Thursday, 28 October 2010

Argumentum ad peer review

A good article by Sandy Starr about the argumentum ad peer review in Times Higher Education, which echoes what Brendan O'Neil wrote in Spiked back in August.

This part particularly appealed to me, for obvious reasons:

Once politicised in this way, peer review becomes a sort of quarantine, where ideas can be contested only by a select few before being presented to us as a fait accompli. Take, for example, the attitude of epidemiologists Kate Pickett and Richard Wilkinson, authors of the book The Spirit Level: Why More Equal Societies Almost Always Do Better. They state imperiously: “Almost all of the research presented and synthesised in The Spirit Level had previously been peer-reviewed…In order to distinguish between well-founded criticism and unsubstantiated claims made for political purposes, all future debate should take place in peer-reviewed publications.”

Such disdain for arguments motivated by “political purposes” speaks (non-peer-reviewed) volumes.

As I have said before, there is no better alternative to peer review and there is nothing inherently wrong with it. The only problem with peer review is its public perception as a stamp of absolute truth. While honest academics in any field tend to be realistic about their limitations, something about human nature requires things to be seen in black and white, good and evil, right and wrong.

That peer review is merely a form of editorial control, which—at times—represents nothing more than allowing colleagues to publish an article the house magazine is a truth that is lost in the rush for certainty. As a rule of thumb, anyone who defends their work on the appeal to peer review and the appeal to authority alone, while shying away from debate about the work itself, should be treated with suspicion.

Starr concludes:

Peer review is valuable and worth defending, but only inasmuch as it promotes impartiality and standards within specialist fields. It should not be used as an arbiter of how we run our affairs. We already have a system for that – it’s called politics. And we are all qualified to participate in it, by virtue of being born human.

Please go read.

Sandy Starr will be appearing at the Battle of Ideas in London at the end of the month. Should be interesting.

Wednesday, 27 October 2010

Lie through your teeth

I've occasionally wondered why dentists have never shown the same  enthusiasm for lifestyle regulation as doctors. You never hear the dental equivalent of the British Medical Association calling for tax rises on sugary drinks and a ban on gobstoppers.

Cynical minds would say this is because dentists usually work in the private sector. While it often seems that doctors view patients as an unnecessary obstacle keeping them from the gold course, dentists could be forgiven for wanting the government to subsidise pork scratchings and boiled sweets.

Whatever the motives, dental patients have learnt not expect to expect the Spanish Inquisition (no one expects the Spanish Inquisition, etc.). But then along comes this idiot, and now Alex Deane at Big Brother Watch has told his tale of unit-counting at his dental surgery.

From Big Brother Watch:

Dentist: we haven’t got details of your alcohol intake.

Me: no, you haven’t.

Dentist: well, there’s a health form - we’ve got to have it!

Me: no, you don’t.

Dentist: well, what am I supposed to put in this space, then?

Me: you can put that I said it’s none of your business.

Dentist: Alex, you don’t seem to understand – this is to guard against oral cancer.

Nought to cancer in four questions!! Talk about bringing out the big guns. Needless to say, the exchange ended:

Me: I’ll take my chances

Dentist: (total disbelief) So I’ve got to put that you won’t tell me?

Me: Yup.

As it happens, my own dentist is a good friend of mine so I have been spared all of this. He knows exactly how much I've been drinking most weekends and any lectures from him would, in any case, be laughably hypocritical. He also tells me that in 12 years in practice, he has only ever diagnosed one case of oral cancer. (It is a fairly rare disease, claiming fewer than 2,000 lives in England and Wales last year.)

But Dick Puddlecote confirms that this line of questioning is now not only standard, but compulsory.

I had a similar experience a couple of months ago when moving to a different dental practice and signing in for a check up. In this case, I was given the form to fill in myself. I completed it but left the question on 'alcohol units per week' blank, assuming that it was optional. Having handed it to the receptionist and reseated myself to continue reading a riveting copy of OK magazine (yes, it was the only *cough* literature available, and yes, I was being sarcy), she called me back to point out that I had not answered all the questions.

"Oh, I didn't think that one was compulsory", said I, politely, to which she countered that she couldn't register me at the practice unless it was filled in. I just took the pen, placed a big fat zero in the box, handed it to her with a smile, and sat down again. The look I received was a mixture of disdain and anger. She knew the answer was untrue but - short of accusing me of being a liar in public - there was nothing she could do about it.

Unless you actually like being lectured, what better way to deal with intrusive questions from the state?


As reported by Iain DaleConservativeHome and others, FOREST have produced a report showing the scale of public funding involved in Britain's anti-tobacco industry (if that doesn't work, try this). It's comprehensive and is worth downloading, reading and keeping for reference.

As is apparent from Iain Dale's post, many people remain unaware that the 'health groups' and 'charities' who petition for anti-smoking (and other neo-prohibitionist) legislation are quangos in all but name. The fact that charities like ASH raise next-to-nothing in the way of public donations speaks volumes about how little grassroots support these organisations have.

Some of the figures are bafflingly high. Smoke Free North West (who contributed the bulk of responses to Labour's dodgy consultation on display bans) received £1.9m from the taxpayer—ten times more than ASH (England). ASH (Scotland) receives £1.4m to serve a population ten times smaller than England, while employing a staggering 27 people. The UK Centre for Tobacco Control Studies—the home of Anna Gilmore and a lobby group in all but name—has been given £3.7m.

In any bonfire of the quangos, these astroturf groups should be the first on the list. I can think of no reason at all why the taxpayer should be forced to fund lobbyists. It is a throwback to the worst excesses of the last government, which routinely used public money to manufacture support for its own policies. Unless the coalition puts an end to this dubious practice, it will be seen to be condoning the Machiavellian tricks of the previous administration while making a mockery of its claim to be the party of responsible spending.

It's really pretty simple. If these groups are providing a public service (such as smoking cessation), they should be incorporated into the Department of Health where they will have to be accountable (and, importantly, subject to the Freedom of Information Act). This is what is happening in Ireland.

If they don't provide a public service (and most are purely lobbyists), then there is no case for them to be funded by the government they are lobbying. If ASH et al. are going present themselves as charities then they should act like charities and do their own fund-raising instead of forcing hardworking people to graft to keep them in the manner to which they have become accustomed. As Longrider said recently:

Well, firstly, if these charities do things that people want, they will fund them voluntarily. If they fail due to lack of funds, then people don’t want them and they will deservedly disappear. If they are providing essential public services, then why are they charities at all?

Quite so. This is an open and shut case. It's time for the anti-smoking lobby to stand on their own two feet.

Who didn't see this coming?

I've written a few times about the myth that smoking bans are truly "comprehensive" outside of Britain and Ireland. In truth, other countries have passed laws which—while still trampling inexcusably on property rights—are far less draconian than those seen elsewhere in the world.

In other nations smoking bans have been relaxed (Holland, CroatiaPoland), or were relaxed to begin with (Portugal, Denmark, Belgium), or are simply ignored (Holland again, Greece and everywhere outside Europe).

And it seems that I am not alone in observing this...

While partial or total smoking bans have been introduced in many European countries ending patrons' ability to smoke in bars, cafes and other public venues, it is still relatively easy in some states to find a bolt-hole where smokers are welcome, whether due to exceptions to such laws or owners flouting the bans.

We can't be having that now, can we? And the response from the (unelected) European Commission should come as no surprise.

Health commissioner John Dalli has said he wants to put a stop to this.

"We need a complete ban on smoking in all public spaces, transport and the workplace," he said in an interview on Monday (11 October) with German daily Die Welt.

The EU wanting to override national sovereignty is not a massive shock. And there had been noises on the smoking front.

Announcing that Brussels is currently preparing a bill to be brought forward next year, he said that exceptions should no longer be tolerated

Then perhaps they could start by banning smoking in the EU's offices, where the last attempt to stop MEPs smoking ended within weeks after the political class revolted?

The commission will furthermore try to win agreement on rules making tobacco products no longer visible to customers and make packaging as unattractive as possible. The packets are to be made identical in appearance and to bear colourful warning pictures, such as of diseased lungs, as well as more information on the toxins the product contains.

"The more uniform and bland packaging the cigarettes are, the better," said the commissioner.

Quite. And who better to make things bland and uniform than the European Commission?

Tuesday, 26 October 2010

How harm reduction works

A little story from Iceland tells a bigger story about how tobacco harm reduction could, and does, work in practice...

The sale of cigarettes has decreased significantly this year compared to 2009. According to the State Alcohol and Tobacco Company of Iceland (ÁTVR), sales dropped by almost 13 percent in the first nine months.

However, at the same time the sale of snuff and chewing tobacco has increased by 9.2 percent—at the end of September almost 18.8 tons of snuff and chewing tobacco had been sold in Iceland, Morgunbladid reports.

Cause and effect? Coincidence? Who knows? But if cigarette smokers are happy to switch to snuff and chewing tobacco, what would happen if they had access to snus, which is both less hazardous and—so many people say—more pleasurable than either?

Alas, the sale of snus remains illegal in Iceland, as it is in the whole EU (Sweden excepted).

Way to go, public health prohibitionists!

ASH launch new campaign

Campaigners call for desert island smoking ban

Anti-smoking campaigners have called a smoking ban on desert islands "the next logical step" in the war against second- and third-hand smoke. Deborah Arnott, director of Action on Smoking and Health, is leading a campaign for a total smoking ban across the world's islets and archipelagos: "It is a common misconception that smoking on a patch of land in the middle of the ocean poses no threat to others," she said.

