Sunday, 31 January 2016

Scottish obesity babble

The latest in a long line of doomed obesity predictions in the Herald...

If things continue at the current rate, 40% of the Scottish population will be obese 15 years from now. 

So what is the current rate? According to the Scottish government...

Between 1995 and 2008, adult (16-64) overweight (including obesity) and obesity rates increased by 10.5% and 8.5%, respectively. However, no further increases have been observed since.

And amongst children?

...the proportion of girls meeting the healthy weight criteria has been relatively stable between 1998 and 2013. Contrastingly, healthy weight prevalence in boys decreased by more than 9% between 1998 and 2008, although it has since increased again.

So, in summary...

Following significant increases between 1995 and 2008, adult overweight and obesity rates in Scotland have since stabilised

The current rate is therefore zero. It could go up. It could go down. But if anyone wants to bet that it will be 40 per cent by 2031, my door is open if your wallet is.

Friday, 29 January 2016

VIDEO: The End of Boozy Britain?

From last year's Battle of Ideas, the panel discussion asking whatever happened to Boozy Britain?


Daisy Blench
policy manager - alcohol policy and responsibility, British Beer & Pub Association

Neil Davenport
writer; teacher; contributor, spiked

Dr Clare Gerada
GP; past chair, Royal College of General Practitioners

Sian Jarvis
managing director, Jarvis & Bo Communications; former director general of communications, Department of Health

Christopher Snowdon
director, lifestyle economics, Institute of Economic Affairs; author, The Art of Suppression

Alan Miller
chairman, Night Time Industries Association (NTIA)

... and a surprisingly large number of young teetotallers in the audience.

If you like this, you might like Planet of the Vapes from the same festival.

Thursday, 28 January 2016

A confederacy of obesity dunces

If you want to understand how the obesity discussion in the UK has descended into pseudo-scientific gibberish in the last few years, the infographic below offers a disturbing guide. These are the most influential Tweeters on the subject according to this website. I can well believe it.

Click to enlarge, but some familiar faces stand out. Leaving aside the handful of health organisations and few relatively sensible academics, here's a who's who...

Jamie Oliver. Millionaire TV chef. Publicity hunter. Jumped on the anti-sugar bandwagon last year.

Aseem Malhotra. A strong contender for the most stupid person I have ever written about. Desperate for fame. Now firmly entrenched in the low carb/Atkins cult.

Simon Capewell. Taxpayer-funded anti-everything authoritarian. Gets a chimpanzee to work his Twitter feed, at least that's what it looks like.

Sarah Wollaston. The House of Common's nanny-in-residence. Has never seen a tax or ban she didn't like.

Action on Sugar. Previously known as Consensus on Action on Salt and Health. Former home of Aseem Malhotra, now home to the genuinely terrifying Graham MacGregor and the fool Capewell. Spends a lot more money than it brings in.

Food Revolution. The political wing of Jamie Oliver Inc.

World Cancer Research Fund. Respectable sounding organisation which is actually the academic equivalent of the Daily Mail. Issues reports claiming that virtually every food on the planet either causes cancer or prevents it.

Children's Food Campaign. Pressure group that could fit in a phone box. Leading campaigners for a soft drink tax and mates with the fat-tongued one.

Zoe Harcombe. Multiple diet book entrepreneur, now firmly on the low carb gravy train.

Tim Noakes. Obsessive Atkins/low carb/banting campaigner, author and entrepreneur. Wrote the 'exercise won't help you lose weight' op-ed with Malhotra last year. Hauled up before the Health Professions Council for telling a mother to wean her infant on a low carb/high fat diet.

Andreas Enfeldt. Another Atkins Diet entrepreneur. You can join his website for nine bucks a month.

Jenny Rosborough. Campaign manager at Action on Sugar.

Sugar Coated. Twitter feed for yet another anti-sugar documentary. Twitter profile literally says 'Is sugar the new tobacco? #toxicsugar #sugartax'

Larry Diamond. Never heard of him before but his Twitter profile carries the telltale #LCHF hashtag that is the mark of the Atkins Diet cult member.

Hannah Brinsden. Never heard of her either but her Twitter profile informs us that she is 'challenging corporate power and Big Food'. With this juvenile anti-capitalism, she's an ideal candidate to work in 'public health' which, of course, is what she does.

Note that this is not hand-selected group of somebody's favourite Tweeters. It is based on an analysis of the most popular obesity-related Tweeters in a three month period. Interestingly, the supposedly all-powerful food industry doesn't have any of its members amongst the big hitters, but nor does the mainstream scientific community.

It is quite remarkable, and yet little remarked upon, how much the low carb/high fat faddists have taken over the obesity debate (sugar is, of course, a carbohydrate). If this network of Atkins zealots and anti-sugar fanatics is really what is driving policy, it is little wonder that it has become almost impossible to inject science and evidence into it.

Wednesday, 27 January 2016

Plain packaging for food and drink - the vultures circle

A quick round up of news from half way down the slippery slope. First, from the Canadian Journal of Public Health...

Alcohol warning label perceptions: Emerging evidence for alcohol policy.


Patterns of alcohol and cigarette use and abuse can be considered parallels due to their similar social, biological and epidemiological implications. Therefore, the cross-fertilization of policy research, including health warnings evidence, is justified. The objective of this study was to apply the lessons learned from the tobacco health warnings and plain packaging literature to an alcohol packaging study and test whether labelling alters consumer perceptions.


Ninety-two adults were exposed to four labelling conditions of bottles for a famous brand of each of wine, beer and hard liquor. Participants were randomly assigned to one of four labelling conditions: standard, text warning, text and image warning, or text and image warning on a plain bottle. Participants then expressed their product-based (i.e., evaluation of the products) and consumer-based (i.e., evaluation of potential consumers of the products) perceptions in relation to each label condition and were asked to recognize the correct health warning.


As expected, participants perceived bottles with warnings less positively as compared to standard bottles in terms of product-based and consumer-based perceptions: plain bottles showed the most consistent statistically significant results, followed by text and image warnings, and then text warnings in pair-wise comparisons with the standard bottles. Some support for the impact of plain packaging on warning recognition was also found.


Unlike previous studies, this study reveals that health warnings, if similar to those on cigarette packs, can change consumer-based and product-based perceptions of alcohol products. The study reveals the importance of serious consideration of stringent alcohol warning policy research.

Secondly, from a forthcoming obesity conference...

Effects Of Plain Packaging, Warning Labels, And Taxes On Young People's Preferences For Sugar-sweetened Beverages: Results From An Online Experimental Study

Consumption of sugar-sweetened beverages (SSBs) is associated with obesity, diabetes, heart disease and dental caries.

Our aim was to assess effects of plain packaging, warning labels, and a 20% tax on SSB preferences, beliefs and purchase probabilities amongst young people. A 2 x 3 x 2 between-group experimental study was undertaken, via an anonymous online survey. 604 young New Zealanders aged 13-24 years who consumed soft drinks regularly were recruited. Participants were randomly allocated to view one of 12 experimental conditions, specifically images of branded versus plain packaged SSBs, with either no warning, a text warning, or a graphic warning, and with or without a 20% tax. Perceptions of the allocated SSB product and of those who might consume the product were measured using seven-point Likert scales. Purchase probabilities were measured using 11-point Juster scales.

All three intervention scenarios had a significant negative effect on preferences for SSBs... Plain packaging and warning labels could significantly reduce adolescents’ and young adults’ preferences for and likelihood to purchase SSBs, and are therefore likely to reduce consumption.

And then there's this from Food Quality and Preference...

