Sunday, 12 November 2017

NHS Homeopathy #2 - More on GP Prescribing

A previous post discussed the NHS England Items which should not be routinely prescribed in primary care: A Consultation on guidance for CCGs. The intention was that this second post on NHS homeopathy would look at GP prescribing data in some detail in. However delays in obtaining the relevant data and certain events have conspired against this.

Some groups and individuals who support homeopathy have responded to the Government response to the petition started by Cristal Sumner CEO of the British Homeopathic Association (BHA). Also, the BHA have started a crowd funding campaign to apply for permission for a judicial review.

Responses to the Government Response
It would appear that the responses of the various UK homeopathy organisations are almost identical. This is not surprising as UK homeopathy tends to coordinate its PR somewhat better than it did in the past in the guise of a group known as 4Homeopathy. To quote from one post -
In essence, the government hasn’t replied to the evidence brought forward in favour of homeopathic and other complementary treatments. Their response blames the rising costs of all prescriptions, citing the need to cut medicines considered of low clinical value. Despite all evidence provided proving the benefits of homeopathy, the statement concludes that: 
“… We are not aware of any evidence that demonstrates the therapeutic effectiveness of homeopathic products.”
The problem here is that the evidence that homeopathy groups and individuals would have submitted would not prove homeopathy to have any benefit beyond placebo. Government, or more specifically the Department of Health, has replied. If UK homeopathy is expecting a point by point refutation of the "evidence" they supplied, it is deluded.

There were also bizarre reactions from the likes of Steve Scrutton but they are of no consequence beyond a possible comedic value.

Messages were also disseminated by 4Homeopathy et al to "keep up the pressure" on NHS England. To quote -
We all need to maintain the pressure during this critical time, to make decision-makers aware of the issues and inconsistencies which plague the consultation and its process. 
MPs need to be aware that NHS England is basing its decisions on a fundamentally flawed report which is not peer-reviewed evidence. Please write to your MP to make them aware of the issues and your concerns. To help create a letter we have provided some helpful information. Read through the points in our template letter, and please write in your own style to help ensure it is opened and read. 
Over 20,000 people have signed the parliamentary petition—Stop NHS England from removing herbal and homeopathic medicines—letting the government know that homeopathy should not have been part of the consultation. Keep sharing so we can have a stronger voice in representing patients and the public.
Although this does not mention it, there is an assumption that if the petition reaches 100,000 signatures, it will be debated in Parliament. The reality is that it may be debated. However, as discussed in the previous post, the petition is factually incorrect. A debate around a petition that states NHS England is attempting to ban GP prescribing herbal and homeopathic medicines when it doesn't have the powers to do so would not really be a debate.

And most recently, this -
The NHS is slowly dismantling our healthcare choices without proper and lawful consultation. 
Two days ago, the British Homeopathic Association (BHA) commenced its legal challenge, asking for a judicial review of the NHS England consultation, Items which should not be routinely prescribed in primary care. 
We have, from the outset, believed this consultation to be flawed, on a number of levels. Not only was the timing of the consultation suspect, homeopathy experts and practitioners were not consulted for the drafting of the proposal itself. But, most of all, it is obvious that this consultation never represented a genuine attempt to engage consultees – which is strongly suggestive of a pre-determined decision, one not to be overturned regardless of the outcome. 
We invite you to visit the British Homeopathic Association’s website to read the full reasoning behind the drive for this judicial review, but also to help support part of the legal costs they will face to get this judicial review.
Putting aside the matter of the judicial review, there are fundamental problems with the above. Nowhere is it made clear on what grounds the consultation is considered unlawful. Nor is any reason given why the timing is "suspect". Anyone with experience of being involved with NHS public consultations will understand that in most cases the decision is predetermined. Public consultation can be regarded as rubber stamping exercise.

Consultation Revisited
Before looking at the BHA's attempt to gain a judicial review, it is necessary to have some context. Returning to the consultation it states -
The commissioning guidance, upon which we are consulting, will be addressed to CCGs to support them to fulfil their duties around appropriate use of prescribing resources. It is proposed that the guidance will be statutory guidance issued under S14Z8 of the NHS Act. We expect CCGs to take the proposed guidance if and when issued into account in formulating local polices, and for prescribers to reflect local policies in their prescribing practice. The proposed guidance does not remove the clinical discretion of the prescriber in accordance with their professional duties.
Statutory guidance is a concept that is rarely explained very well. Essentially, some bodies are empowered by law to issue guidance that must legally be taken into due consideration by the persons/other bodies under the control of the first body. This does not mean that the guidance must be implemented but it necessary to demonstrate that due consideration has taken and the reasons why the guidance has not be implemented must be made clear. In most cases, statutory guidance is implemented. In the case of NHS England, it is not clear what sanctions are available in the case of non-compliance.

