Tuesday, 19 September 2017

Europuppets still thriving

I'm off on holiday for a week so I shall leave you with this, from a recent 'public health' conference organised by the European Public Health Alliance.

As I have shown many times, we already do. Take the EPHA, for example, which is overwhelmingly funded by the unwitting taxpayer.

'Following the guidelines of the EU Civil Society Contact Group and Alliance for Lobbying Transparency and Ethics Regulation in the EU, EPHA has calculated that it spent an estimated €300,000 in 2013 on activities carried out with the objective of influencing the policy formulation and decision making processes of the European Institutions.'

You won't be surprised to hear that 'public interest lobbying' means campaigning for more taxes, more bans and higher prices.

It's bad enough that these vile people are fighting to make us poorer and restrict our freedom but knowing that they're doing it on our dime is too much.

Monday, 18 September 2017

Glantz's 'expanding tobacco epidemic'

From Stan Glantz's wacky blog...

More evidence that the US permissive policy environment for e-cigs is expanding the tobacco epidemic

Hong-Jun Cho, Lauren Dutra, and I recently published “Differences in adolescent e-cigarette and cigarette prevalence in two policy environments: South Korea and the United States” in Nicotine and Tobacco Research. This paper compares changes in e-cigarette and cigarette use in South Korea and the United States between 2011 and 2015. Korea has maintained restrictive policies on e-cigarettes whereas the US has left them essentially unregulated (a situation that the FDA will continue until at least 2022).

We found that In Korea adolescent e-cigarette use remained stable at a low level, whereas in the United States e-cigarette use increased. Most important, combined e-cigarette plus cigarette use declined in Korea whereas it increased in the US. The restrictive policies in Korea likely contributed to lower overall tobacco product use. These results are evidence against the claims that the availability of e-cigarettes is preventing youth from taking up cigarettes. They also add to the case that a permissive e-cigarette policy environment is making the overall nicotine/tobacco epidemic worse.

Wow, really?! Vaping is expanding the 'tobacco epidemic' among youngsters in the US?

*reads the study*

Cigarette prevalence (past 30 day) decreased in Korea from 12.1% (11.6–12.7) to 7.8% (CI: 7.3–8.3) and in the United States from 11.1% (9.5–12.6) to 6.1% (5.1–7.3). Combined prevalence of cigarette and e-cigarette use (adjusting for dual users) decreased in Korea from 13.2% (12.7–13.8) to 8.5% (8.0–9.1) but increased in the United States from 11.3% (9.7–12.9) to 14.0% (12.4–15.7).

It turns out that South Korea only has 'lower overall tobacco product use' if you pretend that e-cigarettes are tobacco products. The 'increase' in tobacco product use in the US also only exists if you make the same mad assumption.

Back on Planet Earth, the adolescent smoking rate in South Korea remains higher than in the US. The rate has dropped sharply among American youth since vaping became popular. It has dropped less sharply in South Korea.

So it's more pitiful junk science from Glantz and co. As you were.

Tuesday, 12 September 2017

Last Orders - new episode

After a long break, Tom Slater and I are back with a new Last Orders podcast discussing all things nanny state. Our special guest is Claire Fox and we discuss the plastic bag tax, loony anti-obesity proposals and ten years of the smoking ban.

Listen here.

And if you're in a podcasty frame of mind, you can listen to me take on anti-sugar fanatic Graham MacGregor in this week's Spectator podcast.

Thursday, 7 September 2017

A shoddy attempt to turn Big Alcohol into Big Tobacco

If you were involved in the revision of the UK's alcohol guidelines, you are the last person in the world who should be criticising others for misrepresenting evidence. As I've explained before, the benefits of moderate drinking were subjected to the full 'merchants of doubt' treatment by the Chief Medical Officer's guidelines committee. They blatantly cherry-picked the evidence, relying heavily on the work of one sceptic (Tim Stockwell) while raising a bunch of zombie arguments that have long since been debunked in the literature.

But 'public health' knows no shame and so Mark Petticrew, the activist-academic who helped lead the evidence review - and who told his colleagues what the conclusion was going to be before it had got started - has popped up today with a diatribe dressed as a study, claiming that the drinks industry 'appears to be engaged in the extensive misrepresentation of evidence about the alcohol-related risk of cancer.' 

His evidence for this comes from the tried and tested quack methodology of doing a Google search and, er, misrepresenting the evidence. Written with three colleagues - although I'll just say 'Petticrew' in this blog post for brevity - he breaks the industry's alleged misrepresentations into several categories.

He starts with what turns out to be his strongest evidence. Under 'Denying, disputing or selectively omitting the relationship between alcohol consumption and cancer', he quotes the International Alliance for Responsible Drinking (IARD) and some Canadian organisation who say:

‘Recent research suggests that light to moderate drinking is not significantly associated with an increased risk for total cancer in either men or women.’  International Alliance for Responsible Drinking

'Some studies show a link between alcohol and breast cancer among both pre-menopausal and post-menopausal women. However, no causal relationship has been shown between moderate drinking and breast cancer.’ Éduc’alcool (Quebec)

The first of these quotes, from IARD, cites a BMJ study from 2015. The study actually does show an increase in total cancer risk from moderate drinking for women, but not for men. The IARD quote is badly worded, at best, and is all the stranger because they go on to explain the results of the study correctly in the sentences that follow (Petticrew doesn't quote that bit). The risks are extremely low, amounting to an increased risk of between two to four per cent, but they are not completely absent.

However, there is evidence from other sources that moderate and light drinkers do not have a higher cancer risk. Only last month a large American cohort study found that overall cancer risk was 0.89 (0.82-0.97) for light drinkers and 0.95 (0.85-1.05) for moderate drinkers. This means that light drinkers were significantly less likely to die from cancer in the study period. Nevertheless, the source used by IARD does not accurately reflect the statement quoted by Petticrew so it's 1-0 to him.

The second quote depends on what evidence you consider sufficient for a 'causal relationship'. Epidemiology famously cannot prove causation, but most authorities consider the statistical association to be good enough to infer it in this instance. On that basis, the Quebec organisation could be said to be 'disputing' the evidence, albeit no more than Petticrew and his chums have been disputing the much greater weight of evidence about the benefits of moderate drinking.

This is as good as the study gets as an exposé of industry 'denial'. Everything else in it is drivel, as we shall see. For the most part, Petticrew excoriates the industry for saying things that are patently true.

Under 'Distortion: mentioning some risk of cancer, but obscuring, misrepresenting or obfuscating the nature or size of that risk', he writes

It is commonly stated by these organisations (12/20 SAPROs) that the risk of some common cancers only exists for ‘heavy’, ‘excessive’ or ‘binge’ drinking. For example,

‘Cancer risk associated with the consumption of alcohol is related to patterns of drinking, particularly heavy drinking over extended periods of time.’ Australia, Drinkwise

In what universe is this stating that risk 'only' exists for heavy drinkers? If Drinkwise had meant to say that, they would have done so. As it is, the use of the word 'particularly' clearly implies that there is risk, albeit less risk, for non-heavy drinkers.

Similar statements also appear on the IARD website, such as ‘In general, alcohol-associated cancers have been linked with heavy drinking’ [27].

The scientific evidence suggests that such statements are misleading (Table S1), because the increased risk of some common cancers, such as breast, oesophageal, laryngeal, mouth and throat cancers and cancers of the upper aerodigestive tract, starts at low levels of consumption, even though it is low at those low levels [7,8] (see also Table S3).

Like the Drinkwise quote above, the IARD statement is true. Cancer risk is clearly related to patterns of consumption and heavy drinkers have a greater risk than light drinkers. IARD's report Drinking and Cancer provides five academic references to support this.

It is an indisputable facts that some cancers, such as liver cancer and possibly pancreatic cancer, are only associated with alcohol if you're a heavy drinker. For those cancers which are linked to moderate consumption, risk is significantly greater for heavy drinkers. Neither of the sources quoted above suggest otherwise, and the IARD document explicitly discusses the cancers that are - or might be - linked to light/moderate consumption.

It should also be noted that in the press release for this 'study', Petticrew says:

'It's important to highlight that if people drink within the recommended guidelines they shouldn't be too concerned when it comes to cancer.'

If IARD had said that, he would doubtless condemn them for downplaying the risks or being 'misleading'.

He continues:

Other industry claims (from three organisations) relate to disputation of the mechanisms, or involve claims about the consistency of the evidence, as in these examples:

‘Recent studies indicate a dose-response relationship between alcohol consumption and breast cancer, although this relationship was not evident in some past studies.’ IARD [27].

