Sunday 30 May 2021

Happy World Vape Day!

When I tried my first e-cigarette in 2008 (or was it 2009?), I didn't imagine that public understanding of their risks, relative to smoking, would have gone backwards by 2021. Nor would I have predicted that the World Health Organisation would have gone to war on them or that the European Commission would be gearing up for another bash at regulating them into the dust.
So let's hear it for World Vape Day, an attempt to raise awareness and counter the misinformation that pours out of Brussels, Geneva and California on a weekly basis. 
The World Vapers' Alliance have got hours of fun in store on YouTube starting at 5pm UK time (4pm CET). I'll be on at 5pm. You can see the full schedule here.

Wednesday 26 May 2021

Another dumb idea from tobacco control: e-cigarette flavour bans

San Francisco's ban on e-cigarette flavours has had a predictable outcome.
A study published in JAMA Pediatrics this week looked a ban on e-cigarette flavours implemented in San Francisco on 1 January 2019. The ban was supposed to make e-cigarettes less appealing to young people. And so it did, but with the unintended consequence that high school students smoked more instead. After the ban came into effect, the youth of San Francisco were more than twice as likely to smoke than their counterparts in other districts. As the author noted: “This raises concerns that reducing access to flavored electronic nicotine delivery systems may motivate youths who would otherwise vape to substitute smoking.”

This finding did not come as a big surprise to anyone familiar with the academic literature. Cigarettes and e-cigarettes are clearly substitute products, as studies have shown in both the USA and the European Union. Last year, a study by Yang et al. found that the ban on e-cigarette flavours in San Francisco led to increased smoking prevalence among 18-24-year-olds. Cigarette sales in the USA overall rose in 2020, partly as a result of federal restrictions on flavours used in certain e-cigarette products.

The observation that e-cigarettes are a substitute for combustible cigarettes might seem obvious, but it has crucial implications for policy because it means that efforts to suppress e-cigarette use are likely to lead to greater use of traditional cigarettes.
Read all about it at the IEA blog.
Despite flavour bans defying evidence, logic and ethics, governments are lining up to adopt them. The Netherlands is the latest and the European Commission is also eyeing one up. 
There is no idea in 'public health' too stupid and counterproductive to not be embraced by gormless politicians.

Tuesday 25 May 2021

The nanny state we're in - interview

I recently had a good chat with Gary Kavanagh of the Edmund Burke Institute. Gary is based in Ireland so he knows all about the nanny state. We talked about the Nanny State Index, vaping, smoking, sugar taxes, Minimum Unit Pricing (MUP) for alcohol, the drive towards increased nanny statism coming from NGOs, and what consumers can do to fight back.

Sunday 23 May 2021

There's one born every minute - the Ivor Cummins story

Update: Cummins has, quite sensibly, deleted most of his tweets about Covid so some of the tweets I embedded in this post no longer work. Where possible, I have replaced the tweet with a screenshot. Otherwise I have reproduced the text (which is saved in the embedded tweet even after being deleted).
In the 1980s there was a TV evangelist in the USA named Peter Popoff who was exposed on national television by the late, great James Randi. It turned out that he was wearing an earpiece during his church services so his wife could feed him 'divine' information about people in the congregation. You may have seen it. It is possibly the most famous debunking in television history.


The thing I find most fascinating about this story is that Popoff is still in business. Despite being caught bang to rights on video tape, Peter Popoff Ministries is today producing 'Miracle Spring Water' and broadcasting on several TV networks (including Faith TV in Britain).  

All you have to do is Google the guy's name to find out what he's been up to in the past and yet he still finds a willing and paying audience.

In January, I mentioned a man called Ivor Cummins in an article about 'coronavirus cranks'. At the time, I thought the jig was up for him and his fellow Covid entrepreneurs. I even made a Downfall video about it. But he's still going. After a brief drop in Patreon subscribers and Twitter followers, he now has more of both than he did before. He's raised another £5,000 for his long-delayed feature film. 

This is a guy who could not have been more wrong over the course of the pandemic. He might just be the wrongest man who ever lived. And yet there is still a paying audience for what he does. With 1,742 subscribers paying a minimum of £3 a month (+VAT), he's making at least £75,000 a year from that revenue stream alone.

His business model relies on people having a very short memory, so let's look back on his record.

In the early stages of the pandemic, Cummins did not take a particularly contrarian line. He made a few comments about the supposed importance of nutrition (his day job involved promoting the low carb diet and he was involved with the Irish Heart Foundation although I understand they have since parted ways). Although he would later describe mask mandates as "the most anti-scientific thing I've seen in my lifetime", he was firmly in favour of face masks in March 2020.

