A desperate attempt to deny the benefits of moderate drinking

There is mounting desperation in 'public health' to debunk the benefits of moderate drinking - or, at least, to make the public think the benefits have been debunked. Various academics are offering their services. It's as if there is a reward on offer to whoever can make the best case against the J-Curve. In a sense there is, because whoever manages it will be set for life in the neo-prohibitionist 'public health' industry.

In recent years, we have seen the J-Curve challenged by ridiculous modelling, lying by omission and the inappropriate use of Mendelian Randomisation. None of this casts serious doubt on the existence of health benefits of moderate alcohol consumption, although the drip-drip effect no doubt leaves the public confused about what the science shows (which is presumably the intention). 

Two weeks ago, the gloriously named Beatriz Champagne from the World Heart Federation falsely claimed that any amount of alcohol harms the heart. She said that any claims to the contrary are "at best misinformed and at worst an attempt by the alcohol industry to mislead the public about the danger of their product." I didn't write about this at the time because it was just an assertion with no evidence to back it up.

But then on Friday, a new study was published which claimed to disprove the J-Curve. The study was grossly misrepresented by its own author and was (unsurprisingly) misunderstood by the media.

The study should have set off warning bells to any decent health journalist. For a start, it was accompanied by some hyperbolic, media-baiting quotes from the lead author, who is a physiologist at Anglia Ruskin University...

 

“The so-called J-shaped curve of the cardiovascular disease-alcohol consumption relationship suggesting health benefit from low to moderate alcohol consumption is the biggest myth since we were told smoking was good for us."

 

The title of the study reads more like a headline than a piece of academic research...

 

Alcohol - The myth of cardiovascular protection

 

And the study ends with a dog whistle call-to-action for the government that is not justified by the findings...

 

Our results do not support the current alcohol consumption guidelines for the United Kingdom of up to 14 units per week in relation to CV risk in the general population.

 

As informed readers know, there is 50 years of evidence showing that moderate drinkers live longer than teetotallers, an effect that is mostly due to their lower heart disease risk. The authors of the new study used UK Biobank data to monitor the health outcomes of drinkers and people who have never drunk, but things start badly for them when they find that teetotallers have higher rates of heart disease and have more heart attacks than drinkers. 

 

Never drinkers were older (P < 0.0001), had a higher body mass index (P < 0.0001), higher systolic and diastolic blood pressure (both P < 0.0001), were less physically active (P < 0.0001), had a higher prevalence of diabetes (P < 0.0001) and higher incidence of overall CV events (P < 0.0001), ischaemic heart disease (P < 0.0001) and cerebrovascular disease events (P < 0.0001). The incidence of overall CV events, ischaemic heart disease and cerebrovascular disease were comparable between never drinkers and drinkers consuming more than 14 units per week.

 

This suggests, a priori, that teetotalism is not particularly healthy, although it could be the result of confounding variables. However, when the results are adjusted for confounders, the picture remains the same. (Note that former drinkers are already excluded to rule out a “sick quitter” effect).

Compared to current drinkers in adjusted models, never drinkers were at higher risk for overall CV events (hazard ratio, 1.31; 95% confidence interval, 1.20-1.42; P < 0.0001), ischaemic heart disease (hazard ratio, 1.51; 95% confidence interval, 1.29-1.76; P < 0.0001) and cerebrovascular disease (hazard ratio, 1.46; 95% confidence interval, 1.14-1.87; P < 0.0001). Consequently, using never drinkers as reference resulted in alcohol from all drink types combined exhibiting protection in relation to all outcome measures...

This is rather awkward for the authors. To deal with this inconvenient finding, they have a simple solution. They exclude ALL the non-drinkers from their analysis and compare light, moderate and heavy drinkers instead! They split the drinkers into five quintiles based on their alcohol consumption and show the results in the figures below. The pink data points are what you get when you compare them to non-drinkers. The blue data points show how the drinkers compare to each other. (Click to enlarge.)

As you can see, the drinkers have a lower risk of ischaemic heart disease at every level of consumption. For wine, the risk drops as people drink more, but for beer, cider and spirits (which are grouped together for some reason) the benefits decline somewhat as people drink more (although none of the changes are statistically significant). 

It's a similar story when you look at the relationship with all types of cardiovascular disease, although the authors exclude ischaemic heart disease from one of these plots (red) for reasons that are never properly explained. Here we see a reduction in risk for all wine drinkers and for moderate drinkers of other alcoholic drinks.

In short, the authors are making some pretty extreme claims about moderate drinking without looking at the only reference group that matters (non-drinkers - or never-drinkers). They effectively use light drinkers as the control. And even then, they barely achieve their desired result. 

We’ve seen this trick performed before in a study from 2018 which made similar claims by comparing light drinkers to moderate and heavy drinkers - and generated similar headlines. The graph used in the main body of that study appeared to show no evidence of a J-Curve...

 

This was sleight of hand designed to catch readers out at a glance. The authors simply ignored the non-drinkers and used light drinkers as their reference point. But if you digged deep into the appendix, there were graphs that showed that the J-Curve was alive and well. Never-drinkers had a 30 per cent increased risk of heart disease and a 20 per cent increased risk of premature death.

Everything about Friday's study seemed designed to mislead. The press release for it said... 

 

 

New study: 14 units a week still harmful to health

Compared to what? Not compared to zero units, that's for sure. It's difficult to find any interpretation of that headline that isn't trivial or wrong.

I see no academic merit in the methodology used in this study. It certainly can't be used to say anything about the relative risks of drinking versus not drinking because it deliberately excludes the non-drinkers. 

It should never have been published.

Unlearning the magic money tree

My City AM column today is about people who believe in the magic money tree developing some desperate excuses for the rise in inflation.

 

When the inflationary chickens came home to roost last autumn, Robert Reich, a professor of public policy in California, insisted that it was not ultra-loose monetary policy that was to blame. Instead, it was the fault of greedy corporations which have “so much market power they can raise prices with impunity”.

Reich was not alone in this belief. When the US faced high petrol prices in November, the obvious explanation was that the price of oil had doubled in the space of a year. Not so, claimed Senator Elizabeth Warren, instead blaming “price gouging” by Chevron and ExxonMobil.