Public policy makers have recently recommended deactivating the marketing functions of unhealthy food packaging by enforcing the use of plain food packaging.

That can't be right, surely? Those good, honest public health professionals promised this would never happen.

Tragically, the Food Quality and Preference study found that plain packaging for snacks made people consume more of them. Perhaps that explains why cigarette sales rose after plain packaging was introduced in Australia.

Never mind though. I'm sure future studies will iron out that little problem and come to the 'right' conclusion, as the studies into booze and soft drinks above did.

The evidence is starting to mount isn't it, nonsmokers? Soon it will be 'overwhelming' and politicians will be forced to act. I can hardly wait to to see the look on your faces when you finally realise that freedom is indivisible.

Tuesday, 26 January 2016

A tobacco levy won't work

One of the consequences of David Cameron's flip-flopping and indecision on issues like plain packaging and the sugar tax is that campaigners won't drop their demands even when the government has said it won't meet them. They know that there is always a chance that Cameron will suddenly change his mind.

So it is with the 'tobacco levy', a hare-brained scheme to claw another £500 million out of the tobacco industry (and therefore out of smokers). It was mooted by the Tories (and Labour), but the treasury later conceded that it was impractical. Anyone who has considered the policy for more than five seconds can see that it has intractable problems.

Foremost amongst them is the awkward fact that most tobacco companies are not actually based in the UK. The UK government cannot demand that a company that is headquartered in Switzerland - as JTI and Philip Morris are - hands over an arbitrary sum of money from its profits. It would be like the Japanese government telling Greggs to give it a profit share. It can't be done.

There are still two large tobacco companies headquartered in Britain - BAT and Imperial - but I doubt they will hang around for long if venal politicians start ransacking their profits. In many respects, it is a mystery why they have hung around for so long. Plenty of virtue-signalling politicians would be happy for them to slip off to Bermuda or wherever, taking their jobs with them. A raid on their post-tax profits would surely the the last straw. 

Windfall taxes are pretty immoral at the best of times. As I have said before, they are the mark of arbitrary and capricious government. Leaving aside the ethics, they only work if the company you are looting is (a) based in the country, and (b) cannot leave the country.

The tobacco levy is a stupid and unworkable idea. Naturally, then, the 'public health' lobby are very keen on it and have made another PR push today. Their new excuse for wanting it is to finance smoking cessation services.

Cancer Research UK is today (Tuesday) calling on the Government to make the tobacco industry pay for the damage it causes and help reduce the number of people killed by its deadly product.

Earlier this month a report published by Cancer Research UK revealed that cuts to public health funding mean local Stop Smoking Services are being closed down.

Indeed it did. What it failed to mention was the obsolescence of these vastly expensive and largely ineffective services. The Local Government Association released a surprisingly forthright statement which said, in effect, that it was about time funding was cut.

Responding to Action on Smoking & Health (ASH) report on budget cuts to stop smoking services, Cllr Izzi Seccombe, Local Government Association Community Wellbeing spokesperson, said:

Since the advent of e-cigarettes and campaigns such as Stoptober, we have seen the number of users of smoking cessation services fall, while the population of smokers left is now more challenging to get to quit. This means councils are re-evaluating what they do on tobacco control and how to be more effective.
“Councils remain committed to helping smokers quit, however they face significant cuts to public health budgets this year, and spending large volumes of money on a service people are not using will fast undermine the cost-effectiveness of providing it.”

The CRUK press release continues:

Smoking continues to kill more than 100,000 people in the UK every year.

Merely as an aside, this 100,000 figure has been used since the mid-1980s when the smoking rate was very much higher than it is today. Are we to assume that halving the smoking rate has had no effect on the number of people dying from smoking-related diseases?

Internationally, the tobacco industry makes around £30 billion in profit.

Assuming this figure is roughly correct, the entire global tobacco industry makes £30 billion a year from 1.5 billion smokers. In Britain, home to less than one per cent of the world's smokers, the government makes £12 billion from tobacco duty. Who is really profiting from this product? (Answer: nonsmokers.)

CRUK then show us a cute little graphic showing how terribly straightforward their proposal is.

Note that it bypasses all the practical problems by simply saying 'The government can pass a law'. This could be the slogan of every ban-everything pressure group on the planet. Unfortunately for them, it's not actually true in this instance and so the plan falls at the first hurdle.

Monday, 25 January 2016

Action on Fruit

It had to happen. Once the hysteria about sugary drinks took hold, it was only a matter of time before fruit juice came under attack. From there, it was only a short step to attacking fruit itself. The Atkins Diet fanatics who are the grass roots of the anti-sugar panic have a particular bee in their bonnet about fructose because they once saw a video by Robert Lustig. Lustig's bête noire is high fructose corn syrup, but fructose is obviously in fruit; the word means 'fruit sugar'.

A campaign against fruit is therefore the logical conclusion of the crusade against sugar, but since demonising fruit would test the patience of all but the most credulous members of the public, few campaigners have gone down that road.

One of the few is the chap in the video below, Garry Fettke, an Australian orthopaedic surgeon who runs a website called No Fructose. He says that fruit has been pushed on the public by Big Food using 'one of the greatest marketing campaigns of the last 25 years'. He says we have been 'fooled by nature and fooled by the food industry'.

It is, by any standards, a remarkable speech. Like many people who fear the modern world, he relies heavily on appeals to nature. Low carb people have a thing about hunter-gatherer societies and they assume, quite bizarrely, that 'natural' means 'healthy'. Since neanderthal man only had to access to fruit for a few weeks each year, they assume that seasonal fruit is probably OK. The rest of the year we should only eat buffalo or something.

Every food faddist needs a catchphrase. Lustig's is 'sugar is alcohol without the buzz'. Malhotra's is 'fat is your friend'. Quite wonderfully, Fettke's is 'fruit is confectionery on a tree'. He begins with what he calls 'a little bit of history' but which is actually the biblical story of Adam and Eve.

'Adam and Eve started it all when they plucked that apple off the tree and that turned us from immortal to mortal. That piece of fruit was advertised by the serpent - the snake - to be better than it actually was and we continue to hear that advertising message. Fruit continues to be advertised as better than it actually is... it advertises itself by being brightly coloured, shiny, sweet and attracts the wild life.'

Later in the talk he makes a reference to that other great historical figure, Snow White, but the real hilarity comes after 25 minutes when he starts favorably comparing Coca-Cola to various fruits. He is right to say that sugar content by weight is the same or higher in many popular fruits, but that is only shocking if you consider a can of Coke, with its 139 calories, to be terribly dangerous.

This is what the 'public health' lobby does believe, however. They usually try to wriggle out of the comparison by muttering something about fibre in fruits being good for you or by making a scientifically meaningless distinction between added sugar and intrinsic sugar. Fruit does indeed contain fibre - although there are more plentiful sources of fibre available - but it is a sideshow if you believe that sugar is toxic/addictive/poisonous etc. Fettke is the one being logically consistent here and Action on Sugar are not. By being consistent he inadvertently highlights the lunacy of the anti-sugar mania.

Confectionery on a tree?! What a time to be alive.

Saturday, 23 January 2016

The Guardian resurrects the Boozy Britain moral panic

The Guardian has had one of its spasms today with a series of articles attempting to revive the Boozy Britain panic. The newspaper is indistinguishable from the Daily Mail on such occasions. Its front page story reads like a press release from the Alcohol Health Alliance. That's because it is.

Earlier this week the Australian neo-temperance lobby got some headlines when it pointed out that a relatively small number of drinkers account for a large proportion of alcohol sales. This is hardly surprising. It is the same in most industries and is known as the Pareto Principle.

