Some public health experts are strongly recommending that wearing of face masks should be made compulsory in public, or at least in some public settings. This is despite the evidence relating to this being equivocal. The 'precautionary principle' is being invoked to support this view.

These experts do not appear to have fully understood the usual meaning of the phrase ‘precautionary principle’ which is the argument that policy makers should NOT enact policies until the potential risks have been fully examined: policies such as recommending or mandating wearing of face masks!

What they instead appear to be invoking is the 'it stands to reason' principle, which is that in the absence of strong evidence, policy should be based on a common sense analysis of one side of the argument that one has already decided is the right one. In so doing it risks reducing 'public health' to 'pub health' and reducing the credibility of the discipline at a time when it is most needed.

The 'it stands to reason' principle applied to face masks argues that when one puts the mask over one's mouth or nose it traps a high percentage of virus and therefore it stands to reason that it will reduce respiratory virus transmission. However, proponents of the argument do not address the possibility that this could turn the face masks into fomites which are then repeatedly touched, thereby creating another route of transmission, or that it may create a false sense of reassurance so that people put themselves in situations where they may infect others or be infected when otherwise they would have stayed at home or maintained a physical distance. Neither do proponents appear to address the possibility that face masks may increase the viral load of the wearer by rebreathing contaminated air. Neither do they seem to consider the possible negative social or environmental consequences of recommending or mandating face coverings. Finally, and very importantly, they do not consider that policy makers may invoke their use to provide people with reassurance that they are safe to resume working in circumstances that are actually unsafe.

Failure to address these arguments is important, not only because they might reverse the balance of argument, but also because they could provide pointers to ways of mitigating the potential harms if the policy is enacted, such as training and education programmes.

So the precautionary principle appears to be being used as a smokescreen for a one-sided argument. If I were a member of the public trying to evaluate an argument about face masks I would start by asking 'Have ALL the pros and cons been fully addressed and analysed?' and then go on to ask 'Is the proponent of a given view expressing that view with a degree of certainty and passion that goes beyond what is appropriate given the evidence?' If the answer to either of these questions is ‘no’ I would dismiss this argument, however eminent the public health expert or organisation putting it forward.

FDA proposal to reduce nicotine content of cigarettes

(Caveat: This is a blog and not a scientific article and has not been through peer review. It reflects my opinion, which may be subject to change as new evidence emerges)

The Food and Drug Administration in the US recently announced that it intends to reduce nicotine content of tobacco products to a level below which it believes that those products will not be addictive. The threshold for this will be very low so that in effect tobacco products will no longer have a significant psychopharmacological effect. It is believed that this will lead to tobacco products ceasing to be used in any significant quantity, thus ending the tobacco epidemic in the US.

The risk from this proposal is that unless the switch is made rapidly and comprehensively, tobacco users will increase their exposure to toxins from tobacco as they puff more intensively and inhale smoke more deeply in an attempt to attain their desired CNS exposure to nicotine. In that regard it is worth noting that with current cigarettes, smokers typically obtain 1-2mg of nicotine. However, they could relatively easily obtain up to 6mg of nicotine if they chose to smoke the cigarettes to maximum intensity. The reason they do not do this is because at doses higher than 1-2mg per cigarette, smokers start to experience the aversive effects of nicotine overdose (mainly nausea and signs of sympathetic over-activation). If the FDA reduces the nicotine content of cigarettes gradually we can therefore expect smokers to compensate by increasing their puffing intensity, and by doing so they will be able to get the dose of nicotine they seek and will continue to be as addicted as they were before. Unfortunately, they will have exposed themselves to much more of the noxious tar and poisonous gases, whose concentrations in the cigarette smoke will be as high as before.

It is only once the nicotine content is reduced to almost nothing that this compensatory puffing will not be successful, and the hope is that the smokers will stop smoking. Unfortunately the research that has been conducted to date shows that this is only likely happen if no other tobacco products are available. If smokers can find a product to give them the nicotine they need they are likely to continue to smoke a mixture of the low and high nicotine products.

One could argue that, as long as the FDA is eventually successful in reducing the nicotine content of tobacco products to below addictive levels, even if additional harm is caused to current smokers along the way, it will benefit future generations of Americans who will not take up smoking.

Besides the questionable morality of this argument in sacrificing the health of millions of current American smokers at a time when other ways of deterring smoking uptake appear to be bearing fruit, there is the very real risk that the process would be halted or reversed by commercial or political pressures before any benefit could accrue. In a country that permits large corporations to make vast profits at the expense of the lives and health of its citizens, there must be a significant risk that tobacco companies will find a way to protect their commercial interests and that the non-addictive nicotine content threshold will never be reached.

The FDA has argued that its proposal has to be seen in the context of the rising popularity of electronic cigarettes, which could provide tobacco users with a way to get their nicotine more safely. However, the proposed regulations are intended to apply to these as well (albeit with a delay), and there are huge uncertainties in predicting how the use of tobacco and non-tobacco products will pan out in the evolving scenario.

The policy makers at the FDA are intelligent and knowledgeable and have thought carefully about these issues. In my experience they are also passionate about protecting the health of Americans from the scourge of tobacco. However, in a very uncertain world I think that they may not have given enough weight to the risks of the proposal as they should. I hope I am wrong.

The future is … the semantic web

Last week my brother and I tried in vain to find a suitable golfing holiday for the New Year. We used all kinds of key word searches and found a whole bunch of websites and then entered a whole load of information in those websites and failed to find what we were looking for: a 4 day break, somewhere warm, that I could fly to using my British Airways air miles, without ludicrously expensive green fees. The reason we failed is that, while the WWW is a wonderful thing, it only allows you to find web pages, not specific items of information within web pages.

The semantic web is the solution to this problem. The WWW uses URLs (uniform resource locators) to identify unique websites. The semantic web uses URIs (uniform resource identifiers) to identify specific pieces of information which may be located anywhere on any web page. This may not seem like much but it is massive.

My colleagues and I are going to be using this for scientific applications, to use the hive intelligence of behavioural scientists to build and test models of behaviour and behaviour change distributed across the web. But the applications in commerce, technology, leisure, health and indeed every walk of life are endless.

For the more technically minded of you, I can recommend ‘Semantic Web for the Working Ontologist’ by Dean Allemang and Jim Hendler. It is a beautifully written introduction to the topic. Otherwise just look it up using the old fashioned Google Search!

The way that information is stored in the semantic web is in the form of what are known as ‘triples’. These are very simple sentences consisting of a subject-predicate-object. (The term predicate is being misused here but we’re stuck with it.) This simple representational system, combined with agreed systems for labelling the elements is incredibly powerful and allows, not only exceptionally powerful searching, but also a whole reasoning system that can create new knowledge from existing facts.

And one more thing. A huge strength of the WWW is also a huge limitation. It arises from the AAA principle: anyone can say anything about anything. This means that there is a need to be able to distinguish trustworthy from untrustworthy sources, and for information to be updated as new information becomes available, and for the updated information to be propagated throughout the web to the extent that it is accurate and useful. The semantic web deals with differences in the way people think and talk about things through the concept of the ‘namespace’. Namespaces mean that elements in the web can be uniquely identified as being within the purview of a given namespace, and overlaps and distinctions between elements can be clearly delineated. This allows for differences to be expressed but trusted sources to be identified and consensus built as need be.

Enough to be going on with. The semantic web is already beginning to take off and within a few years we will look at the WWW as primitive cave drawings.

Robert West

The reason I am voting to leave the EU

Robert West

(I am writing this mostly for myself – to put my arguments to the test and see whether I still agree with them. If others find them of use then that's great.)

