A year of myths about smoking and obesity

Two of the most cherished claims of the health lobby during 2008 have been that public smoking bans reduce smoking and that we are in the midst of an unending epidemic of overweight and obesity, particularly in children. We’re told that endless intervention by public authorities is required to save us from ourselves.

Authorities from Croatia to India introduced smoking bans this year, while many others extended bans to include such previously private spaces as cars. Meanwhile, high-profile campaigns to change our eating habits and restrict healthcare for the obese have also been popular this year with those keen to tell us how to live.

But the claims about smoking and obesity took a decisive and perhaps even fatal hit last week with the publication of the latest Health Survey for England. The surveys, which have been published since 1994, are based on extensive interviews and a nurse visit, and designed to ‘monitor trends in the nation’s health’. The latest survey, covering 2007, included data about hypertension, overweight and obesity, physical activity, diet and healthy eating, and smoking and drinking obtained from over 7,500 children and almost 7,000 adults.

Since the surveys are produced by the National Centre for Social Research and the Department of Epidemiology and Public Health at University College London (UCL), they have an objective character that is often lacking in the spin-based releases from Britain’s health guardians at the Department of Health and the National Health Service. This is particularly true with respect to their findings about smoking and overweight and obesity, which contradict the claims of the British government and its ‘experts’ behind last year’s Foresight Report in several crucial respects.

The government, for instance, has maintained that the public smoking ban, introduced in July 2007, has forced record numbers of smokers to quit. According to a July 2008 report prepared by the chief medical officer, Sir Liam Donaldson, 234,060 people quit smoking in the months prior to and after the ban. In the foreword to the report, Donaldson claims that the ‘significance of the smoke-free laws cannot be underestimated’.

But as the Health Survey for England shows, these claims are false. Indeed, not only has the public smoking ban failed to reduce smoking, its first year has seen an increase in cigarette consumption among males aged 18-34. As the survey notes about smoking after the ban: ‘There was no significant difference in cigarette smoking prevalence after the implementation of the smokefree legislation on 1 July. Among smokers, the mean number of cigarettes smoked per day did not fall significantly overall…’ Indeed, smoking prevalence amongst male smokers increased from 23 to 24 per cent.

Even more crucially, amongst smokers from the lowest socioeconomic quintile – who have some of the highest smoking rates in the country – the number of cigarettes consumed by men increased. Again, 30 per cent of smokers reported that the ban had encouraged them to stay at home where they were free to smoke. This validates research by Adda and Cornaglia of UCL (‘The Effects of Taxes and Bans on Passive Smoking’, 2006) which found that the public smoking ban increased children’s exposure to secondhand smoke (see The hidden dangers of the smoking ban by Patrick Basham and John Luik).

This should not be surprising, for it echoes the experience elsewhere. Ohio, after passing similar public smoking legislation in 2006, saw its smoking prevalence increase by three per cent since 2007. In France, tobacco consumption for 2008 will equal that of 2004, despite a smoking ban. Recently, a government spokesman commented that ‘Measures to prevent passive smoking have not had any effect whatsoever on active smoking. They have completely failed.’ (1) And in the three years since Spain banned smoking in bars, restaurants and most other public places, tobacco consumption has increased. According to the data from the Tobacco Market Commission, 3.797billion packs of cigarettes were sold in 2008 compared with 3.749billion in 2006.

Why is this the case? Part of the answer is to be found in the fact that, like so much of the government’s anti-smoking strategy, public smoking bans are built are built on a foundation of ignorance rather than knowledge. For instance, there is very little evidence that shows that smoking bans motivate smokers in the long run to give up smoking. A major review of why smokers stopped found that it was ‘health concerns’ that primarily motivate smokers to quit, not social or legal pressure or even the cost of cigarettes (2).

Then again, part of the answer might lie in reactance, in which smokers become increasingly resistant to the external efforts of a judgemental society to force them to change their ways. The more society pushes, as with smoking bans, the more smokers push back by declining to quit. In a study about motivations to quit smoking, Curry et al found that smokers who had decided to quit voluntarily and were strongly motivated, as opposed to those who had in some respect felt externally pushed whether through social pressure or legislation, were far more successful at quitting (3).

All of which highlights once again both how very much the government’s tobacco policies are disconnected from research about why people smoke and why they stop smoking, and how ineffective they are at anything other than headline-gathering puffery.

