Christopher Snowdon's Blog, page 275

Another barking mad idea from a doctor

A letter in this week's British Medical Journal has been press released around the world and may feature in today's newspapers. Although it appears to have been written by a precocious child, it is actually from the pen of a grown man, and a doctor at that.

The letter is actually an online comment to an article in the BMJ from last month. The BMJ must have been so impressed by its startlingly original contents that it deemed it worthy of a wider readership.

Fundamental re-think on smoking is needed
Paul D Jepson
F2 doctor, public health

Excuse my naivety, but isn't smoking's continued legality one of the most important factors accounting for its slow rate of decline?

If you mean that fewer people would smoke if smoking was illegal, then yes, but it's not quite as simple as that, is it?

Any other drug causing a fraction of the morbidity and mortality of tobacco would have been outlawed long ago, putting aside alcohol for the moment.

Why should we put aside alcohol? Perhaps because it doesn't fit your argument?

In 2010 mephedrone became a class B drug following widespread media coverage and reports of some deaths in the preceding months, although the evidence surrounding the dangers of mephedrone does not exist.

I agree. Mephedrone should not have been banned, as I argued in The Art of Suppression. Unfortunately, we live in prohibitionist times and there is no greater engine of prohibition than the public health establishment, as epitomised by the British Medical Journal.

This is in stark contrast to tobacco, which is responsible for around 100,000 deaths each year in the UK. Why should smoking get special treatment?

I suppose because 1.5 billion people worldwide like consuming tobacco and people can function perfectly well under the influence of nicotine in a way that they can't under the influence of party drugs and amphetamines. The majority of people believe smoking should be legal so it is. We call it democracy and, in a free society, informed adults have a right to put what they like into their bodies even if it carries a risk to their health. The question is not why should smoking get special treatment, but why shouldn't drugs be legal?

For mainly economic and political reasons, adults with enough change in their pocket can walk into their local shop and buy a packet of cigarettes. They will not be judged and will not feel ashamed: smoking is an acceptable addiction.

If that is true - and broadly speaking, it is - it is not for want of trying from the denormalisers of public health. Every effort is made by alleged health campaigners to stigmatise smokers, demonise tobacco and villify the manufacturers. If this hate campaign has not yet led to actual lynch mobs, it only shows that the general public are more tolerant than the British Medical Association. That, again, answers your question as to why smoking remains legal.

If the tabloid press were to publish a list of the names of the more than 250 people killed by smoking related disease each day, would the government be as fast to react as it did for mephedrone?

[splutter]

[wipes coffee from keyboard]

Assuming this to be a serious suggestion, I will attempt a serious reply. Leaving aside the extraordinary distastefulness of the idea and the unconscionable invasion of privacy, the main problem is that such a scheme would be impossible to carry out. No one is able to name these hypothetical 250 people because doctors and coroners very rarely list smoking as a cause of death. Although the BBC recently affected shock at the reluctance of doctors to name smoking on death certificates, all smoking-related diseases are multi-factoral (ie. have more than one cause) and all smoking-related diseases can be contracted by nonsmokers.

So while there is a good chance that a smoker who dies of lung cancer developed the disease because of his smoking, there is a chance that he would have got it even if he had not smoked. In the case of heart disease - which is the biggest contributor to the 100,000 figure - it is impossible to say that smoking was the cause of any one death. This lack of certainty in individual cases is the main reason why personal injury lawsuits against tobacco companies tend to fail in court.

Imagine a fat smoker with a family history of heart disease, a poor diet and a stressful job. Can a doctor say with any certainty that his heart attack was 'caused' by his smoking, his diet, his stress, his genes or his diet? It can't be done. The 100,000 figure comes from assumptions taken from the epidemiological literature based on aggregate data from hospitals. It is an estimate. It is not based on a running total of clinically proven 'smoking-related deaths'.

Even if such a list could be created, who is going to pay for the column inches in the tabloids every day? Since this letter was written by an authoritarian doctor of public health, we must assume that the taxpayer will, as ever, be expected to foot the bill. And why only tabloids? Are we to assume that smokers do not read the broadsheets?

Finally, on a practical note, the great majority of the 250 daily deaths would be of people in their 70s, 80s and 90s. Smoking prevention campaigns are largely targeted at people in their teens and twenties. It is doubtful whether listing the names of people who, for the most part, enjoyed the proverbial 'good innings' is really going to have desired the shock value for the target group of devil-may-care youngsters.

People's attitude towards drugs should be evidence based, and not informed by politics or popular opinion.

Quite so. Let's legalise them. Prohibition didn't work with alcohol, it doesn't work with drugs and it won't work with tobacco.

How must smokers feel when they are encouraged to quit their habit by the same government that welcomes tobacco taxes so gladly?

I suppose it makes them think that politicians are greedy hypocrites. A valuable lesson learned, no?

While smoking remains legal, the number of smokers is never going to fall significantly—no matter how much taxes rise, how plain cigarette packets become, or how many millions of pounds is spent on cessation.

