Tuesday, 19 July 2022

Smoke without fire?

A study titled 'Should IQOS Emissions Be Considered as Smoke and Harmful to Health? A Review of the Chemical Evidence' was published two weeks ago. The study comes with a big red flag:

The authors acknowledge the support of Bloomberg Philanthropies’ Stopping Tobacco Organizations and Products funding (www.bloomberg.org). The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors also thank Prof. Anna Gilmore and Sophie Braznell from the University of Bath and Dr. Ed Stephens from the University of St. Andrews for valuable discussions and reviewing the content of this article.


Why anyone would ask advice from Anna Gilmore and one of her PhD students when writing about chemistry is a mystery that is only partially solved by the knowledge that they are also on the Bloomberg gravy train. Gilmore is deeply involved with Bloomberg's 'Stopping Tobacco Organizations and Products' (STOP) front group. How can the funder be said to have had no role in the analysis when she reviewed and commented on the study? I guess different rules apply in 'public health'. The authors report no conflicting interests.

IQOS is a heated tobacco product produced by Philip Morris International (PMI). It doesn't burn the tobacco, it heats it. Consequently, there is no smoke and the products are considerably safer than combustible cigarettes. This has been acknowledged in the UK by the Committee on Toxicity and in the USA by the Food and Drug Administration (FDA). The FDA allows IQOS to be marketed as a Modified Risk Tobacco Product, an honour that is rarer than hen's teeth and requires an abundance of evidence to earn.

Mike Bloomberg and his minions loathe reduced risk nicotine products and are determined to crush them, even if it means turning scientific terminology on its head. One strategy is to portray the emissions from heated tobacco products as 'smoke'. This has regulatory implications in many countries and this new study seems designed to be printed off by campaigners and laid on the desk of gullible regulators. It concludes:

The HPHCs [harmful and potentially harmful compounds] present are the same as in conventional cigarette (CC) smoke, albeit in lower concentrations and formed at lower temperatures, analogous to the emissions from the earlier generation of HTPs [heated tobacco products], which were classed as smoke. Also, IQOS emissions contain carbon particles with most of the compounds released being formed by chemical reactions provides further evidence that IQOS emissions fit the definition of being both an aerosol and a smoke.

 

Unlike Anna Gilmore, I am happy to admit that this is beyond my expertise so I invited Dr Roberto Sussman from the Institute of Nuclear Sciences at the National Autonomous University of Mexico to write a guest post. Here is what he has to say...

 

“Must a name mean something?” Alice asks Humpty Dumpty, only to get this answer: “When I use a word… it means just what I choose it to mean – neither more nor less.”

Paraphrasing this Alice in Wonderland dialogue with “a name” replaced by “smoke” and “Humpty Dumpty” replaced by “Tobacco Control orthodoxy” illustrates the determination of the WHO technocracy to attach the term “smoke” to the IQOS aerosol. Earlier this month, scientists funded by Bloomberg Philanthropies attempted in this article to provide technical backbone to this “re-classification” of IQOS aerosol as some form of smoke. It was written by Clement N. Ugana and Colin E. Snape, both from the University of Nottingham's Faculty of Engineering.

Let us first clear the semantics: What is “smoke”? Any textbook on aerosol physics defines “smokes” as aerosols (particulate substrate in a gaseous medium) sharing the following characteristics:

  • the particles are fine and ultra fine (diameters less than 1 micrometer)
  • can be solid or liquid
  • are generated by a combustion process.


What is a combustion process? Chemical reactions that involve a combustible are oxidizing and exothermal (i.e. require oxygen and external energy supply).

So how do Uguna and Snape claim that IQOS aerosol can be characterized as a “smoke”? Basically, they follow the suggestion of a questionable 2017 paper by Auer et al. titled 'Heat-not-burn tobacco cigarettes: Smoke by any other name' which claims that IQOS aerosol contains “compounds from pyrolysis and thermogenic degradation that are the same HPHCs as for conventional tobacco cigarette”. 