It is worth pointing out that the majority of CCGs are already largely compliant with any statutory guidance that may be enacted through local prescribing policies and formularies. It is also clear that there is an expectation on the part of NHS England that prescribers with abide by the guidance. Most GPs already do to some extent and will likely comply without issue.

It is important to note that NHS England says the guidance will not remove clinical discretion.

Rules for Public Consultation
An excellent presentation can be found on the Healthwatch website. It contains lots of references for the interested reader.

Government guidance can be found here. The principles are fairly self explanatory. 

GP Contract
As mentioned in the previous post, GPs are not directly employed by NHS England. They are contractors - generally CCGs contract with GP practices rather than individuals. The GP Contract is a contract in terms of law. The current GP Contract can be found here. Unfortunately, it is various parts and difficult to navigate. It is actually easier to look at the standard contract from 2016/17.

It is a long document and much of it is not relevant to this post. Section 14 deals with prescribing and dispensing. 
The Contractor must comply with any directions given by the Secretary of State for the purposes of section 88 of the 2006 Act as to the drugs, medicines or other substances which may or may not be ordered for patients in the provision of medical services under the Contract.
The Act in question is the National Health Service Act 2006. The relevant parts of section 88 state -
(1) A general medical services contract must contain provision requiring the contractor or contractors to comply with any directions given by the Secretary of State for the purposes of this section as to the drugs, medicines or other substances which may or may not be ordered for patients in the provision of medical services under the contract. 
(2) A direction under this section must, subject to subsection (3), be given by regulations.
The regulations mentioned start from National Health Service (General Medical Services Contracts) (Prescription of Drugs etc.) Regulations 2004. In theory, the Regulations should be updated every year or so but were last done so in 2014. The Regulations represent the blacklisting/greylisting of medicines.

Non-compliance with the GP Contract can result in termination of the Contract or the withholding of monies. However, the process involved is cumbersome. It is not immediately clear if there are processes and systems in place that prevent the prescribing of medicines that are blacklisted. It would make sense if GP and community pharmacy IT systems prevent the prescribing/ordering of such medicines.

Local CCG prescribing policy and formulary enforcement
As stated in the previous post, CCGs do not seem to have any real sanctions against GPs who breach local prescribing policies. This article from the British Medical Association (BMA) spells this out in very clear terms even though it deals with excessive prescribing.

All the above makes clear the nature of the Consultation,the invalidity of petition raised by the BHA and the various "campaigning" communications.

Judicial Review
In essence, a judicial review is when a court is asked to rule whether the actions of a public body that result from powers granted to them by legislation are lawful. Judicial reviews often involve examining the decisions made by public bodies and whether the decisions are lawful. Often the process by which a decision is made is examined.

The Ministry of Justice has published the very useful Pre-Action Protocol for Judicial Review which unsurprisingly outlines the steps that should take place before an application is made for a judicial review. As it points out, the courts take the view that judicial review is a last resort and that alternative means of dispute resolution should be explored.

Before a judicial review takes place, it is necessary to apply to the High Court for leave to persue judicial review. The Court will not automatically grant leave. A number of factors may be taken into account -

  • Whether alternative dispute resolution has been exhausted
  • Whether the application has been made in time (typically a 3 month deadline)
  • Whether the applicant has sufficient legitimate interest (standing)
  • Whether the application concerns public law, rather than tort or contract law
If the Court feels strongly enough, leave may exceptionally be granted even if not all of these conditions are met.