Smoking rates have actually fallen very significantly over the years and may continue to do so. Admittedly, they have flat-lined since 2006, when the government began listening to the 'experts' of tobacco control and introduced divisive, ill-considered policies like total smoking bans, graphic warnings and display bans. Maybe the politicians will learn their lesson and withdraw their funding from astro-turf anti-smoking groups in the same way as it has recently stopped funding Alcohol Concern. (Rather than try and raise money from the general public, Don Shenker has realised that the game is up and has resigned. Cheers!)

Perhaps the smoking rate will continue to flat-line. Or it might start going back up. Or it might fall again. Who knows? It's none of your business and it's none of mine either. The risks of smoking are universally acknowledged and there is a great big warning on every pack saying 'Smoking Kills'. Having accepted that prohibition doesn't work, we must also accept that informed adults have the choice to smoke or not smoke. There really isn't more to say on the matter. You live your life and I'll live mine.

As I mentioned, this letter may be the subject of some news coverage today, presumably because it raises the spectre of the 'next and final step'. I'll be on BBC Radio Sussex at around 9.50am talking about it.

A fat man explains the slippery slope

Kelly "two chins" Brownell.
This man is an anti-obesity campaigner. Seriously.
A day might come when I get sick of reminding self-righteous nonsmokers that the anti-tobacco campaign was only a template for a larger war against every pleasure, but that day is not today.

"It's only smoking," they squealed. "Alcohol, food and fizzy drinks are completely different." Not to the British Medical Association they're not, nor to the Royal College of Physicians, the Surgeon General nor Kelly "wide load" Brownell who writes the op-ed below. Sit back and enjoy how the gluttonous soda tax campaigner draws a direct parallel between Coca-Cola and British American Tobacco. Are we getting the message yet?

Meet Big Soda — as Bad as Big Tobacco

Subtle enough for you?

...But the beverage industry, dominated by Coca-Cola and PepsiCo, and represented by the American Beverage Association, has exercised its might against this public health initiative in ways reminiscent of the tobacco industry when it came under attack in the 1950s. The beverage industry argues that such taxes are "discriminatory" in singling out one category of food, that taxes would not work, and that government should not tell people what to eat. The tobacco industry said taxes would not work (they did work — tremendously well) and that government should stay out of people's choice to smoke.

Similar to tobacco companies, the soda industry has created a front group, Americans Against Food Taxes, to run anti-tax campaigns (a Super Bowl ad, for example). The name of the group implies a patriotic, grass roots movement, not a highly financed entity initiated and organized by industry. The tobacco industry paid scientists who did research disputing links between smoking and lung cancer, the addictive nature of nicotine, and the dangers of second-hand smoke. The soda industry funds scientists who reliably produce research showing no link between SSB consumption and health. The tobacco industry bought favor from community and national organizations by giving large donations. In an ironic twist, Coca Cola and PepsiCo are corporate sponsors of the American Dietetic Association.

Over time, the tobacco companies were outed for their dirty tactics...

And so on and so. You can read the whole thing here. There are soda taxes in more than thirty US states. Hungary and Denmark already have fat taxes. The British Medical Association says it's "time to denormalise drinking". Squeal on suckers. Like it or not, we're all smokers now.

Minimum pricing - still illegal

Scotland's dreadful health secretary Nicola Sturgeon has been banging the drum for minimum alcohol pricing policy at a SNP conference. As with plain packaging in Australia, the opportunity of attracting some media attention from an otherwise indiffernt world is the pathetic carrot being dangled.

The 1,300 gathering heard Ms Sturgeon say: "Delegates, I can tell you today that our minimum pricing bill will be reintroduced to parliament within the next month.

"When that bill is passed, Scotland will become the first country to introduce a minimum price per unit of alcohol. The world is watching us."

Not so much "when" as "if", since minimum pricing is almost certainly illegal under EU law. Rather than wasting time and money on this doomed policy, the Sturgeon General should listen to expert opinion, like this report from Rand Europe.

Minimum prices for alcoholic beverages, also sometimes called Social Reference Prices, are used in different ways in a number of areas outside the EU, including several Canadian provinces (Saskatchewan, Ontario, Newfoundland, New Brunswick, etc) where the regulation applies to licensed on-trade premises (Strang 2008).

But while a recent Scottish expert consultation concluded that minimum pricing is possible under EU competition law, 'provided that minimum prices are imposed on licensees by law or at the sole instigation of a public authority' (SHAAP 2007), minimum pricing practices have tended to be seen as trade-distorting by the European courts (as setting an artificial price floor amounts to resale price maintenance, limiting and distorting price competition), and therefore not typically put in place in the EU (Baumberg and Anderson 2008).

Minimum prices had also been considered, and even introduced through legislation in a few Member States such as Austria and Ireland, for cigarettes as a public health measure, but these moves were contested by the European Commission. This was in line with the jurisprudence of the European Court of Justice, which considers that minimum prices infringe Community law, distort competition and benefit manufacturers by safeguarding their profit margins.