Uguna and Snape extend this to :

  • The same endothermic physicochemical processes that occur when inhaling cigarette smoke might occur in IQOS aerosol: evaporation/condensation of vapors, distillation (separation of liquid/solid phases), pyrolysis and pyro-synthesis (larger molecules decomposing in smaller ones and and recombining).
  • IQOS aerosol contains detectable solid black carbon particles (a generic name for carbonaceous particles)
  • Some spots in the tobacco of the IQOS might reach higher temperatures than the recommended range below 350 C


Uguna and Snape are mistaken in assuming that IQOS aerosol can be cast as a smoke on all these counts.

Let us deal with the first issue. While there is no smoke without combustion (or without oxygen), different smokes might evolve through many other derived physicochemical processes, such as the ones mentioned by Uguna and Snape. However, these are derived processes acting on smoke that has already been produced by oxidizing exothermal reactions. In other words: these processes are not needed to generate a smoke and their occurrence does not by itself imply combustion. This is easily illustrated by looking at the specifics of tobacco smoke.

What we call “tobacco smoke” is really two distinct aerosols, both originating from the same smoke produced by the burning (external energy supply) of the combustible (tobacco leaf). Each aerosol evolves differently: the sidestream emission making 75-80% of the produced smoke at the burning (800-900 C) and smouldering (450-500 C) tip of the cigarette is directly released to the environment and the mainstream emission, the remaining 20-25% that is inhaled by the smoker and undergoes several physicochemical processes, such as distillation, condensation/evaporation, pyrolysis and pyro-synthesis and forced convection and cooling (from 800-900 to 40 C) as the smoker inhales through the cigarette rod.

The confusion of Uguna and Snape is clear: they assume that the IQOS aerosol can be a sort of “smoke” because it may go through some (or even all) of the derived processes (condensation/evaporation, distillation, pyrolysis) in the evolution of 20-25% of the cigarette smoke that forms the mainstream emission of cigarettes. However, such processes do not define combustion and are not necessary to generate smoke (for example, sidestream smoke). Neither are they sufficient to do so: they can occur without combustion with exothermal processes that do not involve oxidizing reactions.

The lack of combustion in the aerosol generated by a heated tobacco device was proven in a rigorous experimental test by PMI scientists (Cozzani et al. 2020). A heated tobacco device in an oxygen-free laboratory environment was capable of aerosol generation. This proves that the aerosol was not generated by combustion, which is an exothermic oxidation process that cannot occur without oxygen and a combustible.

Evidently, depending on the temperature (and thus on the supplied battery power) in which the heated tobacco device is operated, the derived processes (distillation, condensation/evaporation, pyrolysis or pyro-synthesis) might occur in the aerosol evolution, but this does not prove that the generated aerosol is a smoke because 20-25% of cigarette smoke undergoes similar processes. The key difference is that this fraction of tobacco smoke was previously generated by combustion, whereas Cozzani et al. proved that the aerosol from a heated tobacco device is not.

Another reason why Uguna and Snape claim that IQOS aerosols can be characterized as some sort of smoke is the presence of black carbon solid particles. The particulate phase of IQOS has been examined in laboratory studies by the industry, in particular by two comprehensive laboratory studies (the second funded by PMI): Pacitto et al. (2018) and Amorós-Pérez et al. (2022).

Although neither of these is cited by Uguna and Snape, both laboratory studies concluded that particles in IQOS aerosols are quite distinct from those of tobacco smoke that are clearly identifiable with combustion particulate matter (PM). They have much larger volatile content and are overwhelmingly liquid and produced by condensation. Uguna and Snape only cite several sources that have detected black carbon particles in minute concentrations relative to tobacco smoke (for example, less than 1% in Ruprecht et al.). They cite Auer et al., which merely speculates on IQOS aerosol particles.

While Uguna and Snape recognise that IQOS operates at temperatures of less than 350 C, considerably below combustion temperatures, they hint that the tobacco undergoes an inhomogeneous heating, with the creation of spots possibly reaching higher temperatures. However, this is mere speculation without any actual laboratory proof under normal operating conditions of the devices.