During the first lockdown, Cummins developed his own theory about COVID-19. It has undergone several modifications over time, but the basic premise is that the virus is like flu, seasonal and not particularly dangerous. Most people are immune to it because they've had a respiratory virus in the past and the first wave would have subsided with or without lockdowns. Indeed, he believes the first wave was the only real epidemic because "de facto herd immunity" was quickly achieved. This meant that there could be no second wave. There might be a "winter resurgence", but this would be mild and would be little different to what we see in an average flu season. 

In the tweet below he combines his (false) belief that COVID-19 has a low infection fatality rate with his equally false belief about 'de facto herd immunity'.

This was a common refrain of his last summer. He repeated it again and again and it was the basis of his breakthrough video in September which got over a million views and has since been removed by YouTube (you can watch a version of it here). In that video, he explained...
So around 80% are already de facto immune through cross-immunity, T-cells, prior coronaviruses. Around 1 in 5 people will be less immune, they're the ones it has to go through... Then the virus stumbles over immune people."

Since only 20 per cent of the population needed to get COVID-19 for everybody to be immune, Cummins reckoned that any country that had a significant first wave had achieved herd immunity.

Although Ireland had a smaller first wave than the UK, Cummins (who is Irish) claimed that it too had reached herd immunity.

Ergo, there could be no second wave.

'Wave' is a word that doesn't really have a scientific definition, but with COVID-19, you know one when you see it. Since Cummins thought that herd immunity had been achieved, he thought there could be no second wave unless there was a second virus. He thinks this is what happened with the Spanish Flu although, to my knowledge, it didn't. Either way, he repeated this claim ad nauseam.

As case numbers began to tick up again in the summer of 2020, Cummins endorsed the idea that it was an artifact of mass testing, false positives and asymptomatic cases. He maintained that the pandemic was over in the UK and most of Europe and declared a 'casedemic'. 

This, again, was expanded upon in his now-deleted video of 8 September. The conclusion was that lockdowns are pointless and governments should instead encourage the "safe spread" of the virus in the summer to prevent a winter peak. 
There were some elements to his theory that could have been true. It was possible that some people would have some sort of natural immunity and it was certainly likely that warmer weather would reduce the infection rate, if only because people spend more time outdoors. It was an observable fact that rates of infection in Sweden had fallen in the spring of 2020 without the government resorting to lockdown.

Scientists didn't know enough about the virus when it first emerged. We know much more now. Most countries have had a second or third wave and they have often been bigger than the first. We have seen major outbreaks in winter, spring, summer and autumn in various countries. It is clearly not true that 80 per cent of the population acquired natural immunity without being infected or vaccinated.

Most of his ideas didn't stack up even at the time. If herd immunity had been achieved by June, as he claimed, how could there be any resurgence and how could the government get the virus to spread in summer, particularly if it was seasonal? And how do you achieve the "safe spread" of a virus which, contrary to Cummins' claims, has an infection fatality rate of around one per cent in rich countries?

Cummins dressed up his ideas with some terminology from science (such as the Gompertz Curve) along with sciency-sounding terms that he either misunderstands or made up himself (such as 'viral triggering', 'detriggering' and 'double-hump'). None of this has any explanatory value, but it helps him get around the inconvenient fact that countries keep having new waves of infections. 

He now seems to think the virus lies dormant in people before erupting. Viral triggering is a real thing with diseases like herpes, but there is no evidence to suggest that SARS-CoV-2 acts like this and every reason to think it doesn't. If rates unexpectedly rise, Cummins claims that the virus has been 'triggered'. But by what? Initially, it was the seasons (although this is not really an explanation in itself). More recently, he has admitted that he doesn't really know, but it must be something.

The obvious thing the virus needs to be triggered is human interaction, preferably in unventilated indoor spaces, but this is the one explanation that Cummins rejects because it implies that lockdowns must work. 
Why would the virus be triggered in March 2020 but de-triggered in March 2021? Why were cases going up in September and why did they then fall? None of the waves resemble the normal bell curves of seasonal flu. A better and more obvious explanation is that a six week lockdown began in October with tight restrictions until Christmas when rules were relaxed. This led to a sharp rise in infections and another lockdown which sharply reduced case numbers again.

But this was all in the future in September when he began making concrete predictions.

When challenged, he made it clear what he would accept as evidence that he was wrong.

In October he provided another testable proposition.

He also made a video titled 'The Tiger Horn Deceit' which accused the public of mistaking correlation for causation when they saw case rates fall during lockdowns. It was just a coincidence, he said, but governments would whip up fear again and introduce lockdowns in response to a mythical threat in order to convince people that lockdowns work. (I know it doesn't make a lot of sense.) 

In it, he said...

"But then the question, recently, the cases are through the roof, but the deaths are still really low, and it looks like the winter is not going to be much different than a normal winter [...] so you gotta shut all this down, big time, and then the deceit, you have to double down on your lockdown, so when the winter ends up being pretty normal you can end up saying the lockdown made it so."


