Polemics - out now!

I've spent a bit of my lockdown compiling an anthology of old articles and essays for an e-book. It's called Polemics and it is now available. (You'd think somebody would have already published a book by that name, but apparently not.)

It contains 42 articles published online between 2010 and 2020. Ten of them first appeared as blog posts here. The rest appeared on various websites, not all of which still exist. One of them was never published at all. All have been touched up and improved, often substantially. And I've given each of them an introduction.

Because there's an element of money-for-old-rope about this, I have priced it at a recession-proof £2.99 in the UK, $3.99 in the USA and a commensurate amount elsewhere. So if you want some bitesize reading for less than the price of a pint*, you can buy it here in the UK and here in the USA.

Here's the table of contents:

Paternalism

1. The disease of public health and its cure

2. Is the nanny state caused by socialised healthcare?

3. The importance of defending small liberties

4. Sugar: the new monster under the bed

5. The politics of ‘public health’

6. We should stop panicking about Boozy Britain

7. The prohibitionist’s dilemma

8. Jamie Oliver’s Sugar Rush

9. Whatever happens, we’ve won

10. Everything is somebody else’s fault

11. Ignore children and teenagers

12. How not to re-legalise cannabis

13. Planning for prohibition

14. Healthy new towns for a healthy new breed of man

15. Good riddance to the nanny-in-chief

16. Unlearning the lessons of Prohibition

17. Evidence-based puritanism

Politics

18. George Monbiot and stupidity

19. Conspiracy theories: Back and to the Left?

20. Sweden: An apology

21. Reflecting on the 2015 election

22. State schools should be banned

23. Post-truth

24. The ten maddest Remainer moments

Economics

25. Bootleggers and Baptists in the nighttime economy

26. The Happy Planet

27. The economics of Christmas

28. The opportunity cost of explaining opportunity costs

29. Every e-cigarette user should be a free market libertarian

30. There is no minimum pricing windfall

31. The price of rice and alcohol

32. Healthy food is expensive, if you look at it in a certain way

Science

33. The grit in the oyster

34. A tale of two epidemiological findings

35. A new low for health reporting?

36. Drinking and the radio

37. The illusion of evidence-based policy

Culture

38. I, too, hate the Olympics

39. Inception: a review

40. Freeloaders on the land

41. If Breaking Bad was really set in Britain

42. To mute is human, to block is divine


Amazon reckons the print equivalent of Polemics is 112 pages long. It's actually 230 pages. The whole thing is 50,000 words long.

Also, don't be deterred by the 'Look Inside' feature that makes the formatting look dodgy. I assure you that it's spot on.

Any problems, you know where to find me.

* Of beer, in a pub (excluding Wetherspoons).

Last Orders with Konstantin Kisin

There's a new Last Orders podcast out and it's a good one. This time we're joined by the comedian and Triggernometry host Konstantin Kisin to talk about internet censorship, cancelling, lockdown and the Black Lives Matter protests.

Listen below or on your usual device.

Australia delays nicotine ban after backlash from vapers

Following on from Wednesday's post about the once-in-a-lifetime stockpiling by Australian vapers as they prepare for a ban on personal imports of vape juice, I'm pleased to report some good news...

Greg Hunt has delayed the introduction of a ban on imports of liquid nicotine for vaping by six months, after his unilateral decision prompted widespread backlash on the Coalition backbench.

The health minister announced on Friday the ban will now apply from 1 January, with a “streamlined process” for patients to get a prescription from their GP.

The backdown came just two days after Coalition MPs began to openly campaign against the ban and one day after the government made a regulation for the ban to apply from 1 July.

What that 'streamlined process' will involve, I know not. There is a suggestion that vapers will be able to get e-cigarette fluid on prescription, which would be better than nothing in that puritanical country. At the least, the six month delay this allows the government time to have a rethink.

The Guardian article quoted above presents this partial U-turn as the result of a backbench revolt. It doesn't mention that Aussie MPs have had their phones ringing off the hook as furious e-cigarette users expressed their dismay. As Donald Trump found out last year, you don't mess with vapers.

In the Australian, Peter Hoystead suggests that the plan to ban vape juice imports is about protecting tobacco tax revenue. Surely not!

The great Australian nicotine airlift

The stupid Australian government is banning the importation of e-cigarette fluid on July 1st. This has led to a massive, Dunkirk-style effort by vapers to stock up for the rest of their lives.

One retailer in New Zealand had to stop taking orders earlier this week because it couldn't cope. I dare say they were others.

We're extremely sorry we had to take the site offline earlier than planned, and we're keenly aware how devastating this decision will be for those who thought they had more time and didn't make the cut-off.

Frankly, we underestimated just how crazy things would get: over 10,000 people placed huge orders in the last 24 hours, and our number one priority has to be making sure that every single parcel gets shipped before the government's ludicrous deadline.

My eyes were opened to the lengths to which Aussie vapers were going when I received an e-mail from a reader yesterday. With his permission, I am quoting part of it below. For reasons that will become obvious, he wishes to remain anonymous.