‘All the studies show that the knowledge about the causes of breast cancer is still very incomplete and as scientists from the National Institute on Alcohol Abuse and Alcoholism in the USA recently pointed out, some other (possible confounding) factors have not been considered in the research relating the consumption of alcoholic beverages to breast cancer.’ Wine Information Council [28].

This is also a feature of SABMiller materials:

‘The mechanism by which alcohol consumption may cause breast cancer is not fully known.... The relationship... is undergoing vigorous research... If and how these two factors may interact and affect risk is not completely known.’

All of these are uncontroversial statements of fact and plenty of non-industry sources echo them.

Here is the American Cancer Society, for example:

Exactly how alcohol affects cancer risk isn’t completely understood. In fact, there might be several different ways it can raise risk, and this might depend on the type of cancer.

And here is Cancer Research UK:

According to Dr Ketan Patel, a Cancer Research UK expert on how alcohol causes cancer: “We don’t really know. We don’t fully understand why alcohol causes some cancers and not others.”

Petticrew says that statements like this are examples of the industry tactic of 'Claiming or implying that, as knowledge of the mechanism is incomplete, the evidence of a causal relationship is not trustworthy'. That's rich coming from him. The alcohol guidelines review repeatedly cast doubt on the benefits of moderate drinking by falsely claiming that there is a 'lack of well evidenced biological processes that could explain the effect' and then presenting this as proof that the benefits do not exist at all.

Petticrew pulls exactly the same trick in his little polemic when discussing non-Hodgkin lymphoma which has been inversely associated with alcohol consumption. Keen to dismiss any benefits from drinking, he quotes an authority saying that 'there is no immediately obvious mode of action that could explain the association.'

But there is a difference between what Petticrew does and what the industry and cancer charities quoted above are doing. They explicitly state that the risks are real but that the causal mechanisms are not fully understood. Petticrew, by contrast, is claiming or implying that, as knowledge of the mechanism is incomplete, the evidence of a causal relationship is not trustworthy.

Petticrew then mentions the Portman Group...

The Portman Group’s response to the consultation on the revised UK guidelines (issued in 2016) includes a section in which the evidence is disputed, referring to protective effects. It refers to the ‘increased risk of a small number of cancer types’ and states: ‘Different levels of alcohol consumption have a range of effects on cancer risk including no impact on the majority of cancers, and in some cases, an inverse relationship.’ [11]. As well as misrepresenting the evidence, this statement is misleading as it confuses the number of different ‘types’ of cancer, with the risk of specific cancers.

Again, everything the Portman Group says here is true. The press release that accompanies Petticrew's article correctly notes that alcohol 'accounts for about 4% of new cancer cases annually in the UK.' There are more than 100 different types of cancer and IARC has established that alcohol consumption could cause seven of them: 'cancers of the oral cavity, pharynx, larynx, oesophagus, colorectum, liver (hepatocellular carcinoma) and female breast.' They also noted that 'an association has been observed between alcohol consumption and cancer of the pancreas'. But that's it.

It is reasonable to describe seven out of 100 as a 'small number' and it is indisputable that alcohol has 'no impact on the majority of cancers'.

It is also true that an inverse relationship between alcohol consumption and a few forms of cancer, including renal cancer and non-Hodgkin lymphoma, has been repeatedly found in epidemiological studies. Petticrew asserts that there is a 'lack of evidence for protective effects of alcohol consumption on cancer'. An unbiased reader who reads the meta-analyses (see links in previous sentence) might conclude that he sets the bar of proof higher for evidence that shows benefits than for evidence that shows harm.

The Portman Group is neither 'misrepresenting' nor 'disputing' the evidence. Petticrew chooses not to quote from page 20 of Portman's consultation response in which they explicitly say:

'The relationship between alcohol consumption and increased risk of certain cancers is clear and we believe it is important consumers are aware of this.' 

Moreover, the sentence immediately before the one Petticrew quotes (beginning 'Different levels...') says:

'We fully accept the evidence on the links between alcohol and certain types of cancer.'

Under 'Distraction: focussing discussion away from the independent effects of alcohol in increasing the risk of common cancers', Petticrew cites the following examples of the industry saying things that are 'potentially misleading':

‘Not all heavy drinkers get cancer, as multiple risk factors are involved in the development of cancers including genetics and family history of cancer, age, environmental factors, and behavioural variables, as well as social determinants of health.’ Australia: Drinkwise [26].

‘Alcohol has been identified as a known human carcinogen by IARC, along with over 1,000 others, including solvents and chemical compounds, certain drugs, viral infection, solar radiation from exposure to sunlight, and processed meat.’ IARD [27].

‘For example, the fact that you are female is a risk factor in developing breast cancer. We also know breast cancer is age-related so you’re more likely to develop it as you get older and that you’re more prone to breast cancer if it is part of your family history. These are all factors beyond our control. We also know that risk is related to the ‘hormone environment’ that women experience during the course of early pregnancy, child birth and breastfeeding which all exert a protective effect.’ Drinkaware, UK [32].

These are mundane statements of fact. It seems that Petticrew won't be happy until the alcohol industry's only health message is 'IF YOU DRINK, YOU'LL DIE!!! GET AWAY!!!'

In fact, these 'industry messages' are not very different from that of the Committee on Carcinogenicity, who say:

Drinking alcohol has been shown to increase the risk (or chance) of getting some types of cancer. This does not mean that everyone who drinks alcohol will get cancer, but studies have shown that some cancers are more common in people who drink more alcohol.

The Drinkaware discussion of breast cancer is similar to what you will find on Cancer Research's webpage about breast cancer. Although Petticrew doesn't mention it, the quote he uses is from Professor Paul Wallace, an epidemiologist with an impressive CV in alcohol research, who is Drinkaware's Chief Medical Advisor. The full quote runs as follows:

Professor Wallace says it’s important to put this risk into context. There are many other factors which increase the risk of developing breast cancer. “I often sit down with my patients and explain that there are certain factors we can do nothing about,” he says. “For example, the fact that you are female is a risk factor in developing breast cancer. We also know breast cancer is age-related so you’re more likely to develop it as you get older and that you’re more prone to breast cancer if it is part of your family history. These are all factors beyond our control."

There is a lot that Petticrew could have quoted from that Drinkaware webpage but didn't, presumably because it wouldn't fit his narrative of an industry cover up. For example:

When asked to name the main health effects of drinking too much alcohol, many people will first say liver disease. Others will mention heart disease. Some will name mental health issues. Cancers are often low down on the list.

But they shouldn’t be – especially breast cancer.

It is clear from a number of large scale studies that there is a link between alcohol consumption and cancer. Globally, one in five (21.6%) of all alcohol-related deaths are due to cancer. Breast cancer is the most common cancer among women and second only to lung cancer as a cause of cancer death in women.

Professor Paul Wallace, Drinkaware’s Chief Medical Advisor, believes that more people should know that alcohol can increase women’s risk of getting breast cancer.

I challenge any reasonable person to read this - or, indeed, any Drinkaware literature - and claim that the organisation is trying to downplay or deny the risks of drinking. I was on a Drinkaware panel once. They are basically a temperance group. Only a lunatic could think otherwise.

Petticrew says that there are 'two particularly frequent areas of misinformation', namely breast cancer and colorectal cancer. As evidence, he goes back to the Portman Group...

The Portman Group’s response to the UK guidelines includes a section on breast cancer, in which the evidence is disputed. For example, it states that ‘studies associating moderate alcohol consumption are contradictory’.

Is the evidence 'disputed' by the Portman Group? No, it is not. Here is what the Portman Group actually said in their consultation response:

A percentage (6%) of all breast cancer cases in the UK is attributable to alcohol - the links between alcohol consumption and breast cancer are clear and it is right that consumers are made aware of the risks.

As for the studies being 'contradictory', there is some truth in this, but it is not the Portman Group saying it. The Portman Group were only quoting some (reputable) scientists who said:

'Since studies associating moderate alcohol consumption and breast cancer are contradictory, a woman and her physician should weigh the risks and benefits of moderate alcohol consumption.'

Petticrew misquotes this and wrongly attributes it to Portman, which is sloppy at best. In fact, the point being made by the Portman Group is that risks should be explained in a meaningful way. This is not controversial. Cancer Research UK have made an effort to explain breast cancer risk in absolute, rather than relative, terms. John Holmes made a similar point in a journal article this week.