You know what happened next. By the end of December, the UK had 8 people per million dying of COVID-19 each day, four times what Cummins predicted. This rose in January to a peak of 18 per million, nine times higher. Between 1 November 2020 and 28 February 2021, 76,000 people died "with positive PCR for SARS-CoV-2", significantly more than had died in the first wave.

There were far more excess deaths than in the winter of 2015 and 2018 (both of which had quite bad flu seasons). 

The same was true in Europe as a whole.
This really should have been game over for Cummins and his notions, but he rode it out. Initially, he stuck to the casedemic theory and claimed that there was no excess mortality.

The graph comes from Euromomo, a website which was useful to Cummins at the time because it not only has a big time lag in its reporting (shown in yellow), but it invariably under-reports the figures while it is waiting for the data. It also has such a narrow band that even huge increases in mortality look relatively modest (the red line indicates a 'substantial increase'). In any case, the graph now looks like this...

As cases and deaths mounted in December, he continued to claim that the second wave was nothing more than a "muted" winter resurgence.

 On January 4th, Cummins released a video (now deleted) in which he admitted that hospitals in the UK were "filling up here and there" while claiming that mortality was "way, way lower" than in the first wave because of "community immunity".

On January 6th, with the UK back in lockdown and with Covid deaths close to a thousand per day, he put out a video claiming that what was happening was "exactly what we predicted" and that "excess mortality is as per prior years". He claimed that anyone who said otherwise was "lying". In fact, there were thousands of excess deaths that week in England and Wales. In England alone, there would be 15,685 excess deaths in January, 30 per cent more than normal.

In a now-deleted video, he takes Public Health England's weekly surveillance report (wrongly attributed to the ONS) and claims that there is no excess mortality. Like Euromomo, this report suffers from a reporting lag which was made worse by under-reporting of deaths over the Christmas period (bank holidays have a big impact on death registrations). In his video, it looked like this...

By the end of the second wave, it looked like this...

He started ignoring this series of reports once they had outlived their usefulness.

Two days later, Cummins doubled down on his wager that excess mortality in the winter of 2020/21 wouldn't beat prior 'tough' seasons such as 2018.

As shown above, he was very much not correct. 

At around the same time, he suddenly backtracked on his claims about the second wave, insisting that he had "foretold" a second wave all along.

At this point he shifted his rhetoric, claiming that the people who had predicted a "Spanish Flu second wave" would be proved wrong. I am not aware of anyone predicting such a thing. I'm not even sure what it means.

As late as mid-January, when over 1,200 people were dying every day in the UK from COVID-19, he was still insisting that there was no second wave.

Daily deaths peaked on 19 January and then began to gradually drop away. Deaths peaked in Ireland a little earlier and fell sharply for the rest of the month. Having exploited the time lag in excess mortality reporting when the second waves were reaching their peak, he thereafter pointed to falling rates as evidence that the 'seasonal resurgence' had passed and there was nothing to worry about. 

Eventually, he even brought back the casedemic rhetoric as if nothing had happened.
A glutton for punishment, he began making new claims about the pandemic which put him at high risk of looking foolish again.
Far from emptying out, Sweden's intensive care wards were reaching maximum capacity in many parts of the country. The chart below shows daily admissions to ICU with COVID-19. This, in a country that Cummins said had reached herd immunity the previous June.
Another country where people were 'bristling with antibodies', according to Cummins, was India.

You know what happened next. India became the global epicentre of the pandemic. Officially, there are more than 4,000 Covid deaths a day, but testing capacity is limited and experts believe the real figure could be ten times higher.

Then there was Croatia which had not locked down in 2021 and seemed to be doing OK.

 Alas, the infection rate in Croatia had been rising for three weeks when he tweeted this. Inevitably, deaths followed.


As this graph shows, rates in Europe overall have been up and down, reflecting the fact that different countries have had outbreaks at different times. Note how different Europe’s curve is to that of the UK and Ireland’s - and Croatia’s for that matter. There is no pattern to suggest a seasonal outbreak. It isn’t a normal epidemic curve at all because the main thing controlling it is national lockdowns at different times by national governments.

Nevertheless, Cummins declared VE Day on 26 March...

You only need to look at the graphs he is posting here to see that 2020/21 was nothing like "every winter season in history". Rates hadn't collapsed resoundingly and Europe certainly wasn’t  displaying any “natural classic Gompertz curves”. Indeed, infection rates were rising in many European countries as they entered spring.

I could go on, but it would be exhausting. This has been a long post because Cummins is wrong about a great deal. To return to my original point, it does seem - as Abe Lincoln said - that you can fool some of the people all of the time. Cummins doesn't delete his tweets and he tweets a lot. It's all out there for anyone who wants to check his track record. And yet he inspires such trust and devotion among certain people that they will give him money. 

Truly, there is one born every minute.