Never in the history of Australian airport customs will they have seen what they are seeing this week. Literally tens of thousands of litres of nicotine is coming in on cargo planes. It is 'The Great Australian Nicotine Airlift'.

Just think of it, I am in the market for a new garage freezer to store all my nicotine in, I've had to rapidly learn how to inject argon gas into the glass bottles I bought to rebottle the nicotine and make it last decades, which chemists and amateur storers say can be done if you do it right, and very carefully preserve it in the deep freeze.

However, chest freezers are sold out in Australia right now due to the panic buying of meat from Covid.

So twice in one year, a need for chest freezers based on panic buying created and instigated by the government.

I've never spiked my own juice in my life. I hope it tastes neutral when I do it. I bought several years of readymade nicotine-containing Black Note tobacco extracted liquid which in my opinion is the closest vape to a cigarette in the world, but that will run out in 2022 and I'll have to start using the nicotine supply from the freezer to spike the zero-nic Black Note which allegedly will still be permitted to be imported.

As to be expected, there is a lot of naive people online drafting emails to the health minister. They'll get nowhere.

The Australian vaping scene spread by word of mouth, because vape shops are not allowed to sell nicotine, and each new recruit to vaping had to be laboriously trained by a friend or family member in the ways of vaping. I had to train my boomer relatives the in the ins and outs of the learning curve, the techniques one must master, tanks, mods, nic levels, wattage levels, changing the mass produced coils, etc. Nobody ever saw a vape ad on the side of a bus in Australia, nobody ever saw vape shops on the high street except in very rare cases, dozens nationwide at best.

So somehow the vaping population grew, mostly from online reading and forums and knowing someone who vaped, and mail order international import sales, to an estimated 300,000 vapers, out of a nation of 2.7 million smokers, out of the 24 million Australians.

The pride the public health establishment take in being 'world leaders' on ripping away big tobacco's intellectual property rights and forcing poo brown plain packaging, and the massive cig prices, is huge. They were never going to let their reputation as 'leaders' in tobacco/nicotine habit control be taken away by a mid-2010s new interloper, vaping.

In 20 years, a tiny population of die hards, me included among their number, will be traipsing out to the garage freezer to get a few millilitres of nicotine purchased in a panic buy 20 years prior.

No matter how many times the media and elites are reminded 'The UK and NZ don't do this', they just see the UK and NZ as insanely liberal on vaping and they refuse to budge an inch.

It is rather degrading actually, to be stuck here. A despair has come over me. I was energised the first two days, busy purchasing nicotine and eliquid and researching agron gas storage and freezer sizes, but now I am just reminded of the general loss of liberty society-wide in many areas.

Imagine having to talk to chemists in forums about how long drugs, and nicotine, can have its life extended as long as possible, because government constantly bans things and you're reduced to cherishing an irreplaceable stockpile and figuring out how to conserve it.

The panic buying of nicotine I've seen this week is dangerous, in that people who are total neophytes at handling the industrial grade - sometimes gallon! - bottles of freebase nicotine, will be buying this stuff to chuck in their freezer with no training, just because they heard on the panic grapevine via Facebook that this is what to buy.

Australian customs may well even act BEFORE the July 1st deadline, because what's coming in on cargo planes is just unprecedented. Tens of thousands of litres of pure concentrated nicotine freebase.

I couldn't believe when a lady who had no idea about vaping, only started vaping a month ago, said she'd just bought a gallon bottle of freebase nicotine from America.

I'm glad for her, but tens of thousands of brand new freebase nicotine customers, CAUSED BY the government clowns, there's gonna be a few nicotine overdoses believe me. 100mg/ml nicotine can burn through your fingers if you don't use gloves and make you very sick.

It is bedlam right now. The limp 'advocacy' attempts will come after July 1st. Right now it's just about filling up those freezers. I am told my new freezer is on the way, meanwhile I have to deal with five courier packages this week for myself, and have to worry about my relatives not going back to cigarettes by guiding them on how to buy freebase nicotine in a rapidly dwindling market where numerous shops online are just saying 'no more Aussies'. A big supplier in Hong Kong called 'HiLiq' simply said no more Australians we can't handle the demand.

It's just so ugly... loss of liberty. It really is.

Australia to ban e-cigarette imports

Just when you think that Australia's policy on vaping couldn't get any more stupid...

To reduce the risk to public health through addiction to nicotine and nicotine poisoning, the Australian Government intends to ask the Governor-General in Council to make regulations from 1 July 2020 prohibiting the importation of e-cigarettes containing vaporiser nicotine (nicotine liquids and salts) and nicotine-containing refills unless on prescription from a doctor.

Domestic sales are already banned, leaving Australia's 300,000 vapers dependent on mail order sales from abroad. As the Australian Tobacco Harm Reduction Association says...

The plan announced today by the Health Department to block the importation of nicotine for vaping is effectively a death sentence for hundreds of thousands of Australian vapers and smokers.

Many vapers will go back to smoking and smokers will be denied access to a legitimate quitting aid. Vapers who try to import nicotine illegally from 1 July will be fined $220,000!

