Tuesday, 22 August 2017

Stop lying about problem gambling

If the case against fixed odds betting terminals (FOBTs) is so strong, why does everybody who campaigns against them resort to demonstrable lies?

I was going to blog about this article from Victoria Coren in The Observer. It pains me to have a pop at her because she is one of Britain's better writers and one of our finest poker players. Her article centres around a statistic that I have not been able to verify and which she is only able to support with a link to a Daily Mail story. It also contains the false claim that people can lose £500 a minute on FOBTs (which she has tried to justify on Twitter by saying it could happen if you played two machines at once!), but this is chicken feed compared to the outrageous lies that are usually made by anti-FOBT campaigners. Mainly, however, she relies on an argument that is so overtly snobbish that I'm going to pretend it was made tongue-in-cheek and pass over it.

I cannot be so generous towards Iain Duncan Smith and his Centre for Social Justice, however. Last week he was talking through his hat at Conservative Home under the headline 'Problem gambling is soaring – it’s time to cap the stakes on betting machines'. In the article, he claims:

The British Gambling Prevalence Survey identified 450,000 problem gamblers in 2010 with an average debt of £17,500. The number of problem gamblers has now increased to 593,000 in 2015.

IDS was promoting a report from the Centre for Social Justice, which begins by claiming...

In 2006, the Centre for Social Justice (CSJ) published its Breakthrough Britain report on addiction, which outlined the systemic issue of gambling and its pervasive effects on individuals and communities. At the time of publication, there were 250,000 problem gamblers in the UK, whereas estimates now exceed 593,000. [My italics]

Note the word 'exceed' there. The report cites the NHS Choices website as its source, but when you visit it you will see that it says:

There may be as many as 593,000 problem gamblers in Great Britain.[My italics]

Straight away, we have a problem. The NHS website says that 593,000 is the upper limit whereas as CSJ says it is the lower limit and IDS says it is the exact figure.

So who is right? The answer is none of them, although the NHS is slightly closely to the truth. The 593,000 figure is the upper limit of the higher of two estimates from the 2010 British Gambling Prevalence Survey, which reported:

This [problem gambling percentage estimate] equates to somewhere between 342,000 and 593,000 adults according to the DSM-IV and between 254,000 and 507,000 adults according to the PGSI.

That was seven years ago and there have been several more surveys since then, but none has reported an estimate as high as that found in the 2010 report. As I explained a few months ago:

The first three reports in 1999, 2007 and 2010 used two different methodologies and came up with the following estimates:

1999: 0.6 per cent (DSM-IV), N/A (PGSI)

2007: 0.6 per cent (DSM-IV), 0.6 per cent (PGSI)

2010: 0.9 per cent (DSM-IV), 0.7 per cent  (PGSI)

Responsibility for collecting the data was then handed to public health bodies who came up with the following estimate for England and Scotland (combined) for 2012:

2012: 0.5 per cent (DSM-IV), 0.4 per cent  (PGSI)

Since 2013, the figures have been collected by the Gambling Commission which only uses the PGSI methodology. Results are as follows:

2013: 0.5 per cent

2014: 0.5 per cent

2015: 0.5 per cent

2016: 0.7 per cent

Quite clearly, the estimates fall within a narrow range of 0.4% to 0.9% and have not risen over time. It is difficult to explain why the Centre for Social Justice would focus on figures from seven years ago and present them as current. A cynic might say that they are deliberately misleading the reader in their pursuit of a narrative that is not supported by the facts. Naughty cynics.

CSJ's Breakthrough Britain report on gambling (which was actually published in 2007, not 2006) is no longer online and I don't have a copy of it so I don't know whether it claimed that there were 250,000 problem gamblers. However, I am familiar with all the possible sources and the 250,000 figure seems to be plucked out of thin air. The British Gambling Prevalence Survey of 2007 reported:

Taking into account the 95% confidence intervals around the prevalence estimates, one can conclude that the number of adult problem gamblers in Britain is somewhere between 236,500 and 378,000 according to the DSM IV, and 189,000 and 378,000 according to the PGSI.

250,000 fits within these confidence intervals, albeit towards the lower end. It seems that CSJ is happy to take a (roughly) mid-point estimate for 2007 while taking the top end of the highest estimate for 2010 - and then claiming that the real figure exceeds even that!

