The random thoughts of a sceptical activist

Landmark ASA ruling on asthma and colic

The Code of Practice for chiropractors clearly states that claims made by chiropractors have to be:

…consistent with the law and the guidance issued by the Advertising Standards Authority.

There have been several cases where the ASA have found chiropractors to be in breach of this guidance by making claims for all sorts of medical conditions, some serious. Since the adjudications form part of the ASA guidance, you’d have thought that chiropractors would be somewhat cautious about making claims that the ASA either have already rejected or ones not on the list of conditions they will allow (providing the advertiser provides convincing evidence, of course). The only condition the ASA will allow without asking for evidence is migraines (not headaches). Not even lower back pain.

And now there’s another one.

Landmark

In an adjudication, published today, the ASA yet again emphasise that chiropractors making claims must be able to provide scientific substantiation for those claims.

This time it was a chiropractor in Bury advertising in a local newspaper. He was Mark Larsen, a member of the United Chiropractic Association and he claimed:

Facilitating the correct working of the nervous system can not only ease back problems but can also help improve your general health. People with conditions like irritable bowel syndrome, recurrent colds, asthma or colic in infants often find improvement.

Of course, we’ve heard about colic and asthma recently. Only last month the GCC had to rewrite and reprint their main advertising leaflet because it made claims that were not acceptable to the ASA. Those claims included asthma and colic.

In this landmark adjudication, the ASA have now ruled that claiming chiropractic to be effective for asthma and colic breaches the CAP on the grounds of substantiation and truthfulness.

Before considering the implications of this, it’s worth looking further at the adjudication.

Not a jot

We’ve seen before on several occasions that the ASA considers mentions of medical conditions as claims to be able to treat those conditions. This is very sensible: why on earth do advertisers mention those conditions if they don’t want their readers to think they can treat them?

So, what did the advertiser have to say?

Bury Family Chiropractic (BFC) said, in relation to IBS, recurrent colds and asthma, the ad did not claim to treat or improve those conditions. Rather the ad stated that people who suffered from IBS, recurrent colds or asthma often found that chiropractic treatment they received for other conditions also improved their IBS, cold or asthma symptoms.

Treating one (unstated) condition often improved other conditions like IBS, cold or asthma symptoms?

The actual words in the advert were:

Facilitating the correct working of the nervous system can not only ease back problems but can also help improve your general health. People with conditions like irritable bowel syndrome, recurrent colds, asthma or colic in infants often find improvement.

Hmmm…

While trying to justify their position to the ASA, they claimed that chiropractic was more than, well, chiropractic:

BFC said it was the role of a chiropractor to offer dietary and lifestyle advice to patients alongside chiropractic treatments. For example lactose intolerance had been shown to cause similar symptoms to IBS, and therefore a lactose-free diet could be recommended to patients.

So they are dietitians as well?

They said they also offered advice and counselling on how to manage certain conditions, such as asthma.

And counsellors!

How do they know their approach works? What evidence did they supply to the ASA?

They said the claim was based on clinical experience and observation

That may be their experience, but it is well known that personal observation can be extremely biased. Besides, that is just not acceptable to the ASA. They require independent evidence. Oh! They had some:

[BFC] provided references to articles and papers on IBS and asthma

And what did those ‘articles and papers’ say?

BFC said there was no single cause or single effective cure or treatment known for colic, but that it was accepted that colic could be caused or triggered by other processes. They said chiropractors were trained to check for neck, back and muscular triggers to infant crying, and to try and alleviate them if present, which often improved the symptoms of colic.

Accepted by whom? What ‘muscular triggers to infant crying’? All the usual chiropractic nonsense.

The ASA decided that the words in the adverts clearly meant that:

…chiropractic manipulation could improve the named conditions.

No surprise there, then. This is in line with many previous adjudications.

They then noted that the chiropractor didn’t even bother to supply the full articles, just references to them. This didn’t faze the ASA:

…we noted that most of the articles appeared to assess the effect of lifestyle factors only, such as diet and smoking, on those conditions and, therefore, were not relevant.

