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.

Friday, 12 January 2018

Fake statistic of the day

There's going to be a PR stunt in Parliament on January 22nd when Dr Sarah Wollaston uses the health select committee to campaign for minimum pricing. Wollaston is in charge of the committee and has been advocating for this regressive policy for years. There's no word yet on who will be appearing at the 'inquiry', but I expect we will see the usual faces from the Sheffield fantasy modelling club plus the likes of the UK Temperance Alliance (AKA the Institute of Alcohol Studies).

The Lancet's Marxist editor, Richard Horton, has given some publicity to Wollaston's kangaroo court in this week's issue. In addition to making the absurd claim that '[t]he science supporting minimum unit pricing seems overwhelming', he says this:

Chaired by independent-minded Conservative Member of Parliament and former general practitioner, Sarah Wollaston, the committee will review evidence for and against minimum unit pricing at a moment when liver disease is on a trajectory to become the biggest cause of death in England and Wales.

Even by Horton's standards, this is nonsense on stilts. Liver disease is nowhere near being the top cause of death. Here are the figures from the Office for National Statistics for men in England and Wales. Liver disease is tenth on the list, causing half as many deaths as prostate cancer and an eighth as many deaths as heart disease.

For women, liver disease doesn't even make the top fifteen:

If we look at the age-standardised mortality figures from Public Health England, the story is much the same. Here are the men. You'll see the rate of liver disease right at the bottom in blue.

And here are the women. Once again, liver disease doesn't make the cut.

And - without wanting to labour the point - here are the proportion of all deaths in England attributed to each major 'killer'. Liver disease just about sneaks into the top ten for men with 1.9%, but not for women.

If you look at Public Health England's graph for men (above), you can see the trend in liver disease deaths. Although Horton claims that 'liver disease is on a trajectory to become the biggest cause of death', the graph shows that the trajectory is basically flat. This is also the case for alcohol-related diseases in general, which rose in the 1990s but have been broadly flat for more than a decade.

So what the hell is Horton talking about? It can be no slip of the pen because he has been repeating the claim on social media:

The source for the claim seems to be a study he published in the Lancet last month. The Independent reported this study with the headline 'Liver disease to become biggest killer by 2020 with alcohol and obesity to blame' but that's not what the study said.

The study was, in practice, a briefing for anti-alcohol lobbyists written by the usual neo-temperance suspects (Ian Gilmore, Petra Meier etc.). Nick Sheron was one of the authors and he gave a quote to the media when it was published. We have seen before that Sheron likes to ignore the size of the population when he does his calculations, and that trait is in evidence in the Lancet study which says:

Alcohol consumption in the UK, which peaked at around 5642000 hL (hectolitres) in 2008–09, decreased when the duty escalator was introduced to around 4843000 hL in 2013–04, and increased again to 5126000 hL in 2016–17 after the duty escalator was withdrawn.

Sheron and Gilmore used this sleight of hand in Public Health England's risible alcohol policy evidence review. The appropriate measure here is per capita alcohol consumption. Per capita alcohol consumption actually peaked in 2004 and has been falling ever since. Sheron likes to pretend that the decline began in 2008 because it enables him to link it to the alcohol duty escalator. As he says in the study:

These changes show how responsive population alcohol consumption is to small changes in taxation and further support the Commission’s recommendation for an increase in overall alcohol taxation.

Total cobblers. There was a bigger fall in consumption in the four years before the duty escalator was introduced than in the four years afterwards, but since this doesn't fit the temperance narrative they rewrite history.

They then say that...

Alcohol-related deaths in England and Wales decreased from a peak of 7312 in 2008, when the alcohol duty escalator was introduced, to 6999 by 2012, but increased to 7630 in 2016 after abolition of the alcohol duty escalator in 2013.

Again, the authors are using absolute numbers when they should be using death rates per 100,000 people. Reading their statement, you would get the impression that deaths peaked in 2008 and then fell before reaching new heights following the abolition of the alcohol duty escalator. But this, again, disregards population growth. The rate of deaths per 100,000 men in England was 15.5 in 2008 and was 14.5 in 2016. For women, the rate was 7.0 in 2008 and 6.8 in 2016. Rates in Wales were also lower for both sexes in 2016.

Sheron et al. create a false narrative of record levels of liver disease mortality which are rising rapidly (and which can only be reduced by raising prices). But even in this fantasy, it is obvious that the 7,630 alcohol-related deaths mentioned in the study (of which only a proportion involve liver disease) make up less than two per cent of the 500,000 deaths that occur each year in England and Wales.

