Tuesday, 23 January 2018

Snus goes to court again

I was interviewed for the Europeans Podcast recently about the issue of snus. You can listen to it here (iTunes) or here (Android).

The interview was timely because we've just had news out of Norway where Sweden's experience of a mass cross-over from cigarettes to smokeless tobacco has been replicated.

More Norwegians use snus – a form of snuff particular to Nordic countries – instead of cigarettes for their nicotine fix, official figures showed for the first time on Thursday.

The preference for snus in Norway, is certain to revive debate over the health effects of the product, a moist powder tobacco that is popped under the lip.

Though its sale is illegal across the EU, it is manufactured and used in Sweden, which has an exemption, and Norway, which is not an EU member.

According to Norway’s statistics office SSB, 12% of Norwegians used snus daily in 2017, compared with 11% who smoked cigarettes every day.

Uber-tweeter Stephen Fry has also posted one of his occasional tweets on the subject:

On Thursday, the EU's ban on snus will be tested at the European Court of Justice. As I described in The Art of Suppression, the ECJ ruled that the ban was legal some years ago after the IARC rushed out a briefing which conflated snus with hazardous smokeless tobacco products from places like India. Since then, more epidemiology has shown snus's potential to help smokers quit and has found the product to be vastly less hazardous than cigarettes.

The case has been brought by Swedish Match and the New Nicotine Alliance. The latter has issued an update on its website:

The case was originally brought by Swedish Match. The New Nicotine Alliance asked to be joined to this case because it concerns the health of smokers in the European Union. It is not about markets and commerce, but about the right to be able to choose a safer alternative to smoking. For the NNA this case is about whether some 320,000 premature deaths from smoking can be saved in future years, as detailed by Dr Lars Ramström in his statement to the court.

The denial of access to lower risk snus leads to unnecessary deaths. The NNA believes that smokers have a right to safer nicotine products as alternatives to smoking and the right to make choices that help them avoid adverse health outcomes.

The core of the NNA’s case is that the ban on snus is both disproportionate and contrary to the right to health. There is no need for the ban, and the ban, if upheld, will continue to contribute to excess mortality from smoking in Europe.

This is the first time that a ‘right to health’ argument has been used to challenge a bad tobacco law: we argue that the Court needs to examine the compatibility of the Tobacco Products Directive with both the EU Charter of Fundamental Rights and the harm reduction obligation under the Framework Convention on Tobacco Control.

I have written before about how Brexit offers an opportunity to get rid of this ridiculous ban, but the ECJ case offers an opportunity for smokers across the EU to switch to snus.

Fingers crossed.

Monday, 22 January 2018

A junk history of tobacco harm reduction

An article in Tobacco Control by a pair of professional anti-smokers from San Francisco asks why the US and UK have such different approaches to e-cigarettes and other reduced-risk nicotine products.

Major British health organisations support tobacco harm reduction for smokers struggling to quit. The USA, in contrast, classifies e-cigarettes as tobacco products and leaders are less supportive of tobacco harm reduction.

Historians have attributed this transatlantic difference to the tobacco industry’s long history of deception over ‘safer’ products resulting in scepticism towards tobacco harm reduction.

Have they? That's news to me. Elias and Ling cite three articles as proof, but only one of them was written by a historian and that was published in 2004, long before e-cigarettes hit the market. None of them makes the argument that Elias and Ling say they do.

But never mind because the rest of the article makes the argument - such as it is - anyway. They do this by going over the story of the Independent Scientific Committee on Smoking and Health (ISCSH) which conducted safer cigarette research with the tobacco industry in Britain in the 1970s. The story they tell has been mostly drawn from the excellent work of the historian Virginia Berridge. You can read a very short summary of the initiatives of the 1970s in Vaping Solutions, but the gist of it is that nothing really came of them because smokers tend to draw more deeply on low tar cigarettes and regulation prevented more imaginative safer cigarettes from succeeding in the market.

Elias and Ling go through the British experiments for several pages and then, finally, get to the point:

In the eyes of the broader British public health community, the ISCSH work was largely for naught. Yet in recent years, the Committee’s guiding logic and premises of risk reduction have enjoyed a reanimation among British public health organisations.

Hear that dog whistle? The message is 'once bitten, twice shy'. History is repeating. Beware!

British public health should mind past experience, in which industry-backed ‘safer cigarettes’ undermined public health.