Council Directive 95/59/EC states that manufacturers and importers of tobacco products have the right to determine the retail selling price of their products; according to ECJ jurisprudence minimum prices impair this right and are therefore not compatible with this Directive. The ECJ also stated that minimum prices are not necessary since their health objectives can be achieved through increases in taxation.

This report was commission by the European Commission and the sources given in this particular section include "personal communication from European Commission Directorate General Competition official."

When is Sturgeon going to take the hint?

Review of The Art of Suppression

Tom Miers—the author of Democracy and the Fall of the West —has reviewed The Art of Suppression over at The Free Society. Here's an excerpt...

Campaigners build themselves into a self-righteous position from which they cannot climb down, fuelled by selectively interpreted science. 'Moral entrepreneurs', lacking in empathy for their fellow man, forge a career for themselves, glorying in their political and financial successes. For success breeds success and their relentless proselytising finds willing adherents. Government is attracted by the sense of decisiveness attached to prohibition. And the general public is guilty as well, our neighbourly intolerance lending widespread popular support to bans.

Prohibitionists find willing allies in the commercial rivals of those producing the product in question. Brewers supported the early US temperance movement, hoping to damage distillers. Modern pharmaceutical companies fear that the rise of tobacco substitutes like snus will undermine the market for nicotine patches.

Yet for all this, prohibition is doomed to founder on the rock of human desire. It is in our bones to seek out physical pleasure, sometimes at considerable cost. "When the law cuts off one avenue of pleasure, new sources are invariably found," as Snowdon puts it. If there is any great demand for a certain product, be it food, drink, drugs or sex, then the risks of purveying it are met by colossal rewards.

The Art of Suppression is full of great facts – its description of opium-addicted Britain before the wars is particularly memorable. But its real impact is its pithy denunciation of the prohibitionist cause. It ends with a modest proposal for a more practical and tolerant approach to drugs of all kinds. In his modesty Snowdon does not hold much hope for implementation. But this book must make that goal more likely.

Read the rest here.

You can order The Art of Suppression from Amazon UK, Amazon USA, Barnes and Noble, Waterstones or directly from me.

Alcohol Concern's sleight of hand

Alcohol Concern have a habit of using children in their opinion polls, presumably because young people tend to be stupid and impressionable, and therefore more likely to support neo-prohibitionist policies.

Their latest effort is so piss-poor that only The Guardian has bothered to cover it. It finds that...

Under-18s want more protection from alcohol marketing exposure

A survey of over 2300 children and young people reveals concern at alcohol marketing exposure and support for stronger regulation that robustly protects under-18s, finds Alcohol Concern

People under 18 can't buy alcohol and they can't vote, so as far as I'm concerned they can keep their opinions to themselves. But if some of the quotes reprinted in the report are genuine, we might as well pack our bags now. The final triumph of the nanny state cannot be far off.

"[Alcohol products] should contain shocking images like the image you see on packets of cigarettes, as you do not actually see how ill people can get from alcohol"

Female, 15 years-old

However, there are good reasons to doubt whether this survey is reliable.

The survey was disseminated via a targeted email (to youth groups, schools, local-authority youth services and interested individuals) and published on the Alcohol Concern website and on Twitter.

Indeed it was. Here is the tweet announcing it to the world...

[image error]
The only to people to see this tweet would have been those who follow Alcohol Concern on Twitter, which is to say a self-selecting sample of temperance folk, 'public health professionals' and people like me who like to keep an eye on them. The people who visit the Alcohol Concern website are likely to have a similar bias.

These people will be predominantly adults but they might encourage their children to complete the survey, perhaps with a little helping hand.

Or they might just pretend to be children and fill it in themselves. After all, as the survey found, it is not hard to bypass online age checks...

Alcohol websites ask you to enter a date of birth to prove you are not under-18. Is this enough to stop under-18s from visiting these sites?

No, it's easy to enter another date: 78.2%

Yes, this is enough to stop me: 16.6%

Indeed. And this equally applies to Alcohol Concern's online survey which was strictly for the under-18s but whose only age verification process was this:



The survey itself was designed by 13 to 18 year olds (seriously) and it shows. A professional polling outfit would not resort to leading the witness as blatantly as this survey does. Take the introduction to the survey, for example (no longer online, but saved here):

Alcohol companies spend over £800 million each year in the UK on advertising (ads) to increase sales of their product. Under existing rules young people under 18-years-old should be protected from seeing most alcohol ads, but many studies show this isn't the case.

Today, advertising use technoloy to reach us in lots of different ways, like: TV; radio; cinema; billboard/posters; the internet; via mobile phones; through the sponsorship of music festivals and sports events; and even on football shirts... along with many other avenues.

You don't think all this talk of rampant alcohol advertising ("even on football shirts"!) and rules being breached could plant ideas in the respondent's mind, do you?

The report itself claims that...

The Youth Policy project specifically chose not to detail the existing alcohol-promotion regulations to The Voice or to survey participants, wanting to capture their expectations of alcohol-promotion regulation based on what young people see and hear around them.

