Monday, 20 October 2014

Heart miracles: Is the truth emerging?

If there is one pseudo-scientific claim that illustrates the credulity of the media and the duplicity of the public health movement better than any other, it is the idea that smoking bans lead to dramatic reductions in heart attack incidence.

It is now ten years since the British Medical Journal published Stanton Glantz's notorious 'Helena Miracle' study which claimed that the heart attack rate fell by 40 per cent after a small town in Montana banned smoking in pubs and restaurants. Numerous copycat studies followed, typically involving thinly populated towns and regions which, because of the small number of heart attacks that take place each month, are given to large fluctuations in hospital admissions.

From the outset, the most plausible explanation for the heart miracle phenomenon was that activist-researchers were scouring hospital records for unusual declines in heart attack admissions that roughly coincided with 'smokefree' laws. With so many smoking bans being enacted, it was inevitable that they would coincide with a blip in admissions now and again.

But when whole nations bring in smoking bans, the rate of decline has typically been zero or in the low single digits, ie. in line with the long term trend. (The most notable exception was a study of Scotland which claimed a 17% decline—a finding that is totally inconsistent with official NHS data.)

Having written about this for the five years, I was pleased to see some sanity rear its head in the American Journal of Medicine in January. A study by Basel et al.—which I have only just become aware of it thanks to Klaus in Denmark—looks at rates of acute myocardial infarction (heart attacks) in Colorado after a statewide smoking ban went into effect in 2006. This is of particular interest since two widely touted heart miracle studies have involved small pockets of Colorado. A 2006 study of Pueblo, Colorado claimed that there was a 27% decline in heart attacks when it went 'smokefree' in 2003 and a 2006 study of Greeley, a small town in Colorado, also claimed a 27% decline.

The researchers looked at the data for the whole of Colorado before and after its strict statewide smoking ban came into force. They looked first at total admissions for acute myocardial infarction and then they excluded the eleven towns and counties that already had smoking bans in place. In both instances, they found no effect from the ban.

We did not observe a significant decrease in acute myocardial infarction hospitalization rates in Colorado after enactment of a comprehensive statewide smoking ordinance. Even after removal of geographic regions where preexisting smoking ordinances were under enforcement, no statistically significant reduction in acute myocardial infarction hospitalizations was detectable. This contrasts with a number of prior studies, including local smoking ordinance studies in Pueblo and Greeley, Colorado, and adds to a growing literature that the cardioprotective effect of smoking bans may be less than initially suggested.

This finding is important and telling, but the study is also worth reading for its discussion of the existing literature. It is clear that heart miracles are confined to small, obscure towns in a way that can only be described as suspicious. (I have inserted hyperlinks to each study mentioned below.)

Overall, a review of published research shows that acute myocardial infarction RR reduction appears inversely related to sample size. For example, small studies in Bowling Green, Ohio, and Helena, Montana, found dramatic RR reductions (39% and 40%, respectively) but also had few acute myocardial infarction counts (58 acute myocardial infarctions in Bowling Green, 64 acute myocardial infarctions in Helena) and relatively small study populations (30,052 and 68,140, respectively). Studies in Greeley and Pueblo, Colorado, and Graubünden, Switzerland, found less dramatic RR reductions (27%, 27%, and 22%, respectively), corresponding to somewhat larger study populations (∼86,000, 147,751, and 188,000, respectively).

As the authors note, these large declines in small communities (which are not just implausible, but mathematically impossible), contrast sharply with evidence from large communities and whole nations. national study used Medicare Provider Analysis and Review files and national death records; a nonsignificant reduction in acute myocardial infarction-related (RR, −4.1; 95% CI, −9.4 to 1.3) and all-cause (RR, −0.7, 95% CI, −2 to 0.6) mortality was observed 1 year after smoking ordinance enactment. In this study, researchers evaluated all possible pairs of ordinance and nonordinance hospitals and recorded the change in acute myocardial infarction incidence post-ordinance. They found that RR reductions of 10% or greater were common, but that RR increases of 10% or greater were equally as common; taken in aggregate, the mean was near zero.

Another study examined 74 cities geographically distributed across the United States that were affected by smoke-free legislation. Individual cities showed wide variation in acute myocardial infarction incidence after ordinance enactment, with risk ratios ranging from −36% to +54%; however, the mean risk ratio for the 74 cities was 0.97 (95% CI, 0.96-1.02).