Assuming that leave is granted for a judicial review, the Court will take into account various factors. 
  • Illegality (which can involve the Human Rights Act)
  • Irrationality (Unreasonableness)
  • Fairness
  • Procedural impropriety (statutory procedures have not been followed)
  • Legitimate expectation (basically where the complainant has been lead to believe that certain steps would take place and have not)
If the Court finds in favour of the complainant, there are a number of options available.
  • Quashing order (basically overturning a decision made by a public body)
  • Prohibiting order (prohibiting a public body from acting on a decision)
  • Mandatory order (ordering a public body to act when the decision was one of inaction)
  • Declaration (basically stating what the legal position of the parties are without making any order)
  • Injunction
  • Damages (rare)
  • Do nothing
The Public Law Project has produced a guide that is much easier to read that the Wikipedia article.

The costs of applying for leave for a judicial review are those of employing solictors and a barrister as well as a fee of £60 to the courts. These costs are non-recoverable. The legal fees will vary - it depends on how much work is involved.

If judicial review is granted, a court fee of £215 is payable. Again, the legal costs are difficult to ascertain but figures of £30,000 upwards have been mentioned. Something else that needs to be considered is that the losing party may be ordered to pay the costs of the opponent. In the case of a complainant losing to a public body, the costs could be considerable. Although things like Protective Costs Orders exist that can limit costs, these are only granted in genuine public interest cases.

Crowdfunding of a judicial review raises the question if costs are awarded, if and how they are returned to the funders.

 Aims of the BHA
One question that needs to be considered is whether the BHA has standing enough to warrant their application for a judicial review.Their about us says -
The principal objects of the charity are to promote and develop the study and practice of homeopathy and to advance education and research in the theory and practice of homeopathy provided that the useful results of such research shall be published.
 The entry at the Charity Commission states their activities are -
It is unclear whether a court would regard the BHA as having standing.

Previous Application for Judicial Review
The BHA did seek judicial review of the Lothian Health Board decision to decommission homeopathic clinic services. Or rather, they did so through a proxy. Andy Lewis wrote about this at some length so there is little point in repeating his analysis here.

The application for judicial review was dismissed. It is worth repeating a statement from the judge -
In any event, even if I had concluded that the Board had failed to comply with its PSED [public sector equality duty], I would have refused to reduce the decision under review. It is plain that the Board, as it was entitled to do, accepted the view that there was no scientific evidence for the efficacy of homeopathy and that funding for it was a waste of the limited funds at its disposal. In these circumstances the countervailing factor in this case was so powerful, indeed overwhelming, that no decision other than the one taken by the Board was conceivable. A different decision, namely, to continue spending money on a service whose efficacy was not established, would have been unreasonable.
It is difficult to say whether this sets a precedent.

The BHA Application for Judicial Review
The BHA state on their website -
The judicial review seeks, among other things, a declaration that NHS England has acted unlawfully in relation to its proposals, its failure to consult on them properly and to listen to patients! If successful, we can protect the right of patients to choose to be treated with homeopathy on the NHS and the right of the public to properly have input on the services that their National Health Service provides.
The crowdfunding page adds - 
We have commenced an application for judicial review on the basis that consultation was fundamentally flawed from the outset in that the proposal was not formulated with input from any homeopathy experts or practitioners; it was not a genuine attempt to engage consultees (a decision having been ostensibly predetermined) and did not provide consultees with adequate information on which to provide a considered and informed response.
Again, it is not clear on what grounds the BHA believe the consultation to be unlawful. 

There are questions regarding the existence and credibility of homeopathy "experts". It could be read as implying that BHA believe that NHS England is somehow incapable of evaluating evidence. It is not uncommon for homeopathy supporters to state that only those "qualified" in homeopathy are able to make judgements on its merits. This was dealt with in this post.

It is clear that scientific and medical consensus is that homeopathic medicines have an effect that is consistent with placebo and no greater. The National Institute for Health and Care Excellence (NICE) makes it clear that homeopathy is not recommded and that health professionals should make this clear to patients.

In terms of practitioners, although the data analysis has yet to be completed, it seems likely that the number of NHS England GPs who routinely prescribe homeopathic medicines is very low - a few tens. NHS England is under no obligation to consult with "practitioners" who i) are medically qualified and work in the private sector or ii) lay homeopaths or iii) homeopathy advocacy groups that do not directly represent either NHS practitioners or NHS patients. 

The number of patients prescribed homeopathic medicines by these tens of GPs is unknown. Whilst the number of prescriptions is known, it is unknown how many of these are repeat prescriptions. 

