Why vapable nicotine juice via prescription is sensible public health policy

Australia’s Health minister Greg Hunt has deferred the introduction by six months of his decision to prohibit the personal importation of vapable nicotine and to make nicotine containing vape juice available in Australia only by doctor’s prescription. The original decision was announced on June 19 , 2020 and was to be implemented from July 1 – just 11 days later.  This was always going to be far too soon to put in place the key mechanisms of the plan, and adequately advise vapers, GPs and pharmacists of the details of the scheme which are summarised here.

But Hunt’s plan has been very welcomed by everyone in public health I’ve discussed it with.  Here’s why it’s a very smart and responsible move.

  1. Open access to tobacco has been one of the biggest disasters in public health history

When cigarette production moved from being individually hand-rolled to being made in factories by machines that today can produce some 20,000 cigarettes per minute, the price fell dramatically facilitating access by those on even the lowest of incomes. Smoking sky-rocketed in the early years of the twentieth century, pausing only in the great depression and during the two world wars because of scarcity.

As lung cancer rose to become  (by far) the leading cause of cancer death (see graph below), controls on tobacco commenced. These began in the 1960s with early tepid health warnings and public awareness campaigns, from the 1970s by advertising restrictions and then bans, in the 1980s by smoke free public space legislation and tax policy, and in this century by graphic heath warnings, plain packaging and retail display bans.

But across all this time, tobacco and access to it has remained an entirely  unregulated product. Unlike pharmaceuticals, food and drink which are regulated for safety and efficacy (in the case of pharmaceuticals), cigarettes and roll-you-own tobacco have always been unencumbered by any regulatory standards, for the obvious reason that they would instantly fail any imaginable test and never be allowed to be sold.

When post WWII smoking prevalence reached 60-70% of men and 30% of women, and the bad news about smoking and disease began pouring in from the 1950s, any thoughts of governments banning tobacco were entertained only by those in political cloud-cuckoo land. In a 45 year career in tobacco control, I have never until recently heard any serious person ever advocate a set date for a ban on the sale of tobacco. This essay is the most coherent and important expression of where debate on phasing out the sale of combustible tobacco sits today.

But why regulate nicotine?

2. Nicotine is regulated as a poison in Australia. It is not as “safe as coffee”

Vaping interests have long been engaged in a global effort to rehabilitate nicotine’s reputation. They are usually fine in agreeing that it is addictive, but bend over backwards to promote it as being all-but-benign – “as risky as coffee” is the usual trivialising comparison used. Many seem to regard it as having an almost vitamin-like status. 

The late addiction specialist Michael Russell in 1976 that “People smoke for nicotine but they die from the tar”. This has become a talismanic mantra for vapers against nicotine regulation, rarely absent from any discussion. But in fact across the 44 years since Russell wrote those words, a large research literature has emerged on concerns about nicotine’s likely role as a cancer promoter (if you have a few hours, browse through lots of this research that I gathered together in this earlier blog), as a vasoconstrictor with major implications for cardiovascular disease , as a disruptor of cognitive development and as a possible cause of psychosis.

For these reasons, and because of nicotine’s in e-cigs strong addictive potential, Australia’s TGA continues to sensibly regulate nicotine as a poison or a therapeutic substance.

Vaping advocates are fond of arguing that because nicotine is freely available in tobacco products, it follows that nicotine for vaping should enjoy at least, if not more accessibility and be freely sold almost anywhere. This argument has all the integrity of a chocolate teapot. Cigarettes were given their unregulated commodity status  at the beginning of last century, long before the evidence accumulated about two in three long term users dying from smoking.  Vaping advocates insisting that e-cigs should share a regulatory playing field with cigarette accessibility seem happy to risk repeating the Sisyphean task we have faced with tobacco of trying to reduce the damage that 120 years of non-regulation has caused. It’s been 55 years since health warnings first appeared on tobacco packs and tobacco control commenced. The power of the tobacco industry has ensured that the legislative drag has nearly always been glacial.

3. We regulate and restrict access to many addictive drugs. Nicotine should not be exempted.

Every new therapeutic substance first available to consumers is regulated in all but politically chaotic nations where almost anything can be bought over the counter. Vaping advocates seem to believe their virtuous mission should exempt e-cigarettes and vapable nicotine from regulation, despite their every second sentence extolling the therapeutic virtues of vaping in cessation and harm reduction, thus catapulting it into the ambit of therapeutic regulation.

Vaping advocates messianically proclaim that vaping will save a billion lives (an estimated 1 billion smokers will die this century). This cavalier claim would require that all smokers quit or switch to e-cigs and that there are negligible health consequences of people pulling a cocktail of vapourised flavouring chemicals, nicotine and propylene glycol deep into their lungs an average of 172 times a day (62,823 times a year). Both are highly dubious propositions, to say the least.

When nicotine replacement therapy (NRT) first became available the 1980s in gum form, it was scheduled as a prescription-only drug. No one thought this was anything other than sensible and normal for a new drug. When nicotine patches, lozenges and inhaler sprays later appeared, they too were prescription-only. Over the years, as use of NRT proliferated and some ex-smokers used it for many years with only minor apparent adverse effects, NRT access was liberalized through rescheduling. The maximum doses however, have remained small through concerns about toxicity.

Drug scheduling can work the other way too. The very useful opiate, low dose codeine was available across-the-counter in Australia in a variety of pain-relieving medications until February 2018. Following accumulating evidence of abuse, it was then rescheduled to prescription-only access.

Dr Alex Wodak, an unswerving advocate for open access to nicotine vaping juice, argued recently that Vaping is to smoking what methadone is to street heroin.” Correct. But curiously Wodak failed to note that methadone is only available via special prescription authority, dispensed at some pharmacies and clinics. In 2011, 46,446 patients were being prescribed methadone by 1,444 doctors across Australia. Greg Hunt’s plan will make nicotine vape juice available in the same way.

I’ve not aware of Wodak advocating that methadone should be available to whoever wants to buy it from any retailer wanting to sell it, in just the way that cigarettes can be sold. But if he does hold such views, good luck in selling that argument.

4. Prescribed access will greatly reduce teenage access to e-cigarettes

Smoking rates in Australian teenagers have never been lower, a phenomenon also seen in other nations like the USA, Canada and the UK which like Australia, also have had comprehensive tobacco control policies for decades. Like the tobacco industry, the business model for the vape industry (which includes all major tobacco companies) is not just about promoting its products to current adult smokers. Just as any car company which ignored young first car buyers would need its head examined, all tobacco and vaping companies are well aware of the critical role that new (read “young”) nicotine addicts have in their long term commercial prospects.  45% of US vaping retailers and 39% of English shops sell to underage customers.

Vaping advocates  are usually sensitive to the reception that any expressed complacency about teenage vaping will cause, and so concentrate talk about their mission on helping smokers switch. But as the evidence about youth vaping uptake has accumulated and become undeniable, they fall back to “well, isn’t it better that they vape than smoke?”  

The wider-than-Sydney-harbour-heads problem here is that many totally nicotine naïve youth are now regularly – not just experimentally – vaping. In the USA “The significant rise in e-cigarette use among both student populations has resulted in overall tobacco product use increases of 38 percent among high school students and 29 percent among middle school students between 2017 and 2018, negating declines seen in the previous few years.”

In Canada where e-cigarettes are openly accessible, there is now rising alarm at not only the rapid growth in regular vaping by young people, but in smoking rates having risen in this group for the first time in 30 years.

Longitudinal studies of e-cigarette use by teenagers have found strong evidence that, compared with those who have never vaped, later cigarette uptake is much higher in those who have (see studies from Taiwan, Italy, Scotland and USA here, here & here and a meta -analysis of 17 studies “There was strong evidence for an association between e-cigarette use among non-smokers and later smoking (OR: 4.59, 95% CI: 3.60 to 5.85)”).