Cartels can exist but there is no reason to think they have suddenly taken over large parts of the American economy. If these markets are so uncompetitive and the companies so powerful, why did they not raise their prices earlier? Why are they not raising prices even more? The answer is that there is ample competition but companies cannot avoid passing on the higher cost of raw materials to their customers indefinitely.

 

Have a read.

 

(In addition to the copes mentioned above, the White House blamed the rising price of meat on 'dominant corporations in uncompetitive markets taking advantage of their market power to raise prices'.) 

The COVID-19 alcohol "paradox"

From the Belfast Telegraph (and various other local newspapers)...

 

Concerns over biggest drinking households buying even more during lockdown

 

Health campaigners have called for a minimum price per unit to be introduced in England...

 

Of course they have.

 

...after a study found the biggest drinkers bought more alcohol during lockdowns even though pubs were closed.

Perhaps these health campaigners should call for pubs to be open 24 hours a day?

 

An academic study of 80,000 households’ shopping habits could explain why 2020 saw the biggest increase in alcohol-related deaths in the UK in the last 20 years.

Health experts found Britain’s heaviest drinkers – those in the top 20% of alcohol-buying households – purchased 17 times more drink from shops and supermarkets than those in the bottom 20% during the first lockdown.

Official data shows that in 2020 there were 8,974 registered deaths from alcohol-specific causes in the UK in 2020 – up 18.6% increase on 2019 and the highest year-on-year rise in two decades.

 

The study in question is by Peter Anderson, a veteran of neo-temperance academia, and is titled 'The COVID-19 Alcohol Paradox'. 

 

British supermarket-panel data suggest no increases in overall sales and purchases of alcohol following COVID-19 lockdowns, yet survey and mortality data suggest otherwise. This paper attempts to unravel the paradox.

 

But mortality data does not and could not suggest otherwise. Alcohol-related mortality rose sharply in 2020, but that does not imply that overall sales of alcohol rose. There is only a paradox here if you believe the discredited whole population theory of alcohol which assumes that there is a fixed link between per capita alcohol consumption and alcohol-related mortality.

The pandemic has once again shown that this theory, which has never been supported by evidence, is wrong. As I said a year ago...

Alcohol sales fell during lockdown and per capita consumption in 2020 seems to have been similar to previous years (we don't have comprehensive figures yet). Orthodox 'public health' theory suggests that we shouldn't see a rise in alcohol-related harm without a rise in per capita consumption. Moreover, the amount of alcohol advertising fell dramatically during lockdown and availability was greatly limited by bar closures. Since these are (supposedly) two of the main drivers of consumption, we should have seen a substantial decline in per capita consumption and a commensurate decline in alcohol-related harm.

We saw none of that. Instead we saw a spike in alcohol consumption among some (presumably heavy) drinkers which seems to have led to an almost immediate increase in harm. All of this leads to the common sense conclusion, which is alien to the neo-temperance lobby, that harmful drinking is driven by personal circumstance rather than 'commercial determinants'. Efforts to tackle harmful drinking should therefore focus on harmful drinkers rather than the whole population.

 

Rather than accept that the theory is mistaken, 'public health' academics portray evidence that disproves it as a paradox (see also: the alcohol harm paradox and the French paradox). 

The obvious explanation for this 'paradox' is that some heavy drinkers started drinking even more during lockdown while some moderate drinkers drank less. Anybody could work that out in a few seconds without needing academic qualifications or research funding.

Sure enough, that is what the study found. 

 

Increases in purchases were predominantly driven by households that were usually the highest purchasers of alcohol. The top one fifth of purchasing households (by how much they normally purchased) increased their purchases 17 times more than the bottom one fifth of purchasing households.

 

 Fancy that.

 

That the heaviest buyers of alcohol increased their purchases the most, with some independent impact of socio-economic disadvantage, might explain why reported alcohol problems and recent alcohol-related death rates might have increased.

 

D'ya think?!

Obvious though it is, the result of this extreme natural experiment - in which people were confined to their homes and the closure of hospitality restricted the availability of alcohol - should provide food for thought for 'public health' academics. The rise in alcohol-related mortality was clearly not the result of what they lazily assume to be the drivers of heavy drinking: advertising, affordability and availability. Furthermore, it was not related to per capita consumption. 

The authors do not address the question, but the most likely explanation is that a dramatic change in people's circumstances led to a change in behaviour. Boredom, social isolation and anxiety are enough to explain why a minority of drinkers consumed much more alcohol during lockdown, with predictable consequences for their health. 

 

Orthodox 'public health' ideology does not have a solution to these problems and so they ignore them in favour of easier political targets. Laughably, the authors even try to crowbar minimum pricing into their conclusion.

 

That the increase in purchases was much less pronounced in Scotland and Wales, compared with England, could be attributed to the minimum unit price of alcohol introduced in both jurisdictions, such a policy shown to reduce alcohol purchases, particularly amongst the heaviest purchasing households during times of lockdown.

Regardless of whether minimum pricing reduces purchases, it didn't prevent Scotland and Wales seeing a sharp rise in alcohol-related mortality in 2020 that was very similar to the rise seen in England. The authors don't mention this. I can't think why.

 

I guess that's another 'paradox' for someone to investigate...

A swift half with Tom Harwood

There's a new episode of The Swift Half out, this time with Tom Harwood, formerly of Guido Fawkes, currently at GB News. We discussed Boris Johnson's prospects, Covid and more.

Inside the UK's illicit tobacco business

Article in Vice about Britain's illegal tobacco problem.

 

Phil Mykytiuk has spent a decade mapping tobacco crime gangs in the north of England. He is new in post as a trading standards manager at Bolton Council in Greater Manchester but worked for 10 years on a tobacco enforcement team at nearby Rochdale Council.

.. The National Crime Agency said that while it supports partner agencies on tobacco enforcement, its focus is on prohibited commodities like drugs and firearms, with HMRC taking the lead on tobacco. 

Mykytiuk, though, believes the multiple layers of crime behind cheap, illegal tobacco are escaping scrutiny, allowing crime gangs – emboldened by the lack of deterrent – to expand their power base right under the noses of enforcement. Having witnessed Kurdish tobacco gang members invest heavily in property and high street businesses here in the UK, he’s now seeing evidence of them moving into cannabis farms.