Nevertheless, Petticrew repeats his false claim about Portman disputing the evidence, saying:

...in disputing the evidence on increased breast cancer risk, the Portman Group document does not reference the IARC reviews, other systematic reviews, nor the Committee on Carcinogenicity review.

Not only is the initial claim a lie, but the claim about references is also a lie. The Portman Group document cites the Committee on Carcinogenicity reports several times and uses it as a source for a table which shows 60,000 breast cancer cases a year, of which Portman says alcohol causes 3,600 (see below).

This is a strange way of 'disputing the evidence'.

What is the point of all this flim-flam? Regular readers will have probably guessed. It's all part of creating a narrative of alcohol being the new tobacco and Big Booze being the new Big Tobacco. And he's good the headlines he wanted.

If you want to know why a 'public health' study has been written you have to head straight to the 'discussion' section where it all comes out...

The most obvious parallel is with the global tobacco industry’s decades-long campaign to mislead the public about the risk of cancer, which also used front organisations and CSR activities to mislead the public.

...These findings therefore have significant implications. They provide evidence that the AI [alcohol industry], like the tobacco industry, misleads the public and policy-makers about the cancer risks of their products. Our findings are also a reminder of the risk which accompanies giving to the AI the responsibility of informing the public about alcohol and health.

...some public health bodies, academics and practitioners liaise with the industry bodies included in this study, for example by acting as advisors or trustees, or by collaborating with them in implementation activities. Despite their undoubtedly good intentions, we suggest that it is unethical for them to lend their expertise and legitimacy to industry campaigns which mislead the public about alcohol-related harms.

The AI, unlike the tobacco industry, still has significant access in many countries to government health departments. It is also active in the international policy arena, with, for example, partner or stakeholder status at World Health Organization and United Nations meetings relevant to alcohol, on occasions when the tobacco industry is excluded. This study shows that the AI uses similar tactics to the tobacco industry, to the same ends: to protect its profits, to the detriment of public health.

There you have it. Petticrew is none-too-subtly telling academics to back away from the alcohol industry if they want to keep their reputations intact in the coming war on drink. He is also sending a signal to politicians that industry always lies while anti-alcohol campaigners, such as himself, are trustworthy. And he is telling governments to lock drinks companies out of the political process as has happened with tobacco under the Framework Convention on Tobacco Control.

Petticrew gets to this conclusion by saying things that are not true and denying things that are true. His study uses sleight of hand, evasion and downright misrepresentation to create a false narrative that falls apart as soon as you look at the primary sources. He does precisely what he accuses the industry of doing: selectively quoting from research in order to mislead, lying by omission, and making claims that cannot be supported by the weight of evidence.

For all of Petticrew's bluster, the drinks industry is dominated by massive, blue-chip companies with who would get sued if they lied about the harms of drinking. 'Public health' academics have no such incentive to stay honest.

Not for the first time, Petticrew has started with a conclusion and scrambled around for evidence to support it. When he failed to find any evidence, he wrote what he was going to write anyway. If the 'public health' movement had any integrity, the man would be a pariah.

Spectator - obesity edition

I've got an article in tomorrow's Spectator about the government's doomed attempts to control people's waistlines. It's online now...

James Cracknell, the athlete turned anti-obesity campaigner, was the subject of sniggering and derision in April when he said that North Korea and Cuba had got a ‘handle on obesity’. With impressive understatement, he attributed this to both countries being ‘quite controlling on behavioural trends’. It was a bad point poorly made, but in a roundabout way he drew attention to the major obstacles faced by those who want to reduce obesity rates in the rest of the world: freedom and affluence.

Do read it all and also have a listen to the Spectator podcast in which I debate the issue with Graham MacGregor (Action on Sugar/Salt) and Francesco Rubino (KCL).

Wednesday, 6 September 2017

Spanish smoking ban miracle

It is with a heavy heart that I must inform you that someone's written another yet smoking ban miracle study.

This time it comes from Spain where a partial ban was introduced in 2006 followed by a 'comprehensive' ban in 2011. The authors look at these two dates and study two types of hospital admission (for asthma and COPD), thereby giving themselves four bites of the cherry to find a correlation.

They pooled a bunch of hospitals together and came up with this mess of inconsistent and contradictory results:

Can you see clear evidence of hospital admissions falling after either of the bans? Neither can I, but the authors claim that the following findings emerged:

The partial smoking ban was associated with a strong significant pooled immediate decline of 14.7% in COPD-related admission rates...



There was no subsequent effect of the comprehensive ban on COPD-related admission rates...


But for asthma, it was the other way round...

Asthma-related admission rates increased by 12.1% immediately after the partial ban...


...but decreased by 7.4% after the comprehensive ban.


This is pretty much the definition of a mixed result. Can you guess how it was written up in the abstract?

The partial ban was associated with an immediate and sustained strong decline in COPD-related admissions, especially in less economically developed provinces. The comprehensive ban was related to an immediate decrease in asthma, sustained for the medium-term only among men. 

If you guessed they would ignore the null and negative findings and focus only on the positive findings then give yourself a pat on the back. You know them too well.

Let's try to get our heads around this, shall we? The underlying assumption here is that smoking bans reduce hospital admissions by reducing exposure to secondhand smoke. If so, it seems that the partial ban was so successful in reducing secondhand smoke exposure that it reduced COPD admissions by 14.7 per cent. This is pretty bloody impressive when you consider that COPD is a chronic disease that takes decades to develop and which mostly affects smokers.

But despite the miraculous effect on COPD, the partial ban had the weird effect of increasing admissions for asthma by 12 per cent, although you can see from the graph above that there were about the same number of admissions after the 2011 ban as there had been in 2003 when there was no ban of any kind. And when it came to the comprehensive ban, asthma rates fell but COPD rates didn't.

Does any of this seem plausible? Does it make a lick of sense? I would suggest not.

It is sheer garbage. Manifestly so. The best result these jokers can produce is a fall in COPD admissions during a partial ban. That ban must have done a hell of a job of reducing secondhand smoke exposure, huh?

Well, no. Not according to the authors of the Tobacco Control Scale who celebrated the introduction of 2011's comprehensive ban by saying:

The 2005 so-called Spanish model (weak smokefree legislation in bars and restaurants), praised by the tobacco industry, is finally dead. In 2010 Spain adopted far reaching and comprehensive legislation on smokefree bars and restaurants.

The same authors had previously described the 2006 ban as 'weak and ineffective, and a study of it published in 2009 concluded that:

Among nonsmoker hospitality workers in bars and restaurants where smoking was allowed, exposure to SHS after the ban remained similar to pre-law levels.

And yet this 'weak and ineffective' legislation had a massive effect on COPD admissions whereas the 'comprehensive legislation' five years later did diddly-squat. The miracle becomes more confusing when you consider that the ban which reduced COPD admissions somehow increased the number of asthma admissions.

This data-dredging bilge makes no sense on any level. Even if you accept the authors' prior beliefs about secondhand smoke, it defies all logic. The authors don't even attempt to explain the contradictions and yet this utter drivel got published in a peer-reviewed journal, just like all its ludicrous predecessors got published in peer-reviewed journals. It is beyond a joke.

Tuesday, 5 September 2017

Did the smoking ban make the number of childhood chest infections plummet?

From The Herald...

Smoking ban sees child chest infections plummet

Really? I may be jaded from years of bitter experience but I suspect that this claim is going to turn out to be bullshit.

Children needing hospital treatment due to chest infections may have dropped by as much as a fifth since anti-smoking laws were introduced, research suggests.

A study led by the University of Edinburgh and the Erasmus University Medical Centre in the Netherlands combined data from 41 papers in countries where tobacco control policies have been introduced.

The figures suggest rates of children requiring hospital care for severe chest infections have dropped by more than 18% since bans were introduced.

OK, so it's a meta-analysis and, as the BMJ says, it's looking at admissions for lower respiratory infections.

Hospital admissions of children with lower respiratory tract infections have fallen by 18.5% since the public smoking ban and 9.8% fewer children have attended hospital for severe asthma exacerbations, research published in the Lancet Public Health shows.

The BMJ implies that the findings are specific to Britain whereas they are sourced from various junk studies from various countries, but what applies to one country should apply to all and claims have been made in the past about childhood hospital admissions for lower respiratory infections falling by 13.8 per cent in England after the smoking ban was introduced.

So let's see if it's true shall we? Here's something you can do at home. It's called 'fact checking' and at one time journalists were rumoured to have done it.