The proposal continues the governments wanton disregard for the growing scientific evidence and effectively denies Australia’s smokers access to vaping, the world’s most popular and effective quitting aid.

This is a cruel blow for Australia’s marginalized and disadvantaged communities which have far higher smoking rates and lower quit success than the rest of the community. Australia's high cigarette prices cause serious financial stress in the population. Vaping is 90% cheaper than smoking and can reduce health and financial inequalities.

Clown country.

The Global Nicotine Forum starts today - free and online

As mentioned in a previous post, the Global Nicotine Forum starts at 11am UK time today. I am told that well over a thousand people have registered.

Registration is here: https://gfn.events

The live stream is here.

The hashtag is #GFN20

This is their press release:

Global pandemic of smoking-related disease to kill seven million more in 2020: viable solutions blocked by moral panics and Big Philanthropy

Scientists and experts in public health and tobacco control are highlighting the need for 1.1 billion smokers, and millions of adults who have switched away from smoking, to access appropriately regulated safer nicotine products such as vapes (e-cigarettes), Swedish snus, nicotine pouches and heated tobacco products, an approach called tobacco harm reduction.

This year, the seventh annual Global Forum on Nicotine (GFN), the only international conference focused on safer nicotine products’ role in reducing smoking-related harms, is a free online conference (Thursday 11/Friday 12 June) due to COVID-19.

Thirty experts are speaking on a diverse range of topics related to nicotine, including the latest evidence on the interplay between nicotine, smoking and COVID-19; the impact of the deliberate and continued misattribution of the so-called ‘EVALI’ lung-injury crisis to nicotine vaping instead of illicit THC; moral panics over low youth vaping rates taking precedence over the health of millions of adult smokers and vapers and Big Philanthropy’s effect on global public health.

Smoking is the single biggest cause of non-communicable disease (NCD). It kills half of all those who smoke. The Global Burden of Disease study estimates that smoking directly accounted for 7.1 million premature deaths in 2017, with an additional 1.2 million deaths attributed to second-hand smoke.

For decades it has been known that it is the burning of tobacco, and the release and inhalation of smoke, that causes disease. Nicotine itself is not a carcinogen. The UK Royal College of Physicians recognised in a 2016 report that “any long-term hazards of nicotine are likely to be of minimal consequence in relation to those associated with continued tobacco use.”

While tobacco control efforts led by international agencies such as the WHO have lowered global smoking rates, much remains to be done. 80% of the world’s smokers live in low and middle income countries, those least able to implement tobacco control measures and with healthcare systems least able to cope with the disease burden of smoking.

Many smokers can quit alone or with nicotine replacement therapies (NRT). Many cannot, or are unable to access or afford NRT. Where available and affordable, safer nicotine products such as vapes and snus give smokers more options to leave combustible tobacco behind.

International tobacco control operates along prohibitionist lines, despite harm reduction approaches being successfully integrated into the response to many other public health issues since the 1980s.

GFN conference director Professor Gerry Stimson, emeritus professor at Imperial College London and former honorary professor at the London School of Hygiene and Tropical Medicine, said:

“Tobacco harm reduction is good public health. It starts with the people who matter – people who smoke, and people who have switched to a chosen alternative – and it fosters and encourages change. Tobacco harm reduction is not antithetical to tobacco control; it should be part of it.

“Currently, obstacles to widespread adoption of tobacco harm reduction include big US philanthropic foundations with a myopic view of tobacco control, creating divisions where none should exist, and international organisations wedded to a narrow view of what defines success. The global public health community must develop more ambition about what can be done – as well as a healthy dose of compassion for the individuals living with the consequences of inaction, of whom around seven million will die this year.”

Professor David Sweanor, of the Centre for Health Law, Policy and Ethics at the University of Ottawa, is a speaker at GFN. As a lawyer, he was instrumental in regulation of tobacco products and in lawsuits against tobacco companies. He said:

“Consumers in many countries including Sweden, Norway, Iceland and now Japan have shown they move to alternatives to cigarettes when they get an option to. Imagine what would happen if people get access to a broad range of low-risk alternatives to cigarettes, if they get information on relative risk, and if they’re nudged toward those options through intelligent, risk-proportionate regulation? The opportunity we have is to fundamentally change the course of public health history, relegating cigarettes to history’s ashtray.”

Usually, GFN is funded solely by registration fees. This year, it is offered for free with the organisers bearing the cost. The event has an open door policy. Consumers, policymakers, academics, scientists and public health experts participate alongside representatives from manufacturers and distributors of safer nicotine products. The event organisers believe that dialogue and strategic engagement of all stakeholders involved in tobacco and nicotine use, control and production is the only way to effect true, sustainable change - both to industry practices and the public health outcomes related to smoking.

Alcohol sales after minimum pricing

I had a slight sense of déjà vu this morning when I saw this story...

Alcohol off-sales drop credited to minimum unit pricing

There has been a decline in alcohol consumption in Scotland's population, official data suggests. 

A report published by Public Health Scotland said there had been a reduction of between 4% and 5% in Scotland's shops in the year after minimum unit pricing was introduced.

