Liberal Vision

Smoking ban health miracles

Earlier this year a paper was published in a peer reviewed journal that was so contrived and so flawed that I had hoped it would convince any doubters that the evidence for miraculous immediate health effects from smoking bans is entirely the figment of activist’s febrile imaginations. Sadly, it appears that I was wrong and that true believers including David Cameron still cling to the notion that smoking bans “have had a pretty dramatic health effect”.  This delusion is shared by Anna Soubry who unforgivably and untruthfully claimed reductions in heart attacks and childhood asthma admissions as a result of the English smoking ban in evidence that she gave to the House of Lords (page 11).  The fact that she was standing next to the less than impartial Andrew Black at the time is no excuse as only someone without interest in truth or reality would take anything Black says at face value.

The “growing body of peer reviewed evidence” used to justify these counter-intuitive claims is an indictment of public health industry ethics and medical journal standards. This recent contribution claiming a 12% reduction is asthma admissions as a result of the smoking ban originates from Imperial College London which is cause for further concern because Imperial is a top UK research establishment and as such charges young people a small fortune to be educated by what one would hope are top academics.

The culprits behind this affront to science are Stanton Glantz and Christopher Millett. In case anyone is labouring under the illusion that these two are objective scientists, Glantz is a well-known anti-tobacco activist who together with Millett holds extreme views on smoking in movies. Glantz was recently mentioned in the US congress in relation to a $680,000 grant that he used to make the bizarre claim that the Tea Party was created 25 years ago by big tobacco. It is extraordinary that we ban tobacco company funded research on the basis of scientific objectivity but, by a widely accepted double standard, treat the output of blatantly biased activist obsessives as “scientific evidence” fit for Prime Ministers.

This paper is yet another example of torturing numbers to fit a theory. The authors produce a lot of complex statistical waffle to obscure the deception but their essentially simplistic claim can be illustrated using annual data for childhood asthma admissions from the same NHS source they use. In the figure below the blue bars are years pre-ban and the orange ones the year of the ban and one year later. The solid red line is a simple linear fit to the pre-ban data.

The claim that the ban reduced asthma admissions depends on showing that admissions rates were increasing pre-ban and that after the ban admissions were lower than predicted had that trend continued along the path illustrated by the dashed red line.  Millett uses the period 2002-2007 to model the “rising trend” in admissions but the NHS data goes back further and if we use all the available data the “trend” changes somewhat.

Cherry picking time periods is a common deception practiced by the public health industry together with taking advantage of coincidental variations in data series that happen to fit a theory or policy.

Those desperate to believe might argue that I am being too simplistic in that the “experts” took a more sophisticated approach and used monthly data. A 12% fall in admissions should not need sophisticated techniques to be apparent but it is true that 2007-08, the year of the ban, saw a big fall in admissions compared to the previous year. However, a look at NHS data for monthly admissions covering three years around the ban serves only to illustrate how the second element of the trick works.  

If I asked a group of seven year olds which of the lines on the chart above was the odd one out, I would expect the majority to say the orange one. The orange line represents monthly admissions for the year before the ban. We can align the data on the month of July which was when the ban came in but it makes little difference. Admissions were low in the year the ban came into force but not unusually so. Both the alleged upward trend before the ban and the apparent fall in the year it was enacted work for the activists only because peak season admissions were unusually high in the year before the ban. That stroke of fortune combined with the cherry picked time frame form the basis of the deception.

This peer reviewed paper appears to be nothing more than a cheap trick, an abuse of academic freedom for political purposes. The authors admit to some of its flaws but this did not prevent them from issuing a carefully worded press release that inevitably led to a misleading claim being widely broadcast by a gullible and uncritical media. It even made BBC TV news! This is not an isolated incident. It forms part of a body of highly publicised but fundamentally flawed “research” that has led some politicians and at least one national leader to erroneously believe in unlikely health miracles associated with interventions such as smoking bans. This might well influence opinions when reviewing existing or considering additional interventions, which one can argue is the main purpose behind such publications and their attendant publicity.

