Thursday, 13 October 2011

Snus and e-cigarettes work

Two studies have recently been published testing the efficacy of snus and e-cigarettes in smoking cessation.

In the Harm Reduction Journal, Joksic et al. report their results from a randomised, placebo-controlled, double-blind trial in which 158 smokers were given snus and 161 smokers were given a placebo. Smoking status was verified throughout with carbon monoxide tests and 81% of participants enrolled because they wanted to quit smoking.

The results show that the snus-users were three times more likely to reduce their cigarette consumption by more than 75% and were two to three times more likely to quit smoking entirely.

An interesting feature of the study is that it was conducted in Serbia, which has no history of snus use. It is sometimes said that snus is a quintessentially Swedish habit that could never take off in the rest of the world. This seems to me a rather odd and slightly xenophobic view (see Alan Blum's quote in The Art of Suppression!) but this success in Eastern Europe shows that the 'Swedish experience' can indeed be exported.

The e-cigarette trial had a smaller sample (of 40) and no control, but if its results are replicated elsewhere, things look very encouraging. At the end of the six months, 22.5% of participants had given up smoking entirely. Amongst all participants, average cigarette consumption fell from 25 a day to 5 a day. As Michael Siegel says, this compares very favourably with pharmaceutical nicotine products. The special point of interest in this study is that none of the participants expressed any particular desire to quit smoking at the outset.

You might think the anti-smoking movement would be jumping for joy at the prospect of having two effective smoking-cessation products to offer the public. As I write this, ASH Wales is holding a conference in Cardiff (with the temperance lobby, natch). It would be nice to think that they are celebrating the news that there are efficacious nicotine products to compete with Big Pharma's 'nicotine replacement therapies', but somehow I don't think they will be.

I wonder why?




Wednesday, 12 October 2011

Teetotallers die younger, don't let 'em fool you

Reading Eric Crampton's excellent Offsetting Behaviour blog, I came across a post from last year discussing the health benefits of drinking alcohol. Eric provides a succinct summary of how alcohol research is presented to the public.

Every risk is conclusively proven; every benefit needs further study.

That's about the size of it. Of the benefits, there is research going back thirty years showing that the relationship between drinking and mortality is U-shaped or J-shaped, ie. risk is higher for total abstainers, lower for moderate drinkers and then rises again for heavy drinkers. This is largely the result of alcohol's protective effect on the heart. Reduced incidence of cardiovascular disease has been shown in many dozens of studies.




The correlations are consistent and (by modern epidemiological standards) fairly strong, but is there causation? If the popular media were any guide, you might think that the issue is shrouded in controversy. You may even believe that the J-shaped curve has been debunked.

The issue that is often raised is the "sick quitter" hypothesis—the idea that teetotallers are a sickly bunch who don't drink because they are chronically ill or because they have already destroyed their bodies with alcohol. In other words, alcohol doesn't protect health, it just so happens that teetotallers are unusually sickly.

David Nutt is a fan of this explanation, as are these Australians. I have seen Danny Dorling give this explanation on television. Ben Goldacre also uses it his book Bad Science (Unless it's for a Good Cause in Which Case I'll Look the Other Way):

Every time you read in a newspaper that 'moderate alcohol intake' is associated with some improved health outcome - less heart disease, less obesity, anything - you are almost certainly witnessing a journalist of limited intellect, overinterpreting a study with huge confounding variables.

This is because, let's be honest: teetotallers are abnormal. They're not like everyone else. They will almost certainly have a reason for not drinking, and it might be moral, or cultural, or perhaps even medical, but there's a serious risk that whatever is causing them to be teetotal might also have other effects on their health, confusing the relationship between their drinking habits and their health outcomes.

... Perhaps pre-existing ill health will force you to give up alcohol, and that's skewing the figures, making teetotallers look unhealthier than moderate drinkers. Perhaps these teetotallers are recovering alcoholics...

Well yes, perhaps they are. Who knows? If only someone would find out for sure...

Oh wait, they have. The "sick quitter" hypothesis was first put forward in 1988 and has been tested repeatedly in the last twenty years. The results of these studies showed that "sick quitters" do not explain the J-shaped curve.