The arguments in favour of, and against voting to leave the EU are complex and involve considerable uncertainty. We cannot calculate the effects of the decision so we have to use heuristics. I start from the value judgement that the wellbeing of the population of the UK as a whole, and people with greatest disadvantage in particular are paramount. Also important is the wellbeing of people in other countries, both within and outside the EU.

My reasoning focuses on what I think are the most likely scenarios if we vote to remain or if we vote to leave.

If the vote favours remaining in the EU, I believe the most likely scenario following this will be a continuing slide to corporate feudalism with ever decreasing democratic control over key aspects of our economy and public services and ever increasing movement towards policies that favour the super-rich at the expense of the living standards of most people. Even were we to vote in a progressive government, its hands would be tied by EU treaties, preventing it from adopting policies that would benefit the public. This has already happened to a substantial degree and I think it would continue.

It would also strengthen the hand of the present UK government in voting for right-wing, EU policies which together with other right wing EU governments would probably lead to spiralling discontent and destabilisation.

If the vote favours leaving the EU, the UK would have the opportunity to exercise democratic control over national policies that could benefit the population as a whole. Democratic control is a very blunt instrument and there are many factors that could prevent the country from voting in a progressive government, not least of which is right-wing press and media, and a substantial part of the parliamentary Labour party that is seeking to undermine the leadership of the party. However, democracy is an essential check on the worst excesses of government and, even without a change in government, we have seen that it is possible to influence policies through democratic institutions.

A vote to leave could fatally undermine the current government and, together with other events such as investigations into alleged Conservative Party election fraud, lead to an early general election. This would provide an opportunity for Labour to be elected sooner rather than later, notwithstanding the propaganda campaign being launched against the current labour leadership, abetted by many Labour members of parliament. I accept that there is considerable uncertainty about this and it is a secondary argument.

It has been proposed that if we vote to remain in the EU we will have an opportunity to reform it from within. I judge the chances of this being successful to be close to zero. The reason is that corporate feudalism is written into the core statutes of the EU. While most people think of the EU as a social and political alliance, the statutes put the level economic playing field and the interests of financial institutions above all else. It seems inconceivable that we would be able to revise those core statutes by getting agreement of all 28 member states.

A significant downside of a vote to leave the EU in the current situation is that it would be seen as a victory for the far right, both within and outside the Conservative party. It would also probably lead to financial instability for a while. However, I am persuaded by leading economists who argue that the net effect on living standards of UK citizens could be positive, negative or neither. I also accept that having to negotiate trade deals with the EU may leave us with less favourable terms than we have currently. However, given that we have a negative balance of trade with other EU countries, our bargaining position should allow us to maintain the volume of trade we currently have and also give us greater freedom to pursue our own trade deals with countries outside the EU, bearing in mind that when negotiating trade deals as a member of the EU our ability to influence decisions is extremely limited.

Another significant downside of leaving is that we would be seen as abandoning our progressive comrades in other EU countries. However, it seems at least as likely that they could be encouraged by our exit to try to recover democracy in their own countries, and we would not be cut off from them but could demonstrate that it is possible to thrive outside the EU.

A further potential downside to leaving the EU in current circumstances is that the UK may put in place draconian immigration regulations. This is a major issue but it seems to me more likely that if a more right wing government does temporarily take control it would not have a parliamentary majority to put this into effect. Nevertheless, I accept that a vote to leave would make EU citizens residing in the UK feel less welcome and that would be bad.

As I said, there is considerable uncertainty in all this and these are only the headline arguments. In my estimation, the argument about having a minimum degree of democratic control is crucial. We may or may not end up with a more progressive UK political environment but if we are able to persuade a majority of the public that this is a good idea, it can happen. If we stay in the EU it cannot.

Does nicotine have beneficial effects?

Robert West

I said in answer to a question at the SRNT conference today that nicotine’s primary action on the brain is to lead users to need nicotine. I said that it has no positive benefits. I overstated the case and promised to do my best to summarise what I think the evidence is telling us. This is a blog, not a peer reviewed academic article, so I may have got things wrong, but this is my take on the evidence. When time permits I will undertake a more thorough academic review.

Psychological benefits

Around 50% of smokers report at least some enjoyment from cigarettes and this may be due to the effects of nicotine. However, it may also be due to other aspects of smoking or indeed an interaction between nicotine and other psychoactive compounds in cigarette smoke such as mono-amine oxidase inhibitors. Whatever the pleasurable effects, for most smokers they are very subtle compared with drugs such as alcohol and cannabis and primarily experienced after a period of abstinence (e.g. after a meal or on waking).

Smokers report lower happiness and life satisfaction than both never-smokers and ex-smokers. When smokers stop, the large majority report an increase in happiness and life satisfaction. This occurs too quickly to be attributable to improved health and too slowly to be attributable to feeling proud of having made a significant achievement. There is also a reduction in perceived stress on stopping smoking which is reversed if people start smoking again.

Studies of nicotine in laboratory settings have not found any benefit in terms of stress relief except in smokers who have had to abstain for a while, and during a normal smoking day smokers go through cycles of stress and stress relief with a patterning that is consistent with onset of nicotine withdrawal symptoms that are then alleviated.

Nicotine improves attention and concentration, but this effect appears only to be found in smokers who have been deprived of nicotine for at least a couple of hours. There is very little evidence of a benefit in people who are not nicotine dependent. The pattern is consistent with difficulty concentrating being a nicotine withdrawal symptom that is then alleviated by nicotine. An exception to this is ability to tap a key rapidly but it is not clear whether this has much use in daily life.

Physical benefits

It was thought that nicotine may be protective against Alzheimer’s disease but that is no longer the case and smoking is actually a risk factor for the disease. Smoking does appear to be protective against Parkinson’s disease and there is some evidence for small improvements in symptoms in sufferers given nicotine. On a personal note, I had to abandon a trial of nicotine dosing for patients with Parkinson’s disease because some of the patients developed very severe nausea. I don’t know what was going on but I would not want to repeat the exercise. Smoking appears to be protective against ulcerative colitis but experimental studies have not yet found a clear benefit from taking nicotine – though this may be because the benefit only occurs in some cases. Smoking appears to be protective against preeclampsia and morning sickness in pregnancy, but it is not clear whether nicotine plays a role in this.

That is where I think the evidence stands at the moment. Clearly it is not the whole story and there is much to learn, but it is what leads me to the view that nicotine is a drug that in most users solves problems that it creates rather than being a drug that positively enhances quality of life.

E-cigarettes for smoking reduction, blood pressure … and other things

Robert West

21^st February 2016

E-cigarettes for smoking reduction and reduction in blood pressure

There has been a claim, and a study purporting to show, that reducing smoking with the aid of e-cigarettes leads to a reduction in blood pressure. This is probably not the case.

First, there is no reason to believe that there would be such an effect. Stopping smoking completely does not generally lead to a reduction in blood pressure. In fact, there may be a slight increase. Stopping smoking has a lot of beneficial effects, obviously, but a reduction in blood pressure does not seem to be one of them. I appreciate that some official information sources say there is a reduction in blood pressure on stopping smoking but they are incorrect. If complete cessation does not generally lead to a reduction in blood pressure, it is extremely unlikely that a reduction in smoking would do so, whether or not it is assisted by e-cigarettes.

Secondly, the study which was claimed to show a reduction in blood pressure from reducing smoking with the aid of e-cigarettes did not find this. On the primary analysis, there was no evidence for a decrease. It was only when the researchers selected participants who began with higher blood pressure that they observed a reduction on follow up in people using e-cigarettes. There is a well-known phenomenon is statistics called ‘regression to the mean’. If you start by selecting a sample from a gaussian distribution (a ‘bell-shaped- distribution so often found in biological systems) that is higher than the average on one occasion and then re-measure, one almost always sees a reduction which is purely because the chances of selecting values closer to the original mean are greater than the chances of selecting ones that are more extreme. In order for the study’s claim to be demonstrated, the researchers would have had to demonstrate that the reduction among those using e-cigarettes was significantly greater than those in a suitable comparison condition. They did not do this.