Of course, those politicians obsessed with public health are never slow to accept even the most unconvincing “evidence” if it suits their prejudices. Despite widespread incredulity over the facile “evidence” underpinning the implausible notion that smoking bans produce big falls in heart attacks, Sarah Wollaston of minimum alcohol pricing fame has claimed that the UK smoking ban:

“…was a very good example of evidence-based policy. If you look at what has happened in terms of deaths of cardiac disease, it has been staggering. There’s been a huge drop … It surprised even the health experts.”

Wollaston exhibits blind faith in “evidence” that is of no better standard than the article reviewed here. Her need to believe does not make it true, or a good basis for policy.

I have contacted Pediatrics and asked how something so obviously contrived as the Millett paper could survive peer review. I was informed that it was reviewed by people who are “experts in their field”.  I wasn’t told what field, but expertise in either mathematics or ethics was apparently not considered necessary in this case. There are reasons why political stunts like this usually appear in medical journals rather than elsewhere in the literature and it is remarkable just how low some set the peer review bar. Peer review is supposed to be a minimum requirement able to identify fundamental methodological errors or false claims. Every time an article such as this is published in a “peer reviewed” journal, respect for this gold standard and science in general declines a little bit further. The collective damage is becoming significant and the implications extend way beyond smoking.

I have also contacted Imperial College press office but they have declined to comment on why they inflicted this press release on the general public. From direct experience I know that Imperial College employs many excellent lecturers and research scientists but based on this output I think that we should question what exactly young people are being taught for £9,000 a year and who is doing the teaching. Honesty, integrity and academic excellence are qualities that I would expect to see in those who benefit from the fees young people are now being asked to pay. I appear to be in a minority.

By Chris Oakley. Chris’ previous posts on Liberal Vision include: Minimum pricing – policy based evidence ,  Alcohol is Old News – Minimum Pricing for Digestives is the “Next Logical Step” , Soviet Style Alcohol Suppression Campaign Called for By Public Health Activists , Alcohol Taxation: The truth, the whole truth and nothing but the truth ,  Lies, damn lies, statistics &… , The Department of Health is Watching You! , New bounty on smokers helps GPs balance their books.

Tags: Anna Soubry, asthma, Christopher Millett, health miracles, Imperial College, smoking ban, Stanton Glantz

New bounty on smokers helps GPs balance their books

It is coming up to year end for GP practices and that of course means that they will all be diligently filling in reams of paperwork for the DH in order to secure maximum funding via the QOF. In the doctor’s business journal medeconomics Dr Gavin Jamie gives some top tips on how practices can maximise their points score.

According to Jamie:

It is that time of year when practices are polishing their data and preparing for the annual inspection on 31 March of their QOF achievement.

For many it is a matter of pride, and not simply financial necessity, to get the most points that they can. Here are my top tips.

The DH is now effectively offering GPs a bounty on every smoker they can identify and attempt to “reform”, so it is perhaps not surprising that third on his list of top tips for achieving the warm glow of satisfaction that only comes from a good dose of centralist bureaucracy is upping the practice’s smoking score.

TIP 3 Smoking

This has become more complicated with the need to offer smoking cessation advice or prescribe therapy to all smokers over age 15.

Due to the way that this is calculated, improved coding of people who have stopped smoking will enhance the advice indicator.

It really is worth making every contact count – even where patient just calls into reception or speaks to the practice by telephone.

If you are the sort of person who takes pride in this kind of exercise or if your practice just needs the money Dr Jamie recommends that you hassle people about their lifestyles at every possible opportunity.  I haven’t been anywhere near my practice because I am coming to hate the place. I wonder how many others feel the same and how long it will take for politicians to work out that this approach is counterproductive?

Surely even Dave can see that a system that encourages GPs to repeatedly annoy their patients is not a good thing. No doubt his DH advisors will claim to have “peer reviewed” evidence to the contrary and we can assume that it is the same advisors who tell him that minimum alcohol pricing will target alcoholics and that smoking bans have had dramatic immediate health effects. Surely at some point he will work out that these people are rather economical with the truth? Won’t he?

by Chris Oakley

This post is a followup to “The Department of Health is watching you!“

Tags: Department of health, GPs, health, Quality and Outcomes Framework, smoking

The Department of Health is watching you!

