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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Want to work for a pariah industry? Big Tobacco fears it is unable to attract top staff

Lying tobacco applicant

Imagine yourself as a newly-minted, honours-showered graduate from a world class business, marketing or management school. Lots of exciting career possibilities crowd your head: renewable energy, robotics, electric vehicles, affordable housing, to name just a few. You lay out company and agency profiles and analyses across the table and consider the risks and benefits of each, and the leverage of an early strategic choice might have if more exciting but highly competitive priorities were unrealistic at the moment.

How likely would it be today that such a short list would include a tobacco company? How would your resumé look to other employers later if they could see you’d made the choice to work for a tobacco company?

The tobacco industry has suffered public and corporate reputational bottom-feeder status for decades.

A 1993 corporate image study prepared for Philip Morris in Australia found the company were fellow cellar dwellers with other tobacco companies, running last against all other companies in the mix:

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A year later in 1994, an Australian Financial Review article quoted Nick Waterford of Michael Page Recruitment saying:

“I don’t think there’s any doubt that it’s harder to get enthusiasm for tobacco companies. There is a trend. If you have ten qualified candidates and you tell them it’s a tobacco company, five might say they don’t want the job.”

In the same piece, a former industry employee said:

“From a personal and family point of view, it just became wearing having to discuss and defend the industry at every dinner party we went to.”

In the 26 years since, things have almost certainly got a lot, lot worse.

An analysis of 5 years (1993-7) of Australian press reports mentioning the tobacco industry found routine narratives and memes of the industry as callous merchants of death, corporate leviathans, toxic pied pipers beguiling children, and blood money grant dispensers engaged in conspiracies to cover up awkward facts about death, addiction and targeting kids.

A 1999 South Australian survey on community perceptions of honesty and ethics found tobacco industry executives rated lower/very lower (73.6%) than even car salesmen (67%), the time-honoured low watermark of trustworthiness.

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By 2004, 79% of Victorians (and even 71.3% of smokers) believed tobacco companies never or mostly don’t tell the truth. Can there be any other product where so many of its customers think those making and selling it are so dishonest?

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And by 2010, the global Reputation Institute reported  “Again securing the last place [reputational] ranking [of 25 industries], the global tobacco industry’s average Pulse score dropped 4.4 points” with 51.24, against an all-industry average of 64.2. And there was daylight between the 24th place getter (diversified finance) and tobacco in last place.

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No further reports have since been sighted but you could bet your house that if these had shown any upward movement by tobacco, the industry’s spinmeisters would have issued frenzied, gushing releases on the good news. But tellingly, there’s been utter silence, so go figure.

The companies love to publicly congratulate themselves on social media when they rank anywhere remotely respectable on anything other than their core business. Their pool room display cabinets are full of awards no one has ever heard of for every conceivable virtuous activity: affirmative employment action, greening policies, charitable giving, even picking up litter (where cigarettes butts are always the most common item). Yet global awards for annually causing the early deaths of two in every three of their longest, most loyal customers – more than 7 million a year — are strangely uncelebrated.

Decades of relentless, unflushable bad news like this inevitably reduces the quality of staff prepared to work for such industries. Big tobacco has become the index case for shorthanding corporate malfeasance. Just try googling “just like the tobacco industry”, and stand back while a Niagara of appalling fellow travellers pour down the screen.  The world has long calibrated corporate ugliness against the tobacco industry, although coal and other fossil fuel industries may by now be pressing their case for the most-loathed prize.

The tobacco industry has set the low watermark for corporate indecency and indifference to the consequences of its key performance indicators on the health of millions of people.  Unless they have been in a 40 year coma,  those joining the tobacco industry in 2020 do so with their eyes wide open to the toll wrought by the tobacco products which are the backbone of every tobacco company. While some staff would rationalise their decisions after a long draft of industry kool-aid about the recent embrace of ecigarettes and other putative reduced risk products, the day-to-day of working in a tobacco company for most employees remains all about selling as any cigarettes as possible.

A request I made in February 2019 to Philip Morris International for the release of typical key performance indicators of their cigarette division staff was ignored.

In 2016, before the big tobacco companies went into turbo drive to promote their “transformation” into quasi public health agencies via risk reduced products, Mike Daube and I published a collection of statements  companies had made to government corporate regulators about the risks that the companies faced, which were relevant to investors’ decisions.

Altria (Philip Morris USA’s parent company)  reported that, “Altria Group, Inc. may be unable to attract and retain the best talent due to the impact of decreasing social acceptance of tobacco usage and tobacco control actions … our strategy of attracting and retaining the best talent may be impaired by the impact of decreasing social acceptance of tobacco usage … ”

The Lorillard Tobacco Company reported that, “As a tobacco company, we may experience difficulty in identifying and hiring qualified executives and other personnel in some areas of our business. This difficulty is primarily attributable to the health and social issues associated with the tobacco industry”.

Philip Morris International report “… We may be unable to attract and retain the best global talent”.

And Reynolds American report “… Recruiting and retaining qualified personnel may be difficult given the health and social issues associated with the tobacco industry”.

These are all code for “understandably, most people aren’t rushing at the opportunity to work for a company whose addictive products cause the annual death of millions”

And today? 

So how do they see their prospects of attracting top tier staff today? At Altria the company report to the US Securities and Exchange Commission for the quarter ending  Sept 30 2019 stated:

“We cannot guarantee that any forward-looking statement will be realized … You should bear this in mind as you consider forward-looking statements and whether to invest in or remain invested in Altria’s securities …we are identifying important factors that, individually or in the aggregate, could cause actual results and outcomes to differ materially from those contained in, or implied by, any forward-looking statements made by us … These factors include the following …

  • our inability to attract and retain the best talent due to the impact of decreasing social acceptance of tobacco usage and tobacco control actions”

How many other industries and companies would make a special point like this about the calibre of their staff being a possible risk for investors? It’s unlikely that they are referring here to their cleaning staff, their janitors, their gardening, driving, factory or secretarial staff. It seems far more likely that they are alluding to planning and marketing staff employed to maximise sales; to corporate affairs and government relations staff charged with defeating, diluting and if all else fails, delaying tobacco control policy which might adversely impact on sales; and to scientific staff who know which side of optimising nicotine addiction their salary bread is buttered on. And did those at the top who signed off these statements believe they might also apply to them?

So where do these tobacco companies get the idea that the “talent” they recruit and are able to retain may not be the very best? Does it come from intelligence gathered from recruiting agencies, urged to be candid about the quality they are seeing? And frankness about how many fine applicants run out of the room when it’s revealed an anodyne job description is in fact a job in a tobacco company? Or is it from facing up to the hard reality that there has been not a single policy or piece of legislation the industry has fought and won since they first tried and failed to defeat the very early tepid pack warnings, and every generation since? That the tobacco industry is where you go if you are going to fail to stop policy that will be bad for your industry. “What did you achieve in your last job?” “Oh, we lost every battle we fought.”

When I interviewed Australia’s Nicola Roxon, the former health minister and attorney general responsible for introducing our historic plain packaging laws, for our book, I asked her why the Labor government had done it. One of the most emphatic reasons she gave, described in the book, was that “it was a no brainer politically – everyone hates the tobacco industry.” They believed, accurately, that they would be cheered on by all sides of politics (except the tiny irrelevant libertarian fringe), by the public and even by large proportions of smokers. Those we interviewed for the book often made comments about how underwhelmed they were about the staff who led the local industry and fronted for it in media advocacy.

When the companies themselves feel obligated to acknowledge this issue explicitly to corporate regulators, it would be very interesting to be a fly-on-the-wall inside the industry as they struggle to work out this seemingly intractable problem.

Trump’s profligate and unpunished lies threaten to cause an epidemic of ethical collapse

 

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Cathy Wilcox Sydney Morning Herald  Jan 2020

On December 16, 2019, the Washington Post’s on-going logging of Donald Trump’s false and misleading statements since becoming US president listed 15,413 of these across his 1,055 days in office: an average of 32 a day.

Trump has been busier selling his rancid pork pies to the world than a one one-legged man in an arse-kicking contest, all the while braying about other people’s “fake news”.