"But we know there is no safe level of secondhand smoke. Cigarettes contain 4,000 chemicals which can travel hundreds of miles, contaminating nonsmokers, especially children, in neighbouring countries and pose a particular risk to passing sailors, especially children. There is overwhelming evidence that toxins remain on the torn trousers of shipwrecked travellers for years, which poses a serious health threat to potential rescuers, especially children."

At the moment there is little evidence that secondhand smoke can travel over international waters but scientists at the UK Centre for Tobacco Control Studies have promised to study the issue. "We'll get the evidence, don't you worry about," Arnott said. "For too long people have used loopholes like living thousands of miles from civilisation as a way to get around the hugely popular smoking ban. We need to send a clear message to smokers: we will track you to the ends of the earth."

ASH's new campaign has received high profile support from Glasgow-born millionaire Duncan Bannatyne and former desert island resident Man Friday.

Speaking at a press conference organised by Pfizer, Mr Friday said: "For most people, a desert island is a place to get away from it all and listen to their favourite records. They forget that for people like me it is a workplace and we deserve the same protection as other workers. By their very nature, desert islands tend to be unregulated and it is people like me and the fat kid with glasses from Lord of the Flies who end up paying the price."
But critics accused campaigners of going too far. Simon Clark of the smokers' rights group FOREST said: "This is just another example of the nanny state gone mad. Many desert islands are already struggling to attract ship-wreck survivors and this proposed legislation will finish them off. And it's unenforceable. This is just the precursor to banning smoking across whole countries."

In response to the accusation that ASH's real goal is to ban smoking indoors and outdoors in every country in the world, Arnott said: "Have you been reading my diary?"

Nicotine Clegg

Josie Appleton at Spiked has been writing about the Spanish who, like the Greeks, are not taking a "comprehensive" smoking ban lying down. Considering the dire economic conditions in both countries, the decision to spend so much time and money hassling smokers seems puzzling. As Josie says, it reflects the warped priorities of the political class:

The smoking ban springs from elite rather than popular concerns. It’s not because the Spanish elite doesn’t like smoking: prime minister José Luis Rodríguez Zapatero was recently caught smoking on his presidential jet. 

Yes, it's another political leader who (whisper it) smokes cigarettes. Another do-as-I-say-not-as-I-do politico to line up alongside Barack Obama and Nick Clegg. Reading the Dubai edition of The Sunday Times yesterday morning as I trailed back to the Sussex Riviera alongside the knackered commuters, I found Nick Clegg's fondness for an occasional tab on the front page. Even if this wasn't already common knowledge (which I thought it was), who cares?

The answer, as Newsnight found when they asked people on the street yesterday, is nobody. But the fact that the media and the political class think that anyone would, should or could be interested rather proves Josie's point about the divide between the norms of the elite and the norms of, er, normal folk.

The elite view is that smoking is finished, denormalised and is now the preserve of a tiny handful of addicts. This fantasy can just about be maintained by people working in the upper echelons of public health. Very few, if any, of their colleagues smoke and it is hard to imagine them consorting with smokers in their spare time. In their neverland of conferencing and seminars, their Walter Mitty fantasies are rarely challenged by the clunking fist of reality.

Such an option is not open to journalists and politicians. Smoking remains very common amongst hacks, and even politicians are sometimes forced to encounter the general public from time to time. For them to believe that the world changed on July 1 2007 requires a level of self-delusion that approaches cognitive dissonance. It is as if by willing society to change, it will do so, even as one's own colleagues, friends and leaders continue to puff away.

And if smoking is imagined to be no longer normal, then it must therefore be remarkable to find that someone is a smoker, right?

Wrong. For all the nudging and denormalising, it is civil society that ultimately decides what is normal behaviour. Outside of the public health bubble, the conduct of a quarter of the population cannot sensibly be viewed deviant, unusual or even interesting. And so it isn't. As has been the case for five centuries, all but a handful of people are profoundly indifferent to smoking. They are also—as it happens—supremely uninterested in whoever is leader of the Liberal Democrats. It should hardly be surprising, then, that the "revelation" that the leader of the Liberal Democrats occasionally smokes was greeted with a jaw-breaking yawn.

The Hindu Times

Hello, hello. It's good to be back.

My source of news these past three weeks has been The Goa Herald and BBC World. Have I missed anything? I heard that tolerant, crime-free Sweden has a racist serial killer on the loose, that the French strikers in Paris have shown considerably more commitment than the French strikers at the World Cup. And my own football club finds itself managerless and second to bottom in the bloody Championship. Can all this possibly be true?

What of India? I'll spare you my banal observations. Suffice to say it's not the place to go if you don't like curry (hello Patrick Basham!), the streets are filled with delicious cows and the smoking ban is more honoured in the breach than in the observance.

More—much more—to be said later today. I have some catching up to do. Meanwhile, via Dick Puddlecote's link tank, I see The Atlantic has an interview with arch-rationalist John Ioannidis (mentioned before on this blog), whose classic paper 'Why most published research findings are false' should be on the national curriculum.

“The studies were biased,” he says. “Sometimes they were overtly biased. Sometimes it was difficult to see the bias, but it was there.” Researchers headed into their studies wanting certain results—and, lo and behold, they were getting them.

We think of the scientific process as being objective, rigorous, and even ruthless in separating out what is true from what we merely wish to be true, but in fact it’s easy to manipulate results, even unintentionally or unconsciously. “At every step in the process, there is room to distort results, a way to make a stronger claim or to select what is going to be concluded,” says Ioannidis. “There is an intellectual conflict of interest that pressures researchers to find whatever it is that is most likely to get them funded.”


Though scientists and science journalists are constantly talking up the value of the peer-review process, researchers admit among themselves that biased, erroneous, and even blatantly fraudulent studies easily slip through it. Nature, the grande dame of science journals, stated in a 2006 editorial, “Scientists understand that peer review per se provides only a minimal assurance of quality, and that the public conception of peer review as a stamp of authentication is far from the truth.”

Please go read...

Thursday, 21 October 2010

Shisha madness

There was a time when scientific research was presented to reputable journals for peer-review and publication. In the field of tobacco research, however, there is a growing trend towards what Dr Michael Siegel calls "science by press release," which bypasses the scientific journals and delivers findings directly to the media. This has an obvious appeal for some researchers. The media have an insatiable appetite for scare stories and journalists are rarely qualified to ask the appropriate questions.

Science by press release allows fresh 'evidence' to spread worldwide, reaching the public and opinion-formers with immediate effect. By the time any awkward questions have been asked of it, the message has been sent and the media has moved on. An example of this came on 24 August 2009, when the BBC announced the scarcely believable new 'fact' that shisha smoking could be "400 to 450 times more dangerous than having a cigarette."

The news story ('Shisha as harmful as cigarettes') was itself little more than a press release to promote the BBC's Asian Network's radio programme that was broadcast at 6pm the same day. The intention of both the article and the programme was to stoke up fears amongst the predominantly Asian users of shisha pipes (also known as hookahs, nargiles and hubble-bubbles). Both the news story and the radio show were guilty of grossly misrepresenting the known facts.

Misleading statements

The Department of Health research focused entirely on carbon monoxide, with its key finding being that:

It found one session of smoking shisha resulted in carbon monoxide levels at least four to five times higher than the amount produced by one cigarette.

This may be true, but since a 'session' was defined as half an hour's continuous smoking, CO levels were bound to be higher amongst shisha smokers than amongst those who smoked a cigarette for, as the researcher said, "a couple of minutes, five minutes at the most."

The BBC went on to add:

High levels of carbon monoxide can lead to brain damage and unconsciousness.

This, too, is true, but it gives a highly misleading impression. The reader is led to believe that shisha smoking leads to brain damage and unconsciousness without any evidence being presented that this ever actually happens. The reason it does not happen is simple - although "high levels" of CO "can" result in brain damage and even death, the levels found in shisha smokers (and cigarette smokers) are by no means high enough.

Using the same rhetorical trick, I could tell you—with a clear conscience—that your television emits radiation and that high levels of radiation can cause cancer and childhood leukemia. Both statements are true, but by following one with the other I would be giving the unwary reader the false impression that televisions cause cancer.

Questionable research

Similar examples of sleight of hand could be found in the radio transmission itself ('The Trouble with Hubble Bubble', 24/8/09).

The headline-grabbing claim that shisha pipes are 'worse' than cigarettes is based on unpublished research carried out by an unnamed University at the behest of the Tobacco Control Collaborating Centre (TCCC) and released exclusively to the BBC's Asian Network.

The TCCC's Hillary Wareing appeared on the radio programme to reveal the startling results:

"We found that one session of smoking shisha - that's about 10mg for 30 minutes -- gave CO levels that at their lowest were 4 or 5 times as high as having a cigarette but at worst were coming out at 400, 450 times more dangerous. The results would suggest that in most cases it's more harmful and in some cases it's extremely more harmful [sic] than cigarettes."

As always with science by press release, we will have to wait to see how the research was conducted (if, indeed, it is ever published). Incidentally, Wareing reveals her own ignorance of shisha by saying that a 30 minute shisha session uses just 10mg of tobacco. A typical amount of tobacco smoked in one shisha setting is 10-20g, leaving Wareing out by a factor of a thousand.

If the TCCC's experiment involved testing CO levels in smokers, it will be fascinating to see how they came up with the claim that shisha smokers have up to 450 times the carbon monoxide levels of cigarette smokers. Such a level would be in excess of 1,000 parts per million, much higher than the human body can withstand without dying. No living person could give such a reading. If, on the other hand, the experiment merely took CO readings in a laboratory, it is of negligible practical value since smoking has been prohibited in all enclosed places in the UK since July 2007.

