Saturday 30 July 2022

A reasonable question and a sensible answer about the Covid vaccines

This graph has been doing the rounds recently…
It is based on an Office for National Statistics (ONS) dataset which the vaccine hesitant have been getting excited about. Toby Young, editor of the Vaccine Sceptic Daily Sceptic mentioned it a few days ago…


And the rapper Zuby has been tweeting images like this…
Zuby seems to think that the vaccines are useless at best and dangerous at worst. This is, he reckons, a ‘scandal’.

In his defence, he posted a link to the relevant ONS spreadsheet and asked people to put him straight if he had misunderstood. He doesn’t want to spread fake news, you see?

It is a pretty hollow defence because numerous people have explained why he is wrong and yet, at the time of writing, he still hasn’t deleted his tweet.

Throughout the pandemic, smileys and anti-vaxxers have been blissfully ignorant of the base rate fallacy. Insofar as a few of them are aware of it, they don’t think they have fallen into it on this occasion. They note that 93% of the British population have been vaccinated and, since a similar proportion of Covid-related deaths are among the vaccinated, this strikes them as the final proof that the jabs don’t work.

Their raw figures are broadly correct. If you go to Table 1 of the spreadsheet, you can see all the Covid-related deaths each month by vaccination status. And if you go to the effort of tallying them all up, in April 2022 there were 3,571 deaths of which 206 were among unvaccinated people. In May 2022, there were 1,364 deaths, of which 82 were among the unvaccinated (NB. the numbers are based on death certificates so the figure for May will rise once all the deaths have been registered).

The overwhelming number of deaths were indeed among people who had had at least one vaccine: 94% in April and 94% in May. (Zuby’s chart has slightly different figures for some reason, but the general picture is similar.)

Add these figures together and you get 4,935 deaths for April and May combined, of which 288 were among the unvaccinated. These are exactly the figures shown in the red graph above. 94% again.

As the ONS’s Sarah Caul and others have pointed out, none of this tells you very much unless you adjust for the age and characteristics of the people who died. If you look at the age-standardised mortality rates, the picture is rather different.

In April, the age-standardised rate for Covid-related mortality was 204.7 per 100,000 person-years among the unvaccinated and 96.5 per 100,000 among the ever-vaccinated.

In May, the age-standardised mortality rate for Covid-related death was 77.6 per 100,000 among the unvaccinated and 35.5 per 100,000 among the ever-vaccinated.

In other words, people who have been vaccinated are half as likely to die a Covid-related death as those who ‘trust their immune system’.

I won’t go over the base rate fallacy again. Plenty of people have explained it before and those who don’t want to hear it - or can’t understand it - will never be persuaded by me. But it is worth noting that you really have to go out of your way to arrange the figures in the manner shown in the graphs above. You have to add up a whole bunch of numbers, work out the percentages and plot them on a graph. Why go to such trouble when the age-standardised figures are right there in Table 1 next to numbers you’re adding together?

However, in the spirit of genuine sceptical enquiry, it is reasonable to ask why the vaccines only seem to be halving the risk of death when the original trials showed that they reduced the risk by over 90%. Funnily enough, the reasons involve issues with which smileys are very familiar. They just choose to ignore them on this occasion because they don’t fit their narrative.

The first is that the deaths listed in the ONS spreadsheet are what the ONS call ‘deaths involving COVID-19’ (which I call ‘Covid-related deaths’ above). These are deaths for which Covid is mentioned on the death certificate but for which Covid may not have been the primary cause. You may recall the whole ‘with Covid’’ versus ‘of Covid’ conversation in 2020-21. It was a virtual irrelevance back then because around 90% of deaths involving Covid had Covid listed as the primary cause on the death certificate.

But it is a much more significant issue now because the proportion of Covid-related deaths that are primarily caused by Covid has fallen. Since February 2022, the proportion of Covid-related deaths that the ONS classifies as ‘due to Covid’ has only been around 60-65%.

This means that at least a third of the deaths in the graphs above were mainly due to heart disease, cancer, dementia, etc. and Covid played little or no part. Since Covid vaccines do not prevent heart disease, cancer, dementia, etc., you wouldn’t expect a markedly higher survival rate among the vaccinated. Around a third of the deaths could not have been prevented with a Covid vaccine and they cannot therefore be used to gauge the efficacy of the vaccines. They only muddy the water.

It is extremely likely that if the ONS spreadsheet Zuby linked to confined itself to deaths due to Covid, rather than involving Covid, the age-standardised Covid mortality rate would be even lower among the vaccinated and higher among the unvaccinated.

Secondly, there is the issue of another smiley favourite: natural immunity. We were more than two years into the pandemic by April 2022 and the vast majority of people had already had Covid. The ONS estimates that between 27 April 2020 and 11 February 2022, 71% of people in England caught Covid at least once. Something in the region of 5% of the population caught it before 27 April 2020 and a very large number of people have had it since 11 February 2022.

A reasonable guess is that around 90% of the population have been infected at some point and the figure for unvaccinated people may be even higher.

Infection obviously produces a good deal of immunity and makes it likely that your next infection will be milder. If you survived Covid the first time, you’re very unlikely to die from it the second time.

By April 2022, virtually everybody in hospital with Covid had antibodies from vaccination or prior infection. That is why so few people are dying of Covid these days despite high rates of infection in the community.

There is also the small matter of lots of unvaccinated people already being dead by April 2022. They can only die once.

The clinical trials studied vaccinated people versus people who had not yet been infected - and they worked very well indeed. They work less well, relatively speaking, when you compare people who have antibodies from vaccination with people who have antibodies from prior infection. A combination of vaccines plus prior infection works best of all - that is why we still see better outcomes among vaccinated people relative to unvaccinated people - but the pool of unvaccinated people who have yet to be infected and die from it is inevitably running dry.

If Zuby, Toby, et al. want (further) proof the vaccine’s efficacy among people who have not been infected before, they need look no further than Table 1 again. If we check the figures for last April, the age-standardised Covid-related mortality rate was 146 per 100,000 among the unvaccinated but just 16 per 100,000 among the vaccinated.

In May 2021, the rate was 45.5 per 100,000 among the unvaccinated and a mere 6.2 per 100,000. Among those who had received a second dose, it was just 2.8 per 100,000.

All this stuff is right there on the same page of the same spreadsheet that the ‘sceptics’ have pored over to make their cute little graphs. How strange that they didn’t notice it.

