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Sunday, 31 January 2010

Boots and Homeopathy: Reading the Small-print

Yesterday about 300 people took an "overdose" of homeopathic remedies in city and town centres across the United Kingdom.

I was one of them, standing with Dave Gorman, Simon Singh, Evan Harris MP and many others in a frosty Red Lion Square in London.




This event was part of the 10:23 campaign, seeking both to promote a better public understanding of homeopathy and to put an end to the marketing of homeopathic products as medicinal products.

My "overdose" was of 30c Arnica.

(They were supplied to me on the day by comedian and Westminster Skeptic, the estimable Chris Coltrane.)

The label on the tube was revealing.

It expressly states that it is a Boots product.

After the Boots logo, it says "A Homeopathic Medicinal Product".

But, of course, as a matter of simple fact, only three of those words are meaningful.

Nonetheless, Boots formally and deliberately hold this out to be a medicinal product.

There is then the lengthy label small-print.

Without even reading it, without even holding the tube close enough to focus on what the small-print says, the blurb of small-print gives one an overall impression.

And the overall impression which it gives, and is undoubtedly intended to give, is that this is a regulated medicinal product: the sort of which requires all this legalistic waffle.

The small-print actually goes 40% around the circumference of the tube.

So, the consumer is told that this a medicinal product, and the consumer can see there is lots of small-print: all this must serve as a reassurance to the average consumer.

As one's eyes focus on the small-print, certain words and phrases begin to stand out, and are intended to do so because they are in bold, in red font, or block capitals.

In bold are: How to use, Dosage, and Advice.

In red font are: "The 30c Homeopathic potency of Arnica montana" and "Handle carefully, homoeopathic medicine in an inner glass vial".

And in block capitals: "KEEP OUT OF THE REACH AND SIGHT OF CHILDREN".

In such legalistic small-print, one emphasises particular statements because they are more important for the consumer to realise. Sometimes such emphasis is legally required; but sometimes it comes down to the simple good sense or good intentions of the vendor or manufacturer.

So it is telling what Boots chose to emphasise, and what not to emphasise.

In respect of my tube of 30c Arnica, Boots chose to emphasise what would give the average consumer the impression that Arnica 30c is a genuine medicinal product.

Furthermore, Boots carry on with this charade even in the non-emphasised small-print. In particular, there is the astonishing statement: "If symptoms worsen or persist consult a doctor".

The necessary implication of this sentence is that this medicinal product will treat (unstated) symptoms. The words "if" and "persist" can only be read in this way.

It is only with the last sentence, some twelve lines down, and after all the bold, red font, and bock capitals, that Boots finally state:

"A homeopathic medicinal product without approved therapeutic indications."

Boots could have put his in bold, red font, or block capitals. Nothing was stopping them.

But, for some reason, this is the least emphasised statement on the tube...



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38 comments:

Martin Robbins said...

Nice post, and it gets to the heart of the issue with Boots.

The producer of the documentary crew following me yesterday asked me to talk about what was on the label of the product, and in particular they asked me what my pills (Arsenic) were supposed to treat, and if there was any advice on their about safe doses. Needless to say, both were absent, so they just got footage of me looking confused at a vial.

What really gets me though is, like you say (and I'm kicking myself for not stating it on film), that Boots' product seems to have been designed to look as much like real medicine as they can get away with. Not just the label, but the whole design of the tube with its elaborate dispenser and inner glass vial.

If they packaged them as sweets, and sold them at the same sort of price as a tube of Smarties, I'd be a lot happier with them...

Zeno said...

Quite. A medicine that isn't a medicine. Trade Descriptions?

I have the bits from one of the tubes of sugar pills, sorry, pillules, from yesterday. It does have a glass vial in it, but the cap for that is plastic (all the plastic pieces are polyethylene). So these precious magic pills come into contact with plastic from the time they are manufactured until they are used. Some instructions say you can tip the pills into the plastic cap (but on no account touch the delicate little things with your fingers), so maybe plastic doesn't erase the memory of the water (I mean sugar).

So, what's the glass vial for. It wouldn't be to misled the customer into thinking it was protecting something potent, would it?

James-C said...

The wording bothered me as well. I would be much happier if instead of says 'if symptoms worsen or persist' it said something like "Only to be taken under advice of a medical doctor" or something similar. That they claim it is 'homeopathic medicine' is a contradiction in terms.