More fundamentally, the researchers make the mistake of equating carbon monoxide with risk, as if CO were the sole (or even the main) cause of ill-health in smokers. They say nothing at all about cancer, which is the chief health hazard associated with tobacco use. Instead, they assume that risk of brain damage, stroke, heart disease and death is directly correlated with CO levels in the body. It is not.

An expert's view

Dr Kamal Chaouachi is a Paris-based tobacco researcher and arguably the world's leading expert on the science of hookah smoking. Dr Chaouachi has authored or co-authored two comprehensive transdisciplinary books and dozens of biomedical publications. He has already lodged a complaint with the BBC about the programme which he says was based on "misinterpretation" and "gross exaggeration".

"There are numerous studies on this issue and there is absolutely nothing new in this scare-mongering report," Dr. Chaouachi said. "What has been done is recycling and laundering the old stuff and trying to present this as "new research" that would "reveal" new "facts".

"The bottom line is that shisha smokers actually experience the same CO exposure as cigarette or cigar smokers do. Besides, their exposure is, unlike cigarette smokers who generally smoke every day, not chronic. Indeed, for the great majority of them, they indulge in their habit only 1 to 3 times a week. Even in the case of a daily exposure, keep in mind that the CO is quickly washed out from the body because its half life is only about 3 to 4 hours."

"CO is only one chemical out of thousands in cigarettes, so one cannot compare. But even if we look only at CO, shisha is not "worse" than cigarette smoking because regular cigarette use results in chronic intoxication. Shisha use is sporadic and occasional and the CO is quickly washed out of the body."

None of these points were raised in the BBC programme. Indeed they upped the ante by suggesting that shisha use also raised the risk of everything from herpes to swine flu. This could come about, they said, from pipes becoming infected, as the rather inarticulate spokesman for the NHS stop smoking service told listeners:

"There's no kinda, like, direct correlation, but at a time when we're quite protective about, y'know, passing on of germs and being quite, y'know, up on our hygiene it's not the best activity to be taking part in right now."

Despite there being "no direct correlation" and no evidence, the BBC dwelt on the possibilities of a shisha-related swine flu outbreak for some time. In response, Akram, the owner of a London shisha bar told the programme that every shisha is cleaned "from top to bottom" with boiling hot water and disinfectant. In addition, every customer used a disposable mouth-tip. He quite reasonably pointed out there was no more reason to think that reusing a washed shisha could spread infection any more than reusing a washed cup in a coffee bar.

Education or scare-mongering?

There is a case to be made for informing shisha smokers about the potential health hazards of the device. This is particularly true if, as the programme asserted, some smokers believe that shisha is completely risk-free. Unfortunately, a calm assessment of the facts is not sufficiently alarming for Britain's anti-smoking tzars. They strongly resist any suggestion that some tobacco products are less hazardous than others, despite overwhelming evidence that shisha, snus, chewing tobacco, pipes, e-cigs and cigars are all significantly less hazardous than cigarettes.

In the ideal world of public health, overstating the dangers of shisha will persuade its users to cease using tobacco products. In the real world, claims that shisha can be up to 450 "more dangerous" than cigarettes is more likely to encourage users to switch to cigarettes. It is the kind of unintended (but hardly unforeseen) consequence that has dogged the anti-smoking movement efforts for decades.

Dr Chaouachi wonders whether public health is really the issue at all:

"If these people were truly concerned about "public health", the best thing they could do is to invite shisha users not to smoke in ill-ventilated places, as I have been doing for 12 years. However, and cigarette users know this well, the question of ventilation is taboo talk. Therefore, the objective of this new campaign is targeting a lifestyle, not an unhealthy habit."

"This renewed attention is very similar to that about E-cigarettes (banned in some countries on unscientific grounds). Both smokes have, contrary to conventional cigarettes, many common points (a high proportion of DHMO (DiHydrogen MonOxide) and glycerol), far fewer chemicals and crowds around the world are growing mad about them."

"I have the strange impression that this story is the harbinger of a new step towards prohibition..."

[Originally published August 25th 2009 at]

Sunday, 17 October 2010

'The Anti-Smoking Movement'

[This speech was originally delivered at the TICAP conference, Brussels, 27 January 2009]

Good afternoon. I'm here today to talk about the modern anti-smoking movement. Specifically I'm going to talk about the sordid subject of money and how a fairly innocuous campaign dedicated to achieving non-smoking sections evolved into an extraordinarily wealthy enterprise that is dedicated to the extinction of tobacco.

There are virtually no volunteers in today's tobacco control movement and yet it continues to have the appearance of a grass-roots campaign. It has the appearance of being run by volunteers. It has the appearance of being funded by the generosity of the public. And this works in its favour. People are naturally more inclined to support a voluntary group or a charity than they are to support politicians or to support an industry.

But in reality the funding comes from the state, from 'charities' and from the pharmaceutical industry. And these sources of funding are so closely intertwined that sometimes it is difficult to see where one ends and another begins. The pharmaceutical industry funds the charities. The charities are often set up and financed by the government. The government is then lobbied by the charities.

None of this need be an issue. I don't begrudge anyone making a living and I don't have a problem with charities paying the people who work for them. And if you don't like it, then don't give to the charity. The problem comes when you don't have any choice in whether you give to the charity because you are forced to fund it through your taxes. The problem comes when you arrive in the bizarre situation of having government-funded charities using tax money to lobby for something the government has already decided it wants to do. And the problem comes when the makers of pharmaceutical nicotine products are giving millions of dollars to groups whose primary aim is to put the makers of traditional nicotine products out of business.

It might be rather late in the afternoon for a history lesson but I need to tell you that once upon a time there was a genuine grass-roots anti-smoking movement. In fact, anti-smoking groups have popped up throughout history, usually run by small bands of volunteers operating on show-string budgets.

There was a plethora of them in the late 19th and early 20th century. These were the placard-waving, letter-writing, church-hall meeting kind of groups. They disappeared completely after the Second World War and only began to reappear at the beginning of the '70s. The most prominent of them was called GASP - the Group Against Smoking Pollution - and they were quite typical of the placard-wavers that had come before them. GASP was founded by a housewife and environmentalist called Clara Gouin in the state of Maryland. She set up the society with a few friends from her local church and charged a $1 a year membership fee. GASP started out by campaigning locally for nonsmoking sections in public places and, to that end, made badges, printed posters, wrote letters, petitioned politicians and published pamphlets.

New branches of GASP sprang up under like-minded individuals in the 70s, first on the West Coast, then on the East Coast and then throughout America and Canada. GASP had a big voice but it was still a small organisation. Even by the late 1980s, a senior member of GASP was advising anyone who was planning to form their own anti-smoking group: "Don't expect crowds at your meetings. Expect maybe five to ten people at most."

But two things happened in the late 20th century that transformed the make-up and the fortunes of the emerging anti-smoking movement. Firstly, they began to receive very large amounts of money from the state. Secondly, they began to receive money from pharmaceutical companies.

The result of this was that a small-scale nonsmokers' rights movement developed into a large-scale tobacco control movement.

The change began - as it so often did - in California. In 1988, a campaign led by Americans for Nonsmokers Rights and GASP resulted in the passage of Proposition 99. This bumped up the tax on a pack of cigarettes but its real achievement was to secure a commitment from the state's politicians that 20% of the money raised would be funnelled towards anti-smoking projects.

Prop 99 created an almost bottomless pit of money - some $500 million a year - for Californian anti-smoking organisations, and long-serving, unpaid activists were well placed to take up full-time jobs in tobacco control or receive lucrative commissions for tobacco research.

The same thing happened on a much, much bigger scale ten years later when the American tobacco industry settled with the US government resulting in a Master Settlement Agreement worth $246 billion. This deal turned the financial affairs of the anti-smoking movement upside down. New anti-smoking organisations were created all over the country, millions became available in grants for researchers to study every aspect of tobacco control and the anti-smoking movement was presented with more money than it knew what to do with. But it didn't stop there.

The rags to riches story was completed when the makers of nicotine-based pharmaceuticals began to get involved. The nicotine patch had been developed in the early 1980s and first appeared in commercial form as Nicotrol, manufactured by Pfizer and marketed by Johnson & Johnson.

The founder of Johnson & Johnson was General Robert Johnson. He died in 1968 leaving a legacy of $1.2 billion to be used for good causes through the aegis of the Robert Wood Johnson Foundation. To this day, the foundation receives the lion's share of its income from Johnson & Johnson. It currently owns around 40 million shares in J & J with a value of over $3 billion.

What is good for Johnson & Johnson is good for the Johnson foundation and vice versa. And what could be better for a seller of nicotine drugs than smoking bans, the demonisation of the tobacco industry and higher cigarette prices?

In 1991, the US government approved the sale of nicotine patches on prescription and it was in that year that the Johnson foundation began funding anti-smoking projects. Since then it has given $450 million to anti-smoking projects including $84 million to the Centre for Tobacco-Free Kids, $10 million towards a campaign to raise the price of cigarettes and $99 million to the Smokeless States initiative.

The only other suppliers of so-called "nicotine replacement drugs", are Pfizer and GlaxoSmithKline. While the Robert Wood Johnson Foundation's activities are largely confined to the United States, Glaxo and Pfizer are more focused on making tobacco control a truly international affair. By the end of the 1990s, both Glaxo and Pfizer were fully paid-up members of the World Health Organisation's Tobacco Free Initiative. The two companies helped finance the Smokefree Europe conference and they part-funded the Institute for Global Tobacco Control. In the UK, they fund the Roy Castle Foundation. When the 11th World Conference on Tobacco came to Chicago in 2000, the Johnson foundation paid $4 million to be one of the hosts and Glaxo was a patron of the event. The Pfizer foundation has recently donated $33 million to an assortment of anti-smoking groups including the newly formed ASH International.