“But forget drugs,” he says. “Drugs is yesterday. The big thing is tobacco. These gangs are becoming the most capable criminals in this country. Right now it's the biggest threat we’ve ever faced.”

As the article notes, official statistics indicate that the illicit market is large (17%) but has not grown in recent years. Maybe, maybe not. Official statistics are based on a vague estimate that is highly sensitive to the assumptions fed into the model. The government could sample litter to see how many packs were not sold legally in the UK. I suspect this would give a larger and more realistic estimate, but HMRC shows no interest in knowing what's really going on.

 

Tobacco taxes are crazily high these days and it's hard to imagine high rates of 'tax morale' among smokers. If anything, they might feel a moral duty to starve a government that discriminates against them of money.  

Do read the whole article.

Uncomfortable truths about the costs of healthy living

There's a good article in the New Statesman raising some uncomfortable truths about healthcare spending and lifestyle regulation. It mentions some research I commissioned at the IEA a few years ago.

In Britain we talk often of the “cost” to the NHS of people who smoke or are obese – the health support service One Small Step, for example, points out that smoking costs the UK government £12.6bn a year, £2.5bn of which is spent on NHS smoking services. On the same page, however, it notes that “half of all life-long smokers die early, losing on average 10 years of their life”. Given how dramatically health, social care and pension expenditure increases as someone ages past retirement, those 10 lost years actually represent a saving for the taxpayer.

That is an immensely grisly – not to mention heartless – way to look at things. But if your argument is that those who cost more should pay more, it is vital to crunch the numbers. Despite the perception that certain lifestyle choices would save money as well as lives, a Dutch study from 2008 found that smokers and the obese were cheaper to care for over their lifetimes, while research from the Institute of Economic Affairs concludes that: “By dying early, overweight and obese people saved the government £3.228bn in pension, healthcare and benefit payments in England and Wales in 2014.”

The more you think about it, the darker it gets. It is a triumph of medical science that people are living longer and surviving conditions that would once have killed us: someone who three decades ago would have died of cancer at 70 can now have a life-saving operation and live another 15 years. That’s wonderful – but those 15 years of other age-related ailments and potential dementia have a price-tag attached, for the government purse as a whole and in terms of healthcare specifically. Figures from the Nuffield Trust in 2016 published in the Guardian show how health spending in the UK is skewed towards the over-65s: more than £7,000 a year was spent per person on those above the age of 85 compared to a national average of £2,069, with an 85-year-old man costing the NHS seven times more than a man in his thirties. Miraculous but expensive new drugs compound the challenge. The unpalatable truth is that, above a certain age, the most costly thing someone can do in terms of burden to the NHS is to keep living.

 

There is no 'obesity timebomb'. 'Unhealthy' lifestyles do not pose a threat to the NHS or any other health system. What we have in the UK and around the world is a pensions timebomb and an ageing population putting unprecedented pressure on health and social care. Nobody in politics or the media knows how to address this and so disfavoured minorities are used as scapegoats to take our minds off it. 

 

Worthless, economically illiterate estimates of the cost of certain lifestyles are regularly produced (such as this garbage from ASH last week), but for all the talk about 'negative externalities', the reality is that the main economic consequence of people living healthier lives is that everyone has to work for longer before they can retire. Way to go, healthists!

Dishonest arguments against vaping

It's 2022 and certain people are still arguing about e-cigarettes as if it's 2012. Even in 2012, we knew more about them than the European Respiratory Society (ERS) does today. In a head-to-head debate in the British Medical Journal, three members of the ERS take on Nicky Hopkinson, the chairman of Action on Smoking and Health, to discuss whether e-cigarettes should be available on prescription. 

It's a controversial question and there are reasonable arguments on both sides, but the medics from the ERS don't bother with reasonable arguments. Instead, they bluster and lie and act as if no research has been carried out since their organisation took an ideological position against vaping back in the day. Here's how they start off...

There is already enough nicotine addiction. 

 

That is a moral judgement and has nothing to do with health.

 

For decades, smoking rates in the UK have been declining, and few teenagers see themselves becoming smokers. This has been achieved without e-cigarettes, and the decline in smoking has not accelerated after the introduction of e-cigarettes.

 

This is a bare-faced lie. The smoking rate had barely moved in five years before e-cigarettes became popular in 2012. It then fell sharply. 

 

E-cigarettes as an aid to smoking cessation have not been endorsed by a single major respiratory or paediatric scientific society because their effectiveness in smoking cessation is unproved—and remarkably poorly studied.

 

The appeal to authority here is suspiciously narrow. There are not many respiratory societies and I wouldn't expect a 'paediatric scientific society' to have any particular expertise in this area. The authors neglect to mention the endorsement of e-cigarettes for smoking cessation by Public Health England, the Royal College of Physicians, Cancer Research UK, the French National Academy of Medicine and fifteen past presidents of the Society for Research on Nicotine and Tobacco, to name a few. 

 

As for being 'remarkably poorly studied', the authors are either dishonest or woefully uninformed. There have been many observational studies, a number of randomised controlled trials and several Cochrane reviews, all of which show that e-cigarettes work better than anything else, even for smokers who have no intention of quitting. This is tacitly acknowledged by the gormless authors in what follows...

 

In the most cited trial comparing e-cigarettes with medicinal nicotine products, e-cigarettes were found to be superior, showing a one year abstinence rate of 18%, compared with 10%. However, twice as many people in the “old fashioned” nicotine replacement groups were found to have quit nicotine completely, as people using e-cigarettes tend to continue vaping, whereas most people using medicinal nicotine products quit.

 

That's exactly what I did and it's just the way I like it, thanks. The important statistic is that nearly twice as many people quit smoking with e-cigarettes than without. Whether people continue vaping after quitting - or continue using nicotine gum, for that matter - is of trivial 'public health' interest.

There is also the phenomenon of “dual use”: smokers quit by using e-cigarettes and then restart smoking while they continue vaping. In the most cited trial, 40% of people assigned to e-cigarettes were still using them after a year, and more than half of these vapers were also smokers. 

