Failure, failure, failure

A study published this week in Addiction reveals that the Italian smoking ban had no lasting effect on smoking prevalence and quit rates. The researchers found that there was a brief decline in the number of smokers when the ban came in, but that the smoking rate returned to pre-ban levels shortly afterwards.

Findings: Among males, smoking prevalence decreased by 2.6% (p = 0.002) and smoking cessation increased by 3.3% (p = 0.006) shortly after the ban, but both measures tended to return to pre-ban values in the following years. This occurred among both high and low-educated males. Among low-educated females, the ban was followed by a 1.6% decrease (p = 0.120) in smoking prevalence and a 4.5% increase in quit ratios (p < 0.001). However, these favourable trends reversed over the following years. Among high-educated females, trends in smoking prevalence and cessation were not altered by the ban. Among both males and females, long–term trends in the daily number of cigarettes, which were already declining well before the implementation of the policy, changed to a minor extent.

Conclusion: The impact of the Italian smoke-free policy on smoking and inequalities in smoking was short-term. Smoke-free policies may not achieve the secondary effect of reducing smoking prevalence in the long-term, and they may have limited effects on inequalities in smoking.

This study closely echoes the findings of a paper published last year in PLoS (mentioned on this blog in November) which reported a large increase in the use of nicotine replacement 'therapy' when the smoking ban was introduced in Scotland, but no long-term change in the nation's smoking prevalence. It also echoes another study published this month which found no change in the number of nurses smoking in France after smoking was banned in the workplace.

All of this runs counter to the widely held belief that smoking bans encourage smokers to quit. By contrast, new evidence continues to appear showing the efficacy of snus as a smoking cessation aid.

Among male quitters under the age of 45 years, 45.8 % of those who had used snus on their last attempt to quit were current non-smokers (OR = 1.61, CI 1.04-2.29), while 26,3 % of those who had used NRT were current non-smokers.

59.6 % of successful quitters and 19.5 % of unsuccessful quitters who had used snus as a method for quitting smoking had continued to use snus on a daily basis after quitting.

Conclusion: Norwegian men frequently use snus as a method for quitting smoking whereas women are more likely to use NRT. The findings indicate that switching to snus can be an effective method for quitting smoking.

You may also recall the study from 2010 which revealed that graphic warnings on cigarette packs had no effect on the quit rate (or initiation rate)—again, in contrast to the excitable claims made by 'tobacco control professionals'.

There were few changes post implementation of the picture health warnings in the number of health effects recalled or participant’s perception of risk... There were no differences post implementation of the picture health warnings in the number of smokers reporting forgoing a cigarette when about to smoke one or stubbing out a cigarette because they thought about the health risks of smoking... Among young people, the impact of picture health warnings was negligible.

The evidence is mounting that the neo-prohibitionist approach of incremental bans is a busted flush, whereas the harm reductionist approach is not only more civilised, but is more effective in helping people who want to quit do so, rather than hassling and belittling people who don't. As I've said before, tobacco control is not a results-driven business. No one gets sacked for making the wrong call, they just move onto the next policy and hope nobody notices.

The priority for the neo-prohibitionists this year is plain packaging and the usual tired claims are being wheeled out about "overwhelming evidence"which exists only in their imagination. Will the politicians fall for it one more time or will they demand—at long last—that tobacco control be judged by past performance?

UPDATE: In the comments, "Big" Dick Puddlecote brings my attention to yet another example of failure.

Smoking levels among adults in Northern Ireland have not reduced in the last five years, the health minister has said...

The Executive has introduced smoke-free legislation in public areas such as the workplace, bars and restaurants. It has increased age requirements and developed smoking cessation services. There are also measures to scrap vending machines and remove displays of cigarettes in shops...

Smoking prevalence among adults has remained around 24% since 2007 and for manual workers that rate is 31%.

Winning!

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Mission creep

I wrote an article for the Yorkshire Post last week about plain packaging and the phenomenon of mission creep.

The tendency of pressure groups to move towards increasingly extreme positions is a familiar political phenomenon.

