Wednesday, 1 February 2023

Learning lessons from Scotland?

Zero Covid enthusiast Devi Sridhar is in the Guardian today telling the English to learn some lessons from the Scots if they want to reduce alcohol-related mortality. Scotland has a far the highest rate of alcohol-specific death, so I'm not sure anybody is knocking on Nicola Sturgeon's door begging for advice, but let's roll with it.

Over the past 15 years, its devolved government has attempted to reduce alcohol-related harm through a ban on multi-buy price promotions on alcohol, minimum unit pricing, reducing the drink-driving limit and restricting alcohol marketing on TV. And partly due to these efforts, alcohol harm fell in Scotland between 2003 and 2012, before plateauing. The emphasis in Scotland continues to be on high-risk groups.


She is right to say there was a fall in alcohol harm, as measured by alcohol-related deaths, between 2003 and 2012, although the rate is still far higher than in England. 


So which policies does she think achieved this? As you can see, she names four.

1. Ban on multi-buy discounts. 

Introduced in October 2011. When it was evaluated in 2014 it was found to have had no effect on alcohol consumption.

2. Minimum pricing. 

Introduced in May 2018, long after the decline in mortality. Regular readers will be aware that this policy died on its arse. All the evidence to date suggests it reduced alcohol consumption slightly but not among heavy drinkers who are consuming more. There is no evidence of health benefits and some suggestion of harm.

3. Reducing the drink drive limit. Introduced in 2014, after the fall in alcohol-related deaths. It has been evaluated twice. Both studies concluded that it had no effect.

Firstly, this study in 2018 found that lowering the limit "was not associated with a reduction in RTAs [road traffic accidents]" but it did damage the pub trade.

Secondly, this study in 2021 found that lowering the limit "had no effect on drink driving and road collisions".

4. Restricting alcohol marketing on TV. 

This hasn't happened and the Scottish government doesn't have the power to make it happen. It is a figment of her imagination.

So, we have four policy changes, one of which is imaginary. The three that are real didn't work and two of them took place after the period in question. Top work from a public health PhD!

Devi doesn't ask why heavy drinking went up so much in 2020 and 2021 despite overall drinking going down, but if she gave it some thought she might find some useful lessons for how to reduce alcohol-related deaths in the future. 

Tuesday, 31 January 2023

Scots buying more alcohol from England

Further to this morning's post about minimum pricing, Public Health Scotland put out another report today. Based on survey data, it found that the proportion of Scots who have bought alcohol in England to bring back to Scotland rose from 13% in 2021 to 19% in 2022.

The report downplays this somewhat...

In 2022, a majority of 81% of 1,014 respondents did not report ever purchasing alcohol from across the border with England in person. Only 5% (54 respondents) reported travelling for the sole purpose of buying alcohol to bring back to Scotland. A larger proportion of 19% (191 respondents) reported bringing alcohol back to Scotland that they had purchased on a visit for another purpose because it is cheaper there than in Scotland.

"Only" 5%?! If the survey is representative, that's well over 200,000 people going over the English border purely to buy booze to bring back to Scotland. Considering how far most Scots live from the border, that's an incredible statistic. Off licence owners in the north of England should drink a toast to Nicola Sturgeon.

A further 14% are taking the opportunity of travelling to England to bring back some relatively cheap alcohol. It shows how much minim pricing is hitting drinkers in the pocket.

I'd love to see the same stats for Wales, where England is a stone's throw away for large numbers of people. If the Public Health Scotland report is any guide, a lot of them will have been heading over the Severn Bridge to get to an English Asda. 

Among the minority of 10% of panel members in Scotland who reported living within 60 minutes’ travel from the border with England (n=102) it was more common to report buying alcohol across the border, with 22% having travelled for the sole purpose of buying alcohol and 27% having bought alcohol while travelling for another purpose.

The Scottish government's claim that minimum pricing has worked rests solely on alcohol sales dropping slightly in Scotland while they rose slightly in England. I wonder how much of that is due to cross-border shopping?

Minimum pricing had a negligible impact on the booze industry

Public Health Scotland has produced the latest part of its minimum pricing evaluation.

To appreciate the full chutzpah of this tweet, you need to know that Colin Angus is a stalwart of the Sheffield University team responsible for the dire modelling that persuaded the Scottish government to go ahead with minimum pricing. (Not that they needed much persuading - they were committed to the policy before there was any evidence for it.)
It's a bit rich for Angus to have a pop at people for making inaccurate predictions about this policy. You only need to scroll to the bottom of the BBC article to be reminded of how bad his own track record is. 

