Peer-reviewed payback

Temperance academics exact revenge on their enemies

I wrote in April about the growing trend in ‘public health’ research of highly partisan activist-academics posing as honest brokers arbitrating scientific disputes. Inevitably, they conclude that their own side is correct and the other side are unscrupulous liars. This is then turned into a peer-reviewed study and becomes ‘evidence’ to wave under the noses of policy-makers.

This tactic can be seen most blatantly in alcohol research where some studies are nothing more than exercises in settling scores and airing petty grievances (Mark Petticrew and Jim McCambridge are repeat offenders).

A classic example was published in Addiction last week. Some of the world’s most fervent neo-temperance academics, including Tim Stockwell, Tim Naimi and Jim McCambridge, decided to take a look at the International Scientific Forum on Alcohol Research (ISFAR). ISFAR is a broad group of scientists who provide analysis and commentary on new alcohol research. They contribute to the excellent AIM Digest newsletter which gives a monthly update on what’s happening with alcohol science and policy worldwide. If you haven’t heard of them it is because they are not a lavishly funded organisation. The academics are volunteers and the “modest work of the forum is funded by subscription”.

The important thing to note about ISFAR is that they are scientists, medics and experts from a range of disciplines. They are not necessarily part of the anti-alcohol crusade that masquerades as ‘public health’. That irks the likes of Stockwell whose new study in Addiction combines several of his passions: disparaging the supposed opposition, casting doubt on the benefits of moderate drinking, and banging on about supposed conflicts of interests. He and his co-authors read every critique published by ISFAR between 2010 and 2024 (268 of them!) and concluded that, unlike their good selves, they are biased.

Three of the authors of the study have all had their work criticised by ISFAR in the past (Tim Stockwell, Tim Naimi and James Clay). For example, ISFAR criticised them last year for publishing yet another article downplaying the benefits of moderate drinking which cherry-picked a mere five studies and then referenced them incorrectly. You might think that this gives them a bit of a conflict of interest, but they don’t seem to think so. They don’t list it as a COI and at no point in the text do they even hint at having any skin the game.

Meanwhile, the authors’ own biases are clear from the way they frame the issue.

ISFAR periodically publish critiques of scientific publications and policy statements on its website. A major focus of these has been the contentious issue of whether alcohol consumed in ‘moderate’ quantities (i.e. low-volume drinking) can have health benefits. ISFAR members, through both published commentaries and informal critiques, generally support the view that: (1) low-volume alcohol consumption can reduce the risk of serious conditions like ischemic heart disease, stroke, Type II diabetes and all-cause mortality; (2) the risks of low-volume alcohol use are minimal or non-existent compared to the benefits; and (3) daily, low-volume alcohol use can contribute toward a healthy lifestyle [12-15].

That is what the evidence shows.

By contrast, multiple original studies as well as systematic reviews and meta-analyses provide evidence that questions the supposed health benefits of low-volume alcohol use [16-22].

Note that they cite seven studies to support their claim. Not bad, especially if some of them are systematic reviews and meta-analyses, which they are. The reader is supposed to come away from this thinking that the issue must be genuinely “contentious” and the evidence is split 50/50. But what if I told you that every single one of those studies was co-authored by Tim Stockwell? As I have been saying for years, the strategy of Stockwell et al. is to clog up the search engines with contrarian research, none of it of great merit, in the hope of confusing the public. If there was really so much research casting doubt on the J-Curve, why would he need to reference his own work so much?

To be fair, they do manage to find one independent study that supports their hypothesis:

For example, Ortolá et al. [23] recently reported that compared with very light drinkers, moderate drinkers have increased risks of ischaemic heart disease, cancer and all-cause mortality.

But they do not cite any of the hundreds of studies that show health benefits from moderate consumption, such as this and this, nor do they mention all the evidence that moderate drinking unambiguously reduces biomarkers for harm.

Unsurprisingly, such results have been met with highly critical reviews from ISFAR (e.g. Stockley et al.) [15].

Why ‘unsurprisingly’? We are only five paragraphs into the introduction, but they are already begging the question. It is ‘unsurprising’, they think, because some members of ISFAR have “continuing financial and other alcohol industry connections”.

As with other contentious public health debates (e.g. the ongoing anti-vaxxer movement) [24], efforts to distort science and spread conflicting narratives create public confusion and erode trust in scientific advice.

Pots and kettles spring to mind.

Therefore, we aimed to determine whether the ISFAR critiques systematically favour evidence in favour of health benefits from alcohol.