 

This is the same randomised controlled trial mentioned in the previous paragraph and the authors are saying much the same thing in a different way. The fact remains that the smokers who were given e-cigarettes were 83% more likely to quit smoking. That is what should matter to a respiratory society.

 

(The University of Bath’s Tobacco Tactics group has noted that the tobacco industry loves dual use.)

 

Haha! Who cares what a Bloomberg-funded activist group thinks??

 

E-cigarettes are not “95% less harmful than cigarettes.” 

 

Indeed. It's probably closer to 99.9%.

 

This often quoted statement is indefensible because vaping has been associated with many cases of acute lung damage, events not seen in smokers.

 

You're not seriously going to blame the US's 2019 EVALI outbreak on e-cigarettes, are you? It has been proven beyond reasonable doubt that the lung damage was caused by the adulteration of black market THC cartridges. It had nothing to do with nicotine vaping.

Around 80% of these cases are related to cutting the liquids with cannabinoids—but 20% are not.

 

No. In around 80% of cases, the person admitted to consuming black market THC. The other 20% denied it because purchasing black market THC is illegal. 

 

Either that or normal e-cigarettes briefly produced exactly the same symptoms as EVALI among a handful of people in a few parts of the USA for a short period before the contaminated THC products disappeared from the market. Which seems more likely?

 

If the acute effects of vaping are worse than those of tobacco, how can anyone seriously state that the unknown long term effects are less harmful and expect to be believed?

 

What an insanely stupid thing to say. 

The whole article is equally idiotic. Read it here if you must. These chancers couldn't lie straight in bed.

The grips of obsession

A brief follow up on Monday's post in which I discussed the 'public health' academic Mark Petticrew who is obsessed by the idea that alcohol awareness charities are covertly encouraging people to drink.

Absolute monomania.

The Philippines take an enlightened approach to vaping, prohibitionists in the mud

The Philippines have had enough of Mike Bloomberg sticking his nose and money into their business. The wrinkly prohibitionist was caught last year funding numerous 'public health' groups in the country and giving pay outs to the Philippines FDA - the agency that regulates e-cigarettes.

The legal status of e-cigarettes has been all over the place in the Philippines in recent years. As far I can tell, they were effectively banned by the nation's autocratic president in February 2020, but they have now been deregulated in a conscious bid to encourage smokers to switch to them. 

It's all a big turnaround for a country that has been given awards from Mike Bloomberg and the equally prohibitionist WHO in the past. The volte face may have been partly a reaction to having a foreign billionaire using his money to influence policy, but it is certainly a step in the right direction.  

In true 'scream test' fashion, it has annoyed all the right people, not least the fanatics at the Tobacco Control blog...

New laws often build upon and strengthen existing laws, but in the midst of a pandemic when health-protective measures should be prioritised, retrogressive bills seeking to loosen existing restrictions on heated tobacco products (HTPs) and electronic nicotine/non-nicotine delivery systems (ENDS/ENNDS) have advanced in Philippine Congress. 

 

Cry more.

 

Completely disregarding the existing laws that already set a regulatory regime for these products and the repeated and pointed opposition of medical organizations, these bills seek to make HTPs and ENDS/ENNDS more widely available by lowering the minimum age of access from 21 years to 18 years, allowing sales to non-smokers, allowing online marketing and sales, allowing multiple flavours that are attractive to teens, replacing the FDA with the industry-friendly Department of Trade and Industry as the regulatory agency for these harmful products, and limiting the placement of GHW [graphic health warning] to a single message on nicotine as an addictive substance.

Excellent. 

 

Under the guise of balanced regulation, HB 9007 and SB 2239 proponents claim that regulation of HTPs and ENDS/ENNDS should not be stricter than that for reportedly much more harmful cigarettes, as stipulated in RA 9211. 

 

It obviously shouldn't. And note the sly use of the word 'reportedly'.

 

For a more intelligent take, read this report from the Manila Bulletin...

 

The Philippines is poised to join the ranks of progressive countries like the United States, the United Kingdom and New Zealand which are seeing sharp declines in the number of smokers with the passage of the so-called vape bill in the Senate and the House of Representatives, two leading international experts on tobacco harm reduction said.

It is also worth watching the Philippines' video statement at last year's FCTC COP9, the WHO's biannual anti-nicotine conference. The tone is very polite, but the minister makes it clear that they're not going to take any more of the WHO's prohibitionist medicine.

Marginalised outgroup is marginalised, new study reveals

This study would be funny if the subject matter wasn't so grim.

Background

Smoking is often colloquially considered “social”. However, the actual relationship of smoking with current and future social isolation and loneliness is unclear. We therefore examined these relationships over a 12-year follow-up. Methods

In this cohort study, we used a nationally representative sample of community dwelling adults aged 50 years and over from the English Longitudinal Study of Ageing (N=8780) (45% male, mean(SD) age 67(10) years. We examined associations of self-reported smoking status at baseline assessment, with social isolation (low social contact, social disengagement, domestic isolation), and loneliness (3-item UCLA loneliness scale), measured at baseline, and follow-up at 4, 8 and 12 years, using ordinary least squares regression models.

Findings

At baseline, smokers were more likely to be lonely (coef.=0·111, 95% CI 0·025 – 0·196) and socially isolated than non-smokers, having less frequent social interactions with family and friends (coef.= 0·297, 95%CI 0·148 – 0·446), less frequent engagement with community and cultural activities (coef.= 0·534, 95%CI 0·421 – 0·654), and being more likely to live alone (Odds Ratio =1·400, 95%CI 1·209 – 1·618). Smoking at baseline was associated with larger reductions in social contact (coef.=0·205, 95%CI 0·053 – 0·356, to 0·297, 95%CI 0·140 – 0·455), increases in social disengagement (coef.=0·168, 95%CI 0·066 – 0·270, to coef.=0·197, 95%CI 0·087 – 0·307), and increases in loneliness (coef.=0·105, 95%CI 0·003 – 0·207), at 4-year follow-up) over time.

Who could have guessed that a concerted, state-led campaign of ostracism and demonisation in which the law was used to drive smokers out of all indoor venues and a large number of outdoor venues would have led to the outgroup being socially isolated? I for one am stunned.

The discussion section is amazing. 

