Tim Stockwell is at it again

The campaign to make people believe that moderate drinking is bad for their health resumed today with a study in JAMA Network Open. Those who follow such things closely will be unsurprised to hear that it was produced by Tim Stockwell and his colleagues at the Canadian Institute for Substance Use Research.

Stockwell has waged a one man crusade against the benefits of drinking for over a decade. He is past president of the neo-temperance Kettil Bruun Society and was involved - and heavily cited - in the process that lowered the UK drinking guidelines for no good reason. Along with his colleague Tim Naimi, he has since been at the helm of efforts to reduce Canada’s guidelines to two drinks per week. Despite being slapped down by experts in the field, he continues to produce countless journal articles casting doubt on the benefits of moderate drinking. Today’s publication is his third attempt at making a meta-analysis that erases the J-Curve.

The J-Curve shows the well established finding that the health risks of drinking fall and then rise in proportion to consumption. Temperance activists hate it because it shows that drinking nothing is worse for you than drinking a bit.

The copium response to this is to say that some non-drinkers are ex-drinkers who used to drink a lot and wrecked their health. This possibility was first raised in the 1980s and has been comprehensively dealt with by numerous studies that exclude former drinkers and only compare drinkers to lifetime abstainers. The J-Curve holds.

Stockwell’s new study concludes:

This updated meta-analysis did not find significantly reduced risk of all-cause mortality associated with low-volume alcohol consumption after adjusting for potential confounding effects of influential study characteristics.

This conclusion will come as a shock to anyone who follows alcohol research. Barely a month goes by without a new study confirming the health benefits of moderate drinking. Stockwell says his meta-analysis uses ‘fully adjusted, prespecified models that accounted for effects of sampling, between-study variation, and potential confounding from former drinker bias and other study-level covariates’. Whatever this entails (he doesn’t go into detail), it results in a meta-analysis that bears no resemblance to the evidence it is supposed to be summarising.

He says:

Drinker misclassification errors were common. Of 107 studies identified [out of over 2,000 available - CJS], 86 included former drinkers and/or occasional drinkers in the abstainer reference group, and only 21 were free of both these abstainer biases.

Cool, let’s just look at those 21 studies then, shall we? Here they are in alphabetical order…

Bergmann et al. (2013) - Supports the J-Curve. Found that ‘light to moderate alcohol consumption’ was associated with a significantly lower risk of cardiovascular disease. The study includes a J-Curve graph.

Cullen et al. (1993) - Supports the J-Curve. Found that the ‘adjusted relative risk of cardiovascular disease death among moderate drinkers was 0.68 (95% CI 0.51-0.91), and that of coronary heart disease death was 0.66 (95% CI 0.45-0.98).’, i.e the risk for moderate drinkers fell by a third.

Daya et al. (2020) - Supports the J-Curve. Found that: ‘Those who reported drinking ≤1 to 7 drinks/wk had the lowest all-cause mortality rate’.

Friesema et al. (2007) - Supports the J-Curve. Found that non-drinkers tend to rate their health worse than drinkers but that ‘these differences in health do not seem to explain the observed U-shaped curve between alcohol intake and cardiovascular events and only partially explain the U-shaped curve between alcohol intake and all-cause mortality’.

Jankhotkaew et al. (2020) - Doesn’t support the J-Curve. Study from Thailand didn’t find a J-Curve.

Kapiro et al. (2019) - Supports the J-Curve. Finnish study found ‘the lowest age-sex adjusted mortality was found for those drinking 1 drink per week on average, while consistent abstainers (HR 1.27,95%CI 1.09 to 1.49) and those consuming more had significantly elevated risks.’

Kunzmann et al. (2018) - Supports the J-Curve. US study ‘supports a J-shaped association between alcohol and mortality in older adults, which remains after adjustment for cancer risk’. It contains a familiar graph.

Kono et al. (1986) - Supports the J-Curve. Found higher rates of mortality among men who drank heavily, but lower rates of heart attack mortality among moderate drinkers.

Makela et al. (2005) - Supports the J-Curve. ‘Moderate drinking is associated with a lower risk of IHD [ischemic heart disease], whereas drinking in a heavy episodic manner (often referred to as "binge drinking") is not.’ Women who drank moderately had lower rates of all cause mortality but this was not statistically significant among men.

Nakaya et al. (2004) - Doesn’t support the J-Curve. This study from Japan found a linear increase in all cause mortality risk as people drank more. The associations were not statistically significant.

Ortola et al. (2019) - Doesn’t support the J-Curve. This Spanish study didn’t find a J-Curve after making lots of adjustments.

Pednekar et al. (2012) - Doesn’t support the J-Curve. This study from India found that all cause mortality risk was higher among drinkers, regardless of quantity consumed, although this included diseases like tuberculosis which are not caused by alcohol.

Perreault et al. (2006) - Supports the J-Curve. British study found that ‘occasional drinkers’ had lower all cause mortality.

Rehm et al. (2001) - Supports the J-Curve. US study found ‘a significant influence of drinking alcohol on mortality with a J-shaped association for males and an insignificant relation of the same shape for females’.

Sadakane et al. (2009) - Supports the J-Curve. Study from Japan found ‘a near J-shaped association was identified between alcohol consumption and all-cause mortality’.