... A study performed in Christchurch, New Zealand after a countrywide smoke-free ordinance, found a 0% RR reduction in acute myocardial infarction with an approximate population size of 350,000. Countrywide studies with larger population bases provide concordant findings. In England, a 2.4% RR reduction was observed (population of 50 million). In Italy, a 4% RR reduction was observed (population of 58 million). In France, a 0% RR reduction was observed (population of 63 million). Finally, in a study examining the US Medicare population in states with a smoke-free ordinance versus those without, a 0% RR reduction was demonstrated (population of 30 million).

In the case of the English study, the heart attack rate fell at exactly the same rate after the smoking ban as it had been doing before the smoking ban. After dressing this up with some superficial computer modelling, Anna Gilmore—for it was her—relied on nothing more than a post hoc ergo propter hoc assumption. A similar claim, though never published, was made about Wales.

The authors attribute much of the heart miracle phenomenon to publication bias. That is likely to be a part of it, although I think that researcher bias and selection bias played more of a part.

These analyses support the hypothesis that small study populations may be more likely to find dramatic changes in acute myocardial infarction incidence, whereas increasing the study sample size attenuates the magnitude of the reduction. Also, review of the studies in aggregate reveals data asymmetry that suggests the potential for publication bias or heterogeneity not entirely explained by a random-effects meta-analysis. The presence of publication bias may explain why small sample size studies have tended to report large decreases in acute myocardial infarction incidence, whereas relatively few small sample studies have shown no effect.

The whole heart miracle scam has, in my view, been built on two simple tricks:

Firstly, dredging the data for any town that saw a large decline (in percentage terms) in heart attacks at around the time of a smoking ban. Nobody decided to do a study of Helena, Montana or Bowling Green, Ohio before the bans took place. The decision to focus on such obscure places came about only once it was clear that they were anomalous (not unlike Derren Brown's horse-racing trick). They were then presented to the media with the implication that they had been randomly selected.

Secondly, although less frequent, studies of larger populations have portrayed rather small declines in the heart attack rate as being the result of a smoking ban, without acknowledging that that there had been a secular decline of the same magnitude long before the ban was enacted. As the authors of the above study note, the secular decline is simply ignored in such cases.

That's really all there is to it. The 'public health' lobby has been selling this lemon to the public for ten years while describing sceptics, such as Michael Blastland (the creator of BBC's excellent More or Less series), as 'denialists' and 'dissidents'. The American Journal of Medicine study won't be enough to set the record straight in the public's mind—it received no media coverage, naturally—but it is further ammunition for those who do not believe in the 'noble lie'.

Henry Hill on public health

This, from Henry Hill at Conservative Home, is well worth reading...

The most important thing to bear in mind is that public health has no regard for individual choice. As a movement which measures its success largely in averaged outcomes and national statistics, its focus is not on minimising harm to third parties or helping individuals to make informed choices – although it will employ those arguments – but on controlling people to force its desired outcomes.

Boris’ quaint notion that there is no justification in preventing him lying on the grass with a cigar because he was harming nobody but himself will cut no ice with the public health movement. It’s bad for his health, so it should be stopped. Many, probably most, public health activists make no secret of their intention to prohibit tobacco.

But their ambitions are not limited to tobacco. Some months ago there was an outbreak of press hysterics about sugar, the ‘new nicotine’. This should have surprised nobody. There was always going to be a ‘new nicotine’, just as when sugar taxes have tripled the price of a Yorkie bar and we’re drinking cola from olive-green ‘plain cans’ with pictures of clogged arteries on them there would be a ‘new sugar’.

For years it has suited both sides of the public health debate to pick on cigarettes. Lovers of booze, food, or idleness could pretend that there was some particular wickedness in tobacco that warranted making a special case of it, whilst public health activists could establish useful precedents to wield against fresh targets when the time came.

Come that time has.

Do read the rest.

Friday, 17 October 2014

Were there really 9.6 million alcohol-related hospital admissions last year?

Mark Wadsworth has spotted that the number of alcohol-related hospital admissions have risen rather sharply in the last couple of years. In fact 'risen sharply' is an understatement. 'Rocketed into the stratosphere' might be a better way of putting it.