It is really unnecessary to go any further on re-classifying IQOS aerosols as smoke, in the presence of black carbon particles, or in arguing that its toxicity may be comparable to that of tobacco smoke, as these claims were irrelevant in the extremely rigorous testing of the characteristics and relative safety of product that was validated by the FDA in its review of the PMTA application submitted by PMI. The FDA openly recognised that its evaluation roughly agrees with the claims by the manufacturer on all technical issues, with substitution of cigarette smoking by usage of an IQOS device representing for users a significant reduction of their exposure to HPHCs, thus granting the devices the status of “appropriate for the protection of public health”.

Going back to the semantics: perhaps the definition of “smoke” can be stretched to include any aerosol with (even a minimal) presence of solid non-volatile particles and undergoing any one (or all) the physicochemical processes in the formation of the mainstream emission inhaled by smokers. After all, other than the need to facilitate scientific communication, there is nothing sacred about terminology. While stretching the definition of smoke in this way would encompass aerosols from heated tobacco products (HTPs), it would make communication harder and more confusing by also encompassing aerosols that mostly originate from combustion sources (such as cooking aerosols and air pollution) which are not known as “smokes”. Therefore, it could be counterproductive.

Finally, it is interesting to inquire why the pressing need of tobacco control orthodoxy to characterise aerosols from HTPs as smokes? The main reason is political: this characterisation fulfills the need of the technocracy to keep the ongoing crusade against the manufacturers of these devices: the tobacco industry and in particular Philip Morris International (PMI). For this purpose the technocracy is now missing the target of reducing cigarette smoking and giving more preference to keeping the industry in its eternal role of the ultimate evil force deceiving the public. However, the industry's claim that replacing tobacco cigarettes with HTPs such as IQOS significantly reduces user exposure to harmful compounds has been scientifically validated by the US FDA, whereas the most extreme of contrary claims have been only validated by politics and technocratic hubris.



Friday, 15 July 2022

Is drinking "never good" for people under 40?

In 2018, the Lancet published a study from the 'Global Burden of Disease Alcohol Collaborators' which claimed that there was no safe level of alcohol consumption. This was widely reported and was naturally welcomed by anti-alcohol campaigners. The BBC reported it under the headline 'No alcohol safe to drink, global study confirms'. (Note the cheeky use of the word confirms, despite the finding going against fifty years of evidence.)

The study wasn't based on any new epidemiology. Instead it took crude, aggregate data from almost every country in the world, mashed it together and attempted to come up with a global risk curve. 


The study contains no new evidence and uses an unusual modelling approach based on population-wide data from various online sources. If you look at this massive appendix you can see the kind of data they were using. The figures are extremely crude.

The authors don't dispute the benefits of moderate drinking for heart disease but they claim that the benefits are matched by risks from other diseases at  low levels of consumption and are outweighed by the risks at higher levels of consumption. Some diseases which have been associated with benefits of drinking, such as dementia, are excluded from the analysis entirely. They also ignore overall mortality, which you might think was kind of important.
 
A typical risk curve for alcohol consumption and mortality is J-shaped. It looks like this...
 
 

But the GBD's risk curve for "all attributable causes" looked like this...


You will notice that there appears to be no protective effect at moderate rates of consumption in the GBD's curve. One important reason for this is that they associate alcohol consumption at any level with tuberculosis. Tuberculosis remains a serious health problem in much of the world, but not in Britain. So what relevance does a global risk curve have to us? None. 

Moreover, TB is not really an alcohol-related disease and is only viewed as such in this study because (a) drinking might weaken the immune system and (b) because people who go to bars and clubs are more likely to catch an infectious disease. I kid you not.

Today, the Lancet has published a new study by the same team using an improved methodology which comes up with a more conventional curve.


As yet, there has been no report from the BBC to set the record straight. In fact, most media outlets have ignored the study. On exception is the Guardian which - taking its cue from the press release - has focused on the finding that the health benefits of moderate drinking only apply to people over the age of 40.
 
Take a moment to savour the headline and sub-heading, for they tell us a lot about the world in which we now live.
 