It goes on and on, and it doesn't take a genius to work out what their motivation is for this extraordinary generosity. Already by 1999, Nicorette and Nicoderm were selling to the tune of $570 million a year. By 2007, Chantix alone was making $883 million. These sums, enormous though they are, will seem like peanuts if the rest of the world brings in the kind of anti-smoking policies seen in America and Europe.

If you are cynical, you might say that the interests of professional anti-smoking advocates and pharmaceutical companies would not be best served by prohibition. Prohibition would put the anti-smokers out of a job and, after a few years, there would be no need for the nicotine patches and gums that are meant to help people stop smoking.

And if you are very cynical, you might say that the best-case scenario for both groups would be one in which the nicotine has been removed from cigarettes entirely, leaving the pharmaceutical industry as the only legal seller of the drug. This would leave people free to smoke but they'd have to buy the pharmaceuticals if they wanted the nicotine.

Remarkably, this is exactly the scenario put forth by the tobacco control movement. In 2005, the flagship Tobacco Control journal published an article called "Toward a comprehensive long term nicotine policy". This was a rare example of the movement spelling out its ultimate goal. In the short term, the authors said:

"The immediate need is to capture all nicotine into a regulatory system."

This would allow the government to reduce nicotine levels in cigarettes, ultimately to zero, and this is exactly what the Centre for Tobacco-Free Kids are currently demanding of the US government. The authors then go on to say that pharmaceutical nicotine should be available at "reduced prices" and in "more outlets, including vending machines". At the same time "tobacco availability should become progressively less easy" until pharmaceutical nicotine replaces tobacco as "the dominant source of the drug". They go on:

"The ready availability of clean nicotine would also allow addicted smokers who do not obtain adequate nicotine from their reduced nicotine cigarettes to supplement their nicotine intake."

Such a policy would leave pharmaceutical giants as the sole legal purveyors of nicotine. Smokers could still purchase cigarettes and could still damage their health. Smokers could continue to fund the tobacco control industry through cigarette taxes while lining the pockets of the pharmaceutical industry.

By the way, I should you tell you what the long-term goal is. You won't be surprised. It is, of course: "the virtual elimination of tobacco use as it is presently known."

That's what the tobacco control enterprise and the pharmaceutical industry hope to be able to achieve together and they certainly have the cash with which to fight for it. So where does this embarrassment of riches leave the grass-roots anti-smoking groups? The answer is that they barely exist at all. The tobacco control movement continues to portray itself as a David fighting a Goliath but if that was ever a true analogy it certainly is not the case today.

At one time, in the 1980s, the tobacco industry would create front groups to campaign against anti-smoking proposals. Creating fake grass-roots groups is known as astro-turfing and it has now been adopted as standard practice by the anti-smoking movement. For example, when a bill to ban smoking in public places was put before the electorate in Texas it was the American Cancer Society that resorted to manufacturing not one but two so-called 'grass-roots groups' to masquerade as the "voice of the people".

In Britain, regional anti-smoking groups like D-MYST and SmokeFree Action are entirely funded by the Department of Health. England's branch of ASH was created by the government and it currently derives less than 3% of its funding from voluntary donations. It has no volunteers. Nor does ASH Scotland or ASH Wales, both of whom are overwhelmingly funded by the state, with additional funds coming from the Pfizer Foundation.

Those old activists of the 70s are certainly not impoverished any more. The British version of GASP is no longer even a charity. It has long-since become a limited company and it now makes its money selling 'No Smoking' signs and other smoke-free paraphernalia. James Repace has long-since left the EPA and now does very well as a self-employed 'secondhand smoke consultant'. Both he and Stanton Glantz have personally been given $300,000 as winners of the Robert Wood Johnson Foundation's Innovators Awards. Simon Chapman, who was a prominent member of the 70s activist group BUGA-UP, is now the editor of Tobacco Control magazine. John Banzhaf continues to draw a $200,000 salary as the director of ASH when he isn't suing restaurants for making people fat.

While the anti-smoking movement is awash with money, most of the groups that oppose them - and that includes many of the groups here today - do not receive a penny from the tobacco industry and never have. The simple truth is that the only volunteers involved in the battle over smoking today are those in the smokers' rights movement. Yes, it's a David and Goliath struggle but it's not the anti-smokers who are holding the sling and the stones.

In closing, I should say that I am not talking about the funding of the anti-smoking movement because I believe that a cause is any more noble just because it is staffed with unpaid volunteers, or because I believe that corporations should be forbidden from funding research or delving into politics. I mention all this only to highlight the fact there is a fundamental dishonesty about the way the anti-smoking movement operates in 2009. It is ironic that tobacco control campaigners are using the tactics that their archenemies in the tobacco industry used so effectively in the past. Today it is the anti-smokers who are manufacturing the front groups. It is they who are perverting statistics and twisting science for their own ends. And it is they, not the people in this room, who are receiving hundreds of millions of dollars from one of the world's most powerful industries.

The funding is important because it doesn't just get spent on lobbying. It gets spent on research. Research that shows that smoking bans do not hurt businesses. Research that shows that smoking bans slash heart attack rates. Research that shows that third-hand smoke is deadly. This research arguably has more effect on the political process than the lobbying does.

In an ideal world, all scientific research would be funded by utterly impartial organisations which had no interest in anything but the truth. Of course, we understand that that is never the case. We accept that if a company, a government or a pressure group is going to fund research, it is because they have a financial or ideological reason to do so.

I am not suggesting that the makers of alternative nicotine products should be barred from funding research. I am not in favour of preventing the tobacco industry from funding research for that matter. I am not in favour of barring any industry - or any government - from funding anything so long as it is done in an open manner.

And it is this lack of openness that concerns me, both in the way the science is conducted and in the way the campaign for anti-smoking legislation is conducted. The use of front groups, the lack of accountability, the endemic misuse of statistics: these are all now firmly rooted in the movement and I would like to offer just two small suggestions as to how a little honesty could be injected.

Firstly, the medical journals and the mainstream media should face the fact that the Robert Wood Johnson Foundation owns tens of millions of shares in one of the world's biggest producers of alternative nicotine, and that this constitutes a clear conflict of interest when it funds groups whose activities are likely to lead to more use of its products. Similarly, the funding of anti-tobacco projects by Pfizer and Glaxo should be treated with the same scepticism as they would treat funding from Philip Morris or British American Tobacco. I say this not with a view to banning these companies from being involved, but with a view to making the scientific and political process more open.

My second suggestion is that governments simply stop funding charities. The best charities do not require state funding and for governments to set up and finance bogus charities in an attempt to manufacture a consensus degrades the very notion of charity. Any charity that accepts state funding is bound to be compromised by it and any charity set up by the state is little more than another branch of government. The whole point of charity is that it is voluntary. It should not require the input of government at all. If the state stopped funding these anti-smoking charities, people would still be free to donate to them and if, as tobacco control advocates insist, they are popular, they would surely prosper. The state, meanwhile, would remain free to carry out national anti-smoking campaigns, it would just use its own departments and committees to do so. It need not necessarily change very much, but - again - there would be an element of openness and honesty.

Thursday, 14 October 2010

Stanton Glantz: Then and now

Stanton Glantz is arguably the most influential anti-smoking activist of the last thirty years. To his friends, he is a pioneering hero; to his enemies, a dangerous crank. Whether under the guise of activist or researcher, Glantz has been involved in most of the major developments in the tobacco control enterprise since 1975. He was the main proponent of 'denormalisation' in the 1970s - long before the approach even had a name. In the 1980s, he founded American for Nonsmokers Right and led the fight for the first smoking bans in his home town of San Francisco. In the 1990s, he was the source for the claim that 50,000 Americans died every year as a result of secondhand smoke (a figure that was not accepted by the EPA). He was instrumental in bringing secret tobacco industry documents before the public and has written prolifically about almost every aspect of Tobacco Control.

In recent years, Glantz has been a key player in the efforts to persuade the public that secondhand smoke is not merely dangerous but is extraordinarily lethal. His written output in this decade has included such papers as 'Even a little secondhand smoke is dangerous' [PDF] - in which it was claimed that just 30 minutes of exposure to smoke could cause a heart attack. He also co-authored the infamous Helena heart attack study, which purported to demonstrate that exposure to smoke caused 40% of heart attacks in one Montanan town. He is also perhaps the only person on earth who believes that passive smoking causes breast cancer despite a mountain of evidence to the contrary and despite the fact that active smoking does not cause the disease (1).

Glantz has been accused of twisting data and disregarding crucial facts to promote his extreme anti-smoking agenda (he is unashamedly prohibitionist). It comes as a surprise, then, to find that one of his earliest published papers was an appeal for greater scientific rigour in epidemiological studies.

Written in 1978, and published in the American Heart Associations' journal Circulation two years later, 'Biostatistics: How to detect, correct and prevent errors in the medical literature' is one of the least known works in Glantz's extensive canon. It does not get a mention on his lengthy online CV.

There is a reason for that.

"Simple mistakes"

The thrust of Stanton Glantz's 1980 Circulation paper was that too many researchers use statistical methods incorrectly and, therefore, many studies produce erroneous results. As a consequence, he wrote, "readers often conclude that statistical analyses are maneuverable to one's needs, meaningless, or too difficult to understand." One of the most striking sentences in the paper comes when he criticises researchers for making basic errors in study design and interpretation. He makes the rather obvious point that flaws in a study's design can result in an association being found between A and B when, in truth, none exists. Such errors in study design, he says, are often so basic as to be inexcusable:

"Ironically, these errors rarely involve sophisticated issues that provoke debate among professional statisticians, but are simple mistakes, such as neglecting to include a control group."