Friday 21 May 2021

Prince’s death at 57 was no music industry average

First published by Spectator Health in April 2016 

 After the tragic and untimely death of Prince, an internet meme took flight claiming that the singer died ‘at the average age of death for American pop stars’. This is not really true and, insofar as it contains a germ of truth, it is not useful.

The origin of the claim can be traced back to an article from 2014 in which an Australian professor of psychology and music compared the ages at which pop stars died in each decade from 1950 onwards and compared them to the average age of death of the general population. As the graph below shows, there is a big gap, albeit one that has been closing over time.

There is a fundamental problem with this methodology which renders the results meaningless. Pop stars usually start their careers at a young age and pop music didn’t exist until the 1950s. The oldest of the bunch was arguably Bill Haley who rocked around the clock in 1955 at the grand old age of 30. He was born in 1925, a year before Chuck Berry, seven years before Little Richard and ten years before Elvis Presley.

Haley died in 1981 at the age of 55 and Elvis died four years earlier at the age of 42, but Chuck Berry and Little Richard are still rocking at the age of 89 and 83 respectively. We won’t know what the life expectancy of a 1950s pop star is until they are all dead and it will be many years before we know the average age of death of a 1960s, 1970s or 1980s pop star.

You can take any decade and compare the age at which pop stars die and compare it to that of the general population, but it doesn’t tell you anything meaningful. The general population can be born at any time whereas no pop star was born before 1925. It is quite possible that a pop star will live until the age of 100 but it is a mathematical impossibility for them to have already done so.

It appears that the definition of pop music used in the 2014 article is broader than mere rock and roll because the average age of a pop star’s death in the 1950s is shown as a little over 50 years. Presumably, then, we are including practitioners of ragtime, big band and other forms of music who were born as early as the 19th century. But whatever genre we look at, the point still holds. The sheer number of pop stars has risen exponentially in the last 50 years. All the punk rockers, rappers and grunge artists who have passed away have died relatively young, but this could hardly be otherwise given how recently these genres were created. It will be a long time before geriatric boy bands pass away and we begin to see the full picture.

There is, then, a basic sampling bias at work which guarantees that the group being studied will have a lower life expectancy than the general population. There are lots of reasons why drug-taking rockers and gun-toting rappers are more likely to die young, and it would be silly to pretend that there is no difference in life expectancy, but this is not the way to measure it.

A better way would be to compare people who were born in the same year, but you could only do that once they were all dead. Prince was born in 1958 and died at the age of 57. Barring an outbreak of bubonic plague or an unusually methodical serial killer, it is most unlikely that the average age of death for musicians born in 1958 will turn out to be 57. Other pop stars born in 1958 include Ice-T, Madonna, Thurston Moore (Sonic Youth), Neil Finn (Crowded House), Nikki Sixx (Motley Crue), Toyah, Simon Le Bon, Joan Jett, Bruce Dickinson (Iron Maiden), Nik Kershaw, Belinda Carlisle, Paul Weller, Bill Berry (REM), Mark King (Level 42), Michael Jackson and Andy Gibb (Bee Gees). Of these, only Jackson and Gibb are not still with us. In fact, nearly all of the celebrities born in 1958 are still alive.

Sadly, Prince did not have a good innings even by the standards of the music industry.

Thursday 20 May 2021

The Truth Initiative versus the truth

America's lavishly funded (by unwitting smokers) Truth Initiative is not happy about nicotine pouches. The pouches are smokeless nicotine products similar to snus which contain no tobacco, but the Truth Initiative doesn't think manufacturers should describe them as such even though it is, well, the truth.

Increasingly popular oral nicotine products are frequently marketed as tobacco-free alternatives to smoking, claims that could imply lower-risk and are not authorized by the Food and Drug Administration, according to a recent Truth Initiative analysis of direct mail advertisements. 
They are tobacco-free alternatives to smoking and they are clearly lower-risk, so what is the problem here? 
Does the FDA say that products cannot be described as tobacco-free? I doubt it otherwise the Troof Initiative would have gone straight to them with a complaint rather than writing a crummy study about it.

The Truth Initiative study, which was published in Tobacco Control and is one of the first to examine marketing claims used to promote oral nicotine products to U.S. consumers, found that the majority of mailed ads for oral nicotine pouches or lozenges claimed that they did not contain tobacco leaf (55%) and that they were an alternative to other tobacco products (69%). Most advertisements (84%) also featured claims that the product could be used anywhere.

Again, this is a statement of the obvious. They don't contain tobacco leaf, they are an alternative to other tobacco products and they can be used anywhere. 
So what is the problem?

Oral nicotine pouches and lozenges are a new category of tobacco product that includes brands such as Zyn, On! and Velo and come in many flavors. They are similar to snus – a type of smokeless tobacco pouch that does not produce saliva, making it spit-less – but, unlike snus, they do not contain leaf tobacco. 

Woah! Now you're saying it! Careful now. 