These are weasel words. It is true that the survey doesn't "detail" the policies. Instead, it misrepresents them. Existing rules do not say that under-18s should be "protected" from seeing alcohol ads; it says that these ads must not target the under-18s. That is a big difference.

The report (and accompanying press release) emphasises in shocked tones that young people do not even recognise alcohol marketing when they see it.

The survey findings suggest that large numbers of young people regularly do not recognise alcohol marketing when it is channelled through sponsorship, product merchandise or via social networking sites – non-media channels known as 'below the line' promotion. Approximately half of young people do not consider alcohol promotion via such mediums as 'marketing', a finding which is consistent across both genders and all ages. This is of particular concern because investment in such strategies is increasing and is central to the alcohol industry's efforts to associate with youth culture.

• 51.4% do not recognise official alcohol product Facebook groups as marketing

• 51.7% do not recognise alcohol branded events, such as festivals, as marketing

• 49.6% do not recognise alcohol sponsorship of football team shirts as marketing

• 49% do not recognise alcohol product merchandise as marketing.

The Guardian leads with this appalling insight into the ignorance of the young:

Most young people would like more protection from alcohol advertising, but under-18s do not recognise that drink logos on football shirts are a form of marketing, according to a survey.

This is extremely misleading. The question in the survey does not use the word 'marketing'. It uses the word 'ads'. Advertisements are clearly not the same thing as sponsorship, having a website or merchandising. All are forms of marketing, but they are not all forms of 'ads'. The actual question posed was:

Which of the following do you consider to be alcohol ads? (Tick as many boxes as you like)

• A viral video for an alcohol product

• Joining a Facebook group for an alcohol product (e.g. Smirnoff Facebook group)

• User generated content (e.g. an unofficial Facebook page for an alcohol product)

• A festival named after a product (e.g. Carling Weekend)

• A piece of alcohol product merchandise (e.g. Revolution bar's 'I love vodka' t-shirts)

• Brand ambassadors (people who are paid to attend events and promote certain brands)

• Sponsorship of team shirts (e.g. football)

So, if you don't consider sponsorship to be an ad—which it isn't—or if you don't consider joining a Facebook group to be an 'ad'—which doesn't even make sense—then Alcohol Concern assume that you also don't think these things constitute marketing—which they are. This, they say, "is of particular concern."

Alcohol Con, on the other hand, are acutely aware of the difference between advertisements and marketing, which is presumably why they used the word 'ads' in the survey and the word 'marketing' in the report and press release. This sleight of hand is brushed over in the text of the report, which says...

"the term 'ads' was inserted by The Voice to encompass 'marketing', 'advertising' and 'promotion' as the group felt that these terms meant the same thing to most young people." 

Well, it doesn't, and not all kids are as thick as the ones who allegedly designed this survey. The change from 'ads' in the survey to 'marketing' in the final report must be regarded as highly suspect.

And finally, just in case the respondents hadn't quite worked out what the pollsters wanted to hear, the last question in the survey was:

Would you like to be kept informed of a youth led campaign that will challenge Government to reduce the amount of alcohol advertising we see?

No hint of a bias there then. Considering the standard of the survey, we can perhaps take heart that the majority of respondents still opposed Alcohol Concern's desired policy of a total ban on alcohol advertising on billboards, television and cinema.

Although the evidence suggests that a total ban on alcohol advertising would significantly reduce youth drinking, the majority of young people surveyed are not supportive of such strong regulatory intervention.

It also interesting that the under-11s were much keener or bans than the 16-17 year olds. Which just goes to show that neo-prohibitionism is a childish ideology that most people grow out of.

Cigarette butts - some loony proposals

Some shocking news from New Zealand...

Smoking bins being installed at the Greymouth railway station are being partly funded by British American Tobacco.

Pass the smelling salts. Is there no end to the schemes of these evil-doers?

Keep New Zealand Beautiful announced the bin deal on on September 30. The press release did not mention the link with the international tobacco giant.

Dirty, underhand stuff. Looks like Big Tobacco has been caught pushing their evil, er, litter bins on rail companies.

Or perhaps not...

Keep New Zealand Beautiful national programme manager Tracy Shackleton said KiwiRail had requested the bins.

Oh.

"If a company rings up and requests the bin, we will, of course, oblige."

Right.

KiwiRail passenger general manager Deborah Hume said the company was not aware of the connection with British and American Tobacco.

So now what happens?

However, it agreed to accept the bins in order to address a litter and safety issue "and that still stands".

I see.

Erm...

What was the problem again?

West Coast Tobacco Coalition chairwoman Anne Hines, in a letter to the head of KiwiRail, said butt bins normalised smoking.

Of course, it's an issue of denormalisation. There was I thinking that litter was a problem that could be alleviated with litter bins, but I forgot when when tobacco is involved the only solution is the stigmatisation of its users and the total eradication of cigarettes. How silly of me, and how silly of the train company to have made the same mistake.

The bins normalised smoking, and allowed tobacco companies to claim social responsibility, she said.