BBC, 26 May 2011: The number of alcohol-related hospital admissions in England has topped 1m for the first time, according to official statistics.

From The Daily Mirror, yesterday:

Heavy boozers are putting the NHS under “intolerable strain” and risk sparking a health crisis which will cost the country billions, a charity claimed yesterday. Alcohol Concern said 9.9 million NHS admissions in England – including hospital patients and clinic and A&E visits – were related to alcohol last year...

The Office for National Statistics is the usual port of call when looking up alcohol-related hospital data. Their latest figures for England tell us the following:

In 2012/13, there were an estimated 1,008,850 admissions related to alcohol consumption where an alcohol-related disease, injury or condition was the primary reason for hospital admission or a secondary diagnosis. Of the estimated 1,008,850 alcohol related admissions:

65% (651,010) were due to conditions which were categorised as partly attributable chronic conditions

6% (60,830) were for conditions categorised as partly attributable acute conditions

The figure of 1,008,850 admissions is considerably higher than it was a decade ago for various reasons, but it is lower than it was in 2011/12, 2010/11 and 2009/10.

Similar data from Scotland show that there were 35,926 alcohol-related discharges in 2012/13. Feel free to look up the figures for Wales and Northern Ireland, but it's quite obvious that the total number for the UK is nowhere near 9 or 10 million. It is an order of magnitude lower at just over one million. To put that in context, England's NHS deals with 125 million hospital admissions every year and alcohol-related admissions make up 1.4 per cent of the total.

There are various ways of inflating the number of alcohol-related admissions, such as widening the range of 'alcohol-related' illnesses and including admissions which are only partially related to alcohol. However, these techniques have all been exhausted and the ONS figures includes the widest range of admissions that can conceivably be described as alcohol-related.

The majority of admissions are not wholly, or even necessarily mainly, attributed to alcohol use. Most relate to chronic diseases such as hypertension and breast cancer. These figures are not calculated by doctors and nurses making assessments of patients. Instead, the system of alcohol-attributable fractions is used. This assumes that a certain percentage of admissions for each disease were caused by drinking. Chronic illnesses (which typically require many visits to hospital to treat) make up the majority:

Of the 1,008,850 admissions in 2012/13,

- around 711,840 admissions were for reasons that are partly attributable to alcohol consumption (i.e. the attributable fraction associated with the diagnosis (either primary or secondary) most strongly associated with alcohol consumption was less than 1)

- over half (57%) of these partly attributable admissions were for hypertensive diseases (ICD-10 codes I10 – I15), accounting for approximately 404,650 admissions. Admissions with other partly attributable diseases, injuries or conditions were much lower in comparison

- second highest condition in this category was cancer (ICD-10 codes C00 – C15, C18 – C22, C32 and C50 ) with 83,510 admissions (Table 4.1).

It is worth noting the various conditions that people are admitted for and the way they are categorised because the unwary newspaper reader might assume that all, or most, of the alcohol-related admissions are injuries, accidents and overdoses that take place on a Friday or Saturday night in 'Binge Britain'. That's hardly surprising when even the Morning Advertiser uses photos like this to illustrate the story.

But where does the 9.6 million (some papers reported 9.9 million) figure come from? The source is the temperance group Alcohol Concern who have been working their buddies in the pharmaceutical industry to produce a nifty website which supposedly allows users to see how many alcohol-related admissions there are each year in each area of the country.

They explain their methodology as follows:

The inpatient admissions and A&E attendances data in this map are for 2012/13. Estimates for outpatient attendances are based on benchmarks from the Birmingham Heavy Drinkers Project (1997 to 2004), The General Lifestyle Survey (2009) and the number of high risk drinkers taken from Local Alcohol Profiles (LAPE) (2005) estimates.

No more details are available but they have clearly derived estimates based on some (fairly old) data and some unexplained assumptions.

You would only bother coming up with estimates from a computer model if the real figures were not available. But here's the thing. The ONS has detailed hospital admission data for exactly the same areas that Alcohol Concern make guesstimates for. And what a difference there is between the ONS's figures and Alcohol Concern's estimates.

In Barnsley in 2012/13, for example, the ONS says there were 900 alcohol-related hospital admissions (600 were partly attributed to alcohol, 300 were wholly attributed to alcohol). Alcohol Concern says there were 46,992.