Friday 29 July 2022

Trussonomics and Sunakonomics

I was on the Sky News podcast this week with Miatta Fahnbulleh from the New Economics Foundation discussing the economic policies of Liz Truss and Rishi Sunak. You can listen here.

Wednesday 27 July 2022

How to deal with the cost of living


The IEA has a new paper out today titled Cutting Through which looks at six areas where the government should act to address the cost of living and/or reduce inflation.

I wrote the chapter on sin taxes. Download the whole thing for free here.

Tuesday 26 July 2022

Immortal time bias strikes again


I don’t write much about e-cigarette junk science because there is too much of it and it is just too depressing. But I just came across this effort, which I missed earlier in the year, because I saw someone tweet about it. It’s worth looking at as a cautionary tale about statistics.

It’s the first study I’ve come across that purports to show that vaping gives you cancer. The headline claim is: 

The e-cigarette users have lower prevalence of cancer compared to traditional smoking (2.3% vs. 16.8%; P < 0.0001), but they were diagnosed with cancer at a younger age.

Even the suggestion that vapers have a (much) lower rate of cancer than smokers seemed doubtful after they did a regression analysis…

Our regression analysis showed that e-cigarette users have 2.2 times higher risk of having cancer compared to non-smokers (odds ratio (OR): 2.2; 95% confidence interval (CI): 2.2 - 2.3; P < 0.0001). Similarly, traditional smokers have 1.96 higher odds of having cancer compared to non-smokers (OR: 1.96; 95% CI: 1.96 - 1.97; P < 0.0001).

See that? Vapers have a higher cancer risk than smokers, according to this piece of research.

The authors looked at data from the USA’s National Health and Nutrition Examination Survey (NHANES) between 2015 and 2018. They found 154,856 participants, of whom 5% were e-cigarette users, 63.6% were nonsmokers, and 31.4% were ‘traditional smokers’ (the authors insist on calling smokers ‘traditional smokers’, presumably to imply that vaping is a form of smoking). The survey has a question asking whether the participant has ever had cancer.

None of the vapers in the study would have been vaping for more than a decade and the majority would have only been vaping for a few years. Since ‘traditional smoking’ typically takes several decades to cause cancer, the idea that a few years of vaping would have the same - or bigger - effect is deeply implausible, even if you ignore the fact that vapour doesn’t contain smoke and has far fewer, if any, potential carcinogens.

Since the vast majority of vapers are former smokers, you would expect them to have a higher cancer rate than lifelong nonsmokers, all things being equal. But as it happens, none of the vapers had ever had lung cancer.

Looking at all cancers combined, the rate was lowest among the vapers (2.3%), highest among the smokers (16.8%), with the nonsmokers in between (9.5%).

If it seems a little odd that the nonsmokers didn’t have the lowest rate, you need to consider that the average age of the nonsmokers was 50, the average age of the smokers was 62, but the average age of the vapers was just 25. Age is the biggest risk factor for the vast majority of cancers.

Once the researchers adjusted the data for confounding variables, the cancer rates were as mentioned at the start of this post: a relative risk of 2.2 (2.2-2.3) for vapers and 1.96 (1.96-97) for smokers, as compared with nonsmokers.

The authors don’t say which confounding factors they adjusted for. The obvious one would be former smoking, but it is not obvious that they did adjust for it. The fact that vapers were more than twice as likely to get cancer than nonsmokers in the adjusted analysis - and were even more likely to get cancer than the ‘traditional smokers’ - suggests that they didn’t (or that they didn’t do a very good job if they did). There is no credible biological mechanism for a few years of vaping being more dangerous than a lifetime of smoking.

The authors say they had data on age, sex, race, annual household income and various comorbidities so presumably some of these were adjusted for. But the only questions about smoking were “[Have you s]moked at least 100 cigarettes in life” and “Do you now smoke cigarettes?”, so maybe there was no question about whether they used to smoke? If so, this is an absolute howler.

The researchers may have been aware of this shortcoming and were slightly embarrassed about the extraordinary finding that vaping is worse than smoking because they don’t lead with it in the abstract or the conclusion. Instead they focus on the arguably less insane finding that vapers who developed cancer got it at a younger age than nonsmokers.

But which cancers were vapers more likely to get? Not lung cancer. None of them got that. Nor did any of them get cancer of the bladder, colon, prostate, uterus or kidney. Of the vapers who got cancer, they were less likely to have had breast cancer and melanoma than were the nonsmokers.

The only cancers that were more common among the vapers - not in absolute terms, but as a proportion of cancers among the people who had ever had cancer - were cervical cancer, thyroid cancer, leukemia and one form of skin cancer. What these have in common is that they are either not ‘smoking-related’ or not strongly associated with smoking and they have a tendency to affect younger people more than most cancers.

Smoking is associated with a lower risk of thyroid cancer and two-thirds of all thyroid cancer cases are found in people aged between 20 and 55. The highest rates of cervical cancer are among women aged between 30 and 35 and the disease is caused by the human papillomavirus. It’s not clear from the study what type of skin cancer vapers had a greater risk of, but smoking is associated with reduced risk for two types and an increased risk for one. The only outlier is leukemia which was weirdly high among the e-cigarette users who had cancer, accounting for 33 cases (8.5%) as opposed to 1-2% of the smokers’ and nonsmokers’ cases. Childhood leukemia is obviously associated with younger people and has a high survival rate, but it still seems odd.

I can’t explain that bit, but how likely is it that vaping not only causes cancers that smoking doesn’t cause, but also causes them at a younger-than-average age?

The answer is that it almost certainly doesn’t. The authors have fallen into the survivorship bias trap. They say:

Interestingly, cancer respondents had a lower prevalence of e-cigarette use than traditional smoking (2.3% vs. 16.8%), and e-cigarette users were diagnosed with cancer at a younger age than respondents with traditional smoking (median age of 45 years vs. 63 years).

These two statements might seem hard to reconcile on the face of it, but they can both be explained by the e-cigarette users being much younger than the other two groups. The vapers had much lower rates of diabetes, heart disease and stroke for the same reason.

The authors could have pointed out that the ‘cancer respondents’ were more likely to be nonsmokers than vapers, but this has the same explanation: people with cancer are disproportionately old and old people are less likely to vape.