I can't believe that there isn't *something* in this that is not either false advertising or contravenes the trade description act in some manner.

That they give 'dosage' instructions and refuse to say what the 'medicine' is for is demonstrably immoral and should be illegal.

Allo V Psycho said...

The therapeutic indications are contained in a little folder in the shop. This does make clear claims of efficacy for a significant number of identified conditions, and directs you to the particular remedy. Jack, is it legal to have this kind of two part claim - the 'remedy' itself does not make claims, but other in-store documentation does? And Boots weasel 'We have no evidence on effectiveness'...how does that square with claims of efficacy in the folder?
I did try to get the pharmacist in my local Boots to talk to me about it, but he resolutely refused.

UK Expat said...

I am not a lawyer, yet surely it is against the Trade Descriptions Act to sell 30C potions at a higher price than 6C?

Not only is it demonstrably the case that Boots couldn't tell the difference if one switched the labels, it is also - allegedly and apparently, I am not a scientist - impossible to create dilutions above 4C anyway, since water simply cannot be purified to the extent that higher dilutions would require.*

If so, Boots is effectively charging the consumer 70 p more (4.99 for 30C vs. 4.29 for 6C, according to their online shop at http://bit.ly/craJ3b) for - to be quite frank - extra "magic". While I appreciate that consumers don't mind paying more for the same product in certain cases (auctions or signed memorabilia being a good example), this surely cannot be true of (purported) OTC medicines.

I think homeopaths should be forced to "show their working" and reveal the purity of water used in their potions. This fact alone should prevent Boots selling "higher-grade snake oil" at a higher price.

It would also have an important psychological effect on consumers - which you rightly address in your blog post. After all, if 30C costs the same as 6C, then why is it called 30C?

* On the water purity thing, the post by lesmondine got me thinking: http://lesmondine.wordpress.com/2010/01/28/homeopathy-theres-something-in-it/.

Dale Williams said...

James-C said:

"I can't believe that there isn't *something* in this that is not either false advertising or contravenes the trade description act in some manner."

Unfortunately (and I'm no lawyer so am happy to be corrected if my supposition is wrong) but I think the European Regs 2001/83/EC trump any local (i.e. trade descriptions) laws we have in this case. And the European regs specifically allow for homeopathy to be sold as long as it is safe.

Annette said...

At least one of their homeopathic remedies does state what it's for - Boots Insomnia Tablets. I don't have the product itself, but the website describes it as "A homeopathic medicine for the relief of sleeplessness."

http://www.boots.com/en/Boots-Insomnia-Tablets-72-Tablets_1650/

Is this legal?

LR said...

Re-reading my tube of belladonna what worries me is that the dose should be continued over 5 days. It seems to suggest you should give this thing 5 days to work and then consult a doctor.

Belladonna is like for like on "Heat, redness, throbbing and burning" as well as "Scarlet fever" and "Suddenness of onset". I think if I had any of these symptoms (especially with sudden onset) I would want to go to the doctor straight away, not wait 5 days.

I'm guessing that this label is pretty similar for all homeopathic treatments from boots, I dread to think what would happen if someone waited 5 days for Calcarea Carbonica to cure their stiff neck. What with the stiff neck being a good sign of meningitis.

James-C said...

Dale: So it is our MEPs we should be petitioning?

Annette: That does claim active ingredients of "Kali brom, Coffea, Passiflora, Avena sativa, Alfalfa and Valeriana" and even says "Contains ingredients:" ;-) It says nothing about the dilution (as far as I can tell from the website) So I think this might be mislabelled as 'homeopathic' when they really mean 'herbal'. Not sure.

But, look at http://www.boots.com/en/Boots-Sepia-30c-Pillules_923420/ It claims that you must be "016 years old" to buy this product. Erm... why? The homeopathic *arsenic* doesn't require you to be 16... but the homeopathic *sepia* does?!?! (Sepia is either cuttlefish, or the ink thereof, I'm guessing in this instance. I've eaten both, perfectly harmless...good fried with some spring onions, garlic, and sesame oil!) I tried to post a 'customer review' of it, raising the point that the advice maybe should be changed, but strangely enough they ignored it. There don't seem to be many published 'customer reviews' on the homeopathy products.