Researchers have sought to address these concerns in several ways. Some epidemiological studies have separated former drinkers from long-term abstainers to address the sick quitter hypothesis. For example, in an analysis of 87,526 women, the risk of coronary heart disease was only 10 percent higher among former drinkers than among long-term abstainers (Stampfer et al. 1988).

Furthermore, the exclusion of former drinkers among the abstainers did not alter the 40 percent lower risk of coronary heart disease among women who drank 5.0–14.9 grams of alcohol (about 0.3–1 standard drinks) daily. Moreover, Rimm and colleagues (1991) found comparable risks of coronary heart disease among abstainers and light drinkers (i.e., people who consumed less than 5.0 grams of alcohol, or 0.3 standard drinks, daily) in their study of 51,529 healthy men, suggesting that abstainers are not an inappropriate reference group.

Other studies have excluded participants who developed coronary heart disease or died during the first few years of followup, as a means of excluding unidentified "sick" subjects, with similar results (Fuchs et al. 1995).

Taken together these findings indicate that the presence of sick quitters or former alcoholics among the abstainers is not responsible for the apparent benefits of alcohol consumption on the risk of coronary heart disease.

With other factors studied and discounted, the conclusion must be that alcohol has a protective effect on cardiovascular health. This, for example, from Rimm and Moats (2007):

A recent meta-analysis raised questions about systematic misclassification error in observational studies because of inclusion among “nondrinkers” of ex-drinkers and/or occasional drinkers. However, misclassification among a small percentage of nondrinkers cannot fully explain the inverse relation, and there is substantial evidence to refute the “sick quitter” hypothesis. Furthermore, it has been shown that moderate alcohol consumption reduces CHD and mortality in individuals with hypertension, diabetes, and existing CHD.

To address the issue of residual confounding by healthy lifestyle in drinkers, in a large prospective study we restricted analysis to only “healthy” men (who did not smoke, exercised, ate a good diet, and were not obese). Within this group, men who drank moderately had a relative risk for CHD of 0.38 (95% CI, 0.16–0.89) compared with abstainers, providing further evidence to support the hypothesis that the inverse association of alcohol to CHD is causal, and not confounded by healthy lifestyle behaviors.

Amongst those who studied the topic were Richard Doll and Richard Peto who concluded in 1997:

Thus, both in our study and in other studies that involved the observation of large numbers of deaths, confounding, in so far as it has been possible to test for it, does not seem to be responsible for the relatively higher vascular mortality in non-drinkers than in moderate drinkers. Hence we concur with the expert advisors to the European Office of the World Health Organization1141 that 'drinking modest amounts of alcoholic beverages is likely to reduce the risk of CHD [coronary heart disease] for some populations'.

Once of the more recent studies (Holahan et al., 2010) confirmed that alcohol's protective effect is independent of other factors.

Controlling only for age and gender, compared to moderate drinkers, abstainers had a more than 2 times increased mortality risk, heavy drinkers had 70% increased risk, and light drinkers had 23% increased risk. A model controlling for former problem drinking status, existing health problems, and key sociodemographic and social-behavioral factors, as well as for age and gender, substantially reduced the mortality effect for abstainers compared to moderate drinkers. However, even after adjusting for all covariates, abstainers and heavy drinkers continued to show increased mortality risks of 51 and 45%, respectively, compared to moderate drinkers.

This is what science is supposed to do. It asks questions of the data and tests plausible alternative explanations. The sick quitter hypothesis has been tested to death. It does not explain the J-shaped relationship between alcohol consumption and mortality.

Overall, even the most vociferous of critics agree that alcohol taken in light-to-moderate quantities, preferably regularly and with meals, appears to favourably affect ischaemic heart disease.

To ask questions of the data is right and fair. But to keep raising those questions after they have been answered makes me suspect you have an agenda. For some people, the potential of the sick quitter hypothesis to overturn the science was too good to be dropped even after it was disproved.