Other things

The BBC Radio 4 programme, Inside Health, recently broadcast a discussion in which I reflected on the obvious fact that the growth in e-cigarette use has not, at least not yet, had a dramatic effect in increasing population smoking cessation rates and reducing smoking prevalence. I noted that evidence to date suggested that use of these products in a quit attempt improves the chance of success by around 50% on average compared with use of no aid and NRT bought from a shop (which itself appears to be ineffective). So thus far, their population level benefit has been in an increase in the proportion of smokers using a moderately effective aid to cessation. This effect is not trivial, and of course for individuals who have benefitted this can be life-saving.

A couple of prominent e-cigarette academics used a kind of journalistic writing style to present this in a way that non-expert readers would be likely to misinterpret. This kind of writing, in my view, seriously undermines the credibility of public health science. I believe that there is now an urgent need for a code of conduct in public health science so it can serve the needs of the public and policy makers as a trusted source on matters of the utmost importance. I and some colleagues have started to put such a code of conduct together. I hope that by the end of the year it may be completed and start to have an influence. If, on reading this blog, you have suggestions as to what should go into this code of conduct, please email me.

Commentary on proposals by Hong Kong Government on Electronic Cigarettes[1]

Robert West, Department of Epidemiology and Public Health, University College London

18^th July 2015

Recent Hong Kong proposals for electronic cigarettes (1) appear to be based on a misreading of the evidence and reliance on reports, particularly from the WHO, that have misrepresented the evidence (2). Accordingly, the proposals appear to be based on an uncritical acceptance of the view that electronic cigarettes are damaging to public health with no compensating positive effects, and people should be deterred from using them. England has currently the most comprehensive evidence on the potential impact of electronic cigarettes in a country that considers them as consumer products. The key findings from there and elsewhere are summarised in a briefing to the UK parliament (3).

The key findings are that:

1.     E-cigarettes deliver concentrations of toxins that would be expected to make them at least 20 times less hazardous to users as cigarettes and to present no significant health risk to bystanders.

2.     The growth in use of e-cigarettes has been almost exclusively among smokers and recent ex-smokers. Use by never smokers and long-term ex-smokers remains very rare, and similar to use of licensed nicotine products.

3.     The growth in use of e-cigarettes in England has not been accompanied by any renormalisation of smoking, either in terms of smoking uptake in the young, a reduction in motivation to quit among smokers, a reduction in attempts to stop smoking in smokers, a reduction in success of attempts to stop smoking among smokers, or violation of smoke-free legislation.

4.     When e-cigarettes are used to aid a quit attempt, two randomised controlled trials and a large observational study in England find an overall level of effectiveness when used without professional support is similar to licensed nicotine products when used with some health professional support. Because e-cigarettes are more popular than use of licensed nicotine products with professional support, they have probably contributed to an increase in the rate of smoking cessation in England.

5.     When used by smokers to aid smoking reduction or in situations where they cannot smoke, non-daily use of ‘cigalike’ e-cigarettes is associated with a higher motivation to stop smoking completely but lower probability of actually stopping. Daily use of more advanced ‘tank’ models appears to be associated with both higher motivation to stop and higher likelihood of stopping. At a population level, the growth in e-cigarette use by smokers in England has been accompanied by an increase in smoking cessation rates. A causal link cannot currently be inferred, however, because of the existence of obvious potential confounding factors.

6.     In some countries there has been aggressive marketing of e-cigarettes using imagery that is reminiscent of tobacco marketing and appears to seek to glamorise use of e-cigarettes.

7.     Tobacco companies have invested heavily in the e-cigarette market, apparently in products that may be less effective in aiding smoking cessation.

In the light of this, it appears that e-cigarettes offer both an opportunity for public health gain and a potential threat. To maximise public health, policies should be targeted at maximising the gains while minimising the threat.

References

1.  Hong Kong Legislative Council on Health Services. Progress of Tobacco Control Measures LC Paper No. CB(2)1456/14. 2015.

2.  McNeill A, Etter JF, Farsalinos K, Hajek P, le Houezec J, McRobbie H. A critique of a World Health Organization-commissioned report and associated paper on electronic cigarettes. Addiction (Abingdon, England). 2014;109(12):2128-34.

3.  West R HP, Mcneill A, Brown J, Arnott D. Electronic cigarettes: what we know so far. A report to UK All Party Parliamentary Groups. www.smokinginengland.info/reports/. 2015.

Here is a rapid response that I posted on the BMJ website to the article http://www.bmj.com/content/350/bmj.h3317. 

*********************** 

Alas this is a poorly researched article which misses the point. There are four main parties involved in this debate. 1) Public health activists and bodies who are not experts in the field of tobacco control, who misunderstand what is relatively complex evidence and present their misunderstandings to the wider community. 2) Vapers, many of whom have no financial conflict of interest but feel passionately that a solution to the problem of stopping smoking that they have found should not be vilified or discouraged through mis-representation of the evidence. 3) Vested interest, including the tobacco industry, and their supporters. 4) Tobacco researchers and NGOs that have been working tirelessly in the field for decades and have achieved the considerable amount of progress made thus far but believe on the basis of a careful analysis of the evidence that a comprehensive tobacco control strategy is the way forward, including possibly appropriate regulation of e-cigarettes of the kind currently in force in England. ASH, CRUK, the British Heart Foundation, the UK Centre for Tobacco Control Studies, and Public Health England fall into this fourth group - a group that has no truck whatsoever with the idea of engaging with the tobacco industry. Readers may judge for themselves which group the BMA, the Faculty of Public Health and other high profile commentators fall into.

Comment on article by Professor Chapman in The Conversation

Dr Chapman has written an article questioning whether medicines to help smokers to stop should be subsidised by the state (or presumably insurance companies). He has written many previous articles along the same lines.

https://theconversation.com/is-it-time-to-stop-subsidising-nicotine-replacement-therapies-36760

He bases most of the argument on a paper which I co-authored. Here is the comment I posted in response:

I regret to say that Dr Chapman has not accurately represented the findings of our study which can be viewed here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194355/

In addition the premises on which his argument is based are false. Readers will be able to see for themselves that use of subsidised NRT and other medications when provided with at least some professional support (as occurs when NRT is subsidised) was associated with greater success rates than unaided quitting with an estimated effect size broadly similar to what is found in RCTs. Look at the odds ratios after adjusting for confounding variables. This and other studies which Dr Chapman does not mention make his speculation about translation of RCT results into clinical practice redundant since it is based on a false premise.

It is the unsubsidised use of NRT that is producing the low success rates! This is a matter of serious concern and in my view there is an onus on pharmaceutical companies to address this urgently.

Dr Chapman appears to argue that because a relatively small proportion of smokers avail themselves of medicines with at least some professional support, this option should be withdrawn. This is, of course, illogical. Obviously, a cost effective life saving treatment should be provided at a level commensurate with demand and people encouraged to use it rather than less effective methods. Even at the level of use we have in England, the contribution to public health is considerable. He appears not to be aware of our BMJ article which conservatively estimates the numbers of lives saved by this kind of support in England (also open access) (http://www.bmj.com/content/347/bmj.f4921/rr/659105).

Fortunately for smokers in England, the government is keen to follow the evidence and has a broadly based tobacco control strategy that involves mass media campaigns, smoke-free legislation, raising the price of tobacco, removing point of sales displays, and supporting smokers to stop. The result is that smoking prevalence is reducing if anything slightly faster than that in Australia (see http://rjwest.co.uk/blog.php go to Blog of July 23rd)

Varenicline safety

There has been a lot of discussion recently about varenicline safety and there is likely to be a lot more. Much of it is based on lack of awareness of the evidence so I want to try to summarise it as best I can.