Here is the NHS database of hospital admissions.

There you will find 'Emergency admissions for children with lower respiratory tract infections (LRTIs)'.

Click on that and you will get a spreadsheet showing the number of admissions in each financial year for the whole of England between 2003/04 and 2015/16. You can also get the standardised ratio figures.

Chart them on a graph and you will see this. Note that the smoking ban started in 2007.

As I suspected, then, it's bullshit.

Supermarket alcohol: a Giffen good?

The Institute of Temperance Studies - or whatever they call themselves now - published the results of a survey of publicans last week that showed that they want lower tax on pub booze and higher tax on supermarket booze. Fancy that!

It also showed support for minimum pricing. We have seen before that some of the more short-sighted PubCos are happy to get into bed with the temperance lobby on this issue because they think it will benefit them. I think they are mistaken. It would be a disastrous mistake in the long-term to hand the price mechanism to the state and there would be no short-term benefit. Indeed, there is likely to be a short-term cost, as I explain at Spectator Health today...

If the price of food in supermarkets rose by 50 per cent, no one would predict a surge in demand for expensive restaurants. On the contrary, higher supermarket prices would make consumers eat out less to save money for groceries. So it is with alcohol. Consumers are well aware that pub prices are higher than supermarket prices. If pubs were no more than an alternative location in which to buy alcohol, everybody would go to the supermarket and the pubs would be empty.

Pubgoers are buying much more than a drink. They are buying an experience, with ambience, company, service and entertainment. There is no doubt that some consumers would prefer to drink at home less and visit the pub more, but they are unable to do so because of high prices in the off-trade. But minimum pricing is not going to make a pint in a pub cheaper. It is just going to leave people who buy alcohol in supermarkets with less disposable income. Unless these people have a highly inelastic demand for pubs and a highly elastic demand for alcohol – a strange combination of preferences – they will need to cut expenditure elsewhere to maintain their alcohol intake. Buying fewer drinks in the on-trade is one way of doing this.

Monday, 4 September 2017

Send ASH to prison

Mystic Debs does it again - from New Scientist

There is no better way of predicting the future than listening to what Action on Smoking and Health (ASH) have to say and preparing for the exact opposite. Whether they are claiming that high taxes don't cause smuggling, or that smoking bans are good for pubs, or that it makes economic sense for shopkeepers to stop selling cigarettes, the truth can invariably be found by turning their statements at an angle of 180 degrees.

So when prison officers saw this in 2015, they should have been reaching for the tear gas...

Deborah Arnott, chief executive of charity Action on Smoking and Health, said there was no evidence to support claims that depriving prisoners of tobacco could lead to riots.

In a New Scientist article headlined 'I don't predict a riot', Arnott said:

... every time the idea of a ban is raised in the media, the headlines inevitably focus on fears of unrest and riots, rather than the health and wellbeing of inmates and staff.

The hypothesis that depriving smokers of tobacco could destabilise prisons may sound plausible, but there is little evidence to back it up.

As always in 'public health', there is a big difference between what they call 'evidence' and what happens in the real world. There have been numerous prison riots caused by smoking bans, such as those in Quebec in 2008, Kentucky in 2009, Florida in 2013, Queensland in 2014,  Melbourne in 2015 and Victoria in 2015 (the last of these received global news coverage and occurred a month before Arnott's article was published).

Arnott claimed that...

Psychiatric premises, including high-security facilities such as Broadmoor, went completely smoke-free in 2008, without any trouble.

Even this is not true. The smoking ban in psychiatric facilities immediately caused a riot at Ashworth Hospital. And most psychiatric facilities still allow smoking outdoors, although ASH are sadistically working to close that 'loophole'

Over the next few months, a total smoking ban will be 'phased in' across the entire prison estate, indoors and out. They're starting with the Category B and C prisons before moving on to the more problematic high security prisons. Those who know the prison system say that a ban will face the biggest challenges in Category A prisons, but it turns out that banning smoking in Category B and C prisons is not a breeze either.

We want burn!' Rioting prisoners 'demand tobacco' at Birmingham prison with 'one wing lost' as anti-riot teams prepare to storm jail

This follows reports reports in July of a smoking-related riot at Drake Hall Women’s Prison and a nine-hour riot at a Category C prison in Cumbria last month.

These reports only scratch the surface of the trouble caused by banning smoking in prison. A prison riot has to be big before it gets reported in the national press (which usually means something has to be on fire) and sometimes the media will not mention the fact that the smoking ban was the cause - as the BBC's article about the Birmingham riot didn't.

And riots are only the most visible part of the problem. The rise in violence and the increased significance of tobacco as a prison currency are the more persistent problems that plague prisons after bans are introduced. As one prisoner says in this interesting article...

'You've got your violence that'll happen at the start, these riots, that'll die down. You've got your violence that'll come with making baccy contraband – that'll become a way of life.'

It seems to be that since Deborah Arnott and her ASH colleagues have been the main force lobbying for a ban on smoking in prisons, they should be sent into a few jails to explain to the prisoners why they believe it's for their own good. HMP Birmingham would be the ideal place to start.

PS. It appears from the letter below that the prison service did not conduct a risk assessment before introducing the ban (click to enlarge). I guess Arnott's glib assurances were sufficient.

Thursday, 31 August 2017

Get your story straight

Philip Morris (PMI) are in the process of rolling out their heat-not-burn product IQOS around the world. The company has famously said that it wants to stop selling cigarettes once it has converted existing smokers to the reduced-harm device. On Tuesday they announced that three million smokers have already switched, mostly in Asia.

Nothing happens in the world of tobacco without anti-smoking campaigners trawling through the archives to find a shaky historical parallel. Last week, Stanton Glantz tried to poison the well of harm reduction with a bizarre article about PMI being in favour of nicotine gum (or something).

This week, Ruth Malone, the gormless editor of Tobacco Control, has piped up with an article titled '“It doesn’t seem to make sense for a company that sells cigarettes to help smokers stop using them”: A case study of Philip Morris’s involvement in smoking cessation'. The quote comes from a focus group member talking to a consultancy, but it may also reflect American anti-smoking zealots' view of IQOS.

The article is open access so you can read it here if you're bored, but there isn't much in it. The gist is that PMI's smoking cessation service QuitAssist was not to Malone's liking (apparently they resisted using 'anti-industry themes'. Well, duh.) My only reason for mentioning it is to flag up the following quote that was spotted by Sarah Jakes on Twitter.

A particularly notable absence [from PMI's QuitAssist program] was the lack of financial support to help smokers purchase NRT, the very action that consultants Bain and Company had argued would allow PM to have the largest impact on quit rates.

Do try to keep up, Ruth. You're behind the times. In the newly revised history of tobacco, PMI secretly approved of NRT (nicotine replacement therapy) from the early 1990s onwards because they knew it didn't work and it kept people smoking. We know this because Stanton Glantz said so in a peer-reviewed journal.

So if PMI wanted to undermine its own stop-smoking efforts, they should have been shovelling money at nicotine gum and patches. If they had done that, they would have been applauded by the tobacco control lobby while (supposedly) boosting cigarette consumption. Then they could have gone back to their underground lair to laugh demonically like the cartoon villains that they are.

But as you so rightly say, Ruth, they didn't do that. They chose not to hand out NRT as part of their smoking-cessation program which means that either Glantz's theory or your theory is a load of old toot.

Or, quite possibly, both.

Wednesday, 30 August 2017

Alcohol policy in the real world

Neo-temperance dogma says that the best way of reducing alcohol-related harm is to tackle the Three A's: advertising, affordability and availability.

The current available scientific evidence supports prioritization of multiple cost-effective policy actions – the so-called three alcohol policy best buys:

  • Increasing alcohol beverage excise taxes,
  • Restricting access to retailed alcohol beverages and
  • Comprehensive advertising, promotion and sponsorship bans

These policies will supposedly reduce per capita consumption which will supposedly reduce harmful consumption and therefore reduce alcohol mortality. By the same token, relaxing licensing laws, permitting advertising and making alcohol more affordable will have the opposite effect.

The Three A's are the Holy Trinity of alcohol policy, endorsed by the WHO and every 'public health' organisation you can think of. For example, in Health First: An Evidence-Based Alcohol Strategy for the UK, it says categorically...