Actually, what 'normalises' smoking is all the smokers hanging around smoking after being forbidden from smoking for their entire train journey. And since, as already mentioned, the press release did not mention the tobacco company, they can hardly be accused of claiming social responsibility. Nevertheless, social responsibility is what we would call it from any other industry.

They did nothing to encourage people to stop smoking, which would reduce the number of discarded cigarette butts.

This may come as a shock to you, Anne, but not everything in the world is designed for the purposes of social engineering. However abnormal you may view the habit, 20% of New Zealanders continue to smoke and they do so in an increasingly limited number of places. In your excitable imagination, abolishing cigarette bins in designated smoking areas will make smokers think "there's nowhere to put this, I'd better give up smoking now", but here in the real world a lack of cigarette bins leads to lots of cigarette litter. If tobacco companies pay for some cigarette bins, the financial burden is shifted from the taxpayer to the smoker (because, of course, smokers fund the tobacco companies). This is an equitable solution to a negative externality. So, really, what is the problem?

The truth is that tobacco controllers like Ms Hines don't like cigarette bins because they are practical solutions to a simple problem. They prefer to deprive smokers of somewhere to put their litter and then portray them of being inconsiderate, socially irresponsible litter bugs. Like all neo-prohibitionists, they create a problem—in this instance, banning smoking in every indoor place and then abolishing cigarette bins outdoors—and then blame other people for the inevitable consequences.

Cigarette litter is a useful weapon to use against smokers, particularly now that outdoor smoking bans are a priority. A staggering amount of junk research has been produced on the topic this year alone (have a look). Take this article from the anti-smoking comic  Tobacco Control  for example. It encourages advocates to make alliances with environmental groups to capitalise on the cigarette litter 'problem' while attacking the tobacco industry for having the temerity to support tidy-street programmes. As with the New Zealand "news story", the article contains scandalous "revelations" about cigarette companies which don't exactly set the heart racing.

The tobacco industry has been concerned about cigarette butt litter as an issue since the 1970s; a 1979 Tobacco Institute memo stated that smokers' 'careless, offensive and occasionally harmful' cigarette butt disposal practices were contributing to the declining acceptability of smoking. A decade later, the industry was concerned about the 'potential for anti-smoking groups to seize [the litter] issue to attack cigarettes'.

They got that right then, didn't they? How very prescient.

The tobacco industry has responded to the litter issue through partnership with Keep America Beautiful (KAB), an anti-litter organisation.

Yet more secret funding and backroom dealings?
Er, no...

The industry has made no secret of its ties to KAB and similar organisations

Well, fine. Why should they? Cigarette butts are an important source of litter, as tobacco control groups are constantly telling us. So, what is to be done?

Currently, Philip Morris is funding KAB's 'Cigarette Litter Prevention Program'. This program has four strategies: increasing smoker awareness that 'cigarette butts are litter '; installing public ashtrays; promoting pocket ashtrays; and 'encouraging enforcement of existing litter laws'.

In other words, treat cigarette litter the same as every other form of litter. Sounds fair enough. Other industries are expected to encourage responsible disposal of waste, why not the tobacco industry? The answer, apparently, is that...

Like secondhand smoke, litter is a consequence of smokers' behaviour; the industry has no direct control over it.

That's rather contentious, to say the least, and also flatly at odds with the following sentence...

The tobacco industry has managed the litter issue to its advantage by blaming it on individuals and - as with other issues, including tobacco-related disease - denying its own responsibility.

So which is it? Is cigarette litter the result of individual behaviour which the industry has no control over, or is the industry responsible for cigarette litter while blaming helpless individuals? Or do the authors of this article have no coherent argument at all?

Industry-preferred 'solutions' to the litter problem are smoker education, installation of permanent ashtrays and distribution of pocket ashtrays. Although they implicitly blame smokers for litter, these approaches also enable smokers to keep smoking despite increased restrictions and declining social acceptability.

I case you hadn't noticed, smokers are able to smoke regardless of whether there are permanent ashtrays and do so in abundance. It's not a choice between a world with cigarette bins and a world of mass abstinence. It's a choice between lots of cigarette litter and less cigarette litter. The "industry-preferred" solutions are identical to governmental solutions used for every other form of litter: education and the provision of disposal units. No one would seriously argue that removing litter bins from the streets would result in the abolition of rubbish, so what makes cigarette butts any different?

The authors then proceed to give tips on how anti-smoking campaigners can infiltrate environmental groups on the pretext of being concerned about litter while actually pushing an abstinence-only message.

Allies should reach mutual understanding about the nature of the problem. An organisation focused on 'litter ' might regard ashtray installation as a reasonable solution.

No kidding. But what do they know, eh? As far the experts from Tobacco Control are concerned, these organisations are deluding themselves (and probably in the pay of Big Tobacco), so they need to be re-educated by the Johnny-come-latelys of the anti-smoking movement.

The environmental principles 'reduce, reuse, recycle' should be foregrounded, ensuring that smoking prevention and cessation (ie, 'reduce') are considered fundamental.