He stated that 44% of studies made the error of omitting a control group. It is interesting that Glantz specifically identified the failure to include a control group as a "simple mistake" since many of his own studies have been criticised for that very reason. Between 1994 and 2007, Glantz co-authored six papers which purported to show that smoking bans did not significantly damage the hospitality industry. Half of them did not include a control group. Nor was there any no control group in a study Glantz championed which claimed that the New York smoking ban resulted in 8% fewer heart attacks.

His own study of heart attack admissions (in Helena, Montana) did have the virtue of having a control group but, as I have written previously, he made a very "simple mistake" when he claimed that it was scientifically feasible for 60% of all heart attacks to be caused by secondhand smoke (to say nothing of the error of calculating a 60% drop, which later had to be corrected to 40%).

But the main complaint the Stanton Glantz of 1978 had to make about epidemiological studies involved statistical significance.

The significance of significance

Epidemiologists have wrestled for years with the question of whether the statistics they unearth represent a useful line of enquiry or are the result of chance. To deal with this problem, they have long-used a statistical test to distinguish the random from the real and it is one that many readers of this website will be familiar. It is statistical significance.

Statistical significance is not a difficult concept to define and the following quote, from Glantz's Circulation article, succinctly explains why a measure of statistical significance is necessary and how it works. First he explains why a standard of significance is necessary:

"In an experiment, an investigator rarely studies all possible members of the population, but only a small, representative sample. The mean value computed from such a sample is an estimate of the true mean that would be computed if it were possible to observe all members of the population. Because the sample used to compute the mean consists of individuals drawn at random from the population being studied, there is nothing special about this sample or its mean. In particular, had the luck of the draw been different, the investigator would have drawn a sample containing different individuals and computed a mean value."

He then explains how this can be done, using the example of drug testing:

"Traditionally, when the chances of observing the computed test statistic when the intervention has no effect are below 5%, one rejects the working assumption that the drug has no effect. There is, of course, about a 5% chance that this assertion is wrong. This 5% is the p value, or "significance level."

In other words, even if the drug being tested has no effect, there will inevitably be a small variation between the two randomly selected groups of people it is tested on. Because of chance, the difference between two random variables is almost never zero. The standard 95% significance test Glantz described is designed to distinguish small and meaningless associations from those that are significant. (In epidemiology, 'significant' does not mean 'substantial' or 'serious' as it does in normal parlance; it simply means that the association is probably not the result of chance*.)

When Glantz explained statistical significance in his Circulation paper, he did not pretend that there was anything groundbreaking or controversial about its usage, and any professional epidemiologist would have been well aware of the importance of testing for significance. Indeed, nothing in the article was in the least bit radical. Testing for significance, like avoiding "simple errors", was the bare minimum a researcher could do to avoid creating bogus results. (The young Glantz made no great claims for his paper saying: "This article presents a few basic ideas and rules of thumb.")

And, it seems, the reminder was needed. Glantz bemoaned the fact that "approximately half the articles published in medical journals that use statistical methods use them incorrectly" and recommended that "journal editors should insist that statistical methods be used correctly." In closing, he insisted that "students and research fellows should receive formal training in applied statistics, if only to increase the skepticism with which they approach the literature."

When this budding academic wrote his assault on faulty epidemiology, he was still a fairly obscure mechanical engineer-turned-junior faculty member at the University of California, San Francisco. Although he was, even then, a prominent anti-smoking activist, Glantz had no particular reason to question standard epidemiological practice. The first epidemiological study on passive smoking was still three years away from being published. Anti-smoking activists like Glantz expected it to be only a matter of time before science 'proved' that secondhand smoke was a cause of cancer and other diseases. The first step towards finding this proof would be showing statistically significant associations in epidemiological studies.

But epidemiology failed to do so. The first two studies encouraged them (Hirayama, 1981 & Trichopoulos, 1981) but Lawrence Garfinkel's large American study put a spanner in the works when he found a relative risk of 1.17 (0.85-1.61) for nonsmoking women married to smokers. The relative risk of 17% was statistically insignificant and neither Garfinkel nor the American Cancer Society (whose data he had used) pretended that the study lent any support to the passive smoking theory.

Over the next ten years a succession of studies showed no statistically significant elevation in risk (Gao (1987), Brownson (1990), Janerich (1990), Garfinkel (1985), Dalager (1986), Kabat (1984), Shimizu (1988), Nyberg (1989), Koo (1987) etc.) and one even showed a statistically significant fall in risk - ie. passive smokers were less likely to contract lung cancer (Wu-Williams (1987)).

It was at this point that the assault on epidemiological standards began. With the great majority of studies failing to show any tangible association between secondhand smoke and lung cancer, the anti-smoking movement began to belittle and disparage the very concept of statistical significance. At the forefront of this new assault was Stanton Glantz.

In 1993, the Environmental Protection Agency was caught playing hard and fast with epidemiological data in its effort to find a link between secondhand smoke and lung cancer. Even after cherry-picking the data, the EPA was only able to show the slimmest of risks by dropping the measure of statistical significance from 95% to 90%. This doubled the EPA's chances of finding a significant result and understandably raised eyebrows but Stanton Glantz was surprisingly relaxed about it. Fifteen years earlier, he had stressed how important the significance test was, but now he described it as "hairsplitting that only professors care about" and said:

"I know that scientifically it's widely used, but there is a strong body of thought that people are too slavishly tied to 95 percent."(2)

Soon afterwards, Philip Morris began to fund The Advancement of Sound Science Coalition. The organisation aimed to set basic standards for epidemiologists and, in the wake of the EPA report, Philip Morris had an obvious motive for supporting such a body. There was nothing in the Advancement of Sound Science Coalition's guidelines that would have been out of place in Austin Bradford Hill's famous criteria of causation or in Stanton Glantz article of 1980, including this remark about significance:

"Two-sided hypothesis tests are encouraged. If a one-sided test is employed, this should be noted and the rationale for using it provided. The presentation of confidence intervals for the estimate of risk gives more information than a single point value with an associated p value. Generally, 95% confidence intervals are preferred."

This was a statement of fact. 95% was indeed the preferred confidence interval in epidemiology. The EPA's use of a lowered 90% interval was almost unheard of and, in his 1980 paper, Stanton Glantz had firmly promoted the 95% confidence interval. But when The Advancement of Sound Science Coalition did the same, Glantz sang to a very different tune. Glantz accused it of "attempting to change the scientific standards of proof" and complained that its recommendations "would make it impossible to conclude that secondhand smoke - and thus other environmental toxins - caused diseases." (3) That may have been true but it was hardly the fault of epidemiology if it was unable to back up Glantz's beliefs.

Faced with a slew of studies that did not meet the test of significance, the anti-smokers preferred to dismiss the significance test itself rather than dismiss the studies. In truth, it was Glantz who was "attempting to change the scientific standards of proof" by abandoning his faith in a crucial criterion; one which could not be met by the null results that continued to appear in studies on secondhand smoke.

Things got worse for the anti-smokers in 2000, when the World Health Organisation's IARC found no statistically significant association between passive smoking and lung cancer. Glantz was incensed and he launched an all-out attack on the 95% confidence interval and, as ever, sought to blame the tobacco industry:

"The [tobacco] industry imposes a one-sided interpretation of confidence intervals, focusing the entire discussion on whether the lower bound of the 95% CI [confidence interval] for a relative risk includes 1. By definition, if the lower bound exceeds 1, then the risk is statistically significantly raised (with p=0.05).
Whether or not there is anything magic about 95%, the true risk is equally likely to be anywhere inside the 95% CI, including values above the point estimate. In environmental and health and safety regulation, it is common to take the health-protective approach of basing public policy on the upper 95% confidence limit...The industry has represented the fact that the increase in risk observed did not reach statistical significance as indicating that the study did not find any increased risk." (4)

This was an extraordinary turn-around. It was the very opposite of what he had written in 1978. Glantz gives an accurate definition of what constitutes a statistically significant risk ("if the lower bound exceeds 1") but then immediately claims that this is a "one-sided interpretation" dreamed up by the tobacco industry. He then suggests that since the true risk falls somewhere within the two confidence intervals, it is reasonable to pick any figure between the two. Furthermore, it is apparently acceptable for anti-smoking advocates to select the highest figure within the confidence interval as being the true risk. What is this if not a "one-sided interpretation" of confidence intervals?!

The troubling implications of such thinking can scarcely be overstated. Glantz is explicitly stating that environmental and health legislation should be based on the top end of the confidence interval ie. the highest level of risk, even when there is no statistical significant association to begin with and, therefore, no risk. Such an assumption makes it possible to 'prove' anything. Even if an epidemiological study finds a nonsignificant reduction in risk (eg. 0.9 (0.7-1.2)), policy makers will only see the 1.2 upper limit and assume a 20% increase in risk. Nothing studied can ever have a neutral effect; everything is harmful; nothing is safe.

Such a practice is not so much bad science as anti-science since it requires no evidence before a theory becomes a 'fact'. It gives the upper hand to pessimists, fanatics and hypochondriacs at the expense of science and reason. The power lies with anybody who can finance and successfully promote the research. Zero-evidence epidemiology can effectively manufacture health hazards at will and the precautionary principle requires politicians to legislate, regulate and abolish as if the risk was real and proven.