As Eric writes:

The modern literature (ie the last 4 years) seems to have thoroughly answered the critiques raised in the early 2000s about potential confounds in the J-curve. The worries about potential confounds were plausible: if "never drinkers" and "people who quit drinking because their health was terrible" were coded similarly in the data, that could produce a J-curve without any health benefits from moderate drinking. But that just wasn't what was going on in the data. It's been resolved.

Why won't this zombie argument lie down and die? The answer, I think, is that the temperance lobby hates the fact that total abstinence is not the optimal position and the public health establishment is always uncomfortable with nuanced advice. Advising moderation is fine for GPs, but politically active doctors and neo-prohibitionists prefer to frame things in terms of 'healthy' or 'unhealthy', 'good' or 'evil'.

I think it likely that within a few years the official advice will be to drink no alcohol at all. This would bring it in line with the World Health Organisation's absurd claim that there is no safe level of drinking.

The key message was that no safe level of drinking exists, so people should talk about levels of risk and drop terms such as “safe drinking”, “sensible drinking” and “alcohol misuse”.

This would be bad scientific advice and very probably bad medical advice, but what the hell? We can't have people seeing alcohol as anything other than an unmitigated evil can we?

As I recount in The Art of Suppression, American teetotallers scored a crucial victory when they persuaded the public that alcohol was a poison that could never be consumed in moderation. This was a lie then and it is a lie now, but it pathed the way for Prohibition. Moderation is the enemy of the zealous. Expect to hear much more about how the J-curve has been "debunked" in the years ahead.

Do have a read of Eric's blog posts on this topic:

The J-curve: science versus politics

Moderate drinking and health


Tuesday, 11 October 2011

That didn't take long

On Thursday, I mentioned Stanton Glantz's latest contribution to the SmokeFree Movies campaign when he published a study which found that films that showed smoking make 13% less at the box office than 'smokefree movies'.

To give Glantz his due, he did not fall into the trap of mistaking correlation with causation in the study itself.

Fear not, dear reader. Even Stan is not prepared to mistake correlation and causation so grievously (although it surely won't be long before advocates use this study to tell Hollywood: "Get rid of smoking in your films and you'll boost sales by 13%"). He does not claim that smoking in films is the cause of lower revenues. He does not explore what the actual reasons may be, but it seems likely that smoking is more common in indie films, gritty dramas, European releases and other movies which tend to make less money than big budget cartoons and family blockbusters.

I did, however, ask how long it would be before some dumb-bell took the study as 'proof' that putting smoking in a film directly leads to fewer people going to see it and, therefore, making less money.

It didn't take long, and Scientific American is skating on thin ice with this headline:

Smoking Is a Drag at the Box Office

And they plunge straight through the ice with statements like this:

Movie-makers are burning potential earnings when they have onscreen characters light up, new research suggests.

Oh dear, oh dear. All we need now is some dumb-bell to step forward and spell out this fallacious thinking explicitly. Step forward, Stanton Glantz...

"Putting smoking in the film isn't leading to more popular films that make more money," Glantz says. "It's leading to less popular films that make less money."

Bingo.

Monday, 10 October 2011

Somebody's lying

They say you're entitled to your own opinions, but not your own facts.

Wise words, but that's not how it works in tobacco control. Spot the difference between these two BBC news stories taken three months apart.

25 March 2011

Scotland's smoking ban hailed as anniversary approaches

Sally Haw, senior scientific adviser for the Scottish Collaboration for Public Health and Policy, said: "The ban really has been one of Scotland's big public health success stories.

"This bold step has really paid off."

Ms Haw cited a study by Glasgow University which showed a 15% reduction in the number of children with asthma being admitted to hospital in the three years after the ban came into force.


27 June 2011

Scottish health boards 'complacent' over asthma care

Research into the care of young people with asthma has exposed "shocking" complacency by some Scottish health boards, according to charity Asthma UK.

Asthma UK said the number of emergency admissions had remained unchanged for a decade - suggesting the asthma of many young people was still being badly managed.

Asthma UK Scotland's national director Gordon Brown said: "This report makes shocking reading - especially when you consider Scotland has one of the highest rates of childhood asthma in the world.

"Some health boards are doing some things very well - and this is down to the excellent staff within managed clinical networks.

