How's that Scottish heart miracle going?

Being in the mood to look back on the effectiveness of tobacco control efforts (see Ireland's Abject Failure below), let's see how that Scottish heart attack miracle has been coming along. You'll recall the professorship-winning study by Jill Pell which claimed that hospital admissions for acute coronary syndrome  fell by 17% in the first year of the ban.

Pell didn't go down the traditional route of finding out how many cases were admitted to Scottish hospitals and comparing rates before and after the ban (the data are readily available). That would be far too obvious and accurate. Instead, she went to the elaborate effort of limiting her sample to a selection of hospitals and then extrapolated the results across the whole of Scotland. After all, why use the actual data when you can create your own?

The answer, of course, is that there wasn't a 17%, or anything like it. And now, with three years post-ban data in the can, let's see how that heart miracle looks using the real NHS admissions data.

And, just to be sure, let's look at the rates of acute myocardial infarction (heart attacks).

Is any further comment really required?

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Ireland's abject failure

Anyone remember when Ireland was tobacco control's jewel in the crown? The Irish smoking ban of 2004 was reported around the world and was supposed to lead to a "cultural change" that would see smoking gradually fizzle out. Keen to 'lead the way', Ireland has since followed the tobacco control blueprint to the letter. It's banned packs of 10, banned tobacco displays in shops and put more tax on cigarettes than any other country in the world.

The result, as previously reported here, is now official...

More smokers now than before 2004 ban

More people are smoking now than before the ban on smoking in public places was introduced six years ago, the Dáil has heard.

Minister of State for Health Áine Brady pointed to figures showing that 29 per cent of the population smoked despite the ban, the abolition of packs of fewer than 20 cigarettes, the ending of in-store displays and advertising, and the cost of cigarettes, which at €8.55 a pack “are the highest in the world”.

Although, to be fair, Ireland's slavish devotion to tobacco control policies has had some effect:

Sinn Féin health spokesman Caoimhghín Ó Caoláin described tobacco smuggling as a “huge and growing problem”

And let's not forget all those pub closures. All in all, a colossal disaster for all concerned except, perhaps, for the tobacco industry. I've said it before and I'll say it again. It's a damn good job it's not a results-driven business.

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E-cigarettes banned because they are 'confusing'

Kings County, in Washington State, has banned the use of the e-cigarette in public places because it "threatens to undermine the social norming impact [of smoking bans]" and because e-cigarettes "cause confusion". This is an intriguing and dangerous development in 'tobacco control' since there is no evidence that e-cigarettes pose a health risk to the user, let alone to those around them.

I put the words 'tobacco control' in scare quotes because while this is undoubtedly a matter of control, it is no longer a genuine tobacco issue, let alone a smoking issue. Just as the anti-smoking movement became an anti-tobacco movement, so the anti-tobacco movement has become an anti-nicotine movement. When you have people campaigning against a product because it looks like a cigarette, it is difficult to sustain the delusion that we are not in the grips of scientifically illiterate, hysterical and—above all—moral crusade.

The Board of Health states that because e-cigarettes resemble cigarettes, they might cause "confusion and concern [to] the owners of those establishments who seek to comply with the Smoking in Public Places Regulations." Apparently, the possibility of causing confusion is now a legitimate reason for making an activity illegal in the United States of America.

The Health Board overstates the similarities between e-cigarettes and their combustible cousins. E-cigarette vapour dissipates within seconds. They leave no smell. Many of them are multi-coloured and look about as much like a cigarette as a pencil does. Above all, they don't cause cancer, but that doesn't deter those who want to ban e-cigarettes entirely from promoting a campaign that will lead to e-cig users returning to the real health hazard they had successfully given up.

Like all new products, e-cigarettes are bound to attract curious glances at first but this will disappear once people are familiar with them. Maybe some people will react with confusion and concern, but—and this is the real point—so what?

Ladyboys cause confusion and concern. Kerry Katona causes confusion and concern. My tax returns cause confusion and concern. It's not the government's business to protect sentient beings from confusion and concern. If the state must take a role in the e-cigarette issue it should be to quell the confusion through honest information and alleviate the concern with facts. And the facts are that e-cigarettes are, at worst, 99% safer than cigarettes, they create no secondhand smoke and they seem to be a damn fine substitute for smoking.

