Are there really 520,000 current vapers in Australia? What’s the biggest number you can find?

In July this year the Australian Institute of Health and Welfare published our most recent estimate of how many people use various drugs, alcohol and tobacco. They also looked at vaping. So how many people are vaping in Australia? If you believed the lobby group ATHRA (the 4 board members and zero membership vaping advocacy group) when they published their blog on July 22 “520,000 people were ‘current’ vapers (vaped at least once in the last year).” That equates to about 2.5% of the 14+ population or one in every 40 people.

Just let that number sit a while, and reflect if it bears any resemblance to your experience of seeing people vape in public. Vapers, with their ostentatious imitations of stream trains, seem to love proclaiming “look at me! I’m a vaper!” as they billow their clouds for all to see. But one in 40 vaping …?

The Australian Institute of Health and Welfare describes “current” vaping (in a footnote to Table 2.23) as including people who reported smoking electronic cigarettes daily, weekly, monthly or less than monthly.) So that means it includes people who might have had a toke or two at a party out of curiosity, 16-year-olds passing one around after school at the local skaters’ ramp and those who bought the vaping gear, tried it a few times and then put it in the drawer with other seemed-like-a-good-idea-at-the-time 5 day wonders.

Had I been swept up in the AIHW sample a few years ago, it also would have included me, because I once had a pull on an e-cig to see what it was like.

So are many of these 520,000 people any more meaningfully “current” vapers than I am a current Tesla or Aston Martin driver (because I’ve driven both these cars once), a current Grange hermitage drinker (I shared one with neighbours recently) or a current guest at Australian prime ministers’ houses (because I attended a fundraiser at one’s last year)?

The AIHW’s Table 2.19 shows the denominator for  determining “current” vaping is the 11.3% of Australians aged 14 plus who have ever used  e-cigarettes in their lifetime.

There are 20,900,000 Australians aged 14+ years with 11.3% of them having ever used an e-cigarette, even once. AIHW Table 2.21 below  means there are around 433,000 people who vape at least monthly, a whole 16% less than 520,000.

Frequency of electronic cigarette use by people aged 14 and over who have used an electronic cigarette in their lifetime, 2019 (per cent)

Estimated numbers of e-cigarette users by usage categories

Vaping advocates pitch their most emotional appeals for policy change around profiles of heavy smokers who they say have often tried to quit and failed, but who are now vaping. This profile could only reasonably be applied to daily vapers, not those who smoke every day and vape very occasionally, nor those who are not nicotine dependent and neither smoke not vape every day. So this means we are talking about some 222,000 Australians 14+ who daily are vapers (about 1.1%), a large proportion of whom will be dual users who continue vape and smoke.

For these,  angst-ridden “I will go back to smoking if access to vaping is tightened” threats about health minister Greg Hunt’s proposed vapable nicotine via prescription policy, are nonsense because they have never given up smoking anyway. Longitudinal cohort studies show that dual use is very often far from a transitory phase leading to exclusive vaping. Many vapers keep smoking as the table below illustrates with a 12 month follow-up. With all major transnational tobacco companies now marketing both cigarettes and vapable products, prolonged dual use and deepening nicotine addiction is of course very good business. This is why all tobacco companies selling cigarettes Australia today are lobbying hard to be allowed to sell their vapable products here too.

ATHRA seems to have little compunction in claiming all those who might have had a tentative toke on an ecig just once or twice as true current vapers whose interests they hope to champion. But when it comes to others pointing out concerns about the increase in teenage vaping either in Australia or internationally, they seem to prefer a much narrower definition when attempting to hose these concerns down. Consider these examples from a recent publication with ATHRA board member Colin Mendelsohn as an author:

Note “3 or more days in the last month”, “vaping daily”, “vaping at least weekly” and “≥20 days in the last 30 days”, are all measures of far more serious vaping than any figure that lumps in “less than monthly”.

So in summary, claims that there are more than half a million “current” vapers in Australia are wildly exaggerated. Just 1.1% of the 14+ population who vape daily, with it being very likely that a large proportion of these are people who continue to smoke and so for whom posturing about “returning to smoking” are nonsense because they’ve never stopped smoking.

What Dr Fauci didn’t write about COVID19, but well could have

This has been doing the rounds on Facebook, incorrectly attributed to Dr Anthony Fauci (see here). But it is so good, I wish he had written it.