Sempos et al. (2003) - Doesn’t support the J-Curve. Study of African Americans found no J-Curve. The authors say this ‘may be the result of the more detrimental drinking patterns in this ethnicity and consequently the lack of protective effects of alcohol on coronary heart disease’.

Sun et al. (2009) - Supports the J-Curve. Study from Hong Kong found that ‘both occasional and moderate types of alcohol use were associated with lower mortality compared to never-drinkers’.

Thun et al. (1997) - Supports the J-Curve. This US study involving 490,000 people found that heart disease mortality was 30-40% lower among people who had at least one drink a day and that ‘overall death rates were lowest among men and women reporting about one drink daily’.

Tsubono et al. (1993) - Supports the J-Curve. Study from Japan found lower rates of mortality among people who drank up to 3 drinks a day.

Zaridze et al. (2014) - Insufficient evidence either way. This study from Russia found all cause mortality higher among vodka drinkers although ‘there were too few deaths to determine reliably whether a little vodka consumption provided a slight protective effect or a slight hazard.’ A ‘moderate drinker’ in this study was someone who drank up to half a litre of vodka a week.

Stockwell also includes Almeida et al. (2017) in the list of studies that were ‘free from abstainer bias’ but it is a Mendelian Randomisation study and so there is no way of knowing whether the people, who were only represented by their genes, abstained or not. I have explained before why MR studies are useless at identifying risks from voluntary activities.

If you skipped all that, the bottom line is that three-quarters of these studies, which Stockwell portrays as the gold standard, support the existence of the J-Curve. I don’t have time to go through the other 86 studies but I am familiar enough with the literature to know that they are not go to change the overall picture.

God knows what statistical jiggery-pokery he and his team engaged in to take this evidence and draw the conclusion that there are no health benefits from drinking moderately. Either you can believe that the original researchers knew what they were doing or you can believe that a neo-temperance campaigner with a bee in his bonnet can make appropriate adjustments to studies for which he doesn’t have the original data. Amongst other tricks, he seems to have reclassified occassional drinkers as teetotallers.

In the limitations section, he writes:

A major limitation involves imperfect measurement of alcohol consumption in most included studies, and the fact that consumption in many studies was assessed at only 1 point in time. Self-reported alcohol consumption is underreported in most epidemiological studies … If this is the case, the risks of various levels of alcohol consumption relative to presumed lifetime abstainers are underestimates.

This is true but he does not linger on the implications of it. People only report around 50% of what they drink (we know this because we know how much alcohol is sold). Under-reporting also means that an ‘occasional drinker’ drinks rather more often than you might think.

Therefore, if observational epidemiology shows that a risk from a certain disease begins to increase when people are drinking 20 units a week, for example, they are actually drinking 40 units a week. If we see benefits from drinking up to 10 units a week, the benefits actually apply to people who are drinking up to 20 units a week.

The effect of systematic under-reporting is to make alcohol look significantly more dangerous than it is. There has been very little effort by epidemiologists to account for this well known problem in their work.

Stockwell’s previous meta-analysis was accused of cherry-picking studies. I have my doubts about his selection process in his new meta-analysis too. He tells us that he has included all the studies published since his last effort in 2016, but I can think of several that are missing. For instance…

The National FINRISK Study of Härkänen et al. (2020) found that:

As many other observational cohort studies, also the FINRISK Study shows a J-shaped association with alcohol consumption and mortality, with moderate drinking associating to lower hazard than non-drinking.

Xi et al. (2017) studied 333,247 US adults and found that:

‘Compared with lifetime abstainers, those who were light or moderate alcohol consumers were at a reduced risk of mortality for all causes’.

Van den Brandt and Brandts (2020) looked at the odds of living to old age and found ‘the highest probability of reaching 90 was found in those consuming 5- < 15 g/d alcohol, with RR = 1.36 (95% CI, 1.20-1.55) when compared with abstainers’.

Li et al. (2020) also found that moderate alcohol consumption was associated with lower mortality, although you have to read the study carefully to see that.

The fact of the matter is that high quality studies comparing moderate drinkers to lifetime abstainers just keep on coming and they keep on finding the same thing. If this was any other field of research, scientists wouldn’t even bother studying it any more. The case would have been closed years ago.

Instead, we have a fake ‘controversy’ stirred up by people like Tim Stockwell who want to be able to claim that there is ‘no safe level’ of alcohol. The reasons for this are political and ideological. They have nothing to do with science. Studies like the one published today are not aimed at the scientific community. They are aimed at the media and, ultimately, policy-makers.

 

Cross-posted from the Snowdon Substack.

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Public Elf

It seems there will some kind of public consultation about disposable vapes. The media are reporting that they could be banned. Or perhaps flavours will be restricted. Or something else. We shall have to see. In the meantime, I've written about the Elf Bar craze for Spiked.

 

On the face of it, the scale of underage vaping does not seem too alarming. The most recent figures are from 2021 and they show that the proportion of secondary-school pupils who have ever tried an e-cigarette was 22 per cent. This is no higher than it was in 2014, although the proportion who said they were regular vapers rose from four per cent to nine per cent in the same period. Of these regular vapers, only one per cent had never smoked a cigarette. In other words, only 0.09 per cent of secondary-school children regularly vape and have never smoked.