The difference between 900 and 46,992 is non-trivial to put it mildly.

To take another example from my neck of the woods, Alcohol Concern reckons there were 128,922 alcohol-related hospital admissions in West Sussex in 2012/13. The ONS says there were 14,210.

Alcohol Concern reckons there were 52,092 admissions in Brighton and Hove. The ONS says there were 4,640.

Alcohol Concern says there were 48,745 alcohol-related hospital admissions in Westminster. The ONS says there were 3,360.

These are massive discrepancies and Alcohol Concern make no attempt to explain why their figures are ten to fifty times higher than the ONS's. On the contrary, their press release implies that theirs are the official figures.

Since the ONS is a reputable organisation using official NHS records and a transparent methodology, I am inclined to think that their figures are much closer to the truth than those of a partisan pressure group.

Still, it got an enormous amount of newspaper coverage so well done Alcohol Concern. But be careful—one day a journalist might actually bother doing some basic fact-checking.

Thursday, 16 October 2014

Leaked document shows WHO's hard line on e-cigarettes

I've received what appears to be the WHO's draft text about e-cigarette regulation (from this week's top secret FCTC meeting in Moscow).

Apologies for the poor quality of the image. You can click to enlarge, but this is what it says (all strikes and underlines are in the original. ENDs are 'Electronic Nicotine Delivery Systems', a daft term that only 'public health' people use for e-cigarettes):

(a) [preventing the initiation of ENDS by non-smokers and youth]

(b) minimize as far as possible potential health risks to ENDS users and protecting non-users from exposure to their emissions; non-users

(c) prohibit prevent unproven health claims from being made about ENDS the promotion of ENDS by any means that are false, misleading, deceptive or likely to create an erroneous impression about their characteristics, health effects, hazards or emissions; and

(d) protect existing tobacco control efforts activities from all commercial and other vested interests of the tobacco industry that produces and sells related to ENDS, including interests of the tobacco industry with measures similar to those considered in Article 5.3.

3. The Parties are invited to consider banning or regulating ENDS including as tobacco products, medicinal products or consumer products [or other categories as appropriate] taking into account a high level of protection for human health with special attention to vulnerable groups such as pregnant women.

Urges Parties to consider banning or restricting advertising, promotion and sponsorship of ENDs.

5. Invites Parties and WHO to comprehensively monitor the use of ENDS among smokers and non-smokers especially among youth including the relevant questions in all appropriate surveys on risk factors for non-communicable diseases...

The various deletions suggest that this may not be the finished article. Nevertheless, assuming that it is genuine and current, it is important to note that the WHO's position is to urge countries to ban the marketing of e-cigarettes. It would also like them to ban them entirely or regulate them as tobacco or medicinal products (which, of course, they are not).

Moreover, the WHO is also considering rolling out Article 5.3 to e-cigarette companies. Article 5.3 says that tobacco companies shouldn't be involved in setting public health policy. Anti-smoking cranks like to pretend that (a) it is a law (it isn't in most, if not all, countries), and (b) that it stops governments having any meetings with the tobacco industry or anyone who is vaguely connected to the tobacco industry. Some politicians have fallen for this lie. Extending Article 5.3 to e-cigarette companies would be a very bad idea as governments urgently need to hear from people who know what they're talking about with this emerging technology.

Finally, you will note the reference to 'protecting non-users from exposure' to e-cigarette vapour. This assumes that there is something in the vapour that non-users need to be protecting from, but there is no credible evidence for this. Clearly, the aim here is to encourage bans on e-cigarette use indoors (and, if pocket dictators like Lord Darzi have their way, outdoors too).

I stress again that the above may not be the final text, but if it bears any resemblance to the finished draft, it looks like the WHO will be recommending advertising bans, inappropriate regulation (up to and including prohibition), indoor bans on use and the exclusion of e-cigarette companies from the dialogue. Not quite the light touch we were led to believe would be the outcome of COP6. 

A perfect hatred

What can you say about the proposal to ban smoking in the—ahem—beautiful, pristine, pure air of London town? Perhaps the first thing to say is that it is only a proposal from a revolting left-wing doctor-cum-politician. Boris Johnson has distanced himself from it:

"This idea in my view, as a libertarian conservative, comes down too much on the side of bossiness and nannying.