The products are still derived from tobacco and contain nicotine, which is harmful to young people in any form, but due to the absence of tobacco leaf, the FDA does not classify it is a smokeless tobacco product. 

Indeed. It is not a tobacco product.

Some types of oral nicotine products are using synthetic nicotine that isn’t derived from tobacco leaf...

Ooh, awkward. How are you going to wriggle out of that one? 

... raising additional concerns about misleading consumers who may assume that nicotine that doesn’t come from tobacco is somehow safer than tobacco-derived nicotine. 

There's no way to win with you lot, is there?

Until now, there has been little insight into how tobacco companies market oral nicotine products like nicotine pouches or lozenges to consumers, including whether they use claims that could imply reduced harm.

To address the issue, researchers coded a sample of 50 direct-mail ads for the claims that oral nicotine products were an alternative to other tobacco products, could be used anywhere, were spit- or smoke-free, or that the product did not contain tobacco leaf.

... terms like “tobacco-free” in oral nicotine marketing could suggest products are healthier and lower risk to consumers. 
This is a strange thing for an anti-tobacco organisation to say. Tobacco-free pouches may be slightly healthier than snus, which is itself extremely low risk, but they are definitely healthier than any smoked tobacco product. Regulation means that the manufacturers can't say that, even though it's true, so they don't. What people might infer is irrelevant.
Using language that signals a tobacco product is “free of a substance” may meet one criteria of an unauthorized modified risk claim under FDA rules.
It may or it may not. Somehow I suspect it may not.

Researchers found that direct-mail advertising positioned oral nicotine products as alternatives to existing tobacco products, including traditional smokeless products, cigarettes, and e-cigarettes.

They obviously are alternatives to existing tobacco products. What has the Truth Initiative got against the truth?

About half (52%) of the direct mail pieces included claims that oral nicotine was “spit-free,” appearing to position oral nicotine products as an alternative to traditional smokeless products. 

They are and it is.

About one-third (31%) described the product as “smoke-free,” implying that it is an alternative to cigarettes. 

Which it is. 

Many ads contrasted oral nicotine pouches and lozenges to e-cigarettes, urging consumers to “forget about the chargers,” for example, potentially promoting oral nicotine as a product to use in combination with existing tobacco products or as a substitute for other tobacco products.

That is exactly what they're doing. They are substitutes. 

The availability of increasingly popular oral nicotine products in flavors coupled with evidence of marketing the products as alternatives to existing tobacco products calls for greater attention and regulation from the FDA.

Quite right too. Who knows what other factual information might reach the public if the FDA doesn't act firmly?

Wednesday 19 May 2021

Is the European Commission about to crack down on vaping (again)?

I've written an article for Brussels Reporter about the clouds gathering over vaping in the EU. Last year, the EU’s Scientific Committee on Health, Environmental and Emerging Risks (SCHEER) published a preliminary opinion on electronic cigarettes. As I said at the time...

Reading it is like taking a step back in time, or being in Australia.

The authors of the SCHEER report appear to be biased against e-cigarettes and harm reduction. The report reheats several arguments, such as the ‘gateway effect’ and the ‘renormalisation’ hypothesis, which are now a decade old and have been contradicted by real world evidence. While it downplays strong evidence showing that e-cigarettes have been a gateway from smoking for millions of people, it amplifies speculation about hypothetical risks. When the authors are unable to find adequate evidence for anti-vaping claims, they quote from organisations which share the same prejudice. Much of the evidence is treated selectively and some of the conclusions made about the strength of evidence are baffling.  
The final draft was published earlier this month. Some of its claims were toned down but it remains a one-sided and inaccurate piece of work. So what? Well, as I say in today's article... 

This is a worry for consumers because the SCHEER report is designed to alert the European Commission to the ‘potential need for legislative amendments’ to the Tobacco Products Directive.

It wanted to regulate e-cigarettes as medical devices in the last Tobacco Products Directive, which came into force in 2016. Its plans were derailed by the European Parliament, but it may soon try again. The European Commission seems particularly interested in banning flavours in e-cigarette products, a policy copied from American prohibitionists which would make vaping much less appealing to smokers who are thinking of switching to a product that could save their lives.

In reality, the SCHEER report does not compel the Commission to do anything. The only evidence for health risks which the SCHEER report rates as ‘strong’ in the final opinion relates to poisoning and injuries due to burns and explosions. These hazards have already been dealt with in the existing Tobacco Products Directive and do not require further legislation.

However, while the report does not explicitly call for any new laws, it gives the European Commission ammunition if it wishes to table some. As the evidence that e-cigarettes are relatively harmless and effective smoking cessation devices continues to grow, the SCHEER report will be used as a crutch for those who continue to lobby against them.

It could soon be time for vapers to make their voices heard in Brussels again.
Meanwhile, the corrupt and incompetent World Health Organisation is up to its old tricks. To mark World No Tobacco Day, it has put out this rubbish about e-cigarettes...