Elias and Ling argue that efforts in the UK to make cigarettes safer were an industry-led distraction which caused the British government to shelve effective anti-smoking policies. By contrast, the USA got on with the job of clamping down on cigarettes and had no truck with tobacco harm reduction.

As if that weren't bad enough, it's all happening again. When will those limeys learn?

If the past is any guide, the promotion of tobacco harm reduction may serve the interests of tobacco companies more effectively than the public.

The problem with this narrative is that it's ahistorical nonsense from start to finish. It turns a blind eye to the inconvenient fact that America had its own industry-government working group that spent millions of dollars trying to make cigarettes safer. The US National Cancer Institute set up the Tobacco Working Group in 1968 (five years before ISCSH was formed) for this very purpose, but the only acknowledgement of this in the Tobacco Control article is one sentence in the discussion section:

Government and industry collaborations to develop a ‘safer cigarette’ were not unique to the UK. From 1968 to 1979, the US National Cancer Institute spent US$50million to sponsor the Tobacco Working Group (TWG).

Government-approved efforts to launch safer cigarettes in Britain and the US were effectively dead in the water by 1978 and 1979 respectively. The two countries did not have different experiences and, therefore, their different attitudes to tobacco harm reduction today cannot be explained by them.

Moreover, the USA did not choose tough anti-smoking measures over tobacco harm reduction, and the UK did not choose harm reduction over anti-smoking policies. From the 1980s to the present day, the UK has had higher tobacco taxes, more restrictive advertising laws and larger health warnings. It also managed to ban snus, the only viable reduced harm product that existed until e-cigarettes came on the scene.

Elias and Ling's little morality tale is a travesty of history and explains nothing. Britain's approach to tobacco harm reduction, and vaping in particular, doesn't require much explanation. From around 2012, lots of smokers spontaneously switched to vaping and the government ultimately decided that this was a good thing. 

Britain is not unique in this. Across the developed world, governments have recognised the benefits of vaping and have regulated e-cigarettes accordingly, ie. more lightly than cigarettes. The sale of e-cigarettes is now legal in every EU country, for example, albeit with some silly restraints from the EU. The USA is the outlier insofar as it has moved from a tolerant position to a more extremist one. It is this American exceptionalism that requires an explanation.

My explanation is that US policy has been influenced by people, such as those at Elias and Ling's Center for Tobacco Control Research and Education, who are more interested in fighting tobacco companies than in fighting smoking. There is also a stronger puritanical element in the US anti-smoking movement than there is in the UK, and America has a stronger history of prohibition. Furthermore, the pharmaceutical industry has more clout in the US than it does in the UK and funds anti-smoking groups to a much greater extent.

In both countries, the 'public health' lobby is divided between those who are genuinely interested in health and those who are, in effect, moral or political crusaders. In Britain, the former just about managed to gain the upper hand, despite opposition from the likes of Martin McKee and Simon Capewell. In the USA, the latter are in charge. They are all awful, illiberal people to varying degrees, but in America the very worst have risen to the top.

Friday, 19 January 2018

Blame the government, not Brexit, for the biscuit rip off

McVitie's are reducing their packets of Digestive biscuits from 500g to 400g. This means consumers will be getting seven fewer biscuits in their pack. Parts of the media have been blaming Brexit for this and the company itself has pointed the finger at the weaker pound and rising cost of raw materials.

McVitie's is shrinking the size of a packet of Digestives because of price increases caused by the Brexit drop in the pound, it claims.

The company said the value of sterling has made ingredients more expensive and it did not want to damage the quality of the biscuits.

If these were the real reasons, the obvious thing to do would be to raise the price. If companies made their products smaller every time inflation rose, everything would be tiny.

But they are not the real reasons. When the ONS looked at the 'shrinkflation' of chocolate and confectionery last year, it found no evidence that the value of sterling or the price of raw materials were responsible:

Manufacturers’ costs may also be rising because of the recent fall in the value of the pound – leading some commentators to attribute shrinkflation to the UK’s decision to leave the European Union. But our analysis doesn’t show a noticeable change following the referendum that would point towards a Brexit effect. Furthermore, others (including Which?) had been observing these shrinking pack sizes long before the EU referendum, and several manufacturers have denied that this is a major factor.

The real blame lies with Public Health England and its sugar reduction scheme. PHE have set the food industry the target of reducing sugar in its products by 20 per cent by 2020. McVitie's said last year that it was 'confident' it could achieve this.