This week, the Guardian’s Greg Jericho tweeted about  Bridget McKenzie’s “they were all eligible” response to the revelations of the humongous pre-election pork-barrelling of community sporting development grants that “The biggest thing conservatives around the world have taken from Trump is to never admit error even in the face of total evidence. And then to keep doing what you were doing.”

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To which I replied “The legacy of this new normal obdurate political denial & lying for a generation of kids growing up witnessing the opposite of what mum, dad & teachers have always said about lying may be tragic for the basic civilised principle of honesty.”

I’ve helped raise three children and now have two grandkids, 7 and 9. My wife is a retired primary school teacher, with 40 years in front of classes of kids. Our dinner table and pillow talk has often seen long dissections of some outrageous lies that children tell – some highly amusing and others utterly flabbergasting – often in the face of in-your-face evidence that they can’t seem to take on board.

Across these years I’ve been fascinated at the evolution of children’s moral development. Our 9 year old is currently in a full embrace of altruism. She’s busked with her ukulele and set up table in the front of her house to sell unwanted books and toys to help raise money for fire victims. Bless her.

But it wasn’t long ago that she would clock her younger brother when she thought we weren’t looking and then strenuously deny it when it had been in full sight. With our kids, loose change around the house went missing occasionally, and homework had not been set that night when it had been. All very normal when you are a small child.

Jean Piaget’s classic The Moral Judgement of the Child (1932) described the normal moral development in children, with all the implications for when and how we should understand that a child fully understands notions of right and wrong.   A 2008 review of studies into children’s lying concluded:

“These studies have shown that children show rudimentary conceptual and moral understanding of lying around 3 years of age but take more than a decade to reach maturity (e.g., being able to consider intention when categorizing a statement as a lie and evaluate its moral values.)”

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So from this, if we are generous, we might conclude that Trumpian liars probably never made it into their teens and have the moral development of small children trapped in their adult bodies.

When you are an adult, foundational values on which all institutions and codes of conduct are built have honesty at their core. We have all known sad and pathetic adults who regularly lie. The law calls it perjury when it happens under oath. False declarations carry severe legal penalties in every area of finance, licensing, professional standards and the rest. Thou shalt not bear false witness, says the eighth commandment.

It would only be a psychopathic parent who would try to teach their infant children to lie and reward them for doing so. Yet each day the man in one of the world’s most venerated offices, role-models deception to the world. Many have made the point that if Obama or any president before him had misled the nation even once like Trump does every day, he would have been politically lynched.

Lying and misleading parliament has always been unpardonable in nations adhering to Westminster standards of honesty, integrity and concern for public trust in democracy. Under Trump’s example, abetted by slavering Republican politicians who line up beside him and are predicted to wave him through his impeachment, all this may disappear.

Trump has debased the office of the US President in almost uncountable ways.

The deafening silence of (most) global religious leadership to Trump and his ilk’s bottom-feeding ethical standards is shameful. The silence of nearly all of his Republican elected politicians is frightening.

45% of Americans today support Trump. These people presumably would say in ignorance or as mesmerised cultists tend to do, that they do not believe he lies and misleads. But many would say they don’t care if he does.  Ethically corrupt politicians around the world are watching this cataclysmic collapse of ordinary standards of honesty and taking their chances.

All who fear this ethical collapse need to speak out at every opportunity and on every occasion that our elected officials behave dishonestly. Civilisation will depend on it.

OrwellonTruth

Prime Minister: let’s have a national architecture competition to design Australian fireproof housing

I played tennis this morning with a long time friend whose family holiday house was burnt to the ground at Rosedale, south of Bateman’s Bay. Built by his now deceased Canberra based parents many years ago for their children to enjoy, it lies today as ash in the burnt out bush.

One house in the affected area survived. It was a fireproof house.

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http://kyliefeherarchitect.com/karrifirehouse

The house was fully insured, so his family’s agony at the loss of a place he has visited for decades since boyhood was cushioned. This morning we spoke of  his early thoughts on rebuilding. A fireproof construction, sympathetically designed to blend in with the coastal bush was top of mind.

Many hundreds, perhaps thousands of Australian families will be in this position by the end of this summer.

So here’s a thought. Let’s have an national architectural design competition to produce a suite of fireproof building designs suitable for Australian bush living as we unarguably move into the era of extreme climate change on a continent that looks like it will be in the vanguard of what much of the world will experience.

These should traverse the most basic through to the more extensive of designs They should utilize the very smartest of sustainable and affordable  design while forging a new generation of design aesthetics compatible with the values that draw Australians to live in the bush.

The Commonwealth could fund the prizes across several categories, which would include both residences, garages, storage and workplaces.

Local governments across Australia should work closely together to revise building codes to embrace standards that will see all newly constructed and major renovated buildings conform to these codes.

Those affected will will be starting to plan rebuilds very soon. Let’s not repeat the mistakes of the past.

Simon Chapman AO is a life member of the Australian Consumers Association (publishers of Choice) and a past chairman

Scott Morrison at the beach

Photographs of Australian Prime Minister Scott Morrison walking on Sydney’s Bronte beach wearing only  a pair of speedos have been published. They are found easily on the web. Some comments focused on his decision to relax on a Sydney  beach after his Hawaiian holiday while the fires still burn. But many dwelt on  his body.

Morrison is a large-framed 51 year old man with a sedentary job that almost certainly leaves him little time for serious physical activity. His schedule would include many working breakfasts, lunches and dinners.

No one would have therefore been surprised to see that he is considerably overweight.

The photographs gave license to some to add personal ridicule to the widespread anger and contempt that many feel about Morrison and his government’s policies on issues like climate change and asylum seekers, and his sycophancy with Trump. I personally loathe his politics, and contribute my share of denunciation in the hope that his support will reduce.

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The photos reaped the expected response across social media, with uninhibited expressions of disgust about a sight wits argued could never be unseen, calls for him to wear boardshorts and a rash shirt to spare us all from the “trauma” of seeing such a sight (Check the twiter hashtag #PutSomeBoardiesOn)

Body shaming is often a toxic combination of fat shaming and unadulterated ageism. When it comes to older men, a very Victorian puritanism is also thrown in: while it is just fine for lithe and muscular young men to wear speedos that can hint at their hidden endowment, it is never OK for anyone with less than a fully cut body to do so. Older men must do all they can to appear asexual. Tony Abbott, with a fit body, was constantly pilloried for wearing speedos as if he was somehow putting it out to all that he had a cock he wanted us to notice. Morrison too should wear swimming shorts or boardies, the mob insists.

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Princess Anne inspects the Australian rowing medalists at the 2000 Sydney Olympics.

No one other than strict Muslims insist that women should wear swimming gear that covers all suggestions of the existence of breasts. But no man with less than George Clooney magnetism should ever wear speedos and hint that they may have a penis. – that seems to be the message that resonates with many today.

The message being sent to Morrison is a message that is also received by everyone with an older and less than perfect body: stay out of public sight. We find you repulsive. We shouldn’t have to look at you. You should understand how bad you look and keep your awful body covered up.

These messages can have serious repercussions. A large majority of the population don’t measure up to this standard with its neo-eugenic sub-texts: the old and anyone falling outside some ideal body type covers millions of Australians. The net impact of this sort of shaming across the population for feelings of low self-worth, esteem and acceptance manifests itself every day in dieting, anxiety and depression.

Morrison deserves all the criticism he gets. And more. But sorry, body shaming should never be acceptable.

Junk research journal and conference emails: the gifts that keep giving

Simon Chapman & Mike Daube

Every day, every academic we know receives numerous emails from purported research journals and conference organisers. But they are junk, predatory on-line journals and events. The emails never mention that they are from pay-to-publish factories often from India or China, set up to fleece inexperienced researchers who are often desperate to publish work to allow them to take their first steps up the academic ladder. This requires evidence of research publication or international conference presentation. They have portentous titles inferring that they are the key gathering (“world conference” or “summit”) in their fields, and entail substantial fees, but are often equally phoney – even run by the same groups.

The journals claim that they are peer reviewed (indeed, usually promising rapid review), indexed by renowned indexing agencies, and have impressive impact factors.  But in reality they are almost invariably sham operations where perfunctory “peer review” occurs internally, if at all (see an earlier article on these journals here), and the “Impact Factors” can be as spurious as the journals. And they charge – sometimes hundreds, sometimes even thousands of dollars – for the privilege of appearing on their websites as “publications”.