When the successful activist can only recapture the intoxicating feeling of victory by finding new causes to champion, the result is “mission creep”.

Take the Smokefree Action Coalition, for example. Originally formed to campaign for the smoking ban, they have since lobbied for graphic warnings on cigarette packs, higher tobacco taxes, a retail display ban and a ban on vending machines. It is a tribute to their campaigning prowess that politicians have capitulated to all these demands, but this string of easy victories has left them scraping the policy barrel.

The link is here if you want to read it all.

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Backing the USSR

Chris Oakley has written a very interesting article at Liberal Vision about politically motivated doctors' groups attempting to emulate Soviet temperance campaigns.

In an academically inept, blatantly political piece published in The Lancet, a group of liver doctors who in their conceit, believe themselves experts on the causes of alcohol abuse rather than its consequences, propose Gorbachev’s 1985 crackdown on alcohol in the Soviet Union as a template for alcohol control in the UK.

Go have a read. Fascinating history and a sound analysis.

On a barely related note, you can listen to me arguing with a plain pack proponent on BBC Radio Humberside earlier today (23 minutes in). Barely related because I mention the USSR right at the end. Hear here.

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Humorous magazine celebrates 20th anniversary

The Tobacco Control journal—soft, strong and thoroughly absorbent—is celebrating its 20th anniversary, although Anna Gilmore has been working on a computer model which claims it's actually been around for 1,000 years once you make adjustments. To commemorate this occasion, the organ has produced a free issue with a whole section on 'Endgame Visions'. 'Endgame' is the codeword for prohibition and will be featuring in the forthcoming 15th World Conference on Tobacco or [sic] Health. Book early to ensure disappointment, for it has such sessions as:

09:00 – 10:30 - Endgame ideas: Dangerously radical, visionary leadership or both?

15:45 – 17:45 - Planning for a tobacco endgame

Whilst e-cigarettes spread around the world entirely by word of mouth and Sweden enjoys its snus-driven record low lung cancer rate, our prohibitionist friends will be sleepily contemplating such questions as...

11:00 – 12:20 - Harm reduction: Are there "safer products"?

I'm guessing their answer will be: "Yes, but only the stuff made by Pfizer and Johnston & Johnston."

Back at Tobacco Control, we have the same over-optimistic 'endgame' rhetoric, with articles entitled 'What are the elements of the tobacco endgame?' and 'How smoking became history: looking back to 2012'. Would it be impolite to mention that there are more people smoking today than ever before, or that there will be more people smoking tomorrow than today?

It just seems kind of weird to be talking about eliminating smoking when global consumption hits a new peak every day. And even if it wasn't, it's very brave of Stanton Glantz—a man renowned for being economical with the truth—to pen an article entitled 'Pinocchio shows how to end the tobacco epidemic' (I kid you not.)

This rich seam can wait till another day to be mined. For now, let's raise a glass and celebrate what Tobacco Control has been doing better than any other journal for two decades: publishing unspoofable, illiterate, policy-driven garbage under the mantle of science. You may have seen headlines like this yesterday:

Scientists call for smoke-free areas outside pubs

Scientists, cool! I wonder if they are this sort of scientist?

Or this sort of scientist?

Let's examine the credentials of our lead researcher:

Janet Hoek joined University of Otago Marketing Department in 2009; she was formerly a Professor of Marketing at Massey University. Her first degrees were in English Literature, with minors in Botany and Zoology, and her Masterate examined irony in Beowulf, a very early medieval poem. The weak employment market for medievalists prompted her move from the Dark Ages to the Dark Side, and she subsequently completed a post-graduate diploma in marketing and a PhD.

This lady sounds, if anything, rather overqualified for Tobacco Control and, unusually for that journal, her study didn't involve typing in key phrases into Google. Instead, she interviewed real people. And not just people—actual smokers! Well, not actual smokers (you can't risk the thirdhand smoke), but social smokers.