You’d have thought they would have known to supply half-decent studies to the ASA and that supplying duff information wasn’t likely to persuade them one jot.

But there’s hope yet! What about the other articles?

Some studies showed the effect of the Buteyko breathing method, which we understood could be taught by a chiropractor, on the symptoms of asthma and were relevant.

So, they were trying to substantiate chiropractic for the treatment of asthma with studies on breathing? I have no doubt a chiropractor could be trained in the ‘Buteyko breathing method’, but chiropractic it ain’t.

Finally, we get to the nub:

However, because we had not seen robust scientific evidence, such as controlled clinical trials, that showed that chiropractic could improve asthma or the other conditions named in the ad, IBS, recurrent colds and colic in infants, we concluded that the ad was misleading.

The ASA found the advert:

…breached CAP Code clauses 3.1 (Substantiation), 7.1 (Truthfulness) and 50.1 (Health and beauty products and therapies).

Is anyone paying attention?

Any chiropractors listening? They should be. This is ASA guidance. It’s what you are bound to follow. Bound by your very own Code of Practice. Got it yet?

It seems like Bury Family Chiropractic hasn’t.

After getting this adjudication against against their newspaper advert (they will have received notice of it more than a week ago), they should really have updated their website to remove these misleading claims.

However, they’ve not done that yet. They are still making claims for colic (cached) and asthma (cached). Nothing specifically about IBS or colds, but a lot about ear infections (cached) and ‘wellness‘ (cached).

Is there a Doctor in the house?

Not content with a concerned member of the public complaining about these claims, the ASA added their own complaint:

The ASA challenged whether the use of the term ‘Dr’ misleadingly implied that Dr Larsen held a general medical qualification.

The chiropractor styles himself as:

Dr Mark Larsen, principle [sic] chiropractor, at Bury Chiropractic

(It looks like some chiropractors don’t know the difference between ‘principle’ and ‘principal’, just like some don’t know the difference between ‘complimentary’ and ‘complementary’. In principle, it should be easy…just like the difference between ‘evidence’ and ‘anecdote’.)

Anyway, BFC stated:

…they understood that a chiropractor could use the courtesy title ‘Dr’ in their advertising, as long as it was clear that they were a chiropractor and the ad did not imply that they were a medical practitioner. They believed the ad conformed to that position; it clearly stated that Mark Larsen was a chiropractor and described what kinds of conditions he treated and the methods he used. BFC said they would include further qualification to the term ‘Dr’, should they use it again in future advertising.

The ASA’s guidance (free registration required) on the use — or rather misuse — of the title Dr is very clear:

In general, CAP advises that if they do not possess a general medical qualification advertisers should not call themselves “Dr”.

Advertisers who are not medical practitioners but who hold the courtesy title “Dr” (for example, a chiropractor or a dentist) may refer to themselves as “Dr” as long as the similarities and differences between the practitioner’s qualifications and medical qualifications are explained in detail in the advertisement (Midland Chiropractic Group, 28 February 2001). Such explanation should go substantially further than, for example, simply stating “Dr is a courtesy title” in a footnote. The latter is likely to contradict the initial impression, given by the use of the title “Dr”, that the practitioner is medically qualified.

Although we can’t see the whole advert, it looks like Larsen wasn’t making it at all clear he was only a chiropractor, using Dr as a courtesy title and that he did not have a general medical qualification.

The ASA agreed, saying:

We considered, however, that consumers were likely to understand that claim, and the title ‘Dr’ repeated throughout the ad, to mean that Dr Larsen held a general medical qualification, as well as practising as a chiropractor. We welcomed BFC’s assurance that future ads would be amended. However, because we understood that Dr Larsen did not hold a general medical qualification we concluded that the use of the term ‘Dr’ was likely to mislead.

…and said the advert the ad breached CAP Code clause 7.1 (Truthfulness).

Of course, this is also covered by chiropractors’ Code of Practice:

C1.8 must not use any title or qualification in such a way that the public may be misled as to its meaning or significance.chiropractors who use the title of ‘doctor’ and who are not registered medical practitioners must ensure that they make it clear that they are registered chiropractors and not registered medical practitioners.