Seeing the news coverage in Australia, British wowsers made their own back-of-the-envelope calculation and alerted the Guardian's Sarah Boseley who lapped it up.

Exclusive: Firms claim to support responsible drinking, yet data shows those who consume at risky or harmful levels account for 60% of sales in England

Note the implicit accusation of dishonesty here, as if the statistic somehow proves that the 'firms' do not support responsible drinking. It is, of course, entirely up to the individuals how much they choose to drink and they will consume whatever quantity they like regardless of the views of the manufacturer.

The alcohol industry makes most of its money – an estimated £23.7bn in sales in England alone – from people whose drinking is destroying or risking their health, say experts who accuse the industry of irresponsible pricing and marketing.

That £23.7 billion isn't really the industry's money though, is it? About £7 billion is tax, for a start. Only a fraction of it is profit.

While the industry points to the fact that most people in the country are moderate drinkers, 60% of alcohol sales are either to those who are risking their health, or those – labelled harmful drinkers – who are doing themselves potentially lethal damage, figures seen by the Guardian show.

This claim is based on the government's scientifically insupportable drinking guidelines which classify moderate drinkers as hazardous drinkers. 19 per cent of Britons supposedly fall under that category. The Guardian doesn't bother to mention that this percentage has been falling for years. (It will soon rise now that guidelines have been lowered - that was the whole point.) In any case, it should not be surprising that people who drink quite a bit consume a larger proportion of the nation's alcohol than people who don't drink very much.

Separate work in progress from Sheffield University helps to establish the value of this custom to the industry. In 2013, the data shows, 38.2% of the value of alcohol sales in England came from risky drinkers and 24.5% from harmful drinkers. Industry sales in the UK were £45.5bn in 2013.

The Sheffield University researchers are not named but I'll take a wild stab in the dark and guess that they are the same small team of academics who came up with the hopeless minimum pricing model and the laughable new drinking guidelines. If so, how nice of them to share unpublished research with a hardcore anti-alcohol lobby group for propaganda purposes, just as they shared unpublished research with Panorama for propaganda purposes (research that was so utterly inept that the programme had to be re-edited to remove it.) It's almost as if those guys are activists rather than impartial academics, isn't it?

It's not too difficult to estimate how much alcohol 'hazardous drinkers' consume so even the Sheffield mob have a good chance of not totally ballsing up the figures. All the numbers in the Guardian article are in the same ballpark as one would expect if the drinks industry was like any other industry. About 25 per cent of drinkers are buying about 70 per cent of the drinks. The question is 'So what?'

Katherine Brown, director of the Institute of Alcohol Studies, said: “It comes as no surprise to learn the drinks industry relies on excessive consumption of alcohol to boost its profits. Why else would alcohol producers spend millions of pounds on advertising each year encouraging people to drink more...

Aside from the fact that it is illegal for alcohol advertisements to 'encourage people to drink more', the 'why else would they do it?' argument against advertising is just dumb, as I explained on the IEA blog recently...

‘If advertising doesn’t work, why do companies spend so much money on it?’ This is the zinger that is supposed to end all argument about whether marketing increases the consumption of certain products. The products under discussion are usually things that one side of the argument would prefer people did not buy and, to that end, think should not be advertised.

One can reply by saying that advertising is not coercive. One can point out that no amount of advertising can sell a bad product. One can argue that advertising is primarily aimed at making users of a product switch to a different brand. You can explain any of this, but the retort will always be the same. “Ah, but if advertising didn’t work, they wouldn’t do it!”

For example, an organisation called Alcohol Action Ireland currently wishes to ban alcohol sponsorship in sports. ‘Alcohol sponsorship of sports works in terms of increasing sales and, as a result, alcohol consumption,’ it asserts. ‘If it didn’t the alcohol industry simply would not spend so much money on it.’ They assume that the drinks industry hopes and expects advertising to increase consumption.

However, advertisers are not spending their money as an industry, but as rival firms trying to sell their own brands. Their battle for market share may or may not coincide with a growing market for alcohol as a whole, but an individual company does not need a growing market in order to become more profitable. There are plenty of heavily advertised products in markets that are static or declining. Imagine ‘Toilet Paper Action’ Ireland declaring that ‘Toilet paper advertising works in terms of increasing sales and, as a result, toilet paper consumption. If it didn’t Andrex simply wouldn’t spend so much money on it.’ Such a statement would be patently absurd.

It also happens to be a fact that alcohol advertising does not make people drink more. It only encourages people to buy different brands (or stay loyal to the brand they already buy).

It is futile trying to explain this to the morons of 'public health'. They fundamentally do not understand how business works. Speaking of morons, look who else the Guardian approached for a comment...

Gerard Hastings, professor of social marketing at Stirling University, said the data “throws into relief the conflict of interest between industry and public health. Industry is driven by the need to sell as much as it possibly can. Ultimately the marketing department rules the waves.”

No, Gerard. Industry is driven by the need to make as much profit as it possibly can. It can do so when sales are in decline, as has been the case in the alcohol industry for the last decade. It's not about volume, it's about margins. Someone should have explained this to Sarah Boseley before she wrote a front page story that confuses revenue with profit.

Brown said evidence from Canada showed that a 10% increase in alcohol prices led to a 32% reduction in alcohol-related deaths.

Brown is the director of an organisation that used to be called the UK Temperance Alliance. These people say a lot of things, many of them untrue. Journalists are suppose to find out whether the things they are told by lobby groups stand up against the facts. The claim that alcohol-related deaths fell by 32 per cent in Canada is emphatically not true.

Incredibly, this is one of seven Booze Britain articles in the Guardian today. One of them claims that 'up to 35 per cent of A & E visits in the north-east are alcohol-related'. This is based on an unpublished report from another neo-temperance group, the wholly state-funded Balance North East. The 35 per cent figure is at odds with a recent, published study that found the figure in Newcastle to be 12 to 15 per cent. As a rule of thumb, anyone who prefixes a statistic with the words 'up to' is trying it on.

Most of the articles claim that there are more than one million alcohol-related hospital admissions and assert that this has doubled in ten years. This is based on a ridiculously broad definition of 'alcohol-related' which includes primary and secondary diagnoses. As I explained in Alcohol and the Public Purse, secondary diagnoses are more likely to be recorded than in the past and the broad measure gives many false positives...

Under what the ONS calls the ‘broad measure’, there are admissions which involve people who have a partly or wholly alcohol-attributable condition as a secondary diagnosis but who were attending hospital for a condition that was not alcohol-related. For example, if someone who happened to have hypertension went to hospital for treatment of a virus, this would be counted as an alcohol-related admission (or, to be precise, a fraction of an alcohol-related admission) because hypertension is sometimes caused by alcohol use.

Moreover, clinicians are more likely to record a secondary diagnosis than they were in the past, leading to ‘artificial inflation over time due to changes unrelated to the actual occurrence of disease’  and implausibly large increases in putative costs. For example, if taken at face value, the most recent NHS cost estimate showed a 67 per cent rise in the cost of alcohol-related hospital admissions in the space of just three years... These runaway costs, which coincided with a steep decline in alcohol consumption, are an almost inevitable result of including admissions for which alcohol was not the primary diagnosis. It reflects little more than the ageing population, coding drift, and the increased use of hospitals (the number of finished consultant episodes’ in English hospitals for all causes rose from 12 million to 18 million between 2001 and 2013).

The broad measure is so unreliable that the Department of Health no longer uses it. 'Public health' lobbyists still use it because it gives them a bigger number and, as ever, they don't care about the truth.