But how? Artificial sweeteners do not work well in biscuits. When PHE realised that genuine product reformulation was impractical, they told the companies that reducing portion size would count as sugar reduction. Indeed, they actively encourage them to reduce portion size.

Shrinking a pack of biscuits from 500g to 400g is a reduction of twenty per cent and so McVitie's can claim to have met its target. Last year it reduced the number of Jaffa Cakes in a packet from 12 to 10, which is nearly a twenty per cent reduction. There will be more to come.

The price of the new, smaller pack of Digestives is also going to be reduced, but not by as much. It will fall from £1.25 to £1.15, a drop of 8 per cent. The result is that Public Health England can say that their target has been met, McVitie's can make a bit more money and the consumer loses out. Meanwhile, people who don't want to leave the EU can brandish this as further evidence that Brexit is making us all poorer.

But it is fake news. It has nothing to do with Brexit. It is all about the government's ridiculous childhood obesity strategy. They call it 'health by stealth'. Doing it by stealth is bad enough, but denying that it is happening while lying about the reasons behind this rip-off is intolerable.

Wednesday, 17 January 2018

Public Health England vs. the Evening Standard

In November, the Evening Standard published an article about the drinking guidelines scandal in which the methodology of Sheffield University's modelling was changed at the eleventh hour after their initial modelling implied that the guidelines should not be lowered. The methodological change had no scientific justification, as the Sheffield team told Public Health England at the time. Nevertheless, PHE ordered the change to be made (for a fee of £7,800) and the research came back with significantly lower implied guidelines.

This story was covered in the Sunday Times in late October and I published a full account on Spectator Health. The Evening Standard reiterated some of this in an article on November 3rd headlined 'Public Health England "tweaked" alcohol research to impose stricter guidelines, report reveals'.

I would link to the article but it was taken down within hours. I don't know if it was ever published in the newspaper. All I have are these screenshots that I took at the time.

Why was this article taken offline? I suspected that Public Health England might have had something to do with it so I sent a Freedom of Information request asking to see all correspondence between them and the Evening Standard at the time of the incident.

Sure enough, I got this e-mail chain starting on 2 November while the journalist was preparing the article...

From: PHE
Sent: 02 November 2017 13:48
To: standard
Subject: PHE response on alcohol guidelines story in Sun Times


As promised - our full statement in response to Sun Times:

PHE spokesperson:

“The UK Chief Medical Officers’ alcohol guidelines were based on a comprehensive analysis of the evidence and advice from the Guidelines Development Group of independent experts.

“As part of the secretariat to the group, we commissioned the analysis, as requested by the Guidelines Development Group, from Sheffield University. We categorically refute the claim that PHE in any way attempted to influence or pressure Sheffield University on their research work to inform the alcohol guidelines.”

I will forward our final response to the Spectator as soon as possible


The Spectator article was mine. PHE did indeed respond to it and I replied to their points in this article.

PHE then sent the Standard the response that Sheffield had sent the Sunday Times a few days earlier...

From: PHE
Sent: 02 November 2017 14:10
To: Stanfard
Subject: PHE response


Below is part of our response to the Spectator Re: Chris Snowden’s article, which gives a more detailed account from Sheffield Uni about the evidence requested from the expert group. The links provide the minutes of the expert groups (GDG) meetings.

Any queries on the expert group’s decision on the evidence are not for PHE to answer – as we were just part of the secretariat to the group along with DH.

Sheffield Uni press office can also provide you with their full response to the Sun Times.

As part of the secretariat to the group, we commissioned the analysis, as requested by the GDG, from Sheffield University. Any emails from PHE to Sheffield commissioning additional modelling and evidence were based on the GDG’s decisions and at their request, as is clearly shown by the publicly available minutes of their meetings.

This has been confirmed by Sheffield University’s Alcohol Research Group, which has said:

“Minutes from the subsequent GDG meeting on 21 January 2015 state that, after hearing Sheffield's presentation of their work, the GDG concluded: ‘A holistic, expert judgement on guideline levels would be needed, taking account of uncertainties and issues not fully modelled’. This demonstrates that the group recognised there was considerable scientific uncertainty present and that no single piece of evidence or modelling decision used in isolation would determine the final guideline.

“As noted in the Royal Statistical Society's consultation response: "This is a contested area of science with considerable uncertainties" (paragraph 1.1). The change to the base case analyses related to a point of scientific uncertainty. The Sheffield Alcohol Research Group were happy with the decision taken whereby the base case analysis was revised but the original modelling assumptions were retained as one of a series of sensitivity analyses.