Although this is worded slightly differently, the essence is exactly the same and it should be obvious to any chiropractor who was concerned about breaching their contract with the GCC that they need to be absolutely clear that they are not what the general public might call ‘proper doctors’, of the GP kind — the only type of doctor many know.

Just not acceptable

Until today, we knew asthma and colic were unlikely to be acceptable claims because they were not on the list of conditions the ASA would allow for chiropractic.

However, we now have an unequivocal adjudication that claims about asthma and colic are not acceptable. It is reasonable to assume he would have searched high and low for the best evidence available, but he has been unable to come up with any that satisfied the ASA’s criteria.

It’s certainly possible that some other chiropractor just might be able to provide the evidence that would convince the ASA, but, in the light of the utter demolition of the British Chiropractic Association’s plethora of evidence, that seems highly unlikely.

And with the chiropractors’ Code of Practice totally dependent on the ASA guidance, perhaps we’ll see a mass takedown of these claims from chiropractic websites all over the country in the next few days. We know they can act quickly — they certainly did when the McTimoney Chiropractic Association issued its panic email.

Will they be so diligent this time?

Dr. Mark Larsen

8 Responses to Landmark ASA ruling on asthma and colic

  • Might Larsen find himself subject to a new complaint to the GCC for the persistence of his website claims and his previous (and any continuing) use of the title Dr on his website or anywhere else? It would seem to me that these could be the basis of complaints even if he has already been included in the 600 already made. Basically this new ASA ruling provides the opportunity for a more finely targeted complaint to be made with possibly more serious aggravating factors.

  • “Bury Family Chiropractic said…the ad did not claim to treat or improve those conditions. Rather the ad stated that people who suffered from [those conditions] often found that chiropractic treatment they received for other conditions also improved their…symptoms.”

    I don’t see what difference it makes. They still need evidence that people who suffer from [those conditions] often find that chiropractic treatment they received for other conditions also improved the symptoms of [those conditions].

    Cure. Treat. Improve. Who cares what word they use. They still need evidence that is “cures” “treats” or “improves”

  • I’m with BillyJoe. The language they use is, I would say, misleading by omission. I am therefore suspicious about the underlying intent. Are they really trying to inform their customers/patients?

    “[BFC argued that their] ad stated that people who suffered from [those conditions] often found that chiropractic treatment they received for other conditions also improved their…symptoms.”

    How very lawyerly. Let’s take the phrase in the original ad:

    “People with conditions like irritable bowel syndrome, recurrent colds, asthma or colic in infants often find improvement.

    What is omitted is, say, a sentence that follows this and says:

    “However, it is important to be aware that these conditions often improve on their own anyway”.

    It is the omission of this which is the sneaky bit.

    Cf the GCC’s:

    “There is some evidence, though more research is needed, that [if you see a chiropractor] you may see an improvement in some types of asthma… headaches, including migraine…and infant colic”

    Again, where is the qualifying sentence saying these things are episodic or may be self-limiting?

    If one may take a leaf out of the libel law playbook, one really has to ask how an average reader will interpret, in their presented context, the phrases in ads (chiropractors), or in info directed at the public (GCC). As penned by the chiropractors and the GCC, and then read by an ordinary punter, they seem to me to be quite misleading.

    The million pound question is why they are not changed to make them less so.

  • Another excellent blog post Zeno.

    I’m a bit confused about them using the title Dr in their ads.
    Is the folowing acceptable by the ASA?

    Dr Joanne Middleton
    Chiropractor
    and associates.

    That’s exactly how it appears in the newspaper ad.
    I have complained twice to the ASA about this woman, I got acknowledgements of my complaints but she is still calling herself DR some six months after my initial complaint.

  • Alan

    Have the ASA investigated yet?

  • Now there’s an idea, BSM! Would you like to make a complaint?

    BillyJoe/Dr Aust: I think the ASA have made it very clear that woolly weasel words like those will not avoid the CAP. For example, see A claim or not a claim: that is the question.

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