Friday, 22 January 2016

The horror!

Sarah Wollaston in the Telegraph...

‘Do I want to have a kilogram of chocolate for almost nothing when I buy my newspaper? Of course I do but please don’t offer it to me, please don’t make me pass the chicanes of sugar at the checkout while queuing to pay for petrol.’

This is about as pathetic as it gets. I've written a post about it at Spectator Health. Do have a read.

Wednesday, 20 January 2016


If you haven't seen it yet, pop over to Puddlecote's place to see how Martin McKee has been lying to the Chief Medical Officer.

Tuesday, 19 January 2016

A crucial point about alcohol research

There are still so many things to say about the junk science that has been created to support the new alcohol guidelines, but a crucial point that is often overlooked was made in the Guardian's letters page last week.

What is not clear about the new guidelines for alcohol consumption is whether the risks are calculated on what people actually drink or what they report that they drink. In 2013, the Institute of Alcohol Studies used market research data and assessed the average consumption of all those above 15 in the UK at 11.7 litres a year or 1,170 units. That’s 22.5 units per week on average. The same publication gives reported rates of consumption that seem to be about half this level. If the damage from alcohol is mapped against reported consumption – and rules are drawn up on this basis – these rules will be overly strict for those who assess their alcohol consumption honestly.

Robert East
Professor emeritus, Kingston University

The answer is that the guidelines and the epidemiology are both ultimately rooted in research that takes people's self-reported consumption at face value. We know that people only report a half to two-thirds of what they actually drink. If the epidemiology shows that 14 units offers peak protection, the real figure is probably more like 21 or 28 units. If the epidemiology shows that 30 units is safe, we can assume it's more like 45 units.

You only ever hear about under-reporting when campaigners are saying 'OMG! We're drinking more than we thought'. This is not really true since we know how much is sold from tax receipts, but under-reporting has a profound impact on what we believe about safe and harmful drinking because epidemiologists do not have their subjects' tax receipts. As the letter above suggests, under-reporting can only lead to an exaggerated perception of risk.

Monday, 18 January 2016

Exploiting the workers, NHS style

You may have heard that the boss of NHS England wants to bring in a pretend tax on soft drinks (really just a price hike) on hospital property.

It's been amusing to watch the bien pensants slap him on the back for price gouging in a virtual monopoly when the main effect will be to take more money from the supposedly hard-pressed doctors, nurses, porters and cleaners of the health service.

I've written about for Spectator Health. Do have a read.

Well said

Simon Cooke on the public health industry...

It is hard to think of a section of government that so completely (and for its practitioners unconsciously) embraces the warnings about soft totalitarianism set out by Orwell and Huxley - and especially the latter with his observation that totalitarianism would be a matter of acceptance not something violently imposed by a powerful, all-seeing state. Restrictions on our lives - repeat the mantra of don't smoke, don't drink, eat the right food - are accepted because the experts with their evidence tell us that embracing these restrictions is the right thing. Just as as self-appointed stasi helped enforce the smoking ban, we will see similar as new fussbuckets arise to challenge those who drink openly, who eat sugary or salted foods.

The truth about public health spending is that nearly all of it is wasted, is money spent on promoting an ideology of control. No lives are saved by public health's actions. No money is saved for the wider health system by the interventions of public health. No-one's wellbeing is improved by public health. Indeed for many thousands the actions of these ideologues result in a worse life. Yet in my city of Bradford over £30 million is spend on public health programmes, money that could fix the roads, could provide care for the elderly, could smarten up parks. Instead we'll spend it on nannying the hell out of the population, on promoting an unpleasant controlling ideology founded on a myth of wellbeing that has no basis in fact or substantive value to the poor masses it is being imposed upon.

Too right. Do read the rest.

Friday, 15 January 2016

The research behind those alcohol guidelines

This is a guest post by Chris Oakley...

“The benefits for heart health of drinking alcohol are less, and apply to a smaller group of the population, than previously thought. The Sheffield report commissioned for the expert group included a UK analysis which has found that the net protective effect from mortality that may be attributable to drinking regularly at low levels appears now to be significant only for women aged 55+ (with men aged over 55+ showing such a net protective effect only of negligible size).”

This statement is taken from the executive summary of the recently issued Alcohol Guidelines Review. The review is the work of “expert” groups and the implication of this carefully worded text is that experts have reviewed a new body of evidence that shows the well-established and well researched health benefits of alcohol to be very much less important than previously thought and to be dependent on age and sex.

This seems to be how the press has interpreted the report and if they are to be believed so has the DH. According to the Daily Mail

“The Department of Health said researchers at Sheffield University analysed a number of studies showing alcohol only protected the hearts of women over 55. Even so, this was only for small amounts – less than one unit a day …”

This devastating news for moderate drinkers was reported very widely indeed, usually with some reference to protective effects only applying to post-menopausal women and always with the implication that the findings reflected the latest published research.

The problem is that this interpretation is not backed by published research and what the Daily Mail is reporting the DH as saying is not true.  The claim that a protective effect is only seen in women over 55 is in fact based entirely on an unpublished speculative report produced for Public Health England by a team from Sheffield University led by Dr John Holmes. 

Holmes and his team are the same people who came up with a magic bullet in the form of a minimum unit price (MUP) model that they claimed would target problem drinkers without impacting everyone else. Many people were intrigued by the model including me so I went to the trouble of wading through the extensive analysis that was supposed to be the basis for MUP and was shocked to find that it was not only not supported by the literature but was at odds with many of the most relevant publications. The Sheffield team ploughed ahead regardless and were paid by two governments and the BBC for a model that is economically counterintuitive and contradicts much of the published evidence. Fortunately, I was not alone and many people came to understand that MUP would not target the people Holmes said it would and would be a regressive unpopular tax. Some persist in an irrational belief in MUP including Nicola Sturgeon and some of the members of the “expert” alcohol guideline groups who are still lobbying for it when they are not being impartial experts. 

It is hard to imagine, based on the academic quality of the MUP modelling, how anyone might consider the Sheffield team suitable candidates for remodelling UK alcohol guidelines and utterly incredible that its findings should be given precedence over knowledge gleaned from decades of oft tested published research, but that appears to be what has happened.  

The Sheffield report repeatedly challenges the widely held belief that moderate alcohol consumption has significant benefits. Both it and the DH guidelines claim or imply that there is widespread scientific controversy on this issue but an in depth analysis using the most relevant references included and omitted from the Sheffield report demonstrates that the controversy is largely confined to John Holmes et al and Tim Stockwell, a man who is still trying to claim that MUP reduced deaths in parts of Canada based on evidence that nobody else seems able to see and which is at odds with official figures. 

The Sheffield report claims that protective effects are disputed, may be overestimated and are probably limited to particular groups within society. We might assume that those groups would be the post-menopausal women and perhaps older men mentioned in the guidelines and that there is a body of evidence proving it but in fact the report provides only one reference, a Canadian paper written by Michael Roerecke and Jürgen Rehm, who conclude that their findings...

“ current low-risk drinking guidelines, if these recognize lower drinking limits for women”. 

This is at odds with the Sheffield report, the proposed UK guidelines (which now give men and women the same 'limits') and the attendant publicity.