“Chickenpox is a virus. Lots of people have had it, and probably don’t think about it much once the initial illness has passed. But it stays in your body and lives there forever, and maybe when you’re older, you have debilitatingly painful outbreaks of shingles. You don’t just get over this virus in a few weeks, never to have another health effect. We know this because it’s been around for years, and has been studied medically for years.
Herpes is also a virus. And once someone has it, it stays in your body and lives there forever, and anytime they get a little run down or stressed-out they’re going to have an outbreak. Maybe every time you have a big event coming up (school pictures, job interview, big date) you’re going to get a cold sore. For the rest of your life. You don’t just get over it in a few weeks. We know this because it’s been around for years, and been studied medically for years.
HIV is a virus. It attacks the immune system and makes the carrier far more vulnerable to other illnesses. It has a list of symptoms and negative health impacts that goes on and on. It was decades before viable treatments were developed that allowed people to live with a reasonable quality of life. Once you have it, it lives in your body forever and there is no cure. Over time, that takes a toll on the body, putting people living with HIV at greater risk for health conditions such as cardiovascular disease, kidney disease, diabetes, bone disease, liver disease, cognitive disorders, and some types of cancer. We know this because it has been around for years, and had been studied medically for years.
Now with COVID-19, we have a novel virus that spreads rapidly and easily. The full spectrum of symptoms and health effects is only just beginning to be cataloged, much less understood.
So far the symptoms may include:
Acute respiratory distress
Lung damage (potentially permanent)
Loss of taste (a neurological symptom)
Sore throat
Difficulty breathing
Mental confusion
Nausea or vomiting
Loss of appetite
Strokes have also been reported in some people who have COVID-19 (even in the relatively young)
Swollen eyes
Blood clots
Liver damage
Kidney damage
COVID toes (weird, right?)
People testing positive for COVID-19 have been documented to be sick even after 60 days. Many people are sick for weeks, get better, and then experience a rapid and sudden flare up and get sick all over again. A man in Seattle was hospitalized for 62 days, and while well enough to be released, still has a long road of recovery ahead of him. Not to mention a $1.1 million medical bill.
Then there is MIS-C. Multisystem inflammatory syndrome in children is a condition where different body parts can become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs. Children with MIS-C may have a fever and various symptoms, including abdominal pain, vomiting, diarrhea, neck pain, rash, bloodshot eyes, or feeling extra tired. While rare, it has caused deaths.
This disease has not been around for years. It has basically been 6 months. No one knows yet the long-term health effects, or how it may present itself years down the road for people who have been exposed. We literally do not know what we do not know.
For those in our society who suggest that people being cautious are cowards, for people who refuse to take even the simplest of precautions to protect themselves and those around them, I want to ask, without hyperbole and in all sincerity:
How dare you?
How dare you risk the lives of others so cavalierly. How dare you decide for others that they should welcome exposure as “getting it over with”, when literally no one knows who will be the lucky “mild symptoms” case, and who may fall ill and die. Because while we know that some people are more susceptible to suffering a more serious case, we also know that 20 and 30-year-olds have died, marathon runners and fitness nuts have died, children and infants have died.
How dare you behave as though you know more than medical experts, when those same experts acknowledge that there is so much we don’t yet know, but with what we DO know, are smart enough to be scared of how easily this is spread, and recommend baseline precautions such as:
Frequent hand-washing
Physical distancing
Reduced social/public contact or interaction
Mask wearing
Covering your cough or sneeze
Avoiding touching your face
Sanitizing frequently touched surfaces
The more things we can all do to mitigate our risk of exposure, the better off we all are, in my opinion. Not only does it flatten the curve and allow health care providers to maintain levels of service that aren’t immediately and catastrophically overwhelmed; it also reduces unnecessary suffering and deaths, and buys time for the scientific community to study the virus in order to come to a more full understanding of the breadth of its impacts in both the short and long term.
I reject the notion that it’s “just a virus” and we’ll all get it eventually. What a careless, lazy, heartless stance.”

Vaping has two big rugs pulled from beneath it

Rug #1: Vaping nicotine is a very successful way of quitting smoking – much better than all other ways

Two papers just published from the US PATH (Population Assessment of Tobacco and Health Study) have pulled a giant rug out from under one of the major pillars of vaping advocates’ claims about the benefits of vaping: that they are an excellent way to quit smoking. After trying to quit unaided (cold turkey), e-cigarettes are the most common method used by American smokers trying to quit.