As for smoking, it has virtually disappeared among people under the age of 16. Since vaping became popular in 2012, the proportion of regular smokers aged between 11 and 15 has dropped from four per cent to just one per cent. Fears of a ‘gateway effect’ leading teenagers who try vaping to move on to smoking have been shown to be unfounded. Why would anyone switch from e-cigarettes to a product that is much more expensive and vastly more dangerous? A more reasonable assumption is that a lot of teenagers who would have smoked are vaping instead. 

That has clearly happened in the US, which had its own panic about teen vaping a few years ago. High-school kids took up Juul, an e-cigarette that was simultaneously described as looking like a USB stick and being sexy. Vaping rates among US teenagers are relatively high, but smoking rates are almost certainly much lower than they would have been, as the graph below shows. Unless you want to make the perfect the enemy of the good, this seems like a public-health win.

 

Do read it all.

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Round up

It's that time of the year when Peter Hitchens moans about the clocks going forward. I don't think we should ever move them again. I discussed this with him on the Spectator podcast.

I won a longstanding bet against Jonathan Portes last week. I wrote about it here.

And there's a new episode of Last Orders to listen to here.

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Lessons from my fat belly

The meniscus is the cartilage in the middle of the knee that stabilises the knee joint. In October, I bust both of them in a mishap at a friend’s wedding. I won’t go into details but it involved a dance floor, ten hours of drinking and Whitesnake’s Here I Go Again.

It was very painful indeed. I couldn’t really move my knees at all. I developed a silly walk. I would have to straddle stairs, wobbling from side to side. Going upstairs wasn’t too bad, but going down again was agonising.

Fortunately, I didn’t need surgery so all I could do was rest my legs and keep them as straight as posssible. So that’s what I did. It took three months before they got anything close to normal again. They are still slightly sore.

A week before the wedding I happened to buy a new suit. Putting it on again in February I noticed that the trousers no longer fitted me. I had got larger. For the first time in my life I weighed more than 13 stone.

I am not particularly weight conscious but 13 stone is too much. 12 stone would be perfectly OK. 11 stone would be ideal. 13 stone is officially overweight and it showed. I had, undeniably, a fat gut.

In retrospect, it is obvious what happened. My diet hadn’t changed, but for several months I had ceased to do any form of physical activity. I don’t mean exercise, in the organised, sporty sense of the word. I don’t really do that. Essentially, I mean walking.

When I got a phone with a FitBit-style app, I was surprised by how much I move around. Yesterday, for example, I walked 7.1 miles. That’s more than average, but I generally clock up at least two miles just walking into town at lunchtime to get some bread. If I go to London I will walk at least five miles.

This all adds up. According to the app, the 7.1 miles I walked yesterday burned 561 calories. Admittedly, I consumed more calories than that in red wine while in London, but then I would have done that if I was sat at home.

I don’t know about you, but I don’t eat more on days when I walk more. By the same token, I didn’t eat less when I was barely walking at all. The result was a fat belly, as the first law of thermodynamics would predict.

This is how people get obese. It happens gradually. They put on a bit of weight on holiday or at Christmas and never lose it. They just accept that they get bigger as they get older. They just accept that their old clothes will never fit them again. It is why rates of obesity rise with age.

 

You will doubtless be relieved to hear that I am no longer in the 13 Stone Club. I now make a conscious effort to do a bit of walking, I don’t eat cheese and crackers in the evening (as I am sometimes tempted to do) and I have lost more than half a stone.

The reason I mention this rather dull anecdote is that it demonstrates something obvious that is weirdly denied by people such as Henry Dimbleby, whose new book I reviewed this week, namely that physical activity has a major role in regulating body weight. One chapter of his book is titled ‘You can’t outrun a bad diet’ (a line nicked from the full-blown crank Aseem Malhotra). In it, Dimbleby asserts:

 

The idea that exercise is a good way to lose weight is not just incorrect it is actively harmful.

 

He accepts that Britons are more sedentary now than in the 1970s and even accepts that exercise is effective in preventing weight gain among people who have lost weight. But he thinks that everybody else who exercises just gets hungrier and eats more. All I can say is that this is not my experience. Perhaps it is true of people who work out in the gym. The evidence he cites is based on people who exercise, in the sporty sense of the word, whereas I am talking about physical activity - moving around - which, as Dimbleby acknowledges, has been engineered out of most people’s lives by labour saving devices and the decline of manual labour.

 

Now, you could argue that it is abstaining from cheese, rather than walking a few miles a day, that has reversed my weight gain, but that implies willpower, something that Dimbleby also thinks doesn’t work.

 

Libertarians always fall back on that same tired refrain - Education! Exercise! Willpower! - which we know to be utterly ineffective.

 

To which one can only reply, ‘Speak for yourself, Henry’. They are, in fact, the only things that have ever been effective.

 

 

Cross-posted from my Substack.

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Henry Dimblebly's Ravenous

Henry Dimbleby sent me his new book, Ravenous, last week. He must have known I would hate it and give it a bad review. He was right. Here's my review.

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Salvaging minimum pricing

Cross-posted from my Substack...

 

In January, I mentioned that minimum unit pricing (MUP) in Scotland has a sunset clause and the SNP was running out of time in its search for evidence that the policy works. I made a prediction…

 

I wouldn’t be surprised if activist-academics pull a dodgy counterfactual out of their hat at the last minute and claim success, as has just happened with the sugar tax. In fact, I'd put money on it.