Elsewhere in the Sheffield report we are told that the same Roerecke and Rehm paper is used as a basis for risk functions that suggest that “drinking up to 8 units a day for males and 4 units a day for females is associated with a reduced risk of IHD (Ischaemic heart disease) relative to abstainers.  This is true but in a separate analysis Roerecke and Rehm fail to find a statistically significant dose response relationship between people consuming at the lower and upper ends of the moderate spectrum, prompting speculation that protective effects peak at just one drink per day - speculation that the Sheffield report and the expert group seize upon as fact.*

Confused? That’s hardly surprising. The evidence is less than clear and to their credit Roerecke and Rehm explain this in terms of the limitations of the epidemiological data that they are working with.
Interestingly they go on to say: 

“Regarding causality of effects, a potential cardioprotective association is supported by short-term experimental evidence on surrogate biomarkers, such as increasing HDL cholesterol, reducing fibrinogen levels, and inhibition of platelet activation. Indeed, this might be the strongest argument for causality given that observational findings are always prone to residual confounding and bias due to study design.”

This translates as “there is biological evidence to support a protective effect and it is more robust than the epidemiological evidence.”

But the Sheffield report in a statement thought so important that it appears in a special box claims that:

“many researchers…point to a lack of well evidenced biological processes that could explain the effect”. 

Clearly those many researchers don’t include Roerecke and Rehm who are just about the only people other than the Sheffield team and Tim Stockwell who might be claimed to be contributors to scepticism over the protective effects of alcohol.** 

In a considered response to Tim Stockwell in the journal Addiction Roerecke and Rehm observe that...
“...some researchers in the field may be using different standards in assessing the cardioprotective effect of alcohol vs. its detrimental effect.” 

They go on to point out that they...

“...sense a desire by some in the field to apply tough standards on protective effects and more lenient standards on other effects”.

It is hard to disagree that these statements also apply to key elements of the evidence that underpins the proposed new UK guidelines. The Alcohol Guidelines Review is careful to talk about net benefits that take into account detrimental effects but some serious questions need to be asked about the manner in which the net effects were arrived at. 

There is one recent UK study that claims alcohol benefits are only relevant in older women. It isn’t referred to in either the DH Guidelines Review or the Sheffield report.*** The reason for its omission is perhaps that it was discredited as statistically illiterate by the UK’s most famous statistician. That same statistician, David Spiegelhalter was apparently consulted on the proposed alcohol guidelines. I would love to reads his analysis of the Sheffield report with which his name is likely to be inextricably linked.****

In my view, the guidelines and supporting data need to be assessed by competent statisticians and presented by a much more objective group of “experts” before anyone can take them seriously. Someone in Westminster should perhaps mull on the value of exercises such as this review and consider what they tell us about standards at the Department of Health.  

I can't resist adding a few footnotes - CJS
* The peak in protection is almost certainly below 14 units per week but that has no bearing on what the 'safe' level should be. If it is considered safe to not drink, any mortality risk below that of a non-drinker must also be safe. In the Neverland of Sheffield's computer model that level is reached at 14 units. In the real world, as observational data show, it is at least twice that.

** The claim that there are no biological mechanisms to explain the protective effect is such a tired zombie argument - see p. 7 of the previous evidence review from 21 years ago.

*** There is an obvious point that I haven't heard anyone make regarding the protective effects of alcohol 'only' applying to people over the age of 55, namely that heart disease overwhelmingly affects people aged over 55. Sally Davies has strongly implied, if not explicitly stated, that there are no benefits to drinking under this age, but the beneficial impact on heart health is likely the result of long term moderate consumption. The benefits may only pay off in late middle and old age, but they accrue earlier.

**** It should be remembered that even that study - which went out of its way to downplay the benefits of drinking - found that men aged 50-64 years who consumed 15.1 to 20 units of alcohol per week halved their mortality risk compared with nondrinkers - and this finding was statistically significant. This makes the CMO’s decision to reduce the guidelines from 21 units to 14 units per week for men all the more baffling. Moreover, the study did not merely show a reduction in mortality for women over 55 consuming up to 5 units per week, as Sally Davies suggested on the Today programme. It showed a statistically significant reduction in female mortality at every level of drinking up to and over 20 units per week. The strongest effect was shown at the level of 15.1 to 20 units per week with mortality rates falling by around 40 per cent for women over 65 and by around 46 per cent for women aged 50-64 years. In other words, the optimal effect is seen only when people drink above the existing guidelines.

Wednesday, 13 January 2016

Doll parts

I've got an article up at Spectator Health contrasting the 'public health' reaction to two epidemiological findings associated with Richard Doll. The first involved smoking, the second involved drinking.

As before, a noisy minority continued to deny these findings. They insisted that the biological pathways were unproven, though plausible pathways had been identified. They made generic criticisms of epidemiology that could apply to any observational research, though they never made them of studies which showed negative effects from drinking. Above all, they treated the sick quitter hypothesis as an unanswered question, never acknowledging that it had been tested extensively.

Decades after the evidence on moderate alcohol consumption had first been identified, those who refused to accept it were embroiled in a campaign of doubt and denial similar to what Doll had witnessed in the mid-20th century, but this time the naysayers were on the inside of the public health establishment, albeit in its neo-temperance wing. For years, they chipped away at the science, repeating the same old criticisms, cherry-picking studies and demanding an impossible burden of proof from researchers. They received a sympathetic hearing from their public health colleagues who had long struggled with the nuanced message that heavy drinking was bad while moderate drinking was good. Preferring a simple, clear, strong message that alcohol was dangerous, they were similarly inclined to dismiss or downplay the epidemiology.

Do read the whole thing.

Tuesday, 12 January 2016

Doubt is their product

The changes to the drinking guidelines last week represented the first review of the evidence since 1995. The Chief Medical Officer, Sally Davies, and the Sheffield alcohol researchers who advised her went out of their way to downplay and dismiss the evidence that moderate consumption reduces heart disease risk and overall mortality. Why?

First, let's familiarise ourselves with what the review found back in 1995:

'For a number of years studies have provided evidence that there is a relationship between moderate alcohol consumption and a reduced risk of death from all causes, and that this benefit was found in people who regularly consumed as little as 1 unit per day.'

'It is now established that the main specific pathology which benefits from alcohol consumption is coronary heart disease.'

'The epidemiological evidence alone linking alcohol and CHD now makes the existence of a protective effect appear very likely. The written and oral evidence received by the Group confirmed that most of the technical epidemiological criteria for a causal association are now fulfilled.'

'A key issue previously complicating the epidemiological data has been the so called “sick quitter” hypothesis outlined by Professor A G Shaper... However, a number of studies since 1987 have controlled for these factors so that we believe Professor Shaper’s reservations cannot be considered as a major explanation of the cardio-protective effect. Other confounding factors such as tobacco use, obesity, diet and age have now been controlled for in enough studies to allow us, on the basis of expert testimony, to be confident that the basic protective effect for CHD by alcohol is scientifically valid.'

'All the evidence we have received confirms that the relationship between all-cause mortality and alcohol consumption follows a J-shaped curve. Non drinkers have higher all-cause mortality than light and moderate drinkers, and heavy drinkers have even higher all cause mortality than either group.'

'All cause mortality is at its lowest at modest drinking levels (at about 1 unit a day for men and women) and does not exceed the mortality level of abstainers until consumption levels which are somewhat higher than the current recommended sensible drinking levels of 14 units per week for women and 21 units for men.'

Pretty clear, no? In addition to finding a clear relationship between moderate consumption and lower mortality risk - which could not be explained by confounding factors - the working group identified several plausible biological pathways which explained how the effect came about.

It is important to stress that the 'sick quitter' hypothesis - which says that unhealthy former drinkers could explain why teetotallers don't live as long - had already been tested extensively by 1995. In 2002, Richard Doll discussed it in an essay titled 'Proof of causality':

One possibility, that the non-drinkers included ex-drinkers who might have given up because of ill health, was excluded by cohort studies in which ex-drinkers and lifelong non-drinkers had been classed separately and by data like our own, which included information on past medical histories and showed the same proportional reduction in risk in drinkers irrespective of any previous history of vascular disease.