These studies are routinely dismissed by vaping advocates with shallow slogans like “kids who try stuff, will try stuff” dignified by arguments about “common liability theory” or “propensity to use nicotine”. I’ve previously critiqued these often shallow arguments here and here.

With future access to vapable nicotine tied to prescription, shopping around by Medicare number traceable triggering alerts for multiple prescriptions being possibly used for  on-selling to kids, and retail vape shops not allowed to sell nicotine under threat of major fines,  it’s highly likely that teenage access will greatly diminish. Which is what the “official” vape industry message will of course wildly applaud …. Oh wait…

5. Banning personal imports will greatly reduce access to sub-pharmaceutical standard e-juice

When vapers or retailers import nicotine from overseas, they run risks of purchasing preparations manufactured in conditions that are far from the standards set for pharmaceutical grade drugs. This US study found bacterial and fungal endotoxins in vape juice. This study of German sourced e-juice found ethylene glycol as the dominant compound in five products. Ethylene glycol is associated with markedly enhanced toxicological hazards. The kitchen sink and bathtub amateur “labs” cooking up juice to supply the personal import trade are understandably highly anxious about Hunt’s plan.

6. The evidence of likely significant harms from vaping is mounting

The respiratory, cardiovascular and cancer harms caused by smoking rarely manifest clinically in the short term. Instead they take years to first appear as symptoms because of lagged effects. This is why they these diseases are called chronic rather than acute health problems. However, rarely a week passes when new studies or reviews of early markers for these diseases are published.

At the foot of this blog is a small selection of such recent papers in my files. You’re unlikely to find mention of these in the highlights of vaping blogs and chat rooms.

With such uncertainty about the diseases that e-cigs might reap, continuing to treat nicotine e-juice as a hands-off, unregulated commodity is recklessly irresponsible.

7. Fines for non-licensed importing are appropriate

Finally, there’s been much hysteria and melodrama about the $222,000 fines available for convictions for the illegal importation of nicotine. The fine has undoubtedly been set at that level to deter criminals from bringing in commercial quantities of nicotine. No one without an agenda seriously believes that anything but a very small fraction of that would be leveled at individuals chancing their luck by importing personal quantities.  Fining importers of commercial quantities a few hundred or thousand dollars would be treated with contempt – just a small impost on the costs of doing business. Major fine possiblities will be critical in deterrence.

8. But will Australian doctors be willing to prescribe nicotine?

The elephant in the room with this scheme is the possibility that only few doctors will be interested in prescribing access to nicotine juice. At present, less than 10 doctors out of over 122,000 registered medical practitioners have apparently been doing this, with an unknown number of prescriptions being issued as a result of their actions. This hugely underwhelming participation rate may be explained by the current ability of vapers and others to easily import nicotine juice, making going to a doctor to get an authority to buy nicotine from a compounding chemist uncompetitive. When this importing ability stops in 2021, more Australian doctors may be willing to prescribe. But is possible that with nicotine continuing to have what the TGA calls “unregistered status” as a drug, that many doctors will remain uninterested. Challenging legal issues may arise in the event of an adverse reaction or health problems arising from vaping nicotine. It is conceivable that such patients may seek redress from doctors who issued the authorities for them to use such an unregistered substance.

Recent studies on harms from e-cigarettes

ECIG aerosols are harmful to living cells in vitro and in vivo.

Chung S, Baumlin N, Dennis JS, et al. Electronic cigarette vapor with nicotine causes airway mucociliary dysfunction preferentially via TRPA1 receptors. Am J Respir Crit Care Med 2019. doi: 10.1164/rccm.201811-2087OC.

Ganapathy V, Manyanga J, Brame L, et al. Electronic cigarette aerosols suppress cellular antioxidant defenses and induce significant oxidative DNA damage. PLoS One 2017;12(5):e0177780. doi: 10.1371/journal.pone.0177780.

Madison MC, Landers CT, Gu B, et a. Electronic cigarettes disrupt lung lipid homeostasis and innate immunity independent of nicotine. J Clin Invest 2019; doi: 10.1172/JCI128531. Epub 2019 Sep 4.

Raez-Villanueva S, Ma C, Kleiboer S, Holloway AC. The effects of electronic cigarette vapor on placental trophoblast cell function. Reprod Toxicol 2018;81:115-121. doi: 10.1016/j.reprotox.2018.07.084.

Shaito A, Saliba J, Husari A, et al. Electronic cigarette smoke impairs normal mesenchymal stem cell differentiation. Sci Rep 2017;7(1):14281. doi: 10.1038/s41598-017-14634-z.

Zahedi A, Phandthong R, Chaili A, Leung S, Omaiye E, Talbot P. Mitochondrial stress response in neural stem cells exposed to electronic cigarettes. iScience. 2019;16:250-269. doi: 10.1016/j.isci.2019.05.034.

Evidence for ECIG harm to users.

Antoniewicz L, Brynedal A, Hedman L, Lundbäck M, Bosson JA. Acute effects of electronic cigarette inhalation on the vasculature and the conducting airways. Cardiovasc Toxicol 2019. doi: 10.1007/s12012-019-09516-x.

Carnevale R, Sciarretta S, Violi F, et al. Acute impact of tobacco vs electronic cigarette smoking on oxidative stress and vascular function. Chest 2016;150:606-12. doi: 10.1016/j.chest.2016.04.012.

Ghosh A, Coakley RC, Mascenik T, et al. Chronic e-cigarette exposure alters the human bronchial epithelial proteome.  Am J Respir Crit Care Med 2018;198(1):67-76. doi: 10.1164/rccm.201710-2033OC.

King JL, Reboussin BA, Wiseman KD, et al. Adverse symptoms users attribute to e-cigarettes: Results from a national survey of US adults. Drug Alcohol Depend 2019;196:9-13. doi: 10.1016/j.drugalcdep.2018.11.030.

Li D, Sundar IK, McIntosh S, et al. Association of smoking and electronic cigarette use with wheezing and related respiratory symptoms in adults: cross-sectional results from the Population Assessment of Tobacco and Health (PATH) study, wave 2. Tob Control 2019. doi: 10.1136/tobaccocontrol-2018-054694.

Moheimani RS, Bhetraratana M, Peters KM, et al. Sympathomimetic effects of acute e-cigarette use: role of nicotine and non-nicotine constituents. J Am Heart Assoc 2017;6. doi: 10.1161/JAHA.117.006579.

Reidel B, Radicioni G, Clapp PW, et al. E-cigarette use causes a unique innate immune response in the lung, involving increased neutrophilic activation and altered mucin secretion. Am J Respir Crit Care Med 2018;197:492-501. doi: 10.1164/rccm.201708-1590OC.

Australia to allow prescribed access to e-cigarette nicotine

From July 1, 2020 it will be illegal for anyone  to import nicotine liquid or salts into Australia unless they have a doctor’s prescription for the personal use of these substances.  The announcement by Australia’s drug regulator, the Therapeutics Goods Administration (TGA) is causing apoplexy in the social media pages of Australia’s minnow vaping advocacy groups, ATHRA and Legalise Vaping Australia. They see it as nothing less than a de facto ban on nicotine vaping and are reaching deep into their lexicons of hysteria to condemn the announcement and their nemesis, health minister Greg Hunt.

The TGA’s website describes in detail what will be involved. Basically, someone wanting to use nicotine juice or salts in vaping equipment needs to contact their doctor and see if the doctor will agree to write a prescription authorising them to use vaporisable nicotine. The website states “it will need to be obtained on your behalf by a medical supplier or from a pharmacist who dispenses it for your use as the named patient. The company or the pharmacist will need to be given a copy of your prescription.” 