Any fool can survey a dozen people to get the answer they want, but Professor Hoek didn't do that. She surveyed thirteen people to got the answer she wanted. Now, there are some people—cynics, sceptics, party-poopers and so on—who would say that if your sample group is in danger of being outnumbered by your research team, then perhaps you should have broadened the survey. Janet didn't feel the need to do that. She and her colleagues conducted "13 in-depth interviews with young adult social smokers aged between 19 and 25 years and used thematic analysis to interpret the transcripts."

The nay-sayers might tell you that the bit about "thematic analysis" is just a bit of guff to quell suspicions that this was a chat with a handful of impressionable young people who had been given $25 (New Zealand dollars) to talk to some anti-smoking folk. Nothing could be further from the truth. This is science. The woman has been trained in marketing, for flip's sake. She would never tried to manipulate anyone.

The subjects were all nonsmokers who had the occasional tab when they were on a night out. We all know people like this. They are the scourge of our city centres on a Friday and Saturday night. They are the people who have successfully given up buying cigarettes. As one respondent said:

“so yeah, that’s part of my rationalizing, if I’m not buying them, I’m not a smoker. If I’m only getting them off people, then it’s not an issue. Because I’m not wasting my money.”

Temperance campaigners will be pleased to hear that alcohol gets a fair bit of the blame, as this fantastically eloquent participant explains:

“Um, you’re more relaxed so you don’t really mind smoking. I dunno, somehow it makes it ... how do you say that, makes it easier to smoke somehow, I’m not sure how, yeah.”

Another scrounging wretch is quoted as saying:

“well everyone else will be out smoking. You don’t want to sit inside on your own and just drink so you’re like ok, I’ll jump up and have a ciggie with you.”

This phenomenon mentioned in that last comment is, of course, an unintended consequence of smoking bans, which helps explain why smoking bans do bugger all to reduce the smoking rate (as Spain has just found). In so far as we should change policy to accommodate these whiny misfits, it should be to relax smoking bans (as Hawaii has just done). This being Tobacco Control, however, that option is not just off the table, but has been knocked off the table, set on fire, stamped on and swept under the carpet. Instead...

Because alcohol plays such a pivotal role in facilitating social smoking, extending smoke-free areas to the outside of bars would decouple drinking from smoking in this environment... Introducing smoke-free outdoor bars could reduce social smoking by removing cues that stimulate this behaviour and changing the environment that facilitates it. Such a policy would eliminate the current intersection between smoke-free and smoking spaces and create a physical barrier that, for some, would make accessing the smoking zone too difficult.

Funnily enough, banning smoking outdoors just happens to be the 'next logical step' for the readers of Tobacco Control! What extraordinary serendipity that this piece of 'science' appears in 2012 just when it was needed for worldwide press release, despite being a dog's breakfast of half-witted statements of the obvious from New Zealand youth.

A moment's thought tells you that if smoking is banned outside pubs then the dwindling number of smokers who still go to pubs will stop altogether, and where will that leave their social smoking friends? Back home with the smokers drinking cheap beer and smoking endless cigarettes, that's where.

But that's just common sense and real-life understanding and, as such, has no place in the world's leading anti-tobacco comic. So, with its survey of thirteen inarticulate morons to guide policy, let's hear it for Tobacco Control as it moves into its third decade of lowering the intellectual standards of the Western world. Cheers!

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Argumental

I've done a number of interviews today re: the Adam Smith Institute plain packaging report. Here's two of them...

Firstly, versus Deborah Arnott of ASH on the Today programme.

Secondly, versus a woman from CRUK on Victoria Derbyshire's Five Live show (from 1 hour 10 minutes in).

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Plain Packaging: Commercial expression, anti-smoking extremism and the risks of hyper-regulation

Today promises to be a bumper 24 hours of annoying prohibitionists, for it is the day the Adam Smith Institute publishes a paper I wrote about the ridiculous plain packaging proposals. I'll post the link to the report later [UPDATE: It is here.] but, for now, here is the Adam Smith Institute's press release.