Another possibility was that drinkers might have differed from non-drinkers in other ways that would affect the risk of the disease, by, for example, including lower proportions of cigarette smokers, having a lower mean blood pressure and body mass index, a higher level of physical activity, or higher socioeconomic status (Shaper 1995). In fact, an association with smoking has the opposite effect to that postulated, as smoking is more prevalent in drinkers than in non-drinkers (Jarvis 1994), and allowance for it actually increases the evidence of benefit associated with drinking. In many studies it has been taken into account, as have all the other suspect factors in some of the more detailed studies, such as those by Stampfer, et al. (1988), and Thun, et al. (1997). When these factors were all allowed for, the observed differences were hardly altered.

Confounding, often a serious concern when risks vary by less than two-fold, has in this case been tested and found wanting... That the inverse relationship between ischemic heart disease and the consumption of small or moderate amounts of alcohol is, for the most part, causal should, I believe, now be regarded as proved (Doll et al. 1997).

In the last fifteen years, research has continued to show that the J-curve is not the result of 'sick quitters' or other confounding (eg. here, here, here, here and here). A meta-analysis of 34 prospective studies in 2006 showed a clear J-curve that could not be explained by 'sick quitters'. This is how epidemiology is supposed to work. People suggest alternative explanations, new studies test the alternative hypothesis and if the association survives all tests the relationship is assumed to be causal.

In any other field, the debate would have been put to bed years ago. It has been kept alive because many people in 'public health' desperately want to believe that alcohol has no (health) benefits. Almost unbelievably, Sally Davies described the J-curve as an 'old wives' tale' last week. She drew on a report she had commissioned from Sheffield University (the same people who devised the minimum pricing computer model). You can read it here.

The Sheffield report starts the campaign of doubt early in the main text when it mentions the protective effect of moderate drinking and says...

These effects are disputed,(10-13) may be overestimated (14-17) and are probably limited to particular groups within society (18) (see Section If, as appears possible, scientific opinion develops to conclude cardioprotective effects are in fact overestimated and only occur up to very low levels of consumption (e.g. 5 units per week); one of the researchers responsible for the Canadian approach concluded that this would leave the Canadian guideline “in trouble”.(19)

It's worth looking at what all those references refer to:

(10) is an opinion piece in Addiction which discusses the same confounding variables which Doll said had been overcome in 2002.

(11) is a study that doesn't really 'dispute' the J-curve.

(12) is a letter from Tim Stockwell and friends responding to a meta-analysis in the British Medical Journal which found that the link between good cardiovascular health and moderate alcohol consumption was 'beyond question'. That meta-analysis is not cited in the Sheffield report at all, nor is the authors' reply which accuses Stockwell et al. of adopting 'an extreme methodological position, proposing to dismiss an entire body of literature on the basis of the presence of predictable limitations in individual studies. This dogmatic and dichotomous approach to the evaluation of epidemiological studies is counterproductive to scientific epistemology.' If you read Stockwell's letter, you will see that they have a point.

(13) is an opinion piece by Tim Stockwell and friends casting doubt on the alcohol-health link.

(14) is a study that clearly found lower heart disease risk among moderate drinkers.

(15) is a comment piece by Tim Stockwell and friends.

(16) is a revised meta-analysis by Tim Stockwell and friends which claimed that the protective effect of alcohol disappears when adjustments are made to the data and some studies are excluded.

(17) is a study which found that a gene associated with not drinking was also associated with better cardiovascular health.

(18) is a meta-analysis which concluded that 'some form of a cardioprotective association was confirmed in all strata' but that this 'cannot be assumed for all drinkers'. Its authors have since published a meta-analysis which found clear evidence of a J-curve, even when only lifetime abstainers were included (ie. no 'sick quitters').

(19) is a short opinion piece by (you guessed it!) Tim Stockwell.

There you have it - the case for the prosecution. Not quite a one man crusade by Tim Stockwell but not far off. Needless to say, you can find dissenting voices and contrary evidence in any field of research, but on the basis of these minority reports the Sheffield crew not only portray the science as highly contentious but also predict that the science will eventually agree with Tim Stockwell.

Towards the end of the report, the Sheffield boys and gals address the J-curve at more length. They start by acknowledging (but not referencing) the evidence...

An extensive literature including well-executed meta-analyses of high quality primary studies have found an association between moderate drinking and reduced risk of cardiovascular disease and particularly ischaemic heart disease.

There is a 'but' coming, of course...

This literature has attracted substantial debate regarding whether evidence is sufficient to conclude that low levels of alcohol consumption have a causal relationship with improved cardiovascular health. The debate includes detailed critique of both observational and meta-analytic studies, exploration of potential biological mechanisms explaining observed cardioprotective effects and arguments regarding the public health relevance of establishing the veracity of cardioprotective effects given alcohol’s undisputed risk for other diseases and the various alternative options for reducing cardiovascular risk.(10,12,13,17,94)

Those references are some of the articles and studies mentioned above plus a comment piece in Alcohol from 2007 which said 'In view of the potential risks of alcohol, a more cautious view about the beneficial effects of alcoholic beverages is warranted.' It is notable that all the citations given to prove the existence of a 'debate' here are from people on one particular side of the debate. This is a bias that permeates the Sheffield report. For example, no fewer than twelve Tim Stockwell publications are cited in the report, along with eight publications by John Holmes of Sheffield University. By comparison, there are zero citations of studies by people like Richard Doll who produced several studies showing (and testing) the J-curve, nor is there any mention of people like Di Castelnuovo who conducted the 2006 meta-analysis.

The Sheffield crew then proceed to give four possible reasons why this 'extensive literature' is wrong...

First, there is evidence that participants in epidemiological cohort studies may differ with regard to their underlying health status compared to the general population. One reason for this is such studies often recruit participants with no underlying health conditions at baseline. The resulting potential for bias was demonstrated in a major European prospective cohort study which included at baseline people with chronic disease. Risk estimates were calculated for both the whole cohort and for a subsample of the cohort who were free of chronic disease at enrolment. Relative risk of cardiovascular mortality was lowest in those with light to moderate alcohol use; however, this was only the case among the subsample free from chronic disease at enrolment. This suggests sample selection processes for typical cohort studies may disproportionately exclude those at cardiovascular risk from moderate drinking leading to overestimation of any cardioprotective effect.

This is a reference to this study which found that moderate drinkers had a 26-48 per cent lower risk of heart disease mortality. The study included graphs showing a clear J-curve for all-cause mortality (the one below is for men).

The protective effect for heart disease was only statistically significant for people who did not have a disease at the time of enrolment, but even among those who had a disease upon enrolment, heart disease risk was not higher.

Second, estimates of risk relationships between alcohol consumption and health conditions are commonly quantified by calculating the risk of a given level of consumption relative to the risk of zero consumption (i.e. abstention). In practice, this means assuming that, after controlling for a range of confounding factors such as age and gender, drinkers and abstainers only meaningfully differ in terms of their alcohol consumption and a narrow set of other factors.

That's what epidemiologists are supposed to do. Smokers are different to nonsmokers in ways that have nothing to do with tobacco. Promiscuous people are different to virgins. People who drink large quantities of sugary drinks are different to people who don't. This is why epidemiologists adjust for factors that might bias the results. Alcohol research is no different to any other type of observational research in that respect - and, as Doll pointed out, non-drinkers tend to lead healthier lifestyles than drinkers, therefore any bias likely leads in the opposite direction to what the Sheffield authors are implying.