That's right. Anti-smoking campaigners—who are not in the least bit interested in littering as an issue—are going to alter the decades-old environmental message of "reduce, reuse, recycle" and turn it into "reduce, reduce, reduce." The hubris of these people beggars belief. Take this gem of an idea, for example...

Legislation could require that a sealable return envelope be included with each pack sold, that retailers only accept returns in those containers
Recycling mandates and waste mitigation regulations are not ordinarily designed to curb use...

You're right. They're not, but a handful of monomaniacs briefly and disingenuously joining the environmental movement can change all that, right?

However, if laws requiring cigarette retailers to accept butts back for recycling cause them to stop selling cigarettes, this would also be a gain for tobacco control.

Amongst the many problems with this three-o'clock-in-the-morning idea is that the waste involved in manufacturing envelopes to be sold with every pack of cigarettes, combined with the energy used in posting cigarette butts around the world for no useful purpose, is far more environmentally destructive that a few butts on the pavement. And since the aim of this plan is explicitly to inconvenience smokers and shop-keepers, I suspect that even the looniest green activist will be happy to forego this "gain for tobacco control".

The authors also see a chance to pursue their usual objective of upping the price of cigarettes and limiting availability. If you've got a hammer, everything looks like a nail.

Waste mitigation programs may also raise the price of cigarettes, a well-established means of reducing smoking prevalence rates, and reduce the number of retailers willing or qualified to sell particular goods.

And the madness keeps on coming...

One idea that has not been tried is banning cigarette filters.

[splutter]

Filters have not been shown to reduce the harms of smoking.

Actually they have been shown to reduce the harms of smoking (I could write a whole post on this subject if anyone's interested). Filters are probably the only innovation in cigarette design to have helped reduce the harms of smoking in a century of searching, and yet here are alleged health campaigners recommending their abolition.

So let's get this straight. On the pretext of protecting public health, cigarettes need to be made more dangerous. On the pretext of environmentalism, countless trees need to be cut down to manufacture billions of pointless envelopes. On the pretext of reducing cigarette litter, smokers need to be deprived of litter bins.

How can anyone take these people seriously?

Who do you believe?

Further to Monday's post about the childhood asthma rate in Scotland, it is worth comparing the data presented by Jill Pell in her NEJM paper—which claimed there were 18% fewer hospital admissions after the smoking ban—with the actual hospital admissions data recorded by the Scottish NHS.

This is the "smoothed" graph presented by Pell in her study, which as noted in a previous post, does not even fit her own data. (The last 'year' shown is also not a full year.)

[image error]

NHS Scotland has since published the statistics showing how many children were admitted to hospital with asthma between 2005 and 2009. These figures can be viewed here. They do not support Pell's hypothesis in any way, shape or form.

The graph below shows the rate of hospital admissions for asthma for children aged 0-14 years in all Scottish hospitals (per 100,000). The years shown are financial years (April to March - the first year shown is 2005/06), which is useful since the smoking ban was introduced in Scotland at the end of March 2006. Each of the last four bars therefore represent a full post-ban year.


[image error]

The next graph shows the total number of episodes of the same (ie. the absolute number of admissions). It naturally shows a very similar picture.



Although not discussed by Pell, it is interesting to note that the rate of asthma admissions amongst people of all ages has been higher in every year since the smoking ban was introduced.



And, for good measure, let's have a look at hospital admissions for all diseases of the respiratory system combined.


The data available online do not go back further than 2005/06 so we cannot see the long-term trend earlier in the decade. However, it is sufficient to see that there was no decline in hospital admissions for any of these diseases amongst any age group. If anything, there was an increase.

So, once again, you have a choice. You can choose to believe Jill Pell, a researcher who has, shall we say, "form" when it comes to producing studies like this.

Or you can believe the statistics produced by NHS Scotland which are based on the number of people who actually got admitted to hospital. These statistics, incidentally, support the claim made by Asthma UK that the rate of childhood asthma has remained essentially static for a decade.

It's your call.

Snus and e-cigarettes work

Two studies have recently been published testing the efficacy of snus and e-cigarettes in smoking cessation.

In the Harm Reduction Journal , Joksic et al. report their results from a randomised, placebo-controlled, double-blind trial in which 158 smokers were given snus and 161 smokers were given a placebo. Smoking status was verified throughout with carbon monoxide tests and 81% of participants enrolled because they wanted to quit smoking.

The results show that the snus-users were three times more likely to reduce their cigarette consumption by more than 75% and were two to three times more likely to quit smoking entirely.

An interesting feature of the study is that it was conducted in Serbia, which has no history of snus use. It is sometimes said that snus is a quintessentially Swedish habit that could never take off in the rest of the world. This seems to me a rather odd and slightly xenophobic view (see Alan Blum's quote in The Art of Suppression!) but this success in Eastern Europe shows that the 'Swedish experience' can indeed be exported.