I'm not sure which 'opponents' he's referring to. Perhaps the Scotch Whisky Association? Among economists, the only question was whether minimum pricing would make more profits for the drinks industry. Economic theory suggested that they wouldn't, but it was always a possibility since people are not fully rational and competition is not always perfect.

In the IEA monograph Flaws and Ceilings (2015), I predicted that minimum pricing would increase revenues but have little overall effect on profits.
Drinkers who prefer to purchase budget brands with low production costs will have to buy mid-range brands which have higher production costs. The impact on industry profits is negligible; it is consumers who are denied their first choice preference who lose out.
This seems to have been borne out by today's report which combines sales data with interviews with industry 'stakeholders' and finds that there have been some winners and losers, but no clear trend for the industry in either a negative or positive direction.
  • Overall effects on retailer profits were felt to be small with increased margins compensating for decreased volumes, with the effects depending on the mix of alcoholic drinks sold pre-MUP.

This should not be surprising since the impact of overall sales volumes has been pretty marginal. A Public Health Scotland report published last November found that per-unit alcohol sales only fell by 1.1% in the first three years of minimum pricing. Scottish consumers are spending more money on drink and consuming nearly as much as they did before. Some heavier drinkers are consuming more.
I can't remember what the Sheffield mob predicted would happen to industry profits after minimum pricing. I don't think they modelled it, but if Colin Angus wants to take it as a win that the booze industry has done fine out of the policy, we should let him. He hasn't had many wins in his career as a soothsayer.  

There's only a few months to go before minimum pricing has its fifth birthday and the sunset clause kicks in. After that, the Scottish government has twelve months to prove that it has worked. Objectively, it will be unable to do that because the evidence clearly indicates that it has been a flop, but this is politics so I'm sure they will find a way. 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.

Friday, 27 January 2023

'Public health' academics apply lipstick to a pig

Re-posted from my Substack...

Just before Britain’s sugar tax was introduced in April 2018, various advocates of the policy were handed £1.5 million of taxpayers’ money to evaluate it. Marking your own homework is considered perfectly normal in ‘public health’.

They had their work cut out because what the government classifies as child obesity (but actually isn’t) rose in 2018/19, rose again in 2019/20 and then rose dramatically in 2020/21; the latter doubtless being lockdown-related.

Clearly unable to claim that childhood obesity declined after the tax was introduced, the evaluation team settled for arguing that there was less sugar in soft drinks as a result of the tax.

On average, this is probably true, although much depends on how much you trust the counter-factuals above. The effect certainly wasn’t very large and sugar consumption from soft drinks had been dropping for many years anyway.

Since soft drinks only provide around 2% of the nation’s calories and there had been no decline in obesity in previous years when sugar consumption from soft drinks had been in freefall, it was unlikely that the sugar tax would have any measurable impact on obesity rates. This seemed to be confirmed by obesity rates for both children and adults being higher in every year since the tax was implemented.

Today, however, the evaluation team is claiming victory based on an extremely sketchy model. They created a counterfactual based on trends between 2013 and 2016 and then compared it to what actually happened. Child obesity didn’t actually decline among any groups. Even relative to the counterfactual, it didn’t decline among boys of reception age or girls of reception age. It didn’t decline among Year 6 boys either. But there was, supposedly, a 8% decline among Year 6 girls. This, again, was only a relative decline. Even among this subgroup of the population, rates of obesity actually rose.

Even the strongest association of the SDIL [Soft Drinks Industry Levy] among the most levy-responsive groups (e.g., year 6 girls) reflected only a dampening of the rate of increase in obesity prevalence compared to the counterfactual rather than a reversal in trends.

When the researchers produced a counterfactual based on data from 2013 to 2018 - when the tax was actually implemented - it found that obesity was higher than expected among reception age kids and about the same as expected among Year 6 kids. This finding is filed away in the supplementary material and the authors barely mention it.

The authors conclude that…

Our results suggest that the SDIL was associated with decreased prevalence of obesity in year 6 girls, with the greatest differences in those living in the most deprived areas.

And, inevitably…

Additional strategies beyond SSB taxation will be needed to reduce obesity prevalence overall, and particularly in older boys and younger children.

This study will doubtless be cited as evidence that the sugar tax ‘worked’, but it is extremely thin gruel. Apart from requiring some very obvious cherry-picking to find evidence of success, it requires us to believe that the mere announcement of the sugar in 2016 reduced obesity among one very specific demographic, while the introduction of the sugar tax did not.