Rather than explaining what it is about the characteristics of non-drinkers that invalidate alcohol research when the characteristics of smokers do not invalidate tobacco research, the Sheffield crew ignore all the studies that have tested for confounding variables and return the subject of sick quitters:

This assumption has been questioned and the characteristics of abstainers and their similarity to the general population have been closely scrutinised. Most significantly, the classification of former drinkers as abstainers has raised particular concerns, particularly where those former drinkers have stopped drinking due to health problems. Meta-analyses which disaggregate abstainers (e.g. never drinkers, former drinkers, occasional drinkers) have concluded that using a single abstainer category leads to overestimation of the cardioprotective effect of alcohol.(15,16,18)

Reference 15 and 16 are two similar studies from the pen of Tim Stockwell and friends. One is a revised meta-analysis which controversially claimed that the protective effect of alcohol disappears when studies are excluded and adjustments are made to the data. Reference 18 is a meta-analysis which concluded that 'some form of a cardioprotective association was confirmed in all strata' but that this 'cannot be assumed for all drinkers'.

It is certainly true that including 'sick quitters' biases the results and makes the J-curve look steeper than it is. That is why most studies in the last 25 years have excluded former drinkers and still find strong evidence of a J-curve. The Sheffield authors choose not to mention this or cite those studies, preferring instead to imply that this is an unanswered question.

Third, alcohol consumption is typically measured in epidemiological studies of long-term health risks as average daily consumption. However, recent evidence incorporating data on frequency of heavy drinking occasions (defined as more than 7.5 units on a single day) has shown an elevated ischaemic heart disease risk for moderate drinkers who have heavy drinking occasions at least once per month when compared to moderate drinkers with fewer heavy drinking occasions. Further analyses suggest any cardioprotective effect from moderate drinking may be attenuated or no longer present among those who have heavy drinking occasions at least monthly.

This was acknowledged in the government's 1995 report. It is why people are advised to drink moderately, not heavily. It does not mean that there is 'no safe level of drinking', nor does it mean that the protective effect is an 'old wives' tale'.

Fourth, alcohol consumption is only one of many variables which have a positive or negative association with an individual’s cardiovascular risk and it has been argued that “groups with different drinking habits differ in several other ways than their drinking, making it difficult to separate the effects of drinking habits from other factors”. For example, both increasing age and smoking status increase individual risk of ischaemic heart disease and estimated risk relationships for alcohol consumption can be adjusted to account for these confounding factors. However, a recent major meta-analysis noted substantial unexplained heterogeneity in risk estimates suggesting other important confounding factors were not controlled for.(18)

Reference 18 is the same study they have cited twice already. This point really just reiterates what was said earlier about there being differences between teetotallers and drinkers. In effect, they are saying that there might be some other factor that might make teetotallers die younger than drinkers but we don't know what it is. Well, there might be, just as there might be something about smokers which has nothing to do with smoking that makes them more likely to get lung cancer, but the temperance lobby has been hunting pretty hard for this mysterious explanation for a long time and come up empty-handed.

This is the sum total of their objections to the J-curve. Essentially, they are just saying 'confounding factors' over and over again without acknowledging that that question has been emphatically answered. It is difficult to see how any amount of evidence could satisfy them and it is notable that they do not raise the same objections to the epidemiological evidence linking moderate alcohol consumption to various cancers, most of which is weaker and all of which is susceptible to the same potential biases and confounding. This point was well made by two scientists when Tim Stockwell demanded an almost impossible burden of proof in 2013...

... it seems that some researchers in the field may be using different standards in assessing the cardioprotective effect of alcohol vs. its detrimental effect. Consider two examples. One is the effects of alcohol on colon cancer. Would the same arguments used to judge the relationship between alcohol and ischaemic heart disease not hold for this relation as well? The other example is the more than 200 other risk relations between alcohol and disease and injury outcomes. Of course, this is not a good argument against scrutinizing the cardioprotective effect of alcohol, but we sense a desire by some in the field to apply tough standards on protective effects and more lenient standards on other effects, where sometimes the responses to very simple survey questions such as ‘Did your partner’s alcohol consumption contribute to your marriage problems?’ are accepted as causal evidence.

Nevertheless, the Sheffield authors believe that they have thrown enough mud to make some of it stick and conclude:

Given these critiques, there is little consensus in the scientific community regarding the presence or size of any cardioprotective effect.

There is little consensus in the public health community about the presence of a cardioprotective effect, but the public health community should not be mistaken for the scientific community. There is little consensus in the anti-vaxxer community about the protective effect of vaccines and there will never be agreement from people like Tim Stockwell about the benefits of alcohol. Rather than waiting for a consensus amongst people who hate alcohol, let's trust the evidence.

Monday, 11 January 2016

More on those alcohol guidelines

I was going to write about the modelling conducted by Sheffield University's alcohol squad to create the new drinking guidelines, but I am relieved to find that the Stats Guy has got there first. Most of the odd aspects of the research that struck me have also struck him and his post is essential reading for anyone interested in the subject. Be sure to have a look.

As with their efforts to model the effect of minimum pricing, the Sheffield report is superficially detailed but breaks down when you try to find exactly what calculations have been made and what studies have been used as the empirical evidence. It therefore requires more trust in the authors' judgement than I am prepared to invest.

Minimum pricing is an untested policy so theoretical modelling is the only option. By contrast, the link between mortality and alcohol consumption has an extensive empirical literature. As the Stats Guy says, it doesn't require modelling at all. It requires a literature review.

It seems to me that the important question here is how does your risk of premature death depend on your alcohol consumption. That, at any rate, is what was modelled.

But there is no need to model it: we actually have empirical data. A systematic review of 34 prospective studies by Di Castelnuovo et al published in 2006 looked at the relationship between alcohol consumption and mortality. This is what it found (the lines on either side of the male and female lines are 99% confidence intervals).

This shows that the level of alcohol consumption associated with no increased mortality risk compared with non-drinkers is about 25 g/day for women and 40 g/day for men. A standard UK unit is 8 g of alcohol, so that converts to about 22 units per week for women and 35 units per week for men: not entirely dissimilar to the previous guidelines.

Quite so. It should also be noted that the protective effect is stronger for men (ie. they can drink more than women before assuming the same risk as a teetotaller). This makes a mockery of the idea that the only health benefits from drinking apply to post-menopausal women. The evidence simply does not support that.

One thing the Stats Guy doesn't mention, though it strikes me as peculiar, is that the Sheffield research focuses entirely on alcohol-related mortality and alcohol-related hospitalisations. It is a trivial tautology to say that drinkers are at more risk of drink-related problems than non-drinkers, but what we really need to know is what effect alcohol consumption has on overall mortality. The Sheffield report doesn't tell us. Fortunately we have a wealth of epidemiological evidence to show that overall mortality risk does not return to the level of a non-drinkers until alcohol consumption gets to around 20 to 40 units per week.

There are some mildly entertaining attempts to pour doubt on the health benefits of alcohol in the text of the Sheffield report which I will return to another day. For now, read the Stats Guy's post (and, if you haven't seen it, my post from Friday).

Saturday, 9 January 2016

Twists of the ratchet

Regarding the new alcohol guidelines and the 'no safe level' rhetoric spouted by the Chief Medical Officer yesterday, Charles Moore gets it...

