Steer clear of Big Pharma, says... the WHO!

From the BMJ:

The World Health Organization has warned health professionals working in tobacco control not to become too closely involved with drug companies that produce smoking cessation products.

Well, well. This is a breath of fresh air. And it looks like the WHO picked a suitable audience for this message...

The warning came last month at a meeting on smoking prevention in Madrid that was hosted by the National Committee to Prevent Smoking, which represents most Spanish anti-tobacco organisations, and which was sponsored by Pfizer, GlaxoSmithKline, and McNeil—all of which make treatments to help smoking cessation.

Let's be clear on this. I have never had a problem with businesses lobbying or funding research, including pharmaceutical and tobacco companies. In fact, I would rather the government listens to people who have worked for a living than remain in the political echo chamber passing stupid and impractical laws.

Industry primarily represents its own self-interest, of course, but they represent the interests of their customers rather better than politicians represent the interests of the electorate. If we are being charitable, we might say that Big Pharma represents the interests of smokers who want state-funded pharmaceutical nicotine. Likewise—and I realise this is not a popular view these days—the tobacco industry's desire to sell cigarettes more closely matches the desire of the millions of people who want to buy cigarettes than does the desire of the WHO to ban them.

The problem with Big Pharma's role in tobacco control is two-fold. Firstly, it is blatantly hypocritical to ignore one industry while being hand in glove with another industry. Secondly, although the interests of Big Pharma are served by policies that have long since been decided on by tobacco control (smoking bans, higher tax on cigarettes, etc.), in several instances the influence of pharmaceutical companies results not just in damage to liberty but in damage to public health. For example, I do not believe that the ridiculous ban on snus would still be in place were it not for lobbying from Big Pharma at the EU and WHO level. At a national level, I doubt that ASH would be pushing Chantix quite so vigorously if Pfizer weren't a constant presence at every conference they attend.

But more to the point, where does the World Health Organisation get off telling other people not to be too chummy with the pharmaceutical industry? Isn't this the same organisation that welcomed Big Pharma as a partner in its tobacco control program with the barely ambiguous comment that "investing in health yields high returns"? This, from the Director-General of the WHO in 1999:

Three major pharmaceutical companies have joined this partnership: Glaxo Wellcome, Novartis, and Pharmacia & Upjohn. They all manufacture treatment products against tobacco dependence. Together, these companies will support a common goal that will have a significant impact on public health.

We are facing major health challenges. There is a real scope for meeting them. It is within our grasp to drastically reduce the global burden of disease. WHO is determined to do its part. And I am happy to welcome other stakeholders - and that includes industry - to join us - because investing in health yields high returns.

In the same year, Glaxo Wellcome's director of Global Commercial Strategy explained what they wanted in return (link should be here but is broken):

We want to support and be partners in tobacco control in a number of areas. We could use help in the area of reimbursement.

By 'reimbursement', he means using taxpayers' money to hand out free pharmaceutical nicotine products and that is exactly what the pharma-funded National Committee to Prevent Smoking has been lobbying for in Spain, as the BMJ notes:

In Spain public funding of drugs for smoking cessation is only provided in two autonomous communities: Navarra and La Rioja. Attempts by the National Committee to Prevent Smoking and some political parties—the conservative Popular Party and the Catalan nationalist Convergence and Union party—to get the public funding of such drugs put into Spain's new smoking law failed. 

Rodrigo Córdoba, spokesman for the National Committee to Prevent Smoking, denied that the committee had any conflict of interest, despite the fact that drug companies contributed to funding certain events. "We have tried by all means to maintain independence," he said, in the face of pressure from the drug industry "to persuade us to support public funding [of drug therapies] in a more aggressive way."

Some of the medical societies forming part of the committee had much "stronger links" to drug companies, he said. "There may be individual cases of conflict of interest. Clearly that has occurred and will still occur to some extent," he added."

No doubt it has and no doubt it will. It is good that the WHO is at least acknowledging this conflict of interest. Can we now expect the likes of ASH, the Roy Castle Lung Foundation and John Banbanbanzhaf—who are so quick to dismiss anything which has the slightest whiff of tobacco industry funding—to turn their back on pharmaceutical industry funding?

That was a rhetorical question, by the way.


(Thanks to Eric Crampton for sending me the full article.)

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Idiotic statistics

Tobacco Control recently published an 'e-letter' (known to the rest of us as an 'e-mail') from Konstantin Krasovsky, Head of Tobacco Control Unit in Ukraine, about the WHO's measure of "selected smoking-related causes". Bear with me, because it's more interesting than it sounds.

