, 3 May 2020

Something, something, COVID-19

Over on Twitter I have been curating a list of people using COVID-19 as justification for doing things they have always wanted to do. It's quite a long list.

A particularly tenuous effort appeared in the Sunday Times today:


Covid-19 crisis sparks new call in Scotland for tobacco levy


The 'new call' comes from ASH Scotland, a state-funded pressure group that has been campaigning for a tobacco levy for years.

What is the connection with COVID-19? Alas, they can't really tell us and have to resort to some impressive mental contortions to even imply that there is a connection.

Scotland’s leading anti-smoking charity is backing calls for a minimum unit price (MUP) on tobacco after scientists said “now is the time” to tackle the largest preventable cause of chronic disease.

Is it, though? Wouldn't it be better to direct all our energy towards a genuine public health threat that has killed over 20,000 people in Britain and has consigned us to an economically devastating lockdown? Maybe tinkering with the price of cigarettes - which are already among the most expensive in the world - can wait.

Ash Scotland is supporting a new levy similar to that introduced in Scotland on alcohol products two years ago. It would see the price of cigarettes and tobacco rise with the aim of persuading more smokers to quit.

Minimum pricing for alcohol doesn't seem to have worked and the price of cigarettes does rise every year as a result of regressive sin taxes. Moreover, there is already a minimum price for cigarettes because there is a minimum excise duty.  

Ash Scotland said that in addition to a minimum unit price, it would like to see a price cap at the top end of the market to prevent the tobacco industry from shifting price increases from cheap to premium products.

They want to prevent some cigarettes becoming more expensive? That's a new one.

The charity’s support for MUP is echoed by three leading academics in Scotland.

Wow, three people! No wonder a major newspaper has chosen to cover this story.   

The three academics can be fairly described as the usual suspects.

Professor Mike Lean (University of Glasgow), Richard Simpson (University of Stirling) and Professor Linda Bauld (University of Edinburgh) said wider measures should be considered such as reducing tobacco availability and introducing minimum pricing. “Now is the time to align how we respond to the largest preventable cause of chronic diseases — smoking — with our response to Covid-19.”

It is not at all obvious that 'this is the time', nor is it obvious that making tobacco even more expensive will 'align' anti-smoking policy with the COVID-19 response. Have we been using the price mechanism to reduce coronavirus infections?

In an open letter, the academics described it as “perverse” that tobacco is still being advertised outside convenience stores...

I cannot even guess what they mean by this. Tobacco advertising has been completely banned for the best part of twenty years.

And, once again, what has any of this got to do with COVID-19?

“We do not have good evidence that smokers are at higher risk of contracting Covid-19, but it is safe to say that stopping smoking will help with recovery.”

That's one way of putting it. Another way of putting it is that smokers are at less risk of contracting COVID-19 and are at less risk of being hospitalised with COVID-19. It is not 'safe to say' anything at this point. As the aforementioned Linda Bauld said recently, 'there's something weird going on with smoking and coronavirus'. 

The Sunday Times article alludes to this...  

There is a suggestion, however, that smokers could be less likely to catch coronavirus. In France, an in-depth study conducted by the Pasteur Institute, a leading research centre into the disease, found that four times fewer smokers contracted Covid-19 than non-smokers. Scientists believe nicotine in cigarettes could be behind the surprising results but more research is needed.

The journalist was apparently unable to get a response from the activist-academics to these interesting developments and so moves on to the temperance lobby instead.

On Friday, health professionals marked the second anniversary of minimum unit pricing on all alcohol sold in Scotland with a warning to policy-makers not to let momentum slip post-Covid 19.

In the case of Scottish Health Action on Alcohol Problems (SHAAP), another state-funded pressure group, they marked the anniversary by doing what they so often do: lying. This, from the Evening Express...

Shaap chairman Dr Peter Rice said there has been a “substantial fall” in the number of deaths in the 24 months since the policy took effect.

There is no published evidence to suggest this.

SHAAP get a quote in the Sunday Times article too...

“People should be in no doubt about the ferocity and determination of global alcohol producers in seeking to overturn MUP and other policies that affect their profits,” said Dr Eric Carlin, director of Scottish Health Action on Alcohol Problems.

Sorry to break it to you, Eric, but forcing companies to charge more than the market price for their products is more likely to increase their profits than reduce them. If the booze companies got together and agreed to do minimum pricing voluntarily, they would be hauled up for price-fixing.

“We will need to build on progress made prior to the pandemic and to regain the momentum with policies, including MUP that reduce alcohol-related harms, which disproportionately affect the poorest communities.”

Yes, it's important to remember the real victims of COVID-19: neo-temperance campaigners who have lost the momentum in fleecing the poor.