The authors argue that the announcement of the sugar tax incentivised soft drink companies to reformulate their drinks. Indeed it did, but not straight away and not in huge numbers. Lucozade and Ribena took the sugar out in 2017 and Irn-Bru halved the sugar content in 2018. It seems unlikely that this would be enough to reduce obesity among 10-11 year old girls by 8%, especially since it mysteriously had no effect on anyone else.

The counterfactual for those girls is shown below in red. The real obesity figures are shown in blue. You can see that the trend in obesity was essentially flat from 2015 to 2018 - i.e. before the sugar tax - but the counterfactual keeps on rising. Voila! The gap between the two lines is your 8% reduction in obesity. The evidence for the sugar tax being even a partial success starts and ends with this chart.

Even if you have faith in the highly suspect counterfactual scenario, why on earth would the sugar tax drive a significant reduction in obesity among Year 6 girls but not Year 6 boys? The authors confess themselves to be baffled...

‘it is unclear why this might be the case, especially since boys were higher baseline consumers of SSBs [sugar sweetened beverages]’

So they take the opportunity to splutter something about their current policy objective, advertising bans.

One explanation is that there were factors (e.g., in food advertising and marketing) at work around the time of the announcement and implementation of the levy that worked against any associations of the SDIL among boys.

There is no evidence for this whatsoever.

And why would Year 6 children be affected and not reception age children? Apparently, it was never likely to benefit younger children…

This result is congruous with findings from a cohort of British children showing that SSB consumption at ages 5 or 7 are not related to adiposity at age 9 years

Now they tell us! I don’t remember Jamie Oliver saying that, do you?

The lack of impact on young children gives the authors an excuse to once again push for more action from government…

Fruit juices, which are not included in the levy, are thought to contribute similar amounts of sugar in young children’s diets as SSBs and may explain why the levy alone is not sufficient to reduce weight-related outcomes in reception age children. In addition to drinks, confectionery, biscuits, desserts, and cakes are also important high-added sugar items, which are regularly consumed by young children and could be a target of additional obesity reduction strategies.

With the case for sugary drink taxes now ‘proven’ in the fairytale world of ‘public health’ academia, taxes on ‘confectionery, biscuits, desserts, and cakes’ will no doubt be next. And when those taxes also patently fail to reduce obesity, we can expect a lavishly funded evaluation team to turn up wielding the carefully selected findings from another dodgy model to prove that those, too, have been a triumph.

To date, the sugar tax has cost consumers well over a billion pounds.

Tuesday, 24 January 2023

Food reformulation folly - the zombie twitches

The food reformulation wheeze seemed to fade away once Public Health England was killed off, but state-funded charity Nesta resurrected it this week and wants it to be mandatory. 

I wrote about it for Cap-X...

Public Health England (PHE) is dead but its terrible ideas live on. In 2015, PHE initiated a ruse in which it planned to remove 20% of the sugar from most processed food. The target was set for 2020 and the agency started working with its ‘stakeholders’ in the food industry to achieve ‘health by stealth’. 

The idea was that the companies would slyly remove sugar from their trusted brands and consumers would lose weight without having to make any effort. It was assumed that we wouldn’t notice the taste of artificial sweeteners because we are creatures of habit. So long as the packaging looks the same, we will mindlessly consume the same brands in the same quantities as we always do.

It didn’t quite work out like that. The food industry had to break it to PHE that you can’t take the sugar out of a cake or chocolate bar without compromising the size and texture, not to mention the taste. Some products, such as boiled sweets, consist of almost nothing but sugar and cannot be reformulated. Jam has to contain a certain amount of sugar otherwise it cannot legally be sold as jam. In any case, people will not buy artificially sweetened cakes, biscuits, spreads and confectionery because they taste horrible.


Thursday, 19 January 2023

Canada's clown world drinking guidelines

Canada is on the brink of making itself an international laughing stock by cutting its drinking guidelines from two drinks a day to two drinks a week. The previous guidelines were only set in 2011 so Canadian drinkers can be forgiven for being suspicious about this dramatic change. The evidence base has not significantly changed in the interim. The evidence for the health benefits of moderate drinking has continued to pile up. 

The only thing that has really changed is that neo-temperance zealots like Tim Stockwell have tightened their grip on alcohol research. Stockwell and his 'no safe level' pal Tim Naimi both live in Canada and are both authors of the report that has made the ludicrous new recommendations.

