Wednesday, 16 April 2014

The scream test

In the field of public health they have something called the 'scream test'. This says that you know that a policy will work if the industry involved kicks up a big fuss and complains. It is assumed that anything that annoys or damages the industry must be good for people's health.

As childish as this sounds, they really believe it...

One of the measures used by anti tobacco campaigners to determine the effectiveness of an innovation, action, legislation or reform is how loudly the tobacco industry “screams”.

If the tobacco industry complains loudly and long and lobbies all the politicians it can find then you know that you are winning. You know that whatever it is the anti-tobacco campaigners or governments have done is going to reduce sales of tobacco.

Although initially used with regards to tobacco, this theory has inevitably been applied to other industries that zealots dislike...

Tomorrow sees the start of Senate hearings on the alcopops tax. This tax passes the “Scream Test” with flying colours: its impact on sales could not be clearer from the way the distillers are opposing it. [The alcopop tax was another public health glorious failure, see here for details - CJS]

The scream test is one of the most pathetic and risible concepts in a field that abounds with idiocy. It has been much in evidence in the debate about plain packaging. Lacking serious evidence that plain packaging won't be another over-hyped cock up, campaigners have resorted to saying "hey, it must work otherwise the industry wouldn't be spending so much time opposing it, right guys?"

Here are just a few of the many uses of this fallacious argument...

“This absolutely passes the tobacco industry scream test. They have thrown major PR resources at it, major legal resources at it." (Sheila Duffy, ASH Scotland)

"Why would the tobacco industry and its allies be so vehemently opposed to plain packaging if they weren’t so frightened that plain packaging would work?" (Deborah Arnott, Director ASH England)

"If [plain packs] have no impact then Big Tobacco has nothing 2 fear. Go figure." (Simon Chapman, Australian brain donor)

But, as Chapman let slip two years ago, the reason the industry is opposed to plain packaging is the same reason any industry would 'scream' about it. A ban on branding hinders their ability to make more profit from premium brands. It is not about fears that smoking rates will fall - which is what the campaigners mean when talk about the policy 'working' - but about making profits in a declining market from selling more expensive brands. And, since the anti-smoking lobby is in favour of more expensive cigarettes, plain packaging is a counter-productive policy for both sides.

Chapman is not the only one who knows that the 'scream test' nonsense is a rhetorical trick. Tucked way in the transcripts of Cyril Chantler's interviews is the same admission from another anti-smoking sociologist, Luk Joossens.

"There is only reason why [cigarette companies] are campaigning so heavily against plain packaging: because they've made their gains with premium brands and they believe there will be shift to the cheaper brands and they will lose their profits."

Bear that in mind next time someone uses the scream test argument. As the man says, "there is only one reason why they are campaigning so heavily against plain packaging" and it is the fear of brand-switching.

If Breaking Bad was really set in Britain

Since the last season of Breaking Bad was broadcast, there's been an amusing cartoon doing the rounds suggesting that the concept wouldn't have worked in any country other than the US.

Although I hate to tarnish American liberals' rose-tinted view of socialised medicine, I would suggest that the conversation in Britain would go more like this:

"I'm afraid you have incurable lung cancer."

"Can you give me any drugs to prolong my life?"

"I'm afraid not. The NHS can't afford them. Lung cancer patients, in particular, are a low priority."

"Can I pay the NHS to give me these drugs?"

"I'm afraid not. That would be illegal. You can obtain them if you have private health care. Do you have private health care?"

"No. I can't afford it. A large part of my lifetime income has been spent on tax and national insurance to provide me with cradle-to-grave health care. I guess I'll have to start making crystal meth."

"There isn't enough latent demand for crystal meth in the UK to make it worthwhile."

"Damn it."

"You're going to die. There's a 70 per cent chance you'll be dead within a year. Unlike the US, which has the highest cancer survival rates in the world, rates in Britain are very low, particularly for lung cancer."

"Aw, man."

"It serves you right for smoking."

"I don't smoke."


Tuesday, 15 April 2014

An interview with Dr Ashok Kaul

Last week I mentioned that the only piece of real world evidence about underage smoking rates in Australia since plain packaging was introduced was not mentioned in the Chantler review. The research was carried out by the statisticians Dr Ashok Kaul and Dr Michael Wolf. It was presented to Chantler's team in a meeting in London last month and clearly indicates no increase in the rate of decline of smoking prevalence amongst 14-17 year olds in the thirteen months between December 2012 (when plain packs came in) and December 2013.

