Poland rejects total smoking ban

I'm late with this because it hasn't previously been mentioned anywhere in the English-speaking media, but a brief lament in the British Medical Journal has alerted me to Poland's rejection of a total smoking ban.

Over to the Polksie Radio website for the details...

MPs stub out complete smoking ban

The lower house of parliament (Sejm) has voted for a much more liberal amendment to a bill banning smoking in public places in Poland, allowing areas in pubs and clubs where smokers can light up a cigarette.

The vote in the Sejm yesterday evening - carried by 217 for, 165 against and 48 abstentions - came a shock to the parliamentary health committee which had recommended a total smoking ban in public. Under the new amendment, it will be possible in small restaurants and pubs for the owner to decide whether a smoking ban would be in place. In premises over 100 square meters a separate smoking area must be provided. If the premises with an area of over 100 meters has more than one room, the owner decides which of them is a smoking area. Smoking rooms would also available in schools, universities, hospitals, and workplaces.

The rules would not prohibit the sale of e-cigarettes.

Grzegorz Dolniak, the deputy head of the Civic Platform in the Sejm said after the vote that a complete ban would be a “dead law” and probably unenforceable. “It is necessary to preserve common sense and also give a chance to non-smokers who do not want to be exposed to passive smoking.” He also said a complete ban would hurt businesses.

This is yet another example of a European country rejecting the Anglo-Saxon policy of zero tolerance. The Poles have used "common sense" to produce a "liberal amendment". They have respected property rights while accommodating both smokers and nonsmokers. It works in the Netherlands, Spain, Portugal, Austria, Bulgaria, Croatia, the Czech Republic, Belgium, Greece, Germany etc. etc. 

Apart from a handful of well-paid and highly vocal zealots, who could find such a system objectionable?

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On junk science

Two important articles have recently appeared on the subject of what we might properly describe as junk science. At the heart of the issue lies epidemiology which, whilst it has its uses, finds false positives more often than not. The problem is two-fold: there are too many epidemiologists chasing too few real associations and it is too easy to use statistics to 'prove' whatever you (or your funders) want to prove. 

I would argue that the rot set it with the passive smoking studies (particularly after 1990). Certainly, the heart attack miracles represented the moment when epidemiology jumped the shark, but the corruption and folly was evident before that and has infected countless areas of research since. Epidemiology has been hopelessly debased and it is dragging the reputation of real science down with it. 

Passive smoking is just one small part of this, but it is an important case study because it demonstrated that junk science would be tolerated if it was in the name of a 'good cause'. But by accepting nonsignificant statistical associations of 1.10-1.30 (ie. a 10-30% increase in risk), it opened a Pandora's box which could not easily be closed.

In Velvet Glove, Iron Fist, I quote John Brignell, whose book The Epidemiologists I warmly recommend. What he says about the EPA's 1992 secondhand smoke report has come to pass:

There is no doubt about it - every study of passive smoking, if evaluated on the basis of statistical probity, shows that it is harmless; but probity had been jettisoned. It was a deeply symbolic and decisive moment in time. Once you could get the world to accept a relative risk of 1.19 at a significance level of 10%, you could prove that anything caused anything. 

The scientific era that had started with Bacon four centuries earlier had come to an end and the world was ready to return to the rule of mumbo-jumbo.

The problem is exacerbated by the bastardisation of the peer-review process. All too often, peer-review is a rubber stamp from like-minded people who sometimes seem not to have even read the studies they are approving. How else can we explain basic mathematical errors appearing in studies by Konrad Jamrozik and Stanton Glantz?

Dr Richard Smith, the former editor of the British Medical Journal, discussed the peer-review process on his BMJ blog last week in the wake of more junk science being exposed and came up with a radical solution.

Prepublication peer review is faith based not evidence based, and Sudlow’s story shows how it failed badly at Science. Her anecdote joins a mountain of evidence of the failures of peer review: it is slow, expensive, largely a lottery, poor at detecting errors and fraud, anti-innovatory, biased, and prone to abuse.

So rather than bolster traditional peer review at “top journals,” we should abandon prepublication review and paying excessive attention to “top journals.” Instead, let people publish and let the world decide. This is ultimately what happens anyway in that what is published is digested with some of it absorbed into “what we know” and much of it never being cited and simply disappearing.

My answer to this objection is that this happens now. Much of what is published in journals is scientifically poor—as the Science article shows. Then, many studies are presented at scientific meetings without peer review, and scientists and their employers are increasingly likely to report their results through the mass media.