The WHO has a handy website for accessing health and demographic data. One of things you can look up is the smoking-related mortality per 100,000 people. But, as Krasovsky points out, these estimates seem to have no basis in fact.

In the case of Ukraine, to consider just one example, the WHO HFA database shows that in 2004 male "smoking-related mortality" was 1081 per 100,000 population. However, all-cause male mortality for the same year was 1920. So 56% of all deaths were to be considered smoking-related deaths. The respective figures for women were the following: 586, 978, and 60%.

Even if we ignore the fact that female smoking prevalence in Ukraine was about four times lower than among males, it is obvious that smoking could not cause so many deaths even for men.

He's got a point. According to this database, Armenian women—of whom just 1.5% are smokers—have a smoking-related mortality rate of 138 per 100,000, which is 16.3% of all deaths.

This is not a great deal lower than the rate for Armenian men—52% of whom are smokers—who have a rate of 259 per 100,00, or 19.6% of all deaths.

In Kyrgyztan, the smoking rate for women is just 1.7%, and yet the smoking-related mortality is 607 per 100,000. Since the total female mortality rate is only 931 per 100,000, this means that a habit practised by less than 1 in 50 women is responsible for 65% of all female mortality.

For men in Kyrgyztan, the smoking rate is 41%, but smoking is responsible for 60% of male deaths (934 per 100,000 out of total mortality of 1532 per 100,000).

No one expects absolute precision from these kinds of estimates, but what we have here are figures that are so wildly implausible they don't even pass the basic test of common sense.

The WHO quietly acknowledges their uselessness on the page of definitions which almost no one will ever read:

The mortality from combined, selected causes of death which are known from literature to be related to smoking. It has to be pointed out that it is relatively rough indicator and it is NOT the estimate of tobacco-attributable mortality, which is more complex and difficult to calculate.

In other words, they have taken all deaths from any cause that is related to smoking and bundled them together even if the person didn't actually smoke. Nonsmoker dies of a heart attack? Smoking-related death. Nonsmoker dies from throat cancer? Smoking-related death. Seriously, this is what it's come to.

So remember, "smoking-related mortality" is not the same thing as "tobacco-attributable mortality". One is only vaguely related to smoking and has no basis in fact, the other is too "complex and difficult" for the World Health Organisation to bother with.

I'm sure that campaigners, journalists, broadcasters and politicians will understand that these figures are essentially worthless and will explain that carefully to the public before citing figures that might as well have been plucked out of the air. And I'm sure that no serious researcher would ever use these meaningless figures as a basis for making real-world estimates.

Yes sir, that will definitely never happen.

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Drinking league

This really isn't good enough.

Average amount drunk in UK is 16th highest worldwide

Yet again, this once great country fails to make the top 10. We're getting beaten by South Korea now, for goodness sake. The Czechs are making us look positively light-weight. I'm not looking at you, ladies. You've been pulling your weight. But men, especially those aged 16-24, what's happened? Where's your sense of pride? I'm not asking you to keep up with the Irish or the Russians. Let's be realistic. But at least keep pace with the Portuguese and the Slovenians.

This comes from The Telegraph's article about the latest piece of temperance advocacy from the World Health Organisation, which is inviting governments around the world to keep on taxing drinkers:

“One of the most effective is raising alcohol prices by raising taxes."

By how much? Is there no limit? Apparently not, as there is no suggestion in the report that taxes could ever be too high. Alcohol taxes are not immune to the laffer curve and there is a ton of evidence, gathered over centuries, that excessive alcohol taxes result in more dangerous drinking habits and home distilling of strong, unregulated booze. You only have to look at the figures in this very report to the difference between high and moderate tax countries:

Per capita consumption of pure alcohol (litres)

Sweden 

Recorded consumption: 6.70

Unrecorded consumption: 3.60 

United States

Recorded consumption: 8.44 

Unrecorded consumption: 1.00

I use the USA as a comparison because it's not as if they don't have a history of making moonshine when they need to.

"This has the added benefit of generating increased revenues."

If it was truly effective it would result in less consumption, not increased revenue. Touting alcohol taxes as a way of raising revenue rather gives the game away, does it not?

And, dear oh dear, the anti-obesity and anti-smoking factions aren't going to like this...

"Alcohol consumption is the world’s third largest risk factor for disease and disability; in middle-income countries, it is the greatest risk."

That rather depends on what you're measuring. The demon drink came rather lower down the list in a previous WHO report, which showed the number of deaths attributable to various risk factors.

This wasn't sufficiently newsworthy for the new report on alcohol, and since the WHO now seems to be a glorified pressure group, they did what campaigners do and picked the data that best suited their PR people.