ASH director Deborah Arnott has since co-authored a letter to The Lancet in which she complains that 13 months is not long enough to see an effect (she doesn't explain why) and claims (wrongly - see below) that an implausibly large effect would be needed to show up as statistically significant.

I decided to e-mail one of the authors, Dr Kaul, to ask him what was going on and he generously agreed to answer a few questions on the record. Here they are...

You met with some of Chantler's team in March 2014 and explained your research in great detail. Why do you think it was not mentioned in his final report?

It is difficult to speculate about the reasons why our research was not explicitly referenced. The Chantler review team claims that our work was considered in reaching the conclusions of the review. We find this quite remarkable, though, since Sir Chantler apparently did not feel the need to reference the only paper on plain packaging based on real-world data in his report to support his findings. In particular, a neutral reader of the review would expect to find a complete reference list of original research to be able to draw his own conclusions.

In response to your research, some proponents of plain packaging have implicitly accused you of 'misrepresentation of the evidence'. In particular they criticise the 'small sample size'. How do you respond?

We not appreciate being implicitly accused of `misrepresentation of the evidence'. We have analyzed the data in a completely open and reproducible way. If anything, as detailed in the paper, there is a (slight) bias in our methodology in favor of finding a plain packaging effect. But we have not found any evidence of a plain packaging effect. What exactly does `misrepresentation' mean in this context? We agree that the sample sizes are relatively small, and state this explicitly in the paper. Currently, in our opinion, there is no better data set available.

How much of an immediate effect on smoking prevalence would be needed to pick up a statistically significant decline in this data set?

Despite the relatively small sample sizes, the power of our methodology against a meaningful immediate effect on smoking prevalence is not tiny. For example, the power against an immediate effect of reducing smoking prevalence by 0.5 percentage points (beyond the existing time trend) would have been around 0.65. This is quite large, actually. A power near 1.00 is never realistic; a typically number one aims for in controlled (!) experiments is 0.8. In a nutshell, our approach would detect a non-negigible effect of plain packaging on smoking prevalence of minors in Australia with a pretty high probability - despite the small sample size. Criticizing the 'small sample size' is therefore quite absurd.

Are you aware of any other empirical evidence on youth smoking since plain packaging was introduced in Australia?

We are not aware of any other piece of research based on real-world data on the effects of plain packing on youth smoking behavior in Australia. We are therefore quite disappointed that our work was not explicitly referenced in the Chantler review.

Some campaigners have said that they would not expect any short term effect from plain packaging on underage smoking. Do you have a view on this?

Some people expected a short-term effect, others did not. It is a legitimate and important research question to ask whether there is evidence for a short-term (lasting) effect of plain packaging. The empirical evidence so far does not support the conclusion of a short term effect. Of course, short-term effects are important for policy makers around the world who would like to chose their regulatory policies from a set of alternatives that have been proven to be effective - plain packaging is so far not part of this set.

Together with the fact that Chantler ignored the 0.3 per cent increase in cigarette sales since plain packaging came in - along with other empirical evidence - the decision to overlook the only real world figures on smoking prevalence seems rather strange, to say the least.

Monday, 14 April 2014

So now e-cigarettes are tobacco products AND medicines?!

Via Jo Lincoln
From the Financial Times...

Electronic cigarette users are set to be banished to the pavement alongside their tobacco-smoking cousins – and face similar hefty prices – if the World Health Organisation pushes ahead with plans to regulate e-cigarettes in the same way as normal tobacco.

Leaked documents seen by the Financial Times revealed that parts of the WHO are keen to classify the battery-powered devices as tobacco under the Framework Convention on Tobacco Control, a WHO treaty that obliges governments to curtail smoking rates across the globe.

The forces ranged against e-cigarette users are endless and become less accountable at every turn. We have already been faced by the MHRA, the Department of Health and the European Commission. Now comes the World Health Organisation, an unelected body with strong financial links to the pharmaceutical industry which holds its meetings on tobacco in notorious secrecy.

Why, you may ask, has the Department of Health been conniving to have e-cigarettes regulated as medical products while the WHO is conniving to regulate them as tobacco products? Aren't medicines at the opposite end of the spectrum to tobacco products?

Of course they are. It makes no sense at all until you consider that the WHO's Framework Convention on Tobacco Control can only be applied to tobacco whereas the MHRA only regulates medicines. Necessity is the mother of invention, hence the eager rush to pretend that e-cigarettes are something they not.