 

That day has come with this study published in the Lancet. The headline claim is that minimum pricing ‘led to’ a 13.4 per cent decline in deaths wholly attributable to alcohol consumption and a 4.1 per cent reduction in hospitalisations for the same, although the latter is not statistically significant.

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Unusually, the media have given a better account of what the study shows than its authors did. The term ‘activist-academics’ might be a bit strong, but several of them have been advocating for minimum pricing for a decade (e.g. here and here). They are the core of the team that has been evaluating minimum pricing for Public Health Scotland for the last few years and have been unable to find much cause for celebration. MUP seems to have had no effect on A & E admissions or crime. There is ‘no clear evidence that MUP led to an overall reduction in alcohol consumption among people drinking at harmful levels. On the contrary, there is evidence that the heaviest drinking men, in particular, are drinking more.

It may or may not a ‘dodgy’ counterfactual, but today’s study is certainly based on a counterfactual. Nobody is claiming that the number of deaths actually fell by 13.4%. The claim is that the number of deaths is 13.4% lower than it would have been, if we assume the trend in Scotland would have been the same as in England.

In the Herald, minimum pricing modeller Petra Meier (who was not involved in this study but is a big fan of the policy) says:

 

“If changes happen in both countries, they cannot be caused by the policy which only affected Scotland, but Scotland-only changes are highly likely to be caused by Minimum Unit Pricing, given there were no other major alcohol-related changes that occurred in only one of the countries in the meantime.”

 

This is a huge exaggeration. Trends often go in opposite directions in England and Scotland for reasons that ‘public health’ researchers neither understand nor usually care about. Most notably, the alcohol-specific death rate fell sharply in Scotland between 2006 and 2012 while remaining broadly flat in England (there were no policy changes in Scotland to explain this). In 2017, the year before MUP began, rates fell in Scotland but rose in England. In 2018, they went up in Scotland and down in England. As a control group, England is very unreliable.

Nevertheless, it is clear that in 2019 - the first full year of minimum pricing - the alcohol-specific death rate went down by about 10 per cent in Scotland while it rose slightly in England. As I said when these figures were first published, this is ‘consistent with the view that minimum pricing reduces alcohol-related mortality’. But it is also consistent with normal year-to-year fluctuation. A fall of this magnitude is hardly unprecedented. The rate fell by 10 per cent in both 2007 and in 2009, and by 15 per cent in 2012. Nobody paid much attention to any of these declines because no one was looking for a policy to pin them on.

The authors of the Lancet study are able to give a more detailed view by showing the monthly figures, but the story remains much the same. The death rate was a little lower in 2019 than in the most of the previous few years. Interestingly, there were an unusually high number of alcohol-specific deaths in Scotland in the months leading up to MUP, for reasons unknown. This makes the subsequent decline look a little more dramatic.

Still, it’s not very dramatic, is it? If the authors hadn’t highlighted when MUP began, you would be hard pushed to put your finger on it.

The graphs showing alcohol-related hospital admissions are even less impressive (n.b. the sharp fall in spring 2020 was due to Covid)…

If you took this data to a health minister in another country and told them that this is what they could achieve if they introduced minimum pricing, I can’t imagine them getting too excited.

COVID-19 is considered an exogenous shock which makes evaluating MUP in 2020 and 2021 very difficult. The authors do not look at 2021 at all, saying only that ‘the increase in the rate in Scotland from 2020 to 2021 (4%) was lower than in England (7%).’ This is misleading. In percentage terms there was a slightly larger rise in England during the pandemic, but in absolute terms there were an extra 3.8 alcohol deaths per 100,000 in Scotland in 2021 compared to the pre-pandemic year of 2019 whereas there were only an extra 3.0 alcohol deaths per 100,000 in England.

Since MUP only affects the off-trade, one might expect MUP to have had a greater effect during lockdown when alcohol was only available from the off-trade, but there is no indication of this in the data.

I will leave it to statisticians to decide whether the model is dodgy. But if we accept that there is a temporal association, the question is about causation. To decide whether or not MUP ‘worked’, we need to look at the totality of the evidence. Is it plausible that a decline in alcohol sales of three per cent would lead to a 13 per cent reduction in deaths? (Even the three per cent reduction in sales is based on a counterfactual; the real figure is 1.1 per cent, and that doesn’t include cross-border sales.) Is it plausible that MUP would reduce the number of alcohol-related deaths without reducing the number of alcohol-related A & E admissions? Or the number of alcohol-related crimes, for that matter? The claim in this study doesn’t fit with the rest of the evidence.

We also have evidence from Wales which introduced MUP in March 2020, a few weeks before the first lockdown. Like the rest of the UK, and much of the world, Wales saw a sharp rise in alcohol-related deaths in 2020 and 2021. There is no indication that MUP softened this rise. In fact, the number of alcohol-related deaths in Wales went up at exactly the same rate between 2019 and 2021 as it did England in percentage terms (27 per cent) and by slightly more in absolute terms (an extra 3.2 deaths per 100,000 in Wales versus an extra 3.0 per 100,000 in England).

The authors of the study nevertheless assume causality: 

 

Our study reports on the final intended outcome and finds that this reduction in sales led to a 13% reduction in deaths and a 4% reduction in hospitalisations. The methods used suggest plausibility that these effects can be causally attributed to MUP.

 

As Kevin McConway says, the real problem with this quote is the phrase ‘led to’, which clearly assumes causality.