This is the chart, showing the number of Disability-adjusted Life Years. Sure enough alcohol now beats both smoking and obesity, and comes top for middle-income countries (or, more precisely I think, middle income people).

The difference comes down to alcohol tending to kill people at a younger age (that's 'kill' in the broadest sense—over 40% of the claimed death toll is due to intentional and unintentional injuries, which can only be partially attributed to alcohol.)

There's nothing wrong with using 'years lost' rather than 'lives lost' to measure the impact of risk factors. In fact, I think it's a better measure, as children dying of starvation and AIDS is clearly a more important preventable death than a 90-year old dying of hypertension.

It does, however, demonstrate how statistics can be mined to suit the cause. It is now a three-way battle between the temperance lobby, the fat-fighters and the anti-smokers to keep their pet project in the public eye. This involves vying for position both with the claimed death toll and with the ever spiralling 'cost to society'. Tobacco has traditionally been the undisputed champion in this field. For instance:

Smoking Now Leading Cause of Death Worldwide

The use of tobacco is now the primary cause of death around the world. And the Director of the U.S. Centers for Disease Control says not enough countries are taking adequate steps to discourage it.

The World Health Organisation implies the same thing, but note the careful wording:

Tobacco use kills more than 5 million people per year. It is responsible for 1 in 10 adult deaths. Among the five greatest risk factors for mortality, it is the single most preventable cause of death.

You may also have read that obesity is the leading preventable cause of death, at least in America. (Less reliable sources may have even told you that obesity is the leading cause of preventable death worldwide.)

Research confirms obesity is now leading cause of preventable death in U.S.


America's persistent weight problem is now the country's leading cause of preventable death.

For years scientists and health care professionals have warned of the dangers of smoking, and tobacco use is still a major contributor to early mortality. But new research shows that it is is obesity that now causes even more fatal disease.

And now alcohol is well and truly in the race. But, as a point of fact, none of them are the world's leading cause of preventable death. As the data show, the leading cause of lives lost is high blood pressure and the leading cause of years lost is childhood malnutrition. We don't hear so much about these, but then they're not taxable, are they?

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A tale of two studies

The International Agency for Research on Cancer (IARC) is a well-respected body set up by the World Health Organisation. It has conducted many large epidemiological studies into possible carcinogens. Let's take two of them. We'll call them Product X and Product Y.

There were two major findings for Product X. They were:

Odds ratio: 1.40 (1.03-1.89)

Odds ratio: 1.15 (0.81-1.62)

There were also two major findings for Product Y. They were:

Odds ratio: 0.78 (0.64-0.96)

Odds ratio: 1.16 (0.93-1.44)

You will notice that each study found one small but significant finding and one small but non-significant finding. In the case of Product Y, however, that significant finding suggested a protective effect. 

None of these findings are particularly strong, but—if you had to pick—you would say that Product X was the most likely to be the real carcinogen, right? After all, both findings for Product X show a potential increased risk, and the largest of them is not only statistically significant but is more than twice as large as Product Y's.

But that's not how these findings were reported at all. The WHO issued a press release saying that there was no conclusive evidence that Product X caused cancer and blamed "biases and errors" for the study's findings. The WHO also issued a press release for Product Y, saying that it definitely did cause cancer and blamed weaknesses in the study for its failure to show this more clearly. 

Consequently, the BBC reported that Product X "does not appear to increase the risk" of getting cancer, but reported that Product Y represented "a definite, although small, risk" of getting cancer.

So why would the weakest associations be hyped up while the stronger associations were downplayed?

Product Y is passive smoking. Product X is a mobile phone. 

The World Health Organisation has not decided to wipe mobile phones off the face off the earth.

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Fruit and veg

The Journal of the National Cancer Institute has just published a very large study which finds that eating fruit and vegetables has, at the most, a very weak effect on cancer risk (see BBC report). This could be seen as yet another example of lifestyle epidemiology contradicting itself—only a few days ago a study reported that eating a fried breakfast was a good way of combatting obesity—but there are good reasons to take this particular paper seriously.

Firstly, it is a very large study, involving over 400,000 subjects. Secondly, it is a cohort (or prospective) study, ie. it follows people over a period of years rather than interviewing people who are already ill. In these two respects, it trumps most of the studies that have found lower cancer risk amongst those who eat their 'five-a-day'.

The JNCI study found a relative risk for those with a high intake of fruit and vegetables to be 0.97 (95% CI = 0.96 to 0.99), ie. a 3% reduction, and there are serious doubts over whether even this extremely modest reduction is genuine or the result of confounding factors. There are few areas of science where a 3% reduction would be taken seriously.