Haven't we been here before? Ignore the reference to the recently formed Public Health Scotland. This is the MESAS evaluation again. 

This time last year, MESAS reported a 2.9 per cent drop in alcohol consumption in Scotland in 2018. Not a particularly impressive statistic, but the media nevertheless treated it as the final proof that minimum unit pricing (MUP) 'works'. 

What does the new study add? Well, it only looks at off-trade sales, for a start. And it looks at the full twelve months after minimum pricing was introduced, rather than the calendar year of 2018 (MUP began in May 2018). As it is an evaluation of minimum pricing (which only affected the off-trade), this is good.

It also makes various adjustments to the data, using England and Wales as a control group. We'll come to that in a moment, but let's first look at the findings.

The report finds that off-trade sales fell by 2.6 per cent in the first year of MUP (compared with the year before). Spirits sales fell by 2.4%, wine by 1.3%, cider by 17.4% and beer by 0.7%. Sales of fortified wine rose by 6.7% and the sale of ready-to-drink beverages rose by 12.3%.

In England and Wales, meanwhile, there was a 2.3% rise in off-trade alcohol sales. Put very simply, if you assume that the trend in Scotland would have been similar to that of England and Wales in the absence of MUP, the impact of MUP was to reduce alcohol sales by 4.2%. That is the headline figure in the report. Figures of -4.5% and -4.8% also appear, depending on adjustments. This is the source of the claim that there has been 'a reduction of between 4% and 5% in Scotland's shops'.

If you need a control group for a natural experiment of this kind, England and Wales are as good as it gets, culturally and economically, but if you look at the trend over the years, they are not a great counterfactual. There have been several years in the recent past when consumption has gone up in Scotland and down in England and Wales, or vice versa. The trends don't always go in the same direction, let alone at the same rate. 

Nor should you expect them to. Beer sales seem to have risen in the summer of 2018, for example, and the authors of the new report note that this was probably influenced by a heat wave. They argue that this helps explain why overall beer sales barely fell in Scotland in the first twelve months of MUP. However, they note that there was a 4.9% increase in beer sales in England and Wales and conclude that 'the legislation was associated with lower off-trade beer sales in Scotland than would have been the case in the absence of MUP.'

Perhaps so. It was certainly a hot summer, but it was hotter in England than it was in Scotland, and there was a World Cup that year that England was in and Scotland wasn't. You would therefore expect more beer sales in England regardless. You can't treat England as if it was just Scotland without MUP.  

A further problem is that sales in Scotland are not wholly independent of sales in England. Many people in Scotland have reported going on booze runs to Carlisle and Berwick since minimum pricing was introduced. It is difficult to estimate how much alcohol sold in England is consumed in Scotland, and nobody has really tried, but it has surely increased since May 2018. This will have inflated the sales figures for England and reduce the sales figures for Scotland.

The authors of the new report say it is 'highly unlikely that cross-border purchasing could account for the net effect of MUP reported here.' Of course it doesn't account for all of it, but how much does it account for? We will probably never know.

Finally, there is the issue of the sales figures themselves. They do not all come from till receipts, by any means. A lot of them are the result of modelling, estimating and adjusting by the authors. I wrote about that in this briefing paper. It is not a trivial issue.

All the same, based on the evidence published so far, I think sales probably went up a bit in the summer and went down a bit overall. The claim in the BMJ last year that sales fell by 7.6% in the first eight months was activist junk, but a decline of some magnitude is no more than you would expect from the law of demand. It doesn't seem to have been a large decline, and any divergence from England and Wales had no effect on alcohol-related mortality - which, let's not forget, is supposed to be real target of the policy.

But the authors go too far when they start making claims like this:

In unadjusted analysis, the introduction of MUP was associated with a 6.7% (3.1% to 10.5%) increase in the volume of pure alcohol sold as fortified wine per adult in Scotland. In England & Wales, there was a 6.0% (-8.2% to -3.8%) decrease over the same time period. In the unadjusted, controlled model, MUP was associated with a 4.8% (0.4% to 9.3%) increase in off-trade fortified wine sales in Scotland, which increased slightly after adjustment for disposable income and substitution (5.7% (1.3% to 10.3%)).

So there was a 6.7% rise in fortified wine sales in Scotland and a 6% decline in fortified wine sales in England and Wales. Given that England and Wales are supposed to be the control group, this implies that MUP led to a really big rise in fortified wine sales. And yet the Scottish figure goes down after adjustment??

As it turns out, even the 6.7% rise in the 'unadjusted analysis' was the result of adjustments:

...we were able to take into account underlying trends in the data series through the analytical method employed. This allowed us to strengthen the interpretations we made in our descriptive analysis and more confidently isolate the impact of MUP. For example, based on our descriptive analyses, we reported that off-trade sales of fortified wine increased by 16% in the year after MUP was introduced.

So it actually rose by 16%.

However, we also noted that this was a continuation of an already upward trend. Using SARIMA in this study, thereby adjusting for this existing trend, we found that MUP was associated with an increase of less than half of this magnitude.