IAmMarauder said...

I think if I had any of these symptoms (especially with sudden onset) I would want to go to the doctor straight away, not wait 5 days.

When people ask me why I am so against alternative medicines, this is the point I bring up. It can be dangerous to wait 5 days before seeing a doctor, and if it is an infectious illness then it even worse as these people don't usually quarantine themselves. Unfortunately many people don't see this as a problem :(

SkepticBarista said...

Nice post & I've been talking to Boots customer support team along similar lines over the past few weeks.

Via email they have stated:
"we are of the opinion that this product contains active ingredient stated on the packaging"

So when asked exactly how much active ingredient was present they said:
"I'm afraid that we do not have the information you've requested, as this information will be held by Nelson's directly."

I've asked them how they can provide safe dosage instructions if they don't know how much is present & also if this lack of product information only applies to homeopathic products, or are there other 'medicines' that they sell where they don't know how much of any active ingredient a customer will be taking.

All they came back with is that they are sorry I'm dissatisfied with their responses and have passed my questions to their pharmacy and healthcare teams!

Edd said...

UK Expat - I'm not sure selling two identical products in different packaging at different prices is a legal problem is it?
I've certainly found Boots selling over-the-counter real medications at two different prices marketed at two slightly different sets of symptoms.

LR said...

@IAmMarauder agreed, another interesting problem is people using them without realising that they are alt med and thinking that they have an immunity to standard drugs so avoiding treatment because of that.

David Colquhoun said...

I tried a complaint to Trading Standards years ago, on the grounds that the pills were mislabelled. They contain no trace of the ingredient on the label.

The TS officer was an ex-pharmacist and quite sympathetic. A bottle of 30C pills was bought and solemnly sent for analysis. No trace of the ingredient was found. But nothing happened because the TS officer said that a loophole in the law made the misrepresentation quite legal.

These people get away with murder.

John Collins said...

I know it's all nonsense of course but even if the water with 0.00001% chance of having a single molecule of the stuff in it somehow had a lingering "memory" of its glorious undiluted presence why should a bit of sugar somehow have this "memory" transferred to it?

Mike said...

It's the case where parents dispense these to children under the misapprehension they are an affective "medicinal" product that scares me.

Boots' accommodationist position on these products also makes any professional advice they give on any pharmaceutical product rather suspect.

UK Expat said...

@John Collins:

As lesmondine's post explains, after about "5C" (five rounds of dilution) the impurities in even lab-quality water (total organic contamination around 10 parts per billion) outnumber any remaining remedy substance by an increasingly large factor, meaning that if succussion/potentisation DID work, it would actually be potentising impurities to a greater and greater degree, all the way up to 30C.

So instead of getting homeopathic "arnica", you'd be getting homeopathic lead, sulphur, etc. in presumably "lethal" doses.

It's a good job it IS woo.

Ricardohere said...

Another excellent post. I'm just sorry I couldn't get to the Bristol event.

Boots manage to stay the right side of EU law by stating that the product has no approved therapeutic indications, and also qualify the word 'medicinal' with the adjective 'homeopathic', thereby rendering it different in meaning to what most(?) people would regard as the standard meaning of 'medicinal'...
Medicine for the hard of thinking indeed!

Whether homeopathy provides any placebo-based symptomatic relief or not, putting off visiting a real doctor is just plain dangerous.

TK said...

@ James C

I took sepia, which I bought because I liked the name. I then looked up online what it's for and found that it's particularly indicated for brunettes. If I were blonde or ginger, would someone have told me not to buy it?

James-C said...

@TK I doubt anyone in the shop would care or think about it. I'm thinking of finding some 13yr-old to go and buy some Sepia 30C, so that I can then go yell at them for selling such stuff to under 16s...since clearly it must be dangerous if they state as much on their website.

Mike from Ottawa said...

I wonder if someone could start marketing 'fauxmeopathic products', being just lab quality distilled water: "Guaranteed to be exactly identical to expensive "homeopathic" products! Guaranteed exactly as effective as expensive 'homeopathic' products! Not even 'homeopaths' can tell them apart!" "Has your 'homeopath' tried to get you to use multiple homeopathic products? Expense adding up? One 4l jug of Genuine Fauxmeopathic Product can replace ALL your 'homeopathic' prescriptions for life! Guaranteed as effective as 'homeopathic' products!"

