ASA Adjudication on Southampton City Primary Care Trust

Ad

A regional press ad and postcard delivered to residents in Southampton promoted Southampton City Primary Care Trust's support for the South Central Strategic Health Authority's proposals to adjust the level of fluoride in the water in the local area.

a. The press ad was headed "Topping up the natural fluoride levels in our water will reduce tooth decay". Text in bold stated "A shocking 42 per cent of children in the City who have experienced bad teeth have an average of more than four decayed, missing or filled teeth". The body copy stated "Each year, community dental services have to extract hundreds of youngsters' teeth under general anaesthetic ... The figures also show that the children suffering most live in Southampton's most deprived neighbourhoods, despite good NHS dentist access ... You are probably already familiar with fluoride. It's in the toothpaste we use to brush our teeth and it naturally appears it [sic] in our water in Southampton. But there's not enough to protect our teeth. By topping it up to one part of fluoride per one million parts of water (1ppm), it would be possible to make a major difference to the teeth of adults and children locally, and for future generations".

A panel on the left-hand side of the page was headed "What fluoridation would mean for the City of Southampton" Bullet-pointed text stated "less tooth decay for children and adults; less toothache and associated pain; fewer teeth having to be filled or extracted; less general anaesthetics needed for dental treatment ... ". A panel in the middle of the page was headed "Give your support to proposals for fluoridation of local water supplies today ... Southampton City PCT wholeheartedly supports the proposals and calls on those who live and work in the areas that would benefit to use this golden opportunity to express your support to the SHA ... ".

On the right-hand side of the page was a picture of Southampton's Public Health Director. Text stated "Doctor in charge of Southampton's public health says fluoridation is safe and effective". Further text stated "Dr Jacky Chambers, Director of Public Health, Heart of Birmingham Teaching PCT, recently said 'Our own monitoring of local health trends confirms the best available scientific evidence that 1ppm of fluoride - something that occurs naturally in many places, including Uttoxeter in our own region - does not cause health problems. If it did we would do something about it. But it doesn't".

b. The postcard was headed "Water fluoridation Healthier teeth on tap" and showed a picture of a woman holding a glass of water. Text stated "Southampton City Primary Care Trust (PCT) wants the natural fluoride level in local water supplies to be topped up to reduce high levels of tooth decay". The reverse of the postcard stated "Fluoride is a mineral which appears naturally in Southampton's water supply. Southampton City PCT supports topping up the fluoride to reduce tooth decay ... ".

Issue

Three complainants, including Hampshire Against Fluoridation and UK Councils Against Fluoridation, challenged whether the claims "Topping up the natural fluoride levels in our water will reduce tooth decay" in ad (a) and "Southampton City Primary Care Trust (PCT) wants the natural fluoride level in local water supplies to be topped up to reduce high levels of tooth decay" in ad (b) were misleading because:

1. they implied the fluoride (hexafluorosilicic acid) that would be added to water supplies was the same as naturally occurring fluoride (calcium fluoride), and

2. they implied a small amount of hexafluorosilicic acid would be added to a larger amount of naturally occurring fluoride, when the reverse was true.

3. Hampshire Against Fluoridation and one member of the public challenged whether the claim "Our own monitoring of local health trends confirms the best available scientific evidence that 1ppm of fluoride ... does not cause health problems. If it did we would do something about it. But it doesn't" in ad (a) could be substantiated.

4. Hampshire Against Fluoridation, UK Councils Against Fluoridation and one member of the public challenged whether ad (a) was misleading because it did not make clear that increasing the amount of fluoride in the water could lead to increased levels of dental fluorosis in the population.

5. UK Councils Against Fluoridation challenged whether the claim "42 per cent of children in the City who have experienced bad teeth have an average of more than four decayed, missing or filled teeth" in ad (a) could be substantiated.

CAP Code (Edition 11)

Response

1. Southampton Primary Care Trust (Southampton PCT) said there was no difference between the fluoride ions that came out of taps in naturally fluoridated areas and those in artificially fluoridated areas. They sent a statement from Southampton University's Professor of Biochemistry, Keith Fox. It explained that hexafluorosilicate, which was added to increase the fluoride concentration, was fully dissociated in water, and the fluoride that was released was no different from the 'natural fluoride' that was already found in Southampton water at 0.08 parts per million. They said that that meant there was no chemical difference between the fluoride ions in Southampton's water that derived from compounds added to raise the total fluoride concentration, and the fluoride present as the result of naturally occurring compounds already present in the water. They referred to three peer reviewed scientific studies to support that view.