Very few of the vapers had experience of cancer because they were younger than the other groups, but because they were younger than the other groups the ones who got cancer were more likely to have developed it when they were young! A 30 year old vaper can hardly claim to have developed prostate cancer when he was 80.

This is a classic case of immortal time bias. You need to wait until these people are very old, or preferably dead, before you can draw any conclusions from data like this.

You may recall the study which claimed that rock stars die younger than ordinary people and rap stars die youngest of all. This is probably true, but we don’t have the data to prove it until all the rock and rap artists dead. The only rap stars who have died are the ones who died relatively young. No rock star has yet lived to 100 but one of them probably will.

We know the average age of death of the ones who died. We have no idea when the ones who are still alive will die. Keith Richard is still going strong but people like him - i.e. the living - were excluded from the study by design.

In The Spirit Level Delusion, I discussed the study which claimed that actors who win Oscars live longer than actors who don’t. And so they do - but not for the reasons given by the authors (clue: you have to live long enough to win an Oscar).

It’s an easy mistake to make, I guess, but the authors of the vaping study should have been aware of it. Their research tells us absolutely nothing. The fact that vapers with an average age of 25 are less likely to have had cancer (as of 2018) than nonsmokers who are twice their age is entirely unsurpising, as is the news that the relative handful of vapers who have had cancer developed the disease at a lower-than-average age.

Don’t these things get peer reviewed?



Bay Area purveyor of quackery Stanton Glantz has picked up on the study and is trying to turn one of its weaknesses into a strength.

The interesting thing about this finding is that these are not the major smoking-induced cancers (lung and bladder).  This result reinforces the view than e-cigarettes are not simply cigarettes without some of the bad chemicals; they expose users to a different mix of toxic chemicals than cigarettes.

Hmm. If the problem isn't happening in the place where the 'chemicals' make contact (i.e. the lungs), there's some explaining to do.

Friday 22 July 2022

A swift half with Clive Bates

The new episode of the Swift Half is a lively discussion about tobacco harm reduction with Clive Bates (formerly of ASH, Greenpeace, etc.). Be sure to watch...

Thursday 21 July 2022

Nanny state round up

You may fondly recall the activists at Stirling University producing a study - i.e. an online survey - pushing for cigarette-style labelling of alcohol in April.

The same state-funded puritans were back yesterday with another piece of alleged research in the same vein, this time based on focus groups of fifty people, as reported by The Times...

Alcohol packaging must be regulated or come with health warnings similar to cigarettes, say campaigners after a study illustrated how beer and spirits were designed to appeal to young people.

Stirling University found alcohol packaging captured attention, boosted appeal and helped shape the perceptions of the drink and the people who consume it.

I haven't read the study yet as I can think of a thousand things I'd rather do, but this bit amused me...

One participant said: “I don’t actually like beer but I bought it specifically because I liked the packaging.”


Surely a contender for the Didn't Happen of the Year award. As someone said on Twitter (I forget who), this person is either a liar or is insane. Either way, let's not base policy around them. 

An overwhelming majority of EU citizens who responded to a European Commission initiative say they support tobacco harm reduction products.

The Commission’s “Call for Evidence” on the legislative framework for tobacco control received an unprecedented level of feedback, with consumers of alternatives to tobacco products – vaping, heated tobacco and oral nicotine pouches – making their voices heard in huge numbers.

More than 24,000 EU citizens responded to the call, launched by the Commission as part of its ongoing evaluation of what future EU tobacco laws will look like through revision of the Tobacco Products Directive.

The massive interest in the issue may surprise some and may put the European Commission on the back foot as has been seen by some as having previously failed to support ‘tobacco harm reduction’.

Nice. Well done to everyone who responded.

Finally, it was my pleasure to speak to Eric Crampton on the New Zealand Initiative podcast this week. There was plenty to talk about as the Kiwi government is going off the deep end with its Prohibition 2.0 policies. Check it out.

Wednesday 20 July 2022

Delusional anti-vaping ignoramuses

Australia is a basket case when it comes to vaping. Reading newspaper op-eds from Down Under, you would think the country had been completely cut off from the rest of the world. Its health establishment is so detached from reality that all you can do is laugh at it.

So let's do that, starting with this amazing editorial from a chap called Dr Sukhwinder Singh Sohal and a lady called Dr. Kathryn Barnsley. The former is a medic. The latter is best known for working for various anti-smoking pressure groups in Tasmania and recently did a PhD in Tasmanian tobacco control.

They begin by noticing that the prohibition of e-cigarettes in Australia has been accompanied by a black market in e-cigarettes. This is a stupefyingly predictable outcome of prohibition, but as far as the two doctors are concerned, the ban would have worked fine had it not been for a shadowy force at work…

"The advocates for unregulated e-cigarette sales, say that it is causing a black market".

It is almost certainly the industry itself which is fuelling the black market.

The tobacco industry use smuggling to open new markets. This is what they are doing with e-cigarettes.

I don’t know why the first line is in speech marks (or why there’s a comma in it). As far as I can see, nobody has ever said this. Nobody is arguing for unregulated e-cigarette sales and the only countries that have unregulated e-cigarettes are countries that have banned them.

The claim that the tobacco industry is smuggling e-cigarettes into Australia desperately needs a citation or some shred of evidence. It seems rather unlikely as it would require blue chip, listed companies who have to publish their accounts to have extensive contacts in the criminal underworld. On the face of it, this is an unnecessarily high risk strategy for the sake of the nickel-and-dime rewards of flogging a few vapes in Australia when they make so much money operating in the legal market.

In any case, most vapes are not made by the tobacco industry. All the products shown in the tweet below by the outraged prohibitionist Simon Chapman are made by HQD, an independent company.

The photo below comes from an article published in May which says that over $1 million of illegal vapes have been seized in New South Wales since the start of the year. The only brand with any connection to ‘Big Tobacco’ is Juul (Philip Morris has a minority stake in the company).

In the highly unlikely event that tobacco companies were smuggling e-cigarettes into countries that have banned them, you’d think they’d smuggle in their own brands.

To be clear, I very much doubt that independent vape companies are in the international smuggling game either. We can safely assume that smugglers bring in whatever vapes they can from wherever they can.

Big tobacco has directly engaged in smuggling all over the world, including Asia, Europe and Canada. In Canada, they also used it to argue for tobacco taxes to be reduced. A University of Bath report says "Growing and diverse sources of evidence indicate that the tobacco industry remains involved in tobacco smuggling and that TI cigarettes account for around two-thirds of the illicit cigarette market".