Varenicline was launched in 2006 following large randomised trials showing that it was much more effective than placebo in helping people stop smoking and also more effective than bupropion, which has been found to have similar effectiveness to nicotine patches, gum etc. In those trials there was no indication of an increased risk of serious adverse reactions. The main adverse reactions were nausea and sleep disturbance.

In the year following the launch there was no evidence from post-marketing surveillance (reports that are sent in to the medicine regulators by users, clinicians or others) of any problems. However, this changed after a very well publicised case in Texas in which a locally well-known musician who was taking varenicline, was shot by his neighbour after causing a ruckus at the neighbour’s house. The musician was drunk. For reasons that are still obscure, this sparked a huge amount of media activity in which varenicline was blamed for the incident and after that, the rate of spontaneous reports of neuropsychiatric side effects from varenicline have continued to be higher than for nicotine replacement therapy (NRT). It is important to realise, however, that even with this increased rate of reporting, the figure is lower than what we know it must be from national statistics. This reflects the well-known observation that spontaneous reporting of adverse events captures only a small fraction of cases that occur.

(Note that ‘adverse events’ are any problems, whether or not caused by a drug one is taking. They could be caused by a wide range of factors, For example, we know that stopping smoking can in the short term cause depression, anxiety, agitation, aggression, difficulty concentrating, and a feeling of dissociation or light-headedness. ‘Adverse reactions’ are adverse events that are believed to be caused by the drug one is taking.)

As a result of the increase in spontaneous reports, the US Food and Drug Administration (FDA) mandated Pfizer to study this very closely, as did UK and European regulators. The data gathered thus far can be summarised as follows.

Combining the results of 18 randomised controlled trials, no excess risk has been detected for neuropsychiatric events on varenicline versus placebo. Neither can any increased risk be found in studies comparing deaths from any cause, deaths from suicide or hospitalisations for self-harm in large studies involving more than a hundred thousand smokers comparing smokers who used varenicline in a quit attempt versus those using NRT, taking account of a wide range of factors that might bias the results such as previous psychiatric history. The best of these studies, by Kyla Thomas and colleagues at Bristol University, was published in the BMJ and went to considerable lengths to try to see if there was any suggestion of an increased risk when the data were analysed in different ways, and they couldn’t find one.

So the situation is that spontaneous reports of serious neuropsychiatric events in people using varenicline are higher than what is seen for NRT but lower than what we know the rate must actually be in smokers trying to stop. Data from clinical trials and comparative observational studies find no increased risk from varenicline.

Data continue to be collected and a very large observational study will be published later this year. In 2015 or 2016 we will also have results from a very large randomised trial, mandated by the FDA, which focuses specifically on safety.

Banning smoking in London parks 

The proposal to ban smoking in London Parks seems draconian and tests the limits of how far it is reasonable to limit the freedoms of some members of society in what is seen as a good cause. 

The indoor smoking ban which was introduced in 2007 had widespread support because of strong evidence that it would protect the health of a large number of non-smokers who would not be exposed to dangerous concentrations of tobacco toxins. That is not the case for outdoor smoking bans. The concentrations of toxins are generally too low to pose a significant risk to bystanders.

One could argue that breathing in someone else's smoke in a park when one is trying to get away from London's traffic pollution is unpleasant but that would probably not be sufficient reason for a ban - though it might be a reason for signs requesting people to refrain from smoking and leaving them the choice.

The main argument for a ban on smoking in parks is that it would probably provide a further incentive for some smokers to stop and, more importantly, reduce the smoking triggers for those who are currently trying to stop. If it helped as few as 100 smokers a year to stop who would otherwise have carried on, that would amount to some 50 human lives saved a year. Not many perhaps in the context of the 10,000 or so dying from smoking each year in London but precious lives nonetheless - smokers' lives. 

When one is doing something for someone's own good like this, it is very important to ask them what they think. If smokers overwhelmingly support such a ban, having heard all the arguments, then it seems reasonable to put it into place. If they don't, then it probably is not and in any event may not be enforceable without their consent. That is why I said in the press release that I hoped smokers would support this move.

Progress in tobacco control since 2007: England versus Australia in the ‘Ashtray test series’

England and Australia compete every other year for the coveted ‘Ashes’ trophy in cricket. But the rivalry doesn’t stop there. It even permeates the field of tobacco control. As in the cricket, Australia appears to be winning hands down. It is held up as a shining example of innovative and aggressive anti-tobacco policies that have delivered huge smoking prevalence reductions that the rest of the world would do well to emulate.

Australia’s record is certainly impressive. The latest set of figures (for 2013) show headline smoking prevalence in Australia at a record low of 12.3%. The Australian approach has been to invest primarily in policies to persuade and coerce smokers to stop, deter them from starting and limit the capacity of the tobacco industry market their products – the latest examples of this being removal of point of sale advertising and brand imagery from cigarette packs. There are programmes to help smokers to stop, including a telephone quit line, but investment in this aspect of tobacco control has been limited.

England also has much to be proud of with its ‘comprehensive’ tobacco control strategy. Successive governments have decided that to achieve best results in terms of prevalence reduction, particularly in disadvantaged sections of society, it should combine education and persuasion through mass media campaigns and brief advice from health professionals with coercion in the form of tax increases and control of illicit supply. It has also raised the legal age of sale from 16 to 18, banned tobacco marketing and introduced graphic health warnings on packets. A ban on point of sale advertising is being phased in and it is seriously considering introducing ‘plain packaging’.

However, what most differentiates England from Australia is a much greater investment in ways of supporting smokers to stop. Having a National Health Service (NHS) helps; clinical care is paid for primarily out of taxes and is free at the point of delivery. Within that system it has been possible to evaluate whether support for stopping smoking represents good value for money in terms of cost per quality-adjusted life year gained and if so to implement that nationally according to evidence-based guidance. The annual spend on this support per adult smoker (about 8 million of them), including medication costs and costs of healthcare staff delivering ‘behavioural support’, is approximately £20. This support is used by about 10% of smokers each year, mostly those who show evidence of being highly nicotine dependent.

According to the most recent estimate, headline smoking prevalence in England (in 2013) was 19.3%. This might make one think that, as in the cricket, Australia is leading the way and its approach to tobacco control is one that England would do well to follow. It has even been suggested by an Australian commentator (not the great Richie Benaud, I hasten to say) that England should reconsider its obsession with providing support for stopping smoking since it makes next to no difference.

So is that what the figures really tell us? Well, no. The headline percentage figures are not informative when it comes to progress in tobacco control. To begin with, the Australian figures are for daily smokers aged 14+ while the English figure is based on all smokers aged 16+. Also, the methodology of the surveys is somewhat different and Australia has particular challenges in ensuring that it adequately samples from its most disadvantaged sections of the population, including the indigenous community. Doing no more than adding non-daily smokers to the Australian figures brings the prevalence up to 15.8%: still impressive … but still not relevant to the matter at hand.

The key question is what has happened to smoking prevalence in the two countries in recent years. Australia’s cigarette smoking prevalence has reduced from 19.4% to 15.8% over the 6 years from 2007 to 2013, an average fall of 0.6%. Over the same period prevalence in England has fallen from 24.1% to 19.3%, an average fall of 0.8%. Looking further back in time, it is clear that it was in the mid 1990s when we lost ground – there was no decline in smoking prevalence in England for about 7 years. It was also a period in which Australia won every single Ashes series! Over that period the UK government was relying pretty much exclusively on tax increases for its front line attack against tobacco.