2. Southampton PCT said they disputed the claim that the verb "to top up" implied the amount added was less than the amount already present. They said that in common usage the expression "May I top up your glass?" applied both to when a glass was almost empty as well as when it was over half full. They said the Oxford English Dictionary defined the verb as "an addition; that which serves to complete an amount or number; a filling up to the top of something already partly full".

3. Southampton PCT pointed out that the quotation reflected the view of the Director of Public Health and Consultant in Dental Public Health of Heart of Birmingham PCT, an area where the water had been fluoridated since 1964. They said the quote accurately reflected the view of Dr Chambers, and the assessment was a matter of professional judgement for her and her department. Additionally, they referred to a number of studies assessing the safety of fluoride, including the 1985 Knox report, the York review, the subsequent review by the Medical Research Council and the 1976 report "Fluoride, Teeth and Health" by the Royal College of Physicians.

4. Southampton PCT said the issue of dental fluorosis was dealt with in detail on their website under the heading "Fluoridation - The Issues". They said the press ad formed part of a series of four ads that were designed to discuss different issues in relation to fluoridation. They said the issue of dental flourosis had featured in the second ad in the series. They underlined that the public consultation document published by the South Central Strategic Health Authority went into detail on the question of a possible rise in the prevalence of dental fluorosis of aesthetic concern. They pointed out that it would be unreasonable to expect every communication issued as part of a three-month long public health consultation to deal with every issue associated with fluoridation.

5. Southampton PCT sent the results of a survey carried out between 2005 and 2006 on the dental health of five-year-olds in Southampton. They said the survey formed part of a wider national survey co-ordinated by the British Association for the Study of Community Dentistry. The data showed that the average five-year-old had 1.78 teeth decayed, missing or filled, that 42% of five-year-olds had caries experience, and that the average number of decayed, missing or filled teeth among the 42% with caries experience was in excess of four.

Assessment

1. Not upheld

The ASA considered the evidence sent by the PCT. We noted their argument that fluoride ions derived from compounds added to raise the concentration of fluoride in the water were not chemically different from those ions derived from naturally occurring compounds. Although we noted fluoride added to drinking water was not derived from the same source as naturally occurring fluoride, we considered that that was not the claim made in the ad. We considered that readers would understand the use of the word "natural" in the claims "Topping up the natural fluoride levels in our water ... " and "Southampton City Primary Care Trust wants the natural fluoride level in local water supplies to be topped up ..." to refer to the fluoride that occurred naturally in the water. We did not consider those claims implied any fluoride added to the water supply was the same as naturally occurring fluoride. We concluded the ad was not misleading.

On this point we investigated ads (a) and (b) under CAP Code clauses 3.1 (Substantiation) and 7.1 (Truthfulness) but did not find them in breach.

2. Not upheld

Although we noted the phrase "topping up" could be used when the amount added was larger than the amount already present, we did not consider its use was exclusively limited to that context. We accepted that the verb "to top up" could also apply when the amount added was the same or less than the amount already present. On that basis we therefore concluded the ads were not misleading.

On this point we investigated ads (a) and (b) under CAP Code clause 7.1 (Truthfulness) but did not find them in breach.

3. Not upheld

We accepted that the quotation in the ad accurately reflected the views and monitoring practice of Heart of Birmingham PCT. Because that view was accurately represented, and the source was clearly cited, we concluded the ad was not misleading.

On this point we investigated ad (a) under CAP Code clauses 3.1 (Substantiation), 7.1 (Truthfulness) and 8.1 (Matters of opinion) but did not find it in breach.

4. Not upheld

We noted that the ad formed part of a wider campaign in which the PCT drew attention to different issues surrounded fluoridation. We noted they had addressed the issue of dental fluorosis in a separate ad, and on their website under the heading "Fluoridation - The Issues". We accepted their argument that different issues relating to fluoridation could be addressed in different ads published during the three-month consultation process. Because Southampton PCT had shown that they addressed the issue of dental fluorosis in another ad that formed part of the same campaign, and on their website, we did not consider the ad being complained about needed to include that information. We concluded the ad was not misleading.

On this point we investigated ad (a) under CAP Code clauses 3.1 (Substantiation) and 7.1 (Truthfulness) but did not find it in breach.

5. Not upheld

We accepted the evidence substantiated the claim "42 per cent of children in the City who have experienced bad teeth have an average of more than four decayed, missing or filled teeth". We concluded the claim was not misleading.

On this point we investigated ad (a) under CAP Code clauses 3.1 (Substantiation) and 7.1 (Truthfulness) but did not find it in breach.

Action

No further action necessary.

Adjudication of the ASA Council (Non-broadcast)