The PATH study is a large cohort of smokers and vapers whose smoking and vaping use was recorded at baseline in 2013 and who have been followed up each year to monitor any transitions in and out of smoking and vaping. Prospective cohort studies recruited from the general population are arguably the most powerful ways of assessing the usefulness of different ways of quitting smoking over time in real world settings, outside of the artificiality of randomised controlled trials.

Two papers from the same group lead by long time Australian US resident John Pierce from the University of California, San Diego reported on two waves of follow-up after the initial base-line questionnaire. In the first paper, daily smokers were studied to compare methods of quitting used at their last quit attempt. 23.5% used e-cigarettes, 19.3% used pharmacotherapy only (including NRT) and 57.2% used no product. Cigarette abstinence for 12+ months at Wave 3 was approximately 10% in each group (meaning 90% were still smoking). Different methods had statistically comparable 12+ month cigarette abstinence, including quitting without any aids. So much for the unending hype that e-cigs are so much better than other ways of quitting and that all stops should therefore be pulled out to ensure as many smokers as possible can get unhindered access to this new wonder drug.

In the second paper by the Pierce group published in the high ranking American Journal of Epidemiology, the authors sought to allow for possible confounders in known differences between those smokers who self-select to use e-cigarettes and those who don’t. They identified 24 such potential confounders and statistically controlled for these using “propensity matching” to match each e-cigarette user with up to two closely matched control smokers and then compared their experience with quitting smoking.

12.9% of smokers who used e-cigarettes had quit long term but that there was no statistically significant difference when matched non-e-cigarette-users’ success was compared. The authors concluded “These results suggest that e-cigarettes may not be an effective cessation aid for adult smokers, and instead may contribute to continuing nicotine dependence.”

Rug #2: Australia, with far less vaping than nations like the USA, UK, Canada and New Zealand is falling behind these nations in reducing smoking

The USA and the UK have been awash with e-cigarettes for around a decade, with Canada and New Zealand more recently legislating their widespread availability.  Australia by contrast, has always banned the domestic sale of e-juice containing nicotine. More recently, Health Minister Greg Hunt  has announced his intention to legislate that vapable nicotine be made available by prescription.

Vaping advocates’ mantras invariably include claims that without open access to nicotine for vaping, smokers are severely disadvantaged and Australia’s smoking prevalence is falling behind that of our anglophone rivals in being at the front of the world’s lowest smoking prevalence.  Given this, they argue, we should follow the policies of these other nations. The implication here is that our vaping policy is retarding our ability to reduce smoking.

So let’s look at the latest data.

In July this year, the AIHW (Australian Institute of Health and Welfare) released data from its 2019 survey of Australians’ drug use, including smoking.  Below I set out the most recent official data released by Australia, Canada, New Zealand , the UK and the USA that allow us to check the truth of the vapers’ claims that Australia has fallen behind in reducing smoking.

The latest available data on smoking prevalence from these five nations which are often compared would appear to show that the UK has 14.1% of its  ≥18 population who smoke. Canada (14%) and New Zealand (14.2%) report their data from those aged ≥15years (not ≥18), and Australia from  ≥14years (14%). But as teenage smoking prevalence is less than that of ≥18 year olds, this acts to lower their total smoking prevalence. Australia’s ≥18 prevalence in 14.7%. These are important differences in how each of these nations count smoking.

Secondly, of these five nations, only Australia, Canada and the USA include all combustible tobacco products in their data on “smoking” prevalence. Canada also includes chewing tobacco use, but unlike the other four nations, only counts recent (past 30-day) smoking. The inclusion of chewing tobacco would inflate Canada’s “smoking” prevalence figure, while its “within-30-day” limit would reduce it, compared with all other nations which also count less-than-monthly smoking in their current smoking figures.

By not including all combustible tobacco product use (cigars, pipes, shisha), the “smoking” prevalence figures from the UK and New Zealand will thus underestimate the true prevalence of “smoking” in those nations. This point has previously been made about an earlier “headline” smoking prevalence figure of 15.1% for the USA (see extract below).

While the UK Annual Population Survey reported by the Office of National Statistics intends to cover RYO, it is possible that many respondents answering the question would not necessarily interpret it as doing so. As shown in the clips of the survey at the end of this blog, it asks specifically about cigarettes (after asking a lead in question about all tobacco products. Quite a few respondents might expect a follow up question just on RYO. If this was the case, the UK data may additionally underestimate “cigarette smoking” for this reason.

Taking into account all these factors, and noting the confidence intervals and margins of error noted in the data below, it is likely that Canada, Australia and New Zealand have almost the same smoking prevalence; that England may have slightly higher because of it not counting combustible tobacco other than cigarettes and roll-your-own tobacco, and that the USA has the highest smoking prevalence of the five nations.