In what parallel universe, therefore, is liver disease poised to become Britain's biggest killer? It turns out that this isn't what the Lancet study claims at all. It doesn't make any claims about the number of deaths. Instead, it looks at the much more specific issue of lost years of life. This makes liver disease appear more important because it is less of a disease of old age than dementia, heart disease and cancer.

But although Quality Adjusted Life Years (QALYs) are a conventional measure in public health, they do not make liver disease look significant enough for Sheron et al. and so they switch to the rather less conventional measure of lost years of working life before the age of 65. This helpfully disregards all the people who die after the age of 65 - ie. the vast majority of the British population - and results in this graph.

I can't vouch for the figures in this graph because they have been created by the authors of the study and are not available in any of the routine statistics that are published by the NHS or ONS. They could be rubbish, but even if we assume that they are correct, it is clear that the 'trajectory' has been flat for the last decade. If liver disease overtakes heart disease under Sheron's bespoke measure, it will be because the number of lost working-age years before the age of 65 from heart disease falls, not because the number of lost working-age years before the age of 65 from liver disease rises.

None of this has any bearing on the number of people dying from liver disease. Horton's claim that 'liver disease is on a trajectory to become the biggest cause of death in England and Wales' not merely untrue, it is a million miles from the truth. Liver disease is responsible for well under two per cent of all the deaths in England and Wales. Mortality rates have not been rising and they show no sign of rising.

Nevertheless, you can expect this fake statistic to be trotted out for years to come with the once respected Lancet journal cited as the source.

Thursday, 11 January 2018

The Geneva Convention: COP8

The World Health Organisation's highly secretive Conference of the Parties (COP) for the Framework Convention on Tobacco Control is coming to Geneva this year.

Not so much coming to Geneva as staying in Geneva, as that is where the WHO is based. Two years ago, it was in highly polluted Delhi. Two years earlier, it had been in Putin's Moscow. The conference is renowned for locking its door to the public and kicking journalists out of the room. Despite being taxpayer-funded, taxpayers cannot even watch the sessions, let alone participate in them.

Transparency might be zero, but the decisions made at this conference can have a profound effect on nicotine consumers all over the world. The WHO is famously opposed to e-cigarettes and other safer nicotine devices. Many of the bans on the sale and use of e-cigarettes can be traced back to them.

Last year, the UK delegation consisted Andrew Black, an activist-bureaucrat from the Department of Health, and Deborah Arnott of the state-funded pressure group ASH. The WHO FCTC's approach to e-cigarettes and tobacco harm reduction is diametrically opposed to that of the British government, but that didn't stop Black and Arnott using the conference as an opportunity to announce that the Department of Health had decided to give the Framework Convention on Tobacco Control an extra £15 million. Soon afterwards, Andrew Black was given a job at the WHO on the FCTC Secretariat. What a small world!

Let's face it, the general public is not welcome at this shindig and ordinary consumers are not going to get in. Nevertheless, Geneva is a nice place to visit and is easy to get to. The dates are 1-6 October 2018. Why not pop it in your diary?

Wednesday, 10 January 2018

Cancer warnings on alcohol are unjustified

As reported in the Guardian, the Alcohol Health Alliance is concerned that only ten per cent of Britons are aware of the link between drinking and cancer. They are demanding cigarette-style warnings on alcoholic beverages to remedy this. There are several reasons why this would not be a good idea.

The evidence that only one in ten people is aware of the alcohol-cancer link comes from a survey conducted in September 2017 which asked respondents to spontaneously name diseases that they associate with alcohol consumption. It might have been better to ask a question along the lines of ‘do you believe that drinking increases the risk of some cancers (yes/no)?’ If cancer risk was not front of mind when the respondents answered the survey, we should not be surprised. The cancers associated with drinking are mostly quite rare. The lifetime risk of dying from these diseases is mercifully small and, for people who drink moderately and do not smoke, the increased risk from alcohol consumption is trivial to non-existent.

The exception is breast cancer, which appears to be linked to drinking even at low levels – hence the Chief Medical Officer’s claim that there is no safe level of drinking – but the evidence for this has only appeared in recent years and there are reasons to be sceptical of it. Even if the statistical associations between moderate drinking and breast cancer are real and causal, the magnitude of risk is so small that it is unlikely to persuade many women to go teetotal.