“Those analyses explored major areas of uncertainty within the underlying evidence and their implications for the Guideline Development Group's work. The group considered those sensitivity analyses in detail and took them into account in their decision-making.”


From: Standard
Sent: 02 November 2017 14:11
Subject: RE: PHE response


Thanks so much for getting back to me.

All the best,


From: PHE
Date: 2 November 2017 at 14:21:39 GMT To: standard
Subject: RE: PHE response


Grateful if you could let me know if you do decide to write something



It must be said that neither PHE's response nor that of Sheffield's is entirely consistent with the e-mails sent at the time. PHE's defence throughout this whole affair has been to pass the buck to the guidelines committee. I made it clear from the start that the idea of changing the methodology came from the guidelines committee. However, it is a bit much for PHE to deny that they 'in any way attempted to influence or pressure Sheffield University'. Whether acting on behalf of the committee or not, PHE exerted strong pressure on the Sheffield team, and on page 28 of Sheffield's published report it clearly states:

‘At the request of the commissioners (Public Health England), this threshold effect removed for the base case analysis…’

As for the Sheffield team claiming that they 'were happy with the decision taken whereby the base case analysis was revised but the original modelling assumptions were retained as one of a series of sensitivity analyses', the e-mails suggest that they were anything but happy. When asked by PHE to change the methodology, they said:

Our view remains that it does not seem right to assign people drinking at very low levels a risk of acquiring alcoholic liver disease and similar conditions. Unless there are strong opposing views, we think it better to keep the threshold in the base case.

The Standard published the story on November 3rd and received this e-mail from PHE in response:

From: PHE
Sent: 03 November 2017 16:38
To: Standard
Subject: Complaint re: "Public Health England 'tweaked' alcohol research to impose stricter guidelines, report reveals"

Dear XXXX,

Not for publication

I am writing to complain about multiple inaccuracies and errors in Alexandra Richards’ article “Public Health England 'tweaked' alcohol research to impose stricter guidelines, report reveals” and the article’s serious and unsubstantiated claim that PHE made changes to research in order to impose different guidelines.

As I explained in my phone call earlier, this is a serious allegation that assigns intent to PHE as well as claiming that PHE altered evidence. In fact, as our on the record statement made very clear, PHE was not a decision making body and so it is doubly wrong to suggest that PHE altered evidence with an intended outcome.

PHE was acting as secretariat to the independent group of academics, the Guideline Development Group (GDG) which advised the Chief Medical Officer (CMO) on the evidence. It was this group of academics which decided to request additional analysis, a point which is made very clear in the minutes of their meetings which were published by the Department of Health as part of the consultation process some time ago (this evidence, and a link to where it can be found, is detailed here: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/490560/List__of_ documents_acc.pdf). I have attached the minutes of the relevant meeting.

I request that the article is taken down until corrected so that others do not repeat its many errors.

They are:

Public Health England 'tweaked' alcohol research to impose stricter guidelines, report reveals
Wrong. A group of independent academics, the Guidelines Development Group (GDG), were responsible for reviewing the evidence and submitting this to the CMO. They resolved at their meeting of 21 January 2015 to request additional modelling. It should also be noted that the final report included all analyses  

The government asked a leading alcohol research centre to tweak data in order to impose stricter regulations on drinking  
Wrong. As above, the decision to request additional research was made by the independent GDG. Secondly, this sentence alleges, without substantiation, that PHE’s intention was to impose stricter regulations. Finally, the CMO Guidelines are not regulations – as made clear on the government’s website: “These guidelines, produced by the 4 UK chief medical officers, provide the most up to date scientific information to help people make informed decisions about their own drinking.”

Public Health England called on scientists at the Sheffield Alcohol Research Group (SARG) to write into a report
It is wrong to say PHE ‘called on’, this implies lobbying or advocacy. As the published minutes of the GDG and our statement make clear, PHE passed on the GDG’s request in our role as part of the secretariat.

Christopher Snowden, who requested the FOI, discovered that there had actually been an earlier draft of the report
This ‘earlier draft’ is publicly available on the Department of Health’s website in the consultation pack (see link above).