At the very least, this is extremely sloppy. Now let's return to what IDS claimed at Conservative Home, because he uses a different number:

The British Gambling Prevalence Survey identified 450,000 problem gamblers in 2010 with an average debt of £17,500. The number of problem gamblers has now increased to 593,000 in 2015.

Where does the 450,000 figure come from? It is a mid-point estimate from the 2010 survey.

Where does the 593,000 figure come from? It is the top-end estimate from the 2010 survey.

In other words, IDS has taken two figures from the same estimate in the same survey in the same year and pretended that one is from 2010 and the other is from 2015! This is a squalid misuse of statistics.

In fact, the estimate of problem gambling prevalence in 2015 was 0.5 per cent, considerably lower than the 0.9 per cent IDS is relying on for 2010.

Neither IDS nor CSJ have bothered to look at any of the figures since 2010. The Gambling Commission's most recent mid-point estimate of the number of problem gamblers is 320,000. This is in line with estimates published back in 2000 when the population was smaller (and there were no FOBTs in the UK):

The likely number of problem gamblers in Britain is thus 370,000 according to the SOGS, and 275,000 according to the DSM-IV.

Of the 11 estimates made since 1999, the 0.9 per cent figure is the only one that exceeds 0.7 per cent. It is plainly an outlier, but if you took it as gospel you would have to conclude that problem gambling prevalence has fallen significantly since 2010.

A more reasonable interpretation is that problem gambling rates have been essentially static for as long as anyone in Britain has been measuring them, totally unaffected by FOBTs, advertising, casino deregulation and all the other bogeymen of anti-gambling crusaders.

These statistics are not difficult to find so can people please stop lying about them?

Monday, 21 August 2017

Disingenuous puritans

It is my contention that many 'public health' campaigners do not believe their own arguments and do not care about the things they claim to care about. There are two nice illustrations of this today.

Firstly, The Times (which is strangely obsessed with gambling) gives its front cover to some whining from GambleAware about children seeing gambling advertisements. The UK gambling industry's marketing spend was £312 million last year, according to the article, and this is 62 per cent more than it was five years ago.

Kate Lampard, the chairwoman of GambleAware, warns of a 'possible public health crisis in gambling addiction' but presents no evidence that gambling advertising has a negative effect on adults or children. Gambling advertising was largely illegal until 2005 but rates of problem gambling have not risen in the years since.

Gambling advertising is already tightly regulated on television, only permitted after the 9pm watershed or during sporting events.

Not only is it illegal for children to gamble, it is generally difficult for them to do so.

Moreover, it is not obvious that the increase in gambling spend means that children have been 'exposed to [a] huge rise in gambling adverts', as the headline claims. The article notes that the biggest increase in advertising spend has been online, which may or may not be seen by children, and whilst TV advertising has risen by 43 per cent in the last five years, it tends to be spent late at night.

Finally, gambling has nothing to do with 'public health' unless you stretch the definition of 'public health' to the point of meaninglessness.

But what really piqued my interest was this line in The Times article, in which Lampard says:

'With the average age at which children start to watch post-watershed TV unsupervised being 11¾, restrictions based on a 9pm watershed may offer little protection.'

You can expect to hear this kind of argument a lot if the obesity warriors succeed in getting 'junk food' ads banned before 9pm. Unless you ban all forms of advertising everywhere, it will always be possible to claim that somebody under the age of 18 will see them from time to time.

But the watershed is not principally designed for advertising regulation. It exists to reassure parents that programmes shown before 9pm will be reasonably family-friendly. 'Unsuitable material' cannot be broadcast until after the watershed, as Ofcom explains:

Unsuitable material can include everything from sexual content to violence, graphic or distressing imagery and swearing. For example, the most offensive language must not be broadcast before the watershed on TV or, on radio, when children are particularly likely to be listening. 

If Kate Lampard is concerned about 11¾ year old children seeing gambling adverts, she must also be concerned about them seeing 'sexual content', 'violence', 'graphic or distressing imagery' and, perhaps, 'swearing'. And since she thinks it is the job of politicians, not parents, to control what minors see on television, the logical conclusion is that the watershed should be moved back to 10pm, 11pm, midnight, or whatever time children do not watch TV unsupervised.