Last week a number of bloggers focussed on the dishonest, authoritarian nature of the DoH. This is not news to those who have researched the ethically dubious behaviour of a government department that is the only one that admits to paying third parties to lobby government. The department’s track record on public health interventions in particular is justifiable only in the eyes of those whose narrow focus allows them to take the extremist position that “the end justifies the means” and therefore excuses behaviours that are otherwise unacceptable.

I and many others have previously highlighted the lack of objectivity that is a feature of DoH “consultations” and the fundamentally flawed approach that has seen the DoH directly funding social “scientists” to provide “evidence” to support public health policies such as smoking bans and minimum alcohol pricing. To any objective observer the processes and people involved in producing this policy based evidence undermine the credibility of the policies and of the DoH itself.

I have no reason to have confidence in the DoH and ample reason to be concerned about its agenda so I was rather alarmed to find out just how much control it has over GP practices. I recently attended my practice for a routine appointment and was surprised to find out that I had to answer a question about my smoking habits in order to check in using the automated system.  I don’t smoke but as far as I am concerned, that together with my other lifestyle choices is information that I am prepared to share with my GP but do not necessarily wish to share with others.

The Orwellian and in my view unethical nature of this approach to information gathering prompted me to find out why a practice that has served my family well for decades has become increasingly impersonal and public health obsessed.  I was alarmed to discover that the DoH is effectively paying GPs to ascertain the smoking status of everyone over 15 and that this is not the only way in which the relationship between patients and doctors is being depersonalised and centrally controlled.

The mechanism underlying this policy is called the Quality and Outcomes Framework (QoF). The QoF financially incentivises doctors to not only to gather lifestyle information but to treat patients based not on what might be best for a specific patient in a specific GPs experience but on what DoH /NICE centralists deem best practice. This potentially undermines the important GP/patient relationship and represents a major bureaucratic overhead.

The QoF is supposed to be voluntary but is in the Leninist tradition of the DoH is “voluntary” only if GPs can afford to forgo the state funding associated with it. In reality 98-99 % of practices participate as according to one well-placed source it is “almost unsustainable” for practices to opt out of providing this service.

The QoF was introduced by the previous government in 2004. Despite claiming that it wants to empower GPs and reduce paperwork, the current government has done nothing to mitigate either its centralist nature or its bureaucratic content. Each revision seems to be more demanding than the last and some GPs are of the opinion that some of the latest additions make it “unworkable and impractical”

The lifestyle information gathering aspects of QoF are alarming from a liberal perspective and are also likely to have negative consequences for doctor patient relations thanks to the intrusive and repetitive nature of the questioning involved. The government cannot claim to be unaware of this and other issues relating to QoF as medical organisations including the BMA claim to have raised it on more than one occasion.

In 2013 the QoF section on smoking has been changed from being a semi-reasonable attempt to ascertain the smoking status and offer quit services to people with problems such as emphysema, to a blanket demand for practices to catalogue the smoking habits of everyone over 15 years of age.

Alcohol consumption is likely to follow the same path and NICE /DoH have already decided on QoF targets for screening a subset of patients. As the subset includes anyone with high blood pressure it will be quite large, so scaling it up to all patients won’t be a problem at some future review.

The manner in which this information is being gathered, the people who see it and the way in which it is used by the DoH are all further cause for concern. It is one thing to share information with a GP who is bound by doctor patient confidentiality but another thing entirely to supply that information in a format that might be viewed by many other people who are not. Data is supposed to be “anonymised” before practices forward it to the DoH but some professionals are concerned that this may not always be the case in light of increasing government demands for general access to health records.

It is not difficult to imagine a near future scenario in which the DoH thinks it knows the lifestyle choices of the majority of us at an individual level and really is watching us. It is already watching our GPs rather too closely for comfort.

It would appear that whatever government is nominally representing us, it is powerful entrenched bureaucrats with centralist inclinations who dictate the health agenda. Perhaps we might be better off diverting resources to front line services rather than ring fencing DoH funding?