The website provides this information to doctors:

Commercial companies wanting to import into, or manufacture nicotine juice or salts in Australia

“can apply online to the Office of Drug Control (ODC) for an import permit; the ODC will have a dedicated webpage including step-by-step instructions on making an application for a permit including attesting that your business complies with the conditions specified in the Therapeutic Goods Regulations for lawful importation of an unregistered medicine.

You can then sell to doctors (or pharmacists on their behalf) the e-cigarettes containing vaporiser nicotine on evidence of a TGA Special Access Scheme B approval or Authorised Prescriber Authority for supply to a named patient (along with the supporting prescription).”

This means that bona fide companies able to demonstrate that they meet the TGA’s standards of pharmaceutical quality assurance will be apply to apply to import or manufacture vapable nicotine, but it will only be available from pharmacists or possibly directly from an accredited medical supply company.   Kitchen sink and bathtub  mixing amateur “laboratories” need not apply.

So in a nutshell, anyone wanting to vape nicotine legally in Australia will do what millions of us do every day, and have done for decades: obtain what is in effect a license to use a particular drug (here nicotine). It’s called a prescription. It will authorise you to obtain from a licensed drug supplier (a pharmacist or a medical supply company) a supply of a particular drug (not carte blanche access to any or all vapable nicotine from any source).

I have used the same prescribed drug every day for about 15 years. I obtain 3 months supply and when that is finished, contact my GP who re-issues the script which I collect and get dispensed at a pharmacy 50 metres away. My GP monitors my health condition and occasionally changes the prescription by adjusting the dose up or down.

We all understand how this works and why it is a totally sensible approach to allowing access to drugs capable of being abused or causing harm when used incorrectly. But vaping advocates are on a mission that they believe places their cause above all other therapeutic regulation. They think they deserve to stand outside our drug regulatory system.

Nicotine, other than that in tobacco products, has long been subject to controls by the TGA. It scheduled all the various forms of nicotine replacement therapy as prescription-only when they first came on the market. As the years progressed and monitoring for adverse reactions showed NRT to have negligible problems, its scheduling was relaxed and some NRT forms are now available without prescription in pharmacies and supermarkets.

Vaping advocacy groups have always opposed TGA oversight of nicotine in e-cigarettes, fearing it would see regulatory controls on availability, advertising, flavouring, packaging and dosage. While endlessly publicly arguing that e-cigarettes are useful in quitting smoking, they also furiously backpedal and deny that this is a therapeutic claim, which it of course is, undeniably.

Instead, they want e-cigarettes regulated as a “consumer good”, whatever that might mean, to allow it to be sold almost anywhere as occurs now with tobacco. This is in fact a recipe for Claytons’ regulation (the regulation you have when you are not having regulation). When pressed to describe the regulation they agree with, they only talk about child-proof nicotine juice containers and claims about “sensible” advertising restrictions (you know, those same ones we used to have when tobacco advertising was allowed pre-1992 when magic barriers allowed only adult smokers to see the ads but rendered them invisible to children).

Occasionally, they have the temerity to toss in talk about responsible retailing by vape shops, when just as always occurred with the law saying that tobacconists could not sell to children, it is child’s play for kids to buy e-cigarettes.

A favourite meme  that gets a regular workout from vaping advocates is the one that goes: cigarettes are deadly and are sold in every supermarket, corner store and petrol station, while benign old nicotine is to be “banned”.

Aside from the huge body of evidence that nicotine is anything but benign, this argument relies on very specious arguments. As I wrote in an earlier blog

“The argument here runs (1) it is self-evident that cigarettes are far more dangerous than e-cigarettes (2) cigarettes have always been sold and are not banned from sale (3) therefore, consistency and coherency demand that e-cigarettes should also be allowed to be sold in the same way because of the precedent established with cigarettes.

This syllogism takes no account of the reasons why cigarettes are sold in the way they are today, and not in the way restricted substances like prescribed drugs are sold to consumers.  Sales of cheap machine-made cigarettes burgeoned from the early twentieth century when there was no case against smoking, beyond that made by temperance groups. Tobacco control commenced more than 60 years later with the first tepid health warnings appearing in the USA in 1966. Across those years, tobacco consolidated its special exceptionalist regulatory status as being entirely exempt from ingredient controls. Even today, fully comprehensive tobacco control has been enacted in only a minority of nations …

Vaping advocates know that no nation will ban cigarettes any day soon. They know the legacy of cigarettes’ historical circumstances saw them (unlike pharmaceuticals, foods, beverages, cosmetics, agricultural, industrial and household chemicals) totally exempted from regulation. They know this historical legacy has tied two hands behind the backs of any thought that backwards time-travel could somehow magically allow this situation to be undone.

Importantly, they know that when proposing gold standard regulations for any product carrying serious risks, that the very last model any regulatory authority would reach for is that which applies to tobacco regulation. Yet knowing all that, they are happy to set their ethical bar to this lowest imaginable level and accuse supporters of tough regulation as being “incoherent”. We allow cigarettes to be sold everywhere, so therefore we should allow a putative less dangerous cigarette substitute to be subject to the same non-standards of regulation, they argue.

This reasoning is completely arse-up.

Instead, we should commence our comparison by saying “We made every conceivable error in the way we allowed cigarettes to be allowed into commerce, in the way we allowed them to be advertised, packaged and sold as if they were confectionary. We know that we were deceived by the tobacco industry with the harm reduction promises of filters and light/mild cigarettes. We now face a new opportunity to get regulation right with new products carrying unknown risks of daily, long-term use. Let’s learn from the disastrous history of tobacco regulation and not make the same mistakes again.”

ATHRA’s Colin Mendelsohn argues that the prescribing process involved is “so complex and time-consuming that no doctors will do it”. 

Yet every day, every doctor writes out referrals to specialists, orders pathology, writes case notes, and occasionally applies for special access to restricted drugs for patients. For example,   methadone, a prescribable opiate is a Schedule 8 drug. It is regularly used by more than 50,000 people in Australia, all of whom have been prescribed it by a doctor.

The TGA’s Special Access Scheme form that doctors could apply to use with nicotine juice is here.

What Australia’s vaping advocates are deeply worried about but seldom say publicly (because it reflects very poorly on their own failures to convince Australia’s doctors to prescribe e-cigarettes) is that there are currently only a handful of doctors across the country who are currently doing this. With 122,768 medical practitioners currently registered, this homeopathic strength participation rate is hardly a vote of confidence in e-cigarettes.

The track record of e-cigarettes in cessation is anything but spectacular (see sections 7, 8 & 9 in The dirty dozen: 12 myths about ecigarettes). And in some nations that have let e-cigarettes off the regulatory leash, uptake of vaping by  young people has been rapid and rising. Here’s Canada, for example.

As with COVID-19 control, Greg Hunt and the government have listened to people with expertise about disease control. The table below shows the current state-of-play on regulation support among Australia’s health and medical agencies, and vaping advocacy groups. The government has plainly listened to the overwhelming consensus of Australia’s health and medical community when it comes to the regulation of e-cigarettes here.

Access to vaping nicotine has to date been a fiasco. It is illegal to supply nicotine juice or salts, while vaping equipment can legally be sold. Yet audits by NSW Health have found shops are often openly selling nicotine vaping products. There have been no controls at all on what people bring in from overseas by mail or courier. The new regulations are therefore a welcome step away from that chaos. Vaping interests will be already plotting ways to weaken the scheme to get vaping in the same position that cigarettes lucked into at the beginning of last century. The TGA will be monitoring the operation of its scheme closely.

Big Tobacco’s enduring interest in children: insights from its internal documents

Tomorrow is World No Tobacco Day. This year its theme is the targeting of children by the tobacco and vaping industries.

In 2001 I led a team of researchers at the University of Sydney’s School of Public Health on a 5 year US National Institutes of Health grant. Our aim was to explore many millions of pages of previously internal tobacco industry documents on the transnational tobacco industry’s activities in Australia and Asia.