"However, it seems that at a strategic level some complacency has crept in - that asthma has somehow been 'fixed' and priorities have now changed.

"This is borne out by the fact there has been no noticeable change in the unacceptably high emergency hospital admissions for children and young people with asthma in the last decade."

It is impossible for both these statements to be true. Either emergency hospital admissions for children with asthma fell by 15% after the smoking ban or they have remained unchanged for a decade. Someone's not telling the truth. Is is the "study by Glasgow University" or Asthma UK?

You can probably guess the answer. If I told you that the Glasgow study was penned by the infamous Jill Pell, you would be in no doubt at all.

Readers with a long memory will recall that Pell's study was the sheerest junk science. There was no effect from the smoking ban on asthma admissions. In fact, the first year of the Scottish smoking ban saw the largest number of childhood asthma admissions of the decade. Asthma UK is correct. Pell is wrong. Again.

Here we have two 'facts' which are totally at odds with each other appearing on the same news website in the same year. One fact is the number of children who actually went to hospital with asthma. The other is a piece of statistical jiggery-pokery created for political ends. And yet only one of them is true. The other is a fraud which has taken the place of the truth thanks to repetition and the appeal to authority (it was published in the prestigious, peer-reviewed New England Journal of Medicine). The real truth, meanwhile, appears almost by accident in a different context and no one at the BBC makes the connection.

This is the parallel universe created by the charlatans of the anti-smoking industry. They are entitled to their own facts. Whether or not they are true is of no consequence. They want them to be true and that is all that matters.

It is ridiculously easy to see through this garbage. The real hospital admissions data for asthma are available online, just as the heart attack data are. It takes a matter of minutes to distinguish fact from fiction and yet there is only silence and tumbleweed. If the mainstream media do not feel inclined to expose blatant policy-based evidence when it is in its crudest form, what hope is there of more subtle scientific abuses coming to light?

[Thanks to Ivan for spotting the two stories above.]

Saturday, 8 October 2011

The situation in Europe

A bit of news from Spain:

First smokers' club opens

Smokers are free to light up behind the closed doors of a new ‘members only’ club in Alicante.

The club – believed to be the first legally registered smokers’ club in the Valencia region –has attracted more than 200 members, all aged over 18.

Meanwhile in Greece:

Smoking will be once again permitted in Greece given the country’s poor financial situation [but smoking bans are good for business! ASH says so]. The new measure will allow smokers to smoke inside casinos and big nightclubs exceeding 300m2.

According to the decision of Finance and Health Ministers, Mr. Venizelos and Mr. Loverdos, casino and big nightclub owners will be authorized to set up a smoking area, which could cover 50% of the total acreage of their business.

Meanwhile in France:

Gentleman's smoking lounge makes Parisian comeback

While most people are obliged to freeze on the pavement to keep up their cigarette habit, since the ban was introduced three years ago, a growing number of nightspots are offering exclusive and law-abiding shelter for smokers, complete with pianos, leather armchairs, and cigar lockers.

French law still allows indoor smoking spaces provided they have state-of-the-art ventilation and that no staff operate inside.

Consenting adults making grown up decisions for themselves — could this radical idea ever catch on?

This all comes after the Netherlands, Germany, Croatia, Portugal, Belgium, Denmark, Macedonia, Poland, the Czech Republic and several other countries relaxed their smoking bans (or introduced limited bans from the outset). The British media continues put out the message that the whole world is adopting the "comprehensive" smoking ban. The truth is that, along with the Irish, we have a ban that is exceptionally draconian, uncompromising and intolerant.

The lights are coming back on all over Europe. If you haven't signed the petition to review the English smoking ban, do it now.

Friday, 7 October 2011

Panic on a Plate by Rob Lyons: A review

In the last eighty years, the proportion of household income spent on food has dropped from a third to less than a tenth. Fruit and vegetables from around the world are on the shelves all year round. Women are no longer chained to a life of domestic drudgery. Malnutrition and rickets are a distant memory. For the first time in history, we who are lucky enough to live in the West do not have to worry about food.