By Chris Oakley. Chris’ previous posts on Liberal Vision include: Minimum pricing – policy based evidence ,  Alcohol is Old News – Minimum Pricing for Digestives is the “Next Logical Step” , Soviet Style Alcohol Suppression Campaign Called for By Public Health Activists , Alcohol Taxation: The truth, the whole truth and nothing but the truth ,  Lies, damn lies, statistics &…

Tags: Department of Healt, GPs, QoF, Quality and Outcomes Framework, smoking

Minimum pricing – policy based evidence

Based on the output of the English media, one could be forgiven for not having noticed that Scottish ministers appear to have shelved minimum alcohol pricing ostensibly due to legal challenges. It will be unfortunate if minimum pricing is shelved solely on the basis of illegality because the lessons to be learned from the attempts to justify it via policy based evidence will then once again go unheeded.

We hear much talk of evidence based public health policy these days but what we actually get is “evidence” concocted to suit policy. The public health industry seems utterly incapable of delivering honest, objective, scientific evidence and the media contributes to the problem through lazy uncritical reporting combined with establishment bias. This was typified by the BBCs response to being caught out making wild claims about the number of lives minimum pricing would “save” amongst pensioners.  Rather than investigate the obviously questionable reliability of its source, the BBC simply accepted a lower but no more credible number.

The BBCs source was The University of Sheffield, which has now received involuntary taxpayer funding from two governments and a public broadcaster. On each occasion the motive has been the gathering of policy based evidence and it appears that neither the politicians nor the media appear to care how dubious the quality of that evidence is provided that it suits their purpose.

Petr Skrabanek in his 1994 work The Death of Humane Medicine cited Nobel laureate Irving Langmuir from 1953 when making a case against the “science” that underpins public health. He wrote that it “accepts evidence not according to its quality but according to its conformity with a foregone conclusion”. It seems that his wise observations have been ignored because the ersatz science that provides the “evidence” for policy interventions is nowadays more prevalent than ever. The University of Sheffield study provides a classic  example of this anti-science in which every supportive scrap of data, however poor in quality  is treated as “conclusive” or adding to a “growing body of evidence” and every contradictory piece as “flawed”, “controversial” or “in need of further research”.  Evidence at odds with the authors’ predetermined conclusions is often simply ignored. Take for example evidence statement 13:

“There is consistent evidence to suggest that alcohol consumption is associated with substantially increased risks of all-cause mortality even in people drinking lower than recommended limits, and especially among younger people. High levels of alcohol consumption have detrimental effects. The evidence is more equivocal, however, where it relates to establishing cut-off points for lower risk versus harmful levels of consumption. There is an ongoing controversy as to whether or not there are beneficial (cardio-protective) effects at low levels of alcohol consumption.”

This statement is an extremely misleading interpretation of the available evidence. There is no excuse for this form of words appearing in a document paid for by public funds and intended to guide politicians who are not versed in the subtleties of public health disingenuity. Hiding behind theoretical and contestable risk factors, the authors peddle the scientifically improbable but politically powerful concept of “no safe level” whilst ignoring a large body of evidence showing teetotallers to have lower life expectancy than moderate drinkers.  I could write extensively about the “controversy” they refer to but Christopher Snowdon already covered it in some detail.

Unfortunately this is not an isolated example in a production that goes to extraordinary lengths to provide policy based evidence.  The other “evidence” statements display a similar lack of objectivity and, despite using the Household Survey data provided by the ONS as a basis for much of their modelling, the authors ignore it when considering consumption at the population level.  They open their section on areas for possible future research (and of course more taxpayer funding) with the typically convoluted sentence:

“Given the trends in consumption over the past ten years it is unlikely that a ‘do nothing’ policy would result in no change to the consumption of alcohol in the population.”

It is hard to tell, but I think that they are trying to say that consumption is trending up so government MUST act. This is a remarkably inept statement to make in the middle of a trend that, according to the ONS has seen household consumption decline by 20% in a decade without any significant government intervention.