Government’s plain packaging proposals for cigarettes will bring no benefits to public

• There is no evidence that the proposals will reduce consumption or give any public health benefit.
• Plain packaging may lead to an increase in the counterfeit cigarette trade, making cheap tobacco more easily available to young would-be smokers.
• The policy creates a dangerous precedent – plain packaging could be extended to other products such as alcohol and fatty foods.

Ahead of a public consultation on the plain-packaging of cigarettes, the Adam Smith Institute have released a report today (Monday) arguing that the proposals will do nothing for public health and are profoundly illiberal. There is no evidence that plain packaging will have any effect on existing smokers or the smoking rate. The policy represents a desperate attempt by the public health lobby and government officials to be seen as ‘clamping down’ on tobacco in an increasingly maniacal war on smoking.

No Health Benefits

The plain packaging rule is aimed at stopping non-smokers from making a decision to engage in a habit. However, there is no evidence that the colour and logos on a pack of cigarettes is an influencing factor on people choosing to start smoking. Indeed, in the case of increasing the graphic warnings on packs, a comprehensive Canadian study found that “the warnings have not made a discernable impact on smoking prevalence”. Previous studies show that packaging design does little to impact the smoking rate.

Smoking numbers have not changed since 2007 with the rise of the ‘denormalisation’ of tobacco and aggressive anti-smoker policies. Aggressive anti-smoking policies don’t appear to work. Furthermore, plain packaging has been recognised as the weakest and least popular of ASH’s (Action on Health and Smoking) 12 anti-smoking policies proposed in 2008.

The Slippery Slope

Apart from the lack of health benefits there is also the risk that such a policy would be introduced for alcohol, fatty foods or sugary drinks. What happens today in tobacco tends to happen to other unhealthy products tomorrow. In fact, this slippery slope trend has already started in Australia, where they are currently planning to introduce plain packaging. As soon as the Australian government had approved the policy they swiftly moved on to look at how this could be applied to alcohol. Once plain packaging is enshrined in law for tobacco it will be easily extended to other lifestyle choices. That’s why the Adam Smith Institute argues the nanny state juggernaut must be stopped in its tracks.

Counterfeiting and intellectual property

In order to introduce plain packaging the government would need to breach international trade rules and confiscate tobacco companies’ intellectual property, without any proof that this would yield public health benefits. Furthermore, there is reason to believe the policy will have a negative effect both on public health and the tobacco industry.

Already 1 in 9 cigarettes around the world is counterfeit, with counterfeit cigarettes often having two to three times the level of heavy metals found in legitimate brands. Plain packaging will mean the standardising of cigarette packaging, which will help illicit trade. The policy is likely to boost the black market in the UK, offering cheaper cigarettes more likely to lure young and new customers. Any illicit trade can only hinder efforts to reduce smoking, so plain packaging proposals may in reality be damaging for public health.

Plain packaging, if introduced, would be a triumph of a dogmatic minority over the public. It would be an indiscriminate, illiberal law with no basis in evidence, reason or commonsense, whilst masquerading as a public health initiative. Author of the report Plain Packaging: Commercial expression, anti-smoking extremism and the risks of hyper-regulation, Christopher Snowdon, adds:

“It is extraordinary that a government which claims to be against excessive regulation should be contemplating a law which even the provisional wing of the anti-smoking lobby considered unthinkable until very recently. It seems that fanaticism has become institutionalised and a handful of extremists have become the de facto policy makers in matters related to tobacco. The public are gradually waking up to the fact that these neo-prohibitionists will never be satisfied. There is always another cause to campaign for, always new demands to be met. If it is not smoking, it is drinking. If it is not drinking, it is eating.

Plain packaging is the most absurd, patronising and counterproductive policy yet advanced under the disingenuous pretext of ‘public health’. It will serve only to inconvenience retailers, stigmatise consumers and delight counterfeiters. Those who would dictate what we eat and drink are already incorporating plain packaging into their plans. It’s time to say ‘Enough.’ The monomaniacs have had their own way for too long.”

ASH got hold of the report early doors and came up with their own press release on Friday...