So does that mean that, with its comprehensive tobacco control policy, England is edging it in the ‘Ashtray test series’? To be honest, we don’t know for sure. A difference of 0.2% is within the margin of error of the surveys and there will have been demographic changes in both countries that could make a difference – for example, the UK has seen quite a large influx of people from central Europe, with high smoking rates. Interestingly, however, 0.2% is if anything slightly larger than the annual prevalence reduction we would expect given the effectiveness and reach of the NHS stop smoking support (involving medication, behavioural support or both). It may not seem like much but it represents some 80,000 people and some 40,000 lives saved.

So in the true tradition of cricket it seems reasonable at this point to shake hands on a draw. The Australians probably have the better attack in terms of restricting the activities of the tobacco industry and England probably has the better batting line up in terms of supporting smokers to stop. Things are changing, however. When the ban on point of sale advertising is fully implemented and plain packaging introduced, England might end up with a truly world beating line up. Some even think that it can edge ahead with a ‘harm reduction’ strategy that promotes alternative nicotine products for smokers who cannot or do not want to escape from the clutches of this drug. Time will tell …

Sources

Australian cigarette smoking prevalence figures: www.aihw.gov.au/alcohol-and-other-drugs/ndshs/

England cigarette smoking prevalence figures: www.smokinjginengland.info

List of Ashes test series: http://en.wikipedia.org/wiki/List_of_Ashes_series

E-cigarette trends – update June 2014

We have just published the latest national data on e-cigarette use (www.smokinginengland.info/latest-statistics/) and some interesting trends are emerging.

E-cigarette use by never smokers continues to be negligible and similar to licensed nicotine products. The rates of use by long-term ex-smokers are also low and slightly lower if anything than licensed nicotine products (slide 22).

The most striking new thing is evidence that the growth in prevalence of e-cigarette use appears to have stalled (slide 5). If you look at the figures more closely, this seems to be because of a slight downturn in use among people who are also smoking (slide 8). Use for stopping smoking in the past year and current use by recent ex-smokers has continued to rise, albeit more slowly (slides 9 and 11).

From a public health point of view this seems to be a positive development. There is probably not a great deal to be gained by reducing cigarette consumption slightly, while using an e-cigarette to stop smoking completely will produce major health gains even if e-cigarette use continues indefinitely.

When looking at the big picture, we continue to see smoking cessation rates on a broad upward trend (slide 14), subject to quarterly fluctuation and there is no evidence that more people are taking up smoking (slide 15). Smoking prevalence is continuing to decline (slide 17).

One can only speculate as to why prevalence of ‘dual use’ (smoking and using an e-cigarette) may be declining. It seems unlikely that it is the negative publicity because of the growth in e-cigarette use in cessation attempts. A possibility worth exploring is that, contrary to what I would have thought, use of e-cigarettes while smoking is not very rewarding. Perhaps one is continually being reminded that e-cigarettes do not give the same rapid nicotine hit as smoking and so the reality short of expectation. In contrast, if an e-cigarette use is used instead of smoking the contrast with smoking is not ever-present and the e-cigarette has a better chance of providing an acceptable substitute. This is just speculation and it is only worth speculating further when we are more confident that this is a genuine trend.

Someone tweeted in response to the previous blog that we had failed to define addiction. This is a topic about which I know something having written books on the subject and being editor-in-chief of a journal called Addiction. So here's my 30 second version:

Addiction these days is a term usually used to refer to a chronic condition in which there is repeated powerful motivation to engage in a purposeful behaviour (usually involving a psychoactive drug) that is or can be harmful.

I realise this is somewhat involved but in science it is important to be precise to minimise confusion.

if you want to know more see West & Brown (2013) Theory of Addiction or download West (2013) Models of Addiction free from:

http://www.emcdda.europa.eu/publications/insights/models-addiction

Is nicotine per se addictive and what does this mean for the addictiveness of e-cigarettes?

Karl Fagerstrom is one of the founding fathers of research on nicotine dependence. There has been much discussion in social media, quoting Karl, about whether nicotine by itself is addictive. So I asked him if he would be kind enough to set the record straight on this views. This is what he wrote, with some minor input from me. I think he hits the nail right on the head.

******************************************* 

As much as there is a continuum of harm from nicotine containing products there is also a continuum of dependence. Dependence is of course also part of the total harm. We know of no nicotine patch use among people who have never smoked that has resulted into compulsive use i.e. dependence. There are cases, although only a few, of gum use by never smokers that has resulted in dependence  or transition to tobacco use. Thus, nicotine products, without involvement of tobacco, seem to have a dependence potential close to caffeinated drinks. Interestingly, as with tobacco and pure nicotine, few like their caffeine pure in the form of a pill. The question is: why?

One answer is that the more a specific repetitive activity is involved in using a particular nicotine product, the stronger the dependence is likely to be on that product. When there is a lot of activity involved it can be hard to disentangle how much of the dependence comes from the drug per se.

Secondly the speed of delivery is crucial to subjective effects of drugs. The faster the nicotine enters the body and particularly the brain, the more pronounced the effects and dependence potential will be.

Thirdly, new evidence is emerging which suggests that tobacco may deliver chemicals other than nicotine might increase the dependence potential. These are ‘mono-amine oxidase inhibitors’ which increase the amount of neurotransmitters such as dopamine in the brain. These may have dependence potential in their own right, or they may interact with nicotine so that the cocktail of the two together is particularly powerful.

Fourthly, it is possible that what are called ‘conditioned stimuli’ associated with smoking may play a role. This may include the smell of the smoke, the sensations of smoke entering the upper airways or the sight of the smoke being exhaled. These stimuli may be important in amplifying the effect of the nicotine or other chemicals in tobacco.

So, in short, cigarettes may be the most addictive form of nicotine intake because 1) there is a lot of repetitive activity involved, 2) nicotine absorption from them is very rapid, 3) they also deliver to the brain mono-amine oxidase inhibitors, and 4) other sensations of smoking may amplify the drug effects.

I would expect e-cigarettes to be generally less addictive than tobacco cigarettes because they mostly deliver nicotine more slowly and they do not deliver the other psychoactive chemicals. I would expect them to be more addictive than other pure nicotine products because they involve a repetitive activity and sensations that have been linked to smoking.

Karl Fagerstrom

May 2014 

Is nicotine addictive by itself?

There has been some discussion recently about whether nicotine by itself is addictive. This is part of the debate about how e-cigarettes should be regulated.

The idea that nicotine by itself may not be addictive comes from recent studies showing that chemicals called ‘monoamine oxidase inhibitors’ in the smoke could contribute to the addictive potential of cigarettes, together with earlier studies showing that rats and mice have to be carefully trained to get them to press a lever for nicotine whereas it is very easy to get them to press a lever for, say, cocaine.

The most important test of whether using a drug in a particular form is addictive in humans is whether users experience powerful urges and suffer a high rate of relapse when they try to abstain. There are two lines of evidence which indicate that nicotine, even without other components of cigarette smoke can be addictive in humans. The first is that smokeless tobacco users (who chew or snuff it) experience powerful urges to use it and have high rates of relapse when they try to stop. The second is that a substantial minority of smokers who use nicotine products to stop smoking find that they cannot stop using those products. This is more common in people who previously showed higher levels of dependence on cigarettes.

Having said that, there is reason to believe that cigarettes are more addictive than other nicotine products. This could be because of the other chemicals or because they deliver nicotine more rapidly. Speed of nicotine delivery could account for it. Nicotine patches (which deliver nicotine very slowly) have low rates of continued use while nicotine nasal spray (which delivers nicotine much more quickly, though not as quickly as a cigarette) has quite high rates.