Long-term success in minimising the harm from alcohol will only be achieved by population measures that reduce the affordability and availability of alcohol products for all drinkers. The research evidence is unequivocal: such population measures are the most effective in reducing alcohol consumption and alcohol-related harm. [My italics]

As neat and tidy as this theory is, drinkers have conspicuously failed to comply with it. In Britain, for example, campaigners claim that alcohol has become 60 per cent more affordable since 1980 and yet per capita consumption of alcohol is no higher today than it was then. Alcohol has become more widely available thanks to the Licensing Act and yet per capita consumption has fallen by nearly a fifth since it was introduced in 2005.

An interesting little study was published last week with some similarly awkward facts, this time from Denmark. The researchers looked at various factors that could influence the Danish drinking culture and looked for evidence of an impact on consumption and harm.

The first thing they noticed was that there was decline in alcohol consumption between 2003 and 2013 which was accompanied by a decline in alcohol-related mortality. So far, so good (although, interestingly, they found evidence of a rise in problem drinking at the same time).

Was this due to alcohol becoming less affordable? Far from it. There was a large cut in the tax on spirits in October 2003 of 45 per cent. Since then, the authors say, 'prices have either remained stable or have decreased'. Since incomes have increased in Denmark since 2003, this means that...

... purchasing power has made alcohol more affordable, along with lower prices through decreased taxes, theoretically this should have enabled, if not encouraged, Danes to buy and consume more alcohol.

But it didn't.

What about advertising? Unlike other Scandinavian countries, Denmark allows alcohol advertising to be published in the print media with relatively few restrictions and it can be broadcast on television and radio at any time. As in the UK, the content of drinks advertisements is self-regulated.

The only substantive change to the advertising environment identified by the researchers in Denmark was a tightening up of the industry's voluntary code in 2010. They conclude that 'advertising has become more restricted over our study period, even if it has been accomplished by self-regulatory measures of the alcohol industry.' These voluntary restrictions emphasised a commitment to avoid advertising to children, but this was already part of the self-regulatory code before 2010 so it is doubtful whether it made much difference to the content of the advertisements. (Incidentally, 'public health' campaigners claim that self-regulation is ineffective and therefore cannot argue that these minor changes reduced alcohol mortality).

Thirdly and finally, there is availability. Did alcohol become harder to obtain? No. On the contrary, the researchers note that...
Two laws affecting the physical availability of alcohol in Denmark were lifted on 1 July 2005. Both concerned off-premise sales of alcohol and point towards liberalising previous restrictions (Danish Health Authority, 2014). One of these was the elimination of a law which had set the closing of sales at 8 PM in grocery stores and a partitioning off of the display area after alcohol sales hours. Additionally, the ‘‘restaurant law’’ was lifted. Previously sales of alcohol to take away from a restaurant had to take place in a room separate from the eating establishment.

Taken together, the situation in Denmark is very much like that of the UK. Licensing laws have been relaxed, alcohol has become more affordable, and advertising appears in all media under a system of self-regulation. According to the wisdom of 'public health', this should have led to a rise in alcohol consumption and a rise in alcohol-related mortality. It has done neither.

The study's authors acknowledge that this is hardly an isolated example and refer to this study from Italy where alcohol consumption fell from 16 litres per person in 1971 to 7 litres in 2005. Over the same period, deaths from liver cirrhosis fell by around two-thirds.

Which of the Three A's accomplished this miracle? The answer, again, is none of them. The authors note that 'there have been very few implemented policies, and these have often been weak and generic'. The most popular drink in Italy is wine but wine duty was 'zero throughout this period.' Although there were some increases in the tax rate of spirits, they were not introduced until the 1990s by which time alcohol consumption had already fallen to less than 9 litres per person. Advertising continued to be largely unrestricted and the only significant change to licensing laws was a ban on the sale of alcohol after 3am, but that did not happen until 2010.

In conclusion, the Italian researchers say:

The ineffectiveness of the preventive policies on the alcohol consumption trends is striking... Alcohol policies, which are usually considered to be the main contributor to changes in consumption and alcohol-related harm, are not able to explain the changes in alcohol consumption which have occurred in Italy during the last decades.

Neither the authors of the Danish study nor the authors of the Italian study are able to explain why alcohol consumption and associated harms declined in their respective countries. The Italian study is even titled 'The puzzle of Italian drinking'. Given that the outcomes seen in these countries are exactly what 'public health' campaigners claim to want, you would think there would be a concerted effort to find out what caused them. Reducing harm without infringing on the rights of drinkers should be the Holy Grail of alcohol policy and yet there does not seem to be much eagerness to learn from real world case studies.

If the 'public health' lobby took evidence seriously, they would want to understand why there is no correlation between supply-side alcohol policies and alcohol consumption. Instead, they ignore what real people do in real countries and focus on computer models which repeat back whatever assumptions they have programmed into them.

When all you have is a hammer, everything looks like a nail.

Monday, 28 August 2017

Anti-vaping agitprop at the Guardian

An article in the Australian edition of the Guardian has been annoying vapers but the person responsible says she can't understand why.

We have come across Melissa Davey before. Simon Chapman was quick to take her under his wing when she took a Masters in 'Public Health' at Sydney University a few years ago. She has since got a job at the Guardian writing blatantly partisan articles about health policy from the Chapman perspective.

Her latest effort is all the more pernicious for its pretense of balance. On its face, it is about the split in the 'public health' movement over e-cigarettes. Davey implies that this split is somewhere in the region of 50/50 whereas Chapman's prohibitionist stance is extreme and increasingly marginal.

Davey quotes liberally from vaping opponents Miranda Ween, Simon Chapman ('world-renowned tobacco control expert') and Chapman's protégé Becky Freeman. She also quotes from submissions to the government's recent consultation from Cancer Council Australia and the Australian Medical Association, both of which are also in the prohibitionist camp. 

On the pro-vaping side, she quotes Alex Wodak and Colin Mendelsohn. She fails to mention any of the health organisations, such as Public Health England or the Royal College of Physicians, that support vaping but she does quote from Philip Morris's submission to the consultation.

The Philip Morris reference is part of a narrative that portrays e-cigarettes as a tobacco industry plot. Never mind that PMI's focus is on its heat-not-burn product IQOS rather than e-cigarettes. Never mind, too, that the consultation was inundated with responses from ex-smoking vapers, none of which are quoted or even acknowledged in the article. Instead, the phrase 'big tobacco' appears nine times and she ends the piece by writing...

The question of how harmful these products are and whether they can save significant numbers of smokers from a lifelong addiction may still be up for debate. But there is no doubt if the products take off in Australia and become more widely available, big tobacco’s under-pressure profit margins will have some relief.

In fact, there is a great deal of doubt about this. In the UK, where vaping has taken off under a free market, cigarette sales have fallen dramatically and the main beneficiaries have been independent vape shops, such as Totally Wicked. The market is dominated by second and third generation e-cigarettes which tobacco companies have been slow to embrace. Tobacco companies would have a much easier time if the smoking rate had flat-lined, as it has in Australia.

In terms of pure column inches, Davey's article is far from balanced. The image below shows the anti-vaping content versus the pro-vaping content. There is at least twice as much of the former, even if you exclude Davey's own editorialising and focus on quotes from other people.

But there is more to Davey's bias that sheer volume of words. Every claim in support of e-cigarettes is challenged and every fact that goes against her view is given a caveat. For example, she writes:

There are smokers who credit e-cigarettes with having help them quit. The scientific literature, however, suggests they are not all that effective...

The link is dead so who knows what her source is for this claim, but there is ample scientific evidence from clinical trials and observational epidemiology that e-cigarettes work much better than placebos in helping people quit smoking. Davey's implication that the evidence for vaping is purely anecdotal is deeply misleading.

Elsewhere she writes:

A statistic often cited is they are 95% safer than cigarettes, but this has been disputed.

The statistic comes from a Public Health England report but Davey doesn't mention that, presumably because it would confer a degree of credibility upon it. Her source for it being 'disputed' is a Guardian article about a scurrilous Lancet editorial in 2015 which attempted to portray David Nutt and his colleagues as tobacco industry stooges. Aside from this ad hominem attack, neither the Lancet editorial nor the Guardian report offered any reasons to think that the 95 per cent figure was wrong. A subsequent report from the Royal College of Physicians concluded that the risks of vaping ‘are unlikely to exceed 5% of those associated with smoked tobacco’.