The WHO's excuse for classifying e-cigs as tobacco products is that the nicotine in them comes from tobacco. But the nicotine in patches and gum also comes from tobacco. And whilst it is possible to artificially synthesise nicotine without using tobacco, it is much more expensive and the resulting fluid would be exactly the same. It is a risible justification.

The fact remains that e-cigarettes are neither tobacco products nor medicines. They are consumer products and should be regulated as such. They have nothing to do with the MHRA or the WHO. They have nothing to do with the corrupt 'tobacco control' lobby that has objected to them from the start because never featured in the prohibitionist blueprint.

Quite how the British government is going to square e-cigarettes being both medicines and tobacco products is a question for another day. On the plus side, very few of the signatories of the Framework Convention on Tobacco Control have implemented all of the WHO's recommendations. It can be ignored with apparent impunity. On the down side, the UK is one of those countries.

As difficult as it was for vapers to make the EU see some sense on this issue, the hardest task is yet to come. The WHO is completely outside the democratic process and answers only to itself. There is a long road ahead.

For further reading head to City AM and Dick Puddlecote.

Stop press: Business complies with regulation

From Stan Glantz's heavily moderated blog...

Important empirical evidence that tobacco companies are successfully flaunting [sic] the ban on promoting light and mild cigarettes

Greg Connolly and Hillel Alpert recently [actually March 2013 - CJS] published an important paper in Tobacco Control, "Has the tobacco industry evaded the FDA's ban on ‘Light’ cigarette descriptors?," that presents empirical evidence that the ciagrette [sic] companies have effectively nullified the ban on selling cigarettes with the misleading descriptors "light" and "mild" that are in both the Family Smoking Prevention and Tobacco Control Act and Judge Gladys Kessler's RICO decision.

The great professor means 'flouting', not 'flaunting' - a mistake that any idiot could make. The 'study' he refers to made the mundane and obvious observation that the companies have done as they are told and removed terms such as 'light' and 'mild' from their packs.

Results Manufacturers substituted “Gold” for “Light” and “Silver” for “Ultra-light” in the names of Marlboro sub-brands, and “Blue”, “Gold”, and “Silver” for banned descriptors in sub-brand names. 

Since 'gold' and 'silver' and 'red' and 'blue' do not convey any message of reduced risk, they are 100 per cent compliant with the law. These are intrinsically different products and smokers can tell the difference between them. Quite reasonably, therefore, they have a preference for one over the other.

Following the ban, 92% of smokers reported they could easily identify their usual brands, and 68% correctly named the package colour associated with their usual brand [only 68%?! - CJS], while sales for “Lights” cigarettes remained unchanged.

The horror! Was the point of this regulation to make it difficult for smokers to 'easily identify their usual brand'? Was the intention to make smokers of light cigarettes switch to stronger cigarettes?

No, the point was to stop cigarette companies implying that one brand is less hazardous than another. Of course people can still remember what Marlboro Gold used to be called. Short of brainwashing the entire population, that was entirely predictable. The industry is guilty of nothing more than complying with a law that was written by its enemies. Get over it, Stan and stop flouting flaunting your ignorance.

Friday, 11 April 2014

The missing plain packs data

When the Chantler report on plain packaging was published last week, one piece of evidence was conspicuous by its absence. At first I assumed that the empirical research on teen smoking rates from the University of Zurich had been published too late to be included, but I was wrong. It transpires that Chantler's team not only had access to the study, but had spoken personally to its authors, Dr Ashok Kaul and Dr Michael Wolf.

Chantler had every reason to be interested in this research. It is the only study to date that addresses the question upon which all else hinges - does plain packaging help reduce the smoking rate amongst minors?

Kaul and Wolf had access to monthly smoking figures amongst 14-17 year olds that went all the way from 2001 to the end of December 2013, thirteen months after plain packaging was introduced in Australia. The data come from a large survey that has been used by anti-smoking researchers in the past and both authors are experienced professional statisticians. They concluded that there is no evidence from the data that plain packaging had any effect on smoking prevalence amongst this crucial age group. There was no increase in the gradual long term decline of smoking in this age group...

And when the long term decline was accounted for, plain packaging was shown to have had no discernible impact whatsoever...

This is very significant information, so why was it ignored by Chantler? It cannot be because it hasn't yet been peer-reviewed because Chantler looked at plenty of evidence that hasn't been peer-reviewed. It cannot be because it was commissioned by Philip Morris because Chantler looked at plenty of industry-funded research. In any case, if Chantler had any doubts about the research he could have looked at the raw data himself.