Smith's solution is controversial. I tend to prefer James Le Fanu's idea of closing down every department of epidemiology. Making a training course on epidemiology and statistics compulsory for journalists who report on science wouldn't be a bad idea either. 

Smith's idea of scrapping peer-review might back-fire. It could lead to more false positives being reported but, as he says, how much worse can things really get? It would at least stop defenders of junk science hiding under the halo of the peer-review. Science would have to stand on its merits rather than relying on the appeal to authority.

The other important article appeared in Science News, discussing why most epidemiological findings are false. 

It’s science’s dirtiest secret: The “scientific method” of testing hypotheses by statistical analysis stands on a flimsy foundation. Statistical tests are supposed to guide scientists in judging whether an experimental result reflects some real effect or is merely a random fluke, but the standard methods mix mutually inconsistent philosophies and offer no meaningful basis for making such decisions. Even when performed correctly, statistical tests are widely misunderstood and frequently misinterpreted. As a result, countless conclusions in the scientific literature are erroneous, and tests of medical dangers or treatments are often contradictory and confusing.

As I have argued before, the 95% confidence interval beloved of epidemiologists is nothing of the sort. It depends on all things being equal which they never are when human beings are involved.

Replicating a result helps establish its validity more securely, but the common tactic of combining numerous studies into one analysis, while sound in principle, is seldom conducted properly in practice.

He's talking about meta-analysis, in which a bunch of shoddy, nonsignificant statistical associations are combined to manufacture a single significant finding. That is what the EPA in the secondhand smoke report that Brignell mentions above.

“There is increasing concern,” declared epidemiologist John Ioannidis in a highly cited 2005 paper in PLoS Medicine, “that in modern research, false findings may be the majority or even the vast majority of published research claims.”

I am pleasantly surprised to hear that Ioannidis's study is "highly cited". It is, in my opinion, one of the most important articles ever written about epidemiology. I quoted it at length in the collection of extended footnotes I recently published as an addendum to Velvet Glove, Iron Fist. If you only read one article about the science of statistics, read that.

As Ioannidis writes:

A meta-analytic finding from inconclusive studies where pooling is used to “correct” the low power of single studies, is probably false if R ≤ 1:3.

That's your EPA and SCOTH meta-analyses right there (1.19 and 1.24 respectively for passive smoking/lung cancer).

Ioannidis has much to say about the effect of bias. He makes the obvious, but rarely spoken, point that bias does not need to be financial, but can just as readily be ideological.

Prejudice may not necessarily have financial roots. Scientists in a given field may be prejudiced purely because of their belief in a scientific theory or commitment to their own findings.

It is surely difficult to argue that anti-smoking campaigners turned epidemiologists do not have an inherent bias, quite apart from the financial rewards associated with coming up with the 'right' result. Indeed, all the factors Ioannidis identifies as being likely to lead to false positives apply to secondhand smoke studies.

Corollary 1: The smaller the studies conducted in a scientific field, the less likely the research findings are to be true.

Corollary 2: The smaller the effect sizes in a scientific field, the less likely the research findings are to be true.

Corollary 3: The greater the number and the lesser the selection of tested relationships in a scientific field, the less likely the research findings are to be true.

Corollary 4: The greater the flexibility in designs, definitions, outcomes, and analytical modes in a scientific field, the less likely the research findings are to be true.

Corollary 5: The greater the financial and other interests and prejudices in a scientific field, the less likely the research findings are to be true.

Corollary 6: The hotter a scientific field (with more scientific teams involved), the less likely the research findings are to be true.

And, remember, even with all these biases, most passive smoking studies have not found a statistically significant association with lung cancer.

Much of what S. Stanley Young says in this podcast for American Scientist also applies, although most of his examples are related to diet—another area where junk statistics are endemic. He concludes that 90% of epidemiological findings are false. If he's right it would turn the 95% confidence interval on its head. I don't think he's far off.

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The price of deceit

On a day when junk science was inescapable, the BBC's Radio 1 website managed to sink to new depths.

Doctors call for smoking ban in all enclosed spaces

Really? They kept that quiet. You'd think they'd have a well co-ordinated media onslaught, with press releases, fraudulent statistics, press, embargoes etc.

That, of course, is not the bit I'm talking about. This is.

Matthew quit when his four-year-old daughter got asthma.

"We were going to the hospital and we told the doctor. She said it was the particles on her clothing that was the real effect for her asthma."