There are no such caveats when claims are made by the other side. The reader is told that '[m]any e-cigarette brands are owned by tobacco companies' without been given the context of how many brands available (ie. thousands) or how many are owned by tobacco companies (ie. a handful). Both the 'gateway hypothesis' and the 'dual user 'theory go unchallenged. Davey says that Freeman 'believes e-cigarettes are part of a ploy by tobacco companies to get children used to the idea of smoking'. This is a ridiculous and ahistorical claim and should be treated as such. At the very least, a decent journalist would have pointed out that tobacco companies did not so much as dabble in the vaping market until 2012 - and youth smoking rates have nose-dived in countries where vaping has become popular.

None of this is mentioned in Davey's article. Given this partial and misleading propaganda from one of her former students, it is hardly surprising that Freeman has been one of the few people to commend it.

Nuff said.

Saturday, 26 August 2017

Healthy new towns for a healthy new breed of man

This week, NHS England announced its plans to build 'healthy towns' and pay people to go jogging. I had a bit of fun writing about this for Spiked.

There is something about new towns that excites the type of person that Adam Smith called ‘the man of system’. The idea of starting a living space from scratch, without regard to the untidy preferences of human beings, has been like catnip to every top-down organiser of society from Nero to Corbusier. The resulting settlements in such places as Brasilia, Milton Keynes and Canberra must have looked smashing when they were models on an architect’s desk but they are notoriously soulless when experienced in full scale.

They nevertheless retain their allure for dreamers and bureaucrats – new towns for a new breed of man – and it is no surprise that they feature prominently in the NHS’s Five Year Forward View. The five-year plan includes proposals for ‘Healthy New Towns’ which were unveiled on Tuesday and made frontpage news, largely thanks to the suggestion that people be paid to go jogging.

One of the NHS’s mantras is ‘health in all policies’, a phrase that probably sounds better in the original German, and its wonks are salivating at the idea of ‘designing in’ physical activity to the handful of housing developments that the Campaign to Protect Rural England has somehow failed to obstruct.

How do you design a town to encourage physical activity without banning cars and chairs? I don’t know, and neither does NHS England, so it held a ‘design for life’ competition to get some ideas. When the winners were announced this week, the chief executive of the NHS, Simon Stevens, said: ‘The NHS makes no apologies for weighing in with good ideas on how the built environment can encourage healthy towns’. There was no need to apologise because the ideas were not good. On the contrary, they were so fantastically bad that the mind boggles at the thought of what the losers came up with.

Click here to read the whole thing.

Friday, 25 August 2017

Groundhog Day forever with the problem gambling statistics

The Guardian, 2012:

There are an estimated 450,000 "problem gamblers" in the UK, according to the most recent British Gambling Prevalence Survey. And the numbers are rising – up from 0.6% of the population in 2007 to 0.9% in 2010, according to one measure. A further 3.5 million people were categorised as "at-risk" gamblers.

The Guardian, 2015: 

The British Gambling Prevalence Survey 2010 (the last one before its funding was cut) said 900,000 adults were at risk of becoming problem gamblers and 450,000 people admitted they already had a problem.

The Guardian, 2016:

The British gambling prevalence survey indicates that there are around 450,000 pathological gamblers in the country – about 0.9% of the population.

Got that? Is that figure of 450,000 clear enough? That's the official mid-point estimate from the official UK-wide survey of problem gambling in 2010, as repeatedly cited by The Guardian (and other newspapers) for years. (If you are also interested in the more questionable number of 'at-risk' gamblers - see below - that figure is either 900,000 or 3.5 million depending on which hack you ask. Quite a spread, there.)

Now, I'm no Carol Vorderman but if the number of problem gamblers was to rise, it would have to be a bigger number than 450,000, right?

So how do you explain this in today's Guardian?

Number of problem gamblers in the UK rises to more than 400,000

More than 2 million people in the UK are either problem gamblers or at risk of addiction, according to the industry regulator, which warned that the government and industry were not doing enough to tackle the problem.

The report by the Gambling Commission estimated that the number of British over-16s deemed to be problem gamblers had grown by a third in three years, suggesting that about 430,000 people suffer from a serious habit.

A few days ago I issued a plea to people to stop lying about problem gambling being on the rise. I don't know why I bother. See this article from last year if you want to know why this keeps happening.

Instead of checking the facts, the Guardian handed the mic to some anonymous clown from the Campaign for Casino Fairer Gambling - an organisation created and funded by multi-millionaire casino tycoon Derek Webb - to tell its readers what they want to hear:

“The bookies have claimed that because the overall population rate of problem gambling is static, FOBTs are not harmful. The data published today, which shows a rate increase, has totally undermined the bookies’ argument.”

In fact, the Gambling Commission's press release explicitly says that 'overall problem gambling rates in Britain have remained statistically stable' and that the latest estimate of Britain's problem gambling rate is 'similar to the rate published in the 2012 report'.

The Campaign for Fairer Gambling has got nothing to do with making gambling fairer and everything to do with Derek Webb's grudge against the bookies after they put the game he invented onto fixed odds terminal (FOBTs) without giving him a share of the profits ('rather than sue I backed a campaign to make my point'). He will be giggling with glee to see journalists at the Guardian acting as his useful idiots.

But FOBTs are uniquely addictive, right? Not really, not according to today's report from the Gambling Commission:

The lowest rates of problem gambling were found among those who gambled on the National Lottery (1.3%) and the highest were among those who spread bet (20.1%), bet with a betting exchange (16.2%), played poker in pubs or clubs (15.9%), bet on other events with bookmaker (not online) (15.5%) and played machines in bookmakers (11.5%).

The Guardian report didn't mention any of this. Weird, huh?


The Guardian story underwent a a bit of a rewrite before it appeared in print on today's front page. The lie about problem gambling rates rising is still there but it is less prominent and the headline focuses on 'at-risk' gamblers instead.

'At-risk gambler' is one of those terms like 'hazardous drinker', 'overweight' or 'pre-diabetic' which sounds scary but has no clinical significance. Its main purpose is to help campaigners come up with a LARGE NUMBER. (The Sun deserves a dishonourable mention here for interpreting this as 'More than two million people may be problem gamblers'. They're not, otherwise the test would have identified them as such.)

Problem gambling surveys give you a bunch of questions and if you say yes to a certain number of them you are defined as a problem gambler (3 out of 10 for the DSM-IV test and a score of 8 out 27 for the PGSI test - click on the links if you want to do them yourself).

If you say yes to just one of these questions you are defined as a 'low risk' gambler, and being a 'low risk gambler' makes you an 'at-risk' gambler. Say yes to a couple more and you are a 'moderate risk' gambler. Moderate risk gamblers are also at-risk gamblers.

The Guardian tells us that there are two million 'at risk' gamblers in the UK. The implication is that this is a lot (why else would it be on the front page?). In fact, it is a significantly smaller number than has been reported in previous surveys.

In the last UK-wide survey of 2010, 7.3 per cent of respondents were classified as at-risk gamblers. That's about 3.5 million people.

Overall, 5.5% of adults were low risk gamblers (a PGSI score of 1-2) and a further 1.8% were moderate risk gamblers (a PGSI score of 3-7), meaning that overall 7.3% of adults had a PGSI score which categorised them as an ‘at-risk’ gambler. These estimates were similar to those observed in 2007.  

If the report released yesterday is to believed, the percentage has since fallen to 3.9 per cent. That's about two million people.

Overall 2.8% of adults were classed as low risk gamblers (PGSI score of 1 or 2) and a further 1.1% were classed as moderate risk gamblers (PGSI score of 3 to 7). In total, 3.9% of adults had a PGSI score that categorised them as being at-risk gamblers (PGS I score of 1 to 7).

So, in conclusion, we have no change in the number of problem gamblers and a near-halving in the number of at-risk gamblers. Can someone please explain to me why this is front page news?

(Oh yeah, that.)


The Times has managed to outdo the Guardian with its (fairy) story:

Problem gambling grows by 50% in three years

The scale of the gambling epidemic sweeping Britain was laid bare yesterday by official figures showing that 430,000 people in the UK have a serious gambling problem, up from 280,000 in 2012.

A 50 per cent increase in three years has raised pressure on the government to place curbs on the betting industry.

 Times readers with good memories will be confused by this news. In 2011, the paper told them:

It is estimated that there are now between 360,000 and 450,000 problem gamblers in the UK.

 And in February last year they were told:

The last gambling prevalence survey in 2010 found there were 450,000 problem gamblers in Britain but experts at GamCare say the number of addicts is likely to grow in proportion to the size of the industry, which suggests there are now 562,000.

But by October of last year, the 450,000 had doubled to, er, 336,000.

The proportion of people with a severe gambling problem has almost doubled in three years from 0.4 per cent of the population to 0.7 per cent, the equivalent of 336,000 people, according to the Gambling Commission. 