The tobacco industry has continuously attempted to subvert these life-saving public health measures. Over the last decade, the tobacco industry has promoted e-cigarettes as cessation aids under the guises of contributing to global tobacco control. Meanwhile, they have employed strategic marketing tactics to hook children on this same portfolio of products, making them available in over 15,000 attractive flavours.

The scientific evidence on e-cigarettes as cessation aids is inconclusive and there is a lack of clarity as to whether these products have any role to play in smoking cessation. Switching from conventional tobacco products to e-cigarettes is not quitting.

"We must be guided by science and evidence, not the marketing campaigns of the tobacco industry – the same industry that has engaged in decades of lies and deceit to sell products that have killed hundreds of millions of people”, said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “E-cigarettes generate toxic chemicals, which have been linked to harmful health effects such as cardiovascular disease & lung disorders."


Carbohydrate hysteria

First published by Spectator Health in June 2018

One of Twitter’s odder subcultures warns you of its obsessive presence with the hashtag #LCHF. It stands for ‘low carb, high fat’ and its followers have remarkably strong feelings about carbohydrates. Why? Mostly because they used to be fat and then they gave up carbs. They are no longer fat and so, QED, carbs are the cause of obesity and people shouldn’t worry about calories or physical activity. Silly old scientists won’t admit this profound but hidden truth because they have been bought off by Big Grain or Big Pharma or something, but who needs scientists when you have personal testimony?

This rebadged version of the Atkin’s Diet works for many people, at least in the short term, but the conclusions of some of its disciples are based on magical thinking, rather like a cargo cult. People lose weight when they cut out the carbs because they are cutting out a lot of calories. Carbs are easily accessible and energy-dense. That has been their selling point for thousands of years. In a typical meal, the meat provides the protein, the vegetables provide the vitamins and minerals, and the carbs provide the calories (plus fibre, protein, B vitamins and flavour). People in every society on Earth bulk out their meals with bread, potatoes, rice, pasta, noodles or whatever source of cheap carbohydrate is available to fill their stomachs and give them energy. If you cut these foods out of your diet or replace them with vegetables, there is a very good chance that you are going to lose weight.

A low carb diet is not an alternative to cutting down on calories. It is a way of cutting down on calories. It doesn’t guarantee weight loss because you could still gorge yourself on cheese and bacon, but it is so restrictive that you are likely to substitute lower calorie food in practice. In its purest form, it is a highly restrictive diet. A diet which forbade you from eating any food that begins with a letter between N and Z in the alphabet would have much the same effect.

The same magical thinking can be seen in the LCHF view of diabetes. It is well known that obesity increases the risk of developing Type 2 diabetes, perhaps by a factor of seven. In recent years, it has also become accepted that the disease is reversible in some patients through intense weight loss. Since a highly restrictive diet like LCHF can lead to rapid weight loss, there are low carb enthusiasts who have seen their diabetes go into remission. With a little cargo cult science, it is easy to come to the conclusion that a low carb lifestyle is the cure for Type 2 diabetes and, by association, that carbohydrates are the cause of Type 2 diabetes.

This is not the conclusion that mainstream scientists have come to. Rather boringly, they prefer the more obvious interpretation that obesity is a risk factor for Type 2 diabetes, that obesity is caused by excess calories, and that both obesity and diabetes can be addressed by creating a calorie deficit. This is not just their opinion. It is based on empirical evidence. For example, the Scientific Advisory Committee on Nutrition found no association between carbohydrate intake and body mass in its latest evidence review and, with regards to diabetes, it concluded…
No significant association was found between total carbohydrate intake as g/ day and incidence of type 2 diabetes mellitus (RR 0.96, 95% CI 0.86, 1.08 for each 70g/ day increase; p=0.5).

Now, I am as happy as the next man to believe that a scientific consensus can be wrong, but if it is a choice between trusting nutritional scientists on the one hand and a bunch of keyboard warriors and diet book salesmen on the other, I will go with the consensus.

You might also be expected to go with the consensus if you were a BBC executive commissioning a documentary about carbohydrates, especially if your programme was called ‘The Truth About Carbs’ rather than, say, ‘A Theory About Carbs’. But no. ‘The Truth About Carbs’, which was broadcast on BBC1 last week, was presented by Dr Xand van Tulleken, a medic who has written a diet book. He used to weigh 19 stone because, as he asserted it at the start of his programme, he loved eating carbs.

So began an hour of television which purported to show the benefits of a low carb diet but which actually showed the benefits of a reduced-calorie diet that is high in vegetables. First, van Tulleken split carbs into three categories of his own making: ‘beige carbs’ (pasta, rice, etc. which were portrayed as bad), ‘white carbs’ (refined sugar, which were portrayed as unspeakably bad), and ‘green carbs’ (fruit and veg, which were portrayed as being acceptable because they contain fibre).