In emails seen as part of the FOI request, PHE wrote to the SARG suggesting that the group “estimate risk urges without threshold effects for wholly alcohol-attributable chronic conditions" in the model.
It is wrong to say this was PHE’s suggestion. As the published minutes of the GDG and our statement make clear, PHE passed on the GDG’s request in our role as part of the secretariat.

When the Evening Standard contacted the PHE they said that they had been acting at the request of the Department of Health and that any requests to change the report came from them.
Not correct. PHE made clear (see attached emails) that decisions on the evidence were made by the independent experts of the GDG. They are independent of the Department of Health.

PHE added: “Any emails from PHE to Sheffield commissioning additional modelling and evidence were based on the GDG’s decisions and at their request, as is clearly shown by the publicly available minutes of their meetings”
Our full statement makes clear the GDG’s role: “The UK Chief Medical Officers’ alcohol guidelines were based on a comprehensive analysis of the evidence and advice from the Guidelines Development Group of independent experts. As part of the secretariat to the group, we commissioned the analysis, as requested by the Guidelines Development Group, from Sheffield University. We categorically refute the claim that PHE in any way attempted to influence or pressure Sheffield University on their research work to inform the alcohol guidelines.”

He said that after seeing the initial evidence, the Department of Health decided that the evidence was not “robust enough”
See above – it was not the Department of Health but the GDG which requested additional evidence.

They also said that they could not answer questions regarding the GDG’s decision on the evidence.
PHE actually said in a background email (attached), “Any queries on the expert group’s decision on the evidence are not for PHE to answer – as we were just part of the secretariat to the group along with DH.”

I do not speak for Sheffield University, but I would point out that others have run a fuller version of their statement, including a line which was not included in the Standard Online’s piece - “The Sheffield Alcohol Research Group were happy with the decision taken whereby the base case analysis was revised but the original modelling assumptions were retained as one of a series of sensitivity analyses” (see: https://www.theregister.co.uk/2017/10/31/booze_evidence_was_tailored_to_fit/?mt=1509459658 113).

Please confirm receipt and that this article will be corrected.



The article was not just 'taken down until corrected', as PHE requested. It was taken down for good. Without having the full article in front of me, it is difficult to say how accurate it was. Most newspaper articles are inaccurate to some extent, but I don't recall thinking that it was any worse than average.

Looking at PHE's list of complaints, they are right to say that the guidelines are not 'regulations' and they are right to make a distinction between the guidelines group and the Department of Health. These are sloppy mistakes that could have easily been corrected.

Other than that, the article is basically sound. It is simply a fact that it was PHE who commissioned the Sheffield report and it was they who asked them to make the changes. Whatever word you want to use - 'suggested', 'asked', 'called on' - PHE wrote the e-mails to Sheffield requesting the changes. They can argue that they were just middle men acting on behalf of the guidelines group (although Sheffield researchers were on that group and they seemed surprised that PHE was asking for the whole base case to be changed), but they were the ones who told Sheffield to change the methodology.

In any case, the Standard article included quotes from PHE explaining their position so that readers could make up their own minds. That is fair journalism and the Standard was spineless to take the article down.

It is telling that neither PHE nor Sheffield has mounted a defence of the methodological change itself. Sheffield points the finger at PHE and PHE points the finger at the guidelines group. The data were 'tweaked'. PHE do not deny that. The change made to the base case had no scientific justification and no scientist has tried to justify it.

PHE says that '[a]ny queries on the expert group’s decision on the evidence are not for PHE to answer'. So who is going to answer them? Anybody?

Tuesday, 16 January 2018

Stop press: sugar tax = higher prices

Some people seem surprised that Coca-Cola are raising prices and reducing bottle sizes as a result of the sugar levy, despite that being the whole point of it.

I've written a short piece for Cap-X looking at the economics of this and whether Coke are price gouging. Do have a read.

Monday, 15 January 2018

Alcohol and dementia

The front page of yesterday's Sunday Times carried the news that Public Health England intends to use its bizarre new calorie limits to bully restaurants and food manufacturers into downsizing and degrading their products.

Public Health England (PHE) has told fast-food chains and supermarket ready-meal makers to “calorie cap” their foods, cutting down lunches and dinners to 600 calories and breakfast to 400.

The plan, to put the whole of the UK on a diet, is due out in March.

This is as I predicted when the new guidelines of 400 calories for breakfast and 600 calories for lunch and dinner were announced a few weeks ago:

I suspect that there is an agenda at work here. The 400-600-600 'rule' will allow PHE and its army of scolds to name and shame every restaurant portion, takeaway and ready meal that contains more than the government-approved quantity of calories. Individual meals will be portrayed as hazardous per se and will become targets for advertising bans, taxes and reformulation. A whole Pandora's Box is being quite deliberately opened. 