Tobacco companies have sometimes been accused of ‘facilitating’ smuggling by selling more cigarettes in certain countries than domestic demand requires, knowing that they might be smuggled to other countries. I don’t really a problem with that. The cigarettes were sold legally and what happens to them after they leave the warehouse is not their responsibility.
Others would say that the companies were complicit and should try harder to control their supply chain. Whichever view you take, I don’t think anybody is suggesting that the companies are physically smuggling cigarettes themselves.

The big tobacco plan is to get as many people addicted as possible, especially children and adolescents, because the nicotine alters their brain structure, makes them addicted, then they will clamour for vapes to be "legalised" as a recreational drug.

This is becoming a bit of a fever dream. No country is going to legalise e-cigarettes because children want to vape. If anything, that would make the government double down on prohibition, as has happened in Australia. This is a terrible plan! It’s a good job there’s absolutely no evidence for it.
As for nicotine changing people’s brain structure, do you remember being told this as a child in your anti-smoking class? Have you ever heard this mentioned as a side effect of nicotine replacement therapy? No. It is nonsense based on rodent studies. As Clive Bates, former director of Action on Smoking and Health says:
“Over the last 60 years, millions of adolescent nicotine users have grown up as smokers and either continue to use nicotine or have quit.  The problem for the Surgeon General and others is that there is no sign of any cognitive impairment in the population of former teenage smokers and many of today’s finest adult minds were once young smokers. If a detrimental cognitive effect of nicotine existed in the human population, it is inconceivable that we would not already have seen extensive evidence of it from the study of smokers, non-smokers and ex-smokers over several decades.”

There are many things we don't know about the health effects of e-cigarettes because it is too early in the pandemic to ascertain.

We’re two and a half years into the pandemic. Is that early? What’s the pandemic got to do with it anyway?
There are many things we do know about the health effects of e-cigarettes, none of which are mentioned in the article. Crucially, we know that they do not emit smoke. We know that they do not emit carbon monoxide. We know that the Royal College of Physicians - amongst others - concluded that the long-term health risks are “unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure”. We know that the lifetime cancer risks are estimated to be less than one per cent of that associated with smoking. And we know that e-cigarettes have been around for over a decade without a single recorded death being attributed to a conventional, regulated vape device.

However, e-cigarettes will likely cause head, neck and oral cancers, cardiovascular disease, strokes, pediatric injury, and are likely to exacerbate COVID-19 respiratory symptoms.

This is quite a series of assertions coming from people who have just said they don’t know much about the health effects of e-cigarettes. It falls under the category of ‘asserted without evidence and can be dismissed without evidence’.

Indeed, in a recently published study, we confirmed that electronic cigarette condensates increase the expression of SARS-CoV-2 (COVID-19) receptor on human lung cells.

The only study that meets this description is this hastily written effort published on 20 March 2020. Not exactly ‘recently’ in the context of COVID-19 and it was highly speculative, saying that ‘smokers may be more susceptible to infection by SARS-CoV-2, and possibly Covid-19.’ As it turned out, this couldn’t have been more wrong. Since then, many dozens of studies have shown that smokers are less likely to be infected with SARS-CoV-2, although that hasn’t stopped these two authors penning such articles as ‘Covid-19 and smoking: the elephant in the room?’ and their understated masterpiece ‘COVID-19, propelled by smoking, could destroy entire nations’

In Australia, e-cigarettes can be prescribed by a doctor and dispensed by a chemist, for people who are interested in quitting smoking.

Indeed that is the only way Australians can get hold of them, but it is too much for Drs Sohal and Barnsley.

Unsurprisingly few doctors will do this, as there are many other drugs, proven to be relatively safe, and which have been approved by the TGA, and services available to help people quit.

Furthermore, the evidence on successful quitting using e-cigarettes is very thin.

This can only be described as a lie. There is a wealth of evidence showing that e-cigarettes not only help smokers quit but are more effective than nicotine-replacement therapy. This has been shown in numerous observational studies such as this, as well as evidence from entire countries such as this. Impressively, e-cigarettes lead to quitting even among smokers who express no interest in quitting. There is a growing body of economic research showing that e-cigarettes and cigarettes are clear substitutes, with suppression of one leading to consumption of the other. Last but by no means least, there are randomised controlled trials (RCTs) like this and the Cochrane Review of RCTs which found that e-cigarettes help smokers quit.
If this evidence base is ‘very thin’, how should the evidence base for the claim that vaping causes head cancer and pediatric injury be described? Microscopic? Invisible?

One 2022 study concluded, "The use of e-cigarettes as a therapeutic intervention for smoking cessation may lead to permanent nicotine dependence."

E-cigarettes are not designed to wean people off nicotine. They exist to give people a much less harmful way of consuming nicotine. If you don’t know that, perhaps you should keep your opinion of tobacco harm reduction to yourselves?

Doctors prefer evidence.

You’d hope so, wouldn’t you? And yet surveys consistently show that doctors are woefully misinformed about e-cigarettes and most of them wrongly believe that nicotine causes cancer. Just this week in the UK, an over-confident doctor went on TV and claimed that vaping causes ‘popcorn lung’. Vaping has never caused a single case of this rare disease.

And as patients, we prefer doctors who follow evidence-based medicine. Not quacks who have been "bought" by industry".

Who are these mercenary shysters? We should be told. Alas, the authors do not name names, presumably for fear of successful litigation.

Numerous researchers agree that the development of electronic cigarette-related illnesses will outweigh any short-term benefits, but the evidence for short-term benefit is lacking. Of utmost importance, we amongst an array of other scientists have repeatedly shown electronic nicotine delivery devices to be toxic and in no regard a "safer" option for smoking tobacco.

It is a shame that these ‘numerous researchers’ are not identified because it would be interesting to see their work. Looking at the thin publication CV of Kathryn Barnsley, I can see no studies showing that e-cigs are toxic. Dr Sohal has co-authored a number of journal articles about e-cigarettes but these are mostly glorified opinion pieces containing no original research and a good deal of scaremongering.
I’m not aware of any study by anyone showing that e-cigs are as dangerous as combustible cigarettes. Even anti-vaping headbangers like Martin McKee and Stanton Glantz acknowledge that vaping is at least somewhat safer than smoking.

Tobacco manufacturers can lawfully insert anything they choose, however toxic, in their products and the same applies to electronic cigarette manufacturers.