And now it's doubled [sic] again to 430,000. How many times can a number be doubled without getting any bigger?

Thursday, 24 August 2017

That shady link between Big Tobacco and nicotine gum

Just when you think the world of tobacco control can't get any crazier we get headlines like this:

The Shady Link Between Big Tobacco and Nicotine Gum

This represents a new narrative opening up. The story now is that Nicotine Replacement Therapies (NRT - gums, patches, etc.) are not very effective and this somehow the fault of the tobacco industry, rather than the pharmaceutical industry.

Stanton Glantz - for it is he - jumped the shark a long time ago so I am reluctant to say that this is a turning point for him. Nevertheless, this is quite a pivot. Not only does he say that NRT doesn't work, he says that it keeps people smoking.

“The problem is, without the behavioral support, they actually inhibit quitting,” he said. “Unfortunately, a lot of people think they are making progress and quitting when that’s not so. That’s what tobacco companies have known for decades. They’re developing products under the guise of nicotine replacement therapy.”

Glantz's co-author on this occasion is one Dorie Apollonio from San Francisco's bonkers Center for Tobacco Control and Research.

“It was surprising to discover the industry came to view NRT (nicotine replacement therapy) as just another product,” said Dorie Apollonio, an associate professor in clinical pharmacy at UCSF and lead author of the study. “The tobacco companies want people to get nicotine — and they’re open-minded about how they get it.”

Are they really though, Dorie? Do they really not prefer you to get nicotine from tobacco products that they sell for a profit rather than from pharmaceutical products made by the pharmaceutical industry? Or, for that matter, e-cigarette products made by the vaping industry? If you can't see the difference, you should probably keep your views about business to yourself.

In the press release, she says:

“Tobacco companies put out these products as a way to sidestep policies, by giving people a way to ‘smoke without smoking’. 

The tobacco industry - I knew it was them! Even when it was Big Pharma, I knew it was them!

It is unclear which policies are being 'sidestepped'. If they are anti-smoking policies then it should be considered a success that people are 'smoking without smoking' (ie. not smoking).

It is also unclear which products they are talking about. NRT is almost entirely manufactured and sold by Big Pharma. Always has been. Glantz and Apollonio suggest that FDA regulation of tobacco under the 2009 Family Smoking Prevention and Tobacco Control Act has opened the door to Big Tobacco selling NRT on a grand scale, but their only example is Zonnic, an obscure nicotine gum company that RJ Reynolds bought before the Family Smoking Prevention and Tobacco Control Act was passed.

To shore up their hypothesis, they also mention a nicotine lozenge called Verve but this is not marketed as a stop-smoking product and is only sold in the state of Virginia. They have no other examples and they ignore the rest of the world where FDA regulation does not apply.

Have tobacco companies gone wild with NRT outside the USA? No they haven't. The only 'therapeutic' product from a tobacco company that springs to mind is BAT's e-cigarette (sort of) Voke, which was licensed as a medicine in the UK a few years ago when it looked like the government was going to demand that all e-cigs be medically licensed. When the government changed its mind about this, BAT gave up on Voke and it never came to market. So much for the tobacco industry riding the NRT bandwagon. 

Obviously, it is Big Pharma that sells NRT and it is an open secret that they make the most money when people use patches and gum indefinitely, rather than for the six months that are recommended on the pack. I know at least two people who have been using Nicorette gum for twenty years. The problem with NRT is clear to anyone who has tried it: it is good enough to relieve cravings a little, but not enjoyable enough to make you want to switch full-time and give up smoking (this is one of the big differences between NRT and vaping - and vaping doesn't require counselling to work).

Rather sweetly, the authors claim to only have just realised this:

Now, a new study conducted by scientists at UC San Francisco reports that tobacco companies have known for decades that, without counseling, NRT hardly ever works and that consumers often use it to complement smoking. 

You don't say! If you've got a problem with this - and you would be justified in complaining - take it up with the pharmaceutical industry (who make them) or the FDA (who approved them as efficacious stop-smoking medicines) or the anti-smoking groups (who have ceaselessly touted NRT to consumers and governments). And if Glantz and Apollonio are alleging fraud, misconduct and deceit, they should encourage the tobacco control community to reject any further funding from Big Pharma.

(Incidentally, the best explanation for the failure of NRT seems to be Carl Phillips and colleagues' observations about second-order preferences: It is marketed to people who want to smoke but want to not want to smoke, with the message that it will indeed change their preference to smoke. It doesn't, and so they start smoking again. In so far as it works better in the presence of counseling, this is probably just self-selection: smokers who are inclined to volunteer to be in studies of cessation counseling are an odd subset of all smokers who want to quit more than average.)

This insight [!!! - CJS] from the formerly secret industry documents known as the “Tobacco Papers” reveals why companies that once viewed nicotine patches and gum as a threat to their cigarette sales now embrace them as a business opportunity, the researchers said.

One tobacco company buying up one small nicotine gum company hardly represents the tobacco industry 'embracing' nicotine replacement therapy. But even if it did embrace them, so what? Tobacco companies have bought up food and drink companies in the past, why shouldn't they invest in the alternative nicotine market?

And what are these 'insights' are whence did they come? You won't be surprised that they came from yet another cherry-picking trawl through the archives...

Apollonio’s researchers analyzed 90 million pages of documents from seven tobacco companies dating back as far as 1960, obtained in litigation against the tobacco industry.

Obviously they didn't actually analyse 90 million pages of documents. That would take several lifetimes. What they did was do a word search of the chaotically assembled industry documents hosted at UCSF, of which there are reputed to be 90 million pages, and hoped for the best. As they explain in the study, it's the kind of 'analysis' that anybody could do.

We used a snowball strategy, beginning with the keywords “nicotine patch,” “NRT,” and “nicotine gum,” and then we refined search terms and dates using named individuals, organizations, and products and adjacent (by Bates numbers) documents. 

The Legacy Documents archive is actually a very good resource. I used it a lot when I was writing Velvet Glove, Iron Fist. It is massive, however, which means that (a) no one can read enough to get the full picture, and (b) it lends itself to cherry-picking in the wrong hands. 90 million documents written by countless individuals from rival companies over seventy years cannot easily be distilled into a handful of quotes giving the definitive view of the whole industry. Some will be statements of official policy, others will be ideas brought up for debate and others will be random musings of individuals. Quotes can be illustrative, but they need to be supported by a substantial amount of other evidence before we use them to make generalisations.

The historian Virginia Berridge has something to say about the way the tobacco archives have been used in her book Marketing Health:

The enthusiasm for online industry archives is an interesting phenomenon. We are seeing a new type of family history, a Whig history revived and a rediscovery of 'the document' whose main role is to play to the policy objectives of the anti-tobacco field.  

So what does the study by Glantz and Apollonio say?

Firstly, it says that American tobacco companies began looking at alternative nicotine delivery devices in the 1950s. Glantz and Apollonio claim that they did not take any of them to market because they wanted to avoid regulation by the FDA. This is true, although they do not ask why tobacco companies outside the USA also failed to pursue them.

Secondly, they say that the tobacco industry had concluded that NRT didn't work as early as 1992. Life is too short for me to trawl the archives to see whether this is a fair judgement, but here are all of the quotes Glantz and Apollonio use in their study to prove that Big Tobacco 'knew' that NRT was a non-starter. All of them come from 1992 and all but one of them were written by the same person (Doran Stern of PMI):

'Clinical results indicate the nicotine patch was more effective against placebos. . . . It is important to keep in mind, however, that in objectively validated tests (1 full year after quitting) nicotine patch scores were less impressive vs placebos. . . . Some sort of behavior modification was administered during the clinical tests. Without some degree of psychological therapy, many experts warn that the nicotine patch is powerless [as a method of smoking cessation]... The explosive growth of nicotine patch sales has not seemed to increase rate[s] of quitting (currently holding at 6.7% for 12 [month period] ending June [1992]).'
'301 past two year quitters (out of a sample of 551 quitters identified in January–February) were reinterviewed . . . to determine their usage of and reactions to the Nicotine Patch. . . . Roper [the polling organization Philip Morris hired to track smoking trends] data through December indicate that quitting rates on a 12 [month] basis have been roughly flat.'
'Studies of the efficacy of nicotine gum or transdermal patches on smoking cessation invariably show a significant benefit in the short term, but only a small advantage (if any) over placebo in the long term (6+ months). . . .'
'Monthly and 12 [month] quitting rates have been roughly flat through April. The use of Nicotine Patch as a way to stop smoking jumped dramatically in April (8% - 26%). . . . The results seem to suggest that Nicotine Patch [use for quit attempts] evidenced growth at the expense of ‘stopped all at once’ quitting.'
'Based on the attached results from our Continuous Tracking Study [Roper polls of smokers], it appears that usage of the nicotine patch has dropped steadily since it peaked in June. . . . [A] possible explanation for the patch’s loss in popularity may relate to the difficulty quitter’s [sic] experience in adhering to the strict, but necessary, regimen prescribed for the patch treatment.'
'Almost all the men we spoke to [who used NRT patches] went back to smoking... Some believe that the novelty [of the nicotine patch] has started to wear off.'