But she is not calling for this. Instead, she wants to get rid of gambling advertisements after 9pm while keeping all the other 'unsuitable material' on air. Therefore, I don't believe her when she claims to be concerned about protecting children's fragile little minds. I think she just wants to stop adults seeing gambling adverts.

As a second example, take this from the state of Victoria in Australia where a ban on smoking in outdoor places where food is served has effectively turned into a ban on people eating in smoking areas.

Victoria’s new anti-smoking laws could actually mean food is making way for cigarettes in many of the state’s pubs, bars and restaurants, a move anti-smoking campaigners have warned against.

In so far as this legislation had a rationale, it was to 'protect' people who are dining out from smelling tiny wisps of tobacco smoke. That dubious policy goal has been achieved. It doesn't make any difference whether business owners allow smoking and ban food sales or ban smoking and allow food sales. In both cases, the smoking and the eating are separated. 

But guess what? The anti-smoking zealots still aren't happy:

Quit Victoria policy manager Kylie Lindorff said venues that chose food over smoking areas would be making a smart business decision, because more than 85 per cent of Victorians do not smoke.

“We would encourage venues to provide smoke-free outdoor dining as a priority. We believe that it’s really good for business and it’s what the majority of Victorians support,” Ms Lindorff said.

A quick Google of Kylie Lindorff reveals that she is a career nanny statist who has never had a proper job in her life, so the pubs and restaurants of Victoria could be forgiven for ignoring her business advice. But what's it to her? She wanted to separate smokers from diners, right? She was delighted when the law was passed in 2014, saying: 'Victorians can all breathe a little easier today knowing that Victoria has committed to putting public health first by creating smoke-free drinking and dining areas'.

Now she wants a total ban on smoking outdoors in the state. The only conclusion one can draw from this is that smoke-free dining was never her real concern, just as children's exposure to unsuitable material on television are not Kate Lampard's real concern. These people are insincere, opportunistic puritans.

Tuesday, 15 August 2017

Teetotallers still dropping like flies

Another day, another large cohort study confirming the benefits of moderate drinking. This time it's a 14 year study involving 333,247 Americans which concludes:

Compared with lifetime abstainers, those who were light or moderate alcohol consumers were at a reduced risk of mortality for all causes (light—hazard ratio [HR]: 0.79; 95% confidence interval [CI]: 0.76 to 0.82; moderate—HR: 0.78; 95% CI: 0.74 to 0.82) and CVD (light—HR: 0.74; 95% CI: 0.69 to 0.80; moderate—HR: 0.71; 95% CI: 0.64 to 0.78), respectively. In contrast, there was a significantly increased risk of mortality for all causes (HR: 1.11; 95% CI: 1.04 to 1.19) and cancer (HR: 1.27; 95% CI: 1.13 to 1.42) in adults with heavy alcohol consumption.

So that's a reduction in mortality risk of more than a fifth for both light and moderate drinkers compared to teetotallers. A similar magnitude of risk reduction was found in a BMJ study earlier this year. Numerous studies have been showing the same thing since the benefits of moderate drinking were first noticed (and covered up) 45 years ago.

The usual alcohol policy tweeps from the 'public health' lobby have been quiet today - perhaps because they are on holiday - and so the task of muddying he water has fallen to Buzzfeed. Its article, by Tom Chivers, mentions the usual excuse that non-drinkers are all terribly ill because they used to be alcoholics. Although Chivers acknowledges that this study only looked at lifetime abstainers, he implies that most studies of this kind do not. In fact, most studies conducted in the last fifteen year have only looked at lifetime abstainers. The 'sick quitter' hypothesis is a thoroughly debunked zombie argument that should have been dropped long ago.

With the sick quitters put to one side, he takes the fall back position of suggesting that there is something else about teetotallers that makes them less healthy:

But people who've never drunk in their lives are fairly unusual, in Western society, as well. So there may be some other factor that we haven't thought of.

There are several problems with this line of argument.

Firstly, saying 'teetotallers are less healthy because, er, reasons' isn't much of an argument to begin with.