Tobacco industry “invisible hand” behind Adam Smith Institute ‘plain packs’ report

A report by the Adam Smith Institute published today in advance of a public consultation on tobacco packaging advances the views of the tobacco industry, namely that putting cigarettes in plain standardised packaging would have no public health benefit, would increase the illicit trade in tobacco and would set a “dangerous precedent” for other products.

All of these arguments misrepresent the truth and ignore the fact that glitzy packs are designed to attract new young smokers to replace the100,000 in the UK who are killed each year by their habit.

Firstly, there is now a large body of evidence to show that plain packaging will be effective. Experimental studies and surveys from around the world show that plain packs are less appealing, strengthen the impact of the health warnings, and make the packs less misleading.

Secondly, there is no evidence that plain packaging will lead to an increase in tobacco smuggling. Existing packs are already easily counterfeited. Plain packs will still have to have covert markings, tax stamps and health warnings that are required on current packs so they will be no easier to counterfeit. And the argument that it will “breach international trade rules and confiscate tobacco companies’ intellectual property” is also fallacious, according to the tobacco industry’s own legal advice, revealed in litigation.

Thirdly, the “domino theory” i.e. that once a measure has been applied to tobacco it will be applied to other products is patently false. The same argument was used against the ban on tobacco advertising, but 9 years after the tobacco ban in the UK, alcohol advertising is still permitted with no sign of it being prohibited. Tobacco is a uniquely dangerous consumer product which is why there is a WHO health treaty (the Framework Convention on Tobacco Control) to regulate tobacco use.

Deborah Arnott, Chief Executive of ASH commented:

“Why would the tobacco industry and its allies be so vehemently opposed to plain packaging if they weren’t so frightened that plain packaging would work? [Er, if you read the report, you'll find out—CJS] The Adam Smith Institute, by publishing this report, is acting as the mouthpiece for the tobacco industry, as it has done on many previous occasions. It should come as no great surprise that the Institute takes a pro-tobacco line but it should be more transparent about its association with Big Tobacco.”

The Adam Smith Institute has in turn responded to the 'Big Tobacco' allegation...

We commissioned this report ourselves because it reflects our free market, libertarian ideology. Indeed, the Adam Smith Institute does not do commissioned research.

However, there are a couple of tobacco companies that have corporate subscriptions at the Institute. The revenue from this – while welcome – is not terribly significant. It amounted to less than 3 percent of our 2011 income. Moreover, neither of these companies has played any role whatsoever in the production or editing of this report. We take our independence very seriously.

The British Medical Journal asked for a response from me so I sent them this. As they probably won't publish it, I'll post it here:

I'm pleased that Action on Smoking and Health (ASH) are familiar with Adam Smith's "invisible hand" concept despite their obvious contempt for free markets and free societies. As usual, they offer not a shred of evidence that plain packaging will deter people from smoking. Their claim that counterfeiters' lives will not be made easier by making cigarette packs look virtually identical is as credible as their belief that plain packaging will not inconvenience retailers.

ASH say that it is "patently false" to think that "once a measure has been applied to tobacco it will be applied to other products". Have they been living in a cave for the past five years? The British Medical Association is currently demanding that graphic warnings be placed on wine bottles. Where does ASH suppose they got that idea from? The BMA also wants - in their own words - "a complete ban on [alcohol] advertising as has been done very successfully with tobacco." Activists in Australia are already calling for junk food to be sold in plain packaging. Rather than denying these facts, ASH should be proud that they are blazing a trail for busybodies, cranks and authoritarians of all varieties.

Fun and games...

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A prohibitionist writes

Are you ready? Then we'll begin.

Abolish the Food Industry

Bang! That's the headline of this piece from The Atlantic. It sprang from the biro of Raj Patel. Dick Puddlecote's readers may recall the name. He thinks that each hamburgers "costs" society $200 in terms of environmental destruction and obesity. That is nonsense but, as we shall see, nonsense is Mr Patel's middle name.

He begins his article with a line of which the Daily Mash would be proud...

In the fall of 2008, San Francisco polished its progressive credentials by banning something.