This is the thirdhand smoke myth, is it not? If this anecdote is true, and it's not just some ASH stooge telling tale tales, this doctor should be struck off. There is no place in medicine for the near-medieval superstitions that this quack is peddling. Get rid of her.

"That was when we realised it wasn't helping even smoking outside."

"We thought we were doing the right thing by going outside and smoking. We didn't want to smoke in the house with the kids because of the passive smoking.

"We thought going outside was eliminating it, but it wasn't."

Dear me. A lie really can get around while the truth is still putting its shoes on. 

A few weeks ago someone found this blog under the key phrase 'can third hand smoke cause a 1 year old to wheeze?' That stuck in my mind because I pictured a mother whose baby was unwell neglecting the real reason for its illness in favour of some garbage she had read in a newspaper. 

That, to me, is the human cost of all this trash. Lies have been everywhere today and those who have told them will go home believing that it's all in a good cause. They have said, for example, that passive smoking causes 40 cot deaths a year. 

Now, I can sit here and explain that this is an estimate built on a projection built on a flawed study. I can tell you that the supposed relative risk is almost certainly due to a failure to control for socio-economic status. I could add that cot deaths are rare in countries like Russia which have high smoking rates and that there is no correlation between rates of smoking and rates of cot death. But ultimately what matters is that some parents who have been bereaved through cot death, and happened to smoke, will feel that they are to blame for their child's death. And that, I think, is unforgivable.

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Just open the window!

I was interviewed on BBC Scotland radio this morning on the subject of banning smoking in cars (listen here for 7 days, 2.17 hours in). Sleepy though I was—and coming off the back of a hilariously one-sided vox pop—I tried to make the point that the simple act of opening a window in a moving vehicle provides ample ventilation to disperse secondhand smoke.

Prof John Britton had earlier told the BBC that levels of secondhand smoke in cars are twenty times higher than in smoky bars. As a medical man, his opinion naturally trumped mine as far as the presenter was concerned. Nevertheless, it's worth finding out this '20 times higher' claim comes from.

A good place to start is a heavily referenced report from ASH (UK). It claims that:

According to a report by the Ontario Medical Association, secondhand smoke levels in cars can be 23 times greater than in a house.

ASH give a citation of this report from the Ontario Medical Association, which says:

Based on the evidence that exposure to SHS in a vehicle is 23-times more toxic than in a house due to the smaller enclosed space, the state of Colorado drafted a bill that would impose fines on adults caught smoking in cars when a child is present.

But what evidence is this? Their only reference turns out to be a news story from the Rocky Mountain News, not exactly a reliable scientific source.

ASH do, however, have another source:

A study comparing secondhand smoke particle concentrations in a vehicle with those in a bar which allowed smoking, found in-vehicle concentrations 20-times greater than inside the bar.

Again there is a citation, this time to an actual scientific journal, but the article in question does not measure secondhand smoke in cars, nor does it attempt to. It certainly doesn't give any estimate of how much more secondhand smoke is in cars than other locations, and it doesn't cite any references that might lead us to find an article that does.

And there the trail ends. Such is the game of Chinese whispers that passes for evidence-based medicine these days.

If you want to find some real science on this issue, you have to turn to an American Journal of Preventive Medicine study from 2006, which measured particulate matter (PM2.5) in vehicles.

Bearing in mind that the EPA's 'hazardous' level for 24 hour exposure is 250 ng/m3, this study found average peak concentrations of 271 ng/m3. But they did so by keeping the windows closed. When a window was opened, the level was only 51 ng/m3. This is a fraction of what would be found in a smoky bar (200-500 ng/m3) and is well within the EPA's limit (which, remember, is for 24 hour exposures, not the occasional car journey). And after smoking, levels quickly fell to the same found in a nonsmokers' car.

The study also measured carbon monoxide levels, with even less impressive results. When the window was opened, levels barely changed at all.

Another study sometimes cited carried out a similar experiment but only opened the window by 3 inches. Even with this restricted ventilation, average levels of PM2.5 were 119 ng/m3—well below the EPA's hazardous level.

All of which suggests that—if smoking in cars is a problem at all—it is one that can be simply solved by opening the window. And that, of course, is what everyone already does. 

Would I agree with a law forcing people to open the window whilst smoking? I probably would, if I thought that would be the end of the matter, but we all know that it won't be because protecting people from secondhand smoke is not the purpose of the Royal College of Physicians' latest 'demands'. By calling for a total ban on smoking in cars, even when no one else is present, they have finally given the game away. This issue isn't about science and it's not about 'protecting' nonsmokers. It never has been.