Once they adjust for 'seasonal and secular trends', they manage to show that minimum pricing led to a 5.3% decline in the sale of fortified wine! 

I'm sorry, but that's just being silly. Even people who work in the drinks industry can't predict next year's category sales based on 'existing trends' and if there's one thing everybody agrees on, it has that minimum pricing in Scotland has led to a rise in fortified wine sales. Buckfast, in particular, is an obvious substitute for strong cider and was already sold at more than 50p per unit before minimum pricing was introduced. Its sales reached a record high last year and it has overwhelming dominance in the fortified wine category.

Minimum pricing campaigners lie, but sales figures don't. Any analysis that turns a 16% rise into a 5% decline is highly suspect.

I've been relatively impressed with MESAS evaluation so far (I have low expectations), but this kind of black-is-white overreach does it no credit.

The inevitable face mask U-turn

Nothing was more inevitable than the British government making face masks compulsory - starting with public transport - but what a ride it has been. As with everything involving the coronavirus, we are just copying the rest of the world with a lag of a month or two

Everyone knew the government was only discouraging people from buying face masks because it wanted to make sure medics had a good supply of them. And everyone knew that face masks provided some protection against the virus because that's why medics use them.

The government's concerns were perfectly understandable, but it must have known a U-turn would eventually come, so why did the authorities leave so many hostages to fortune?

In a document from February that deserves to go down in infamy, Public Health England said that even medical staff wouldn't generally need to wear face masks:

During normal day-to-day activities facemasks do not provide protection from respiratory viruses, such as COVID-19 and do not need to be worn by staff in any of these settings.

Facemasks are only recommended to be worn by infected individuals when advised by a healthcare worker, to reduce the risk of transmitting the infection to other people. 

Perhaps, but people don't know they're infected until the symptoms appear a few days after the infection took place.

As if determined to get this paragraph included in the list of all-time bad takes, the next sentence says:

It remains very unlikely that people receiving care in a care home or the community will become infected.

That, as they say, didn't age well.

On 3 March, the day after the mayor of London claimed that there was 'no risk' of catching the coronavirus on public transport, the Advertising Standards Agency banned two adverts for face masks because they were 'misleading, irresponsible and likely to cause fear without justifiable reason'. One of the adverts said:

"It would be an understatement to say that there is a growing sense of panic.

"The best advice I've heard is to stay calm and take practical measures to protect yourself.

"One of the best ways to protect yourself is to get a high-quality face mask that can protect you from: viruses, bacteria, and other air pollutants."

Who said this was misleading? Step forward again, Public Health England...

The ASA said the adverts were "misleading" because the claims went against official advice.

A spokesman said Public Health England informed the ASA "that they do not recommend the use of face masks as a means of protection from coronavirus".

"We understood there was very little evidence of widespread benefit from their use outside of clinical settings," the ASA said in a statement.

 
NHS medical director Stephen Powis also stuck his oar in, saying:

"Callous firms looking to maximise profits by pushing products that fly in the face of official advice is outright dangerous and has rightly been banned."

A defensible position would have been to say that the evidence on the general use of face masks is mixed and that they do not guarantee protection. Instead, the authorities actively discouraged the public from wearing them and attacked the companies selling them.

In fact, the evidence that they provide some protection is quite strong (which, as I say, is why medics wear them) and Public Health England began its reverse ferret last month when it advised people to wear 'face coverings' in enclosed public places and gave us instructions on how to make them.

We've finally arrived at the "actually, face masks do work" stage of the pandemic. 🍻 https://t.co/ujCRLkEOuU

— Christopher Snowdon (@cjsnowdon) May 11, 2020

But remember, these are face 'coverings', not face masks, and so the science is obviously totally different and you'll have to wear them by law on public transport from 15 June. Why not straight away? God knows, but I'm sure the government is still FoLLoWiNg TeH SciEnCe 🥴.

Smoking and COVID-19 update

I'm finding it difficult to keep up with all the evidence on smoking and COVID-19.  I suggest you follow Phil on Twitter if you want to get up to speed. He's catalogued 117 pieces of evidence so far in this heroic thread, (UPDATE: he is now at over 3,000!)  most of which show smokers significantly under-represented among Covid patients/cases.

I still have my doubts about whether smoking/nicotine confers any protection against the disease. Simple comparisons between the proportion of Covid patients who smoke and the proportion of smokers in the general population are not the strongest evidence. The smoking rate in Britain, for example, is 15% and all the British studies find smoking prevalence to be about half of that among Covid patients. This one, for example, finds that only 6% were current smokers.

But the average age of patients in that study was 73 and smoking rates are much lower at older ages. In the UK, it is only 8 per cent among people aged 65+. This still implies a difference - and it is certainly striking that decades of smoking don't make people more likely to be hospitalised with this respiratory disease - but claims based on unadjusted figures are bound to exaggerate any protective effect.

This is why it is better to focus on the relatively small number of studies that use epidemiological methods and adjust for other factors. There are not many of them (UPDATE: there are quite a few now, and the list below is incomplete), but it has to be said that their results are fairly consistent.