If it is just speed of nicotine delivery that makes cigarettes so addictive, then those e-cigarettes which deliver nicotine to the lungs (a minority at the moment)  might in theory be as addictive, because that it how one gets really rapid absorption. If the other chemicals in cigarette smoke are playing a role then e-cigarettes would be less addictive. Right now we don’t know.

One final word of caution when interpreting data from animal studies. There is an unfortunate tendency in some cases to cherry pick results and one often gets different results from different strains of the same species, let alone different species. That is why I place more confidence in results from large scale studies in humans. 

Claire Fox portrays herself as someone speaking out for freedom and choice. But not necessarily informed choice it appears. She recently invited a prominent expert in behaviour change to a fancy pre-Xmas dinner to discuss nanny state interference in our lives. Her email mentioned that the dinner was sponsored by SABMiller. The expert asked me whether she should go. As someone who is used to dealing with alcohol industry tactics, I had to inform her that SABMiller is an alcohol producer and from that point on she would have to include having received hospitality from the alcohol industry on her conflict of interest declarations!! This would be very effective in undermining her credibility in the field.

Earlier this year I had a brush with Claire Fox in a 'debate' in which she was opposing legislation to stop tobacco companies making their cigarette packaging attractive to young people. 

Is Claire Fox an unwitting pawn of the alcohol and tobacco industries who have a long history of trying to distort science and public policy in furtherance of their gigantic profits, at the expense of an unimaginable toll in human suffering? That would perhaps be a charitable explanation. 

Does smoking reduce stress and increase blood pressure?

I was asked by a Dutch journalist to comment on the following myths.

1. Smoking helps with stress

2. Smoking raises blood pressure

Below is my reply

Myth 1: Many smokers report that smoking relieves stress and some studies in non-human animals suggest that it might reduce whatever the non-human version of anxiety is (behavioural manifestations include freezing). However, controlled experiments in humans have failed to show such an effect except in regular smokers who have abstained for a while and are suffering from nicotine withdrawal symptoms. Moreover, there is evidence that when smokers stop, after the initial period of physiological adjustment lasting a week or two their stress levels improve so that ex-smokers are calmer than they were when they were smoking. If they relapse, their stress levels go up again. In addition, studies have failed to show that drugs that control anxiety help smokers to stop. My reading of the evidence, therefore, is that smoking causes smokers to experience cycles of stress caused by nicotine withdrawal and stress relief when they smoke, and that there is no overall benefit conferred by smoking. In fact smoking may well increase stress if one averaged the cycles out through the day.

A couple of additional comments: It is important not to confuse biological markers of stress with stress itself. ‘Stress hormones’ are not stress and show little relation to each other and often paradoxical relations with stress. For example, adrenaline output decreases substantially in the first few days of nicotine withdrawal when withdrawal induced stress is at its height. Heart rate goes down as soon as you take nicotine out of the system but this bears no relationship with stress.

Myth 2: A single dose of nicotine to a non-smoker will increase blood pressure. However, smokers have on average slightly lower blood pressure than non-smokers and blood pressure rises on average very slightly when smokers stop. We do not know the mechanism underlying this but it is possible that smoker adapt physiologically to nicotine and other chemical in cigarette smoke such as carbon monoxide, are playing a role in reducing blood pressure.

                                                            Undercover

My friend and colleague Professor James Elander wrote the following book review. On the strength of it I have decided to buy the book!

Undercover: the true story of Britain’s secret police, by Rob Evans and Paul Lewis

Book review by James Elander

Do you know someone who appeared in your community without much trace, and with a life story that meant no one met his family? Did he have a job that often took him away, or have more money than you would expect? Did he have a van and help people with transport? Did he hook up with a woman who was trusted by people involved in protests or demonstrations? At the end, did he have a sort of breakdown then disappear, with just a postcard from abroad?

If so, did you ever wonder if he wasn’t who you thought at all, but actually a secret agent, sent to infiltrate the organisation you or your friends were involved in? Undercover tells the story of multiple cases like that, where police spies were planted as long-term infiltrators in the lives of people the police regarded as ‘domestic extremists’. The effects on everyone involved were terrible, but the infiltration operations often had farcical outcomes with a certain comedy value, so that a film of the book would be an excellent dark comedy. With multiple infiltrators from different branches of the police, as well as ‘corporate’ infiltrators from the private sector, for example, there were meetings and protest events where the infiltrators outnumbered the genuine activists.

When the cream of Special Branch infiltrates an amateurish little group of protestors or activists, the infiltrator is often the most capable, well-organised person in the group, not to mention their van and access to police funds, so the group’s performance often improves dramatically when they get involved. The incendiary devices start to cause real damage, the protests get bigger and better organised, and the group begins to have a real impact. In some cases, the infiltrator was such an important player that the group more or less ceased to function when he was withdrawn.

            The book also paints a portrait of a special kind of masculine adventure, with turbo-charged alpha males mistreating women in both the worlds they inhabited (there was just one known female infiltrator, who had much less impact than her male colleagues). The spies claimed that if they were not having sex, they would not be credible in the permissive world of social activists and demonstrators. However, getting into a long-term sexual relationship with a woman who was trusted by more central and active members of the group also worked extremely well as a strategy, first for gaining trust, then information and influence.  This strategy was followed in a very similar way in multiple cases, and the infiltrators used a similarly formulaic exit strategy when they eventually needed to disappear.

The infiltrators ended up like bigamists, with a wife or partner in each of their worlds, and several had children with their protester ‘girlfriends’. Police officers had to be married or in a long-term relationship to be selected for this work, otherwise they were considered too likely go native with their new girlfriends in the protest movements. The situation obviously put a terrible strain on everyone, including the infiltrators themselves, who often ended with drink problems and mental breakdowns, but also in disputes with the police over claims the force had neglected their mental health and should pay compensation for their stress-related mental illnesses.

The book does not say much the effects on the infiltrators’ ‘real’ wives and families, but there must be another book waiting to be written about the impact their adventures had on them. What could their husbands possibly have told them about the work they were doing, when they returned to their wives, homes and children in the suburbs for a snatched day or two on a break from their missions undercover? The situation can’t have helped those marriages, and in one case that raised eyebrows in the safe house where the infiltrators used to gather periodically to exchange notes and give each other sympathy and support, an infiltrator and his wife in the real world were having relationship counselling at the same time as he and his girlfriend in the protest movement were also in relationship therapy because the course of their love was not running so smooth.

As the protesters pick up little things about their new comrades that don’t make sense, or don’t smell right, a Le Carré-like world of mutual suspicion is conjured, and the book sketches a part of British live that resembles the world portrayed in The Lives of Others, the film about East Germans living under the Stasi. In other places, the rampaging spies’ behaviour is reminiscent of the way MI5 agents burgled and bugged their way across London, according to Peter Wright’s Spycatcher, the banned book about MI5’s out-of-control espionage on citizens.

The types of groups that were targets for infiltration changed over time as the police paranoia shifted from cause to cause and issue to issue, but the police took a special interest in trying to undermine groups who campaigned and protested against police misconduct and brutality – like the one calling for justice for the murdered black teenager Stephen Lawrence.

The police infiltration put the protesters and activists they were intended to undermine in the most sympathetic light possible. Indeed, the protesters sometimes had such good causes that the infiltrators ended up taking the protesters’ side themselves, especially after they had some first-hand experience themselves of being beaten up or abused by the police at demonstrations or direct actions.

So, if your fledgling protest or activist group is flagging, with apathetic members and not much tangible impact, perhaps you need to get infiltrated by a top-of-the-range police office on secondment from Special Branch, to give the group an injection of energy, organisation and professionalism. Before you know it, your little group might have upped its game to the extent you genuinely do pose a threat to the established order.