We published 40 papers from this grant, including 32 in these two Tobacco Control supplements on Australia and Asia.

As we excavated the relevant documents housed in University of California at San Francisco’s Legacy  (now numbering over 14 million) our team would make screen shots of important passages and add these to powerpoint sets, as well as filing whole documents in various work-in-progress files.

This morning I revisited one of these powerpoints, containing 72 slides on what we found about the tobacco industry’s interests in children. As you will expect, these show naked, intense interest by the industry in children, sometimes very young children. They also show the ways in which the industry tried to deny this interest whenever confronted with it.

The standard response by the industry to these documents today is to dismiss them as being old and irrelevant: they would, of course,  never pass such data, analysis and comments among themselves today. Of course.

The slide collection is here (in powerpoint form)

When the COVID-19 pandemic going gets tough, the conference scammers get going

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I’ve written here before about the relentless deluge of obsequious email supplications all academics get, tempting them to part with thousands of dollars to submit their research to junk, predatory journals or to attend often shady conferences in far-off places.   To my amazement, these junk conference temptations have continued through the global COVID-19 pandemic. This week  my inbox offered jaunts to Tokyo, Amsterdam and California, all on subjects totally unrelated to my own areas of interest.

During the COVID-19 lockdowns, there are stories about of one-way, economy class passengers being asked to pay $20,000  to or from Europe. Once you arrive, you get to spend two weeks in quarantine often in a low grade hotel room and so the same  when you get back home. You get to attend a conference on a topic of zero relevance to your interest, run by scammers who sometimes forget to actually put it on after you shell out your registration fee and early-bird discounted slide packages from the other missing speakers. So what’s not to like here? Particularly when you get addressed like this.

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But amazingly, the emails keep coming. These offers often make me try to imagine those who are suckered by these dogs-balls obvious swindles.  An email this week took me to a whole different level of audacity out there.

It started with this from an “Iris Reed”

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My interest was piqued. Here we had a brazen pitch to sell contact details about conference attendees whom I felt certain would have all given their full permission for their private information to be flogged off like this to anyone paying up. I immediately wrote back to Iris “Dear Iris, I’m very interested in looking at this list. Where and when was the meeting held?”

Twenty six minutes later, I got a reply, not from Iris, but from her helpful top dog colleague “senior business analyst” Macie, who had a small dose of the stray apostrophes and a helpful yellow highlighter.

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Now what a coincidence that just 26 minutes after I enquired about the pain conference attendance data, the company cancelled the conference! However, the agile Macie, perhaps anticipating my disappointment, now dangled the prospect of 10,000 names from something called a “Careers Expo” in Perth held in 2020.  But Iris had been offering 12,147+ names from the just cancelled “Pain Society 36th Annual Scientific Meeting”.

I needed to share my confusion with Macie. I wrote  “But I thought it was a Pain Society 36th Annual Scientific meeting 2020? Now it is a “Careers Expo” meeting in Perth. That sounds rather different.” I’d googled “36th annual pain scientific meeting” and found that one by that name was held in Perth, not in 2020 but in 2016. I gave Macie the link (https://www.dcconferences.com.au/aps2016/).

Twenty minutes later the indefatigable Macie was back:

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She just wasn’t listening! So I quickly replied wrote, “No, the email I got was explicit that it was a pain conference.   That’s what I’m interested in. I will pay big money for this.”

So imagine my confusion when I then heard from yet a third employee, Selah Lloyd, suffering from the exact same stray apostrophe problem as Iris:

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So, they “reached out” to me with a pain conference (cancelled), then switched to a Careers Expo in Perth, and within two hours that one had apparently been postponed too. But now they figured I would like to get my hands on 3500 names from a TedXSydney 2020 meeting. I steeled myself in anticipation  that this one would shortly also be postponed.

The next day, Iris was back on my case, answering my yesterday’s questions about when and where the pain conference was being held. Apparently it had just recently been held in Hobart, not Perth.

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By now smelling the unmistakable odour of fetid bullshit, I called the Hotel Grand Chancellor in Hobart, asked for reservations and enquired whether they had recently hosted a conference with 10,917  in attendance during the COVID-19 lockdown. I could hear the receptionist spray her coffee into her headset microphone.

sprayCoffee

Having been earlier told by Iris that the pain meeting had 12,147 participants, but now reading there were only 10,917 (9 times more than could fit into the hotel’s plenary hall), it was time for some plain talking with Iris. I wrote:

“So first question. Could you please ask your manager if I can please have a 12.3% discount for the smaller number of names? That would be $438.50. I’ll round that up to $440.00 for you.

Second – and this is a little awkward for me to raise with you – but I have just spoken to the management of the Hotel Grand Chancellor in Hobart, and they said that they have not been holding any conferences there for months because of COVID.  They suggested that you are probably a scammer.

I’m sure that can’t be right. But is it true, Iris? I hope not!”

Iris now kicked this one upstairs to the top brass.

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Mr Williams got back to me immediately.

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So the 2020 pain conference in Hobart, which never took place, started out with 12,147 attendees, fell to 10,917 and then rose to 14,927, all within two days. I politely let him know I was no longer interested.

Chris’ very professional company website, said to be in Fort Worth, Texas is here  www.influxdatasolutions.com

Indelibly sear this into the national public and political DNA: evidence-based prevention saves many lives. So let’s all honour our COVID-19 heroes.

If we went back two months, “epidemiologist” was a word you might need occasionally to complete a crossword. But now we hear it all day long. Throughout each day, we see and hear people who with a few exceptions, have never been household names. Most prominent have been  Brendan Murphy, the chief medical officer and secretary of the Department of Health and Aging;  his deputy, Paul Kelly, as follicularly challenged as his more famous musician namesake but lately also bringing us daily salve in the form of hopeful news about falling new cases; and the peerless Norman Swan, for 35 years the presenter of ABC’s The Health Report, mandatory listening for all seriously interested in evidence-based health and medicine.

There’s also Professor Raina McIntyre from UNSW, a global expert in pandemic epidemiology; state chief health officers like NSW’s Kerry Chant, also with post graduate qualifications in public health; a phalanx of highly connected mathematical epidemic modellers; and many, many others working tirelessly in the background to fast-track testing, obtain personal protective equipment for front-line health care workers, contact tracing, record keeping, and scientists working in vaccine development.

The daily ritual for many of us in checking bookmarked data sites mapping the COVID-19, pandemic has lately brought huge relief. The chart showing newly confirmed cases is the first we click on. Since hitting a peak of 450 new cases on March 28, Australia has seen almost continual daily falls, with an average of 37 a day reported in the last 10 days, a fall of 413 or 92% off the peak.

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While it is very early days, and while cautions about possible upswings if we take our foot off the brake too quickly are deadly serious, these encouraging data look very much like a trend. There are key signs that we are getting on top of this thing, quite fast.

Four lessons

The decline is exactly what our newly limelighted national heroes, the public health experts advising the government and communicating with the public, would have hoped for. If it continues, and does not dramatically bounce back when isolation is eventually relaxed, it will go down in our history as a triumph of evidence-based health policy, the lessons of which deserve to be indelibly seared into the national public and political DNA.

What are some of these lessons? First, if it ever needed saying, this is a dramatic, thundering reminder that health protection and prevention can avert national catastrophes. In medicine, the “rule of rescue” has for decades dominated health care resource allocation and political urgency. This rule states that those in need of medical attention will always take primacy over vague backroom recommendations from faceless committees about how we might prevent people from needing medical attention in the first place.

Public health (health protection, prevention and education) has long been the Cinderella of the health services. Next to high tech treatment centres, it has drab offices, much less than 2% of the health care budget, and few prominent individuals to fight for its goals. Unlike treatment with its memorable patients, its waiting lists are unnamed statistical victims who will need health care in the future, if prevention fails. Prevention can often wait for the next budget. Treatment cannot. This might well change for good, thanks to COVID-19.