I find it hard to understand why politicians continue to pay homage to what Skrabanek described as healthism despite the huge flaws in the “evidence” that underpins it being repeatedly exposed. Perhaps Skrabanek gives some insight into the reasons when he writes:

“Politicians find the facile rhetoric of healthism rewarding. It increases their popularity at no cost, and it enhances their power to control the population. It meets no resistance from the opposition, who promise to improve the ‘health of the nation’ even more.”

Robin Fox, former editor of The Lancet describes Skrabanek as a “humorous man of immense culture and learning” in the Preface to The Death of Humane Medicine and despite not completely agreeing with Skrabanek’s pessimism, goes on to add that he “speaks many truths that we should heed”. I cannot help but feel that the world would be a better place if politicians, journalists and others did heed the words of this humorous, cultured medical man above the strident clamour of the health zealots. After all, without aggressive healthism there would be no need to insult our intelligence with pseudo-scientific policy based evidence and I sincerely doubt that the public would bemoan redundancies amongst the social “scientists”, non-practicing medics and psychologists who contribute to its socially divisive message. I doubt that these commenters on the BBC’s umpteenth plug for minimum pricing would mind at all:

For anyone who empathizes with Bauer and /or who is interested in a more liberal and less miserable future I recommend reading Skrabanek’s book which can be downloaded for free here.

By Chris Oakley. Chris’ previous posts on Liberal Vision include:  Alcohol is Old News – Minimum Pricing for Digestives is the “Next Logical Step” , Soviet Style Alcohol Suppression Campaign Called for By Public Health Activists , Alcohol Taxation: The truth, the whole truth and nothing but the truth ,  Lies, damn lies, statistics &…

Tags: BBC, minimum pricing alcohol, Sheffield University

Minimum Pricing– autocratic, badly researched, regressive & unchallenged by liberals.

It seems that the increasingly weak case for minimum pricing for alcohol is being promoted mainly on the basis of “something must be done and this is the something makes us look best” by those to whom gesture politics is second nature. Sadly that category appears to include allegedly liberal democrats.

As someone who prefers to drink alcohol socially rather than at home I have to admit to having been intrigued and initially quite positive about the concept. It was only after reading most of the 500 plus pages of poorly explained, opaque gibberish produced by the University of Sheffield on the subject that I came to realise how bad an idea it actually is

The theory that has been heavily sold to the public by politicians and the public health industry, supported by the BBC , can be summarised as follows:

• Alcohol is price elastic so increasing the price of alcohol reduces consumption and small acceptable changes produce big effects.
• At risk groups including heavy drinkers, binge drinkers and young drinkers tend to consume lower cost products.
• Increasing the price of lower cost products therefore targets “problem” drinkers
• As only lower cost alcohol is affected the impact on moderate drinkers is minimal
• It’s all good so people will support the idea.

The problem is that it isn’t this simple as I will attempt to illustrate using examples from the Sheffield Study. The Sheffield team admit that one weakness in their analysis is that there is very little UK data to work with. However, amongst the few studies that they cite are two that appear to undermine the price elasticity theory that is the basis for their model:

“Reviews of demand models from 1989 and 1990 in the United Kingdom found that the demand for beer, wine, and spirits was generally price-inelastic, with the demand for wines and distilled spirits being more responsive to prices than the demand for beer (Godfrey 1989 1990).”

It is logical that at some point, price affects behaviour but the idea that small changes will have big effects is extremely suspect unless you ignore common sense and evidence to the contrary:

“Chaloupka and Wechsler (1996) used a questionnaire approach to explore likely reactions to a tenfold increase in the tax on beer and found it would reduce binge drinking by young women by about 20%, but would have no effect on young men.”

They concluded:

“A substantial tax increase is thus required to achieve modest reductions in binge drinking by female students.”

 With respect to minimum pricing targeting “at risk” groups:

“Wagenaar (2008) found in his meta-analysis that price/tax also significantly affects heavy drinking (p<.01), but the magnitude of effect is smaller than effects on overall drinking.”