Alcohol is never good for people under 40, global study finds

Largest project of its kind concludes young people should not drink at all but small amount may benefit older adults


I drank a lot of alcohol when I was under 40 and my experience is not consistent with the claim that it is "never good". As I recall, it was nearly always good. I assume that it still is good because many millions of people under the age of 40 continue to do it.

And yet we are told, on the basis of a modelling study, that young people "should not drink at all". Why? Because they won't get any health benefits from doing so.

This is not mere editorialising from a paternalistic newspaper. It is the conclusion of at least one of its authors:

“Our message is simple: young people should not drink, but older people may benefit from drinking small amounts,” said the senior author, Dr Emmanuela Gakidou, professor of health metrics sciences at the University of Washington’s School of Medicine.
 
Let us not dwell on the fact that the same team's message four years ago was that nobody should drink. Let us instead marvel at the mindset of people who think that the only things worth doing are those that make you live longer and that the only benefits worth considering are health benefits.

This worldview, which Robert Crawford called healthism but which could more accurately be called longevitism (since long life does not imply good health and usually leads to poor health), is implicit in government drinking guidelines. Guidelines are supposed to be recommendations, but they soon become targets, as in Scotland where the government wants to double down on its failed policy of minimum pricing because "Scots are still drinking 30 per cent more alcohol than the 14 units per week guidelines."

If the aim of policy was to maximise happiness, the government would recommend that people drink as much as they want. At higher levels of consumption, the optimal quantity would be influenced by potential health risks which could be informed by the kind of research mentioned above. Pigouvian taxation on alcoholic beverages would optimise consumption across society.

In the UK, the drinking guidelines were blatantly fabricated for political reasons, but even if they were more robust, they could only tell us what the optimal level of consumption is from the perspective of health and longevity (spoiler: it is more than zero).

Most people in Britain are blissfully unaware of what the drinking guidelines are. Insofar as they know what they are, they understand that they only apply to health risks (and benefits). They take a broader account of the costs and benefits when they decide how much to drink. 

Only a fanatic would say that something is 'never good' on the basis that it poses a risk to health that is negligible in practice, let alone that something should never be done unless it improves health. It does not take much imagination to see how such a principle, especially if accompanied by government coercion, would lead society down a dark and miserable path.

Notice, by the way, that nobody involved in this research is recommending that teetotallers over the age of 40 should start drinking moderately, despite the study showing that this would improve their health. Even in the world of 'public health', fanaticism has its limits.
 
 
UPDATE
 
David Spiegelhalter is not impressed.


Thursday, 14 July 2022

A swift half with Eamonn Butler

There's a new episode of The Swift Half out, this week featuring the indefatigable and unflappable Eamonn Butler, director of the Adam Smith Institute.



Wednesday, 13 July 2022

How the nanny state blob beat Boris


I've written a postmortem of Boris Johnson's premiership for Spiked, focusing on his failure to stand up to the nanny state blob.
 

What we got under Johnson is what we get under every Conservative government: an inexorable slide towards a paternalistic, authoritarian, micromanaging state – but at a slightly slower pace than might have happened under Labour and the Lib Dems, and at a significantly slower pace than would happen under the SNP.  

Until 1979, the Conservative Party existed to slow, but not reverse, the country’s slide towards socialism. Since 2010, it has taken the same approach to the nanny state. If even the party-loving populist Boris Johnson could not find it in himself to challenge the miserable, finger-wagging, killjoy consensus when he got into Downing Street, perhaps no one ever will.

 
 
The article includes a link to Boris's appearance on Room 101 which is worth watching if you haven't seen it.


Monday, 11 July 2022

Are 409 suicides a year caused by problem gambling?

I've set up a Substack because Google has pretty much given up on Blogger and hasn't made any improvements in years. Substack also allows you get new posts delivered straight to your in box. I will still be posting here, but most of the Velvet Glove content will also be available on Substack, so if you want to subscribe (it's free) you can do here. That's the link to my first cross-posted article which goes like this...