Second, Australia’s likely success is a reminder that Nanny State policies and interventions for public safety are politically hobbled and denigrated to our great peril. Never in anyone’s living memory have we seen more draconian measures here than we are all living with today. With each new ratcheting up of social isolation edicts, we have heard pin-drop silence from the doctrinaire civil libertarians. The National Cabinet of conservative and Labor  leaders are behaving like a socialist politburo and everyone is applauding them wildly.

Nanny is not just good for us, she is yet again saving many, many lives. Meanwhile, the libertarian right remain in the brace, foetal position, seeing their dogmas collapsing around them.

Third, the truth serum of science and evidence being force fed  to our political leaders seems likely to have lasting impacts in tempering the global creep of anti-science. As former Liberal leader John Hewson put it, the coronavirus story is a dress rehearsal for what happens if governments continue to ignore science.  Its few remaining carnival barkers in parliament have been struck a fatal blow with the political unanimity across all major parties. The last memorable time I recall this happening was when the Opposition fully supported the Gillard Labor government’s plain packaging bill way back in 2010.

And next, the widespread population-wide embrace of social isolation, and the stories of untappable  geysers of community support and care for those doing it tough may be rejuvenating communities, in many wonderful ways.  We are enduring the deprivations not just for the sake of reducing our own risk, but because suddenly we all understand that Margaret Thatcher’s infamous “no such thing as society” has deadly, dehumanising consequences. It feels very good to be living among a resurgence of such values. They will resonate well into the future with progressive policies right across government.

Australia’s achievement is simply remarkable

In 2018, Australia 158,493 people died from all causes. So far, COVID-19 has claimed 74 Australian lives, at a median age of 79 (which is around the same as all-cause life expectancy). Australia has 261 cases per million population and 3 per million deaths, while Spain – at the moment the nation worst infected on a per capita basis — currently has 4367 cases per million  people and 455 per million deaths, 17 times our per capita rate of cases and 152 times our death rate.  These are just remarkable differences.

In 1996, I wrote one of my columns in the BMJ on the paradox of prevention. I wrote:

“That’s the paradox with prevention – it works when nothing happens. People thank doctors for performing a lifesaving operation, but if they grow up without being badly injured or without taking up smoking and developing emphysema they are seldom thankful for the preventive actions of people who bore the brunt of public anger about inconvenience years ago.”

Our infectious disease prevention heroes deserve our greatest thanks and support for all they are doing. As of course do our thousands of front-line health care staff. We’re not just some lucky country. We’re a public health vanguard country, setting standards for the world.

How can we erode self-exempting beliefs about COVID-19 contagion and isolation that might subvert flattening the curve?

Cognitive dissonance is a much-studied phenomenon concerned with a branch of the mental heuristics that people use to enable them to sustain particular beliefs or behaviours in the face of overwhelming evidence that could swing a wrecking ball at the foundations of those beliefs and behaviours. Coined by American psychologist Leon Festinger in 1957, cogntive dissonance theory suggests “we have an inner drive to hold all our attitudes and behaviour in harmony and avoid disharmony (or dissonance). This is known as the principle of cognitive consistency. When there is an inconsistency between attitudes or behaviours (dissonance), something must change to eliminate the dissonance.”

Self-exempting beliefs about smoking

Early in my career I was struck by the multitude of ways that smokers rationalised their smoking, in the face of what US Surgeon Antonia Novello noted 30 years ago that “It is safe to say that smoking represents the most extensively documented cause of disease ever investigated in the history of biomedical research.“

With others, I published two well-cited papers in the American Journal of Public Health (1993) and Preventive Medicine (2004) documenting the range and clustering of these beliefs in Australian smokers.  We called them “self-exempting” beliefs: beliefs that people cling to as psychological talismen they found useful in warding off the deluge of unsettling information about the risks of smoking.

In the first paper, we found that while 50-80% of smokers agreed that several diseases were caused by smoking, nearly half of all smokers we surveyed agreed with 5 or more of 14 different self-exempting beliefs we asked them about. So smokers could simultaneously agree that smoking caused lung cancer, but also believe that “scientists are telling us every day that all sorts of other things also cause cancer” or “I play sport every week and get the toxins out of my system”.

In the second paper, we grouped these beliefs into three clusters.

“Bulletproof” beliefs: Beliefs suggesting smokers think they have some personal immunity to the health effects of smoking. Examples:

  • Cancer mostly strikes people with negative attitudes
  • They will have found cures for cancer and all the other problems smoking causes before I am likely to get any of them
  • You can overcome the harms of smoking by doing things like eating healthy food and exercising regularly
  • I think I must have the sort of good health or genes that means I can smoke without getting any of the harms
  • I think I would have to smoke a lot more than I do to put my health at risk

“Skeptic” beliefs: Those  indicating smokers do not believe medical evidence about smoking and disease. Examples:

  • Some doctors and nurses smoke, so it cannot be all that harmful
  • The medical evidence that smoking s harmful is exaggerated
  • Smoking cannot be all that bad for you because many people who smoke live long lives
  • Smoking cannot be all that bad because some top sports people smoke and still perform well
  • More lung cancer is caused by such things as air pollution, petrol, and diesel fumes than smoking

“Jungle” beliefs: Beliefs normalizing the dangers of smoking because of the ubiquity of risks to health (‘‘life’s a jungle of risks’’) Examples:

  • If smoking was so bad for you, the government would ban tobacco sales
  • It is dangerous to walk across the street
  • Smoking is no more risky than lots of other things that people do

We found that ex-smokers adhered to far less of these beliefs than smokers. This made us wonder if some of these beliefs were porous and vulnerable to being eroded to flaccid levels of talismanic potency by strategic efforts at countering them. The NSW Cancer Institute ran a campaign called “excuses” where it targeted several common beliefs about why smokers often delayed quitting.

Self-exempting beliefs about COVID-19

With COVID-19, self-isolation and distancing are the two behaviours that all infectious disease experts agree are absolutely critical to “flattening the curve” and reducing contagion. But we have all by now heard a wide range of  self-exempting excuses for why some are taking self-isolation lightly.

Some I’ve noticed include:

  • It’s only very old people who are dying
  • 170,000 people – mainly old — die in Australia every year. Old people will die anyway from something if not COVID-19
  • I’m young and healthy, I’ll be fine
  • I’ve had the ‘flu a few times. I can live with getting that again
  • We’ve got such a low rate of cases per million population, my chances of being getting near to someone with it are negligible
  • The odds of getting it in Australia are far, far lower than the risks we take all the time – driving, flying, surfing, skiing
  • How come it’s OK to have a barber or hairdresser stand right next to you and touch your head for 30 minutes or more but not OK to go to a beach?
  • Look at all the shops that are open selling non-essentials, like some department stores, Ikea, Bunnings, Officeworks, and garden nurseries. How come lots of people can go to these, but not have a picnic in a park?
  • How come you can still take a domestic flight and sit well within 1.5 metres of other passengers?
  • Why are the distances you must keep different in different states?
  • The Bluetooth movement monitoring app they are planning is just an excuse for a surveillance state
  • It’s a conspiracy to under the cover of isolation, roll out the pernicious 5G network

Doubtless there are many more of these in circulation. Some will have a tiny number of adherents, but others will be muttered by larger swathes of the community and may be amenable to strategic efforts to render them less potent. Those in government who are planning the communication campaigns would do well to get a handle on which of these sort of beliefs are most prevalent in those who are breaching isolation. What they learn could then stimulate efforts to deflate these beliefs.

Respectful communication is critical

It is important to understand that those who are sub-optimally isolating and breaching the guidelines are not all simply stupid or willfully ignorant. Efforts through announcements and interviews to set them right with fact-based refutations will have only limited success.