But it is not simply on the question of public smoking bans that the Health Survey challenges the government and the public health community’s claims; it also calls into question the foundation of its entire obesity strategy by showing that the hysteria around spiraling rates of overweight and obesity is not supported by the facts.

For at least the last five years, the government, a host of special interest groups like the diet and weight-loss industries, and the media have constantly asserted that we are in the midst of an unprecedented and catastrophic epidemic of overweight and obesity. We have challenged these claims before: in our book Diet Nation: Exposing the Obesity Crusade, where we examined the Health Survey for England statistics about childhood obesity, and earlier this year, in an invited article in the British Medical Journal. The Health Survey results confirm how unfounded are the claims about increasing prevalence of overweight and obesity, both in adults and children.

For adult men, for instance, there has been a decline in the prevalence of overweight and obesity, something that is difficult to square with the claims about an epidemic, while for adult women, prevalence has remained unchanged. In the 2007 survey 65 per cent of men were either overweight or obese compared with 67 per cent in 2006. When this data is compared with the 2004 results, for instance, there have been either declines or no significant changes in male prevalence of overweight and obesity in all age groups from 16 to 54. Further, hypertension, which should be increasing given the epidemic of overweight and obesity, also did not change significantly. In fact, in men prevalence was 31 per cent in both 2006 and 2007.

It is in children, however, that the myth of an obesity epidemic takes it most significant hit. According to the survey: ‘There was no significant change in mean body mass index (BMI) overweight/obesity prevalence between 2006 and 2007, and there are indications that the trend in obesity prevalence may have begun to flatten out over the last two to three years.’ But this hardly tells the entire story.

For example, according to the 2006 survey, there was a decrease in obese girls, aged two to 15 between 2005 and 2006 from 18 per cent in 2005 to 15 per cent in 2006. Yet this decrease was almost completely unreported in the press, and ignored by the government in its claims about increasing rates of childhood obesity. Among boys aged between two and 10 years, the prevalence of overweight declined from 16 per cent in 2005 to 12 per cent in 2006.

Indeed, according to the survey, amongst boys and girls aged between two and 15 years old, overweight and obesity has been declining since 2004. In fact, in girls obesity levels in 2006 are largely unchanged from where they were in 2001. The survey smoothes this over by saying that between 1996 and 2007 ‘there were yearly fluctuations in obesity levels’. But how do such ‘fluctuations’ fit within the government and the media’s incessant claims about an epidemic of childhood obesity?

But the survey not only contradicts the government’s claims about the ‘epidemic’ of overweight and obesity, it also undermines the central pillars of its strategy for combating this phantom epidemic. To judge from the UK’s broadcasting regulator, the Office for Communications (Ofcom), and the government, the root causes of much of the supposed increase of obesity and overweight in children is to be found in food advertising and in the prevalence of junk food in children’s diets. Yet the survey suggests a quite different answer, namely, the absence of physical activity. For instance, the survey reports that among girls, the prevalence of obesity varied according to the level of physical activity: ’21 per cent of girls aged two to 15 in the low physical activity group were classed as obese, compared with 15 per cent of the high group’. A similar pattern was found in the 2006 survey which found that 33 per cent of girls aged two to 15 who had low levels of physical activity were either overweight or obese compared with 27 per cent of those with high levels of physical activity. Again, obesity prevalence was higher in both boys and girls in the lowest income group, suggesting that it is not only smoking that has higher prevalence rates amongst the disadvantaged.

In a sane world of public policy these sorts of results should result in changes in both smoking and obesity strategy in the year ahead. But the world we have is one in which it is much easier to allow crucial public health policies to be shaped by a combination of myth, ignorance and ideology.

Patrick Basham and John Luik are co-authors, with Gio Gori, of Diet Nation: Exposing the Obesity Crusade, a Social Affairs Unit book. (Buy this book from Amazon(UK).)

Who spiked rated and hated in 2008, by Tim Black

2008: the year of living dangerously, by Rob Lyons

The year that humanity became the baddie, by Nathalie Rothschild

Twelve months of music to the ears, by Tom Slater

(1) Daily Mail, 16 December 2008

(2) McCaul et al, ‘Motivation to quit using cigarettes: A review’, Addictive Behaviours 31: 2006

(3) Curry et al, ‘Reasons for Quitting: Intrinsic and Extrinsic Motivation for Smoking Cessation in a Population-Based Sample of Smokers’, Addictive Behaviours 22: 1997