No it doesn’t. Here is a non-exhaustive list of some of the ingredients that cannot be put in e-cigarettes in the UK, for example:
  • Diacetyl

  • Pentane 2,3 dione

  • Diethylene glycol

  • Ethylene glycol

  • Formaldehyde

  • Acetaldehyde

  • Acrolein

  • Metals, including cadmium, chromium, iron, lead, mercury and nickel

  • Preservatives liable to release formaldehyde.

  • vitamins or other additives that create the impression that a tobacco product has a health benefit or presents reduced health risks;

  • caffeine or taurine or other additives and stimulant compounds that are associated with energy and vitality;

  • additives having colouring properties for emissions;

  • Substances classified as carcinogenic, mutagenic or reprotoxic (CMR categories 1 and 2)

  • Substances classified with specific target organ toxicity for the respiratory tract (STOT category 1)

The sensible thing for Australian regulators to do would be to legalise e-cigarettes and produce a similar list, rather than tolerate Aussie vapers inhaling whatever the people who run the black market give them.

We do not believe that substantial evidence exists for electronic cigarettes to be used as a tool for smoking cessation.

In fairness, it has already established that you don’t know what you’re talking about and that your opinions are worthless.

The risks of electronic cigarettes are far too great for them to be deemed safe to be prescribed by medical professionals.

Let’s leave that the judgement of medical professionals, shall we? Even in Australia, some of them must know more than you.

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Tuesday 19 July 2022

Smoke without fire?

A study titled 'Should IQOS Emissions Be Considered as Smoke and Harmful to Health? A Review of the Chemical Evidence' was published two weeks ago. The study comes with a big red flag:

The authors acknowledge the support of Bloomberg Philanthropies’ Stopping Tobacco Organizations and Products funding ( The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors also thank Prof. Anna Gilmore and Sophie Braznell from the University of Bath and Dr. Ed Stephens from the University of St. Andrews for valuable discussions and reviewing the content of this article.

Why anyone would ask advice from Anna Gilmore and one of her PhD students when writing about chemistry is a mystery that is only partially solved by the knowledge that they are also on the Bloomberg gravy train. Gilmore is deeply involved with Bloomberg's 'Stopping Tobacco Organizations and Products' (STOP) front group. How can the funder be said to have had no role in the analysis when she reviewed and commented on the study? I guess different rules apply in 'public health'. The authors report no conflicting interests.

IQOS is a heated tobacco product produced by Philip Morris International (PMI). It doesn't burn the tobacco, it heats it. Consequently, there is no smoke and the products are considerably safer than combustible cigarettes. This has been acknowledged in the UK by the Committee on Toxicity and in the USA by the Food and Drug Administration (FDA). The FDA allows IQOS to be marketed as a Modified Risk Tobacco Product, an honour that is rarer than hen's teeth and requires an abundance of evidence to earn.

Mike Bloomberg and his minions loathe reduced risk nicotine products and are determined to crush them, even if it means turning scientific terminology on its head. One strategy is to portray the emissions from heated tobacco products as 'smoke'. This has regulatory implications in many countries and this new study seems designed to be printed off by campaigners and laid on the desk of gullible regulators. It concludes:

The HPHCs [harmful and potentially harmful compounds] present are the same as in conventional cigarette (CC) smoke, albeit in lower concentrations and formed at lower temperatures, analogous to the emissions from the earlier generation of HTPs [heated tobacco products], which were classed as smoke. Also, IQOS emissions contain carbon particles with most of the compounds released being formed by chemical reactions provides further evidence that IQOS emissions fit the definition of being both an aerosol and a smoke.


Unlike Anna Gilmore, I am happy to admit that this is beyond my expertise so I invited Dr Roberto Sussman from the Institute of Nuclear Sciences at the National Autonomous University of Mexico to write a guest post. Here is what he has to say...


“Must a name mean something?” Alice asks Humpty Dumpty, only to get this answer: “When I use a word… it means just what I choose it to mean – neither more nor less.”

Paraphrasing this Alice in Wonderland dialogue with “a name” replaced by “smoke” and “Humpty Dumpty” replaced by “Tobacco Control orthodoxy” illustrates the determination of the WHO technocracy to attach the term “smoke” to the IQOS aerosol. Earlier this month, scientists funded by Bloomberg Philanthropies attempted in this article to provide technical backbone to this “re-classification” of IQOS aerosol as some form of smoke. It was written by Clement N. Ugana and Colin E. Snape, both from the University of Nottingham's Faculty of Engineering.

Let us first clear the semantics: What is “smoke”? Any textbook on aerosol physics defines “smokes” as aerosols (particulate substrate in a gaseous medium) sharing the following characteristics:

  • the particles are fine and ultra fine (diameters less than 1 micrometer)
  • can be solid or liquid
  • are generated by a combustion process.

What is a combustion process? Chemical reactions that involve a combustible are oxidizing and exothermal (i.e. require oxygen and external energy supply).

So how do Uguna and Snape claim that IQOS aerosol can be characterized as a “smoke”? Basically, they follow the suggestion of a questionable 2017 paper by Auer et al. titled 'Heat-not-burn tobacco cigarettes: Smoke by any other name' which claims that IQOS aerosol contains “compounds from pyrolysis and thermogenic degradation that are the same HPHCs as for conventional tobacco cigarette”. 

Uguna and Snape extend this to :

  • The same endothermic physicochemical processes that occur when inhaling cigarette smoke might occur in IQOS aerosol: evaporation/condensation of vapors, distillation (separation of liquid/solid phases), pyrolysis and pyro-synthesis (larger molecules decomposing in smaller ones and and recombining).
  • IQOS aerosol contains detectable solid black carbon particles (a generic name for carbonaceous particles)
  • Some spots in the tobacco of the IQOS might reach higher temperatures than the recommended range below 350 C

Uguna and Snape are mistaken in assuming that IQOS aerosol can be cast as a smoke on all these counts.

Let us deal with the first issue. While there is no smoke without combustion (or without oxygen), different smokes might evolve through many other derived physicochemical processes, such as the ones mentioned by Uguna and Snape. However, these are derived processes acting on smoke that has already been produced by oxidizing exothermal reactions. In other words: these processes are not needed to generate a smoke and their occurrence does not by itself imply combustion. This is easily illustrated by looking at the specifics of tobacco smoke.