The e-cigarette trial had a smaller sample (of 40) and no control, but if its results are replicated elsewhere, things look very encouraging. At the end of the six months, 22.5% of participants had given up smoking entirely. Amongst all participants, average cigarette consumption fell from 25 a day to 5 a day. As Michael Siegel says, this compares very favourably with pharmaceutical nicotine products. The special point of interest in this study is that none of the participants expressed any particular desire to quit smoking at the outset.

You might think the anti-smoking movement would be jumping for joy at the prospect of having two effective smoking-cessation products to offer the public. As I write this, ASH Wales is holding a conference in Cardiff (with the temperance lobby, natch). It would be nice to think that they are celebrating the news that there are efficacious nicotine products to compete with Big Pharma's 'nicotine replacement therapies', but somehow I don't think they will be.

I wonder why?

Teetotallers die younger, don't let 'em fool you

Reading Eric Crampton's excellent Offsetting Behaviour blog, I came across a post from last year discussing the health benefits of drinking alcohol. Eric provides a succinct summary of how alcohol research is presented to the public.

Every risk is conclusively proven; every benefit needs further study.

That's about the size of it. Of the benefits, there is research going back thirty years showing that the relationship between drinking and mortality is U-shaped or J-shaped, ie. risk is higher for total abstainers, lower for moderate drinkers and then rises again for heavy drinkers. This is largely the result of alcohol's protective effect on the heart. Reduced incidence of cardiovascular disease has been shown in many dozens of studies.




The correlations are consistent and (by modern epidemiological standards) fairly strong, but is there causation? If the popular media were any guide, you might think that the issue is shrouded in controversy. You may even believe that the J-shaped curve has been debunked.

The issue that is often raised is the "sick quitter" hypothesis—the idea that teetotallers are a sickly bunch who don't drink because they are chronically ill or because they have already destroyed their bodies with alcohol. In other words, alcohol doesn't protect health, it just so happens that teetotallers are unusually sickly.

David Nutt is a fan of this explanation, as are these Australians. I have seen Danny Dorling give this explanation on television. Ben Goldacre also uses it his book Bad Science (Unless it's for a Good Cause in Which Case I'll Look the Other Way):

Every time you read in a newspaper that 'moderate alcohol intake' is associated with some improved health outcome - less heart disease, less obesity, anything - you are almost certainly witnessing a journalist of limited intellect, overinterpreting a study with huge confounding variables.

This is because, let's be honest: teetotallers are abnormal. They're not like everyone else. They will almost certainly have a reason for not drinking, and it might be moral, or cultural, or perhaps even medical, but there's a serious risk that whatever is causing them to be teetotal might also have other effects on their health, confusing the relationship between their drinking habits and their health outcomes.

... Perhaps pre-existing ill health will force you to give up alcohol, and that's skewing the figures, making teetotallers look unhealthier than moderate drinkers. Perhaps these teetotallers are recovering alcoholics...

Well yes, perhaps they are. Who knows? If only someone would find out for sure...

Oh wait, they have. The "sick quitter" hypothesis was first put forward in 1988 and has been tested repeatedly in the last twenty years. The results of these studies showed that "sick quitters" do not explain the J-shaped curve.

Researchers have sought to address these concerns in several ways. Some epidemiological studies have separated former drinkers from long-term abstainers to address the sick quitter hypothesis. For example, in an analysis of 87,526 women, the risk of coronary heart disease was only 10 percent higher among former drinkers than among long-term abstainers (Stampfer et al. 1988).

Furthermore, the exclusion of former drinkers among the abstainers did not alter the 40 percent lower risk of coronary heart disease among women who drank 5.0–14.9 grams of alcohol (about 0.3–1 standard drinks) daily. Moreover, Rimm and colleagues (1991) found comparable risks of coronary heart disease among abstainers and light drinkers (i.e., people who consumed less than 5.0 grams of alcohol, or 0.3 standard drinks, daily) in their study of 51,529 healthy men, suggesting that abstainers are not an inappropriate reference group.

Other studies have excluded participants who developed coronary heart disease or died during the first few years of followup, as a means of excluding unidentified "sick" subjects, with similar results (Fuchs et al. 1995).

Taken together these findings indicate that the presence of sick quitters or former alcoholics among the abstainers is not responsible for the apparent benefits of alcohol consumption on the risk of coronary heart disease.

With other factors studied and discounted, the conclusion must be that alcohol has a protective effect on cardiovascular health. This, for example, from Rimm and Moats (2007):

A recent meta-analysis raised questions about systematic misclassification error in observational studies because of inclusion among "nondrinkers" of ex-drinkers and/or occasional drinkers. However, misclassification among a small percentage of nondrinkers cannot fully explain the inverse relation, and there is substantial evidence to refute the "sick quitter" hypothesis. Furthermore, it has been shown that moderate alcohol consumption reduces CHD and mortality in individuals with hypertension, diabetes, and existing CHD.