At the heart of cognitive dissonance theory is the understanding that people cling to self-exempting beliefs because they make them feel comfortable and more harmonious across values and decisions they cherish. Self-exempting beliefs bring comfort and sustain these wider and deeply held beliefs and decisions. So a communication objective which sets out only to say “you’re wrong, listen to this instead” will miss the point.

Subverting false beliefs to render them unsustainable in a COVID-19 non-isolator’s top-of-mind lexicon may be an intermediary goal on the way to them changing their behavior, but it needs to be done respectfully, not combatively.

Apposite analogies

Over my four decades in public health advocacy, I’ve found analogy to be very useful in gently eroding sticky beliefs.

In gun control, resistance to gun registration was eroded by pointing out that we all understand that cars, boats and even dogs require registration for good reasons. So why not guns too? And law-abiding gun owners outraged at gun control measures which assumed every gun owner could be dangerous, is no different to assuming every driver might be alcohol affected in random breath testing. Or every airline passenger a terrorist when passing through airport security. Or every shopper a thief when bags are inspected at the checkout.

In tobacco control, resistance to the news that other people’s smoke could be harmful was memorably disarmed by analogies from cartoonists like the one below and about the urinating and non-urinating sections of public swimming pools.

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Peeing v non-peeing

Smokers who insisted that it was “all the additives and chemicals” in cigarettes (not tobacco smoke itself) that caused all the health problems were reasoning as if the infernos in hell might be less uncomfortable if the temperature was turned down one degree by removing additives.

And tobacco companies’ hand-on-heart efforts to tweak the toxicity of their products was like the owners of the White Star Line removing the splinters from the handrails of the Titanic.

Analogies are inherently respectful as they memorably point to equivalences between things that everyone agrees with and seed the idea that “this is just like that”.

Freedom to vs freedom from

With COVID-19, the “freedom to” imperative often dominates resistance isolation, while the “freedom from” the risk of rapid exponential growth in an untreatable, often fatal disease takes a back seat. Efforts to reframe freedom as importantly including freedom from the indelible scenes we have seen playing out in the USA, Italy, Spain and the UK are likely to provide fertile ground strengthening the already widespread view that our deprivations are helping us dodge a hideous population-wide bullet.

And the deprivations of staying at home can be flipped in the memorable words of the (unknown) creator of this  art compilation put it “Don’t count the days, make the days count.”

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COVID-19 home isolation: except for food, medicine and exercise. So why are so many other stores open?

Ikea is open today in Sydney from 10am to 9pm. They have an online catalogue and will deliver, but yes, it’s open to us all too. My nearest Bunnings has been open since 6am, and will close 7pm. Tradies (who can keep working) need supplies, and they have cards to prove their work status. But non-tradies can go to Bunnings too and buy whatever they like, no questions about “essentials” or “necessities” asked.

If you want stationary supplies, you can get on down to Officeworks. You might want to sit a while and print some photos while you are there.

Think your garden could so with a makeover? All plant nurseries are open. And what about a haircut? No problem – many are open and your hairdresser, even if he’s Edward Scissorhands, certainly won’t be cutting your hair from 1.5 metres away.

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And fancy a new pair of shoes, a shirt or dress? Off you can go to a department store. Furniture? Yep. Open as usual. A new TV to help your isolation? A hair dryer or coffee machine? Sure, go out right now and just walk in. No problems.

But meanwhile, we read stories and hear people calling into radio about being fined, warned or moved on for sitting reading or eating on a park bench or sunbaking, or simply driving – sometimes alone. Police are patrolling beaches and parks.

Yet we aren’t hearing any stories about police frisking shoppers coming out of any of the shops above and quizzing them to explain why each of the goods they have just purchased are essential. The shops haven’t been told to rope off non-essential items. It’s all for sale.

Each time we hear a government official, police spokesperson or politician summarising how we should understand home isolation and self-distancing we hear the litany of food and medicines purchasing, distanced exercising in a maximum of two people (unless in the one family) and visiting family members who live elsewhere, within the guidelines (one person only).

However, the current gazetted NSW guidelines  list of 16 “reasonable excuses” starts off with an “excuse” far wider than being out to purchase food and medicines. The first point explains that you can be “obtaining food or other goods or services for the personal needs of the household or other household purposes (including for pets) and for vulnerable persons.” [my italics]

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Neither “needs” nor “purposes” are anywhere defined in the guidelines. But Prime Minister Scott Morrison told the country on March 31 that his wife had gone out to purchase jigsaws “Our kids are at home now, as are most kids, and Jenny went out yesterday and bought them a whole bunch of jigsaw puzzles. I can assure you, over the next few months we’re going to consider those jigsaw puzzles absolutely essential.”

Unless he was openly declaring family lawlessness, Morrison’s example role-modeled a process of legitimate individual  decision-making: his household regarded non-nutritious or medicinal jigsaws as “absolutely essential” and a justifiable reason for leaving their house. Others might equally regard regularly buying cut flowers, stocking up on new plants for the garden, buying hobby, art or musical instrument supplies as essential to their household “needs”.

The NSW government’s very broad guideline would seem to have been worded in the way it was to provide such latitude. But the contrast with what it states and the constant far narrower emphasis on food, medicines and exercise is stark.

Let me here be emphatic. In concert, quarantine, social isolation and distancing, and the virtual closing of Australia’s borders together appear to be to not only flattening the curve of new cases, but to be quite rapidly reducing the daily rate (see graph below).  Importantly too. as an island continent, Australia has very non-porous borders compared with the great majority of the world’s nations in Asia, Europe, Africa, and the Americas where many nations have several land borders.

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Source

The changes we have seen in the last week owe a great deal to  Australians having taken home isolation very seriously. Citymapper’s global mobility index shows people in Australian cities have dramatically decreased their movement. Sydney for example, has fallen from 121% of normal movement on March 2, to 17% on April 5.  As many infectious disease experts have warned, any rapid abandonment of current policies that saw equally dramatic rises in movement (and erosion of self-isolation) could see the fall in daily new cases reverse. And as we have seen in nations like Italy, Spain, France, Germany and the USA, this can be very, very  rapid and catastrophic.

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It is beyond important that we sustain high levels of home isolation and social distancing when we need or choose to go outside.

The contradictions between the constant narrow framing of where you can go when you leave your house, reports of over-zealous policing directed at individuals engaged in very low risk activities and what the government guidelines currently say we can actually do, risk eroding trust in important government messaging.

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People are not stupid. When they are told repeatedly they should only go out for food, medicine or exercise and then see the car park at Bunnings, Ikea and Officeworks chockers with cars and people pushing trolleys, they join the dots that this just doesn’t add up. Maybe the other messaging is shonky too, many will reason. Crying wolf has always been fatal for public health messaging.

Absolute transparency, as far as our current knowledge allows us to go, should be a cardinal principle of all communication in this crisis. It makes no sense that we are told to keep a minimum of 1.5 from others in the street or in shops, then read the truly bizarre “Hairdressers and barbers can continue to operate under strict new rules. The 4 square metre rule and social distancing must be observed.”

The hairdressing example may be nit-picking (sorry …) but hassling people driving or quietly reading and getting some sunshine in a park risks fomenting corrosive community conversations about other political agendas and disproportionate surveillance.

Aussie vaping advocates’ latest lobbying fiasco

In an earlier blog, I explored the luvvy relationships between Australia’s vaping advocates and the far right of Australian politics (Leyonhjelm, Bernardi, Abetz, Wilson, Paterson et al).

In a recent Senate motion from the Centre Alliance’s Sen Stirling Griff urging the government to regulate the manufacture and labeling of e-cigarette liquid to ensure safety and consistency of ingredients in imported and domestically-available products, and ban the importation of e-cigarette liquids containing nicotine, Griff was supported by his colleague Sen Rex Patrick, and all Coalition, Labor and Green Senators, with only the predictable brains trust of Pauline Hanson, Malcolm Roberts and Jacqui Lambie voting against the motion. The funereal-faced vaping supporter Senator Paterson was not there for the vote.