What we call “tobacco smoke” is really two distinct aerosols, both originating from the same smoke produced by the burning (external energy supply) of the combustible (tobacco leaf). Each aerosol evolves differently: the sidestream emission making 75-80% of the produced smoke at the burning (800-900 C) and smouldering (450-500 C) tip of the cigarette is directly released to the environment and the mainstream emission, the remaining 20-25% that is inhaled by the smoker and undergoes several physicochemical processes, such as distillation, condensation/evaporation, pyrolysis and pyro-synthesis and forced convection and cooling (from 800-900 to 40 C) as the smoker inhales through the cigarette rod.

The confusion of Uguna and Snape is clear: they assume that the IQOS aerosol can be a sort of “smoke” because it may go through some (or even all) of the derived processes (condensation/evaporation, distillation, pyrolysis) in the evolution of 20-25% of the cigarette smoke that forms the mainstream emission of cigarettes. However, such processes do not define combustion and are not necessary to generate smoke (for example, sidestream smoke). Neither are they sufficient to do so: they can occur without combustion with exothermal processes that do not involve oxidizing reactions.

The lack of combustion in the aerosol generated by a heated tobacco device was proven in a rigorous experimental test by PMI scientists (Cozzani et al. 2020). A heated tobacco device in an oxygen-free laboratory environment was capable of aerosol generation. This proves that the aerosol was not generated by combustion, which is an exothermic oxidation process that cannot occur without oxygen and a combustible.

Evidently, depending on the temperature (and thus on the supplied battery power) in which the heated tobacco device is operated, the derived processes (distillation, condensation/evaporation, pyrolysis or pyro-synthesis) might occur in the aerosol evolution, but this does not prove that the generated aerosol is a smoke because 20-25% of cigarette smoke undergoes similar processes. The key difference is that this fraction of tobacco smoke was previously generated by combustion, whereas Cozzani et al. proved that the aerosol from a heated tobacco device is not.

Another reason why Uguna and Snape claim that IQOS aerosols can be characterized as some sort of smoke is the presence of black carbon solid particles. The particulate phase of IQOS has been examined in laboratory studies by the industry, in particular by two comprehensive laboratory studies (the second funded by PMI): Pacitto et al. (2018) and Amorós-Pérez et al. (2022).

Although neither of these is cited by Uguna and Snape, both laboratory studies concluded that particles in IQOS aerosols are quite distinct from those of tobacco smoke that are clearly identifiable with combustion particulate matter (PM). They have much larger volatile content and are overwhelmingly liquid and produced by condensation. Uguna and Snape only cite several sources that have detected black carbon particles in minute concentrations relative to tobacco smoke (for example, less than 1% in Ruprecht et al.). They cite Auer et al., which merely speculates on IQOS aerosol particles.

While Uguna and Snape recognise that IQOS operates at temperatures of less than 350 C, considerably below combustion temperatures, they hint that the tobacco undergoes an inhomogeneous heating, with the creation of spots possibly reaching higher temperatures. However, this is mere speculation without any actual laboratory proof under normal operating conditions of the devices.

It is really unnecessary to go any further on re-classifying IQOS aerosols as smoke, in the presence of black carbon particles, or in arguing that its toxicity may be comparable to that of tobacco smoke, as these claims were irrelevant in the extremely rigorous testing of the characteristics and relative safety of product that was validated by the FDA in its review of the PMTA application submitted by PMI. The FDA openly recognised that its evaluation roughly agrees with the claims by the manufacturer on all technical issues, with substitution of cigarette smoking by usage of an IQOS device representing for users a significant reduction of their exposure to HPHCs, thus granting the devices the status of “appropriate for the protection of public health”.

Going back to the semantics: perhaps the definition of “smoke” can be stretched to include any aerosol with (even a minimal) presence of solid non-volatile particles and undergoing any one (or all) the physicochemical processes in the formation of the mainstream emission inhaled by smokers. After all, other than the need to facilitate scientific communication, there is nothing sacred about terminology. While stretching the definition of smoke in this way would encompass aerosols from heated tobacco products (HTPs), it would make communication harder and more confusing by also encompassing aerosols that mostly originate from combustion sources (such as cooking aerosols and air pollution) which are not known as “smokes”. Therefore, it could be counterproductive.

Finally, it is interesting to inquire why the pressing need of tobacco control orthodoxy to characterise aerosols from HTPs as smokes? The main reason is political: this characterisation fulfills the need of the technocracy to keep the ongoing crusade against the manufacturers of these devices: the tobacco industry and in particular Philip Morris International (PMI). For this purpose the technocracy is now missing the target of reducing cigarette smoking and giving more preference to keeping the industry in its eternal role of the ultimate evil force deceiving the public. However, the industry's claim that replacing tobacco cigarettes with HTPs such as IQOS significantly reduces user exposure to harmful compounds has been scientifically validated by the US FDA, whereas the most extreme of contrary claims have been only validated by politics and technocratic hubris.

Friday 15 July 2022

Is drinking "never good" for people under 40?

In 2018, the Lancet published a study from the 'Global Burden of Disease Alcohol Collaborators' which claimed that there was no safe level of alcohol consumption. This was widely reported and was naturally welcomed by anti-alcohol campaigners. The BBC reported it under the headline 'No alcohol safe to drink, global study confirms'. (Note the cheeky use of the word confirms, despite the finding going against fifty years of evidence.)

The study wasn't based on any new epidemiology. Instead it took crude, aggregate data from almost every country in the world, mashed it together and attempted to come up with a global risk curve. 

The study contains no new evidence and uses an unusual modelling approach based on population-wide data from various online sources. If you look at this massive appendix you can see the kind of data they were using. The figures are extremely crude.

The authors don't dispute the benefits of moderate drinking for heart disease but they claim that the benefits are matched by risks from other diseases at  low levels of consumption and are outweighed by the risks at higher levels of consumption. Some diseases which have been associated with benefits of drinking, such as dementia, are excluded from the analysis entirely. They also ignore overall mortality, which you might think was kind of important.
A typical risk curve for alcohol consumption and mortality is J-shaped. It looks like this...

But the GBD's risk curve for "all attributable causes" looked like this...

You will notice that there appears to be no protective effect at moderate rates of consumption in the GBD's curve. One important reason for this is that they associate alcohol consumption at any level with tuberculosis. Tuberculosis remains a serious health problem in much of the world, but not in Britain. So what relevance does a global risk curve have to us? None. 