The idea that the government has to act to uphold "social norms" is particularly sinister. Quite simply, it is not for the government to decide what is normal and what is abnormal. Civil society decides what is normal and the concept of normality varies from person to person and community to community. And so it should.

A system that allows different people to plough their own furrow has been working just fine for years, thanks. And even if we did require a one-size-fits-all benchmark for normality, it is unlikely that we would turn to the inherently freakish collection of politicians and single-issue campaigners to provide it. You uphold your social norms and I'll uphold mine. K?


(For you early risers, I'll be making a similar point but less well and with more hesitation on BBC Radio 4's Today programme tomorrow. Or not, depending on what hits the cutting room floor.)

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Is this the love child of Glantz and Gilmore?

The other day I was thinking of running a worst-junk-science-of-the-year poll. Thank God I bided my time otherwise I would have missed the chance to nominate this beauty.

Isle of Man smoking ban 'cuts heart attacks'

A ban on smoking in public places has reduced heart attack admissions, according to research commissioned by the Isle of Man's Department of Health.

The department has compared admissions in the two years prior to introduction of the ban on 30 March 2008 and the two years since.

It discovered that the number of men over 55 admitted for heart attacks had dropped since the ban.

But if we take a look at the 'study' (unpublished and not peer-reviewed, not that that makes a lot of difference these days), a very different picture emerges:

Do my eyes deceive me or does this graph show that there significantly more heart attacks after the smoking ban?

They don't and there were. In the 23 months before the smoking ban, there were 109 heart attack admissions, or 4.7 per month. In the 23 months after the smoking ban, there were 153 heart attacks, or 6.65 per month.In what universe does this count as a drop in heart attacks?

In the crazy world of tobacco control, that's where. Note the regression lines, designed to take your eye off what is actually happening. Note how the second half of the graph has a line that is driven down by the lowish figure for the last month shown (since the next month needed to make it a full two years has mysteriously gone missing).

This is a method taken straight out of the Anna Gilmore's box of tricks, with a dash of Glantz's Helena magic thrown in for good measure (small community, inaccessible hospital records, data mining etc.). If there isn't a drop in heart attacks, you simply 'predict' how many would have occurred if the smoking ban hadn't come in and make sure your prediction is higher than the real number. And before you know it the BBC will be falling over itself to report that "a ban on smoking in public places has reduced heart attack admissions" and the New England Journal of Medicine will be beating a path to your door.

And the feeble effort shown above is the best this researcher—a maths student at Rutherford Polytechnic the University of Northumbria—could conjure up. The graph that shows all heart attack admissions, (ie. the relevant, non-cherry-picked data set) is even less compelling.

Notice that before the ban, there were usually fewer than ten heart attack admissions. Notice, too, that after the ban the rate was usually well above ten. And, of course, there were more heart attacks in total after the ban than before it. And, as the flat black line shows, the monthly rate of admissions did not go down one bit in the nigh-on two years after the ban.

But you're not supposed to look at any of that. Instead, you are invited to look at the upwards line in the pre-ban period and assume that the rate would have continued rising, even though that line only goes up because of a big jump (by Isle of Man standards) to 14 cases shortly before the ban. Nor are you supposed to notice that any responsible statistician would identify that unusual leap as a statistical artifact. The fact that more than two-thirds of the data points are below the regression shows that it's being contorted by an outlier.

It's truly unbelievable that this sort of stuff gets taken seriously. Or it would be if it didn't happen every few months. This is a world where a flat line equals a decline, and a 50% increase in heart attacks equals a reduction in heart attacks.

In a year that has seen fierce competition for the title, Ms Howda Jwad of Northumbria University—for it is she—may just have clinched the inaugural World's Worst Junk Science Award in the dying days of the year. Glantz, Pell, Gilmore, Winickoff—it's time to up your game.


Thanks to Brian Bond for the tip

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The ban and the Beeb

A very busy day of smoking ban-related items at the BBC yesterday, evidently inspired by the Dutch rolling back its smoking ban. Belinda has the run-down and sound clips at F2C Scotland.