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In the eighth report of the Petitions Committee presented to the 46th Parliament on Feb 10, 2020, we read that a whole 238 Australians signed a Legalise Vaping Australia petition to  the parliament. This was considerably more than the 15 or so dedicated vaping advocates who turned out in a Sydney suburban park to launch Australia’s  first “Aussie Vape Day” in May 2019.

Undeterred by the political demise of  its political heavyweight champions Leyonhjelm and Bernardi, and the above rather modest numbers that Legalise Vaping Australia has  inspired to turn out at shows of strength or to sign petitions, like the limbless, gallant Black Knight with only a flesh wound, our local vape warriors are currently at it again. Another petition is up and running and there’s an on-line campaign to have vapers get into the inboxes of their local members and warn them that “we vape and we vote”, an observation that has not exactly changed the course of politics in earlier outings.

A few minutes of web browsing reveals that some vaping advocates risk getting a serious bout of repetitive strain injury from all this button clicking, not to mention a virulent dose of  dreaded Pinocchio nose syndrome.

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This is producing some hilarious examples of unleashed lobbying ineptitude that seem destined to become case studies in how to not run a lobbying campaign. Here for your enjoyment and early voting for the political division in the 2020 Darwin Awards, are a couple of examples, out there in plain sight:

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Shayne didn’t seem to realise that senators don’t have electorates.

But the goalkeeper for the darts team?  Meet Stuart who has the same misconception, but … errm … has missed the idea that you are not allowed to be registered to vote in more than one electorate.

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Vaping Australia is a project of the Australian Taxpayers Alliance, and part of the same stable of regulation-loathing libertarians which all apparently share exactly the same thoughts on issues they tweet about.

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Legalise Vaping Australia says it has over “13,000” signatures on its latest petition.

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But LVA’s fraternal twin, the Australian Taxpayers’ Alliance, has what some might some  rubbery form with numbers.

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Funny, but I have a feeling someone might be poised to go through these 13,000+ signatures and do some random checks on the bona fides of some signatories.

If self-isolating COVID-19 cases won’t isolate, should they be monitored with GPS wearables?

Update: since I published this blog 12 days ago, I’ve learned that the Singapore government has implemented GPS monitoring of its citizens who are required to self-isolate. This news report and the illustration below describes the process which involves daily texts sent to those in isolation requiring them to send their GPS coordinates.

As at 22 March 2020, Singapore has recorded 432 cases of COVID19 and 2 deaths, in a population of 5.7 million (74 cases per million population). This compares with Australia’s tally of 1072 cases and 7 deaths (42 cases per million).

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On March 8, ABC News reported that a Tasmanian man who was awaiting his COVID-19 test results and had been asked to self-isolate until the results were known, ignored this and worked several shifts at a Hobart hotel.

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Self-isolation or self-quarantining at home is a core infectious disease containment strategy which can see forced isolation and strong penalties apply when a person fails to self-isolate. For example Queensland Health advises:

What happens to those who do not comply with self-quarantine orders?

“The health and wellbeing of Queenslanders is our top priority, and we know Queenslanders are always supportive of measures that protect the community.

Queensland Health is issuing notices to people who have travelled to at-risk areas, or who have been in contact with a confirmed case, that requests them to voluntarily quarantine themselves.

If a person is suspected to have breached the notice they had voluntarily agreed to, we’ll initially work closely with the person to ensure they not only understand their obligations, but also the importance and seriousness of self-quarantine under the current global circumstances.

There are additional compliance measures available to Queensland Health under the Public Health Act 2005, and any further failure to comply may be subject to enforced quarantine and receiving fines of up to $13,345 and other penalties.”

The British Medical Association’s ethics manager, Julian Sheather, has written this excellent summary of the ethical issues that arise in the decision of a state to coerce citizens into quarantine. He writes of the rights and duties of citizens, and of the key considerations of proportionality and government reciprocity when it requires the serious restrictions on individual liberty in quarantine:

“But where restrictions are justified, another critical principle comes in to play: reciprocity. Where individual rights are limited, the state accrues additional duties. These include ensuring that any burdens imposed are as limited as possible. Basic amenities such as food, water and medical care must be met. Compensation for lost income should be given. Priority access to novel treatments should be considered. Experience from Ebola suggests that without these guarantees, people will be imaginative in dodging restrictions.”

Here’s what the Australian Health Department means about isolation

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As I write today, there are an estimated 50 million people in China’s Hubei province in lockdown, and 16 million in Northern Italy. [breaking: Italy has just declared the whole country to be in lockdown]. In Australia in the early days of the epidemic, those with Australian passports returning from China were asked to self-isolate. This has been extended to those coming from Iran and Korea with those arriving from northern Italy being carefully checked.

On seeing the ABC breaking news item above, I tweeted

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The Tasmanian case struck me as highly unlikely to be unique. With a high proportion of COVID-19 positive cases experiencing mild symptoms, particularly in younger age groups, it seemed very likely that many being asked to stay fully at home for 14 days would self-diagnose that, hey, I’m not feeling  too ill, and self-exempt themselves from isolation, thereby risking infecting others in the community. If hundreds or thousands were to do this should the epidemic accelerate as it did in Hubei and is now doing in Italy and Iran, the consequences could be catastrophic.

Quarantine has been used around the world for centuries as a major strategy to try and contain outbreaks of deadly, highly infectious diseases like smallpox, plague, leprosy and TB (before the advent of effective drugs). Quarantinable diseases today include smallpox, cholera, diphtheria, plague, yellow fever, TB, Marburg and Ebola.

Courts have long used home detention in lieu of prison custodial sentences for those deemed suitable. Home detention is far less expensive than detaining someone in prison. It keeps families intact, avoids immersing some without previous criminal records in brutalising prison incarceration, keeps offenders away from the public in consideration of public safety and serves as a punishment. Wearable GPS-linked monitors like Fitbits are today inexpensive and in extremely widespread use particularly for personal activity and journey tracking, monitoring of those with dementia, and by parents wanting to track where their kids are. Programing them to signal when a person has moved out of a prescribed area is a basic capability. Making them non-removable without activating a signal is also the way they have long operated in custodial use.

The comparative costs of combining 14 day self-isolation of COVID-19 people with cost free, state-supplied, returnable mandatory wearable and non-removable monitors, against the stratospheric costs to lives and the economy of rapidly spreading COVID-19 is a no brainer.

Negative responses

My tweet set off several hours of extremely negative responses, all of which were highly case-in-point relevant to my assumption that the failure of self-isolation without monitoring would be anything but rare.

Here’s a sample of what I received. Stu opened the batting with:

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Another agreed:

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This of course, is an objection to quarantine per se, when those quarantined are not able to draw on employment sick leave benefits, nor compensated (almost never the case).

Ian seemed to think I was extremely wealthy and by raising monitoring for discussion, was offering to fund it!

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Note the host of assumptions with all of these: that some ordered to self-isolate, particularly those with hand-to-mouth incomes, in the casualised or gig economy workforce with no sick or holiday leave entitlements, will put economic necessity, hunger and shelter ahead of any concern that they might infect others; that quarantine  “criminalises” and stigmatises people who are sick (when silly me thought it was all about trying to control a rapidly spreading disease with no cure or vaccine that could kill many, many people); that because China was engaging in quarantine, this is all we needed to know: it is a totalitarian state strategy (conveniently overlooking that every nation has quarantine laws and practices, Australia’s dating from the arrival of the first fleet); and that quarantine was somehow a knee-jerk authoritarian solution being proposed instead of every other possible strategy (rather than being just one vitally important component).