© James Elander 2013 

In my view the most profound speech in all of English literature is the soliloquy from Macbeth on learning of his wife’s death, while he waits in his castle as the English army advances. It goes: 

She should have died hereafter; 
There would have been a time for such a word. 
To-morrow, and to-morrow, and to-morrow, 
Creeps in this petty pace from day to day 
To the last syllable of recorded time,
And all our yesterdays have lighted fools 
The way to dusty death. Out, out, brief candle! 
Life's but a walking shadow, a poor player 
That struts and frets his hour upon the stage 
And then is heard no more: it is a tale 
Told by an idiot, full of sound and fury, 
Signifying nothing.  

The reason I like it so much is that to me it perfectly captures, on the one hand our lack of perspective on our existence - the way that we strut and fret our way through life for its short span failing to appreciate the pettiness of most of it - and on the other hand the fact that we cannot escape this, because in railing against it, as Macbeth does, usually when things are not going well, we are still reacting emotionally with our petty concerns at centre stage. 

What had troubled me until today was that I didn’t understand the first two lines.      And the notes I read on the speech did not seem convincing, to me at least. What gave me the clue was learning that there should be a pause before ‘hereafter’ and then looking up the word to get a more precise meaning for it. ‘Hereafter’ means any time from now on and now I see, of course, that this is the pivotal word in the whole play and in the speech. 

This is what I think. Macbeth learns that his wife, who has been the source of his ambition (and the future orientation) has just died. By this stage his ambitions are falling apart, so he reacts with a line to the effect of ‘She would have died at some time anyway, perhaps sooner rather than later’. But as the word ‘hereafter’ comes to him he pauses because he recognises its significance. So he expresses the thought that up until now ‘hereafter’ - looking to the future, ambition, hopes and fears and so on would have meant something - but now that is gone. And the rest of the speech dwells, not on the pointlessness of existence, but on the folly of our petty strutting and fretting and hopes and fears for the future. 

One way of deducing someone's true values is to look at how they require different standards of evidence for propositions that they like versus those that they do not like.

David Cameron has defended his decision not to proceed with legislation to prevent tobacco companies from promoting cigarettes to young people through attractive packaging with the claim that the evidence is not strong enough that it have any effect. Ditto with the volte face on minimum unit pricing of alcohol. This flies in the face of the near unanimous judgement of public health experts who have reviewed the research literature very thoroughly.

On the other hand David Cameron 'believes' the 'evidence' that a range of other policies involving voluntary agreements with food and drinks industries will deliver public health gains.

Wouldn't it be refreshing if politicians were at least honest enough to say 'We realise that the evidence says X will save lives but we don't think that is enough to make it worth it.'

Here is an interesting article on how to destroy a cherished institution

http://stephenlaw.blogspot.co.uk/2011/02/my-plan-for-destroying-nhs.html

The university system and the rest of the public sector are also well on their way to the same fate.

This is perhaps a small taste of what it must have felt like to those peoples who were invaded and plundered by the British Empire. 

You might want to think again. A couple of weeks ago I got an ominous sounding voicemail message from Santander saying to call them about an important matter. I had just made an online bank transfer to pay a plumber for replacing the boiler in my mother's house. And knowing the way that banks apply security procedures I suspected this has triggered some kind of warning - not that it would make any sense, but still ...

Anyway I called Santander and that is when the trouble started. They said that in order to deal wiith my call they would have to ask some security questions. That's fine - I'm used to that. The first few were easy ... then things got progressively harder ending with a question about the exact amount and date of a standing order ... oh dear - how could I possibly know this without having the statement in front of me - which of course I didn't because I was at work.

So unfortunately they would have to terminate the call that they had asked me to make! I pointed out the nonsense of this and the person on the other end of the line said I should try again and perhaps would get some easier security questions. So I did - alas they were not easier and so I failed again. Then I thought - OK I'll go online and get the information for the next call.

Alas because of two failures to answer the security questions my online access and now all telephone access was blocked! I was told I would have to go to a branch and sort it out.

As it happens there is a small sub-branch in my university. I was told that I would need a photo ID and some other form of identification. I asked specifically if I would need a bank card from Santander (which I didn't have on me have because it’s not the account I mainly use). The supervisor to whom I had ‘escalated’ the call told me with total coinfidence (and I pressed her on this) that my Co-op bank bank card would be fine.

So off I traipsed to the sub-branch. There was just the one young lady there and she was serving another customer. After about 20 minutes she finished and asked if she could help me. I explained the situation and she said she would have to call the central office - we waited on the phone for about 30 minutes to get an answer but eventually we got through. Unfortunately it turned out that I did need to bring a Santander bank card or statement after all! I asked, through the young lady in the sub-branch, to speak to the supervisor of the person on the other end of the line but this was refused.

So far I had wasted about 3 hours trying to respond to a request by my bank to contact them.

The following day I returned to the branch with my statement. Unfortunately there was a sign on the door saying it was closed because the one person manning the sub-branch was on a course. Another 30 minutes wasted.

Eventually I made my way to a main branch about a mile away  from where I work and after another wait I managed to speak to someone. She manage eventually to get through to someone on the phone who confirmed that, yes, they had blocked my account because of the payment to the plumber. They did not explain why but just asked me whether I intended to make it. I confirmed that I did. That was it.

Santander had wasted about half a day of my life.

What should have happened? First they should not have blocked the payment - there was no reason to do so but their security procedures are not set up with any regard for the customer. Secondly, when I called the first time they should have told me that they would ask security questions which I could only answer if I had a statement in front of me and that failing to answer would lead to my online banking and telephone banking being blocked. Thirdly, the supervisor should not have misled me into thinking that my Co-op bank card would be satisfactory for identification. Fourthly,  they should not have a one-person sub-branch with no cover.

As a post-script, I got a letter from Santander saying that they had reviewed this series of events and it was clear that the problem was solely due to my failing to answer their security questions.

Clearly Santander is a badly run bank with poor staff training and inadequate procedures. Unfortunately it is not alone. My main bank, the Co-operative bank, failed to make a crucial payment for a house purchase last year which caused me a lot of stress and almost cost me a lot of money.

What is the wider lesson? De-facto monopolies (where competition is restricted by the time sand effort needed to change a provider or find out about their products) are able to get away with providing a very poor service. This is one reason why people at the top of these kinds of organisations can receive huge salaries and bonuses even when they are incompetent.

What is the solution? Clearly the regulatory systems operating are not working adequately. There was a very good reason why these kinds of company had been in public ownership before and they should be returned to them as soon as possible - with personal incentive structures and training in a public service ethos being used to drive performance.

Clearly a lot of people like having a queen and a family of people around her who they can look up to and in some way identify with. And a lot don't. In fact some people, myself included, think that the world would be a better place if we did not treat some people as more important than others by virtue of their heritage and that there are more important calls on the public purse.

So I have an idea that should please everyone. Let's have royalty by subscription. All those people who want to support the royalty would pay an annual subscription and that would give them the identification they want and the satisfaction of knowing that they have a personal connection with the admired personages. Those who do not wish to take part in the scheme would not have to. They would not be able to claim the royalty as theirs and would not get invited to the palace etc. 

One advantage of this scheme is that one would not have to be British to take part. I notice that a lot of americans seem quite keen on the royal family. It seems unfair that they do not have the opportunity to get a piece of the action simply because their ancestors decided they no longer wanted to be part of the British empire.

In these days of commercialisation, austerity, choice and so forth this proposal seems very much in keeping with the modern approach to things. If some feel that perhaps it is a bit disrepectful I would just remind them that this is a special offer that would only be available to the current royal family and so they would still be getting a very good deal. 

There is something odd with an economic system in which, in order for a country to be able to afford essential services such as education, healthcare, justice etc. there must be enough non-essential economic activity to generate the tax revenues.

In other words we can only afford education if we buy enough iPhones.