One of us tested the bona fides of these “journals” by creating a CV for his Staffordshire Terrier, Ollie (AKA Dr Olivia Doll DCS, Senior Lecturer in the Subiaco College of Veterinary Science, with research interests including “The benefits of abdominal massage for medium-sized canines”) and an older colleague, Professor Curig L’Épagneul, a spaniel whose CV indicates that he died in 1954, and who rejoices in the title of Macallan Professor of Alcohol Experiential Proficiency. They were both speedily accepted as editorial board members, and have co-authored papers accepted by these “journals” –  notably a paper co-authored by Dr. Doll with a distinguished American Staffie, Dr. Alice Wünderlandt (who works in association with a distinguished marine scientist, Dr. Phillip Clapham), entitled “ Solicitation of patient consent for bilateral orchiectomy in male canids: Time to rethink the obligatory paradigm” – a plea for informed consent by dogs before they are castrated.

Ollie

Dr Olivia Doll DCS (left)

Over the years we have shared many of the more comical attempts to extract money from our wallets from these outrageous scam publications. In the spirit of Christmas, here are some winners from the last 12 months. In the spirit of academic collaboration, we would welcome any further suggestions, which might form the basis of a paper to be submitted to one of these journals.

Bonhomie bursting out

When we receive invitations from professional journals to review, write commentaries or editorials, the tone is matter-of-fact. They write to you because of your track record and reputation. There’s no need for the saccharine. But junk journal “editors” gush all over you from their very first words: “greetings of the day!” and “Hope you are doing well”.

And they like to target their greetings with Exocet precision: “Seasonal Greetings”, Autumn season wishes” – or even “Happy Tuesday!” and “Happy August!”.  Who knew there was a happy Tuesday?

Sometimes, there’s pathos too.

Dear Dr. Simon Chapman,

Good Morning!  Having seen your eminent profile, I would like to send you below cordial invitation. Advances in Cancer Research & Clinical Imaging is planning to release the Volume 1 Issue 2 by the end of this month.

All the authors around the globe are cordially invited to submit any type of the article based upon your research interest for the Christmas Edition.

I really need a warm support from an ideal person like you.

Await your submission.

Regards,
Julia Vinscent

Awr shucks, Julia we’ve never actually met.

Or (albeit in a form of English that might not pass muster in second grade):

“Hello Editor. OLIVIA DOLL,

Hope you will available for this mail. I’m disappointed a lot with the lack of response from your end…… We feel the presence of articles from Editors in an issue is very worthful. Kindly consider about the welfare of the journal, for any credential the Editor’s activity is must so, please cooperate with us. We do accept manuscripts with your reference.

Hope to read from you at least this time.

Expecting your response!”

Slavering, obsequious, baroque praise

No recipient of these missives escapes a deluge of fawning flattery. Understand that the people at these journals have read your other publications. All of them. And, very correctly, they grasp that they are all wonderful, and that you are “a celebrated leader in this field” – even if this field is “Nano/molecular-medicine engineering”! They now want you to write more about the same thing or travel around the world to deliver a talk to a small room full of  saps who have fallen for all this – or perhaps want an excuse to use unscrutinised travel funds and enjoy Paris or Tokyo.

So we get “Respected Dr. Simon Chapman”, “The interest that our team has for your expertise is immense, so please make us delighted by letting us know your possibility of article submission for the upcoming issue.” “It is a pleasure to put my request to a great scholar like you.” “I appreciate the substantive intellectual contributions to your published study.” (Ermm.. which study was that, now?) ”Having seen your eminent profile, I would like to send you below cordial invitation”  “We expect your precious comments or suggestions” or “Dear Dr. Daube M, Good Wishes! Journal of Public Health Hygiene and Safety (JPHHS) aims to develop and uphold the standards by publishing the cut-edge research…..We have recently had good fortuity of reading your article…… which was rare well-written and informative……In this regard, we take honor in inviting you to contribute your upcoming research work towards our journal.”

Keep a knockin’ but you can’t come in

The editors are often deaf or perhaps just persistent and undeterred by your having thrown them many times before into your spam bin.

“Please accept my apology if this email bothers you, as I have tried to send you this invitation in last months but without any response from you.”  “We have tried to contact you earlier, but with no response from you, we would like to contact you again.”

Game’s up: they know your secret expertise

We both work in public health. Yes, this is a broad church. And of course we know those in public health who stand ready and waiting to run at the mouth on any topic whatsoever. So this was tempting. “Currently we are seeking contributions on food science and nutrition therapy which is relevant to the area of your expertise.”

Then there was this: “Our committee came across your profile which is very impressive and we suggest you to present a talk at our conference 2nd International Meeting on Cosmetology and Trichology which is to be held in Dubai, UAE during April 19-20, 2019. This Year we adopted a theme for the conference “Allocating new possible innovations in cosmetology and Trichology fields”.

Captain, start the engines! We’re on the plane!

In the last two weeks one of us has had invitations from journals and events in some twenty areas ranging from “Plant hormones and other growth regulators” to “Economics and International Business Management” and “Pesticide, Fertilizers and Crop Cultivation”.

It is also clear that delegates at an upcoming gene conference would be scouring the program for any papers on alcohol policy, a leading edge topic in gene therapy: “It is our great pleasure and privilege to welcome you to join the World Gene Convention-2020 (WGC-2020) conference, which will be held during June 7-9, 2020 in Osaka, Japan. On behalf of the Organizing Committee, we would be honored to invite you to be a chair/speaker at Session 4-7: Antibodies/Vaccines while presenting about “What should be done about policy on alcohol pricing and promotions? Australian experts’ views of policy priorities: a qualitative interview study” at the upcoming WGC-2020.”

Now, do you understand what we’re looking for?

The editors can give precise, helpful directions on what the hope to get from you “We are looking forward for most complicated/rare cases which may help the future residents train to tackle with challenges.” The future residents? WTF?

Great strides on a great surface

When winnowing the grain from the chaff in journal selection, we always look at what advantage the journal can offer our careers. This one almost did it for us:

“Our organization is well affiliated with giant strides in the field of sports medicine. It is providing excellent services to the researchers with knowledgeable information.”

Then we wondered whether this one might have a ballroom dancing breakout session, always a bonus: “We really encourage you by providing with this great surface to share your experience of your research work.”

The mangled English that infects nearly every one of these emails is very surprising because they are mostly signed by people with very Anglo names like Christine Moore and Peter Smith who have US or English addresses (which when you chase them down are often paid forwarding addresses) and phone numbers (which are never answered). Call us cynics if you must, but we wonder if these are real people.

Taking the piss?

It’s remarkable  how many of these journals get becalmed in a publishing drought and are always falling short of their next issue’s paper quota by just one article. This urological journal went straight to a top urine researcher in its latest predicament.

“Dear Dr. Simon Chapman,

Good Morning…..!

Can we have your article for successful release of Volume 2 Issue 4 in our Journal?

In fact, we are in need of one article to accomplish the Issue prior December; we hope that the single manuscript should be yours. If this is a short notice please do send 2 page opinion/mini review/case report, we hope 2 page article isn’t time taken for eminent people like you.

Your trust in my efforts is the highest form of our motivation, I believe in you that you are eminent manuscript brings out the best citation to our Journal.

Anticipate for your promising response. Hope so this invitation will gives you a better opportunity and future endorsements.”

Time to open the judging panel’s envelope

After many hours in operating theatres undergoing recurrent hernia repair from laughing so much, we have made two awards for 2019.

The Dramatic Opening Award goes to the SM Journal of Preventive Medicine and Public Health:

Dear Doctor,

Desire to consider a proposal! 

 

The Least Appealing Award goes to the Scientific Journal of Research in Dentistry.

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The restrained opening sentence (“This is our heart whelming colossal desire to welcome you to a new era of innovative gatherings and scietific publications”) followed by the compelling incentive of “flashing with new peers” saw off all rivals.  Happy Christmas to all readers.

 

 

 

Je twitte, donc je suis (I tweet therefore I am): my 10 years on Twitter

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Ten years ago today, I tentatively signed onto Twitter. My friend Melissa Sweet who in 2007 started Crikey’s then infant sibling, the Croakey health  blog, was an early adopter. She’d given a presentation to staff and students at Sydney University’s School of Public Health on the potential of various new-fangled social media to advance health.