But worry we do – about genetic modification, fast food, BSE, childhood obesity, adult obesity, salt, margarine, cholesterol, fat, pesticides, red meat, food miles, carbon footprints and school dinners. At the very moment when we should be most relaxed about the food supply, we are bombarded with fears. Fast food is “addictive”, so we are told, and the food industry is trying to kill us for profit. Unless we take drastic action, most Britons will be obese by 2030.

As Rob Lyons patiently explains in this splendid plea for sanity, these beliefs owe more to ignorance and prejudice than fact. Take the humble hamburger, which obesity crusaders have chosen as their very own Moby Dick. On the face of it, it is bewildering why “two all beef patties, special sauce, lettuce, cheese, pickles, onions on a sesame seed bun”—to quote the old Big Mac slogan—should be the embodiment of evil. A burger is only bread, meat and salad. Each Big Mac contains 500 calories – a fifth of a man’s daily ‘limit’ - and you wouldn’t want to copy Morgan Spurlock’s silly experiment of eating nothing else, but it is no more fattening than the supposedly more wholesome alternatives. Ketchup is rich in vitamin C and so are fries - surprisingly, a portion of fries contains between a quarter and a third of an adult’s daily recommended vitamin C intake. There are better candidates for demonization in every middle class kitchen. “Cheese is roughly one third fat. Parmesan is also pretty salty. Olive oil is pure fat. Butter must be, by law, 80 per cent fat," writes Lyons. "Honey and raisins – usually regarded as ‘good’ – are practically pure sugar. Orange juice is 87 per cent water, almost all the rest is sugar.”

Although equally calorific, pasta is 'good', chips are 'bad'. Fizzy drinks are out, but fruit juice – though more sugary – is in. Whether measured by salt, sugar, fat or calorie content, there is little to distinguish ‘junk food’ from haute cuisine. Our perception of good and bad food has less to do with nutrition than it does with class. The dominant view of diet in modern Britain, Lyons argues, “has more to do with a combination of middle-class angst and plain old-fashioned snobbery than anything else.” If you are what you eat then junk food is for junk people. Oh, how we sneered at those ghastly common folk in Rotherham when they shoved fish and chips at their offspring through the school railings. Except that these ‘junk food mums’ - these ‘sinner ladies’ - were actually delivering meals, including sandwiches and jacket potatoes, which any adult would remember from their own school-days, and were only doing so because the school had operated a lunchtime lockdown to force the hapless children to eat Jamie Oliver’s low-fat fodder.

The Rotherham 'sinner ladies'

Jamie Oliver is the proverbial bad smell in Panic on a Plate, popping up with depressing regularity as the voice of the diet police. After making the transition from Sainsbury’s shill (catchphrase: “none of that low fat malarkey”) to canteen crusader, the TV chef turned a reasonable campaign for better school dinners into a witch-hunt against the “tossers” and “arseholes” who dared to give their offspring a packed lunch. Few images sum up the absurdity of the obesity panic than the stocky mockney berating stick-thin kids for eating chips. If you watched it with the sound turned off, Jamie's School Dinners was an hour long illustration of how few school children are overweight. Turn the sound up, however, and Oliver was saving these young 'uns from certain death.

Sausage, beans and chips might not be the most adventurous dish, but it is a perfectly nutritious lunch for active teenagers. With their boundless energy and growing bones, children burn off more calories than stout celebrity chefs. They also have naturally conservative palates, hence the nosedive in school dinners being served after the government capitulated to Oliver’s demands and substituted the much-despised Turkey Twizzlers for broccoli.

There is little that can be usefully said about food beyond the common sense observation that calories consumed should be roughly commensurate with energy expended. For the food faddists, it is not a question of excess versus exercise, but of wholesome food versus killer junk. Despairing of the "numpties" of Rotherham, Oliver could only sigh in exasperation: "If these mums want to effectively shorten the lives of their kids and others' kids, then that's down to them." Like many a culinary campaigner, Oliver is fond of repeating the grotesque lie that today’s children will die before their parents. Even when put in its less misleading form of ‘this generation will die at a younger age than their parents’, this reference to the ‘obesity timebomb’ remains unlikely and is belied by ever-increasing life expectancy estimates. Obesity is not going to bankrupt the NHS. Centenarians might.