Imagine a society that was the other way around. It was organised so that there were enough human and other resources applied to  ensure that everyone was housed, clothed and fed, and had access to healthcare, education and justice; and that the spare capacity after that could be used for other things.

In other words, imagine an economic system in which we could afford iPhones once we had taken care of the basic needs of the population.

This makes more sense to me. In fact a lot of the really fun things in life don't turn out to cost very much and a lot of the non-essentials we spend our money on don't lead to greater enjoyment and satisfaction.

It also makes sense because getting fun out of non-essentials that rely more on what we do than on producing things that we don't really want once we have bought them, involves less use of global resources.

Getting to such an economy from where we are now may seem daunting but in fact it just requires a collective act of will and an economic theory that is based on real value rather than notional GDP.

The use of quantitative easing (essentially printing money) shows us one possible mechanism by which this can come about. Basically, the government simply decides that needs to be done and prints the money needed to do it. It sounds ridiculously simple and surely it couldn't be that easy. But we are already printing money - the only difference is that the moment we are printing it in effect to recapitalise private banks in the vain hope that they will lend it to businesses. 

At the same time our government has to re-acquire the assets needed for a civilised society to operate and set up organisations and structures to make it happen.

This is not something that can be done overnight. But there are some obvious places to start. For example, the public already owns a couple of major banks and part of the railway system because the private owners couldn't run them.

The only people who have anything to lose from a model such as this are those who are grabbing more out of the economy than they are putting in. Thatcher, Blair, Cameron and their supporters have managed to convince much of the public that such people have a right to do this. But logical reasoning and sense of justice militates against such a view. 

http://www.transparency.org/news/pressrelease/20121205_political_scandals_hinder_uk_fight_against_corruption1

http://www.opendemocracy.net/ourkingdom/stuart-weir/transparency-international-raises-serious-concerns-about-corruption-in-uk

http://www.nuffieldtrust.org.uk/publications/going-gold-redistributive-agenda-behind-market-based-health-care-reform

Here is very detailed and clear account of what is being done to the NHS. It's a long interview but even the first few minutes is worth watching. 

 tinyurl.com/cdx3pb7

 Please pass on to as many people as possible.

So what is to prevent the advent of e-cigarettes from being perhaps the single most important public health breakthrough this century?

First the tobacco industry. I presume they don’t want to kill millions of people but they would clearly rather do this than see a fall in their profits. They are buying up e-cigarette companies but unless it turns out to be in their interest to get people using these instead of smoking, they will do everything they can to keep them to a small niche market. They might even see them as a way to get more people smoking cigarettes, for example as a ‘gateway’ product to smoking for young people.

Second, well-intentioned tobacco control advocates and regulators. Belief that any form of nicotine addiction is as bad as any other and concern that e-cigarette users might be exposed to harmful levels of nicotine or other toxins has already led to e-cigarettes in effect being banned in some countries and to other jurisdictions to consider regulating them in such a way that they will not be a viable alternative to smoking.

What do I think? I think this is too good an opportunity to miss. Of course regulation should ensure minimum manufacturing and labelling standards, but it should also be used to nurture their development as an alternative to smoking and an opportunity to legislate cigarettes out of existence. 

There is almost nothing generalisable that we can 'know' in the the area of social, clinical and epidemiological research. There are lots of things that we can 'think' or 'believe' with varying degrees of confidence. Pretending that we can know things is stopping us being able to think things that are likely to be true and useful.

As an example, let us take the effect of nicotine patches in helping people stop smoking. There are numerous experimental studies comparing these with placebos which provide the strongest possible evidence (one might think) that on average the patches help smokers to stop - not a huge amount but enough for it to be very worthwhile to use them. But there are those who say - no! Patches do not work because these findings do not generalise beyond the clinical trials. They demonstrate that when you survey smokers in the real world, patch users are not more likely to succeed than people who try without this help. But those surveys cannot possibly take account of all the possible pre-existing differences there might be between patch  users and non-users. As it happens users tend to be more nicotine dependent and so start with a worse chance of stopping. When you adjust appropriately for that it seems that patch users do end up with a better chance of succeeding after all. But that is using survey data which the experimentalists say is too weak. And the patch opponents say you are biased and just sucking up to the pharmaceutical industry. 

What does all this mean? Each side of the argument is setting the knowledge bar unreasonably high for the other side under the guise of science.  This kind of nonsense is going on in just about every area of study I am aware of. Pretending that our science can lead to knowledge allows each side to raise and lower the bar as it sees fit depending on whether it likes or does not like the conclusions.

This happens to the same degree with funding organisations. Studies get funded only when those reviewing the applications are willing to lower the knowledge bar because they like what is being proposed. If they don't like it, or do not find it interesting, or it is not proposed by one of their friends ... sorry.

What does this lead to?  Huge amounts of wasted resources, irrational conclusions, and an incentive for researchers to go for what is currently a fashionable method rather than one that is appropriate to the task in hand.

What is to be done? As a field we need to start by being honest with ourselves about our biases. Then journal editors need to commission articles setting out what is and is not an acceptable methodology for a particular kind of research question. Funding should go where there will be the greatest expected utility not what has the greatest apeal to the board. I doubt whether I will see this shift but you never know. 

The Conservative government tells us that it cares what happens to the British people and that is why they are making us suffer the cuts. Sadly that is not so. They want to live in a society in which they and their friends and family can exploit the rest of us without constraint to maintain their wealth and power. Nothing they do makes any sense if they care about the British people and everything they do makes sense if they want to maintain the ability of the powerful to accumulate wealth at the expense of the rest of the population. So the Conservatives are the party of those whose core values are about pursuing self-interest.

So what are Labour's values? Unfortunately, it is not easy to tell any more. They used to be about social justice and preventing the rich and powerful from exploiting the rest of us. In the class struggle, they were supposed to be on the opposite side to the Conservatives. Unfortunately they weren't. New Labour pretended that the class struggle was history. But the Conservatives knew it wasn't, and if one side is fighting and the other isn't - the result is going to be one sided. 

So Labour needs re-establish its core values and then fight for these with every fibre of its existence. 

There was a young royal named Will

Whom everyone loved until

Of his wedding they learned

Despite what he earned

It was they who were footing the bill!

Nudge is a book and a doctrine. It has become central to the British Government's thinking on behaviour change. The fundamental tenet is that governments should not attempt to change behaviours through coercion, restrictions or regulation but through subtly altering the 'choice architecture' so that people find themselves doing what is best for them or society. 

This sounds attractive in many ways but, while it is fine as a rhetorical device, it untenable as as a method of devising policy for two reasons:

1) It begins the process of designing a policy, not on the rational basis of what the evidence indicates is likely to be effective, affordable, practicable and publicly acceptable but by choosing from a more limited set of options; coercive and restrictive options (e.g. tax increases on tobacco) are very often the most effective solution and widely accepted by the public because they see them as helpful in overcoming temptations

2)  It neglects the fact that all our behaviours are subject to powerful manipulation by companies through marketing and product design. The tobacco, gambling, fatty food and alcohol industries spend many millions of pounds and dollars exploiting our psychology to sell their products. If governments eschew interventions that protect us against this manipulation, 'choices' are not free - they are just being dictated by profit rather than our own welfare.

With the decline of our industrial base and relentless  media brainwashing, many workers, particularly in institutions such as universities, have lost a sense of the vital importance of unions in protecting workers' rights. 

UCL academic staff, like many other organisations,  have recently voted to strike to protect jobs against a proposed system of applying cuts that many of us think will damage the university and the country.  

I think we owe our current conditions of service to the sacrifices made by our forebears and we owe it to future generations to band together to protect our universities. It is very easy to join the UCU, our main trade union. Just go to www.ucu.org.uk