The same Sunday Times article also suggested that the alcohol guidelines might be lowered yet again:

To add to the agony, it coincides with research showing that the UK’s alcohol rules are too lax, with even drinking one pint or glass of wine a day poisoning the brain and raising the risk of dementia.

It's unclear whether Public Health England tipped off the press about this study or whether the Sunday Times decided to combine two 'public health' stories. The idea that the government would change the drinking guidelines on the back of a single study that looks at single outcome is absurd, but you never know these days.

The study itself involved a group of people being given sort of online quiz to test their reaction times (details are not provided) and asked how much they drank. Non-drinkers were excluded. The authors report that 'cognitive performance declined as alcohol consumption increased beyond 10 g/day' (a UK unit is 8 grams) and their conclusion reads as follows:

Current advice from the UK Department of Health is for men and women to not consume more than 16 g of pure alcohol per day (two units) on average. Findings reported here suggest that daily alcohol consumption above one unit is may have an adverse cognitive impact. Recommendations should be sensitive to this, especially among middle-aged and older members of the population.

But, as David Spiegelhalter points out in this blog post, the data do not support the conclusion. Here is the graph showing response times in milliseconds (y-axis) and daily alcohol consumption (x-axis).

The first thing to note is that this is not a study of dementia and the differences in response times are pretty small. The second thing to note is that the scale of the x-axis is insane! The third thing to note is, as Spiegelhalter says, response times are not quickest at around 10 grams of alcohol a day. They are quickest at around 18 grams a day, ie. more than two units. Moreover, response times remain relatively low even for very heavy drinkers.

In reality, the main finding seems to be that light drinkers don't have very good cognitive skills (and therefore, in the world of newspapers, are more likely to suffer from dementia). This is clearly not what the researchers wanted to find.

The usual excuse given by those who don't want to admit that there are any benefits from drinking alcohol is the hoary old 'sick quitter' chestnut, but the authors can't use that here because they excluded non-drinkers from their analysis. And so they resort to a 'sick light drinker' hypothesis that they seem to have invented for convenience:

The ‘J’ shaped association reported here should be considered critically. To reduce the ‘sick quitter’ effect abstainers were omitted. However, participants who may have only reduced alcohol intake for health reasons rather than quit, remain in the analysis.

No evidence for this little theory is presented. As usual, negative effects of drinking are reported uncritically while positive effects are met with a wall of speculation, doubt and hypotheses that are unevidenced but unfalsifiable.

The reality is that this study supports previous studies (such as this) that find a U or J-curved relationship between alcohol consumption and cognitive ability, with abstainers and light drinkers doing worse than heavier consumers. Its authors were evidently displeased with their findings and so they misrepresented them, created a misleading graph and called for a change to government guidelines.

The media then covered the study with such headlines as Just ONE pint a day ‘poisons your brain and increases your risk of dementia’ and another lie from 'public health' had travelled the world before the truth could get its shoes on.

Saturday, 13 January 2018

The editor of the Lancet is an idiot

One of the big questions about the 'public health' racket is whether its most prominent figures are conscious liars or mere idiots. I have to tell you, dear reader, that I sometimes suspect deliberate deceit.

Yesterday, I wrote about the absurd claim that 'liver disease is on a trajectory to become the biggest cause of death in England and Wales.' The claim appeared in the Lancet and was made by its editor, Richard Horton. The source for claim seems to be an article published in the same journal last month, although it does not actually support Horton's factoid.

The reality is that liver disease is responsible for less than two per cent of deaths in England and Wales and its 'trajectory', such as it is, is flat. Several people, including myself, have pointed out this error to Horton and he responded last night with a tweet that doubles down on the original claim.

There is no ambiguity in this tweet: 'Liver disease deaths are on a trajectory to overtake deaths from ischaemic heart disease' (which is currently the biggest cause of death) And yet the graphs he uses to prove this clearly do not show the number of deaths. They show the number of working-age years of life lost before the age of 65, which is a very different thing indeed.

If Horton is deliberately trying to deceive us here, he is doing so with the Trump tactics of repeating himself and never backing down. I don't think that's his style do I can only conclude that he doesn't understand his own evidence and is an idiot.