"One feature of life in London is that we are a city that allows people to get on with their lives within the law provided they are not harming anyone else.

"I think smoking is a scourge and it's right to discourage it (but) I am very sceptical at the moment."

He drew on personal experience as he described his opposition: "I have to think back to my own life two decades ago when my wife and I had a baby.

"It came to that point when everybody was asleep and I was in such a mood of absolute elation I wondered out into a park in Islington and it was in the middle of winter but I laid on the ground and had a cigar.

"I don't want to be in a city where somebody can stand over me and say you've got to pay £115 for doing something that is of no harm to anybody except me."

I would have preferred it if Johnson had openly mocked Lord Darzi's plan (of which an outdoors smoking ban is only one element). Nevertheless, he has made it quite plain that he will not be acting on it.

But, oh!, what a nest of vipers came to life when the idea was unfurled. How quickly the bottom feeding prohibitionist slime rose to the surface at the thought that the Overton window had moved in their direction. Deborah Arnott, Alan Maryon-Davis, John Britton, Alex Cunningham and Sally Davis went into spasms of delight, bewitched as they were by the prospect of smokers being further harassed and humiliated. As Dick Puddlecote notes, proposals like this are a wonderful way to smoke out the lurking sadists in society.

...the period of time between the press release going out in the early hours and Boris's statement at lunchtime was open season for every irrational smoker-hating whacko, psychopath, and berserker to spew their bile on every possible platform. Lord Narzi and Sally Davies effectively signalled to thousands of society's most vile that hyperbolic hatred was officially sanctioned by the authorities.

Seemingly terrified that their crown of health fascism might be slipping from their heads, the Labour party showed its true colours (which they have never really tried to hide, even in opposition) by pledging to turn the idea into law at the first opportunity:

Dame Tessa, the former Olympics minister, seized the initiative to promise action if she makes it to City Hall in 2016.

She told the Standard: “If you are asking somebody of Ara Darzi’s eminence and reputation to conduct an investigation like this, you have got to have a pretty good reason for not accepting it if you want to improve the health of Londoners.

“The recommendations are all grounded in evidence and have public support - 59 per cent are in favour of a ban [as far as I can tell, this is a made-up statistic—CJS].

“Lord Darzi has looked at the very radical proposals that Mayor Bloomberg introduced in New York. These have been tried and tested. Similar protections should be offered to Londoners.

“If I were Mayor of London, promoting the health of Londoners would be one of the key areas I would want to act on.”

To be clear, the proposal is to ban grown adult human beings from smoking in 20,000 acres of outdoor space in London, including the city's large parks (Darzi wants to turn parks into "beacons of health"—a phrase that probably sounds better in the original German). Why? Few had the nerve to evoke the phantom of passive smoking. Instead, they said that people have a duty to be "role models" and that children might see somebody smoking and seek to emulate them.

Words almost fail me. Most of the remaining words are expletives. I was in Brussels when the news was announced and I was in no mood to suffer fools gladly when I did a couple of interviews I did over a mobile phone (Voice of Russia and BBC Suffolk, the latter starts 14 minutes in). Is it necessary to give a reasoned response to arguments that are so obviously made with no sincerity? Are we really supposed to deal with ad hoc bans as if they were stand-alone measures rather than pieces of a mounting prohibition?

It hardly needs to be said that smokers, like nonsmokers, have never volunteered to be role models for other people's children. The claim that adult activity should be criminalised if it can be witnessed by minors does not have to be taken to its logical extreme for it to be exposed as absurd and totalitarian. It is plainly not a serious argument. And yet, if I did feel the need to act as a role model to children, I would, first and foremost, impress upon them the importance of ignoring and despising unjust laws. I would hope to teach them that there is, in any society, a minority of bigots who resent liberal values and who will do whatever they can to impose their own lifestyles upon them. If flouting a draconian law will help a child realise that the state is not its friend, then I will cheerfully light a cigarette in any street or park.

Even if the argument wasn't bogus, it would have no bearing on the law. But it is bogus. The proposal—like most anti-smoking policies—is really about belittling, stigmatising and hassling smokers because a certain class of people despise smokers and are keen to encourage the public to share their contempt. But, as I have discussed at length elsewhere, it is the hateful, authoritarian bigots who should be denormalised.