Moreover, TB is not really an alcohol-related disease and is only viewed as such in this study because (a) drinking might weaken the immune system and (b) because people who go to bars and clubs are more likely to catch an infectious disease. I kid you not.

Today, the Lancet has published a new study by the same team using an improved methodology which comes up with a more conventional curve.

As yet, there has been no report from the BBC to set the record straight. In fact, most media outlets have ignored the study. On exception is the Guardian which - taking its cue from the press release - has focused on the finding that the health benefits of moderate drinking only apply to people over the age of 40.
Take a moment to savour the headline and sub-heading, for they tell us a lot about the world in which we now live.
Alcohol is never good for people under 40, global study finds

Largest project of its kind concludes young people should not drink at all but small amount may benefit older adults

I drank a lot of alcohol when I was under 40 and my experience is not consistent with the claim that it is "never good". As I recall, it was nearly always good. I assume that it still is good because many millions of people under the age of 40 continue to do it.

And yet we are told, on the basis of a modelling study, that young people "should not drink at all". Why? Because they won't get any health benefits from doing so.

This is not mere editorialising from a paternalistic newspaper. It is the conclusion of at least one of its authors:

“Our message is simple: young people should not drink, but older people may benefit from drinking small amounts,” said the senior author, Dr Emmanuela Gakidou, professor of health metrics sciences at the University of Washington’s School of Medicine.
Let us not dwell on the fact that the same team's message four years ago was that nobody should drink. Let us instead marvel at the mindset of people who think that the only things worth doing are those that make you live longer and that the only benefits worth considering are health benefits.

This worldview, which Robert Crawford called healthism but which could more accurately be called longevitism (since long life does not imply good health and usually leads to poor health), is implicit in government drinking guidelines. Guidelines are supposed to be recommendations, but they soon become targets, as in Scotland where the government wants to double down on its failed policy of minimum pricing because "Scots are still drinking 30 per cent more alcohol than the 14 units per week guidelines."

If the aim of policy was to maximise happiness, the government would recommend that people drink as much as they want. At higher levels of consumption, the optimal quantity would be influenced by potential health risks which could be informed by the kind of research mentioned above. Pigouvian taxation on alcoholic beverages would optimise consumption across society.

In the UK, the drinking guidelines were blatantly fabricated for political reasons, but even if they were more robust, they could only tell us what the optimal level of consumption is from the perspective of health and longevity (spoiler: it is more than zero).

Most people in Britain are blissfully unaware of what the drinking guidelines are. Insofar as they know what they are, they understand that they only apply to health risks (and benefits). They take a broader account of the costs and benefits when they decide how much to drink. 

Only a fanatic would say that something is 'never good' on the basis that it poses a risk to health that is negligible in practice, let alone that something should never be done unless it improves health. It does not take much imagination to see how such a principle, especially if accompanied by government coercion, would lead society down a dark and miserable path.

Notice, by the way, that nobody involved in this research is recommending that teetotallers over the age of 40 should start drinking moderately, despite the study showing that this would improve their health. Even in the world of 'public health', fanaticism has its limits.
David Spiegelhalter is not impressed.

Thursday 14 July 2022

A swift half with Eamonn Butler

There's a new episode of The Swift Half out, this week featuring the indefatigable and unflappable Eamonn Butler, director of the Adam Smith Institute.

Wednesday 13 July 2022

How the nanny state blob beat Boris

I've written a postmortem of Boris Johnson's premiership for Spiked, focusing on his failure to stand up to the nanny state blob.

What we got under Johnson is what we get under every Conservative government: an inexorable slide towards a paternalistic, authoritarian, micromanaging state – but at a slightly slower pace than might have happened under Labour and the Lib Dems, and at a significantly slower pace than would happen under the SNP.  

Until 1979, the Conservative Party existed to slow, but not reverse, the country’s slide towards socialism. Since 2010, it has taken the same approach to the nanny state. If even the party-loving populist Boris Johnson could not find it in himself to challenge the miserable, finger-wagging, killjoy consensus when he got into Downing Street, perhaps no one ever will.

The article includes a link to Boris's appearance on Room 101 which is worth watching if you haven't seen it.

Monday 11 July 2022

Are 409 suicides a year caused by problem gambling?

I've set up a Substack because Google has pretty much given up on Blogger and hasn't made any improvements in years. Substack also allows you get new posts delivered straight to your in box. I will still be posting here, but most of the Velvet Glove content will also be available on Substack, so if you want to subscribe (it's free) you can do here. That's the link to my first cross-posted article which goes like this...


It is becoming common for any article about gambling in Britain to include a claim about suicide:

A Public Health England study published in September estimated that there are more than 409 suicides a year in England associated with problem gambling. (The Guardian)

The statistics are stark and brutal – between 400 and 500 people die by suicide related to gambling issues in the UK every year (The Telegraph)

The Gambling Commission has looked into just nine deaths since 2016 – a tiny proportion of the total number. Yet there are thought to be 409 gambling suicides a year in England alone (Daily Mail)

The same statistic has been quoted by Chris Philp who, until a few days ago, was the gambling minister at DCMS.

We now have evidence, including a Public Health England report, which identified 409 gambling suicides a year. It is imperative that we respond to that. Change is certainly needed.

Campaigners against gambling advertising have even made some T-shirts. 
There is no doubt that some problem gamblers commit suicide and that gambling and gambling-related debt can be an underlying cause of suicide.

But 409 suicides is a curiously specific figure for something that is not recorded on death certificates and for which the UK collects practically no data.

A variation of this estimate was used in the closing stages of the campaign against fixed odds betting terminals (FOBTs). In October 2018, the government announced that it would be cutting the stake limit on FOBTs to £2 from October 2019. Sports minister Tracey Crouch claimed that this was an unacceptable delay and that the government had previously promised to enforce the new law from April 2019. The government had never said any such thing, but she nevertheless resigned over the matter and ultimately pressured the government into bringing it forward to April 2019.

In her resignation letter, Crouch claimed that two people committed suicide every day ‘due to gambling related problems’, thereby implying that there were 700 gambling-related suicides a year.

When the government capitulated and brought the stake reduction forward, she said:

‘There was never any excuse for delay. Bringing forward by six months the day maximum stakes are capped will save an estimated 120 lives.’