And who better to do that then a bunch of anti-alcohol zealots who have had their junk science criticised by ISFAR in the recent past!

The conclusion is obviously foregone…

Studies reporting health benefits had higher odds of receiving positive reviews from ISFAR [odds ratio (OR) = 6.50, 95% confidence interval (95% CI) = (3.62–12.00)], as did studies minimising alcohol harms [OR = 2.47, 95% CI = (1.40–4.45)]. Studies reporting health harms had higher odds of receiving negative critiques [OR = 0.29, 95% CI = (0.15–0.14)], as did studies minimising health benefits [OR = 0.21, 95% CI = (0.10–0.41)].

I’m not at all sure what a study “minimising alcohol harms” looks like. It sounds rather subjective and must depend on what you think the real level of harm is. And since some, if not all, of the authors of the Addiction paper have explicitly claimed that there is “no safe level” of drinking, it wouldn’t be difficult to lowball the risk if they’re the ones setting the threshold.

Unfortunately, the authors only reference a few ISFAR critiques directly, but there is enough for us to see that their analysis is, shall we say, idiosyncratic.

Our findings suggest that ISFAR critiques largely promote the narrative that low-volume alcohol consumption offers health benefits and that harms only occur at higher levels of consumption. For example, several critiques emphasised cardioprotective effects of alcohol while downplaying harms, such as cancer risk (e.g. critique 18).

Critique 18 is here. The study being critiqued was mainly about alcohol and breast cancer and is here.

The study concluded that:

Alcohol intake was not associated with all-cause death and possibly associated with decreased risk of non-breast cancer death.

Consuming three to four alcoholic drinks or more per week after a breast cancer diagnosis may increase risk of breast cancer recurrence, particularly among postmenopausal and overweight/obese women, yet the cardioprotective effects of alcohol on non-breast cancer death were suggested.

The ISFAR critique says:

The present study was based on a large number of women with generally early-stage breast cancer who were followed for an average of 7.4 years. It found an increase in risk of breast cancer recurrence and breast cancer death, but no effect on total mortality, to be associated with consumption of 3 to 4 or more drinks per week.

This is an accurate summary of what the study found. Stockwell et al. accuse ISFAR of focusing on “cardioprotective effects of alcohol while downplaying harms” but Critique 18 doesn’t mention cardiovascular effects at all except on one occasion when it directly quotes from the study. As for “downplaying cancer risk”, the critique actually suggests that the study might have under-estimated cancer risk and uses the ‘sick quitter’ theory so beloved of Tim Stockwell to do so:

The lack of data on lifetime abstainers and former drinkers might have underestimated the relation between alcohol and overall mortality; sicker women may have been less likely to drink (lower proportion of stage I and higher proportion of mastectomy in low alcohol group). In addition, sicker women may have stopped drinking within the 2-year window in which alcohol was assessed.

With 268 critiques to choose from, this is the one they pick as their first example?!

But they have more…

Furthermore, critique 13 highlighted a review suggesting protective effects of low alcohol use against liver cirrhosis.

And why not? The study exists and is relevant to the questions that the research was addressing, i.e. whether or not there is a threshold of risk for liver cirrhosis and whether there is “no safe level”. The overall conclusion of the critique was that “the present meta-analysis supports a strong role of heavy alcohol drinking in the development of cirrhosis” and that it “provides evidence for a ‘threshold’ of alcohol intake for the development of cirrhosis.” Both of which are true.

Other narratives minimised harm by suggesting that only specific drinking patterns may be harmful. For example, binge drinking (critique 57), spirit consumption (critique 51) or drinking without meals (critique 200).

Critique 57 was about a study of mice which found that moderate drinking lowered LDL cholesterol while binge-drinking increased it. ISFAR’s critique simply repeats what the study showed and says that it was well conducted and potentially important. You’d have to be high to think they were saying that only binge drinking is harmful.

Critique 51 was about a study titled ‘Effect of type of alcoholic beverage in causing acute pancreatitis’ which concluded that:

The risk of acute pancreatitis was associated with the amount of spirits consumed on a single occasion but not with wine or beer consumption.

The critique merely outlines the methodology and findings before suggesting some mechanisms that could explain why only spirits drinkers were affected. They are clearly talking specifically about acute pancreatitis, not “harm” in general.

Critique 200 is about a study looking at light drinking and cancer risk which concluded:

We found that very light or light alcohol drinking was not associated with the risk of most of the common cancers except for the mild increase in the incidence of breast cancer in women and colorectal cancer in men.