Glantz's transition from being a defender of scientific standards to becoming an assailant is an extraordinary one. That it came about due to his need to 'prove' that secondhand smoke kills offers an explanation but is scarce justification. It would a laughable exaggeration to claim that Glantz is some sort of fallen angel. His Circulation article would be unexceptional were it not for its author's subsequent U-turn and Glantz has done as much as anyone to discredit epidemiology as a serious science ever since. Since his training was in mechanical engineering rather than epidemiology, a charitable defence of the man's work might be that he simply does not know any better. I would suggest that his Circulation article, written at the dawn of his career, removes that defence. At one time, Glantz clearly did understand the principles of epidemiology and was prepared to defend them. The fact that he has since become a ringleader of junk science and debased epidemiology is all the more striking in the context of this forgotten article.

(1) 'Alcohol, tobacco and breast cancer', British Journal of Cancer, 2002, 87, pp. 1234-1245; doi: 10.1038/sj.bjc.6600596; see also 'Cigarette smoking and breast cancer', Field et al. International Journal of Epidemiology 1992; 21: 842-848.

(2) Quoted in Michael Fumento, 'Is EPA Blowing Its Own Smoke?' Investor's Business Daily, January 28, 1993. Republished by the American Smokers Alliance at articles/08-epa_ blowing _ smoke html.

(3) http://
Incidentally, in his Circulation article, Glantz cites the work of the great epidemiologist Alvas Feinstein. Glantz would later dismiss Feinstein as a "industry consultant" when he cast doubt on the passive smoking theory.


* In reality, the idea that significant results are correct 95% of the time is a fallacy that can easily be confirmed by reading about the health scares and miracle cures that are reported in every daily newspaper. To quote John Brignell in The Epidemiologists:

"In the comparison of two random variables the correlation coefficient is never zero. The first question to be determined is whether it is far enough from zero to be significant, which in the case of epidemiology means resorting to the one-in-twenty lottery. Even if the correlation is deemed significant, however, that is not sufficient evidence to warrant a claim of causation." (p. 199)

[Originally published at]

Monday, 11 October 2010

The curious case of The Spirit Level

Myths rarely turn into conventional wisdom overnight. Usually they evolve gradually, exaggerated and embellished in the retelling. But in the case of The Spirit Level, a work of political science published last year, the transition from legend to gospel has been made with dizzying speed.

As its subtitle suggests, The Spirit Level: Why more equal societies almost always do better argues that the success of entire nations depends not on their absolute wealth but on the size of the gap between the highest and lowest earners. The ‘less equal’ nations suffer most severely from health and social problems, while the ‘more equal’ countries—particularly the Nordic states—are happier, healthier, more trusting, slimmer, more charitable and more socially cohesive.

The book’s authors—social epidemiologists Richard Wilkinson and Kate Pickett—insist that this phenomenon is not due to poverty, but is the result of the ‘psychosocial’ stress of living in an “unfair” country. Inequality, they say, acts like a “pollutant spread throughout society” with rich and poor equally susceptible to its toxic effects. The lesson is clear—if you want to mend the broken society, reject free market capitalism and adopt the Scandinavian model.

What raises The Spirit Level above the average left-wing polemic is what The Guardian described as its “inarguable battery of evidence”. This takes the form of a series of scatter graphs which, while crude, are consistent in their message: nearly all undesirable outcomes are more common in less equal countries. So neatly does this “battery of evidence” appeal to those who thought Gordon Brown was too right-wing, that it has been readily embraced by many on the left, including both Milliband brothers. A hotly debated political issue has, it seems, now been answered by science; an ethical question that has exercised the greatest minds for centuries has been answered with hard data.

If only things were so simple. In reality, The Spirit Level presents the world as its authors would like to see it, with inconvenient facts ignored and whole nations erased from the narrative. While claiming to study all rich market economies, countries such as Czech Republic, South Korea, Slovenia and Hong Kong never feature. If they had, the reader would see that the latter performs very well under almost every criteria despite extreme inequality (as does Singapore), while the Czech Republic and Slovenia do much less well despite having a very narrow gap between rich and poor.

If the sample group seems oddly selective, so too are the criteria of what makes a country “do better”. Wilkinson and Pickett focus on Scandinavia’s relatively low rate of illegal drug use without mentioning its high rate of alcoholism. They devote a chapter to the higher rate of imprisonment in less equal countries without discussing the more pertinent—and hardly coincidental—fact that these countries also have less crime. They confidently assert that people in egalitarian societies are more philanthropic, have stronger family relationships and are more involved in the local community. Had they sought empirical evidence for any of this, they would have found that it is actually the people in less equal countries who give more to charity, have fewer divorces and are most likely to be a member of a local club or association.

And so it goes on. Remarkably few of The Spirit Level’s claims stand up to scrutiny. If the book demonstrates anything, it is how easily statistics can be transformed into the proverbial ‘damned lies’. Nonetheless, it is a book that should not be ignored. Not only has it built up a large and avid readership, but it represents a milestone for those who view the narrowing the wealth gap as more important than creating wealth. While the traditional aim of the left was to alleviate poverty by making the poor richer, inequality can be alleviated by narrowing inequality in ways that need not make anyone richer.

Indeed, Wilkinson and Pickett seem indifferent to how inequality is reduced and explicitly state that economic growth is not the answer. By their rationale, society would improve if the poor got 5% poorer so long as the rich got 20% poorer. Rounding up Britain’s millionaires and sailing them to the Antarctic would not only make life better for the poor but, still less improbably, would make life better for everyone. But without a compelling reason to believe such a reduction will materially benefit the working class, the authors leave themselves open to accusations of trading in the politics of envy.

Herein lies the problem with focusing on relative income instead of absolute income. There are things we can do to make the poor richer which might also reduce inequality, and vice versa, but the two objectives are not always compatible. The government’s recent decision to raise the tax threshold to £10,000, for example, should make the poor richer, but if the rich find ways to get even richer in the mean time, will the resulting inequality make things worse? It is not obvious how or why, but the logic of The Spirit Level says it must.

In the end, the case for reducing inequality remains a moral and political question. It is not one that be answered by science. The Spirit Level represents an ingenuous attempt to bridge the gap between faith and reason but, like all grand unifying theories, it can be filed under ‘too good to be true’.

[Originally published at the Cobden Centre]

Friday, 8 October 2010

Nuns, prostitutes, witches and toads

[A fairly lengthy article about cervical cancer might not sound the most interesting way to spend ten minutes but it provides a good example of epidemiology confusing cause and effect.]

In 1842, the Italian physician Domenico Antonio Rigoni-Stern noticed that nuns in Verona were more susceptible to breast cancer than other women. Ruminating on what aspect of convent living might explain the phenomenon, he concluded that the nuns' corsets were too tight. This explanation was wide of the mark but the initial observation was sound; we now know that having children makes a woman less likely to develop breast cancer.

But the Italian found another association. It seemed that the nuns were less prone to cervical cancer than the rest of society. Furthermore, cervical cancer was unusually common amongst prostitutes. This observation provided the first clue to the real cause of the disease but it would take a further century and a half of confusion and dead-ends before the real truth emerged.

Early myths

The very earliest myth about cervical cancer emerged in early modern Europe where witches were believed to curse their victims with warts which ultimately led to a painful death. As we shall see, even this bizarre notion was not entirely without reason but, by the dawn of the 20th century, medicine had moved on and in 1901 The Lancet observed that cervical cancer was rare amongst Jewish women.

Suspecting that the disease was caused by excess salt, The Lancet correspondent surmised that Jews were less susceptible because they avoided bacon. An alternative explanation was offered when the subject was revisited in 1959, when a doctor speculated that circumcision reduced the risk (1). Neither man was correct about the cause but, again, the association was real.

In the 1970s, epidemiological studies showed that cervical cancer was more common amongst women who had a history of herpes. It was therefore assumed that the cancer was caused by the herpes virus. It was not, but it was becoming clear that the disease was in some way connected with sexual activity. At this point, with the answer now within reach, researchers dived down a blind alley.

Modern myths

The suggestion that cancer of the cervix was caused by smoking was first made in 1977 and, by the end of the 1980s, the belief that passive smoking was also a risk factor had reached the pages of the Journal of the American Medical Association (2). A number of epidemiological studies had shown a small but consistent relationship between tobacco smoke and cervical cancer, and yet something strange seemed to be happening. Studies frequently showed that passive smoking carried as high or higher risk than active smoking. This was completely at odds with the expected dose-response relationship. The association with passive smoking was, as one researcher commented, "almost too strong".

Nevertheless, anti-smoking groups let it be known that smoking doubled a woman's risk of contracting cervical cancer and, with tobacco now firmly in the frame, the earlier observation that the disease was related to sexual activity came under fire. In 1991, the British Journal of Obstetrics and Gynecology published an article by Malcolm Griffiths which flatly stated that Rigoni-Stern's research had been sloppy. There was, said Griffiths, no reason to believe that nuns had a lower rate of cervical cancer than the rest of the female population (3). The implication was obvious: cervical cancer was not related to sexual activity.

Griffith's theory took hold and the became the orthodox view. Still, not everyone was convinced. In 2000, when the British Medical Journal reopened the debate, an exasperated professor wrote to ask:

"We now know, with lots of evidence, that cervical cancer is a venereal disease, the responsible herpes type virus being passed from female to female via male sexual partners. Why is there no comment about this in your letters and no statistics about the number of sexual contacts found in the various studies, which is clearly the most relevant fact in incidence and death from the condition?"