This implied that 240 suicides took place every year as a result of FOBT gambling alone. I have no idea where she got this figure from. I suspect it was rectally sourced.
At around the same time, Nicky Morgan MP said of the Chancellor’s explanation for the 12 month ‘delay’:

‘it doesn’t really help the expected 300 people who may end up taking their lives, suffering mental health problems from gambling addiction’.

Insofar as these claims were based on evidence, they seem to have come from an unpublished estimate by the pressure group Gambling With Lives. Based on extrapolations from three studies from the UK, Hong Kong and Sweden, they estimated that there were between 250 and 650 gambling-related suicides per annum. They later described their workings in a submission to a House of Lords Select Committee, but it has a back-of-an-envelope feel and is far from being an official estimate.

The official estimate of 409 suicides per annum comes from a 2019 Public Health England report. This was one of the last things it published before it was dissolved and the methodology is frankly terrible.

The figure is entirely based on one study from Sweden published in 2018. The study looked at 2,099 people who had been diagnosed with gambling disorder by a doctor while receiving inpatient or outpatient care (but not primary care) in the Swedish health system between 2005 and 2016. Of these 2,099 individuals, 67 subsequently died, including 21 who committed suicide. This suicide rate implied that these people were 15 times more likely to kill themselves than members of the general population.

Public Health England arrived at their estimate by working out how many problem gamblers were in England in 2019 (based on a prevalence rate of 0.4%). Adjusting for age and gender, they then extrapolated from the suicide data in the Swedish study and applied it to England’s problem gambling population to work out how many gambling-related suicides took place in that year. They did not show their workings and described their methodology in a single paragraph:

The ONS age-standardised suicide rates for 2019 (42) are multiplied by the prevalence of problem gambling in the general adult population (0.4%, sourced from the HSE (3)) to first estimate the number of gamblers who died by suicide in England for all persons (25; 95% CI 14 and 44). Multiplying this figure by the age-standardised SMRs (sourced from Karlsson, and others (36)), produces an estimate of the expected number of suicides (434; 95% CI 257 and 746). Calculating the difference between these figures results in the estimated number of deaths by suicide associated with problem gambling only (409; 95% CI 242 and 702).

You can’t do this! You can’t take a prevalence estimate from one group of people and apply it to a totally different group of people. I don’t mean that Swedes and Brits are totally different - although there may be important differences - I mean that a group of 2,099 people who are seeking medical help are very different from the several hundred thousand people who are estimated to be problem gamblers in England.

These are the questions in the survey used to estimate problem gambling in the UK:

Thinking about the last 12 months…

  1. Have you bet more than you could really afford to lose?

  2. Have you needed to gamble with larger amounts of money to get the same feeling of excitement?

  3. When you gambled, did you go back another day to try to win back the money you lost?

  4. Have you borrowed money or sold anything to get money to gamble?

  5. Have you felt that you might have a problem with gambling?

  6. Has gambling caused you any health problems, including stress or anxiety?

  7. Have people criticized your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true?

  8. Has your gambling caused any financial problems for you or your household?

  9. Have you felt guilty about the way you gamble or what happens when you gamble?

You can say never (zero points), sometimes (1 point), most of the time (two points) or almost always (three points). If you get 8 points or more, you are a problem gambler.

The test is fine as a diagnostic tool. It is used internationally. But someone who scores 27 points is clearly in a worse state than someone who scores 8.

The point is that problem gambling is on a spectrum. Most problem gamblers do not suffer serious consequences as a result of their gambling. Most problem gamblers stop being problem gamblers at some point (a large proportion are young men who essentially grow out of it). But others get into serious trouble. A small number get into horrendous debt and some end up needing professional help.

The Swedish study is slanted towards the latter. Obviously, not everybody who gets treated by the Swedish health system is asked to complete a problem gambling questionnaire. 2,099 people is an incredibly small proportion of all the people who had medical treatment in Sweden between 2005 and 2016. These individuals took the test because there was something manifestly wrong with their physical or mental health. For example, they may have been admitted because of a suicide attempt which may or may not have been related to gambling. (The authors of the study don’t say, but it seems likely that the problem gambling questionnaire was one of several mental health questionnaires they were asked to fill out.)

Whatever they were being treated for, it is clear that the Swedish patients were at higher risk of all sorts of things that the average problem gambler. The authors say this explicitly:

It is therefore likely that results may be skewed toward a population of individuals with more severe forms of GD [gambling disorder]. It is likely that this once again implies that this study sample might contain patients with higher mental health comorbidity, as well as individuals with more severe forms of GD, since these individuals are more likely to receive specialized psychiatry care.

51% of the Swedish patients were suffering from depression. 60% had an anxiety disorder. 41% had a substance-use disorder. 29% had an alcohol-use disorder. 12% were bipolar. 19% had a personality disorder. This was not a normal group of people, even by the standards of problem gamblers. Some of their problems may have been exacerbated by gambling, but it takes some heroic assumptions to suggest that they would have all been fine had they never gambled or that gambling was at the root of all their problems.

Applying the suicide rate from this group of people to all the people in England who score 8 or more in the problem gambling questionnaire is like taking the liver cirrhosis rate among people who have been to Alcoholics Anonymous and applying it to everyone who drinks more than 14 units a week. It is - quite obviously - an apples and oranges comparison.

There were 5,316 suicides in England in 2019. Undoubtedly, some of them were related to gambling, but there is no reason to think that there were 409 suicides caused, directly or indirectly, by problem gambling. The true figure could be higher but it is probably lower. We really have no idea.

Monday 4 July 2022

Last Orders with Claire Fox

On the latest episode of the Last Orders podcast, we welcomed back Claire Fox (Baroness Fox). Her ladyship discussed smoking, gambling, Steve Bray and abortion. Tune in!

Saturday 2 July 2022

15 lousy years

Yesterday was the 15th anniversary of England's smoking ban. I tweeted about it in the morning, noting that it marked the point at which everything started to go terribly wrong, and was pleased to see a good deal of agreement in the replies (alongside the usual people who don't like washing and think the world should revolve around them), so when Spiked asked me to expand on it, I wrote this...

We have all paid a price for this malevolent legislation, but the cost that will linger the longest is the precedent it set. The passive-smoking issue was always window-dressing. Everyone knew the real reason for the ban was that a significant number of non-smokers didn’t like the smell of tobacco smoke and the government wanted to make smokers’ lives difficult. In the final analysis, smoking in pubs was banned because people in power didn’t like it.