He then tried to convince the viewer that beige carbs are really white carbs in disguise by having a dietitian explain how much energy is released into the human body by ingesting the likes of a jacket potato or a bowl of rice. The normal way of doing this would be to give the calorie count, but low carbers don’t believe in counting calories and so sugar cubes were used instead. Sugar cubes are often used to illustrate the amount of refined sugar that is added to fizzy drinks, but in this instance the sugar was neither refined nor added, nor even in the food. It was the amount of glucose produced naturally by the human body as part of the digestive process; a rather different proposition.

Members of the public were asked how many ‘sugar cubes’ were in various food products. The big reveal came when the dietitian explained that a jacket potato releases twice as much energy in the form of glucose as a chocolate muffin. ‘There’s 19 sugar cubes in this jacket potato,’ she declared, not entirely truthfully. A bowl of rice was shown to be even worse, with 20 quasi-sugar cubes. The effect on the members of the public was immediate and predictable. ‘It’s grains of sugar that we’re eating!’ said one. ‘I’m not eating rice no more,’ said another.

I don’t want to sound like a Reithian paternalist, but it seems irresponsible of the BBC to give its viewers the strong impression that a chocolate muffin is a healthier option than a bowl of rice. Aside from the other nutritional considerations, a chocolate muffin has at least 50 per cent more calories than a bowl of rice, and yet this went unmentioned by van Tulleken who concluded the segment by saying:
‘The thing that this really rams home for me is that there is a huge amount of energy in a potato, and that pile of glucose that your body will turn the potato into will be stored as fat unless you burn it off.’

There are about 250 calories in a jacket potato. Regardless of whether you consider this to be a ‘huge amount’ (it is only a tenth of an adult male’s recommended intake), energy from any type of food will be ‘stored as fat unless you burn it off’. This basic truth was never alluded to in The Truthiness About Carbs. How could it be? If van Tulleken had acknowledged the laws of thermodynamics he would have debunked his own programme.

The BBC’s intrepid truth-seeker then travelled north to visit Dr David Unwin who lives the low carb life and recommends his patients do likewise. Although the documentary offered no hint that Unwin was anything other than an ordinary family doctor, he is a controversial figure by his own admission. A low carb manifesto he co-authored in 2016 was widely criticised by scientists and was such an embarrassment to its publishers at the National Obesity Forum that its trustees issued a statement to ‘make it completely and transparently clear that they were not given the opportunity to see the document, or give any input into it’. Several of them resigned on principle. It would have been interesting to see Unwin respond to his critics. Instead, van Tulleken asked him softball questions like this:

Van Tulleken: ‘Is it fair to say that almost everyone in the UK is eating more carbs than they need and more carbs than is good for them?’

Unwin: ‘I think that’s probably fair.’

The less said about the rest of the programme, the better. Suffice to say that van Tulleken underwent a colonoscopy while interviewing a bowel cancer specialist and came away with the conclusion that low carb diets reduce bowel cancer risk despite the specialist saying nothing of the sort. He then got a chef to cook some reduced-calorie meals for a group of overweight people in Merseyside, telling him that their ‘lives depend on you seducing them with low carb food.’ Sure enough, after two weeks on a reduced calorie diet that was high in fruit and vegetables, they were healthier and had lost weight. Van Tulleken treated this as a near-miraculous demonstration of the dangers of carbohydrates. Eating well, he concluded, is about ‘counting the carbs, not the calories’.

Whatever public service broadcasting is, The Truth About Carbs was the opposite. Scientifically illiterate, willfully misleading and ludicrously one-sided, it ensured that no matter how little the viewer knew about nutrition when they tuned in, they would know less about it by the time it was over.

Tuesday 18 May 2021

Vaping junk science and the gateway effect

Carl Phillips has written the definitive critique of low quality vaping research (available in draft form here). He looks at the most popular studies (as measured by their Google Scholar ranking) and concludes that the whole field is plagued by fatal flaws. Some of the problems are intractable, but researchers could get closer to answering the key questions if they improved their methodology and looked at the issue down the right end of the telescope. Most of the time they can't be bothered or they deliberately choose sloppy methods to get the answers they want.

A classic example is the so-called gateway hypothesis - that taking up vaping leads people who would otherwise not become smokers to start smoking. Although many studies have purported to find such an effect, it has been pointed out ad nauseam that the kind of people who start vaping are often - usually? - the kind of people who would have started smoking had e-cigarettes never been invented. The fact that smoking rates tend to decline as vaping prevalence increases strongly suggests that the gateway effect is either nonexistent or so negligible that it is easily outweighed by the gateway in the opposite direction, ie. people using vaping as a means to quit smoking.