Critics of the new guidelines have already pointed out some of their defects – how they depend too heavily upon research at the University of Sheffield conducted by those committed to the minimum pricing of alcohol (another entirely political, unscientific cause); how they concentrate so much on cancer risk that they play down alcohol benefits for the heart; how they show no sense of proportion about what we mean by risk; how binge-drinking is less of a problem than it was 20 years ago. 

But something more important is being missed. These guidelines are not intended to stand alone. They are twists of a ratchet. Public health zealots, like environmentalist ones, work always to construct a net of public policies that will eventually ensnare whatever group it is they dislike. 

The model in their minds is tobacco. Having succeeded in virtually outlawing smoking, they want to do the same with alcohol. If they can create the public “fact” that there is no such thing as safe drinking, they can then attack everyone who brews, distills, makes wine, or runs a pub, club or restaurant, for pushing something which is unsafe. 

They can also have a go at anyone who advertises any of the above, and insist on health warnings and, later, bans.

Emulating the anti-tobacco blueprint is the name of the game. This has been clear to seasoned observers for some time. This week should be a wake up call to the general public.

From this moment on every campaign for policies to attack drinkers will be accompanied by references to there being no safe level of drinking, to alcohol causing cancer (with no reference to the small level of risk or the rarity of the cancer), and to there being no health benefits from drinking (a lie).

Happy new year.

Friday, 8 January 2016

The Chief Medical Officer is misleading the public

The change to the alcohol guidelines today was an opportunity to bring official advice closer in line with the evidence. Instead, the Chief Medical Officer has taken it further away.

I have predicted for years that the guidelines will one day be reduced to zero. This is another step in that direction. In the 1960s, people were told not to drink more than a bottle of wine a day (or the equivalent). Then, in 1979, Britons were advised to drink no more than 56 units a week. This fell in 1984 to 14-21 units for women and 21-36 units for men. By the end of the 1980s it had become 14 units for women and 21 units for men. They have now fallen to 14 for both sexes - one pint of beer a day.

Most men will find their new 14 unit 'limit' laughable and rightly ignore it but guidelines are not really designed for the public. They are designed for 'public health' campaigners. The effect of today's change will be to drag hundreds of thousands of people into the at-risk category and revive the flagging narrative of Booze Britain.

It is also being done because the 'public health' lobby hates a complex message. The reality is that there is no safe drinking level. Being teetotal offers protection against a few cancers but drinking offers protection from other diseases, including heart disease and stroke. So what do you want to be 'safe' from - cancer or heart disease? You have to choose.

Sally Davies has got around this thorny question by ignoring or downplaying the benefits of moderate drinking to health. She relied on one piece of quack research to do so.

Last year, a study claimed that drinking only had a protective effect for certain groups. The authors used a simple statistical trick. They gathered data which clearly showed health benefits from moderate drinking and then divided it into so many subgroups that it was almost impossible for them to produce statistically significant results. By the time the authors had sliced and diced the data, the only people who appeared to benefit from drinking were post-menopausal women. I wrote about it at the time, as did David Spiegelhalter. It was absolute junk.

Everybody knew the guidelines were under review. I said at the time that the study was a concerted effort to overturn decades of evidence. Countless studies have found a J-shaped relationship between drinking and disease/mortality. This can be illustrated with this graph from Doll and Peto (1994)...

Richard Doll returned to the subject in 2005 and found much the same effect...

The J-curved relationship between alcohol consumption and coronary heart disease is particularly strong. It has been summarised in this meta-analysis of 84 studies and can be illustrated with this graph from Corrao et al. (2000)...

What about overall mortality? It's the same picture. As many researchers have shown, for example Gronbaek et al. (1994), the relationship is also J-shaped.

The only real question is how much do drinkers have to consume before they assume as much risk as non-drinkers? Di Castelnuovo et al. (2006) was quite typical in finding a lower rate of mortality up until drinkers consume 40 units of alcohol per week. Beyond this, risk increases above that of the teetotaller. A unit of alcohol is 8 grams so this works out at five standard drinks or more (nb. a unit is 10 grams in the US hence it is four drinks in the graph). 

From time to time, 'public health' people who don't like to admit that drinking can be good for you wheel out the 'sick quitter' hypothesis, a zombie argument that was debunked years ago. (Even the slice-and-dice study showed that the risks of not drinking were not due to unhealthy former drinkers - only lifelong non-drinkers were studied. Doll's 2005 study found the same thing).

The facts are clear. Moderate drinking - or by today's puritanical standards, even relatively heavy drinking - reduces not only heart disease risk but overall mortality risk. And the relationship is causal.

So how does Davies - or rather Davies' advisory group, which was made up of familiar anti-drinking zealots such as Ian Gilmore and Gerard Hastings, with the research shipped out to Sheffield University's minimum pricing modellers - get around this dilemma? She cites that one terribly flawed study from last year which split the drinkers into lots of non-significant subgroups. That's it. Actually she doesn't cite it explicitly - the report contains remarkably few citations to academic studies - but it is clear what she is referring to.

Meta-analyses have identified that for some conditions, notably ischaemic heart disease (IHD), drinking alcohol at low levels may have a protective effect (compared to not drinking), particularly for all-cause mortality. However, the group noted that any potential protective effect seems mainly relevant to older age groups

This claim is repeated again in the main text of the report...

Evidence for a net protective effect of alcohol from risk of death (which has been linked to possible reduced risks of heart disease late in life) is considered less strong than it was. A reduced risk still exists, but, in the UK, it now appears to matter overall in a significant way only for women aged 55 or older.

And again...

Previous analyses suggested the protective effect was only likely to be relevant to men from age 40 onwards and for post-menopausal women. 

She follows this up with some classic merchants of doubt stuff...

The evidence for a direct, protective, effect of alcohol on mortality is a subject of continuing scientific discussion

Whereas there is no scientific discussion about one contrarian study based on nothing more than statistical chicanery?! That study is sufficiently robust to overturn everything else in the literature, is it?

The reality is that the J-curve has been repeatedly shown in a body of evidence that is much larger, stronger and more consistent than the evidence for a relationship between moderate drinking and most of the cancers Davies focuses on and yet she portrays the former as controversial and the latter as rock solid. As Eric Crampton said some years ago, in the world of alcohol research 'every risk is conclusively proven; every benefit needs further study.'

She then seeks to say, in effect, that reducing heart disease risk isn't very important...

Deaths from this type of disease have been falling in the UK population for some years, which means there is less risk for which low alcohol consumption might give protection

Maybe heart disease declined partly as a result of the increase in drinking? Just a thought. In any case, coronary heart disease still kills more people than all the 'alcohol-related' cancers Davies mentions combined.

And then there is this remarkable statement...

Lifestyle changes, such as stopping smoking, increasing levels of physical activity, and eating a healthy diet, can help protect against heart disease, so any potential protective effects from alcohol could be achieved in other ways, which avoid the other health risks which come with any drinking of alcohol.

Imagine them saying this about anything else! Imagine them saying that people don't need to bother about eating too much salt because they can always reduce the risk of having a heart attack by losing weight. In any case, it's not true. A non-smoking teetotaller is as greater risk than a non-smoking moderate drinker.

This whataboutery is a blatant attempt to downplay the significance of alcohol's protective effect on heart disease to such an extent that they are even happy to downplay the significance of heart disease as a cause of death. The lengths these people will go to is extraordinary.

Anyone who cares about scientific probity should be outraged by the Chief Medical Officer's behaviour in this report. Casting out decades of research in favour of a single claim from a single study is a shocking abuse of her authority. People have a right to receive honest and accurate information from the government. I would call for her to be sacked but she'd only be replaced by somebody cut from the same corrupt cloth.