ISFAR said that is was “a well-done meta-analysis” and reminded readers that…

“Larger amounts of alcohol are associated with increased risk of a number of cancers, and even light consumption is associated with the risk of breast cancer, and possibly colorectal cancer.”

That doesn’t sound like downplaying cancer risk to me.

The critique barely mentions food. The idea that the critique suggests, even vaguely, that alcohol is only potentially dangerous if consumed without a meal is just bizarre.

Another common theme was minimizing risk by highlighting wine additives or folate in the diet to reduce risk of disease (e.g. critique 197).

Critique 197 is about a study which found that moderate drinking is associated with less risk of dementia. The critique is balanced (as are all the others I have read) and even mentions the risk of a ‘sick quitter’ effect. It includes a discussion of why wine drinkers have the lowest dementia risk which mentions various compounds in wine. Presumably that’s what Stockwell et al. mean by ‘additives’.

Finally…

Although some critiques may highlight genuine harm-reduction strategies, such as thiamine fortification [42], our analysis suggests that ISFAR critiques primarily support the alcohol industry’s interests by promoting unregulated alcohol availability. For example, some critiques argued against restrictions on alcohol availability (i.e. World Health Organization SAFER interventions) [43], citing the supposed health benefits of moderate drinking as outweighing population-level harms (critique 38).

Once again, Stockwell et al. are shooting the messenger. The study under discussion in Critique 38 looked at what happened when alcohol prices suddenly dropped in Finland in 2004. It found that…

… the reduction in alcohol prices led to an increase in alcohol-related mortality, except in persons <40 years of age. However, it appears that beneficial effects in older age, when CVD deaths are prevalent, counter-balance these adverse effects, at least to some extent.

Although ISFAR noted that the study suggested that “lowering alcohol taxes is not going to cause a public health emergency”, its members were quite sceptical about the purported benefits, saying that “it is difficult to see an abrupt change in the downward trend of CVD and total mortality after the introduction of lower-priced alcohol; in other words, it is hard to notice an obvious acceleration from 2003 of the steady reduction of CVD mortality that has been taking place in Finland for years.”

Needless to say, the critique does not promote “unregulated alcohol availability” and at no point does it say that the health benefits of moderate drinking ‘outweigh’ the population harms, although the experts do say - as the authors of the study acknowledge - that there is a trade-off that policy-makers should be aware of…

Future comprehensive analysis of reductions in the price of alcohol should examine both the detrimental and beneficial consequences.

This is a statement of the obvious, but you can see why it would rile up a single-issue fanatic.

With 268 critiques to choose from, it is fair to assume that the authors picked the strongest examples to make their point and yet the critiques they reference are all fair, balanced and accurate. It seems to me that Stockwell and his friends object to the findings of the studies being discussed rather than the discussion itself. From what I have seen, ISFAR do not rave about studies that ‘minimise health harms’ nor are they highly critical of studies that report health risks.

Having been on their mailing list for a few years, the only ISFAR critiques that stick in my mind for being stinging rebuttals were about studies from Stockwell and his team (Zhou, Naimi, Clay, etc.). Writing about one of their many attempts to downplay the benefits of moderate drinking, ISFAR said that they “markedly distorted the accumulated scientific evidence” and that their “[f]ailure to acknowledge the robust body of knowledge supporting the opposite conclusion and disqualifying extensive studies that offer plausible biological explanations of observed benefits is unconscionable.” An ISFAR member described their most recent attempt to rewrite the scientific literature as the “latest re-hash of the same biased arguments”.

It is reasonable to believe that such criticism has stuck in the craw of Stockwell and his crew, hence the new ‘study’. Having read the critiques mentioned above, I don’t have any faith in Stockwell’s methodology which is obviously highly subjective and comes from a biased and extremist perspective. Even if it were true that ISFAR is more critical of studies that ‘minimise health benefits’, it would not necessarily be evidence of bias, let alone of bias caused by conflicts of interest. It could simply be that those studies are of lower quality, as they probably are.

I may be biased myself, but the ISFAR commentaries look to me like they are written by serious, open-minded scientists from a range of relevant disciplines who have a good knowledge of the literature. By contrast, the work of Stockwell, McCambridge, Naimi et al. looks like dogmatic, partisan, politically motivated flim-flam. That impression is confirmed by the very last sentence which makes it clear that the objective of the study is, once again, to isolate their perceived opponents from policy-makers.

Academics, policymakers and stakeholders should not regard ISFAR critiques as objective evaluations, as this analysis provides evidence of significant bias and alignment with alcohol industry narratives.

To which I would say, if I were as ISFAR member, ‘Grow up’.