Some researchers have sought, with varying degrees of enthusiasm, to control for this personality trait, but it is an intractable problem. Carl's explains better than anyone else why this is...
Though not strictly trans-scientific, it turns out to be practically impossible to assess whether vaping is causing people to smoke (let alone become smokers) with any of the data that is apparently available. Even the best potential matching or deconfounder covariates are inadequate to control for propensity to use a tobacco product. The covariates used in practice are nowhere near close enough. Variables that are supposed to control for the propensity are typically measures of “risk taking” or “rebellious” behavior and perhaps inclination to use drugs of any sort. (These are often described with the phrase “common liability”, another term that should be avoided by ethical researchers because of the obvious pejorative double entendre of the word “liability”. Notice that in other contexts where there is a common cause -- the appropriate scientific term -- that makes someone more liable to choose both the exposure and outcome, researchers never use this loaded phrase.) 

The variables used are terribly imprecise proxies for the overall propensities to take risks and use drugs. Moreover, the proxies should include the logistics of someone’s peer and adult social environment, which are at least as important as attitudinal inclinations, but do not. But even if “risk taking” proclivity were measured perfectly (which is far from the case) it could only explain such questions as why vaping is associated with motorcycle riding. It would still miss a major common cause of why vaping is associated with subsequent use of other drugs. There are inclinations, often traceable to specific psychological or environmental conditions but unlikely to be measured in a dataset, that cause a desire to pursue not “risk” or “rebellion” generally, but specifically pursue altered states of consciousness. This is the major, and effectively intractable, confounding problem for honest attempts to assess various drug gateway claims.

Yet it turns out that in the present case, the “risk taking” and “rebellious” variables plus wanting altered states are still not the most important nearly-intractable confounding problem. A “risk taker” might like motorcycles but not cannabis, someone seeking a particular altered state might like cannabis but not cocaine, and someone seeking altered states in general might still not like motorcycling. But almost everyone who likes the specific experience of smoking likes the specific experience of vaping because it is almost the same drug and almost the same behavior pattern. Researchers in this area, as well as most critics of this research, seem oblivious to this.

About half the population likes being under the influence of nicotine and half does not. This variation alone guarantees a substantially higher smoking uptake among vapers (and vice versa). This is partially a result of physiology and psychological characteristics, and partially a matter of attitude. Most people who do not use any nicotine product are actively averse to using any nicotine product. Thus people who never vape, smoke, nor use any other tobacco product will inevitably initiate one such product less often than users of one of the other products. This is no different from the fact that people who smoke one brand of cigarette are far more likely to subsequently smoke another brand than are people who do not smoke. No one would take that observation to mean that in a counterfactual world in which the first brand did not exist, the person never would have smoked any cigarette (i.e., the product that happened to be used first obviously did not cause someone to be inclined to use some product).

Attempts to control for this common cause are generally doomed. It is almost impossible to control for having a physical/psychological “taste” for nicotine, since the only good measures of it are already in use as the exposure and outcome variables. Smoking status of close relatives (getting benefits from nicotine seems to be heritable and attitudes toward it certainly are) is a very rough proxy for both tastes and attitudes, but clearly not good enough.


Much of the problem here seems to be a particularly bad result of the generic problem in tobacco research of not stating, much less testing, clear causal hypotheses. An expectation that a causal study must have a clear causal hypothesis would change the entire literature. It is difficult to figure out how to non-absurdly finish the sentence, “we hypothesize that many young people who find they like vaping then switch to the harmful, less flavorful, less socially acceptable, and more expensive (in all the jurisdictions where these studies happen) alternative -- something that they would not have otherwise ever done -- because....” The only apparent non-absurd conclusions are “...because their access to vaping products was interrupted while cigarettes remained easily available” or “...because someone convinced them that smoking was less harmful to their health.” It seems unlikely the worst papers would ever have been written if the authors had been required to finish that sentence.

And so, in conclusion...

The lessons available from the papers in this review are almost all negative. There are several papers that are solid workaday building blocks, but their generalizable lesson is basically just the negative “don’t overreach”. But most of the papers offer only errors to learn from. The questions most of the authors here are attempting to answer simply cannot be informed by the methods they chose. There are a couple of papers that are reasonably informative about some of their study questions. But we are sadly unable to point to a single example of someone using suitable methods to try to deal with the particular challenges of answering these questions.

.. There are, however, countless sources of good building-block information that can be pieced together to provide knowledge. It is thanks to such information that we know key facts, like vaping is approximately harmless and that it helps many people quit smoking. Part of the reason those salient facts are obscured by the journal literature is the political bias of the well-funded authors. But that is not the only reason. The typical bad practice in public health type research -- pretend your data is what you wish it were rather than what it is, thoughtlessly calculate simple associations, ignore all other information, and then declare sweeping conclusions as if the outputs from one logistic regression were divine revelation -- is what allows intentional propagandists to get away with junk science. But it also makes even honest efforts largely uninformative.

It's a long read but anyone interested in the science of e-cigarettes should get stuck in.