Set up outside homeopaths' offices and pharmacies that sell homeopathic water and give out free samples.

Holy hanna! No google hits for "fauxmeopathic". I'd better get out and trademark the term and make my fortune as a 'healer'.

guthrie said...

Mike from Ottowa - we could just make up sugar pills and water and give them away free, saying they are just as good for you as homeopathic stuff. The problem is that some people would complain later when you point out that their miraculous cure was not due to the miracle sugar pill.

And I know it would play into some people's hands, but it would be interesting to try saying only weak people need homeopathy, if you are strong enough/ know yourself well enough, you don't need the placebo effect to cure yourself. Encourage them to think that they can get better themselves without the crutch of homeopathy. Mind you there's still lots of people who suffer from that condition where you think youa re ill but aren't relaly, I can't remember what it is called.

MrAverage said...

@ Mike from Ottowa - Though I share your sentiments, I would warn that the consumption of highly purified water isn't generally recommended...

See this "renowned" reference for further info: http://en.wikipedia.org/wiki/Purified_water

The Random Pedestrian said...

"A homeopathic medicinal product without approved therapeutic indications."

I would bet you that not one customer in 20 understands what this means.

Labelling is for the benefit of the lawyers, not the patients. If you're in any doubt about this, go to fda.gov and look up the patient information for any drug you choose.

Katie said...

I never quite understood how trusted chemists (such as Boots) can get away with selling bottle of potions to vulnerable and gullible people, when in truth they're going to do as much to cure them as holy water, or even some puddle scooped up and put in a fancy bottle.

It's a sad thing indeed that in this day and age when we should have robot kitchen helpers and hovercars that we are still being tricked into buying Dr Honkton's Rejuvenating Eel Tonic. The only difference between now and the 1910 side-show is that the grifters are putting believable small print on their bottles of "cure-what-ails-ya" and they're being allowed by law to sell their wares alongside real medicine.

To pray on stupid people is one thing, but to prey on ill and desperate people is quite another, and something really needs to be done about this appalling situation. Fantastic job in going along to the demonstration, I hope absolutely nothing happens and you prove your point :)

nickthewaster said...

Excellent post Jack.

Regarding the memory of water thing, I use this thought to counter a Homeopath's argument. Since water is in a cycle of evaporation, cloud formation and precipitation, that means every molecule of water has come into contact with everything on earth. Therefore, if water has a memory, a glass of tap water should be an excellent homeopathic cure for all known diseases.

Reluctant Blogger said...

I had a quick flick through the comments and I think I am right in thinking that everyone here agrees with you. That's a pity really as it is those who do not agree with you who you need to reach. Or perhaps they are just too scared to comment?

I do agree with you re the labelling and the efficacy of homeopathic products.

However, it does concern me a little that if these products are removed, or labelled as placebos or whatever, then many people will lose access to a proper placebo. The placebo effect is well-documented but it less clear how, unless you are part of a medical trial, you get a placebo. For a placebo to work you have to believe it is something designed to tackle your symptoms. People who buy homeopathic products presumably believe and some of them will be cured because they believe. The mind is a powerful thing. You may argue that more die/suffer because they delay getting medical treatment. But it is hard to prove isn't it, that more suffer than are helped even if the product is a bottle of nothing other than belief.

The other point I wanted to make is that it is not ALWAYS right to rush down to a doctor. Many people go too soon - and get unnecessary medicines thrown at them by busy doctors, plus they spread their germs around in the waiting room and affect people who are ill. Again it is hard to know who suffers from not going to a doctor when they need to against those who do the right thing and stay at home (sending someone out to get their bottle of sugar).

I did actually give my children something (can't recall what) when chickenpox was going round. Sometimes it just feels better to be doing something than not. I'm sure it didn't help (although they didn't get bad spots) but they liked the warding-off potion.

Nick said...

@Reluctant blogger: "I did actually give my children something (can't recall what) when chickenpox was going round. Sometimes it just feels better to be doing something than not. I'm sure it didn't help (although they didn't get bad spots) but they liked the warding-off potion.
"

Homeopathic chicken soup?

Oz Digger said...