When she described Twitter, I tuned out. I didn’t want to know about anything with such a ridiculous, trite name. But she persisted and got in my ear a few times, emphasizing that you could curate your own feed to have regular material seamlessly pop into your Twitter feed from all the outlets that you would otherwise take lots of time to manually search out. I instantly got the sense in that, so took the plunge. Twitter rapidly became an indispensable part of my day.

Among my earliest follows were the journal I edited for 17 years Tobacco Control, the New Yorker, the Atlantic, the Guardian’s George Monbiot, Stern’s world music shop, and Ben Goldacre, author of Bad Science.

I also rapidly followed individuals I knew as polymaths, wits and those in possession of high powered bullshit detectors and truth serum dispensers for issues that interested me.

I started out by setting a personal rule that I wouldn’t follow more than 200 accounts. I didn’t want to be deluged every day with thousands of tweets that I could never hope to follow in any meaningful way as they flooded my inbox. I pruned those I lost interest in and some who turned out to be Twitter incontinents. I later nudged this limit to 300.

Today I have 10,998 followers and have tweeted (tweets, retweets and responses) 34,800 times, an average of 9.5 times a day. My follower-to-tweet ratio is 1:3.2 – so across 10 years, I’ve picked up (and retained) a new follower every 3.2 tweets.  In the past 12 months, my tweets have had 4.814m impressions. My two most retweeted tweets have been those below.

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On December 14, 2012 when the Sandy Hook gunman in Newtown, Connecticut killed twenty 6 and 7 year old children and six adult staff members, I tweeted a link to our 10 year evaluation of the impact of Australia’s 1996 gun law reforms on mass shootings.  In the month of December 2012, the paper received 83,310 views and downloads, far more than it had received across the 72 months it had already been available on-line. Today, it has an Altmetric attention score of 2,442. If it had been published in 2018 and had that score, it would rank as the 54th highest ranking paper published across all fields of research in the year, In my experience, Twitter is peerless as a dissemination tool for research.

The joys

The joys of Twitter are endless. By the time my non-tweeting wife has read the newspaper in bed on her iPad each morning, I have often read the same stories with rich commentary from those I follow, and a spiral of those I don’t follow but who’ve interacted with some of those I follow. When well curated, Twitter is incomparable in surrounding you with information and perspectives on your interests at breakneck speed.

Want deep legal takes on the latest moves against Trump? Interpretations of new data on climate change? A look at what the world’s best cartoonists are saying? A deep dive into the collection of maps and graphics on just about anything? Then geographer/demographer Simon Kuestenmacher is the go-to. Twitter allows you to liberate a mind-boggling selection of your reading interests, and to refine that selection as time goes by.

With your own posts, you quickly learn a lot about the sort of tweets which attract high interest. Arresting, apposite pictures plundered from Google images often punt a tweet into a large crowd far more rapidly than a text-only one. Twitter’s real time tweet analytics tab which provides an instant account of whether a tweet has died or is rocketing through cyberspace can by quite addictive. A tweet that rapidly soars past a 1000 impressions, can start building exponentially across the following days, particularly if it’s been retweeted or commented on by several with humungous followers.

There have been many, many occasions when someone has come up to me saying they follow me on Twitter and talks about a memorable tweet. I do the same with local people I follow. I often tweet about public health and climate change, so the knowledge is very motivating that tweeting spreads information I’ve thought was important and useful, or calls out nonsense to thousands of people who may have trustingly taken some misleading bait.

The tribulations

Twitter is sadly a magnet for miscreants, haters, obsessives and other RWFW detritus craving your attention and reaction. Their accounts are mostly dismal, anonymous little affairs with desultory followings from their tiny echo chambers. They often open their attempt at communication with slander and abuse.  Here’s a large selection from the cyber sewer I collected about me a few years ago.

A few years ago, some colleagues and I researched the characteristics of public health researchers in Australia who had been voted by their research peers as being most “influential” in Australia. (see our papers here, here, here, here  and here). We also interviewed policy makers like health ministers, a state premier, their senior staff and senior health bureaucrats.

In explaining why they chose to seek advice from some experts and avoided others, expected factors like reputation, responsiveness, and having an understanding of the political process were important. But several emphasized that, like us all, we prefer the company and advice of people whose first, second and continual impulse is not to abuse you, but to be respectful. When someone opens their engagement with you with a salvo of derision, coupled with an attempted Twitter pile-on from their fellow travelers, the future of your relationship looks grim.

The politician and mandarins we interviewed emphasized that this did not mean they wanted to just surround themselves with sycophants. They were very open to interaction with experts, practitioners and consumers seeking policy change. There were few if any who didn’t. But just as we all give wide berth to bores, drunks, dope heads and one-topic finger jabbers at parties and conferences, politicians unsurprisingly actively avoid them as well.

I’m not in the habit of politely listening to the pitch of every door-knocker trying to sell me something or offering to show me the path to salvation. I have a phone block on all “private” unidentified numbers and tend to let unknown, number-showing callers through to voice-mail where I can screen them. Abusive emailers get blocked or sent a reply advising the sender that “some idiot seems to have hacked your account and is sending out the garbage below. I suggest you contact your ISP.”

With Twitter, I either instantly block or browse their feed for any form that suggests anaesthetic-grade tedium ahead. If their handle identifies them with their cause (I’m -not-a-racist racism, climate change denial, Trump-love, firearms, anti-vax, electrophobia, whacko snakeoil, vaping and pouting on-line hookers) a decade of experience has long taught me that little to nothing is to be gained by interaction. These people’s identities are almost entirely bound up with their missions.

Twitter is a hugely positive thing in my life. I’ve “met” lots of extraordinary people on-line I’ve never met  face-to-face. For me, it’s been an indispensable tool to both learn from and help shape debates.

So thank you so much, all my followers and those I follow. Here’s a cyber gift of 50 wonderful music tracks I discovered and re-discovered in 2019 (on Spotify). I hope you’ll enjoy them as much as I am.

See you on Twitter!

 

 

Wind turbine syndrome: the non-disease that only speaks English

Fig3.1 WindTurbinesEurope

Wind farms across Europe

I’ve just returned from a three week trip northern Germany and Denmark. After a week in Berlin, my wife and I drove north to Rügen Island on the Baltic Sea, then west towards the northern-most city in Germany, Flensburg. From there we took buses up into Denmark, ending in Copenhagen where I was speaking at a conference.

Shortly after leaving the outer Berlin suburbs, we began to see wind turbines. Lots and lots and lots of them. Sometimes we’d remark that in the last hour of driving, there were only moments when we could not see any turbines. On previous European holidays I’d seen similar densities concentrated in parts of Andalusia in southern Spain, in southern Portugal and in the Minervois region of Languedoc in France.  But in the north of Germany, they were ubiquitous. There were not just extensive pockets of them. They were just everywhere.

Occasionally they would be older models about as tall as a 4 to 5 story building, with towers constructed of crisscrossed, latticed steel. But far more often they would be truly gigantic modern turbines reaching over 150 metres.

We often drove off main roads and the autobahn to get a closer look and to see if we could discern anything that might suggest local policies about setback distances from houses, hamlets and towns.

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While we saw plenty which were located in truly rural areas away from towns, we saw many  on the periphery of towns and hamlets, sometimes a few hundred meters away and often within a kilometer or two.

We also saw uncounted hundreds of single, obviously occupied farmhouses which were sometimes very close to individual turbines.

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Parking next to a vast field of dozens of the very tallest we had seen, we turned off the car engine. We wound down the windows, immediately looked at each other and involuntarily said in unison “you have GOT to be kidding!”  Neither of us could hear a thing except the sound of a gentle wind in the poplar trees on the side of the road.

I got out of the car and walked over to the nearest one, about 40 metres away from the paved country road. I slowly walked around it to see if being upwind or downwind made any difference to what I might hear. I’d been similarly close to turbines in Victoria, New Zealand and on the earlier European holidays. With those, you could hear a gentle whoosh as they turned, often barely discernable within the soundscape of wind in your ears and in roadside trees or from passing cars. But with these German towers, neither of us could hear a thing.