I have been saying for over a decade that the 'public health' plan is to get the guidelines down to zero so they can start regulating alcohol like tobacco. The evidence does not support this fundamentally ideological campaign and so the evidence has been dropped in favour of fantasy modelling and cherry-picking.

There is a continuum of risk associated with weekly alcohol use where the risk of harm is:

  • 0 drinks per week — Not drinking has benefits, such as better health, and better sleep.
  • 2 standard drinks or less per week You are likely to avoid alcohol-related consequences for yourself or others at this level.
"Likely"!? How about certain
  • 3–6 standard drinks per week — Your risk of developing several types of cancer, including breast and colon cancer, increases at this level.
The only source given for the claim about colon cancer is this meta-analysis which claimed that 10 grams of alcohol per day was associated with a seven per cent increase in colon cancer risk. This is a smaller risk than having a portion of red meat a day. It found no statistically significant increase in risk in studies which had data on what happens when people have one 'drink' a day.

A Canadian 'standard drink' contains 13.45 grams of alcohol. Three standard drinks equals 40 grams. Four standard drinks equals 53 grams. The meta-analysis has no data on people who drink so little, so the claim that colon cancer risk increases at three or more standard drinks is not supported even by the authors' own preferred source.

As for breast cancer, which can only affect half the population and is partly why most countries have different guidelines for men and women, the report cites this meta-analysis of 22 studies, 13 of which found no statistically significant association with drinking. It pooled the studies and reported a 10 per cent increase in risk for people drinking 10 grams of alcohol a day. As with the colon cancer study, this was the minimum quantity studied so it tells us nothing about Canadians who drink 3-5 standard drinks.

In terms of mortality, another meta-analysis found that light drinking was not positively associated with any form of cancer, including breast cancer, and was negatively associated with cancer in a couple of instances:

.. light drinking reduced the mortality of female stomach cancer (RR, 0.65; 95% CI, 0.44 to 0.98; n=1) and male lung cancer (RR, 0.79; 95% CI, 0.70 to 0.87; I2=0.0%; n=5). There was no significant association between light drinking and the mortality of oropharyngeal cancer, esophageal cancer, larynx cancer, colorectal cancer, liver cancer, female gallbladder cancer, pancreatic cancer, breast cancer, cervical cancer, prostate cancer, and hematologic malignancy.
As with all this evidence, we should remember that people under-report the amount of alcohol they consume by around 50 per cent, so when a study says 10 grams a day it probably refers to 20 grams a day. This is an important point that anti-alcohol researchers are well aware of but only mention when it suits them.
  • 7 standard drinks or more per week — Your risk of heart disease or stroke increases significantly at this level.
This is just a flat out lie. As countless studies have shown, heart disease and stroke risk is substantially reduced among light and moderate drinkers. For example, a meta-analysis of prospective cohort studies (which track people’s drinking habits and health status over a number of years and are the most reliable studies in observational epidemiology) found that drinkers were 25 per cent less likely to die from coronary heart disease than teetotallers. The evidence for strokes is similar.
This is main reason why life expectancy is longer for moderate drinkers and the relationship between alcohol consumption and mortality is J-shaped.

The authors of the Canadian report essentially ignore all this evidence and instead focus on a cherry-picked meta-analysis written by Stockwell, Naimi and pals which massively adjusted the figures to arrive at their desired conclusion. This is inexcusable.
  • Each additional standard drink radically increases the risk of alcohol-related consequences.
"Radically"! Be careful out there!
The whole thing's a joke and I suspect the public will see it as such. There is a legitimate debate about whether low levels of alcohol consumption slightly increase cancer risk, but this has to put within the context of the reduction in risk for cardiovascular disease. The fact remains that the positive effects of moderate drinking on heart disease and other conditions exceed and outweigh the negative effects on cancer risk
People want to know what the overall risks of light, moderate and heavy alcohol consumption are. This is what drinking guidelines should tell us. Focusing on small and unproven cancer risks at very low levels of consumption while ignoring the benefits is lying by omission. 

Wednesday, 18 January 2023

Secondhand cake

“If nobody brought in cakes into the office, I would not eat cakes in the day, but because people do bring cakes in, I eat them.”

Who is this co-worker from hell? Who is this whining, snivelling infant demanding that the rest of the world forfeits their small pleasures because she has no self-control?

It is none other than the head of the Food Standards Agency, Susan Jebb, who is in The Times tomorrow comparing cakes to passive smoking.