Nevertheless, don’t people have the right to know about these risks? Don’t we free market liberals want informed consumers? Well, yes we do. The question is how we go about telling them. Britain is not California. We do not plaster cancer warnings on every product on the shelves. We do not demand health warnings on bacon, steak, french fries and ‘very hot drinks’, even though they have all been declared carcinogenic (or ‘probably carcinogenic’) by the International Agency for Research on Cancer.

Plenty of everyday products have been linked to cancer or can cause harm if abused. With the exception of cigarettes, we do not demand health warnings on them because the risks are not particularly great and there are plenty of other ways for people to get this information if they are interested. Indeed, there are ways for people to be given this information even if they are not interested. Public Health England spent a staggering £4.5 billion last year. The British taxpayer pays for an army of ‘public health professionals’. If they wanted to inform people about the cancer risks associated with drinking, they have the resources with which do so.

I am not against labelling per se. People have a right to know what they are buying and I am in favour of putting calorie counts on alcoholic drinks. But a functioning market does not require consumers to know every possible cost and benefit before they make a purchase, and it certainly doesn’t require every possible cost and benefit to be listed on the label.

Let’s be realistic about this. The Alcohol Health Alliance are not demanding cancer warnings on wine bottles because they want consumers to be fully informed. They want cigarette-style health warnings because they want to treat alcohol like cigarettes. They want every bottle and can to scream a message that ‘Alcohol causes cancer’ and ‘Drinking kills’ in order to deter people from buying the product. Moreover, they want these messages to be carried alongside graphic photographs of diseased livers.

This would not lead to the public being better informed. On the contrary, it would mislead people into thinking that the cancer risks associated with drinking were of the same magnitude as those associated with cigarettes.

What would an accurate health warning on alcohol look like? I tackled this question in my book, Killjoys:
The British public, we are told, are woefully ignorant about the link between alcohol and cancer, and labelling drinks with a cigarette-style cancer warning would be an effective way to spread the word. Perhaps it would, but the risks are so small in practice that such a system would either discredit scientific advice in the eyes of the public or alarm consumers to such an extent that they would make worse choices than if they remained ignorant. A truthful alcohol label would explain that associations have been found between alcohol consumption and several cancers, most of which are rare. It would explain risks in absolute, rather than relative, terms (e.g. ‘Heavy drinking increase your lifetime risk of developing disease X from Y per cent to Z per cent’). Finally, it would explain that moderate consumption of alcohol reduces the risk of heart disease, stroke and diabetes, and that premature death is less common among moderate drinkers than teetotallers, although heavy drinkers have a higher mortality rate than either.

Aside from the fact that this is too wordy to fit onto a bottle of wine, a label that explained the science adequately would make consumers better informed whereas a warning saying ‘alcohol causes cancer’ would lie by omission. A truthful label would probably have no effect on alcohol consumption other than possibly increasing it. It is questionable whether it is worth putting it on the bottle at all, particularly since the information is available from other sources for those who are interested. And yet it is only the verbose yet truthful label, not the crude cancer warning favoured by paternalists, that can be ethically justified if the aim is to inform rather than alarm.
The ‘public health’ lobby is not interested in educating people about the health effects of alcohol consumption. One only needs to look at its campaign of doubt and denial over the benefits of moderate drinking to see that. There is no more justification for putting health warnings on alcoholic drinks than there is for putting them on sausages.

Cross-posted from Spectator Health.

Tuesday, 9 January 2018

Doctors are the new children

Following the NHS ban on sugary drinks, the manager of Tameside Hospital in the north-west has announced a ban on sugary snacks:

Tameside hospital in Greater Manchester has banished fizzy drinks, chocolates, sweets and biscuits from its canteen and vending machines as it encourages overweight staff to set a better example to patients.

Simon Stevens, chief executive of NHS England, is planning to ban the sale of sugary drinks in hospitals this summer... However, Tameside is going further, saying that in its staff canteen there will be no more sweet treats except the odd dessert and sugar for hot drinks. It is also trying to persuade its Costa Coffee outlet to get rid of cakes and muffins.

I saw the press release for this yesterday when it was under embargo and gave a comment to the Times:

Chris Snowdon, from the Institute of Economic Affairs, said: “The manager of this hospital has a very low opinion of her staff if she thinks they need to be nannied like this. It is an insult to the intelligence of every doctor and nurse. If trained medics can be trusted with patients, surely they can be trusted with a dessert trolley?”

(Incidentally, why was it press released? Could it be that the managers at Tameside hospital are looking for brownie points from Simon Stevens?)

The first thing to note is that this is not about children and it is not a hospital patients. It is not about the quality of school food or hospital food, both of which can be sensibly regulated to meet nutritional standards.