 

These findings have important policy implications. Firstly, they further strengthen the justification for anti-smoking legislation

 

That's one interpretation, I guess.

 

Adding to other research on the health impacts of smoking, our results suggest that smoking is potentially detrimental to aspects of psychosocial health.

 

I mean, it might be, but a more obvious inference is that smoking bans are detrimental to aspects of psychosocial health, something the late Frank Davis spent the last thirteen years of his life 'banging on about'. A simple way to test the proposition would be to see whether smokers felt socially isolated in the decades before the government decided to make an example of them. I know of no evidence that they did. 

 

Or we could study people in the dwindling number of countries where smoking is not yet treated as being akin to paedophilia and see whether they have 'less frequent engagement with community and cultural activities'. I suspect not, but further research would be welcome.

That is not the kind of research the authors have in mind, however.

Although causality cannot be assumed, and further research is warranted, the idea held by some that smoking might be prosocial appears to be a misconception, with serious implications for health and wellbeing throughout the lifespan.

As I have said before, 'public health' activists are the kind of people who would put a brick through your window and then try to sell you double glazing. For years they have shed crocodile tears over tobacco sales leading to secondary poverty, as if it were not the direct result of the exorbitant taxation they campaigned for. Now they are claiming, in effect, that smoking causes loneliness. 

And don't expect self-awareness to emerge any time soon. Guess what their solution is?

 

These findings emphasise the intersection of two major public health priorities which requires further attention. In policy terms it provides a further basis to increase efforts to achieve Smokefree society.

That's right. More smoking bans.

Behold the merchants of doubt!

Public health epidemiologists have been dining out on the smoking-lung cancer link since the 1950s. They're not going to find anything as big as that again and the trophy cupboard has been fairly empty ever since. 

'Public health' activists have been dining out on the tobacco industry's 'merchants of doubt' campaign since the 1990s and are eager to tar every industry of which they disapprove with the same brush. 

The latest example of this is a study titled Manufacturing doubt: Assessing the effects of independent vs industry-sponsored messaging about the harms of fossil fuels, smoking, alcohol, and sugar sweetened beverages written by our old friends Mark Petticrew, Nason Maani et al. You may recall that Petticrew has an obsession with the bland alcohol education charity DrinkAware which was set up by the government and is funded by the drinks industry. 

 

Petticrew is convinced that DrinkAware exists to downplay the risks of drinking and encourage pregnant women to get drunk. He and his colleagues have been knocking out studies trying to prove this at a rate of one or two a year for the last five years. I've covered some of them on this blog, mainly because I find them funny.

 

The latest study is no exception. The gist of it is that the tobacco industry circa 1950-1980 put forward 'alternative causation arguments' to cast doubt over the smoking-lung cancer association. Indeed they did. There was talk of sulphur in matches being the real problem. Hans Eysenck suggested that the personality traits which led people to smoke also happened to increase the risk of developing cancer.

 

This was all obviously nonsense and we can laugh about it now. Petticrew's theory is that the same thing is going on today with regards to sugary drinks and alcohol. To get to the bottom of this, he and his chums conducted an online survey - the gold standard for 'public health' research these days - and gauged people's reactions to a series of statements. 

 

They were subsequently presented with a short, anonymized, paragraph containing either an alternative causation argument about a particular harm obtained from one of the four industry-sponsored sources (randomly selected from examples from either the fossil fuels, smoking, alcohol, or sugar sweetened beverages industries), or information from an independent scientific or non-governmental agency. Respondents were then asked about their certainty about the risk of the specific harm from that product (certain it does increase risk, uncertain it increases risk, certain it doesn't increase risk).

The idea was to see whether the industry's filthy lies would outweigh the impartial truth in the mind's of ordinary folk. Alas, they did.

 

Overall, (i.e. grouping all industries together) industry-sponsored uncertainty messages significantly increased the odds of uncertainty, or false certainty, by 60%, compared to independent sources of information (Summary OR 1·60, 95% CI 1·28–1·99) (see Fig. 1 and Table 2).

It seems that about seven per cent of participants went from being certain to uncertain when presented with the 'industry text'. Weirdly, it seems that the biggest effect was found when people were presented with ancient statements from the tobacco industry, albeit from a lower (but still surprisingly high) base.

 

 

What kind of statements are we talking about? This is where it gets interesting. The authors don't include them in the study but they can be found in a ropey Word document in the supplementary material. For alcohol, the first statement from 'an independent scientific or non-governmental agency' is this...

 

"Alcohol is a Group 1 Carcinogen. Like Tobacco." (Balance North East) http://www.balancenortheast.co.uk/our-campaigns/alcohol-and-cancer/

Balance North East is an anti-alcohol pressure group entirely funded by the taxpayer. It is questionable whether it is 'independent' (from whom?) or 'non-governmental'. Either way, it has an incentive to portray alcohol in the worst possible light to drive support for its various campaigns, which include minimum pricing and advertising bans. 

The claim about alcohol being a Group 1 carcinogen is true, but IARC's classifications are notoriously confusing to the general public since they are based on the strength of evidence rather than the magnitude of the risk. Processed meat is also a Group 1 carcinogen, but it is nothing like tobacco. As Cancer Research UK explains...

 

While this may sound alarming, it’s important to remember that these groups show how confident IARC is that red and processed meat cause cancer, not how many cancer cases they cause, as we wrote when we covered a previous IARC decision on diesel emissions, and interviewed one of our experts in the causes of cancer.

As Professor David Phillips – a Cancer Research UK-funded carcinogen expert from King’s College London – explains, “IARC does ‘hazard identification’, not ‘risk assessment’.

“That sounds quite technical, but what it means is that IARC isn’t in the business of telling us how potent something is in causing cancer – only whether it does so or not”, he says.

To take an analogy, think of banana skins. They definitely can cause accidents, explains Phillips, but in practice this doesn’t happen very often (unless you work in a banana factory). And the sort of harm you can come to from slipping on a banana skin isn’t generally as severe as, say, being in a car accident.

But under a hazard identification system like IARC’s, ‘banana skins’ and ‘cars’ would come under the same category – they both definitely do cause accidents.