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In late February I’d tweeted in anticipation of employers trying to shaft their staff, and especially causal workforces, who may have little to no sick leave to fall back on, that legislation should make it illegal for any employer to not pay an employee in isolation, or caring for child from a shut-down school, for example.

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No one tweeting against the monitoring idea who invoked the impact of short term quarantine on the most vulnerable workers seemed to have thought about the consequences on those same workers if COVID-19 became very widespread and devastated economies. Many industries employing casual staff would suffer badly with many casual staff laid off. So such objections seem very myopic.

Remarkably, those making these arguments were actually using them as arguments against fully complying quarantining, or perhaps didn’t understand that ordered self-isolation was already happening. They argued that there will be significant recalcitrance, pointed to the numbers who have “gone underground” in previous epidemics and implied that therefore because all won’t comply with its conditions, it should be abandoned.

But no public health and safety regulation has 100%  compliance, and this is usually not a sensible argument for abandoning liberty curtailing policies like random breath testing or speed limits. When I asked a few if they therefore did not support quarantine, interestingly none answered.

Just like HIV/AIDS

Some also castigated me for my alleged ignorance in not understanding the lessons from the HIV/AIDS epidemic, where coerced isolation (for example with HIV positive sex workers who kept working without condoms, needle sharing drug users) was only rarely used with just 5 cases of forced quarantine in the USA. If it didn’t need to be used with HIV/AIDS, it doesn’t need to be used for this new disease, ran the argument.

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But there are of course immense differences between deliberate attempts to not avoid HIV transmission by knowingly positive people via sex, needle sharing and blood donation and the unintentional way that COVID-19 is spreading around the world (eg: skin contact, sneezing and contact with everyday surfaces that harbour live virus).

Importantly, there is a large body of research showing that social distancing is an effective way of slowing contagion of infectious diseases (eg: see here, here, here and here).  A very recent paper with eye-watering modelling the of the comparative impact of quarantining and active monitoring of COVID-19 contacts concluded:

“individual quarantine may contain an outbreak of COVID-19 with a short serial interval (4.8 days) only in settings with high intervention performance where at least three-quarters of infected contacts are individually quarantined.”

Epidemic waning in China

The graph below compiled from WHO data by the University of NSW’s global biosecurity group shows how dramatically the Hubei epidemic is waning, following lockdown. Today, China reported zero new cases outside of Hubei for the third day in a succession. Few countries will be willing or able to enforce lockdowns or self-isolation in the manner China has been able to do (recall the ghastly, dramatic scenes from the recent Four Corners program where highly distressed COVID-19 positive people were being forcibly dragged into detention by authorities and doors of apartments were shown being welded shut to keep sick people inside).

 

In Australia, GPS monitoring of confined people over the two-week period of isolation may be a reasonable and far more humane way of minimising the spread of COVID-19. Some would very understandably have the instinctive reaction that a requirement to wear a GPS monitor for two weeks would be frankly insulting and a sign that the government did not trust them. For this reason, it may frighten policymakers off.

But against this, there are quite obviously many who already do not trust governments, very many who very sadly say they do not trust science and medicine (while relying on and benefit from it in practically all they do every day) and many who give little concern to infection control when they have colds, influenza and other communicable diseases.

People won’t like it

This is an idea that will have many practical, cost and social acceptability implications. Many will not like it, as Anthony below suggested.

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For debate.

 

Did the Royal Australian College of General Practitioners really back vaping as a second-line therapy?

This is a guest blog from Sarah White PhD, director of Quit Victoria. Reproduced from Australian Doctor, with permission

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The RACGP’s Smoking Cessation Guidelines are generally excellent.

However, I worry the e-cigarette recommendation is not pragmatic and that deliberate misrepresentation of the nuance in the recommendation risks will create a situation in which doctors are faced with an ethical dilemma.

The guidelines acknowledge the lack of approved nicotine-containing e-cigarette products and argue this is creating an “uncertain environment for patients and clinicians, as the constituents of the vapour produced by vaping have not been tested and standardized”.

They add: “However, for people who have tried to achieve smoking cessation with approved pharmacotherapies but failed, and who are still motivated to quit smoking and have brought up e-cigarette usage with their healthcare practitioner, nicotine-containing e-cigarettes may be a reasonable intervention to recommend.”

So is this the college endorsing vaping as a possible second-line therapy for doctors dealing with patients wanting to quit?

To me, the recommendations, when read in context, suggest that doctors should gently dissuade patients from using e-cigarettes through a “shared decision-making process”

It’s important to acknowledge the very real qualifications the guidelines make.

Firstly, they suggest doctors discuss the option only if brought up by the patient themselves when all else has failed.

They also say that doctors should make sure the patient is aware of the following:

  • there are no tested and approved e-cigarette products available;
  • the long-term health effects of vaping are unknown;
  • possession of nicotine-containing e-liquid without a prescription is illegal;
  • in order to maximise possible benefit and minimise risk of harms, only short-term use is recommended; and
  • dual use needs to be avoided (for example, with continued tobacco smoking).

This advice is not surprising given the current low certainty of evidence. However, more importantly, no products have been assessed as meeting basic Australian consumer safety standards, let alone having gained TGA approval.

There are literally tens of thousands of e-cigarette products available to any patient in Australia, presented by the possible combinations of multiple devices (some with adjustable temperature and electrical resistance settings) with e-liquids that can contain one (or more) of 2000+ chemical flavours, different ratios of carrier and flavouring liquids and a range of nicotine concentrations.

We don’t know which devices shed heavy metals and other chemicals from their interior or which e-liquids contain impurities or contaminants.

We don’t know the by-products created by admixture, pyrolysis and decomposition of e-liquids. Australia’s chemicals watchdog, the National Industrial Chemicals Notification and Assessment Scheme (NICNAS), set out these concerns in a comprehensive—and alarming—2019 review of a small number of non-nicotine e-liquids available for retail sale in Australia.

In my view, the e-cigarette recommendation should have been much less equivocal and based on a synthesis of evidence as it applies to the current retail and regulatory contexts in Australia.

Had this been the case, the recommendation would have been along the lines: “The RACGP is unable to recommend the use of e-cigarettes until a product has been approved by the TGA. If a patient chooses to use an e-cigarette, they should be made aware of the following issues to maximise potential benefit and to minimise potential harm….”

Naturally, inevitably, lobbyists and commercial interests (including tobacco companies) leaped to publicise the RACGP’s new guidelines, conveniently omitting the e-cigarette recommendation’s nuance.

One media release appeared an impressive 35 minutes after the guidelines were issued, claiming the RACGP “endorses” e-cigarettes “in a major policy shift”.

Some hours later, RACGP president Dr Harry Nespolon was forced to tweet an unequivocal “the RACGP does not endorse vaping”.

I note these public relations efforts because I fear that doctors will start seeing patients wanting to discuss e-cigarettes because they have been told by those with vested interests that “doctors recommend them now”.

So, what is a doctor to do if a patient is adamant about trying an e-cigarette in the absence of any safety or efficacy data for a retail product?

Which device type or e-liquid(s) should be recommended? What dose of nicotine should be used? Is it a doctor’s responsibility to inform the patient how to dilute a potent neurotoxin to the right dose?

And how often should the device be used and for what duration? What is the legality of possessing liquid nicotine? (As of December 2019, nicotine possession, even with a doctor’s prescription, is illegal in the Northern Territory.)

Are doctors really going to recommend their patients pop down to the nearest high street ‘Wicked Groovy Vapes’ shop—as advocated by e-cigarette lobbyists—for the answers to these and other questions?

It seems inevitable that doctors will be forced into a choice of either refusing to provide a prescription for liquid nicotine or providing one in the full knowledge their patient could be harmed by how they use it.

To my mind, this presents an ethical dilemma that could have been avoided by a more definitive recommendation along the lines of that issued by Dr Nespolon on Twitter.

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