It is about an employer deciding what its adult employees eat, as Steve Morton, a fat cat from Public Health England North West, says:

“Large employers can set a great example by encouraging their staff to think about their health by opting for healthier food and restricting less healthy options such as sugary snacks and fizzy drinks.”

Part of me thinks that it is quite funny that the members of the vile British Medical Association are the first in line for this patronising treatment, but then I remember that most medics are perfectly normal people who don't deserve it.

Managers acknowledge that the reaction from staff has been mixed, with some demanding to know where their favourite treats have gone. 

Too bad, medics. You're being 'encouraged to think about your health', dontcha know?

It's no surprise to find that this initiative is being led by somebody who has the words 'human resources' in their job title:

“We’ve taken away the sugary drinks, we’ve taken sugary snacks out of vending machines, we’ve taken away cookies and muffins and replaced them with fruit,” Amanda Bromley, director of human resources at the hospital, said. “You’d go to the till and there’d be a Twix and a Bounty bar staring back at you. People are working long shifts and if things are in front of them we know they are going to reach for them.”

That's up to them though, isn't it, Amanda? If people have been working hard - something I suspect you know little about - a Twix or a Bounty could be just the ticket.

The hospital's new chef sounds like a wrong 'un as well:

“I started here in May and the menu at that point was standard northern fare, so pie and chips, comfort food – what people are used to. We looked to introduce certain specialised dishes, such as wild and mixed mushroom stroganoff, served with light couscous."

Sounds disgusting. How long before the long suffering staff at Tameside Hospital get their children to bring them fish and chips at lunchtime? In a reversal of the scenes in Rotherham in 2006, they could pass it to their parents through the gates. 

That's what this is, isn't it? It's Jamie's School Dinners for adults. It cannot be said too often that whenever 'public health' invoke the chiiiiiildren, it is never about children. The goal is always, ultimately, to restrict the choices of adults.

Monday, 8 January 2018

Review of Killjoys

Rob Lyons has kindly reviewed my book Killjoys for Spiked. Do have a read, and if you haven't downloaded the book yet, swing your eyes over to the right hand side of this blog and click.

Friday, 5 January 2018

NHS bans sugary drinks

Over the Christmas period the implicit threat that always comes when the government introduces a voluntary measure was made explicit:

NHS England warns that unless health trusts reduce sugary drinks sales will be banned from hospitals

The NHS's head honcho said:

"It's important the NHS practices [sic] what it preaches on healthy food and drink," said NHS England chief executive Simon Stevens. "We want 2018 to be the year when the tasty, affordable and easy option for patients, staff and visitors is the healthy option."

Not a healthy option, please note. The healthy option. To the 'public health' lobby, the mantra of 'making healthy choices easier' always involves removing choice.

"Many NHS hospitals have answered the call and are taking positive action."

But some of them haven't. Some of them have decided that it's okay to allow citizens to buy harmless and refreshing soft drinks on the premises. And so, inevitably, NHS mandarins have dropped the carrot for the stick:

Sugary drinks will be banned from sale in NHS hospitals across England from July, the health service has announced.

This week NHS England released an updated contract for hospitals, which for the first time included a clause prohibiting the sale of sugar sweetened beverages.

As people waited for hours in A & E and slept on trolleys in hospitals, Katherine Button from the Campaign for Better Hospital Food said:

“This bold leadership from NHS England Chief Executive Simon Stevens is exactly what we need to tackle these big health challenges.”

Incidentally, the Campaign for Better Hospital Food is part of the state-funded pressure group Sustain. So too is the Children's Food Campaign, which is now drooling with anticipation at the prospect on extending the ban...

Give 'em an inch...

Thursday, 4 January 2018

Sinclair Davidson on plain packaging

Euroactiv conducted an interesting interview with Sinclair Davidson recently. You may remember Sinclair as the independent academic who has picked apart the data on plain packaging in Australia. If you're interested in the issue, you'll like this video. He explains it very well.

Tuesday, 2 January 2018

Public Health England: attention-seeking trolls

Last week, Public Health England was reported to be changing the calorie guidelines to a system by which you have no more than 400 for breakfast, 600 for lunch and 600 for tea. This amounts to 1,600 calories a day, and there was a suggestion that people could have another 200 calories in snacks.

This was reported first in the Daily Mail and was not accompanied by an official statement, leading some people to think that it was either #fakenews or (more likely) that PHE were flying a kite to see what the reaction would be.