 

So the first supposed statement of fact from an impartial organisation related to alcohol is not from an impartial organisation and is likely to mislead the vast majority of people. In the study, Balance North East's claim is juxtaposed with the following statement from - you guessed it! - DrinkAware.

"It's important to put the risks from drinking alcohol into context. There are many other factors that increase the risk of developing breast cancer, some of which we can't control, like:
 - Age: you're more likely to develop it as you get older
- A family history of breast cancer
- Being tall
- A previous benign breast lump
 However, in addition to alcohol, other lifestyle factors such as being overweight and smoking are thought to increase your risk of developing breast cancer." (Drinkaware, UK)

Again, this is all true. Is it misleading? Aside from the fact that smoking isn't actually a risk factor for breast cancer, I wouldn't say so. In any case, it needs to be put in the context of an entire webpage and a downloadable fact sheet which makes it very clear that "drinking alcohol increases your risk of breast cancer". This is hardly 'merchants of doubt' territory. 

The next pairing of 'non-industry sponsored' and 'industry sponsored' texts is...  

 

"The Chief Medical Officers advise: Alcohol can cause cancer, including breast and colon cancers" (Warning msg from Hobin et al, 2020)

"Not all heavy drinkers get cancer as multiple risk factors are involved in the development of cancers including genetics and family history of cancer, age, environmental factors, and behavioural variables, as well as social determinants of health" (Drinkaware, UK) 

This is not actually from DrinkAware. It is from the Australian equivalent, DrinkWise. The same webpage says 'Excessive drinking can increase the risk of developing colon cancer' and 'Studies indicate a relationship between alcohol consumption and developing breast cancer'. Hardly the stuff of a hardcore denier.

It seems that Petticrew's beef is that DrinkAware and DrinkWise acknowledge that alcohol is not the only cause of cancer. This is obviously true. Alcohol causes only a small minority of cancers. If the aim is to educate the general public, the quotes from DrinkAware and DrinkWise are more informative than "Alcohol is a Group 1 Carcinogen. Like Tobacco."

Some may disagree, but everyone should be able to agree that these 'industry-sponsored' organisations are not putting forward an 'alternative causation argument'. An alternative causation argument would be something like this:

 

Some studies have found a link between alcohol and cancer, but correlation doesn't equal causation and the statistical association may be due to factors such as X, Y and Z.

That is what the tobacco industry and its supporters did in the twentieth century. It is not what DrinkAware are doing. Pointing out that not every drinker gets cancer and listing some other causes of cancer is not an alternative causation argument. It is the truth and it is quite useful since most people would like to know what risks they face in life.

The next pairing takes a quote from Alcohol Concern - a defunct anti-alcohol pressure group - and the International Alliance for Responsible Drinking, an industry-funded body. 

 

"For some cancers, any amount of alcohol increases the risk. For other types of cancer, the risk only increases after drinking two or three drinks per day – around 26 to 35 units per week.

Any amount of alcohol increases the risk of:
- Mouth cancer
- Upper throat and voice box cancer
- Food pipe (oesophagus) cancer
- Breast cancer" (quote from Alcohol Concern information on alcohol and cancer (now Alcohol Change https://alcoholchange.org.uk/alcohol-facts/fact-sheets/alcohol-and-cancer)

“Breast cancer is the leading cancer among women, and is associated with a large number of individual risk factors. Research has shown that breast cancer risk is associated with family history and hormonal and reproductive factors. Increased risk has been reported with hormone replacement therapy, but varies by the type of breast cancer (ductal, lobular, or mixed). Similarly, risk associated with other reproductive factors, such as age at menarche or breastfeeding, have been shown to differ by cancer subtypes. According to IARC, cancer of the female breast is causally associated with the consumption of alcohol beverages." (IARD, global)

In this instance, the 'industry-sponsored' message is more factual than the 'non-industry' message. The idea that light drinking increases the risk of breast cancer is actually pretty shaky. The same is true of laryngeal ('throat box') cancer. Meanwhile, the IARD statement is factually correct. It's difficult to see what Petticrew's problem with a sentence like 'According to IARC, cancer of the female breast is causally associated with the consumption of alcohol beverages' could be. Presumably he is upset because they mention other risk factors. It is understandable that a temperance pressure group wouldn't want to mention other risk factors, but it hardly seems unreasonable to do so.

The authors then move on to drinking in pregnancy with examples such as this:

If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. (UK Chief Medical Officer Guidelines, UK) https://www.gov.uk/government/publications/alcohol-consumption-advice-on-low-risk-drinking

There is confusion about how much one can safely drink during pregnancy. We know very clearly that excessive amounts, either in isolated binge drinking or in prolonged drinking, are very harmful. What we don’t know for sure is the lowest possible level that you can drink safely. We therefore say, for that reason, the safest possible thing that you can do is to not drink at all during pregnancy or while you’re breastfeeding. (Drinkwise, Australia) 

It is certainly true that there is 'confusion about how much one can safely drink during pregnancy'. It is likely that there is a 'safe level' but it would be unethical to run a randomised controlled trial to establish what it is. In the absence of firm data, total abstinence is clearly the risk-free option. And that is exactly what DrinkWise recommends! Presumably Petticrew included this quote because it mentions uncertainty, but the uncertainty is very real. 

They then move on to sugary drinks.

“Children who consume higher amounts of sugary drinks have a 55% greater chance of being overweight or obese compared to those who consume less [sic] sugary drinks." (American Heart Assn: (https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_474846.pdf)

"Obesity is a complex problem that is influenced by many factors, most importantly diet, exercise and genetics. … The key to living a healthy lifestyle is to incorporate a balanced, healthy diet that balances calories consumed and calories burned through activity and exercise." (American Beverage Institute, sourced from Lim et al, 2019)

The 'impartial' commentators here are citing one meta-analysis. Other meta-analyses have been published which find no such effect (see here and here). This suggests a large degree of genuine uncertainty. Meanwhile, the 'industry-sponsored' commentators make a statement of fact that is so uncontroversial I am at a loss to see why it is included by Petticrew et al. 