And we know that Chantler was aware of the research. We know this because Kaul and Wolf have now put online a 27 page transcription of the meeting he had with Chantler's team (the man himself didn't attend). It leaves no doubt that the study was carefully and patiently explained to Department of Health officials when they met the authors in London on 20 March.

At this meeting, Dr Kaul described that the methodology they used allowed maximum leeway for finding some effect from plain packaging. Alas, there was none...

"Even if you are not talking about statistical significance, I mean, sort of hoping for an effect, even a small one, you would at least expect something, a little, tiny effect, 12 months after in comparison to 12 months before but we don't find that, we find the contrary."

At the end of an extensive conversation, DoH official Christoper Cox thanked the pair for travelling to London and said of the presentation: "that is incredibly helpful and thoroughly interesting". So why was there not a trace of it in the final report? Why was the only empirical, real world evidence about underage smoking rates after plain packaging excluded?

Readers can draw their own conclusion.

(You can read the transcript here (PDF))

Thursday, 10 April 2014

Tamiflu - a con from day one

So, it turns out that Tamiflu does virtually nothing to prevent or alleviate swine flu. This is another kick in the teeth for taxpayers around the world, but especially in Britain where the hysterical scare tactics of Liam Donaldson et al. led to a colossal waste of money. Having spent £500 million on Tamiflu, only a fraction was ever used and large quantities had to be thrown away because the inept NHS didn't know how to store it. The New Zealand government recently threw away nearly 1.5 million doses of the stuff. Only 55,000 were ever used.

The fact that Tamiflu doesn't really work is just another chapter in the swine flu farce, but the real point is that it should never have been stockpiled in the first place, whether efficacious or not. It's easy to be wise with hindsight, but it was clear very early on that swine flu was not particularly contagious and was very unlikely to be lethal. This could be concluded within days of it emerging in Mexico City - one of the world's most crowded cities - and it was crystal clear by the time the flu season descended on the Southern Hemisphere.

It's difficult now to recall quite how hysterical the government, advised by Chief Medical Officer Liam Donaldson, became in 2008-09. As I wrote in 2010...
Donaldson described swine flu as the "biggest challenge [to the NHS] in a generation" and predicted that a third of the UK population would come down with the virus in the winter. In an act of near-insanity, the British government ordered 110 million doses of the swine flu vaccine Tamiflu, the Department of Health ordered 32 million face masks and the Home Office made plans to dig mass graves.

In the event—despite the coldest winter for 30 years—there were fewer deaths than in the average flu season. The final death toll was 450—0.7% of the 65,000 predicted in Donaldson's worst-case scenario. Of these 450 deaths, only 70 could be solely attributed to swine flu.

Like all disciples of the precautionary principle, Donaldson could attribute the low death toll to his own policies. But there were even fewer deaths in Poland, whose government did not buy a single dose of Tamiflu.

In truth, it was obvious within a week of the initial outbreak that swine flu was not going to be a major killer. If it was going to slay millions, it would have done so in crowded and poverty-stricken Mexico City, where the scare began. Clearly, this was a fairly contagious but not very potent disease. Swine flu single-handedly brought the phrase "chronic underlying health problems" into the popular lexicon, as they seemed to be a prerequisite for any swine flu-related death. The chance of dying from the disease once you contracted it was 0.0001%.

As Paul Flynn - with whom I disagree about nearly everything, but who has followed this story doggedly and admirably - notes...

The Swedish Institute for Communicable Disease Control found that 5.4 million swine flu jabs saved 6 lives in Sweden.

60% of the Swedish population was vaccinated in 2009.

The European Centre for Disease Prevention and Control (ECDC) found Sweden had a death rate of 0.31 fatalities per 100,000 people after the pandemic.

In Germany, where only eight percent of the population was vaccinated, the fatality figures were the same.

In Poland, the death rate was only 0.47 per 100,000. They spent next to nothing on vaccines. UK spent £1.2 billion. Our equivalent death rate was double, 0.74.

There are questions that need answering, not only about how Tamiflu was presented as being more efficacious than it is but about how the swine flu scare was harnessed to sell it in vast quantities to gullible governments. Big Pharma and the WHO are both culpable. The latter changed the definition of a pandemic in May 2009 in a way that was very convenient for manufacturers of Tamiflu and the whole organisation is rife with people who have serious competing interests.

Donaldson himself has since got himself a job at the WHO as well as a job at a lobbying company that represents pharmaceutical companies. Perhaps, as Longrider says, "we, the taxpayers, should be knocking on Donaldson’s door demanding our money back?"