The inevitability of parents burying their children in extra-large coffins is one of several oft-repeated ‘facts’ parroted by dietary dogmatists which do not stack up. Campaigners rarely acknowledge that obesity rates levelled off on both sides of the Atlantic ten years ago, and the claim that fast food is ‘addictive’ requires a definition of addiction that is so broad it would include any activity people find enjoyable. The claim that it is cheaper to buy 'junk food' than cook a meal at home is demonstrably untrue and the sainted Mediterranean diet has proved to be less healthful than was believed thirty years ago, while fears of salt, GM crops, BSE and manmade fertilisers have been shown to be greatly exaggerated when not utterly groundless.

The middle classes have been susceptible to food faddism since the Victorian era, when the ‘back to the land’ movement ignited the first stirrings of popular vegetarianism and organic farming. As the urban population began to outnumber that of the countryside, a romantic, idealised view of nature emerged which can be seen to this day in such eccentric organisations as the Soil Association and the Center for Science in the Public Interest. “The underlying temper of our times,” writes Lyons, “is that anything processed or industrialised can be seen as adulterated and harmful, while anything that appears to be natural or close to nature can be regarded as pure and uncorrupted.”

Jamie Oliver and his chins

The fetish for organic vegetables epitomizes this foodie flim flam. Study after study has found no health benefits from eating organic produce and even organic devotees are unable to distinguish one from the other in blind trials. Far from being led by the evidence, the organic movement is deeply suspicious of science. Fearful of the slightest trace of ‘chemicals’ and suspicious of industry, the organic/anti-GM crowd is backward looking and elitist (hello, Prince Charles). Over-priced and over-rated, organic food is little more than a tax on the credulous.

Just as Oliver yearned to return to the Golden Age of school dinners (no soggy semolina or concrete chips in his recollection), nostalgia for a bygone age of wholesome grub figures heavily in the modern war on fast and/or convenient food. “Don’t eat anything your great-great-grandmother wouldn’t recognize as food,” says the writer Michael Pollan. Mmm, all those handpicked vegetables and buxom maidens toiling over churns of butter. Jumpers for goalposts. Marvellous.

Or perhaps not. Your grandmother would probably not recognize spaghetti, hummus or kiwi fruits as food, but she would certainly be familiar with bread and dripping, gruel, fried everything and the early symptoms of scurvy. The range and quality of British food has improved immeasurably since the turn of the last century and supermarkets have broadened our horizons considerably. An illustration of this came when Delia Smith updated her 1970s cook books in 1995 and found that: “Almost everyone now has access to good olive oil, fresh herbs, imported cheese. I found myself over and over again deleting the words ‘or if you can’t get it…’” More choice, lower prices, less toil. What's not to like?

What the food faddists don't like is the modern world. After decades of lingering on the fringes of public life, lentil-munching hypochondriacs have now found an audience at a time when the micromanagement of private behavior is the raison d'etre of British politics. The public health establishment is gearing up for a legislative crusade of tax rises and advertising bans on food which is overtly based on the anti-smoking campaign. Big Food is already being wheeled out as the new Big Tobacco, and politicians who lack bigger ideas are happy to lead the assault against what they are told is a new ‘epidemic’. The food on our table will be targeted by law-makers and single-issue campaigners for many years to come. The myths and half-truths discussed in Panic on a Plate will be echoed often and loudly. Prepare yourself by reading this excellent book.


Buy Panic on a Plate from Amazon (UK) or Amazon (USA)

Thursday, 6 October 2011

Stanton Glantz: Clueless clown

"..and then divide by the number you first thought of..."

It is a rare month when Stanton Glantz, doctor of mechanical engineering and professor of something-or-other at the University of San Francisco, does not publish some advocacy-based junk in a low-grade public health journal. The old fellow has many imitators these days, but efforts like this from the forthcoming issue of Tobacco Control show that he will not give up his crown without a fight.