Suddenly, as if we were being watched by CCT on some remote monitor, the turbine I’d walked around began to stop turning. When its blades became stationary we heard the sound of a mechanical alteration taking place to the shape of the curved blades. A sensor had triggered that the blade setting was sub-optimal and at least two points on each blade, we could see adjustments in process, with sections slightly pivoting to maximise the harnessing of the wind.

I’ve often asked European public health colleagues about whether they are aware of complaints being made about wind turbine noise or vibration or claims about illness being caused by exposure to sub-audible infrasound being generated by the turn of turbine blades. Their usual reply is “yes, some people don’t like them. They think they are ugly.” But when I press them on complaints about noise or health issues, I’ve never had anyone say they have ever heard of such a thing. When Fiona Crichton and I wrote our 2017 book Wind Turbine Syndrome: a communicated disease (free download), we were unable to find even a single clinical case report of “wind turbine syndrome” in the peer reviewed literature. Nothing has changed in the two year since.

From the late 1990s, a Portuguese research group has sought to describe something called “vibroacoustic disease” which they argue afflicts some in occupations where workers are exposed to various combinations of sound and vibration. They have described a single case of a boy said to have VAD because of exposure to wind turbines near his family property. I forensically eviscerated this claim in a 2013 paper and further comment in 2014.

The 50,000 watt sunlight question

But the question which shines 50,000 watts of plausibility-wilting sunlight on any claim about wind turbine audible and sub-audible noise  causing health problems and upsetting people who live near them is this: if it was really the case that wind turbine noise could distress and harm people, how is it that globally, many hundreds of thousands of people have lived very near to these turbines for (collectively) millions of individual exposure years, with it never occurring to them that the inaudible or barely audible noise is even worth remarking on, let alone something that causes them to become sick?

How is it that across all of this allegedly toxic exposure over these millions of individual exposure years, that there are no records of any doctor or hospital reporting case reports of such sickness in the clinical research literature, let alone of any national public health agency or government declaring it to be real? How is it that the residents of Copenhagen can go about their ordinary lives for years, with their city surrounded by wind turbines (see pictures below). In 2017, Denmark lead the world, producing 43.4% of its total energy from wind. If the “direct causation” hypothesis had even a mere sliver of plausibility, where are all all bodies in such places?

Claims about wind turbines causing annoyance and health problems have been highly concentrated in parts of the USA, Canada (especially Ontario), Australia, UK, New Zealand and Ireland, all English-speaking nations, while being very uncommon elsewhere. Some have asked whether this is a “disease” that only speaks English.

Health arguments now binned in Australia?

On my last day in Denmark, I read that the NSW Independent Planning Commission had decided that a new batch of 23 wind turbines would not be given approval to be built near Crookwell, 25km northwest of Goulburn.   The Commission based its judgement on visual amenity considerations, with objectors apparently having given up on spearheading objections based on health grounds. In accepting “we don’t like the look of them” objections, the Commission has inhabited the 2014 Joe Hockey “utterly offensive”  and Tony Abbott’ “ugly, offensive, dark satanic mills”

Australia, with its vast land mass, currently ranks 16th in the world for installed wind energy capacity.

Country Installed capacity 2017 (mw)
China 211,392
USA 96,665
Germany 59,560
India 35,129
Spain 23,484*
UK 20,964
France 15,307
Brazil 14,707
Denmark 14,700
Canada 12,816
Portugal 12,300
Italy 9,388**
Turkey 7,369
Sweden 7,216
Poland 5,807**
Australia 5,679*
  • End of 2018 ** 2016

With comparatively geographically small nations like Denmark, Portugal, the UK, the Netherlands and Sweden dwarfing us in installed wind generated energy, it’s enough to make you sick.

The dirty dozen: twelve myths about e-cigarettes

[updated 29, 30 Sep, 15 Nov 2019] Advocates for e-cigarettes often appear to display cult-like adherence to a set of beliefs. Like beings possessed of inviolable truths, they repeat these as often as possible. Here are 12 articles of vaping faith, and why they are highly questionable.

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  1. E-cigarettes are 95% less harmful than smoking

The “95% less harmful” claim was first made in a 2014 report chaired by Professor David Nutt, notable and perhaps unique in publicly declaring that e-cigarettes are “the most significant advance [in medicine] since antibiotics” and would be “the greatest health advance since vaccinations.” Seriously. The report was written by a selected group of 12 individuals who each were asked to estimate the relative harmfulness of e-cigarettes and other nicotine containing products compared to cigarettes. Their Big Number was repeated in a 2014 report by Public Health England, which again endorsed it in a 2015 update where it once again cited the Nutt report as a source, but again provided no transparent workings of how this figure was actually calculated. This is all PHE deigned to tell us in 2015:

 “It had previously been estimated that EC [electronic cigarettes] are around 95% safer than smoking [10, 146]. This appears to remain a reasonable estimate.”

Reference #146 in the above update stated “The precise extent of harm from long-term use is not known but has been estimated at around 1/20th that of smoking tobacco cigarettes (5)” with the reference supporting that statement being – you guessed it – the Nutt report!

In its 2018 updated review PHE nudged the 95% even further toward certainty by slipping in “at least”:

 “Vaping poses only a small fraction of the risks of smoking and switching completely from smoking to vaping conveys substantial health benefits over continued smoking. The previous estimate that, based on current knowledge, vaping is at least 95% less harmful than smoking remains a good way to communicate the large difference in relative risk unambiguously so that more smokers are encouraged to make the switch from smoking to vaping.”

The 2016 report of the Royal College of Physicians had this to say about the 95% less harmful figure:

“An analysis based on expert opinion quantified the likely harm to health and society of e-cigarettes at about 5% of the burden caused by tobacco smoking,(112) and a recent report by Public Health England supported this conclusion.(113)With appropriate product standards to minimise toxin and contaminant exposure in       e-cigarette vapour, it should be possible to reduce risks of physical health still further. It is also possible, although unlikely, that other, unexpected harm from inhaling e-cigarette vapour over the longer term might yet emerge. Although it is not possible to quantify the long-term health risks associated with e-cigarettes precisely, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.” (p84)

“There appear to be few, if any, significant short-term adverse effects of e-cigarette use, but adverse health effects from long-term exposure to constituents of vapour cannot be ruled out. Although unknown, the hazard to health arising from long-term vapour inhalation is unlikely to exceed 5% of the harm from tobacco smoke.” (p185)

Reference 112 cited by the RCP was, yet again, the Nutt report. Indeed, all roads from the 95% estimate since 2015 have led back again and again to the Nutt report, or in the case of the PHE 2018 update, to no references at all tied to the calculation.

But what did the Nutt report itself  say about its now famous number? Critically, the Nutt group conceded that “A limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria”.

In 40 years of academic life in public health, and after editing a research journal (Tobacco Control)  for 19 of these, I don’t ever recall reading such an eviscerating “actually, we have no evidence” caveat about the foundations of a supposed scientific risk assessment.

Despite this most sweeping and fundamental of caveat emptor statements about the lack of hard evidence, a senior Public Health England official told an Australian Parliamentary inquiry in October 2017 that “We are very clear that this is just one of the figures that we have used, and there are plenty more. We say what really matters is the evidence underlying this figure from the Nutt report”. (my emphasis).

So where then, is this “what really matters” underlying evidence which is not cited in the Nutt report nor in Public Health England’s reports? Where can we read and critically appraise the calculations that tipped the figure out into the ether?

Certainly  in this video where Martin Dockrell of Public Health England  explains how the magic number was conjured, there’s no reference to anything  other than the consensus process used by the assembled Nutt meeting invitees, of which he was one.

Interviewer: Describe for us the evidence in the report and what is the science behind the 95% less harmful determination.

Dockrell: “…95% less harmful or 5% of the harm  is a good way of expressing that – that subsequently appeared in the Royal College of Physicians report, It first appeared in a report published in 2014. It was led by Professor David Nutt. And David had done this kind of study before where it was a professional consensus process where you get a bunch of experts in the room. .. and we looked at what data we had for example on fires … we looked at what evidence  we had about cancer risk  and toxicant exposure and we had some data on that. And on the basis of the data we had [describes which nicotine containing products were compared] ..them the computer churns out a figure and we see .. e-cigarettes coming out at 5% of the risk…

Interviewer: You’ve got the 5% of potential harm … how conservative is that? Like if you were to go through everything today would it be the same number?