 

It is becoming common for any article about gambling in Britain to include a claim about suicide:
 

A Public Health England study published in September estimated that there are more than 409 suicides a year in England associated with problem gambling. (The Guardian)

The statistics are stark and brutal – between 400 and 500 people die by suicide related to gambling issues in the UK every year (The Telegraph)

The Gambling Commission has looked into just nine deaths since 2016 – a tiny proportion of the total number. Yet there are thought to be 409 gambling suicides a year in England alone (Daily Mail)

 
The same statistic has been quoted by Chris Philp who, until a few days ago, was the gambling minister at DCMS.
 

We now have evidence, including a Public Health England report, which identified 409 gambling suicides a year. It is imperative that we respond to that. Change is certainly needed.

 
Campaigners against gambling advertising have even made some T-shirts. 
 
 
There is no doubt that some problem gamblers commit suicide and that gambling and gambling-related debt can be an underlying cause of suicide.

But 409 suicides is a curiously specific figure for something that is not recorded on death certificates and for which the UK collects practically no data.

A variation of this estimate was used in the closing stages of the campaign against fixed odds betting terminals (FOBTs). In October 2018, the government announced that it would be cutting the stake limit on FOBTs to £2 from October 2019. Sports minister Tracey Crouch claimed that this was an unacceptable delay and that the government had previously promised to enforce the new law from April 2019. The government had never said any such thing, but she nevertheless resigned over the matter and ultimately pressured the government into bringing it forward to April 2019.

In her resignation letter, Crouch claimed that two people committed suicide every day ‘due to gambling related problems’, thereby implying that there were 700 gambling-related suicides a year.

When the government capitulated and brought the stake reduction forward, she said:
 

‘There was never any excuse for delay. Bringing forward by six months the day maximum stakes are capped will save an estimated 120 lives.’

 
This implied that 240 suicides took place every year as a result of FOBT gambling alone. I have no idea where she got this figure from. I suspect it was rectally sourced.
 
At around the same time, Nicky Morgan MP said of the Chancellor’s explanation for the 12 month ‘delay’:
 

‘it doesn’t really help the expected 300 people who may end up taking their lives, suffering mental health problems from gambling addiction’.

 
Insofar as these claims were based on evidence, they seem to have come from an unpublished estimate by the pressure group Gambling With Lives. Based on extrapolations from three studies from the UK, Hong Kong and Sweden, they estimated that there were between 250 and 650 gambling-related suicides per annum. They later described their workings in a submission to a House of Lords Select Committee, but it has a back-of-an-envelope feel and is far from being an official estimate.

The official estimate of 409 suicides per annum comes from a 2019 Public Health England report. This was one of the last things it published before it was dissolved and the methodology is frankly terrible.

The figure is entirely based on one study from Sweden published in 2018. The study looked at 2,099 people who had been diagnosed with gambling disorder by a doctor while receiving inpatient or outpatient care (but not primary care) in the Swedish health system between 2005 and 2016. Of these 2,099 individuals, 67 subsequently died, including 21 who committed suicide. This suicide rate implied that these people were 15 times more likely to kill themselves than members of the general population.

Public Health England arrived at their estimate by working out how many problem gamblers were in England in 2019 (based on a prevalence rate of 0.4%). Adjusting for age and gender, they then extrapolated from the suicide data in the Swedish study and applied it to England’s problem gambling population to work out how many gambling-related suicides took place in that year. They did not show their workings and described their methodology in a single paragraph:
 

The ONS age-standardised suicide rates for 2019 (42) are multiplied by the prevalence of problem gambling in the general adult population (0.4%, sourced from the HSE (3)) to first estimate the number of gamblers who died by suicide in England for all persons (25; 95% CI 14 and 44). Multiplying this figure by the age-standardised SMRs (sourced from Karlsson, and others (36)), produces an estimate of the expected number of suicides (434; 95% CI 257 and 746). Calculating the difference between these figures results in the estimated number of deaths by suicide associated with problem gambling only (409; 95% CI 242 and 702).

 
You can’t do this! You can’t take a prevalence estimate from one group of people and apply it to a totally different group of people. I don’t mean that Swedes and Brits are totally different - although there may be important differences - I mean that a group of 2,099 people who are seeking medical help are very different from the several hundred thousand people who are estimated to be problem gamblers in England.