As the outcome of the consultation is not yet know the application can only be on the basis of process. It certainly the case that the consultation period was long enough. The consultation was widely publicised, especially by homeopathy supporters. Questions about whether enough engagement with patients etc was carried out are moot given the publicity.

The BHA's previous attempt at an application for judicial review focused on questions of health inequality. NHS England has addressed this here.

Without wishing to prejudge what the High Court determines, it seems very unlikely that leave for a judicial review will be granted. Even if it were, it is difficult to understand exactly what the BHA hope to achieve. It would be easy for NHS England simply to remove the sections of the Consultation that relate to homeopathic and herbal medicines. Not that it would change very much - CCGs would still be able to have local prescribing policies against such medicines.

The danger for the BHA and UK homeopathy in general is that any hearing could end up as placing the efficacy and validity of homeopathic medicines on trial. It could easily set a precedent that impacts on any further attempts by NHS England and/or CCGs to limit prescribing or comissioning of services.

The reputational damage that a hearing could cause for the BHA is impossible to estimate. If the mainstream media wereinterested, it could be considerable.

Tuesday, 24 October 2017

More on CEASE Therapy

The nature of CEASE Therapy was discussed in a previous post. There was also a post listing some UK practitioners and also another post listing Irish practitioners.

Whilst the latter two posts were not intended as "name and shame", it is disappointing to note that none of the mentioned practitioners seem to have amended their claims. Of course, it is entirely possible that they are unaware of these posts.

This will be a short post for this blog.
This website was analysed in quite some depth in the first linked post, so it makes little point repeating here. However, it is important to note that linkage to this website does have repercussions in the degree to which a practitioner's website is in compliance with their trade association's Codes of Ethics, advertising regulation, consumer protection law and even medicines regulation.

The Stichting Reclame Code (SRC) is the Dutch Advertising regulation, very much like the UK ASA. It recently published a ruling against the website - unfortunately in Dutch but in summary -
The complaint refers to a website on which the CEASE-therapy is proposed as a "very effective way to treat autism with amazing results". This is explained by saying that the CEASE-therapy ‘detoxes’ all causes of autism with a homeopathic prepared substance. On the website, there’s a possibility to order books about the CEASE-therapy and to take a course about this therapy. Also the nearest “Cease therapist” is shown. Because of this all, the website has to be considered as an advertisement for the CEASE-therapy and falls therefore within the meaning of article 1 of the Dutch Advertising Code (NRC). Not relevant is that, according to defendant, there is no financial or commercial interest in the website nor that the website is only meant as an opinion about the CEASE-therapy.

Defendant has not substantiated that the CEASE-therapy is an effective way to treat autism and that the CEASE-therapy can treat autism with "amazing results". The average consumer will perceive this as 'Healing'. Therefore, defendant is falsely claiming that the product may cure illnesses, ailments or malformations as referred to number 16 of annex 1 to article 8.5 NRC.

Further, the defendant didn’t substantiate that autism can be caused by vaccinations of children or their parents. As a causal link between vaccination and autism is not proven, the advertisement appeals without justifiable reasons to feelings of anxiety as referred to in article 6 NRC.
The SRC has instructed the owner of the website to make amendments to comply with the Dutch advertising code. Amendments have yet to be made. If they are not, the SRC can contact the Autoriteit Consument & Markt (ACM) - which has the legal powers to enforce consumer protection legislation.

It's not clear how the website can comply. The links promoting the book, training courses and the practitioner directory would have certainly have to be removed but even then much of the content could well be considered advertisement.

It's problematic enough for UK and Irish practitioners to link to the CEASE therapy website but some have quite detailed entries on the practitioner lists which would place them in breach of regulations etc even if their own websites are compliant.

Given that in several jurisdictions it has been established that promotion of CEASE therapy is question able to say the least, the practitioner lists do potentially provide a list of people to be reported to regulators, trade associations, etc. Assuming anyone was motivated to do that.

As seen in previous posts, promotion of CEASE therapy on a website is often associated with other non-compliance. Any reporting of CEASE therapy could well result in scrutiny that would bring that to light.