It is reasonable to assume that other industry insiders have commented on NRT since 1992. Did they take a different view? Did they see NRT as a threat? Glantz and Appollonio do not tell us, but I reckon I could write a paper showing that tobacco companies were terrified of NRT if I spent a couple of days searching the archives and set my threshold of proof as low as they do. Nevertheless, the press release for this study baldly states that 'by 1992, the industry had determined that patches and gum by themselves do not help smokers quit.'

Even if this were true, so what? According to one newspaper, working from the press release:

They discovered that as companies knew in 1992 that patches and gum alone did not help people quit smoking but did not act on that information.

Where to begin? There is no evidence that these companies had any information about NRT that couldn't be acquired by regulators or 'public health' professionals. They certainly didn't have information in 1992 that the rest of us didn't have by, say, 2002. But let's suppose they did. What were they supposed to do about it? Imagine what would have happened if cigarette companies had launched a campaign to deter people from using smoking-cessation drugs in the 1990s. Imagine if they had accused the pharmaceutical industry of pushing junk science to support their claims of efficacy. How do you think the anti-smoking lobby - which was by then heavily funded by the pharmaceutical industry - would have reacted if Philip Morris had come out and said 'these stop-smoking products are worthless, don't use them'? They had no incentive to do this and they would have been vilified if they had.

Isn't it the job of the 'public health lobby' to do due diligence on these products? Or the pharmaceutical industry? Or the regulators? If it was so obvious that these products don't help people quit - indeed, that they reduce quit rates, as Glantz now claims - why have the 'experts' of tobacco control been sitting on their hands for the last 25 years? Why have so many studies, such as this one in the anti-smoking lobby's house journal Tobacco Control, concluded that over-the-counter NRT works if it doesn't? And why does Glantz have more faith in the opinion of two random tobacco company employees than in the 'public health' lobby's finest minds?

On the howling wilderness of Planet Glantz, the tobacco industry should have been promoting nicotine gum and the 'public health' lobby should have been calling bullshit on it. The reality, of course, was pretty much the opposite. The industry quietly recognised that NRT was an unwelcome competitor but was unlikely to be an existential threat while the 'public health' lobby went around touting it despite mounting evidence that it didn't work as advertised.

It is true that NRT is largely ineffective (Glantz's study does not actually show this, but it happens to be true) and so it is the self-appointed experts of tobacco control who have to explain themselves, as do Big Pharma, the FDA, the WHO and all the governments that have been using taxpayers' money to dish out patches and gums for decades.

But Glantz does not point the finger at any of them. Instead, he comes up with an excuse that is quite something:

"The tobacco companies are generally 20 or 30 years ahead of the public health community in their thinking about their issues," Glantz says. "They have much more resources [sic] than the health community does to study their products."

This is the David and Goliath delusion on crystal meth. The 'health community' has had vastly more resources with which to research NRT than would have been available to a couple of analysts in 1992. All these guys seem to have done is look at published research, monitor smoking rates and used some common sense. The idea that the tobacco companies knew something about NRT in the early 1990s that nobody else could have known until Glantz and Apollonio published their 'insights' is laughable.

The implication of Glantz's paper is that the debate over how well NRT works has been settled by a handful of comments in some tobacco industry briefings a quarter of a century ago. It suggests that a couple of dudes working in commerce had a better understanding of nicotine, addiction and smoking cessation in 1992 than the entire global tobacco control movement has acquired in the years since. This does not reflect well on him or his colleagues and yet he seems happy to admit it.

He also seems happy to admit that NRT is not much good. Indeed, his condemnation of NRT - and over-the-counter NRT in particular - is arguably more fierce than the scientific literature justifies (that literature may be junk, but it is his colleagues' junk and he normally treats it as gospel). This is surprising, not only because so much pharmaceutical money swishes around in tobacco control, but because it makes his previous support of NRT look rather foolish. In 2005, for example, he wrote:

Individual smoking cessation is a highly cost-effective clinical medical intervention for individual smokers; nicotine replacement therapy (NRT) is a key element of this approach to combating nicotine addiction... NRT should be recommended in both clinical practice and public health practice.

When a study suggested that over-the-counter NRT didn't work in 2012, he said 'this is just one study, and it's not terribly huge', adding that 'we don't necessarily want to throw out the baby with the bathwater'.

He has now thrown the baby halfway across the bathroom. Why? What has possessed him to do a screeching U-turn on NRT which will embarrass his colleagues and upset Big Pharma?

As with most of his activity these days, it can be explained by his fanatical opposition to e-cigarettes. He insists that e-cigarettes do not help smokers quit and now he is saying the same about NRT. He says that 'dual users' of e-cigarettes are less likely to quit and now he is saying the same about dual users of NRT. He claims that the tobacco industry likes e-cigarettes because they sustain smoking rates and nicotine addiction - now he is saying the same about NRT.

The purpose of the study is to draw a parallel between the tobacco industry's supposed attitude to NRT in the 1990s and its supposed attitude to e-cigarettes and other alternative nicotine devices today. Never mind that it was the pharmaceutical industry that brought NRT to market and his own colleagues who hawked it. Never mind that the tobacco industry has never supported NRT and has never made any serious effort to take an NRT product to market.

When Glanz and Apollonio make the (dubious) assertion in the conclusion of their study that 'NRT can expand nicotine use while maintaining smoking rates' it is done with a nod and a wink to the FDA. What they are really saying is that e-cigarettes and any other safer nicotine device that smokers might switch to can expand nicotine use while maintaining smoking rates.

The purpose of the study becomes clear in the final line when they write:

These findings suggest that the least harmful way to sell nicotine delivery products is to restrict them to smokers whose quit attempts are medically supervised, consistent with the original studies of NRT for smoking cessation. 

This is a complete non-sequitur. Nothing in what has come before leads to this conclusion. Nowhere in the study do they discuss the vastly different risk profiles of the various nicotine products. There is no reason to think that the 'least harmful way' of regulating the nicotine market is to restrict access to the least harmful products. Quite the reverse.

This is just another thinly-disguised, puritanical attack on harm reduction approaches. It is a nonsensical conclusion, but it is whole purpose of the study from Glantz and Apollonio's perspective and they hammer the point home again in the press release, saying: 

“Our study shows that by not regulating nicotine in all tobacco products, including NRT, the FDA could be walking into a trap.”

There is method in Glantz's apparent madness of severing of relations with the pharmaceutical industry. By turning on NRT, he can be consistent in his opposition to all alternative nicotine products and demand consistent regulation, ie. medical licensing and a ban on over-the-counter sales.

If I may speculate for a moment, it has another possible consequence. By rejecting all nicotine products, it opens the door to the full demonisation of nicotine. Nicotine underwent an image change when Big Pharma started selling it. The public had often assumed that it was carcinogenic because of its connection with smoking, but this myth had to be debunked once it was being sold as medicine. The scientific consensus is that nicotine is addictive and can be toxic in large doses but is basically harmless when consumed at the levels found in recreational tobacco products. Smokers smoke for the nicotine but die from the tar, as Michael Russell said back in 1976.

Opponents of vaping have an incentive to resurrect the old myths. Lacking evidence that vaping kills, bottom feeders such as Simon Chapman have been scrambling around for any crumb of evidence implicating nicotine as a health threat. The existence of medically licensed NRT is a problem for these fanatics, but if Glantz's bizarre new narrative takes hold, it will be less of an obstacle. If you can do the mental gymnastics required to believe that the tobacco industry loves the pharmaceutical industry's stop-smoking products because they make people smoke, you can easily believe that same is true of e-cigarettes, snus, lozenges etc.

These people do not just want a tobacco-free world, they want a nicotine-free world, and this extraordinary rewriting of history is another step towards it.