These are the questions in the survey used to estimate problem gambling in the UK:

Thinking about the last 12 months…

  1. Have you bet more than you could really afford to lose?

  2. Have you needed to gamble with larger amounts of money to get the same feeling of excitement?

  3. When you gambled, did you go back another day to try to win back the money you lost?

  4. Have you borrowed money or sold anything to get money to gamble?

  5. Have you felt that you might have a problem with gambling?

  6. Has gambling caused you any health problems, including stress or anxiety?

  7. Have people criticized your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true?

  8. Has your gambling caused any financial problems for you or your household?

  9. Have you felt guilty about the way you gamble or what happens when you gamble?

You can say never (zero points), sometimes (1 point), most of the time (two points) or almost always (three points). If you get 8 points or more, you are a problem gambler.

The test is fine as a diagnostic tool. It is used internationally. But someone who scores 27 points is clearly in a worse state than someone who scores 8.

The point is that problem gambling is on a spectrum. Most problem gamblers do not suffer serious consequences as a result of their gambling. Most problem gamblers stop being problem gamblers at some point (a large proportion are young men who essentially grow out of it). But others get into serious trouble. A small number get into horrendous debt and some end up needing professional help.

The Swedish study is slanted towards the latter. Obviously, not everybody who gets treated by the Swedish health system is asked to complete a problem gambling questionnaire. 2,099 people is an incredibly small proportion of all the people who had medical treatment in Sweden between 2005 and 2016. These individuals took the test because there was something manifestly wrong with their physical or mental health. For example, they may have been admitted because of a suicide attempt which may or may not have been related to gambling. (The authors of the study don’t say, but it seems likely that the problem gambling questionnaire was one of several mental health questionnaires they were asked to fill out.)

Whatever they were being treated for, it is clear that the Swedish patients were at higher risk of all sorts of things that the average problem gambler. The authors say this explicitly:
 

It is therefore likely that results may be skewed toward a population of individuals with more severe forms of GD [gambling disorder]. It is likely that this once again implies that this study sample might contain patients with higher mental health comorbidity, as well as individuals with more severe forms of GD, since these individuals are more likely to receive specialized psychiatry care.

 
51% of the Swedish patients were suffering from depression. 60% had an anxiety disorder. 41% had a substance-use disorder. 29% had an alcohol-use disorder. 12% were bipolar. 19% had a personality disorder. This was not a normal group of people, even by the standards of problem gamblers. Some of their problems may have been exacerbated by gambling, but it takes some heroic assumptions to suggest that they would have all been fine had they never gambled or that gambling was at the root of all their problems.

Applying the suicide rate from this group of people to all the people in England who score 8 or more in the problem gambling questionnaire is like taking the liver cirrhosis rate among people who have been to Alcoholics Anonymous and applying it to everyone who drinks more than 14 units a week. It is - quite obviously - an apples and oranges comparison.

There were 5,316 suicides in England in 2019. Undoubtedly, some of them were related to gambling, but there is no reason to think that there were 409 suicides caused, directly or indirectly, by problem gambling. The true figure could be higher but it is probably lower. We really have no idea.



Monday, 4 July 2022

Last Orders with Claire Fox

On the latest episode of the Last Orders podcast, we welcomed back Claire Fox (Baroness Fox). Her ladyship discussed smoking, gambling, Steve Bray and abortion. Tune in!



Saturday, 2 July 2022

15 lousy years

Yesterday was the 15th anniversary of England's smoking ban. I tweeted about it in the morning, noting that it marked the point at which everything started to go terribly wrong, and was pleased to see a good deal of agreement in the replies (alongside the usual people who don't like washing and think the world should revolve around them), so when Spiked asked me to expand on it, I wrote this...
 

We have all paid a price for this malevolent legislation, but the cost that will linger the longest is the precedent it set. The passive-smoking issue was always window-dressing. Everyone knew the real reason for the ban was that a significant number of non-smokers didn’t like the smell of tobacco smoke and the government wanted to make smokers’ lives difficult. In the final analysis, smoking in pubs was banned because people in power didn’t like it.