A bunch of sad looking individuals making fools of themselves. What a waste of intellect and effort. The NHS and health system would benefit from you all pooling your talents and look at some serious things affecting health. The amount of money saved by the NHS not paying for homeopathy is minuscule when you compare it to..
1) The number of prescription medications wasted, by patients not completing the dosages.
2) The "off-label" prescribing of medications for conditions they were never intended for.
3) The use of anti-depressants for mild and moderate depression.


As long as you pick "soft targets", like homeopathy, you will have no credibility with anyone, but people of the same ilk.
I am not a homeopath, but have recently been doing post-graduate studies in bioethics.

Zeno said...

Oz digger

It's sad that you don't think cases likethis are serious enough to bother about and that we are foolish to waste our time trying to educate people.

Perhaps by informing people that there really is nothing in homeopathy, they will begin to realise how they are conned by snake-oil salesmen.

I take it you are involved in the three campaigns you mention?

James-C said...

Oz Digger:

I understand your point that there are more serious wrongs in the world, and that there are certainly more serious drains on the public purse.

For example, I think the Pope being personally responsible for hundreds of thousands of deaths a year through stating that condoms help cause AIDS while in Africa is immoral and that despots like him are much worse than the whole alternative medicine malarkey rolled into one. Or, that our tax money goes towards funding many NHS chaplains (4.7FTE's worth in my local hospital), whereas I believe these should be funded by the religions themselves.

However, the difference between these issues and Boots/NHS support of Homeopathy is precisely that homeopathy is low-hanging fruit on the tree of irrationality. There are catholics who agree that homeopathy is scientifically impossible, who wouldn't necessarily agree that we should get rid of the pope. The point is that most people having the 'science' of homeopathy explained to them recognise it as bollocks...but most people don't know what it purports to be.

I don't see that there is anything wrong with moving society slowly towards more rational thinking by popularising critical appraisal of evidence and scientific thinking. It is precisely because homeopathy is a 'soft target' for anyone made aware of how it is meant to work that awareness campaigns such as ten23 are useful. All it is doing is saying: look, this is what they claim homeopathy is, use your own critical judgment to realise it is nonsense. The three issues you mention are also serious issues, but two of them have nothing to do with the general public, but with the medical community itself prescribing off-label or anti-depressants too easily. While all these may be more serious problems (I have no figures to back that up), it isn't really the kind of thing you can easily raise awareness of in the street. Hopefully point out homeopathy is nonsense is something one can do. If we stop funding it in the NHS, and boots stops selling it with the word 'medicine'/'medicinal' on it, then we'd have won. If just the market for such nonsense goes down a bit, then that is also a win.

-JamesC

Chris (from Oz) said...

On my bottle of pills, it said to take 2. But, as professional homeopaths have told us when they heard of our overdose plans, it isn't the quantity that matters. 1, 2 or the whole bottle should have the same effect. (Which is of course true. Zero would work just as well too.) So, already homeopaths disagree with Boots. They have also commented that the remedies must be individualised, and not just sold like Boots does. Can we use these disagreements between the woo-merchants to our advantage ?

Plus, do we know how Boots actually makes their homeopathic remedies ? I note that they COULD just sell sugar pills without doing any of the magic stuff, and not be found out, but of course I do NOT allege this...
What do they do though ? Do they have teams of hundreds of qualified homeopaths sitting in a big room banging test tubes on bits of leather ? Presumably they do some sort of large-scale manufacturing. Is there a way we can get the details of the full process, and ask the professional homeopaths what they think about the process ?

It's all very well having skeptics battling against Boots and other homeopaths... But what about letting Boots and the homeopaths battle it out, with a little help from us ?

If anything will get our message across to the public and cause embarrassment to Boots, it would be public arguments about what is the correct variety of leather to be banging your tube of water against, and what the difference between taking one or two pills is.

Oz Digger said...