“Excessive consumption of sugar is one factor promoting overweight and obesity. In 2013, about 37% of men and 38% of women worldwide were overweight or obese. Excess weight increases the risk of non-communicable diseases, including some cancers”. (NCD Alliance https://ncdalliance.org/sites/default/files/resource_files/Curbing-Global-Sugar-Consumption.pdf)

"Obesity is complex and there can be many causes. These include eating more kilojoules than your body uses, inactivity, genetics, conveniences linked to modern living, and socio-economic factors. For many, too much energy or kilojoules consumed from any source, including sugars, contributes to weight gain. For sugars and obesity, the research continues to show no direct causal relationship, outside of the contribution to energy intake." (Sugar Nutrition Research Centre https://www.sugarnutritionresource.org/sugar-health/sugar-and-obesity)

I can't see much of a difference between these two statements. They are both factually correct and uncontroversial.

It would be tedious to give more examples. The most that can be said is that the 'industry-sponsored' messages sometimes have a slightly different emphasis than the messages from campaign groups. Specifically, the 'industry-sponsored' messages - or, more precisely, the messages that have been handpicked by Petticrew and friends - are more likely to mention other risk factors than the messages from 'non-industry sponsored' organisations. 

Even this is debatable. If you look at the NHS's webpage about breast cancer, it only briefly mentions alcohol at the bottom of its list of risk factors. It is the same list of risk factors given by DrinkAware in the quote above which is supposedly 'misinformation'. 

The study concludes with a little rant and a call to action.

 

The potency of this misinformation is of concern in part because exposure to it is widespread. Compared to the tobacco industry, which has now been prevented from many forms of public engagement, the fossil fuel, alcohol, and sugar sweetened beverage industries have far wider access to the public as conveyors of misinformation, including by funding charities with the express purpose of communicating on product harms to the general public, as well as to children and young people through schools.

 

He is talking about DrinkAware, of course. Did I mention that he is obsessed?  

By way of example, Drinkaware, an alcohol-industry-sponsored charity in the UK, whose misinformation is used in two of our examples, is named on most alcohol-related advertising labels, posters and adverts, and its website, from which the information used in this study was obtained, received over 10 million unique visitors in 2018 (DrinkAware. Impact Report, 2018). Just as “the dose makes the poison”, the impact of these messages is a function of both their potency, and their breadth of exposure.

DrinkAware need to take out a restraining order against this guy. 

Dialing the madness up to 11 in the conclusion, the authors suggest that charities such as DrinkAware should be banned from talking about health risks, presumably by law.

 

.. This evidence brings into question whether manufacturers of harmful products and charities with funding from such manufacturers should be permitted to communicate about health risks with the public. 

 

And there is a clue as to what their next studies are going to be about. 

 

.. Future research could focus on messages regarding other harmful products such as gambling or vaping.

 

Something to look forward to. 

 

And, in case you were worried, the researchers took their duty of care very seriously. No one was hurt as a result of this experiment.

 

At the end of the survey respondents were presented with accurate independent (non-industry) information, and a link to a trusted source (e.g., the relevant NHS England information or other independent source). Each respondent was exposed to misinformation from only one industry.

 

 That's a relief.

What is 'ultra-processed food'?

In 'public health', the name of the game is to interfere with people's lives without having your own choices meddled with. This is straightforward with smoking since the philosopher kings of the nanny state don't smoke. Alcohol is more tricky since most of them drink, but minimum pricing - which was introduced in Ireland yesterday - offers the perfect way to penalise ordinary people while leaving fine wine and craft beer unaffected. 

The war on food poses the trickiest problem since its pretext - obesity - is the result of over-consumption and physical inactivity rather than the consumption of any specific type of food. 'Junk food' is too narrow since most people interpret it to mean 'fast food' from a handful of restaurant chains. And so, in the absence of an obvious dietary culprit, the 'public health' lobby is shifting towards a crusade against 'ultra-processed food'. 

 

Most people don't know what this means, but it sounds bad if you have an instinctive objection to industry and modernity. Perhaps it evokes thoughts of 'chemicals' and 'E numbers'. Certainly, it sounds like the opposite of the 'natural', 'organic' and 'home made' food so beloved of those who think they are superior to other people. It is, however, a classic 'public health' bait and switch. Just as people didn't realise that a ban on 'junk food' advertising would result in adverts for cheese and butter being banned, people won't realise what a war on ultra-processed food means for them until it is too late.

In a deranged op-ed in BMJ Global Health, some of Mike Bloomberg's minions from Vital Strategies call for tobacco-style regulation of 'ultra-processed food', starting with warning labels.

Simply put, ultra-processed foods are foods that can’t be made in your home kitchen because they have been chemically or physically transformed using industrial processes. They are recognisable on the supermarket shelf as packaged foods that are ready-to-eat, contain more than five ingredients and have a long shelf-life. The industrial processing, as well as the cocktail of additives, flavours, emulsifiers and colours they contain to give flavour and texture, make the final product hyper-palatable or more appealing and potentially addictive, which in turn leads to poor dietary patterns.

 

With more than half the total calories consumed in high-income countries coming from ultra-processed foods and rapid increases in low- and middle-income countries, these products are exposing billions of people to a higher risk of type 2 diabetes, heart disease, stroke, depression and death.

Scary stuff, eh? Alas, they don't give any examples of ultra-processed foods so let us instead turn to a recently published study about them....

Baked goods, including cakes, pastries, industrial breads, and soft drinks ranked among the top contributors to sales of UPFDs [ultra-processed food and drinks]

According to the the British Heart Foundation, ultra-processed foods include...

Ice cream, ham, sausages, crisps, mass-produced bread, breakfast cereals, biscuits, carbonated drinks, fruit-flavoured yogurts, instant soups, and some alcoholic drinks including whisky, gin, and rum.

 

I'm not sure how hard liquor made the cut, but I suppose if you're going be a fun sponge you might as well go all the way.

 

The Soil Association adds confectionery, margarine, milk drinks, ‘instant’ sauces, pies, pasta and pizza dishes, poultry and fish nuggets, burgers, hot dogs, noodles, desserts, infant formulas, follow-on milks and 'other baby products' to the list.

It's hardly surprising that high-income countries get more than half their calories from products on such an extensive list. A humble ham sandwich with margarine consists entirely of 'ultra-processed food' (unless you bake the bread yourself in which case it becomes magically healthier). If there is to be a war on ultra-processed food, you will have to be a very unusual person not to be affected.