UPDATE

While I was on BBC Scotland, Tony Blows was on Radio 5, making his point rather more forcefully. He called Deborah Arnott a liar which, considering she brought up the Scottish heart scam, I suppose is fair comment. F2C have the audio. 

Incidentally, I was told that the producers wanted me to debate with a spokesman from an anti-smoking group but the spokesman refused! I bet Arnott now wishes she'd ducked out as well.

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Another peer-reviewed study dismisses the heart attack myth

Further evidence that smoking bans do not reduce heart attacks has recently appeared in the Journal of American Physicians and Surgeons. A new paper by Dr Michael Marlow points out the numerous methodological problems with the 'heart attack miracle' studies that have appeared in recent years. He also warns that using junk science to make claims that do not meet the "simplest tests of believability" may have adverse consequences.

Marlow concludes:

Publicly led research on public health effects of smoking bans has overstated benefits by overreaching on conclusions, excluding studies that contradict predetermined conclusions, and relying on studies subject to biases outlined above. This pattern is lamentable for a number of reasons. One is that efforts claiming to improve public health appear to be driven more by social agendas than by science.

Regular readers will already be aware that the largest study ever conducted found no significant reduction in heart attacks following smoking bans. And we know that heart attack miracles in England, Scotland and Wales have been disproved by routine hospital data. As I have said before, a cut in heart attacks of 10%, 20% or 30% as a result of a smoking ban is not just implausible, it is literally impossible. Even if everyone gave up smoking as a result of a ban, the heart attack rate would not drop so sharply.

It will, however, take more than mere facts to obstruct a fairy-tale that holds appeal for so many. Indeed, a new shaggy-dog story is being constructed in England as we speak.

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Targeting celebs: ASH versus Albarn

From Das Bild two months ago:

The EU has declared war against smokers! Brussels wants to eliminate cigarettes with a ‘smoking police’, ashtray bans and high-publicity legal processes against celebrities who enjoy a puff.

• Celebrities who smoke will also be targeted and exposed publicly as smoking offenders.

Which was based on this EU document...

When active enforcement begins, many jurisdictions recommend the use of high-profile prosecutions to enhance deterrence. By identifying prominent violators who have actively defied the law or who are well known in the community, by taking firm and swift action and by seeking maximum public awareness of these activities, authorities are able to demonstrate their resolve and the seriousness of the law.

Which brings us to Damon Albarn of Blur and Gorillaz...

Prosecute Damon Albarn over on stage cigarette urges anti-smoking charity

An anti-smoking charity called today for Gorillaz frontman Damon Albarn to be prosecuted for smoking a cigarette on stage on the first night of a tour.

Bass guitarist Paul Simonon, formerly of The Clash, also smoked during the show in front of an "intimate" audience of about 500 fans.

Now the anti-smoking charity Action on Smoking and Health (Ash) has called for Albarn and Simonon to be prosecuted to make an example of them.

Spokeswoman Amanda Sandford said: "There can be no excuse for that as it is an indoor place and the law is very clear."

"No-one is allowed to smoke on stage unless it's relevant to the act. They should be fined. It's not just the artist, it's the premises where the act is held. I would expect the local authority to take the appropriate action. It's not just illegal but more importantly it's about the message it sends out to fans."

"People in the public eye have a duty not to promote smoking. It's very irresponsible - I suppose they think it's rebellious and they may get some extra kudos from it and maybe some extra publicity."

Hmm. Who do you think is trying to get "extra publicity" here? Unpopular, state-funded pressure group ASH or world famous musician Damon Albarn? 

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Do smokers pay their way?

The Policy Exchange believes that even with tax on cigarettes being nearly £5 a pack, smokers are a drain on the economy. Let's see what other studies have concluded, shall we?

Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure, van Baal, 2008

Despite the higher annual costs of the obese and smoking cohorts, the healthy-living cohort incurs highest lifetime costs, due to its higher life expectancy, as shown in Table 1. Furthermore, the greatest differences in health-care costs are not caused by smoking- and obesity-related diseases, but by the other, unrelated, diseases that occur as life-years are gained (Table 1). Therefore, successful prevention of obesity and smoking would result in lower health-care costs in the short run (assuming no costs of prevention), but in the long run they would result in higher costs.