Thursday, 12 October 2017

Letter to Twitter

Twitter, Inc.
c/o Trust & Safety – Legal Policy
1355 Market Street Suite 900
San Francisco, CA 94103

To whom it may concern,

Violations of (Indian) The Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954 and The Homoeopathic Practitioners - (Professional Conduct, Etiquette & Code of Ethics) Regulations 1982

It has come to my attention that there are many Indian homeopaths and homeopathic medicines manufacturers who use Twitter as a form of promotion for their business. Some examples would include -

  • @HomeoPositive - Positive Homeopathy
  • @homeosure - Homeosure
  • @drcarehomeopath - Dr. Care Homeopathy
  • @drsantoshhealt2 - dr.SantoshHealthcare
  • @HomoeopathyDr - Dr. Naik Homoeopathy
  • @drrajneesh - Dr. Rajneesh Sharma
  • @Baksons - Bakson's Homoeopathy
  • @ShreeHomoeo - Shree Homoeo
  • @homeohealer - Dr.Ramesh Bhardwaj

There are many more of them. It is clear that all of them are in breach of Indian legislation and regulations. It is also likely that there are in breach of Twitter standards in that they are using the platform for illegal advertising. In some cases, it would appear that Twitter is in breach of Indian legislation by providing a platform.

Homoeopathic Practitioners Regulations
The Homoeopathic Practitioners Regulations ( effectively bar all forms of advertising beyond simple listings if changes to address, etc, occur. It also prohibits publication of case details outside of specialist media. To quote section 6.

  1. Advertising Solicitation of patients directly or indirectly by a practitioner of Homoeopathy either personally or by advertisement in the newspapers, by placards or by the distribution of circular cards or handbills is unethical. A practitioner of Homoeopathy shall not make use of, or permit others to make use of, him or his name as a subject of any form or manner of advertising or publicity through lay channels which shall be of such a character as to invite attention to him or to his professional position or skill or as would ordinarily result in his self-aggrandisement provided that a practitioner of Homoeopathy is permitted formal announcement in press about the following matters, namely :-
i) the starting of his practice;
ii) change of the type of practice;
iii) change of address;
iv) temporary absence from duty;.
v) resumption of practice
vi) succeeding to another’s practice.

  1. He shall further not advertise himself directly or indirectly through price lists or publicity materials of manufacturing firms or traders with whom he may be connected in any capacity, nor shall he publish cases, operations or letters of thanks from patients in non-professional newspapers or journals provided it shall be permissible for him to publish his name in connection with a prospectus or a director’s or a technical expert’s report
Additionally, the Regulations mention the need to comply with legislation.

Physician to obey law and regulation:-

A physician, –

  1. shall not act contrary to the laws regulating the practice of Homoeopathy;
  2. shall not assist others to disobey the law regulating the practice of Homoeopathy;
  3. shall act in aid of the  enforcement of sanitary laws and regulations in the interest of public health;
  4. shall comply with the  provisions of the Drugs and Cosmetics Act, 1940 (23 of 1940), Drugs and Cosmetics Rules, 1945; the Pharmacy Act, 1948 (8 of 1948); the Narcotic Drugs and Psychotropic Substances Act 1985 (61 of 1985); the Medical Termination of Pregnancy Act, 1971 (34 of 1971), the Transplantation of Human Organ Act, 1994 (42 of 1994); the Persons with Disabilities (Equal Opportunity and Full Participation) Act, 1995 (1 of 1996) and Biomedical Waste (Management and Handling) Rules, 1998 and such other related Acts, Rules, of the Central Government or the State Government  or the Local Administrative bodies relating to protection and promotion of public health.

The Central Council for Homeopathy is the statutory body responsible for enforcement of these regulations. However, it has devolved them to State level bodies.

Drugs and Magical Remedies Act
Although the Regulations do not specifically mention it, it is clear that compliance with the Act ( is a requirement.

This is arguably the most important piece of legislation covering advertising of homeopathic medicines as it places absolute prohibition on advertising medicines for certain diseases.

3. Prohibition of Advertisement of Certain Drugs for Treatment of Certain Diseases and Disorders.–
Subject to the provisions of this Act, no person shall take any part in the publication of any advertisement referring to any drug in terms which suggest or are calculated to lead to the use of that drug for –  
a) the procurement of miscarriage in women or prevention of conception in women; or  
b) the maintenance or improvement of the capacity of human beings for sexual pleasure; or
c) the correction of menstrual disorder in women; or  
d) the diagnosis, cure, mitigation, treatment or prevention of any disease, disorder or condition specified in the Schedule, or any other disease, disorder or condition (by whatsoever name called) which may be specified in the rules made under this Act:  
Provided that no such rule shall be made except,–
(i) in respect of any disease, disorder or condition which requires timely treatment in consultation with a registered medical practitioner or for which there are normally no accepted remedies, and  
(ii) after consultation with the Drugs Technical Advisory Board constituted under the Drugs and Cosmetics Act, 1940 (23 of 1940) and, if the Central Government considers necessary, with such other persons having special knowledge or practical experience in respect of Ayurvedic or Unani systems of medicines as that Government deems fit.