Let me know if I am missing any, but I can find the following... (UPDATED 7 May 2021)

1. This recent study from Israel involved testing 114,545 people for the virus. The smoking rate was 9.8% among those who tested positive (the national rate is 19%). After adjustments, the authors found that smokers were half as likely to test positive, with an odds ratio of 0.46 (0.41-0.51). This is, as the authors conclude, an 'intriguing finding' which 'may reveal unique infection mechanisms present for COVID-19 which may be targeted to combat the disease and reduce its infection rate.' (Israel et al. 2020)

2. That is very similar to this British study which found that 'active smoking was linked with decreased odds of a positive test result' with an odds ratio of 0.49 (0.34–0.71). (de Lusignan et al. 2020)

3. This British study found that smokers were 27% less likely to test positive for COVID-19 although you have to look carefully to find the evidence because the lead author is the chairman on Action on Smoking and Health and he buries it as much as he can. The odds ratio is 0.73 (0.65-0.81). (Hopkinson et al. 2020)

4. Meanwhile this British study looked at the likelihood of dying from COVID-19 and found that smokers were slightly more at risk, or slightly less at risk, or neither, depending on how the figures were adjusted. (Williamson et al. 2020)

5. Then there is this study from the USA which 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 55% less likely to test positive, with an odds ratio of 0.45 (0.35-0.57). (Rentsch et al. 2020)

6. Finally, there is this study from a badly hit area of France where 661 people were tested for COVID-19 and smokers were 67% less likely to test positive. Odds ratio after adjusting for age: 0.23 (0.09 –0.59). (Fontanet et al. 2020)

7. Large study from Mexico: "Current smokers were 23% less likely to be diagnosed with COVID-19 compared to non-smokers." (Giannouchos et al. 2020)

8. Study from the USA finds smokers 90% less likely to test positive. Odds ratio: 0.1 (0.01-0.8). (Lan et al. 2020)

9. This study - another one from Britain, this time using the Biobank data - claims in the abstract that smokers were 'slightly more likely' to test positive. In fact, the results section show that there was no statistically significant difference. (Cho et al. 2020)

10. By contrast, this study using Biobank data shows smokers under-represented (with an implied odds ratio of 0.73 (0.6-09). (Kolin et al. 2020)

11. French study finds that daily smokers are 76% less likely to be infected with COVID-19 (after adjusting for age and sex). Odds ratio for inpatients: 0.24 (0.14-0.40). For outpatients: 0.24 (0.12-0.48).  (Miyara et al. 2020)

12. This study from Italy found that "current smokers were significantly less likely to be hospitalized for COVID-19 compared with non-smokers (Odds ratio 0.23; 95% CI, 0.11-0.48 after adjusting for age and gender). (Meini et al. 2020)

13. Interesting study of a Covid outbreak on a French Navy aircraft carrier. 76% of the crew members got the disease but smokers were 36% less likely to get it. There was also a "trend towards a lower risk among e-cigarettes users". (Paleiron et al. 2021)

14. Web-based study from Italy finds smokers were half as likely to get COVID-19 than nonsmokers. There was a dose-response relationship, with heavy smokers 62% less likely. (Prinelli et al. 2021)

15. Study of 4,137 Covid patients in South Korea finds smokers 67% less likely to be infected (0.33, CI = 0.28–0.38). (Lee et al. 2021)

16. Study of Covid hospital patients in Turkey finds no difference in disease severity between smokers and nonsmokers, but finds that the "mortality rate was significantly increased in ex-smokers (p= 0.037) and non-smokers (p= 0.001) in comparison to active smokers (p= 0.123)". (Gonca et al. 2020)

17. Large study from Germany finds, based on a seroprevalence survey, that regular smokers are 52% less likely to have had COVID-19 (0.48 (0.31-0.72)). (Gornyk et al. 2021)

18. Study of 10,614 nurses in Madrid finds smokers 77% less likely to have had COVID-19 (0.23 (0.20-0.27)). The finding is not mentioned in the abstract. (Candel et al. 2021)

19. UK study finds smokers are 27% less likely to be hospitalised with COVID-19. The authors do not mention this finding in the text (0.63 (0.44-0.88)). (Cummins et al. 2021)

This meta-analysis finds smokers to be 27% less likely to test positive, based on seven 'fair' quality studies. These include studies 1, 2, 5, 9 and 10. It takes an implied odds ratio from this study of 76 patients, of whom 2 were smokers and 1 tested positive. It also manages to derive an odds ratio from this study, but it is not obvious how this was achieved.

The meta-analysis doesn't include study 3 because it relied on self-diagnosis. There is no explanation for why studies 6, 7 and 8 are absent. Studies 7 and 8 are not in the references so perhaps the authors are unaware of them. Study 11 was published after the meta-analysis was conducted.

There is also an ecological study that compared smoking rates and COVID-19 mortality rates in 38 European countries and found an inverse relationship.