Secondly, if it is an argument, it is an argument against all epidemiology. Different groups are usually different in several ways. That is why epidemiologists adjust for confounding factors. Of confounding factors, Chivers says: 'You can try to avoid these problems, but you can never do it perfectly.' This is trivially true, but there is a hint of the Nirvana fallacy about it. Perfection is impossible in observational epidemiology. The question is not whether it is perfect, but whether it is good enough. In this study, the researchers took account of a wide range of factors, including physical activity, smoking, race, body weight and education. They also adjusted for the prevalence of various diseases. The association between teetotalism and death remained.

Thirdly, it is not at all clear that teetotalism correlates with unhealthy behaviour. On the contrary, it often correlates with healthy behaviour (whereas heavy drinking correlates with unhealthy behaviour).

Fourthly, teetotallers are not 'fairly unusual' in the United States. A third of Americans are teetotal. Forty per cent of the people in this study did not drink and 23 per cent of them had never drunk. By contrast, only 5 per cent were heavy drinkers. It is therefore heavy drinking that is fairly unusual, but Chivers doesn't fault the evidence on alcohol harm from heavy drinking on the basis that there might be something weird about heavy drinkers.

A few other points are worth mentioning because they have been generally absent from the news reports about this study:

Firstly, the authors found a reduction in risk for cancer mortality among light drinkers, and no increase in cancer mortality risk for moderate drinkers. So much for there being 'no safe level'.

Secondly, they found no increased risk of heart disease mortality among heavy drinkers (but a large reduction among the other drinkers).

Thirdly, moderate drinking was defined as up to 14 drinks per week for men and up to 7 drinks a week for women. A 'drink' is not a unit, however. In this study, a drink is 14 grams of alcohol whereas a British unit is 8 grams of alcohol. The male moderate drinkers were therefore consuming up to 24.5 units and the female moderate drinkers were consuming up to 12.25 units.

The Buzzfeed piece claims that the statistician David Spiegelhalter 'says [the study is] a vindication for the new, low-risk NHS guidelines'. It's hard to see how. The authors clearly define moderate drinking differently to the NHS and there was a reduction in mortality in the group that included men who drink much more than the 14 units now recommended by the government. (NB. the only change to the guidelines was the reduction in the male limit.)

Spiegelhalter (who was on the guidelines committee) is quoted as saying: 'Once you get above the NHS guidelines of 14 units a week, that's when risk starts taking off.' Nothing in this study supports that statement. Is he getting confused between a US 'drink' and a UK 'unit'?

Fourthly, the health outcomes for light drinkers and moderate drinkers were virtually identical across the board, so there is no evidence for the claim that is sometimes made about the benefits of drinking only existing for people who drink tiny amounts.

Finally, an accompanying editorial notes that...

For most older persons, the overall benefits of light drinking, especially the reduced cardiovascular disease risk, clearly outweigh possible cancer risk.

Can we expect the 'public health' lobby to recommend that teetotallers start having a few drinks? Don't hold your breath.

Tuesday, 8 August 2017

Public Health England's shrinkflation

The British government's underhand manipulation of the food supply should be a major news story. So far it has been largely ignored so I was pleased to see Blair Spowart get to grips with it at Spectator Health today...

Don’t expect PHE to stop its interference when its targets are inevitably not met. It’s already tackling salt in much the same way as sugar. Next on their naughty list is saturated fat. Because PHE needs perpetual public health crises to justify its existence, it is always sure to find one – to the detriment of consumers. This wide-ranging food reformulation programme is all happening, moreover, without even the pretence of public consultation.

More needs to be done to show consumers who’s really ripping them off. The first step is moving beyond our kneejerk reaction to shrinkflation and related phenomena – ‘blame it on Brexit’ – and looking more closely at the subtle but powerful impact of our economically illiterate public health lobby.

Monday, 7 August 2017

The economic consequences of clean living

I'm pleased to announce the publication of the third part of the IEA's Public Purse trilogy looking at the net cost of bad habits to the nation's finances. We have previously looked at alcohol and obesity. We now turn our attention to smoking which is often said to impose a cost of £13.7 billion per annum on UK taxpayers. That figure comes from a risible Policy Exchange report from 2010 and is overwhelmingly made up of dubious lost productivity costs.

The question we ask in this series of reports is simple and important: what would be the impact on government revenues and spending if the 'public health' lobby won the war on drinking, smoking and obesity? Campaigners often claim, or strongly imply, that costs would fall but this is based on an economic calculation that exaggerates and misrepresents costs while ignoring savings.