Dockrell: Well we published that study 5 years ago and now we have 5 years,  more than 5 years more data. We have these excellent biomarkers studies. We know much more about e-cigarette vapour and how that might effect bystanders — not at all is the shorthand for that one.  And so, yeah it would depend on the experts  you got around the table [my emphasis] but I think that looking at the data that we’ve got even it would be less than 5%. It would be substantially less than 5%.”

A factoid is “an item of unreliable information that is repeated so often that it becomes accepted as fact.” The “95% safer” statement is nothing but a factoid that has attained an almost Trumpian-like resonance. It is an emperor with suspiciously few clothes.

  1. We don’t know the long-term effects of vaping but toxicology has advanced massively in past decades, so it’s not too early to now call e-cigarettes as all-but-safe

Cigarette use exploded at the beginning of last century after mechanisation replaced handmade cigarettes, making smoking very affordable. But tobacco-caused diseases didn’t start showing up in larger numbers until 30-40 years later.  The  US surgeon Alton Oschner, recalling  attendance at his first  lung cancer autopsy in 1919, was told he “might never see another such case as long as we lived”. He saw no further cases until 1936 — 17 years later –   and then saw another nine cases in six months. Today lung cancer is (by far) the world’s leading cause of cancer death.

The incidence of lung cancer rose rapidly in the decades 1930-1980 but it was not until 1950 that seriously compelling evidence was published in the USA and the UK that long-term smoking caused lung cancer. Knowledge about smoking’s causal role in other diseases followed.

If any scientist had declared in 1920 that cigarette smoking was all but harmless, history would have judged their call as dangerously incorrect. But this is the doctrinaire call that many vaping advocates are making regularly today, after just 10 years of use.

With vaping only having been around in large numbers for about ten years, it is predictable and unsurprising that we have as yet seen little clinical disease presenting from e-cigarette vaping, although the recent growing numbers of deadly serious respiratory diseases now appearing in the USA may be an early  canary in this coalmine.

The recent New England Journal of Medicine report of serious pulmonary disease in two states in 53 vapers with a median age of just 19, found that 17% of these patients reported vaping only nicotine products. British vape advocates have been quick to point out that none of these cases are occurring in the UK. Oh … wait …  hold the press. Here’s a case-report just in.

When many have pointed out this fundamental “too soon to know” problem, vaping defenders argue that toxicological science has progressed exponentially, with the implication being that we can now tell very early with a high degree of certainty if a drug or chemical is likely to cause disease down the track.

That would be all that advanced crystal-balling toxicology capable of detecting long term risk so brilliantly that between 1953-2014, 462 drugs initially assessed as being likely to be safe and let into the market have been withdrawn with some causing death, or very serious health problems. Remember thalidomide?

A reason why we have Therapeutic Goods Administration drug assessment, scheduling, adverse event reporting and the possibility of recall and bans is because pre-registration drug trials can never provide data on the consequences of long term use. In 2017 vaping activists were jubilant about a 3.5 year follow-up study of just 9 subjects (with another 7 having dropped out) which, hey presto, showed no “long term” ill-effects.  “Case closed: study shows no lung damage from vaping” screamed one report.

This baby-steps follow-up compares with the 30-40 years that passed before the huge upswing in smoking in the first decade of the twentieth century began to show lung cancer in case control studies in the early 1950s.

The recent door-stopper report on e-cigs of the US National Academies of Sciences, Engineering  and Medicine found:

  • There is substantial evidence that e-cigarette aerosols can induce acute endothelial cell dysfunction, although the long-term consequences and outcomes on these parameters with long-term exposure to e-cigarette aerosol are uncertain.
  • There is substantial evidence that components of e-cigarette aerosols can promote formation of reactive oxygen species/oxidative stress. Although this supports the biological plausibility of tissue injury and disease from long-term exposure to e-cigarette aerosols, generation of reactive oxygen species and oxidative stress induction is generally lower from e-cigarettes than from combustible tobacco cigarette smoke.
  • There is substantial evidence that some chemicals present in e-cigarette aerosols (e.g., formaldehyde, acrolein) are capable of causing DNA damage and mutagenesis. This supports the biological plausibility that long-term exposure to e-cigarette aerosols could increase risk of cancer and adverse reproductive outcomes. Whether or not the levels of exposure are high enough to contribute to human carcinogenesis

Reckless calls to just allow unregulated e-cigs to flood corner stores and be promoted with advertising like this https://twitter.com/SimonChapman6/status/970366837719314432 promising “risk free” vaping and  within one corker of a self-contradictory sentence, that vapers can “entirely avoid the harm” while “lessen[ing] the possibility of inducing danger on your lungs” is the sort of world we are supposed to embrace by these flatulent arguments.

If e-cigs are so safe and so effective, their manufacturers surely have nothing to fear by applying for registration through the Australian Therapeutic Goods Administration. Why is it then, that no such applications have apparently been received? What might these manufacturers know or fear that the TGA might conclude?

  1. Nicotine is all but benign. It’s cigarettes that cause all the harm

Like pilgrims at a religious shrine, vaping advocates also have cult-like veneration for a statement by the late addiction research Michael Russell who stated in 1976 that “People smoke for the nicotine but they die from the tar”.

Since Russell made that statement a whole 43 years ago there has been  an extensive body of evidence published suggesting that nicotine, while not being carcinogenic, is a tumour promoter. For example:

“Although nicotine itself is regularly not referred to as a carcinogen, there is an ongoing debate whether nicotine functions as a ‘tumour promoter’. Nicotine, with its specific binding to nAChR, deregulates essential biological processes like regulation of cell proliferation, apoptosis, migration, invasion, angiogenesis, inflammation and cell-mediated immunity in a wide variety of cells including foetal (regulation of development), embryonic and adult stem cells, adult tissues as well as cancer cells. Nicotine seems involved in fundamental aspects of the biology of malignant diseases, as well as of neurodegeneration.”

This 2015 review of research relevant to nicotine and the adolescent brain looked at “how acute exposure to nicotine impacts brain development and how drug responses differ from those seen in adults.” The authors discussed “the persistent alterations in neuronal signaling and cognitive function that result from chronic nicotine exposure, while highlighting a low dose, semi-chronic exposure paradigm that may better model adolescent tobacco use” and argued “that nicotine exposure, increasingly occurring as a result of e-cigarette use, may induce epigenetic changes that sensitize the brain to other drugs and prime it for future substance abuse”.

Those like John Britton still asserting in 2019 that long term use of nicotine represents a health risk similar to coffee consumption might like to dive a little deeper into the toxicological literature on nicotine.

  1. The thousands of flavouring chemicals used in vape juice have all been declared safe by regulators

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There are now some 8000 beguiling and often child-friendly flavours being sold in e-juice [Allen et al, 2016; Barrington-Trimis et al, 2014]. Many of these have been approved for ingestion as food additives, but have never been approved for inhalation.  The U.S. flavouring industry has said about this important difference:

“The manufacturers and marketers of ENDS [electronic nicotine delivery systems], and all other flavored tobacco products, and flavor manufacturers and marketers, should not represent or suggest that the flavor ingredients used in these products are safe because they have FEMA GRASTM status for use in food because such statements are false and misleading”

Science journalist  Dr Heather Goldstone  put it beautifully like this (at 11m10to 24m50)

“It doesn’t take someone with an advanced degree in toxicology to understand that drinking water is different than breathing water”.

So beware of fake news that inhaling #vaping flavourants are benign because many used in food flavouring.

For some flavourants, for example cinnamon, there is already evidence for cytotoxicity [Behar et al, 2014] and for the very commonly utilised additive diacetyl, which produces a pleasant, buttery taste in e-liquid, there is an association with the causation of the non-reversible respiratory condition Bronchiolitis Obliterans [Farsalinos et al, 2015]. The English Cherry flavoured vaping fluids have also been demonstrated, via the inhalation of the irritant benzaldehyde, to be a potential concern for long term users [Kosmider et al, 2016].

Our knowledge of the impact of long-term inhalation, on average 200 times a day (and up to 600) over many years in daily vapers, of vapour arising from the heating of these chemicals is in its infancy.