This is where you would be better off getting your information from the media. As the Guardian rightly says…

 

The research was observational, so cannot prove conclusively that the significant fall in deaths was due to the minimum unit pricing policy.

 

While the BBC adds the helpful reminder that…

 

The actual recorded number of alcohol-specific deaths in Scotland has generally been rising since 2012.

 

The BBC also recognises that the supposed decline in hospitalisations (which actually rose in both 2018 and 2019) is not significant. 

 

But they didn't quite see a difference in hospital admissions or in deaths partially due to alcohol, like liver cirrhosis.

And so this study is evidence for the effect of MUP, rather than proof.

 

It will, I suspect, be seen as proof by the SNP. This is the study they have been waiting for. All the evidence suggesting that the policy has been a flop will be disregarded and the minimum unit price will be raised from 50p to 65p. Job done.

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A swift half with Dan Malleck

You may have read that the Canadian government is under pressure to drop the drinking guidelines to two standard drinks per week (yes, week). Dan Malleck, Professor of Health Sciences at Brock University, has been one of the few people calling this out as temperance-driven nonsense. It was a pleasure to talk to him in the latest episode of The Swift Half.

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Sweet Jesus, not plain packaging again!

Oh joy, a new study...

 

Objective  To examine the association of fully branded and standardized e-cigarette packaging with interest in trying products among youths and adults in Great Britain.

...

Results  This study included 2469 youths (1286 female youths [52.1%]; mean [SD] age, 15.0 [2.3] years) and 12 046 adults (6412 female [53.2%]; mean [SD] age, 49.9 [17.4] years). Youths had higher odds of reporting no interest among people their age in trying the e-cigarettes packaged in green (292 of 815 [35.8%]; adjusted odds ratio [AOR], 1.37; 95% CI, 1.10-1.71; P = .005) but not white (264 of 826 [32.0%]; AOR, 1.16; 95% CI, 0.93-1.44; P = .20) standardized packaging compared with the fully branded packaging (238 of 828 [28.7%]).

...

Conclusions and Relevance  The findings of this survey study suggest that standardized packaging measures may reduce the appeal of e-cigarettes among youths without reducing their appeal among adults.

 

They showed a bunch of people some mocked up e-cigarette packaging, some of which was 'plain'/grotesque, and found that people preferred the normal packaging. Fancy that! 

 

The people were also less likely to say they would try vaping if the packaging was 'plain'. I suppose they would, wouldn't they?

 

From this the authors conclude that there would be less underage vaping if e-cigarettes were sold in plain packs.

 

Action on Smoking and Health (ASH) were straight out of the blocks demanding legislation (without mentioning that two members of their tiny staff had co-authored the study).

 

HMG should take note of this research @NeilDotObrien and commit to implementing standardised packaging for vapes to reduce the appeal to children while not discouraging use by adult smokers trying to quit as recommended by @JavedKhanCEO https://t.co/w44E8DDDNz

— ASH (@AshOrgUK) March 14, 2023

 

Anyone else getting a sense of deja vu? There were literally dozens of survey-based studies like this published before plain packaging for tobacco was introduced. Many of them were authored by the same people who published this new study, including ASH's very own Deborah Arnott. 

They were all wrong! Plain packaging didn't work! 

 

Has everyone forgotten that already?

 

It turns out that the stated preferences of people answering leading questions in surveys are a poor predictor of behaviour in real world settings. Who knew?!

Why am I so confident plain packaging didn't work? Partly because I've read the post-implementation review (PIR) that was quietly slipped out last year. The very fact that it was released without fanfare is a bit of a clue that the policy didn't quite live up to expectations.

 

The authors of the PIR claimed that the plain packaging regulations "had met their original objectives, without producing any significant unintended consequences", but you only had to read it to see that this was outrageous spin. 

 

The Department of Health commissioned a review from the University of Stirling to explore "the response of consumers, retailers, and tobacco companies to standardised packaging". The lead author was Crawford Moodie, an anti-smoking fanatic who had produced two reviews promoting plain packaging during the course of the campaign for the policy and who wrote many of the studies he was reviewing. 

 

His PIR review looked at eleven studies, seven of which had been co-authored by Moodie, focusing on issues such as compliance, pricing strategies and self-reported consumer responses. None of them examined smoking trends or cessation.

 

In a desperate cope, the PIR noted an unusually large decline in smoking prevalence between 2015 and 2016. The authors attribute this to plain packaging despite plain packs not being mandatory in shops until May 2017 and very few tobacco products being sold in plain packaging before January 2017.

 

The only study mentioned in the PIR that looked at smoking rates is this one which used monthly smoking prevalence data to build a model which found "a statistically significant level decrease in the odds of being a smoker after May 2017 (adjusted OR 0.93; 95% CI: 0.87 to 0.99)". But the decline was even greater when May 2016 was chosen as the start date. Since plain packs were hardly ever sold until 2017, the authors resorted to the laughable speculation that the smoking rate fell because smokers had heard that plain packaging was one its way:

 

‘the suggestion is that smokers were influenced more by the prospect of standardised packs … than the actual adoption of standardised packaging.’

This is obviously bollocks and since the only study cited in the review that looked at cigarette sales found "no clear deviation in the ongoing downward trend", I'm going to go ahead and say that plain packaging didn't work.

Are we really going to have to gone through this again? Are we going to have to tolerate more years of survey-based junk science being published to promote plain packaging for another product?