Written with Mark Tovey (author of Obesity and the Public Purse), Smoking and the Public Purse takes a full account of the costs, savings and tax revenues associated with smoking and finds that the government would be spending £14.7 billion more per annum if nobody smoked.

In the absence of smoking, the government would spend an extra £9.8 billion annually in pension, healthcare and other benefit payments (less taxes forgone). Duty paid on tobacco products is £9.5 billion a year. In total, the gross financial benefit to the government from smoking therefore amounts to £19.3 billion. Subtracting the £4.6 billion of costs (above) produces an overall net benefit of £14.7 billion per annum.

The report also looks at the impact on the treasury if all three of the most discussed 'lifestyle factors' - obesity, alcohol and smoking - miraculously disappeared.

Alcohol and tobacco duty provide £10.7 billion and £9.5 billion to the government respectively, with an additional £4 billion of VAT charged on this duty. If, as expected, the forthcoming sugar levy raises £500 million per annum, the government will be in receipt of £24.7 billion of ‘sin tax’ revenue by 2018.

Taken together, the net benefit to the government from the three most hotly discussed ‘lifestyle factors’ - alcohol, obesity and smoking - is £22.8 billion.

You can download Smoking and the Public Purse here.

There is some news coverage here, here, here and here.

You can read my blog post for the IEA here.

And you can see Mark Littlewood talking about the findings on Sky News below:

Smoking and the Public Purse brings this series to an end. You can read all the relevant publications below. Nothing in them should be particularly controversial (see Death and Taxes for a review of the literature). It is obvious that a cost-benefit analysis requires benefits to be included alongside costs. Unfortunately, including benefits and savings doesn't suit single issue campaigners because it shrinks their estimates of the 'burden on taxpayers'. With the exception of obesity, which incurs a relatively small overall cost to the health service, doing the job properly turns a cost into a net saving.

I don't suppose this body of research will make much difference because it doesn't confirm what people want to believe (contrast that with the wafer-thin Policy Exchange document which has been cited hundreds of times in public debate), but I will keep banging this drum because it happens to be true.

 Alcohol and the Public Purse - Christopher Snowdon (2015)

Obesity and the Public Purse - Mark Tovey (2017)
Smoking and the Public Purse - Christopher Snowdon and Mark Tovey (2017)

Death and Taxes - Christopher Snowdon (2016)

Saturday, 5 August 2017

Chlorine, chickens and Brexit

I was on the Spiked podcast this week talking about the chlorinated chicken thing and why Remainers briefly became obsessed with it. Have a listen.

Thursday, 3 August 2017

Fast food, obesity and junk science

I was on the radio yesterday debating with some busybody from the NHS who wants to limit the number of takeaway shops in Britain's high streets. The feeble hook for this story was the news that the number of takeaway outlets in the country has increased by eight per cent in the last three years, according to a pearl-clutching Guardian analysis.

This would seem to reflect the resurgent economy and population growth but for the 'public health' lobby it is a crisis. Why? Because fast food causes obesity, dunnit?

But does it? Leaving aside the fact that takeaway food shops do not necessarily sell 'junk' or 'fast' food, the assumption that takeaways cause obesity has always been just that: an assumption.

What empirical basis does it have? A 2010 evidence review identified 12 studies looking at fast food outlet availability and obesity. Six found a positive association, five found no association and two found a negative association.

It also looked at six studies of fast food consumption and obesity. Three found an association, the other three didn't.

This is hardly compelling and I recommend reading this post by Mike Gibney in which he discusses some of the more recent evidence, starting with a 2017 study from the USA which concluded:

Our a priori prediction that FFRs [fast food restaurants] and FSRs [full service restaurants] would be positively linked to obesity prevalence was not supported

He also mentions a study of Europeans which found:

Our results suggest, contrary to normative views, that away from home food expenditures negatively affect BMI and that BMI is negatively related to the percentage of the food budget spent away from home.

And he mentions another recent study from the USA which found that...

Neighbourhood convenience stores and fast-food restaurants were not associated with BMI in any model.

The authors of that study argued that 'weak findings in the literature [which report an association between fast food and obesity] may be due to residual confounding'.