 ----

With the exception of the Goldacre study, all of these look at the likelihood of testing positive for the virus, not the probability of being hospitalised or dying from it. (Update: this is no longer true. There are several studies testing whole populations for antibodies which find that smokers are less likelyyyy to have had the disease. This makes what is written below somewhat redundant.)

There are dozens of other studies and datasets showing a low proportion of smokers among Covid hospital patients, but these studies do not specifically look at the question of smoking's effect on the virus. In many cases, the authors do not even comment on the rate of smoking, and in some of them the rate of smoking is not particularly low anyway.

If smokers are less likely to be hospitalised with the coronavirus, it could be because smoking/nicotine makes symptoms less severe or it could be because smokers are less likely to get it in the first place.

The original hypothesis put forward by Konstantinos Farsalinos lent towards the former explanation, but I tend to lean towards the latter because there are studies adjusting for other factors, crucially age and sex, which back it up. In addition, there are several other studies which do not produce odds ratios, but which strongly suggest protection against infection, such as this, this, this, this and this.

All in all, the evidence that smoking reduces the chance of a person testing positive for the virus is methodologically stronger than the evidence implying that smoking helps combat the disease once a person is infected. From the evidence above, one might tentatively conclude that smoking reduces the risk of infection by 50 per cent.

But there is one thing that has been bugging me about this theory for weeks. A lot of the evidence showing low rates of smoking among patients comes from China where the smoking rate is 27%. That figure masks a huge gender divide, with 52% of men smoking and only 3% of women. The official figure for women is probably an underestimate as there is a certain taboo about women smoking in much of Asia, but there is nevertheless a very large gap in prevalence between the two genders.

Therefore, if smoking confers some sort of protective effect, we should expect to see men enjoying a disproportionate benefit. Do we see that in the statistics for testing and hospitalisation? Not really, no. Men tend to be slightly over-represented in Covid wards.

However, we also know that men are more likely to be hospitalised and die from COVID-19 - twice as likely in some studies. (We also know, although it won't have a big impact on these statistics, that there are more men than women in China as a horrible consequence of the one child policy.)

So the real question is whether China has a smaller proportion of men with COVID-19 than countries that have a more equal distribution of smokers across the sexes. The evidence must be out there, but I have yet to find anything conclusive.

Looking at the studies that have crossed my radar while looking at the smoking hypothesis, here's some evidence for China. I include only relatively large studies involving more than 100 patients/cases:


Large study of 1,056 COVID-19 cases in China found that 536 (50.8%) were male.

Study of 585 confirmed cases in Beijing found that 268 (45.8%) were male. No smoking history recorded.

Study of 292 patients in China found that 50.7% were male. The smoking rate among the patients was just 5.1%, although smokers were more likely to be classified as 'severe' than 'mild'.

Study of 285 patients in China found that 128 (44.9%) were male. 11% of the patients were smokers.
 
Study of 276 patients in the Zengdu District found that 56.2% were male. 12.8% of the total had a smoking history.

Study of 202 patients in China. 107 (51.4%) were males and 101 (48.6%) were females. 5.8% had a history of smoking.

Study of 200 patients in Wuhan found that 99 were male (49.5%). Unusually, most of them were smokers, although 'no difference on the fatality rate of COVID-19 patients was found between smokers and nonsmokers'.

Study of 143 patients in Taizhou, China found that 77 were male (53.8%). 9.8% had a history of smoking (see table - text is wrong) and smokers were no more likely to suffer severely than nonsmokers.

Study of 134 patients from 9 cities outside Wuhan found that 65 (48.5%) were male. 10.4% were smokers.

Study of 121 patients in Wuhan found that 66 (54.6%) were male. 5% were current smokers. 

Study of 101 Chinese medical staff infected with COVID-19 found that 32 (31.7%) were male. Only four were smokers. However, what proportion of Chinese medical staff are female?

I've also looked at the larger Chinese studies previously mentioned in this blog post. The numbers are:

Guan (1,099) 58% male

Shi (487) 53% male

Zhou (191) 62% male

Zhang (140) 51% male

Wan (135) 53% male

Liu (78) 50% male

From this sample of studies, the gender balance is not far off 50/50, with several studies showing a majority of women. Of particular interest are the two large studies at the top because they show cases rather than patients (ie. people who have tested positive but are not necessarily hospitalised). Taking those two sets of numbers together, a slight majority of 51% of cases were women.

How does this compare to countries where there is less of a gender gap in smoking rates? It's not easy to say, but here are the results from the largest of the studies I have come across. The figures refer to COVID-19 hospital patients unless otherwise noted.


Various countries (8,910 patients of whom 1,507 were in China) 59.6% male (5.5% were smokers)

UK (8,699 patients) 71.1% male (smoking data not included)

UK (7,346 patients) 60% male (number of smokers is unclear)

New York (5,700 patients) 60.3% male (15.6% had history of smoking)

UK (5,683 deaths) 63.1% male

New York (4,103 patients) 50.5% male (5.1% were current tobacco users) 

New York (1,999 patients - same study as above) 62.6% male (5.2% were current tobacco users)

Sweden (2,158 ICU patients on 3 June) 74% male

USA (1,482 patients) 54.5% male (smoking data not included)

Italy (441 patients) 61.9% male (4.8% were smokers)

New York (393 patients) 60.6% male (5.1% were smokers)

Switzerland (200 patients) 60% male (4.5% were smokers)

In all of these studies, the majority of patients were male. In most of them, at least 60% were male. By contrast, in the Chinese studies above, only one had a male rate above 60%.