  1. Many smokers have greatly reduced the number of cigarettes they smoke daily: this is no-brainer harm reduction in action!

If you smoke 20 cigarettes a day, and vaping sees you reduce this by half, surely anyone with half a brain can understand that this means you will have greatly reduced your risk of disease and death from smoking? But counter-intuitive as it seems, this is not what the evidence shows. Cohort studies which have followed large numbers of smokers for years have found that those who cut back the number of cigarettes they smoke but do not quit, experience negligible reductions in mortality.

A Norwegian cohort of 51,210 people followed from the 1970s until 2003 found “no evidence that smokers who cut down their daily cigarette consumption by >50% reduce their risk of premature death significantly.” A Scottish study of two cohorts followed from the 1970s to 2010 found no evidence of reduced mortality in reducers, but clear evidence in quitters and concluded “that reducing cigarette consumption should not be promoted as a means of reducing mortality.” The largest study, from Korea and involving 479,156 men followed for 11 years, found no association between smoking reduction and all cancer risk but a significant decrease in risk of lung cancer, with the size of risk reduction  “disproportionately smaller than expected”.

As illustrated in the table below, when randomly selected groups of vapers are followed up at 12 months, by far the most common outcome is that those who were smoking and vaping at the beginning of the 12 months study period will still be vaping and smoking at the end of the 12 months. That might suggest that the vaping holds far more in smoking than it tips out of it.(2018) colemantransitionssummary

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6202279/pdf/nihms965122.pdf

Also, studies of the number of cigarettes foregone by dual-using vapers have shown that compared with smokers who never vape, that average daily cigarette consumption is little different. See for example below:Ecigs-trivial reduction insmoking 2016-02-21

  1. Secondhand vape is harmless and nothing to worry about

Our knowledge of the harms of secondhand smoke comes almost entirely from studies of non-smokers who live with smokers and those who worked in enclosed environments where smoking was allowed. While it is true that e-cigarette emissions are far less than those from combusted tobacco, they are very much not the equivalent of water vapour from a kettle, as a senior Philip Morris official recently tweeted (below). Vape consists of vapourised propylene glycol or vegetable glycerine, nicotine, flavouring chemicals  and often tiny metal particles (chromium, nickel and lead) shed from the heated metal coil in vaping equipment.

Gichrist tea particulates 2019-09-02 at 5.24.47 am

Vape advocates argue, in all seriousness, that we should all be happy to allow vaping in all indoor spaces because this will discourage vapers from going outside and joining smoker where they might relapse back into smoking. As I wrote in a debate

“Another argument used by indoor vaping advocates is that indoor vaping bans will cause former smokers who now vape to go outside, where exposure to sensory cues from exiled cigarette smokers will trigger their relapse back to smoking.   This would be all the fault of non-smokers selfishly putting their own health and comfort ahead of vapers and contributing to their stigmatisation.  By this argument non-smokers should be happy to be exposed to ambient vape in aircraft, workplaces, restaurants and bars (or even sustained clouding sessions) to make e-cig users feel more “included” and in the hope that they might quit smoking.”

Importantly, vapers often gather together in social groups where they billow clouds of vape into the air producing particle concentrations comparable or greater to that found in bars when smoking was permitted. Vaping advocates want to wind the clock back and start fighting the same arguments that were won long ago over secondhand smoke exposure.

 

  1. E-cigarettes are a very effective way to quit smoking

There’s no shortage of individuals who swear blind that they had tried all sorts of ways to quit smoking until vaping worked for them. This is true for those individuals, just as there are success stories with methods of quitting like acupuncture, and hypnotherapy which have poor outcomes when assessed by principles of evidence-based medicine.  In this recent blog of mine, I summarized recent evidence from randomized control trials, cohort studies and national population data, the three most important sources of information.

In a recent RCT from New Zealand,  after six months 93% of the patches plus nicotine e-cigs group were still smoking; 96% of the patches plus nicotine-free e-cigs group had not quit; and 98% of the nicotine patches group were still smoking. The authors described the impact of the patches + nicotine e-cigs group as having attained “a modest improvement” in smoking cessation over patches alone.

I cannot think of any prescribed drug used for any condition where the condition persisted after 6 month use for 93% of users and where anything but the language of failure would be used about such an outcome. Is there anyone who would hail a 93% failure rate for contraceptives, antibiotics, cholesterol lowering drugs, analgesia, malaria prophylaxis or anything else as even a “modest” success?

  1. There are many smokers who just can’t quit, so we need e-cigarettes to help them

This claim derives from the so-called hardening hypothesis which states that, as smoking prevalence falls ever lower, the remaining smokers will be die-hard addicted “refractory” smokers who just can’t quit. They are impervious to the suite of tobacco control policies and campaigns that have driven hundreds of millions of smokers around the world to quit. It’s time we acknowledged that these smokers just can’t quit and so we are condemning many of them to death if we don’t put policies in place that will help them quit smoking with e-cigs. To do anything else would be unethical, they try to argue.

Aside from the dismal evidence referred to earlier that e-cigs are pretty hopeless in helping people quit, the entire premise of the hypothesis is an evidence-free house of cards.

Whenever this hypothesis has been tested against the evidence it has been found wanting. In nations or states where smoking prevalence has fallen most, one would expect (if the hardening hypothesis was correct) that indices of hardened smokers (such as mean number of cigarettes smoked per day) would be rising because the remaining smokers would be over-represented by heavy, addicted smokers.

Unfortunately for this argument, John Hughes, one of the world’s most respected and prolific researchers on smoking cessation, recently let all the air out of the hardening hypothesis tyres in a paper in Nicotine and Tobacco Research. He reviewed 26 studies on hardening and found:

“None of the 26 studies found that conversion from current to former smoking, number of quit attempts, or success on a given quit attempt decreased over time and several found these increased over time.” He concluded “Some have argued that a greater emphasis on harm reduction or intensive treatment approaches is needed because remaining smokers are those who are less likely to stop with current methods. The current review finds no or little evidence for this rationale.”

  1. Countries with lots of vaping have lower smoking rates than those which don’t. Look at England! Vaping has rapidly supercharged the fall in smoking

As at September 2019, the latest available data on smoking prevalence among five anglophone nations which are often compared shows that Australia and the UK are level pegging at 15.1% as nations with the lowest smoking prevalence.

  • Australia (2017-18 ages 18+): 15.1% (this figure includes cigarette and roll-your-own smokers plus all exclusive users of other combustible tobacco products like pipes, cigars, hookah and shisha)
  • USA: (2017 ages 18+) 16.7% (like Australia, includes all combustible tobacco product users)
  • Canada (2017 ages 12+): 16.2% (cigarettes & Roll Your Own tobacco only)
  • New Zealand (2016 ages 15+) 15.7%. (Māori adults 35.3%) (cigarettes & RYO only)
  • UK (2017 ages 18+): 15.1% (cigarettes and RYO only)

Most recently Victorian data on changes in smoking prevalence in that state between 2015-2018 show the lowest daily smoking prevalence ever recorded: 10.7% (down from 13.5% in 2015)  with falls in the most disadvantaged group down from 16.8% to 13%.

In summary, of these five nations, only Australia and the USA include all combustible tobacco products in their data on “smoking” prevalence, while other nations only include cigarettes (factory made and hand-rolled). The “smoking” prevalence figures from Canada, New Zealand and the UK thus underestimate the true prevalence of “smoking”. Australia and the UK have the same (lowest) prevalence of these nations, although UK data does not include combustibles (cigars, pipes, shisha) other than cigarettes. It is therefore likely that Australia has the lowest smoking prevalence. Yet it has the lowest prevalence of vaping and the most restrictive e-cigarette policies. You can go many days without ever seeing anyone vaping in Australia.

Vaping advocates argue that nations with widespread vaping are seeing their falls in smoking prevalence accelerate because of vaping. Just this month, the UK’s John Britton argued that while “it would be premature to attribute these differences in smoking trends solely to differences in electronic cigarette policy”  that “the figures do suggest that the UK approach of medical endorsement with marketing controls and product regulation has to date succeeded in harnessing the potential of electronic cigarettes to significantly accelerate the decline in adult smoking prevalence.”