Nicky Campbell had a spirit-sapping phone-in on Radio 5 (all phone-ins are spirit-sapping). The usual suspects called up: people who gave up smoking and think everyone else should too, people who believe that bar-workers have no choice but to work in pubs, people asking why we don't ban drinking as well, etc. etc.

Points of interest included Rosemary Gillespie from the Roy Castle Lung Cancer Foundation twice refusing to answer the question of whether Roy Castle smoked. Since the whole organisation is built on the idea that he got lung cancer despite not smoking, this is hardly a intrusive line of enquiry and her silence does make me wonder.

And a call from a gentleman who is happy that he can now enjoy a smokefree pint of real ale (CAMRA member?) crystallised the inherent snobbery and contemptuousness of the whole public health movement:

"Can I just say, quite a lot of the pubs that have closed down, to be honest I'm quite grateful they have. I think they were the most awful places which were actually just big smoking dens and had the most dubious clientele in them and they were just asking to be closed down."

I also find it very hypocritical for Cecilia Farren to talk (on Radio 4) about the "vested interests of the tobacco industry" when she is the director of GASP (UK). Aside from the fact that the tobacco industry had no hand in the grass-roots Dutch campaign, GASP is not just any ordinary anti-smoking group. It's not a volunteers' group, of course—hardly any of them are—but it is more explicitly commercial than most. It is a limited company that sells no-smoking paraphernalia and is therefore dependent on smoking bans for much of its business. Aren't conflicts of interests like that worth mentioning?

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Smoking 'n' apple sauce

An interesting period piece, this.

Death in the West was the 1976 British TV documentary which used the Marlboro cowboy as the starting point for a discussion on smoking and health. The film became controversial when Americans for Nonsmokers' Rights started showing it in America in spite of the industry's legal protests.

Someone has now put it up on Youtube and it's still worth watching, especially for those of you who have been following the debate round at Frank's. Of particular historical interest are the interviews with the still defiantly doubtful executives from Philip Morris. Some of this dialogue is quoted in Velvet Glove, Iron Fist.

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Who pays for these studies?

I'm not in the habit of fisking studies based on the abstract alone, but I'll make an exception in this instance.

Overestimation of Peer Smoking Prevalence Predicts Smoking Initiation among Primary School Students in Hong Kong

Purpose:

To investigate the relationship between perceived prevalence of smoking and smoking initiation among Hong Kong primary second- to fourth-grade-students.

Methods:

A cohort of 2,171 students was surveyed in 2006 and again in 2008. Students who perceived ever-smoking prevalence in peers as “none” or “some” were considered as correct (reference group), whereas those who perceived it as “half” (overestimation) or “most/all” (gross overestimation) were considered as incorrect.

Hmm. So if they perceived that none of their peers smoked, they were assumed to be correct. That may be true in the sheltered world of tobacco control, but for the rest of us that should be classified as an 'underestimate'. Except there isn't an 'underestimate' option available in this study, which leads me to think that it isn't very well designed.

Results:

At baseline, overestimation was found to be cross-sectionally associated with ever-smoking. At follow-up, 7.2% of never-smoking students with incorrect estimation at baseline had started smoking, which was 79% (95% confidence interval: 3%–213%), greater than that of 3.7% for those with correct estimation. Among the never-smoking students with incorrect estimation, subsequent correct estimation was associated with 70% (95% confidence interval: 47%–83%) lower risk of smoking initiation compared with persistent incorrect estimation.

Regardless of whether these kids' estimates are right, it's fair to assume that those who said 'most' had more friends who smoked than the ones who said 'some' or 'none'. And since having friends who smoke is a major predictor of smoking initiation, that—not the overestimating—is the reason they start smoking. The ones who said 'all' would, of course, be liars having a laugh at the researchers' expense. Given that the subjects are schoolchildren I believe, and hope, that there were many of them.

Conclusion:

Overestimation of the prevalence of peer smoking predicted smoking initiation among children. Interventions should be carried out to evaluate whether correcting children's overestimation of peer smoking could reduce smoking initiation.

Rubbish. The conclusion is that if your friends smoke, you're more likely to smoke yourself. But I think we knew that already, didn't we?

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