To which a fellow doctor replied:

"I had, until recently, believed that nuns did not get cervical cancer. I accepted the received wisdom since I found it repeated so frequently. I realized how mistaken I was when I encountered the paper on this topic by Griffiths. In his paper Griffiths clearly and persausively demonstrates that the assertion that nuns are not at risk of cervical cancer is based on a mis-reading of Rigoni-Stern's original report of 1842. I hope that if enough of us highlight Dr Griffiths' work often enough this myth will be laid to rest." (4)

But, as was already becoming clear, sexual activity was very closely related to cervical cancer risk. By the end of the millennium, scientific—as opposed to statistical—evidence conclusively proved that the sexually transmitted human papillomavirus (HPV) was implicated in all cases of cervical cancers. HPV did not guarantee the onset of cervical cancer but it was impossible to contract the disease without first being infected with it. With this knowledge, the age-old observation of the nuns and prostitutes made perfect sense.

The truth

Biological evidence indicated that cervical cancer was no more caused by herpes than breast cancer was caused by tight corsets. The rarity of cervical cancer amongst Jewish women was, scientists now realised, due to the protective P53 gene which was far more common amongst Jews than other races. Salt had been a red herring. Even the old myth that cervical cancer was connected to witchcraft had some bearing in fact, since HPV causes warts to grow. In medieval society warts were associated with toads which were, in turn, associated with witches.

Smoking, like herpes, was not the cause of cervical cancer, it was simply more common amongst women who were sexually active and, therefore, more likely to be infected with HPV. Had the Italian doctor looked at tobacco use, he would have observed that smoking was more common amongst prostitutes than amongst nuns. He might also have noted that prostitutes were more likely to drink alcohol, have children and be atheists. But none of these things caused cervical cancer; they were just more common amongst prostitutes. The statistical correlations were real, but they were meaningless until the nature of HPV was understood.

The clues had always been there. For one thing, cervical cancer mortality had fallen by 80% in the second half of the 20th century, at a time when tobacco consumption had never been higher (5). This, in itself, strongly suggested that smoking was not a cause of the disease.

That smoking was correlated with sexual activity had been known for many years. In 1994, an article in the International Journal of Epidemiology had flagged up the issue:

"The correlation between cigarette smoking and sexual activity that exists in most cultures makes evaluation of the potential additional role of smoking difficult." (6)

Indeed it did. One epidemiological study (Nischan, 1988 (7)) had found a relative risk from smoking of 1.5 (ie. a 50% increase in risk), but, as the authors noted, "the risk for smokers depended significantly on number of sexual partners"—a telling observation which warranted closer scrutiny. Indeed, when they adjusted their figures in an effort to account for this mysterious confounder, the risk—already low—fell to just 1.2 (0.8-1.6) and was no longer statistically significant.

The real giveaway was that the risks for passive smokers were as high, or higher, than those found for smokers. Given the vastly lower dose of smoke inhaled by the former, this was a biologically implausible finding which defied both common sense and the expected dose-response relationship. Another study (Scholes 1999 (8)) found a risk of 1.4 for both smokers and passive smokers. The study that attracted the most attention from the press (Slattery 1989 (9)) found a relative risk for smokers of 3.42—much higher than the association found in other studies but still not quite as high as that found in the same study for passive smokers where a 3.43 risk was reported.

To take such findings at face value would require tearing up the toxicological text-book. It was hugely improbable that passive exposure to tobacco smoke in any setting could be as harmful of smoking. What was much more likely was that cervical cancer was not a smoking-related disease at all and that the findings had been skewed by the confounding factor of sexual activity.

The key to the riddle was the human papillomavirus. Once it was shown to be implicated in every case of cervical cancer, the long observed correlation between sexual activity and cervical cancer made sense. And since smokers—as a group—were somewhat less likely to be celibate and somewhat more likely to be promiscuous, the correlation between smoking and cervical cancer had a rational explanation. Correlation did not equal causation. Yes, there was an association between smoking and cervical cancer but the one did not in any way cause the other.

The association with passive smoking was more intriguing and had a unique explanation. Because HPV is carried by men and easily transmitted to women, a woman's risk of catching the virus depends as much on her partner's sexual history as her own. She may be a nonsmoker with no previous lovers but if her partner has slept with many women she remains at high risk. And since the smoking male tends to be have had more sexual partners than his nonsmoking counterpart, the woman who lives with him is at higher risk of contracting HPV and, therefore, cervical cancer. Yes, living with a smoker slightly raises a woman's risk of cervical cancer but not because he smokes. Correlation does not equal causation.

The passive smoking researchers who had adjusted their results for sexual history had made the mistake of only asking questions of the women. They had, of course, made every effort to find out about the man's smoking status but had neglected to enquire about his own sexual history which was far more important, considering his role as the HPV carrier.

As the role of HPV in cervical cancer became known, it became clear that smoking was not independently associated with the disease. HPV was the key and, by 2006, an effective vaccine against it was developed. Immunisation programmes were initiated by governments around the world and the possibility of wiping out cervical cancer within a few generations became a realistic proposition.

It was a rare breakthrough in the war against cancer. It came about thanks to advancements in our understanding of biological science and was facilitated by the development of new drugs. It was, if you will, an 'old-fashioned' way of dealing with a public health problem. It owed nothing to the army of epidemiologists who were dominating popular science, nor to the proponents of the fashionable belief that cancers were caused by tobacco, diet, alcohol and environment. Not only had the social theorists missed the mark, but their preoccupation with smoking had sent researchers on a wild goose chase for more than two decades.

Carry on regardless

And yet, the anti-smoking organisations still had a slew of studies showing an association between smoking and cervical cancer. To admit these studies were worthless would be to accept the failure of their methods. Not only that, but admitting that cervical cancer was not a smoking-related disease would be to lose a weapon in their campaign to dissuade women from smoking. And so they carried on as if nothing had happened.

Today, the American Cancer Society maintains that smoking doubles the risk of cervical cancer (10), based only on the statistical correlation. The fact that the organisation also claims that chlamydia, multiple pregnancies and oral contraceptives are also risk factors shows that the ACS has learnt nothing from the long history of mistaken cause-and-effect that has surrounded cervical cancer over the centuries. Chlamydia, multiple pregnancies and oral contraceptives—like herpes, warts and prostitution—are obviously associated with unprotected sex. It would be a truly extraordinary coincidence if these factors also happened to be independent risk factors from smoking.

At least the ACS no longer claims that passive smoking raises the risk. The same cannot be said of other anti-smoking groups. Rather than accepting that the studies had been flawed because they had failed to adjust for HPV infection, they continue to take them at face value.

As implausible as it is, the idea that passive smoking is more dangerous than smoking holds an appeal to such groups. Recently, a study on breast cancer showed a higher risk for passive smokers than smokers. In truth, smoking of any kind was not a risk factor for breast cancer, as even the American Cancer Society accepted. Nonetheless, ASH released a press release titled 'Secondhand tobacco smoke more dangerous than smoking itself - implications for women especially frightening' (11) and Stanton Glantz described the finding as "the most important scientific development in the last 10 years" (12).

Their motives were obvious. Having banned smoking in virtually all indoor places, their attention turned to the outdoors, but to ban smoking in the open air required persuading the public that secondhand smoke was exceptionally toxic.

Further 'evidence' for this wacky idea appeared in the form of the Helena heart attack study (co-authored by Glantz) which claimed that heart attack incidence fell by a whopping 40% once smoking was banned in bars and restaurants. Not accepting for a minute that this study might also be fatally flawed, anti-smoking groups used it as further evidence that secondhand smoke was far more dangerous than had been previously thought. Glantz also wrote an article titled 'Even a little secondhand smoke is dangerous' (13) and claimed that 30 seconds of exposure could kill.

In 2006, the Surgeon General told the American public that there was "no safe level" of secondhand smoke exposure. Secondhand smoke had become the most deadly entity known to man.

(1) Dunn JE, Buell P. Association of cervical cancer with circumcision of sexual partner. J Natl Cancer Inst 1959;22:7469.
(2) In January 1980, the American Journal of Epidemiology reported that there "an apparent connection, as yet unexplained, between smoking and cancer of the uterine"
(4) 'Screening and mortality from cervical cancer', Rapid responses; BMJ 1999; 319: 642
(5) Cancer Research UK, 'UK Cervical Cancer mortality statistics'
(6) 'Cigarette smoking as a potential cause of cervical cancer; has confounding been controlled?', Andrew Phillips & George Davey Smith, International Journal of Epidemiology, 1994, Vol. 23, No. 1, pp.42-49
(7) 'Smoking and invasive cervical cancer risk: Results from a case-control study', Nischan et al. American Journal of Epidemiology, 1988, vol. 128, No. 1: pp. 74-77
(8)Scholes et al. Cancer Causes & Control, Vol, 10, No. 5, Oct. 1999 pp. 339-344 'The association between cigarette smoking and low-grade cervical abnormalities in reproductive-age women'
(9) JAMA, vol. 261, No. 11, 17/3/89, Slattery et al. 'Cigarette smoking and exposure to passive smoke are risk factors for cervical cancer'
(11) ASH press release, 2005
(12) 'Lecture ties secondhand smoke to breast cancer', Michael Coburn, The Dartmouth News, 7.3.08

[Originally published at in 2009]

Tuesday, 5 October 2010

Smoking out ‘deniers’ and ‘dissidents’

[Originally published at Spiked on February 19 2009]

In a five-page journal article published online, Martin Dockrell, the policy and campaigns manager for the UK’s main anti-smoking campaign, Action on Smoking and Health (ASH), has launched an extraordinary attack on the journalist and broadcaster Michael Blastland (1). Calling him a ‘conspiracy theorist’ and a ‘dissident’, Dockrell explicitly compares Blastland to the ‘AIDS dissidents’ who disputed the link between HIV and AIDS.