If you want to get an idea of how weak the evidence is for the fast food/obesity link, take a look at this study from the British Medical Journal. This is the one that campaigners like to cite because it concluded:

Exposure to takeaway food outlets in home, work, and commuting environments combined was associated with marginally higher consumption of takeaway food, greater body mass index, and greater odds of obesity.

The study looked at people's 'exposure' to takeaway food in Cambridgeshire and claimed that people who were heavily 'exposed' were 80 per cent more likely to be obese. The study concludes with a call for 'policies designed to improve diets through restricting takeaway food availability' which is a bit of a red flag for activist-driven research. This response from a statistician (which the authors never addressed) is devastating. It reveals that the finding was entirely dependent on adjustments to the data.

After reading the interesting article by Burgoine et al. I was at first irritated by the lack of a table to compare the characteristics (as shown in Table 1) of participants grouped according to quarters of take-away environment. Further, I missed a simple presentation of outcome variables (mean take-away consumption, mean BMI, percentage overweight and obese) grouped according to these same quarters. Usually one would expect such tables in order to assess the comparability of the groups with respect to possible confounders and for a direct, unadjusted comparison of outcomes, respectively.

Then I discovered this information in Web table 3 of the online appendix. Here, we see systematic differences between quarters with respect to education, smoking and car ownership. I think the authors should have presented these tables and drawn attention to these differences in the main printed article, even if the multiple linear regression models adjusted for the covariables concerned.

What surprised me even more in Web table 3 was the fact that mean take-away consumption was slightly inversely correlated with combined take-away availability, varying between 36.3 g/day in Q1 and 34.2 g/day in Q4. This contrasts completely with the results of the multivariate analysis (Fig. 1) in which a significant positive correlation between take-away availability and consumption was obtained. Moreover, In Web table 3 mean BMI is almost constant in all quarters of take-away availability, contrasting with the significant positive correlation between take-away availability and BMI derived from the multiple linear model (Fig. 2). While I accept that the multivariate analysis adjusting for potential confounders is the analysis of choice for such an observational study, the complete lack of agreement with the simple univariate analysis is worrying and should be presented and discussed.

A hint on the possible explanation for these inconsistencies is given under ‘sensitivity analyses’. ‘In models that omitted supermarket exposure as a covariate, the associations between combined take-away food outlet exposure, consumption of take-away food and body mass index were attenuated towards the null…’. These sensitivity results are given in Web figures 5 and 6. The expression ‘attenuated towards the null’ is an understatement: no association remains at all, in agreement with the simple univariate comparison.

If you look at the supplementary data, you can see that he is correct. There is no difference in average weight between those who have the greatest exposure to takeaways (4) and those who have the least (1). Moreover, the people who had the easiest access to takeaway food ate less of it than those who had the least access.

Your faith in the authors' conclusion therefore depends on how much faith you have in their numerous adjustments to the data. To my mind, it is junk science, but whatever you think of it, it is simply untrue to claim that the people in this study who were most 'exposed' to takeaways were fatter than other groups.

It brings to mind a study I wrote about five years ago which looked at fast food consumption among teenagers in Tower Hamlets. It concluded:

This study revealed a very high frequency of fast food consumption among the schoolchildren. Taste, quick access and peer influence were major contributing factors. These schoolchildren are exposed to an obesogenic environment, and it is not surprising that in this situation, many of these children are already overweight and will likely become obese as adults.

Notice how the authors beg the question. It is assumed that those who eat the most fast food will be most likely to be obese. They say that 'many of these children' are already overweight or obese but they do not say how many, nor do they compare obesity rates between those who eat a lot of it and those who do not.

You have to dig into the study to discover why they are so coy about this. It goes unmentioned in the text of the study, but we can see in Table 2 that there is an inverse relationship between frequency of takeaway consumption and body weight. The children who ate the most of it weighed the least and those who ate the least of it weighed the most.

This was clearly not what the authors were hoping to find so they ignored it and editorialised with a blatantly activist conclusion:

Clearly, actions need to be taken to either limit the ability of these children to access fast food outlets or to change the foods they purchased at these outlets (eg, less calorie dense, with more fruit and vegetables, with less fat and salt) and to have a ban on the sale of sweetened soft drinks at these outlets.

 Ever get the feeling you're being cheated?