The reaction was mostly laughter and PHE issued a statement the following day to insist - as Theresa May might say - that nothing has changed:

The government dietary recommendations on how many calories the population should consume in a day to maintain a healthy weight have not changed. Women should still aim to consume 2,000 calories a day from food and drink, men should aim for 2,500.

However, they did confirm the new 400-600-600 rule...

There will be a simple rule of thumb to help them do this: 400:600:600 – people should aim for 400 calories from breakfast and 600 each from lunch and dinner.

So if a man should consume 2,500 calories, but only get 1,600 of these from main meals, where should the rest come from?

All other snacks and drink consumed between meals should make up the difference.

This is surprising advice to come from Public Health England, as I said in a letter to The Times* on Saturday:

Dear Sir,

Duncan Selbie assures us that Public Health England’s advice that we consume no more than 1,600 calories from breakfast, lunch and dinner does not imply a change to the existing guidelines (Letters, 29 December). As those guidelines advise adult males to consume 2,500 calories a day, I can only assume that he wants me to consume 900 calories in snacks, alcohol and sugary drinks to prevent malnourishment.

Public Health England have gained a reputation for being hectoring busybodies in recent years but this new fun-loving approach is to be applauded.

Yours faithfully,

Christopher Snowdon

The letter was somewhat tongue-in-cheek but it is an accurate reflection of what PHE are saying. Despite their anti-sugar and anti-alcohol stance, they really do seem to want men to consume 900 calories in snacks, alcohol and soft drinks (with women consuming 400 calories of the same. Why do women need to eat the same sized meals as men, but eat half as many snacks? Only PHE knows).

On the face of it, this is odd advice, but as I wrote in a previous post, I suspect that they are teeing up some political activity:

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.

Today, Public Health England issued some more eating advice, this time for children's snacks...

Each year children are consuming almost 400 biscuits; more than 120 cakes, buns and pastries; around 100 portions of sweets; nearly 70 of both chocolate bars and ice creams; washed down with over 150 juice drink pouches and cans of fizzy drink.

So that's just over one biscuit a day, one cake, bun or pastry every three days, two portions of sweets a week, a little more than one chocolate bar or ice cream a week and a soft drink three times a week. Am I alone in thinking that this is not a great deal?

PHE have devised a new rule, which is to not buy any snack containing more than 100 calories for people under the age of 18. So that's most chocolate bars, ice creams, cakes, buns, crisps, nuts and large apples out of the window.

Its chief nutritionist Dr Alison Tedstone said: “We’ve developed a simple rule of thumb to help families move towards healthier snacking… look for 100 calories snacks, two a day max.”

If PHE want to recommend that parents gives their kids healthier snacks, that's fair enough. If they want to advise parents not to give their kids more than a certain number of calories in snacks, there is an argument for issuing such advice.

But they are not doing this. Instead, they are putting an arbitrary limit on the number of calories that should be in each snack. It is an entirely unrealistic limit and has been greeted with derision. And so PHE have already started to backtrack on it somewhat...

PHE’s Orla Hugueniot insisted there was no ban on giving kids snacks but urged parents to use the traffic lights guide on food ­packaging that ­indicates the levels of unhealthy ­products such as sugar, salt and fat.

She added: “It’s a really simple way of bringing down the amount of sugar in children’s diets. We are not saying they can never give children a chocolate or biscuit ever again. But it cannot be a daily occurrence."

Leaving aside the fact that there is nothing wrong with having a biscuit every day and it is none of the government's damn business in the first place, we are once again being given guidelines that have no basis in evidence and that no normal person would want to follow.

The PHE website explicitly says that their new rule is ‘100 calorie snacks, two a day max’, but when pushed on this they say only that giving people under the age of 18 a normal snack should not be 'a daily occurrence'.

It is difficult to believe that the people at PHE, puritanical zealots though they may be, believe in this 'rule of thumb'. It is more likely that they wanted to start the new year with a healthy eating message, but realised that a sensible message of moderation would not be front page news and so invented a ridiculous rule to get attention.

If it was headlines they were after, they certainly got them:

Hooked on publicity, Public Health England have become attention-seeking trolls. This is a good thing. The 'public health' racket does not deserve to be taken seriously, and PHE's behaviour over the festive period should ensure that many people never take them seriously again.

For what it's worth, my own advice is to buy snacks for your children but then eat them yourself. If they complain, blame for government for setting you a quota of 900 snacking calories a day.

* For reasons best known to themselves, the Times' subs changed the 1,600 figure to 1,800 when the letter was published, thereby making it look like I can't count.