Walter Willett, a prominent figure in the epidemiology of diet, has written a frank editorial to accompany the study, calling the association "very weak" and noting that there is not a single type of cancer that is significantly reduced by eating fruit and veg (full free text). The history of how such a belief came about bears repeating:

During the 1990s, enthusiasm swelled for increasing consumption of fruits and vegetables with the expectation that this would substantially reduce the risk of many cancers. Potential reductions as large as 50% were suggested... 

However, the evidence for a large preventive effect of fruits and vegetables came primarily from case–control studies, which can be readily biased by differences in recall of past diet by patients with cancer and healthy control subjects...

In the late 1990s, the results of large prospective cohort studies of diet and cancer began to accrue, and these did not confirm the strong inverse associations found in most case–control studies. Furthermore, a series of analyses that pooled the data from prospective studies for specific cancer sites confirmed the weak and non-statistically significant associations.

There are clear parallels with the evidence for passive smoking and lung cancer here. In both cases, the largest risks were reported when research was in its infancy (eg. Hirayama, 1981) and most of the evidence came from case-control, rather than cohort, studies. As the years went on, the reported risks diminished, falling from over 2.0 (100% increase) to less than 0.3 (30%). 

Just as the World Cancer Research Fund used a meta-analysis of questionable studies in 2007 to condemn almost everything except fruit and vegetables are carcinogenic, so the EPA and SCOTH conducted meta-analyses based on shaky science to condemn secondhand smoke as carcinogenic.

In both cases, larger and more reliable studies found no risk. In the case of secondhand smoke, one of the most important null studies came from the World Health Organisation's  IARC with Paolo Boffetta as lead author (1998). It found no statistically significant association with lung cancer despite one of the largest sample groups every studied. In the case of fruit and vegetables, the lead author is, again, Paolo Boffetta, and he finds a significant, but very weak, association.

In 1998, the WHO went to the unprecedented lengths of issuing a press release to contradict one of its own studies, so important was passive smoking (and thereby, smoking bans) to the battle against active smoking. It will be interesting to see if there is any backlash against this new study. 

As it is a less heated area, possibly not. Willett concludes his editorial by calling for "heightened efforts to reduce smoking and obesity" which remain the key battlegrounds, but there are many food faddists and vegetarians who will not be happy to hear that their lifestyles are not as healthy as they believed. There will also be many epidemiologists who will (justifiably) feel their work has been discredited.

Ultimately, after a brief period of controversy, the IARC's secondhand smoke report was forgotten about and attention shifted back to the grab-bag of smaller studies which had been favorable to the passive smoking theory. This new study may meet the same fate; already the tiny association it reported is being taken as fact, with all the caveats and doubts ignored:

In any event, a reduced risk of 2.5% should not be dismissed out of hand, the World Cancer Research Fund argues.

"For the UK, this works out as about 7,000 cases a year, which is a significant number," says Dr Rachel Thompson from the charity, which in a major 1997 report said there was "convincing evidence" of the protective effect of fruit and vegetables.

In Velvet Glove, Iron Fist, I described the World Cancer Research Fund's report as "a veritable encyclopedia of weak associations and questionable meta-analyses" (p. 310). Today's JNCI study only reinforces that view. Whatever the truth about this particular issue, basing policy on statistical studies that change like the weather is a fool's errand. 

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This is really happening

Quote of the week comes from Dick Puddlecote, writing about the World Health Organisation's plans to copy the anti-smoking blueprint to the letter when they launch the war on alcohol in January:

I once suggested to some beardy tossbag from CAMRA that he should throw his weight behind objecting to tobacco prohibition because his vice was next. He piffled that drinkers were too numerous to be subject to the same denormalisation.

May God rot his middle class pompous paunch if he doesn't now realise that he was disastrously wrong.

Please read Dick's whole piece, as well as both New Scientist articles, because I find the whole thing too wearying, depressing and predictable to write about right now. Suffice to say, the phrase "passive drinking" is going to enter common parlance over the next few months and years. The WHO intends to challenge the "neoliberal ideology which promotes the drinker's freedom to choose his or her own behaviour" (since when was the freedom to choose one's own behaviour a "neoliberal ideology"?)

And, this being the World Health Organisation, the policies they come up with will apply not just to individuals, nor even to individual countries, but to the whole of the human race. There is no escape.

Those of us who have been warning against this for the last few years get no pleasure from being proven right. And yet still there will be those who say it won't really happen. That they'll be happy with a little extra tax on alcohol. That they'll stop once they've banned drinks advertising. Meanwhile, the tee-totallers will assure themselves that food isn't the next thing on the list.

Why am I reminded of Charlie Brown running up to kick that football again and again and again?

And all they wanted was non-smoking sections on aeroplanes...

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