This issue is beautifully clear-cut. If you have any sympathy at all for the idea that smoking in the open air should be a criminal offence, you are the enemy. To call you a 'nanny' would imply a level of compassion and concern that doesn't exist.You are a cancer in the body of society, spreading fear and hatred. You sow misery and division where none existed before. To quote the Book of Psalms (later appropriated by the prohibitionist Billy Sunday) I hate you with a perfect hatred. You do not deserve to live in a free society and, therefore, I don't think you would miss living in a free society. Perhaps, then, you should leave.


I can't leave this topic without highlighting a shameless and obvious lie that appeared in the Evening Standard yesterday. Don't these people have editors?

Regressive, illiberal soda taxes

I have an article up at Spiked that looks at how the words 'liberal' and 'progressive' have become so debased that they are used by proponents of patently illiberal and regressive soda taxes.

Please read it.

Wednesday, 15 October 2014

The trivial impact of Mexico's soda tax

There was much rejoicing amongst 'public health' campaigners when Mexico brought in a soda tax at the start of the year. A tax of one peso per litre—about 5p—might not sound much, but in a country where the minimum wage is $5 per day, it is significant and will increase the price of fizzy drinks by about ten per cent.

The usual hyperbolic claims were made for this tax in advance. It was predicted (by advocates) to reduce consumption by 10 to 13 per cent. They said it would prevent "up to" 630,000 cases of diabetes by 2030.

Obviously, we can't yet measure the effects on diabetes (if any), but can see what effect the tax is having on consumption. Via Jon Fell, I see that the PepsiCo quarterly results have been published. They show a small rise in sales since the start of the year. Regarding their soft drink sales in Latin America in the 12 weeks up to the 6th September 2014, they say this:

Volume increased 1%, which included a contribution of nearly 1 percentage point from certain of our bottler’s brands relating to our new joint venture in Chile. Latin America volume increased 5%, primarily reflecting a mid-single-digit increase in Venezuela and a low-single-digit increase in Mexico, partially offset by a low-single-digit decline in Brazil.

And in the 36 weeks up to the 6th September...

Volume increased 0.5%, which included a slight contribution from certain of our bottler’s brands relating to our new joint venture in Chile. Latin America volume increased 3.5%, reflecting nearly 2 percentage points from certain of our bottler’s brands in Chile, a mid- single-digit increase in Brazil and a slight increase in Mexico.

Coca-Cola will release its latest results later this month, but its quarterly statements for the first half of the year have already been published. In contrast to Pepsi, they show a small decline in sales. In the first quarter of the year:

Volume in our Latin Center (+5%) and South Latin (+2%) business units continued to grow, partially offset by a low single-digit volume decline in Mexico given the new excise tax that impacted the beverage industry and our business.

And in the second quarter:

Latin America’s volume was even in the quarter, as strong 8% volume growth in our Latin Center business unit was offset by a 3% volume decline in Mexico.

So there we have it. Soft drink sales are up slightly for Pepsi and down slightly for Coca-Cola. Coca-Cola is twice as large as Pepsi in terms of sales in Latin America so we can surmise that overall sales are down, but only by about two per cent.

For the anti-soda crowd, this represents success. They deal in a world where there are no costs, only benefits (a defining characteristic of the fanatic) and so any decline in sales is a victory, no matter what economic burdens are placed on the population.

More objectively, however, this is a very feeble outcome from a major tax initiative in a low income country. Once again, the predictions have proven to be hopelessly optimistic. This natural experiment suggests that the elasticity of demand for soda in Mexico is in the region of -0.3, much more inelastic than the computer models assumed. (Soda consumption may continue to decline in Mexico—we shall see—but you would expect the biggest decline to take place in the first months of the tax.)

What effect will a decline of 2 or 3 per cent have on obesity and health? Even if we leave aside the substitution effects that tend to offset any effect on calorie consumption, it is hard to see it being anything other than negligible. Mexico has the highest per capita consumption of soda in the world, but soft drinks still only account for 5 per cent of calories consumed. A low single digit decline in a source of calories that only made up one twentieth of total energy consumption in the first place is so trivial that any impact on weight, let alone diabetes, is going to be too small to measure.

The Mexican soda tax should be seen as what it is: just another stealth tax.