The Proposed Tobacco Settlement: Who Pays for the Health Costs of Smoking? Gravelle, 1998

A more complete accounting of the health costs of smoking not only increases the size of the costs, but also reallocates costs and implies net financial benefits for some parties. Governments save on the costs of old-age medical care, social security, and nursing home care due to the earlier death of smokers. (This result does not mean that it is desirable that people die early; it means that in determining financial cost, if that is the justification for a payment, a correct measure of the loss will only be calculated if these effects are included.) Smoking has apparently brought financial gain to both the federal and state governments, especially when tobacco taxes are taken into account. In general, smokers do not appear to currently impose net financial costs on the rest of society.

Smokers' burden on society: Myth and reality in Canada, Raynauld, 1992

Net additional external costs borne by non-smokers worked out to $244 million for Canada in 1986. However, smokers are responsible for a much larger flow in the other direction. In the pension area alone, nonsmokers benefit from a transfer of $1.4 billion mainly because smokers tend to die before non-smokers do if we use risk coefficients established by the medical profession. Finally, the massive tax burden borne by smokers alone means that they account for a further transfer of close to $3.2 billion to the benefit of non-smokers.

Social cost and the cigarette excise tax: A misguided rationale for an inefficient and unfair policy, D. Lee, 1995

The widespread belief that smokers do not pay their own way is the result of repeated assertions that are totally lacking in empirical support. There is simply no evidence that smokers impose costs on others by making more use of medical care than do nonsmokers.

Risk perception, addiction, and costs to others: An assessment of cigarette taxes and other anti-smoking policies, Menzel, 2005

The proper goal of tobacco taxation policy should be to recoup only the extra costs that smokers place on others (at most a $1/pack tax on cigarettes)

Confusing, misleading CDC figures on economic costs of smoking, Entin, 2002

On balance, most studies find that smokers cost the government less in terms of health care outlays than the sum of what they save the government in unclaimed retirement benefits and pay the government in tobacco taxes at existing tax rates.

The Taxes of Sin: Do Smokers and Drinkers pay their way?, Manning, 1989

Although nonsmokers subsidize smokers' medical care and group life insurance, smokers subsidize nonsmokers' pensions and nursing home payments. On balance, smokers probably pay their way at the current level of excise taxes on cigarettes; but one may, nonetheless, wish to raise those taxes to reduce the number of adolescent smokers. In contrast, drinkers do not pay their way: current excise taxes on alcohol cover only about half the costs imposed on others.

Does smoking increase medical care expenditure? Leu, 1982

The results imply that lifetime expenditure is higher for nonsmokers than for smokers because smokers' higher annual utilization rates are overcompensated for by nonsmokers' higher life expectancy. Population simulation, taking into account the effects of past smoking on present population size and composition, suggests that 1976 expenditure would have been the same if no male born since 1876 had ever smoked. The male population would have been larger, particularly at older ages, increasing medical care expenditure, but this increase would have been offset by lower annual medical care utilization rates. Thus the results imply that smoking does not increase medical care expenditure and, therefore, reducing smoking is unlikely to decrease it.

Bear in mind that since many of these studies were conducted, tobacco taxes have risen substantially and, therefore, the government's net profit from smokers has increased further.

The Policy Exchange also reckons that smokers are absent from work more often than nonsmokers, but that's not what this study found...

Do smoking, body mass and exercise affect sickness absence and job satisfaction?, Critchley (2006)

There was no difference in sickness absence between smokers and non smokers, however there was an increase in sickness absence with increasing Body Mass Index (BMI) (correlation coefficient 10.9 %-p=0.005) and perhaps surprisingly there was an increase in sickness absence with increasing exercise participation (correlation coefficient 7.7% p=0.045).

So what do we do? Tax people who take exercise?

Thanks to Klaus K.

UPDATE!

A couple more...

The Health Care Costs of Smoking, Barendregt 1997

Results: Health care costs for smokers at a given age are as much as 40 percent higher than those for nonsmokers, but in a population in which no one smoked the costs would be 7 percent higher among men and 4 percent higher among women than the costs in the current mixed population of smokers and nonsmokers. 

Conclusions: If people stopped smoking, there would be a savings in health care costs, but only in the short term. Eventually, smoking cessation would lead to increased health care costs.

Does Preventing Obesity Lead to Reduced Health-Care Costs?, McPherson, 2008

The study found that although annual health-care costs are highest for obese people earlier in life (until age 56 years), and are highest for smokers at older ages, the ultimate lifetime costs are highest for the healthy (nonsmoking, nonobese) people.

Thanks to Dave A for spotting these.

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