“Manning et al (1995) derived a price elasticity response function with respect to drinking quantile, indicating that moderate drinkers are the most price elastic”

“One study found that modest increases in levels of taxes have no effect on the number of drinks consumed or on binge drinking (6 or more drinks on one occasion) (Gius, 2002)”

And from Gallet (2007)

“Moreover, if we are particularly concerned with teenage drinking, since we find that teens are least responsive to price, then perhaps the best approach to reducing teen alcohol consumption should involve alternatives to taxation, such as education campaigns.”

So there is some evidence from the Sheffield study suggesting that price increases do not target the groups the politicians say that they do and that it is somewhat speculative, without the benefit of hard evidence, to claim that because those groups currently consume a disproportionate amount of the cheapest alcohol that increasing bottom end prices will change their behaviour.

The Sheffield team do acknowledge some quite significant discrepancies between their model and previous work. Faced with the fact that their methodology produces results inconsistent with other findings for price elasticity in heavier drinkers they do provide an analysis that is consistent with the literature…

“To enable more direct comparability with the estimates in the literature we have also generated elasticity estimates for total alcohol purchasing from the EFS, shown in Table 11. These are in broad agreement with the literature, showing that  – at the highest level of aggregation – hazardous and harmful drinkers (combined elasticity of -0.21) are less price elastic than moderate drinkers (elasticity of -0.47).”

….but then ignore it.

 “Note that these high-level estimates are provided for reference only and are not included in the model.”

This is an extremely important aspect of the whole exercise because if price elasticity is lower for people who are heavy consumers, the result of minimum pricing will not be a reduction in their consumption but a significant increase in the amount they spend with attendant social consequences for them and their dependants.

The high level analysis suggests that heavy drinkers are less than half as likely to change their habits as a result of price increases but even that may be misleading because the Sheffield team lump “hazardous” and “harmful” drinkers together in the analysis placing a man who drinks a couple of pints each evening in the same category as one who consumes a bottle of brandy a day.

“Hazardous” and “harmful” together with “moderate” are entirely arbitrary non-evidence based definitions that are used in rather cavalier fashion throughout the Sheffield study and apparently in subsequent media interviews. According to the BBC:

“This would reduce levels of alcohol consumption by 10.3% among harmful drinkers – those who drink above the recommended limit of 4 units per day for men or 3 units per day for women”

It appears that either an error prone BBC journalist or the Sheffield team themselves have chosen to broaden the definition of “harmful” to include “hazardous” drinkers. It should be pointed out to those unfamiliar with bizarre WHO definitions that the inappropriately named “hazardous” group is defined by the absence of any symptoms /ill effects making it very different from the “harmful” group.

I believe that there is strong evidence to suggest that the neat analysis presented by politicians and the public health industry is extremely questionable and that the claims made for minimum pricing are based not on evidence but on speculation. Furthermore, I believe that there is credible evidence that minimum pricing is a regressive tax that will impact lower income consumers of alcohol at any level and will have potentially serious impact on families of heavier drinkers on low incomes.

The politicians have certainly failed to convince the public on this subject.  A perusal of comments on even left wing media such as the Guardian and BBC shows consistent public antipathy towards the idea. It is a heavy handed statist solution to what most people view as a social problem that is more in keeping with soviet style government than liberal democracy. I am not surprised that it is advocated by the Marxist public health industry and most ardently supported by those on the far left such as Nicola Sturgeon and Kevin Barron, but I am amazed and disappointed by the absence of either a social or classical liberal political challenge to an illiberal regressive law that like many similar interventions is doomed to failure and unforeseen negative consequences.

Dodgy expenses are not the only reason why people don’t trust politicians.

By Chris Oakley. Chris has previously posted on Liberal Vision:  Smokers-State Approved hate and Intolerance is UK policy,   Alcohol is Old News – Minimum Pricing for Digestives is the “Next Logical Step” , Soviet Style Alcohol Suppression Campaign Called for By Public Health Activists , Alcohol Taxation: The truth, the whole truth and nothing but the truth , A Liberal Tolerant nation? ,  What hope is there for liberty if truth becomes the plaything of political lobbyists , Public Health Success? & Lies, damn lies, statistics &….

Tags: minimum pricing alcohol, Sheffield University