The full quote reads:

“We all like to think we’re rational, intelligent, educated people who make informed choices the whole time and we undervalue the impact of the environment,” she said. “If nobody brought in cakes into the office, I would not eat cakes in the day, but because people do bring cakes in, I eat them. Now, OK, I have made a choice, but people were making a choice to go into a smoky pub.”

Indeed they were, Susan, before people like you took that choice away to such an extent that even a pub that put up a sign saying ‘SMOKERS ONLY’ on the door and employed no one but smokers would still forbidden from accommodating them.
I’ve made a few slippery slope arguments in my time - contrary to midwit opinion, they are often valid - but even I never imagined that a workplace smoking ban would evolve into a workplace cupcake ban. Talk about the thin end of the wedge!

While saying the two issues were not identical, Jebb argued that passive smoking inflicted harm on others “and exactly the same is true of food”.

To inflict something on someone implies that it is done without their consent. In that sense - and leaving aside the question of whether wisps of secondhand smoke are actually harmful - passive smoking doesn’t inflict harm on a person who knowingly goes to a smoky pub. The same is obviously true of someone who offers you a cake. If they held you down and physically shoved it down your throat, that would be a different matter, but surely that is already illegal under some law or other?
Since Jebb doesn’t want people to see cakes in the flesh, it no great surprise that she doesn’t want people to see them on television either.

Jebb told The Times that advertising of junk food was “undermining people’s free will” and insisted restrictions were “not about the nanny state”.

Jebb is a fanatic. As such, she thinks people are only exercising their free will if they make the health-maximising choice. If they do otherwise, it can only be the fault of some external pressure that needs taming by the state.
Needless to say, she has a teenage socialist’s view of advertising.

“Advertising means that the businesses with the most money have the biggest influence on people’s behaviour. That’s not fair.”

It’s s’unfair!
“At the moment we allow advertising for commercial gain…
Commercial gain!
…with no health controls on it whatsoever and we’ve ended up with a complete market failure because what you get advertised is chocolate and not cauliflower.”
Does she think there is a huge latent demand for cauliflower? Does she believe that a nationwide marketing campaign for it would lead to people snacking on cauliflower instead of chocolate? Economists would predict that such an advertising blitz would, at best, lead to vegetable eaters consuming slightly less swede and slightly more cauliflower, but let’s test it. Let the Food Standards Agency put some of its £143 million budget into advertising vegetables and see how it goes. My guess is that it will go about as well as all the other expensive media campaigns governments have wasted money on trying to get people to eat a more ascetic diet.

And yes, Susan, making it illegal for food companies to tell consumers about their products is ‘nanny state’. And no, what you’re describing is not a ‘market failure’.

Apparently, Jebb is on The Times Health Commission because of course she is. I must admit that I didn’t know she’s also been running the Food Standards Agency since 2021. I am familiar with her mainly as an activist-academic who keeps getting taxpayer-funded jobs, so I can’t say I’m shocked to hear that she’s ended up in charge of a bloated, Blair-era government agency that never needed to be created in the first place and has long since deviated from its original purpose to become a soapbox for the paternalist elite.

The descent of the Food Standards Agency is such an egregious example of mission creep that I used it to illustrate public choice theory when I wrote Sock Puppets

Public choice theory provides a plausible explanation for why governments fail to deliver what is expected of them, both in terms of public services (which are hampered by bureaucratic inefficiency) and legislation (which is hijacked by special interests). It explains why bureaucracies become ever more bloated and taxes rise ever higher, even under governments which come to power on a ticket of deregulation and smaller government. It explains why bureaucracies are so resistant to budget cuts and why it tends to be frontline services, rather than management, which bear the brunt of such cuts if and when they arrive. It explains why an organisation like the Food Standards Agency can go from having a tiny staff investigating restaurant poisonings to having a staff of 2,000, a budget of £135 million and a mission that has expanded to campaigning against salt, fat and eating crisps during football matches.

It is not obvious to me why the Food Standards Agency’s day job couldn’t be done by the likes of Trading Standards, but the question that really baffles me is why, after 13 years of nominally Conservative government, are people like Jebb still being appointed to run these quangos? Just as a matter of pure self-interest, why give money and status to people who are going to attack and undermine you? Why do the Tories make life so difficult for themselves? After all this time, why have they still not made the slightest attempt at a counter-revolutionary march through the institutions?

When the Conservatives once again find themselves languishing in opposition, I suspect that quite a few of them will ask themselves exactly that.