Didn't ASH swear on a stack of bibles that this is exactly the kind of thing that wouldn't happen?

Why, yes they did! In 2012, ASH said: 

 

... the “domino theory” i.e. that once a measure has been applied to tobacco it will be applied to other products is patently false. The same argument was used against the ban on tobacco advertising, but 9 years after the tobacco ban in the UK, alcohol advertising is still permitted with no sign of it being prohibited.

 

ASH have deleted that webpage now (it's still available thanks to the Wayback Machine), which is just as well seeing as the Scottish government is consulting on banning alcohol advertising and ASH is actively campaigning for plain packaging for be "applied to other products".

Putting vapes in plain packaging reduces their appeal to children and could even stop them taking up vaping in the first place, a major new study has found.https://t.co/mesvDivOrk

— ASH (@AshOrgUK) March 15, 2023

The Science Media Centre got some crank from the UCL Tobacco and Alcohol Research Group to comment. I suspect it is a sign of things to come:

“In the UK, plain packaging requirements for cigarettes and hand-rolled tobacco have been in place since 2017 – and data suggest smoking rates have fallen as a result..."

 

How can they lie like this?

... so there’s precedent for this type of intervention."

 

A 'slippery slope', if you will, with tobacco being the first domino to fall.

But while cigarettes look very similar across brands (meaning packaging is the main opportunity for branding), e-cigarette devices come in a wide range of shapes and colours which may still appeal to young people once the packaging is removed. So while standardising packaging may go some way towards reduce e-cigarettes’ appeal to youth, it’s likely to only be part of the puzzle.”

 

So not just standardised packaging then, but standardised e-cigarettes, and all with the backing of the vapers' frenemies at ASH.

 

It's not the flagrant mendacity. I'm used to flagrant mendacity in 'public health'. It's the tedium and predictability of it all that gets me.

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Open season on smokers

 

The tax on a packet of cigarettes will rise by about £1.30 today thanks to the tobacco duty escalator. If recent history is any guide, the Chancellor won't even mention it because smokers don't matter in Britain in 2023. They are second class citizens to be vilified while the state uses them as cash cows. 

With the 'smoke-free 2030' target treated as if it were an eleventh commandment, rather than a feeble attempt by Theresa May to secure a legacy (and wasn't even in the last Tory manifesto), it's open season on smokers. I'll be speaking on a panel about this at the IEA next Thursday. Feel free to come along.

The blurb...

 

Is the ongoing war on smoking justified? Is there an alternative to creeping prohibition and infringing on an adult’s right to choose? And what are the implications for future generations if the state controls our lifestyle choices, be it smoking, eating or drinking?

Chaired by Simon Clark, director of the smokers’ rights group Forest, panellists are: Henry Hill, deputy editor of ConservativeHome; Reem Ibrahim, a final year student at the London School of Economics and communications officer at the IEA; Kara Kennedy, staff writer at The Spectator World and author of ‘An ode to smoking’; and Christopher Snowdon, head of lifestyle economics at the IEA.

The discussion starts at 19:00 and will be preceded by drinks from 18:15.

Spaces are limited and will be given on a first-come-first-serve basis.

Please RSVP to events@iea.org.uk or call 020 7799 8900

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Obesity and personal responsibility

Last week the weight loss drug semaglutide was authorised for prescription from the NHS. It can reduce body weight by around 15 per cent and has been used successfully by various celebrities in the USA. It's not cheap, costly perhaps £1,000 a month but eventually it will be off-patent and could play a significant role in tackling obesity. There is a detailed article about it on Works in Progress.

Meanwhile, in the Observer, Martha Gill makes a good point...

 

Nesta, the UK’s “innovation agency for social good”, spends a third of its considerable budget on tackling obesity, but treats the jab with suspicion, even though it can cause weight loss of 15%. The risks of “effective weight loss drugs” such as semaglutide, it wrote, was that it “might well deepen the emphasis in the public discourse on a ‘personal responsibility narrative’”, distracting from “the root cause – the food environment”.

This, again, is strange. Let us remember that obesity kills and semaglutide will save lives. Imagine greeting a new treatment for lung cancer with the concern that fewer people coughing their last in hospital might take the pressure off tobacco companies.

That is very easy to imagine. Look at how 'public health' activist groups have tried to shut down vaping in many parts of the world (though not so much in Britain). Look at how neo-temperance groups have responded to the rise of alcohol-free beer. Look at how many food cranks want to get rid not only of sugar but of artificial sweeteners.

The dominant puritanical element in 'public health' doesn't want science to solve problems. They want people to change their behaviour which, in their view, requires changing 'the food environment'.

How much success has Nesta had in 'tackling obesity', despite the millions of taxpayer pounds it has got through over the years? None whatsoever. 

 

Does Nesta have any policies which would reduce body weight by 15%? No, not even if they were all introduced at the same time. The sugar tax didn't work, the reformulation scheme didn't work (and yet Nesta still supports it) and the food advertising ban won't work either. 

It is essential for these tax-sponging authoritarians to portray personal responsibility as ineffective. It seems to be like Kryptonite to Nesta...

 

The arrival of effective weight loss drugs and increasingly personalised nutrition services to the market might well deepen the emphasis in the popular discourse on a ‘personal responsibility’ narrative.