The Schedule lists the following conditions -

1. Appendicitis
2. Arteriosclerosis
3. Blindness
4. Blood poisoning
5. Bright’s disease
6. Cancer
7. Cataract
8. Deafness
9. Diabetes
10. Diseases and Disorders of brain
11. Diseases and Disorders of the optical system  
12. Diseases and Disorders of the uterus  
13. Disorders of menstrual flow  
14. Disorders of the nervous system
15. Disorders of the prostatic gland
16. Dropsy
17. Epilepsy
18. Female diseases (in general)
19. Fevers (in general)  
20. Fits
21. Form and structure of the female bust
22. Gall stones, kidney stones and bladder stones  
23. Gangrene
24. Glaucoma
25. Goitre
26. Heart diseases
27. High/Low Blood Pressure
28. Hydrocele
29. Hysteria
30. Infantile paralysis
31. Insanity
32. Leprosy
33. Leucoderma
34. Lockjaw
35. Locomotor ataxia
36. Lupus
37. Nervous debility
38. Obesity
39. Paralysis
40. Plague
41. Pleurisy
42. Pneumonia
43. Rheumatism
44. Ruptures
45. Sexual impotence
46. Smallpox
47. Stature of persons
48. Sterility in women
49. Trachoma
50. Tuberculosis
51. Tumours
52. Typhoid fever
53. Ulcers of the gastro-intestinal tract
54. Venereal diseases, including syphilis, gonorrhoea, soft chancre, venereal granuloma and lympho granuloma.

Some of the terms have very broad scope and potentially cover many different conditions/diseases. Asthma and AIDS were added at a later date.

“Any drug” must be understood in more broad terms than “any specific drug”. In the context of homeopathy, it is the claim to treat a condition with homeopathic medicines.

4. Prohibition of Misleading Advertisements Relating to Drugs.– Subject to the provisions of this Act, no person shall take any part in the publication of any advertisement relating to a drug if the advertisement contains any matter which a) directly or indirectly gives a false impression regarding the true character of the drug; or b) makes a false claim for the drug; or c) is otherwise false or misleading in any material particular.

Twitter, by publishing what is advertisments in the form of tweets would be in breach.

6. Prohibition of Import into, and Export from, India of Certain Advertisements.– No person shall import into, or export from, the territories to which this Act extends any document containing an advertisement of the nature referred to in section 3, or section 4, or section 5, and any documents containing any such advertisement shall be deemed to be goods of which the import or export has been prohibited under section 19 of the Sea Customs Act, 1878 (8 of 1878) and all the provisions of that Act shall have effect accordingly, except that section 183 thereof shall have effect as if for the word ‘shall’ therein the word ‘may’ were substituted.

Whilst this was written before the advent of the internet etc, Tweets, Twitter profiles and linked-to webpages could be considered “documents” in that they contain text. The uploading/creation of such “documents” could be considered export if the platform is based outside of India and/or the “documents” can be seen outside of India.

Twitter Terms
As Twitter makes clear -

  • Unlawful use: You may not use our service for any unlawful purposes or in furtherance of illegal activities. International users agree to comply with all local laws regarding online conduct and acceptable content.
As both the Regulations and the Act place prohibitions on promotion by Indian homeopaths, use of Twitter, except in very limited ways, would place them in breach of this.

Suggested Actions
Twitter could very easily remove offending tweets, remove links from profiles of Indian homeopaths and Indian vendors of homeopathic medicines. Twitter could also suspend accounts until the users are compliant with Twitter’s terms and conditions of use. Detecting violations of T&Cs is not difficult and suspect tweets and accounts could be easily identified.

Twitter would do well to engage with the Advertising Standards Council of India (ASCI).

It is also important to note that reporting breaches of local law regarding illegal marketing claims is almost impossible via Twitter’s tweet reporting system.