You might have noticed that a lot of the foods on these lists do not fit the definition given by Bloomberg's people. A lot of them, such as pastries, don't have a long shelf life. Most of them can be made 'in your home kitchen' if you can be bothered. They don't need to be 'chemically or physically transformed using industrial processes'. For the most part, 'processing' simply means 'cooking', ie. combining ingredients and heating them up. Chicken nuggets can be made at home, as Jamie Oliver famously demonstrated. They may or may not have more salt in them than the 'industrial' versions, just as a home cooked cake may or may not have more sugar in it than a shop-bought cake. That's up to you, but the idea that home-cooked food is inherently healthier has no basis in fact.

As for having 'more than five ingredients', what kind of ludicrous, arbitrary threshold is that??

None of this has any scientific standing whatsoever. The only thing these products have in common is that they are mostly sold in shops by businesses. Nevertheless, the authors claim that the foods listed above 'are not real foods'. Indeed, their article is titled '"Warning: ultra-processed" - A call for warnings on foods that aren't really foods'. 

 

It's high time that consumers had the opportunity to see ultra-processed foods for what they are: foods that are not real foods, containing nutrients but not real nutrition, pervasively marketed by supranational companies offering choices that are not real choices.

 

This is juvenile stuff and insofar as it makes any sense, it is garbage. The authors do, however, admit that when people are told what kind of foods are 'ultra-processed', they say that they rather like them.

We found evidence that while people are not familiar with the term ‘ultra-processed products,’ they recognise the group of products as harmful. That said, these products are also associated with positive emotions, which might be the result of decades of persuasive marketing by the food industry.

Of course. That's why people like eating sausages, bread and cakes. Persuasive marketing! What else could it be?

 

For instance, a considerable number of people associate the products with satisfying cravings, being tasty and bringing joy. 

This is totally unacceptable, naturally, and the authors see an urgent need to crack down on it.

 

If we are to stave off the devastation to our food system and our health, governments with the support of the global public health community need to urgently implement effective strategies that lead to decreasing consumption of these unhealthy products and enable healthier choices. 

One such strategy would be to establish the image of ultra-processed foods—those glossily packaged, alluringly marketed, ready-to-eat, convenient and tasty products—as the vector for obesity and a risk factor for serious diseases alongside tobacco, alcohol and other unhealthy commodities. It’s time to invest in establishing the negative brand identity that ultra- processed foods and beverages deserve. We could start by taking lessons learnt from tobacco control...

 

Heavens to Betsy, a slippery slope! Who could have seen that coming?

The awesome power of vaping

I don't post many studies about e-cigarettes and smoking cessation these days. The science was settled years ago, regardless of how much the WHO-Bloomberg spin machine tries to muddy the waters. Nevertheless, it cannot be said too often that vaping is remarkably good at getting people to stop smoking even when they have no intention of quitting. I have personal experience of this and it has been shown empirically in observational studies. 

 

It is quite something when you consider how few people manage to stop smoking even when they have a strong desire to do so.

A new study in JAMA Network Open provides some dramatic new evidence of this phenomenon. The researchers found 1,600 smokers in the USA who did not use e-cigarettes and had no intention of giving up smoking. They were followed for five years between 2014 and 2019. By the end of that period, 6.2% of them had stopped smoking, but there was a massive difference between the quit rates of those who had taken up e-cigarettes in the meantime and those who hadn't. 

The odds of cigarette discontinuation were significantly higher among those who used e-cigarettes daily (28.0%; 95% CI, 15.2%-45.9%) compared with those who did not use e-cigarettes at all (5.8%; 95% CI, 4.6-7.2; aOR, 8.11; 95% CI, 3.14-20.97), while the odds of cigarette discontinuation among those who used e-cigarettes nondaily did not statistically differ from those who did not use e-cigarettes at all.

 

... results showed that those who subsequently used e-cigarettes every day experienced an 8-fold higher odds of cigarette discontinuation compared with those who did not use e-cigarettes at all.

You read that correctly. The smokers who used e-cigarettes were eight times more likely to have stopped smoking after five years than the ones who didn't. 

Studies like this have some major implications. Firstly, vaping obviously works. If it can work for people who don't want to stop smoking, it can certainly work for the large number of smokers who do. 

 

Secondly, the anti-vaping crusades going on in the USA and elsewhere are extremely counterproductive and the prohibitions on e-cigarette sales in places such as Australia and India are insane. But you already you knew that, I'm sure. 

Thirdly, the UK government should take note. Thanks to Theresa May, it has an arbitrary target of bringing the smoking rate below 5% by 2030 (it is currently about 14%). It has very little chance of achieving this, not least because while groups such as ASH claim that 80% or 90% of smokers want to quit, this is a self-serving lie. In fact, the proportion of smokers who say they want to quit has been falling for years. In the most recent ONS survey, only 53% of smokers expressed a desire to quit.

In other words, even if every smoker who wants to quit manages to do so - a highly improbable outcome - the 5% target will not be met. There is no hope of getting near this target unless ways are found to make people quit 'accidentally' by giving them a more attractive substitute. 

This is particularly relevant because, as the authors of the study say... 

Smokers with no plans to ever quit smoking tend to smoke more cigarettes per day and have lower educational attainment and household income compared with their counterparts who do plan to quit...

This is as true in Britain as it is in the USA. These are the 'hard to reach' people who are patronised or ignored by 'public health professionals'. 

It should also be remembered that a third of smokers in Britain have still never tried an e-cigarette. Many of those who have tried vaping but have not made the switch might be tempted if the products were improved through technological innovation or better regulation, or if a more concerted attempt was made to counter the tidal wave of misinformation about the risks of vaping. For those who do not like vaping, newer products such as heated tobacco and nicotine pouches might be more to their liking. 

There are plenty of options and plenty of scope for constructive action. I don't think the government should have a target for smoking prevalence at all. If people enjoy smoking and don't want to quit, then they should be left alone. They are adults and this is supposed to be a free society. But if, as this study suggests, there is significant latent demand for vaping as a substitute for smoking, it is pretty obvious where the government should be focusing its attention.