To address the issue of residual confounding by healthy lifestyle in drinkers, in a large prospective study we restricted analysis to only "healthy" men (who did not smoke, exercised, ate a good diet, and were not obese). Within this group, men who drank moderately had a relative risk for CHD of 0.38 (95% CI, 0.16–0.89) compared with abstainers, providing further evidence to support the hypothesis that the inverse association of alcohol to CHD is causal, and not confounded by healthy lifestyle behaviors.

Amongst those who studied the topic were Richard Doll and Richard Peto who concluded in 1997:

Thus, both in our study and in other studies that involved the observation of large numbers of deaths, confounding, in so far as it has been possible to test for it, does not seem to be responsible for the relatively higher vascular mortality in non-drinkers than in moderate drinkers. Hence we concur with the expert advisors to the European Office of the World Health Organization1141 that 'drinking modest amounts of alcoholic beverages is likely to reduce the risk of CHD [coronary heart disease] for some populations'.

Once of the more recent studies (Holahan et al., 2010) confirmed that alcohol's protective effect is independent of other factors.

Controlling only for age and gender, compared to moderate drinkers, abstainers had a more than 2 times increased mortality risk, heavy drinkers had 70% increased risk, and light drinkers had 23% increased risk. A model controlling for former problem drinking status, existing health problems, and key sociodemographic and social-behavioral factors, as well as for age and gender, substantially reduced the mortality effect for abstainers compared to moderate drinkers. However, even after adjusting for all covariates, abstainers and heavy drinkers continued to show increased mortality risks of 51 and 45%, respectively, compared to moderate drinkers.

This is what science is supposed to do. It asks questions of the data and tests plausible alternative explanations. The sick quitter hypothesis has been tested to death. It does not explain the J-shaped relationship between alcohol consumption and mortality.

Overall, even the most vociferous of critics agree that alcohol taken in light-to-moderate quantities, preferably regularly and with meals, appears to favourably affect ischaemic heart disease.

To ask questions of the data is right and fair. But to keep raising those questions after they have been answered makes me suspect you have an agenda. For some people, the potential of the sick quitter hypothesis to overturn the science was too good to be dropped even after it was disproved.

As Eric writes:

The modern literature (ie the last 4 years) seems to have thoroughly answered the critiques raised in the early 2000s about potential confounds in the J-curve. The worries about potential confounds were plausible: if "never drinkers" and "people who quit drinking because their health was terrible" were coded similarly in the data, that could produce a J-curve without any health benefits from moderate drinking. But that just wasn't what was going on in the data. It's been resolved.

Why won't this zombie argument lie down and die? The answer, I think, is that the temperance lobby hates the fact that total abstinence is not the optimal position and the public health establishment is always uncomfortable with nuanced advice. Advising moderation is fine for GPs, but politically active doctors and neo-prohibitionists prefer to frame things in terms of 'healthy' or 'unhealthy', 'good' or 'evil'.

I think it likely that within a few years the official advice will be to drink no alcohol at all. This would bring it in line with the World Health Organisation's absurd claim that there is no safe level of drinking.

The key message was that no safe level of drinking exists, so people should talk about levels of risk and drop terms such as "safe drinking", "sensible drinking" and "alcohol misuse".

This would be bad scientific advice and very probably bad medical advice, but what the hell? We can't have people seeing alcohol as anything other than an unmitigated evil can we?

As I recount in The Art of Suppression , American teetotallers scored a crucial victory when they persuaded the public that alcohol was a poison that could never be consumed in moderation. This was a lie then and it is a lie now, but it pathed the way for Prohibition. Moderation is the enemy of the zealous. Expect to hear much more about how the J-curve has been "debunked" in the years ahead.

Do have a read of Eric's blog posts on this topic:

The J-curve: science versus politics

Moderate drinking and health

That didn't take long

On Thursday, I mentioned Stanton Glantz's latest contribution to the SmokeFree Movies campaign when he published a study which found that films that showed smoking make 13% less at the box office than 'smokefree movies'.

To give Glantz his due, he did not fall into the trap of mistaking correlation with causation in the study itself.

Fear not, dear reader. Even Stan is not prepared to mistake correlation and causation so grievously (although it surely won't be long before advocates use this study to tell Hollywood: "Get rid of smoking in your films and you'll boost sales by 13%"). He does not claim that smoking in films is the cause of lower revenues. He does not explore what the actual reasons may be, but it seems likely that smoking is more common in indie films, gritty dramas, European releases and other movies which tend to make less money than big budget cartoons and family blockbusters.

I did, however, ask how long it would be before some dumb-bell took the study as 'proof' that putting smoking in a film directly leads to fewer people going to see it and, therefore, making less money.

It didn't take long, and Scientific American is skating on thin ice with this headline:

Smoking Is a Drag at the Box Office

And they plunge straight through the ice with statements like this:

Movie-makers are burning potential earnings when they have onscreen characters light up, new research suggests.

Oh dear, oh dear. All we need now is some dumb-bell to step forward and spell out this fallacious thinking explicitly. Step forward, Stanton Glantz...

"Putting smoking in the film isn't leading to more popular films that make more money," Glantz says. "It's leading to less popular films that make less money."

Bingo.