Movies with smoking make less money

Stanton A Glantz, Jonathan R Polansky

Objective: To determine the relationship between presence of smoking in films and total box office receipts.

The conclusion of this study is rather given away by the title. By reviewing a whole load of films, Glantz found that movies which depicted smoking made l3% less money than those which didn't. The methodology was as follows:

...we compared the reported box office gross receipts (in 2010 dollars) of the 1316 films, with and without tobacco imagery, that ranked among the top 10 in ticket sales in any given week of their ‘domestic’ (USA and Canada) theatrical release between 2002 and 2010.

What a pitiful thought it is that someone in California has been paid to watch over a thousand movies to look out for a glimpse of tobacco smoke. And how tragic it is that Glantz keeps the resulting dossier in his office to be whipped out for studies like this. Nevertheless, the methodology is not unreasonable and we shall assume—possibly naively—that the basic conclusion is sound.

The question is: So what? No one has ever claimed that directors portray smoking to boost sales. It is an artistic decision which reflects a real world in which 1 in 5 people smoke. Surely Glantz is not going to insist—as he does with smoking bans—that cow-towing to tobacco controllers is going to be good for business?

Fear not, dear reader. Even Stan is not prepared to mistake correlation and causation so grievously (although it surely won't be long before advocates use this study to tell Hollywood: "Get rid of smoking in your films and you'll boost sales by 13%"). He does not claim that smoking in films is the cause of lower revenues. He does not explore what the actual reasons may be, but it seems likely that smoking is more common in indie films, gritty dramas, European releases and other movies which tend to make less money than big budget cartoons and family blockbusters.

Since there is no cause-and-effect here, what is the point of the study? For Stan, the point is that Hollywood has nothing to fear from his SmokeFree Movies ruse because a lack of smoking on the screen does not put off punters.

One hypothesis to explain the persistence of high levels of smoking in US films is that smoking pays off at the box office.

Er, no it isn't. As far as I'm aware, nobody has ever made such an argument and it is telling that Glantz does not provide a reference for this claim. Nobody seriously believes that people are specifically attracted to films which show smoking, nor is anyone deterred from seeing films which do show smoking. It's irrelevant at the business end. This is purely an issue of artistic freedom versus censorship.

Having constructed his straw man, Glantz demonstrates that it is false. Well done him. However, while he shows that tobacco imagery has no effect on box office takings, he inadvertently manages to show that his SmokeFree Movies scheme would financially damage the movie industry.

This study shows why movie studios tend to push for a PG-13 rating: such movies make 18% more at the box office compared ones with an R rating.

This is the real point of SmokeFree Movies. The purpose is not merely to restrict smoking in the movies to R rated films. The purpose is to coerce movie studios into getting rid of all smoking from their films for fear of losing their PG rating and, therefore, a significant proportion of their audience.

Under Glantz's regime, the makers of The Simpsons Movie or Avatar would have to think very carefully about whether they wished to maintain their artistic vision or maintain their PG rating. If they say "screw these cranks, the film stays as it is" then they will lose their PG rating and, therefore, will lose money—to the tune of 18%, according to Glantz, although this gap may not be entirely due the classification status.

What Glantz demonstrates in this study is that the presence or absence of smoking has no effect on box office takings (no one ever thought it did), but that the SmokeFree Movies plan will lead to a significant loss in box office takings if directors choose not to capitulate to the anti-tobacco fanatics.

Glantz, however, comes to exactly the opposite conclusion in his new study:

...implementing an R rating for smoking to remove it from youth-rated films will not conflict with the economic selfinterest of producer-distributors.

Garbage. R ratings have a negative effect on sales. The SmokeFree Movies plan will lead to more films being given an R rating. Therefore, the SmokeFree Movies plan will very much "conflict with the economic self-interest of producer-directors."

The only way to escape this financial damage will be for film-makers to remove every hint of smoking from their films. That is what Glantz wants, of course, but if they refuse—as they have every right to do—they will be penalised at the box office. This is blackmail, pure and simple. Comply or die. If directors refuse to cleanse their films to suit the zealots they risk losing millions of dollars. No wonder Hollywood has consistently told them to sod off.