Data from the Smoking in England project in the graph below show that the role of e-cigarettes in accelerating the downward trend in England is far from obvious or significant. The dramatic upsurge in smokers using e-cigarettes in quit attempts  using e-cigarettes that commenced in late 2012 and has more-or-less plateaued since mid 2013, does not appear to have had any marked impact on the slope of the historically declining smoking prevalence rate.

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An important report from late 2017 considered the surge in e-cigarette use in England and whether this was reducing the number of cigarettes being smoked at the population level across the country. The conclusions?

“No statistically significant associations were found between changes in use of e-cigarettes while smoking and daily cigarette consumption. Neither did we find clear evidence for an association between e-cigarette use specifically for smoking reduction and temporary abstinence, respectively, and changes in daily cigarette consumption. If use of e-cigarettes and licensed NRT while smoking acted to reduce cigarette consumption in England between 2006 and 2016, the effect was likely very small at a population level.”

Robert West is a world leader in smoking research, and the editor-in-chief of the journal Addiction. He told the BBC in 2016

“[This widespread use of e-cigarettes] raises an interesting question for us:  If they were this game changer, if they were going to be – have this massive effect on everyone switching to e-cigarettes and stopping smoking we might have expected to see a bigger effect than we have seen so far which has actually been relatively small” [my emphasis]

However, if we look at the data on smoking prevalence and changes in smoking affordability in the UK, we can see a rather different picture.

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  1. There are very few health agencies which don’t unequivocally support vaping and “light touch” e-cigarette regulation

Oh really? If you’ve got half an hour to spare, take a tour through this list of 46 global, regional and national agencies who very much beg to differ. The list Includes the World Health Organization, the US National Academies of Science, Engineering and Medicine, and just about every major US and Australian health agency.

  1. Big Tobacco is a minor player in the global vaping business

Vaping advocates like to paint pictures of plucky, noble start-up minnow vaping companies valiantly “game changing” the nicotine addiction landscape. “Big tobacco is not at the leading edge of either product innovation or sales” they protest. And in Australia, they point out that none of the transnational tobacco companies are selling their products here … yet.

The history of transnational tobacco company take-overs of profitable smaller tobacco companies shows us that the transnational companies gobble up all profitable or threatening small companies whenever they can. The same pattern is rapidly emerging with e-cigarettes.

Altria, which sells Marlboro in the USA, has bought 35% of Juul. This article describes the take-over of the e-cigarette market by Big Tobacco. All of these companies continue to resist and attack effective tobacco control policies, while posturing about caring about harm reduction.

  1. Tobacco companies are doing all they can to reduce smoking in concert with their efforts to promote vapourised nicotine products

Philip Morris International currently has a global “unsmoke” campaign trying to convince us all that it really, really wants all its customers to switch from cigarette to its putative reduced harm vapourised product, IQOS. In the tweet below it even profiled Bryan, a smoker who had given up all nicotine too! That’s right. Philip Morris has broken out the maypole and has all its employees and shareholders dancing around it each lunchtime because the company is doing all it can to get all its customers off all its products and publicly broadcasting its success stories!

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But the company has set no targets for its reductions and around the world. It’s business as usual trying to maximise sales of its cigarettes and its IQOS heat not burn product. It has its foot-to-the-floor promoting cigarettes in every market and doing what it can to oppose effective tobacco control which would actually reduce smoking.  Here are ten questions I put to Philip Morris about this sham, their reply, and my response.

 

 

 

 

 

 

 

 

 

 

Every school principal should write a letter like this

 

 

This letter from the headmaster, Michael Parker, of Newington College, Stanmore was sent to all parents and teachers of Newington College, Stanmore on 17 September 2019

The climate strike and our students

Statement from Newington at the end of the article.

Damn these Year Elevens. They come into my office asking me to support the climate strike. They tell me that it is their planet too and that they should be able to protest about what is the most important issue of their lives. They ask whether the school will stand up for them.

I don’t want to catch the political nuclear-grade hot potato that is the climate ‘debate’. I have a strategic plan on education to write and a Council retreat to prepare for. As well, I have always prided myself on being able to teach current affairs without my classes being able to work out which way I would vote in an election. I stay neutral and allow all points of view – sometimes to a fault. And, anyway, I am not a scientist.

But these kids say that they are probably going to live into the 22nd century and they are terrified about tipping points and a runaway greenhouse effect. They say that the climate science is overwhelming. They say that leaders in my generation are not doing anywhere near enough about it.

Heavily I consult my own conscience about climate science.

We teach our kids in Year Seven that the scientific method, whilst not irrefutable, is the best thing we have to work out physical truths about the world. We teach them that when there is a consensus amongst almost all reliable scientists, then they are probably right.

To prepare for the meeting with these Year Elevens, I have read the beginning of the 2014 report of the Intergovernmental Panel on Climate Change (the ‘IPCC’ – a pretty reliable group of scientists). Their chief point is that that human-made effects are extremely likely to have been the dominant cause of the observed global warming since the mid-20th century (SPM 1.2, p4). When they say ‘very likely’ they mean with 95–99% confidence.

Even more strikingly, the IPCC say ‘continued emission of greenhouse gases will cause further warming and long-lasting changes in all components of the climate system, increasing the likelihood of severe, pervasive and irreversible impacts for people and ecosystems.’ That’s severe, pervasive and irreversible impacts for the kids sitting in front of me – as well as my own children.

I think that accepting the reality of climate science is different to expressing political views. It’s a (pretty settled) opinion about a fact, not an opinion of evaluation. The IPCC may all be wrong in some bizarre mass hallucination or corrupt stitch-up job, but I very much doubt it.

But another climate strike?

I ask what’s going to happen when they want to march about immigration or abortion or any other issue. What’s to stop them marching out for that? They say I am committing a ‘slippery slope fallacy’ (damn those critical thinking lessons we teach them) and that climate change is different in kind to any of these issues because it affects the lives of everyone. Anyway, they say, all these other issues have all been prominent since the last climate change march and there have not been any student marches.

I point out the lessons that students everywhere will be missing – that they all need to be in school to get an education. They say to me that the very vision of Newington is for boys to make an active and positive difference in the world. Going on a march for climate fits the school’s vision better than one more regular day around the classrooms, they tell me. (Damn the school’s vision  – I should have seen that one coming).

Why not Saturday? I say. Show your commitment that way. ‘It’s not a strike if it’s on a Saturday’ they say. They get passionate now. They say they have no voice, no vote, that those in power have deserted their generation. They say all that they can do to be heard is to stop doing the thing the government expects them to do that day – going to school.

This isn’t going well. What about ‘slacktivism’ I ask – kids who don’t care and just want to skip out of class. But they are ready for this one too. One of the boys says that he went to the previous march and that everyone he met was committed. Then they say that it is a chicken and egg argument – that going to a march is what will make some kids care passionately and then do more about it. (Damn those critical thinking lessons again). They point out that they have put their own money where their mouth is. They run the school’s sustainability and recycling groups.

They point out that the NSW and ACT Synod of the Uniting Church – the church with which we are affiliated – has supported the strikes. (Hmmm… damning the Uniting Church is going to be tricky). If the church can do it, why can’t their own school? they say.

I’d rather they went away. I’d rather get back to the school’s strategic plan and the Council retreat. But these kids are passionate, they are smart and they have thought it through. They have put their money where their mouths are and they are scared about their future. Students who have shown they care about this should be able to march about it. If their parents have allowed them to be absent to go to the strike, then the least we can do is give them the school’s support too.

Damn these Year Elevens. Because they’re right.

STATEMENT ABOUT SUSTAINABILITY, CLIMATE SCIENCE AND THE CLIMATE STRIKE.

Newington College encourages our boys to act positively through our Sustainability Group and school recycling programs. We engage in sustainable practices such as installing solar panels, recycling, efficient building management systems and grey water reuse. However, there is always more that we can do. We plan to focus on further measures such as food and packaging waste and upgrading plant to more efficient systems in our 2020–2025 Strategic Plan.

Newington College also accepts the reality of climate science. We consider that climate change caused by humans is an urgent issue, particularly for young people. We understand the importance of student critical thinking and student voice in addressing this singularly important issue. We thus support the decision of our boys whose parents have given them permission to be absent to represent their views about climate change at the climate march on 20 September.