Blastland’s crime was to criticise a study that claimed that the incidence of acute coronary syndrome (ACS) fell by 17 per cent after Scotland’s public smoking ban came into force in 2006. The study then applied a logical fallacy: since the reduction followed the ban, it must have been caused by the ban. Blastland covered the story for the BBC in November 2007, two months after the findings were reported by the international media following a presentation at a tobacco control conference.

Since the paper was, at the time, unpublished, Dockrell accuses Blastland of ‘reject[ing] the research before they had had the opportunity to look at it’. Strangely, Dockrell does not criticise those journalists who unquestioningly reported this unseen study with headlines such as ‘Scottish smoking ban brings big cut in heart attacks’ (2). Nor does he criticise the Scottish government for producing a press release to promote the findings. And he has nothing to say about the report author Jill Pell’s decision to announce the results of a study that had been neither peer-reviewed nor published.

Nor, for that matter, does he criticise his own boss at ASH - Deborah Arnott - for greeting the study with the words: ‘We knew from epidemiological statistics there was a risk from secondhand smoke to cardiovascular health, but not how much of a risk until now.’ (3) For Dockrell, blind faith is the only acceptable response to an unpublished study. Scepticism is not.

Blastland had good reason to debunk the study. Using official data from the Scottish National Health Service (NHS), he could see that the fall in heart attack admissions had been nowhere near 17 per cent: ‘These [data] show a fall in heart attacks for the year from March 2006 - not of 17 per cent, but less than half as much at about eight per cent. What’s more, taking out the recent trend, this is halved again. Heart attacks have been falling steadily for some years now.’

This was the essence of Blastland’s critique. Using official data, rather than the case group selected by Pell, it was plainly obvious that the fall in 2006-07 was an unexceptional extension of an existing downward trend. (For more on Blastland’s article, see Health fears go up in smoke, by Christopher Snowdon).

One of the most puzzling things about the Pell’s ‘StopIt’ study was that she chose to use a sample group when hospital admission data was freely available. Dockrell leaps to her defence, saying: ‘Pell makes no secret of the difference between the data from the StopIt study and the routine discharge data… Although Pell and colleagues had access to the AMI [acute myocardial infarction] discharge data, the StopIt study refers to ACS, a broader measure for heart attacks, verified by assay.’

This is true, but Dockrell fails to mention that Pell had access to the ACS discharge data, too. Everybody does - it is freely available on the Scottish NHS website - and it shows that admissions fell by 7.2 per cent in the first year after the smoking ban and rose by 7.8 per cent in the second year.

Brazenly ignoring the elephant in the room, Dockrell does not mention the rise in admissions in year two, instead pointing out that ‘raw discharge data’ from hospitals is ‘not peer-reviewed’ and suggests that it is not, therefore, reliable. This is not only a ridiculous assertion, it is also a slur on those who compile them. The NHS employs professional statisticians to compile and publish this data. There is no requirement at all for these figures to be peer-reviewed by a medical journal. They are official statistics, reviewed meticulously before being published.

It is hard to believe that Dockrell is seriously suggesting that Pell’s 20-month study of patients in a selection of hospitals trumps a decade of comprehensive data from the Scottish NHS, but that does seem to be the implication.

The news that rates of acute coronary syndrome are now higher in Scotland than they were before the smoking ban was enforced would have been enough to kill off the hypothesis in a less politicised area of research. The Scottish ‘miracle’ has ceased to be. It is no more. It has gone up to join the choir invisible. If Pell hadn’t nailed it to its perch, it would be pushing up the daisies. But instead of quietly backing away from this minor embarrassment, ASH has resolved to defend it at any cost. Left high and dry by the facts, they have resorted to name-calling.

Ad hominem attacks are often used against those who question any aspect of passive-smoking epidemiology. Activists frequently accuse critics of being employees or ‘allies’ of the tobacco industry. Such claims are usually untrue, and certainly are in the case of Michael Blastland. But he writes and broadcasts for the BBC - hardly a pro-tobacco organisation - and is the author of The Tiger That Isn’t, a book which looks at the misuse of statistics. He rarely discusses smoking at all except when, as here, it involves statistical sleight of hand.

Deprived of an opportunity to accuse critics such as Blastland of being in the pay of industry, Dockrell resorts to the slur of saying that: ‘Their position echoes the so-called “AIDS dissidents” who continued to contest that HIV was a causal agent in AIDS long after the scientific debate was over.’

This is a poor argument, particularly coming from a member of ASH. Anti-smoking activists like Dockrell are the first to complain when smokers’ rights groups accuse them of being ‘Nazis’ on the basis that the modern anti-smoking campaign has ‘echoes’ of Hitler’s own efforts to stamp out tobacco.

Comparing critics of these heart studies to AIDS deniers could hardly be more spurious. AIDS deniers, as Dockrell states, protested ‘long after the scientific debate was over’. Debate about studies that purport to show that smoking bans reduce heart attack admissions has barely begun. The first of them only appeared in 2003 and the majority of the other studies have been published in the past two years. Pell’s paper appeared barely six months ago. To compare this slender and recent body of epidemiological evidence to the vast body of scientific evidence about HIV is absurd.

By mentioning the AIDS ‘dissidents’, Dockrell is clearly attempting to persuade the reader that both bodies of evidence are of equal merit, and both sets of detractors are equally deranged. Worryingly, this fallacious argument comes hot on the heels of an article published in the European Journal of Public Health, titled ‘Denialism: what it is and how should scientists respond?’. The article, by the journal’s editor Martin McKee, groups together creationists, AIDS deniers and critics of the Pell study as being peas in the same pod (4).

McKee writes: ‘It took many decades for the conclusions of authoritative reports by the US surgeon general and the British Royal College of Physicians on the harmful effects of smoking to be accepted, while even now, despite clear evidence of rapid reductions in myocardial infarctions where bans have been implemented, there are some who deny that secondhand smoke is dangerous.’

The implication is clear: those who dispute studies such as Pell’s also deny that primary smoking is dangerous. Somewhat inevitably, McKee then introduces the most infamous and most repellent form of ‘denial’: Holocaust denial. ‘This phenomenon has led some to draw a historical parallel with the Holocaust, another area where the evidence is overwhelming, but where a few commentators have continued to sow doubt.’

This goes beyond the pale, but it serves as a reminder of why the word ‘denier’ is becoming so popular amongst those who would prefer to close down debate. It is quite deliberately chosen to bring to mind images of cranks, fraudsters and neo-Nazis. It is, perhaps, the ultimate insult and it is, of course, utterly fallacious.

The evidence for the Holocaust is documented in hours of film footage and is remembered by hundreds of thousands of eyewitnesses. Similarly, the link between HIV and AIDS has been proven by solid biological evidence. What McKee laughably calls the ‘clear evidence of rapid reductions in myocardial infarctions where bans have been implemented’ consists of nothing more than a handful of epidemiological studies of dubious value, created and funded by highly partisan bodies and individuals. Comparing this feeble selection of flawed studies to the thousands of studies conducted into primary smoking, let alone 60 years of evidence for the Holocaust, is obscene.

This kind of abuse ‘echoes’ (as Dockrell might say) the accusation - common in Stalinist Russia - that those who failed to accept the state’s ‘scientific Marxism’ (or the junk science of Lysenko) were either mentally ill or were ‘dissidents’ (Dockrell uses the word dissidents or dissidence seven times in his article). This prevailing view effectively ended scientific and political debate in the Soviet Union in the 1930s just as Dockrell and McKee would like to end the debate over the ‘heart miracles’ today. Both their articles push for a revival of the notion of scientific heresy, rebranded as denialism, something so devilish that it must not be allowed to be heard. It is hard to think of a concept that could be further removed from the scientific method.

Dockrell refers to the famous criteria of causation set out by the noted epidemiologist Austin Bradford Hill - who produced the first, definitive research on smoking and lung cancer in the UK - and claims that the Pell study would pass Hill’s test of strength and consistency. Aside from the fact that the rise in heart attacks in year two of the smoking ban shows this to be sheer nonsense, both he and McKee would do well to remember that neither Hill nor his colleague Richard Doll ever resorted to character assassination when their early studies were contested by other scientists. They might also learn from the example of Albert Einstein, who invited Arthur Eddington to put his ideas to the most rigorous of tests. Or do they believe the findings of Dr Pell to be more robust than the theory of relativity?

Scientific debate should not be reduced to ad hominem attacks. Good scientists are happy to have their theories scrutinised, even when they believe their opponents to be utterly misguided. Good scientists do not announce their findings to the press and then refuse to answer questions. Good scientists do not refuse to release their raw data. Good scientists do not claim that a scientific debate is over before it has been allowed to begin. Above all, good scientists do not slander their critics with barely concealed accusations of madness, corruption or worse.

It is time for the scientific community to speak out about the erosion of scientific discourse and reject the ugly concept of ‘denialism’, censorship and all the twisted reasoning inherent in the rottweiler-style attacks of Dockrell and McKee.

(1) ‘Eye and heart at mortal war: coronaries and controversy in a smoke-free Scotland’, Martin Dockrell, Expert Review of Pharmacoeconomics & Outcomes Research, February 2009

(2) Smoking ban brings big cut in heart attacks in Scotland, study finds, Guardian, 17 September 2007

(3) Heart attacks drop by 17 per cent after smoking is banned, Daily Mail, 17 September 2007

(4) ‘Denialism: what is it and how should scientists respond?’, European Journal of Public Health, 2009, 19 (1): pp.2-4