Perhaps this is telling, but unfortunately all of these studies look at patients, not cases. Global Health 50/50 has the gender breakdown of cases for various countries, but there is no clear pattern. In some, such as Pakistan and Ecuador, there are more men. In other, such as Sweden and the Netherlands, there are more women.

I'm not sure what to make of this. I only mention it in the hope that somebody will pick up the gauntlet and find something more conclusive. But it seems to me that for the smoking hypothesis to be correct, we should be seeing disproportionately few cases among groups in which the smoking rate is high (eg. Chinese men). If such an effect is not apparent from the aggregate data then any positive effect from smoking/nicotine is either non-existent or too small to get excited about.

Restricting the sale of high strength beer and cider doesn't work

One of the pet projects of England's overpaid public health directors is getting shops to stop selling high strength beer and cider. Alcoholics and/or street drinkers are known to favour these products and so, in the stunted imagination of paternalists, it is assumed that there will be fewer alcoholics and street drinkers if they are removed from the market. It is exactly the same logic that lies behind minimum pricing.

More worldly people argue that these people will substitute other types of drink (or drugs) and that such policies will, at best, make them even poorer.

Nevertheless, many shopkeepers have gone along with these schemes and their local implementation has created some natural experiments.

Two years ago, I mentioned a study looking at the Reduce The Strength initiative in Suffolk which concluded that 'the overall findings showed no intervention attributable impact.'

Our findings suggest that voluntary RtS [Reduce The Strength] initiatives, have little or no impact on reducing alcohol availability and purchase amongst a broader population of customers.

Brighton and Hove has a similar campaign called Sensible on Strength which has led to more than 200 off-licences (74%) no longer selling high strength beer and cider. A new study looks at the alcohol consumption and health outcomes of people admitted to hospital with liver disease in the city.

The study is called 'Does regulating the sale of high-strength beer and cider impact hospital admissions with decompensated alcohol-related liver disease?'. The answer is no. The individuals consumed less beer and cider after Sensible on Strength began but they consumed more wine, and there was no change in their overall consumption of alcohol. Nor was there any change in rates of alcohol-related liver disease (ALD) mortality after the scheme took effect.

Comparing patients admitted in both phases, there were no significant differences in liver prognostic scores, liver-related complications, length of stay and inpatient/long-term mortality (p>0.05). However, the SoS initiative was associated with a 33% move away from beer and cider consumption (36.3% vs 54.0%; p=0.034), but without a significant change in units of alcohol consumed.

Awkward.

Though there was a 33% reduction in the consumption of beer and cider post introduction of the SOS initiative, the total number of alcohol units consumed did not change. This might explain why the SOS initiative did not impact the number and severity of hospital admissions with ALD [alcohol-related liver disease] nor have an effect on ALD-related mortality.

D'ya think?

'Public health' academics can never fully admit defeat so they conclude by saying that their study shows that 'regulating alcohol sales can modify drinking behaviour' and conclude as follows:

Despite having no apparent impact on the clinical spectrum of local ALD admissions, it is conceivable that longer follow-up is needed to determine the true impact of this initiative.

Hmm. Since the scheme didn't lead to a decline in alcohol consumption, I wouldn't get your hopes up for that.

Beer and cider sales down, wine sales up, and no improvement in health outcomes? There are obvious parallels here with the minimum pricing flop.

Alcohol prohibition relaxed in South Africa, tobacco prohibition continues

People in South Africa were finally allowed to buy alcohol yesterday, and there was much rejoicing.

⁦@cjsnowdon⁩ Thought you might like to see these well ordered celebrations as alcohol prohibition ends in Pretoria today. pic.twitter.com/b6zkc5l0m0

— Martin Narey (@martinnarey) June 1, 2020

The government is maintaining the prohibition on tobacco, however. Its Covid-related excuses for doing so are threadbare and I suspect the state has simply seized an opportunity to experiment with 'endgame strategies', as tobacco prohibitionists euphemistically call them.

There are no prizes for guessing how this will work out, but expect to see some 'studies' in the likes of Tobacco Control saying what a success it's been.

I've written about lockdown prohibitions in South Africa and elsewhere for Cap-X.

Students of history will not be surprised that certain criminal activities have soared under South African prohibition. Fully stocked liquor shops have been sitting ducks for looters and armed robbers while criminal gangs have been bringing contraband alcohol over the country’s notoriously porous borders.  

Do have a read.

The Global Forum on Nicotine goes online

The Global Forum on Nicotine is normally held in Warsaw in mid-June. I've been a number of times and it is great event with some excellent speakers discussing vaping and tobacco harm reduction.

This year, for obvious reasons, it is shifting online. It's free to access and open to all, so register here.