 

And yet personal responsibility has prevented far more cases of obesity than Nesta or semaglutide have ever done. The reason why the 'personal responsibility narrative' remains popular with the public is that most people are not obese, despite living in a supposedly obesogenic environment, and those who are not obese do not attribute this to sheer luck.

 

Like nearly everybody, I like chocolate and I could eat it every day if I wanted. The reason I don't is that I don't want to be obese. I like eating cheese and crackers in the evening but I don't do it most days for the same reason. What is that if not taking 'personal responsibility'? And while I don't expect everybody to have the same utility function as me, it's still a choice.

The argument against personal responsibility is sometimes made with reference to the rise in obesity since the 1950s. "Are we to believe that there has been a loss in willpower since 1950?", they ask rhetorically. 

To which the answer is YES! Of course there has! Haven't you seen the state of people these days?! And you're not helping by telling people that they're not responsible for what they eat and that physical activity won't help the lose weight.

Sure, there are genetic factors to take into account and people have different appetites, but the fact that 28% of the adult population is obese does not prove that personal responsibility doesn't work. Personal responsibility is pretty much the only thing that has ever worked.

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Last Orders with Matt Ridley

In the new episode of Last Orders, we welcomed back Matt Ridley – co-author of Viral: The Search for the Origin of Covid-19 – to discuss why the authorities are coming around to the Covid lab-leak theory, what we’ve learned from the Lockdown Files, and the bizarre scandal over tobacco firms donating to charity. 

Listen here. 

On a different note, I have written about grammar schools for The Critic.

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Scotland's alcohol advertising bluff

I've responded to the Scottish government's public consultation on alcohol advertising (which closes today so if you want to give them a piece of your mind, hurry). 

I found the consultation document to give a very misleading picture of what 'the science' says about alcohol advertising (and advertising in general). Perhaps this is not surprising since it leans heavily on a report from the neo-temperance group Alcohol Focus Scotland.

I've written about this on my Substack, so have a read (and subscribe!)

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Nicotine Wars event tonight

I'll be speaking at this event this evening. It's at 6pm in the London School of Economics Centre Building on the 2nd floor, in room 2.05.

I don't think you need to be a student to attend and you can sign up here (it's free). We'll be having drinks at the Edgar Wallace afterwards, the pub with the biggest collection of cigarette advertisements in London and quite possibly the world.

Meanwhile, here's a pressure group that lobbies for endless rises in tobacco duty gloating about how much harm they've done.

 

New research commissioned by ASH Scotland for #NoSmokingDay reveals the real cost of smoking.

Households with 2+ people who smoke in the most lowest income group of Scotland will spend 73.5% of their total income in 2023 on tobacco.
Read more here: https://t.co/ONhKn8hwaj pic.twitter.com/vvRpW04udx

— ASH Scotland (@ASHScotland) March 8, 2023

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The Transport for London food advertising con

4 years since unhealthy food was restricted from advertising on Londons tubes & buses 😊

And we now know its led to households purchasing:
🙌1000 fewer calories per week
🤩20% less sugary productshttps://t.co/uHkfJQ3prU @LSHTM @stevencjcummins @UKSustain @sugarsmartuk

— Children's Food Campaign (@Childrensfood) February 27, 2023

 

There's a nice article by Duane Mellor and Dan Green in the Journal of Human Nutrition and Dietetics (no paywall) looking at how weak scientific findings are exaggerated in press releases and misrepresented by the media.

The age old question is who is to blame when the media reports false claims - journalists, academics or the press office? Increasingly, it seems to me that it is the academics themselves. When press releases are misleading it's usually because the politically motivated academics have provided quotes that go beyond the findings of their research, and the research is often worthless anyway.

Mellor and Green look at a number of case studies, one of which is the execrable study that used an insane model to claim that the Transport for London had led to a patently implausible reduction in calorie consumption. I wrote about it at the time. Mellor and Green pull their punches more than I would, but they get their point across.

 

The first example of this type of report and accompanying news story relates to the advertising ban on foods high in fat, salt and sugar across the Transport for London estate, which came into effect in 2019. The latest evaluation exploring the effects of this work was a piece of modelling from researchers at the University of Sheffield and London School of Tropical Medicine and Hygiene.⁶² This work was based heavily on data which explored household food consumption in London (intervention area) against households in urban areas in the north of England.⁶³ 

As with other examples discussed in this review, the premise of the work is not being questioned, as when designing public health intervention, evaluation is complex and modelling potential effects is important when making policy decisions. However, when reporting this type of research, inherent differences in food intake and choices between the north of England and London need to be considered as these residual confounders may explain the difference in energy (calorie) intake beyond any influence of advertising restrictions on public transport. 

The assumptions and the low quality of evidence supporting the development of the model used to predict changing prevalence of higher weight are not well explained, especially when translated into press releases.^64-66 

What is perhaps of greater concern is that this was then used to predict the number of people living with obesity.⁶² Then through the institutional press releases,^{46, 48} these have been translated to actual fewer numbers of cases of people living with obesity and having developed type 2 diabetes and cardiovascular disease. This is concerning, as presenting modelled data as actual cases is not only overstating the value of the work, but when explained to the public,⁶⁷ it can undermine public confidence in health messages. It is therefore recommended that when modelled data are presented, it needs to be clear that the data are modelled and not actually measured cases, therefore not ‘shown’ as one of the institutions involved in this work claimed.⁶⁸

 

Since that study was published we've had 'public health' academics trying to pretend the sugar tax worked, despite child obesity rising for three years in a row after it came into effect. Having failed to find any impact among anyone except Year 6 girls, they ignored everything else and generated headlines which any normie would assume meant that child obesity had fallen (and note the use of the word 'know' in the tweet at the top of this post).