Low flying fruit. The nail has been hit on the head. As long as you aim at soft and low targets then your credibility will be nil. Pick a hard topic, put a stake in the ground over something that has real merit and affects the health of the public. Then people may take you seriously enough to back any comments you make on weak and soft subjects such as homeopathy. At present, you appear to me to be a bunch of weak, but intelligent people, with nothing better to do than perform stunts like this.
Many people have been affected by family, friends and loved ones committing suicide. Having a demonstration of "mass suicide" by you would be seen by these people to be trivializing a traumatic and painful period in their lives. No points there for sensitivity and integrity.
I have no vested interest in the subjects I mentioned in previous posts. They are just examples of serious issues in health care that could be honestly and successfully addressed by Jack et al. My interests are more on medical ethics, which I have done post-graduate university studies in.
At present, hundreds of teenagers and young adults have attempted suicide. Some have succeeded. The common factor is that they have all been taking anti-depressants, that are prescribed only for over 18 year olds. Help these young people!!!! Don't waste your time on puerile publicity stunts.

Dr Aust said...

I think Mike from Ottawa's "faux-meopathic" medicines are a brilliant idea. I'd put the sugar in, though, as guthrie suggests. Sugar pills, sold cheap, preferably directly outside Boots and in similar looking vials marked:

FAUXmeopathic Pills

"Contains exactly the same ingredients as Major Brand Name homeopathic medicines but ONE TENTH of the price!"

Like I said, class idea Mike - perhaps ten23 could pursue it as a second phase to the campaign.

Chris (from Oz) - Boots' homeopathic pills are made, I'm sure, by Nelsons, a big homeopathic manufacturer. The dispenser gizmo is identical to what Boots sell, with only the stick-on label different. As to the "magic shaking", it will likely all be done by a machine rather than a sweating shaking homeopath - see the bits about the Helios Potentiser machine in this page from the rival homeopathic manufacturer Helios.

Since the ingredients (lactose and distilled water) are dirt cheap, the production is almost certainly mechanised, and the packaging is mass produced, I do wonder what the profit is on each "unit" that Boots are selling for just under a fiver. My other half, the medical doctor, was utterly flabbergasted when I told her what the stuff cost.

Anonymous said...

Oz Digger -

I think you managed to cram in all known fallacies and sloppy argument mistakes known to man in that diatribe. The Ad Homs and Well Poisonings alone have reached almost legendary levels of triteness. That is actually quite an achievment especially since your much touted post grad studies - tell me again, were they in bioethics or medical ethics: you seem a little hazy on that point - should have at least touched on fallacies and good argumentation. (One would think there were papers, theses and oppositions?)

You are obviously very upset and I find it hard to understand why, despite your holier than thou goal post moving from "What do we want? - Worthier causes! - When do we want them? - NOW!" to "Won't someone PLIIIZ think about the (suicidal) childrenz! And their fambliez!" in the time it takes to write out a thoughtful answer, like James Z and Zeno did.

I find you intellectually dishonest - as all goalpostmovers are.

Or to put it bluntly: Who died and made you supreme ruler of worthy causes? If you wish to argue why this particular action was not worth while, then please address the action and not which actions would have been worthier (according you your very subjective opinion)- In the end, you simply are not the boss of them, and you do not get to say who should dedicate themselves to what. The arrogance in presuming this is staggering.

The world _is_ bigger than your chosen subject, and moral outrage does not work well as an argument. JoK and friends will put their time, dedication and efforts into whatever they find worthwhile whether you like it or not. If you feel so strongly about whichever it was that you actually feel strongly about, then I suggest you put your efforts behind that, instead of trying to bully other people into doing it for you.

But be aware - if you want to raise awareness of an issue, putting it into a false dichotomy with a different issue is not going to cut it.

Kind Regards,
Jessica

guthrie said...

Actually I put sugar pill not for any grand reasons but because I was under the impression thats what they were. Ok, so the homeopathic ones, if done properly, wont have any other molecules in them apart from sugar and binder and whatever coating they get, but lets take this seriously...

Or we could do a double blind trial with pills which aren't sugar against those which are and see who reports physiological effects...

Dr* T said...

Boots have absolutely no control as to what goes on the label, I'm afraid.

This is sprecified by the MHRA and Boots are following exactly what they are required to do, the wording is not their responsibility or jurisdiction.

Homeopathy, regulation and the MHRA may be of assistance.

T

rtved said...

The Claims Made By BOOTS on their Homeopathic preparations are against the Principles of Homeopathy.

In Homeopathy There are No Treatments for specific Diseases.One Cannot say So and so Homeopathy preparation can be used against any specific diseases.

There is every Possibility that People could get Hurt if they Use these preps instead of Getting Treated By a Doctor.