Isn't that beautiful? I wish I'd thought of that. The essence of both "progressives" and the city of San Francisco encapsulated in one simple sentence.

He is referring to a ban on pharmacies selling cigarettes. This leads him to discuss tobacco advertising...

Joe Camel isn't familiar to children today, as he was in the 1970s

The first Joe Camel advertisement appeared in 1988, but never mind.

He then moves seamlessly onto alcohol...

Alcohol is similarly circumscribed, again with an eye to public health and, again, with a particular concern for young people.

And then comes the kicker...

But if public health is a legitimate reason to curb corporations' advertising to kids, why limit bans to cigarettes and booze, and not include, say, unhealthy food?

A very familiar argument, of course—the proverbial slippery slope. Last week we saw a textbook case of how one ban on "corporations' advertising to kids" snowballs; see JuliaM's post at Orphans of Liberty. Patel's article is one long attempt to blur the distinction between products while rehabilitating the reputation of prohibition. After giving a shout out to last month's risible 'toxic sugar' article, he brings his argument to its logical conclusion.

Why allow an industry that profits from the sale of unhealthy food at all?

Boom! He gets from a ban on cigarettes in pharmacies to the abolition of the food industry in three easy steps. This is world-class stuff.

The history of banning things is admittedly inglorious. 

No fooling.

The war on drugs, Prohibition, and censorship have few fans.

More than you might think, Raj. Take Robert Proctor, for example, who has recently published a weighty tome about smoking in which he calls for tobacco prohibition. Patel very much admires Proctor, of course, but dare not mention the P word. Instead, he talks about 'abolition'.

[Proctor] doesn't want to ban smoking. The language of abolition -- not prohibition -- is well chosen. Proctor doesn't yearn for the criminalization of smokers, nor does he foresee the end of cigarettes or tobacco.

See, he's not one of those nasty prohibitionists. The very idea!

He's simply arguing that the industry that profits from it oughtn't to exist in a society that has a minimum concern with public health. If you want to smoke, you're free to grow and cure your own tobacco, he suggests.

Gee, thanks. Nice of you to compromise on that, Proctor.

Look, here's the thing. People were free to make their own alcohol during Prohibition. Drinking was never illegal. Prohibition "only" outlawed was the sale, import and manufacture of alcohol. Just like Proctor, the prohibitionists blamed an industry for a habit which they detested. They thought that if they put the industry out of business, drinking would virtually disappear. They couldn't imagine that people drank because they liked it, just as today's tobacco prohibitionists cannot imagine that people smoke because they like it.

There is no difference whatsoever between Proctor's position and the position of the Anti-Saloon League. Indeed, the Anti-Saloon League was more moderate in that they allowed alcohol to be sold under certain conditions (religious ceremonies, medical use etc.). Proctor is, in the most literal sense, a prohibitionist.

And so is Patel...

...our food choices are far from free, in no small part because of the commercial and cultural power of the food industry. Weaned as most of us are on Big Food's free speech, we ought to be suspicious of our instincts when it comes to food.

What fresh sophistry is this? Free speech makes us less free? This is the rhetoric of every totalitarian—that "true" freedom comes from restricting freedom. That speech should be free unless the government doesn't like what is being said.

The food industry is an oligopoly that has transformed not only what we eat but how we eat it, and what we think of food.

The food industry is not an oligopoly. Their are millions of farms, millions of individual retailers and millions of independently owned restaurants. The very fact that food is so cheap is a reflection of the competitive market. If you don't like McDonald's and Tesco, you can go to a fruit and veg stall or your local restaurant. The barriers to entry are low.

Extending Proctor's argument to those very corporate powers invites us to imagine what a world without Big Food might look like -- and dream ourselves freer still.

Extending Proctor's arguments would mean abolishing the food industry while leaving us "free" to grow our own food, just as we will be "free" to grow our own tobacco. This is the kind of half-witted back-to-the-land garbage we hear from the New Economics Foundation and other upper-middle class misanthropists. Half the world would be "free" to live like medieval serfs and the other half would be free to starve. Get thee behind me, Patel.

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