 

UK sugar tax ‘prevents 5,000 cases of obesity in year 6 girls annually’

  

Sugar tax ‘prevents obesity for 5,000 year 6 girls a year’

 

Mellor and Green made a reasonable recommendation, but it will fall on deaf ears. Junk modelling will continue to be employed - because it is the only way to pretend that a failed policy has worked - and numbers on a spreadsheet will continue to be portrayed as if they were real people.

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Martin McKee: still wrong about vaping after all these years

When a man points at the stars, McKee stares at his finger

 

The heavily overweight Zero Covid crank Martin McKee had a letter published in The Times yesterday in response to an op-ed from the paper's resident puritan Alice Thomson (whom we have come across before). Thomson has spotted a real problem - the sharp rise in vaping among teenagers, especially those using Elf bars - but characteristically comes up with the wrong solutions: banning flavours, banning colours and getting Public Health England (which she thinks still exists) to "treat vaping in the same way as cigarettes".

 

This is music to the ears of Fatty McKee who is claiming that his ignorant and dishonest campaign against e-cigarettes has been vindicated.

 

Sir, Sadly, the massive growth in e-cigarette use among adolescents comes as no surprise to those of us who warned that this would happen (“ ‘Harmless’ vapes are creating teenage addicts”, Mar 1). Unlike public health organisations worldwide, Public Health England (now the Office for Health Improvement and Disparities) has been promoting these products heavily, arguing that restricting the features that make them most attractive to young people, especially flavouring, would deter the adults they wanted to switch from cigarettes. Although no longer using the discredited “95 per cent safer than cigarettes” claim, it at least accepts that e-cigarettes are not risk-free but seem oblivious to the evidence linking their use to heart disease. We always knew that it would be a struggle to counter the efforts of the tobacco industry to get a new generation addicted to nicotine but, sadly, in England, those who should have been protecting these young people did not even try.
Professor Martin McKee
London School of Hygiene & Tropical Medicine

 

What is this "evidence linking their use to heart disease" to which McKee refers? Presumably he isn't referring to this study from last year which said...

 

We did not find a significant difference in the cardiovascular risk of exclusive e-cigarette use compared with nonuse of cigarettes and e-cigarettes

Nor can he have been referring to this study which found a "positive cardiovascular impact" among vapers who had quit smoking, with e-cigarettes being no worse for the heart than nicotine patches.

 

I can only assume that he is talking about cross-sectional studies which find that people who have been smoking for many years have a higher risk of heart disease even after they've switched to vaping. Disingenuous activist-academics present such findings as evidence that vaping, rather than prior smoking, increases the risk. Control for past smoking, however, and the association disappears. 

 

McKee's anti-vaping wingman Stanton Glantz had a paper retracted after it turned out that the heart attacks among vapers occurred before they started vaping. Perhaps that's the study he's thinking of?

 

As for the Office for Health Improvement and Disparities no longer using the '95% safer than cigarettes' claim, let's see what they have to say about that: 

 

We are aware that summarising the relative risks of vaping versus smoking across a range of different products and behaviours and assessed across multiple biomarkers can be simplistic and misinterpreted. Based on the reviewed evidence, we believe that the “at least 95% less harmful” estimate remains broadly accurate, at least over short term and medium term periods. However, it might now be more appropriate and unifying to summarise our findings using our other firm statement: that vaping poses only a small fraction of the risks of smoking. 

 

This is arguably a better way of putting it, since it is vanishingly unlikely that vaping carries five per cent of the risk of smoking.

 

John Britton replied today...

Sir, Martin McKee (letter, Mar 2) is right that the recent increase in vaping by young people is a cause for concern but I disagree that this represents a failure of public health policy. Between 2011, when vaping entered the mainstream, and 2021 (the most recent available national data), UK smoking prevalence has fallen from 20.2 per cent to 13.3 per cent — a fall roughly 50 per cent larger than in either of the preceding two decades, and equivalent to about three million smokers. While many of these former smokers are still vaping, the facts that smoking kills half of all long-term smokers and that vaping is unquestionably far less harmful than smoking make this a massive public health gain. We need to ensure that existing laws protecting children from e-cigarette promotion and under-age sale are observed and enforced, but ought not lose sight of the reality that vaping has contributed to a record reduction in the UK’s biggest avoidable cause of premature death and disability.
John Britton
Emeritus professor of epidemiology, Nottingham University

 

Britton is right about the solution. The law needs to be enforced. Notwithstanding the black market, which is the consequence of nanny state policies, it is generally very difficult for people under the age of 18 to buy cigarettes (and alcohol) these days. There is no reason why it should be any easier for them to buy e-cigarettes. 

 

There will be more media hysteria about Elf bars this year, I'm sure, but we already have the laws needed to limit underage vaping.

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A swift half with Maria Chaplia

In the Swift Half this week, I talk to the Ukrainian libertarian Maria Chaplia about the war with Russia.

If you enjoyed that you'll like the interview I did with Konstantin Kisin last year.

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