  • Australia:(2019 AIHW ages ≥14 and  ≥18): (all combustible tobacco users, at any smoking frequency –people who reported smoking cigarettes daily, weekly, monthly or less than monthly) ≥14yrs: 14.0% (margin of error 0.6); ≥18 yrs: 14.7% (margin of error 0.7%) Daily smoking by 11%.
  • Canada:(2019 Canadian Tobacco and Nicotine Survey ≥15yrs  14% (Only past 30-day use of any tobacco product — including chewing tobacco)
  • New Zealand:2018 Current smoking (smoke at least monthly, and have smoked more than 100 cigarettes in their whole life time) among persons aged  ≥15): 14.2%  (CIs: 13.4-15.0) (Māori adults 34% (31.1-37.1) (cigarettes & RYO only at any smoking frequency)
  • UK:(2019 Office of National Statistics; ages  ≥ 18): 14.1%  “who smoke cigarettes nowadays”)
  • USA: (2018 NHIS ages ≥ 18): 16.5% (CIs 15.9-17.2) (all combustible tobacco users at any smoking frequency “every day or some days”

With Australia having far less vaping prevalence that the other nations, and keeping in mind the unflattering track record of vaping in smoking cessation, as shown in the two PATH papers above, it is hard to argue that Australia is losing out in the race to have the lowest prevalence of smoking because it has not liberalised access to vapable nicotine.

As leading English smoking cessation researcher Robert West told the BBC in 2016

Questions asked by UK’s UK Annual Population Survey

Oh what a party it was that night, what a party it was …

She’d been to parties, but never hosted one. So in 2001, when she was 17, our daughter asked if she could have one, we agreed. We’d be in the house. We’d stay in the front room watching a movie and would feel free to come down the corridor to the party zone in the back living room/kitchen and back garden. That’s fine, as long as you don’t do it too much and hang around, she said.

She’d told us to expect that whatever we tried to do to stop alcohol coming in, that some would bring it. We wondered about supplying some low alcohol beer which is very hard to get drunk on, but we’d had an earlier experience with one of our sons, a year younger than her, who’d pleaded to be allowed to take some to a party. We’d called the parents – two prominent Sydney journalists who we thought were likely to agree – but they were adamant that no alcohol would be allowed. When we picked him up at midnight he threw up out of the car window. The parents had gone out, leaving the big sister in charge and she’d turned a blind eye.

On the Saturday night they all arrived in a rush, too excited to be fashionably late. Parental cars disgorged several who’d come together. A few parents came with them to the door and we put on our very best reassuring voices, exuding that we’d keep a close eye on things. Trish checked anyone who had a bag and found several with small bottles of vodka and bourbon. Sorry guys, we’ll have to keep these here, she told them to lots of eye-rolling.

What a lovely bunch of girlfriends she had, we told each other. But the boys. Gawd. What an awkward bunch. All from two of Sydney’s highest performing public schools.

After about 20 minutes I feigned the need to get something from the kitchen and walked into the crowded back of the house. There were around 40 of them. The music was up very loud. It was summer, and the back French doors were open so I could see into the garden. Several couples were already hard at work monstering each other with frantic, deep kissing. I thought back to the parties I went to in the 1960s and knew little had changed.

Minutes later, I saw a boy in front of me vomit all over the clivias. He was with two mates who were obviously very drunk. I went and got Trish from the front room. It was only about 8.30pm.

I think we’d better watch this for a while, I suggested. So we went out to the garden and told the drunken boys that they should stop drinking and take things easy. That ought to work. A couple of the girls tut-tutted to us that most of the boys had been pre-loading before they came, and that some had gone around to the back lane and waited when they arrived with their booze stashed in bags. Their accomplices went through the front door, polite as pie, and then went and let the lane guys through the garage roller door. Just about everyone is drinking you know, the girls said.

Trish went out to the garage to see if there was a drinking scene happening in the lane. At the back of the garage, leaning up against the car was a boy with his trousers around his ankles, with a girl on her knees on the concrete floor giving him a blow job.  She shoo-ed them out, saying “oh no not here, you don’t!”.

Our daughter kept darting over to us, pleading with us to go back to the front room. PLEASE, don’t stay out here, she begged. We dutifully obeyed, but began considering what we should do if things got out of hand. Apart from the three drunk boys, the torrid pashing among three or four couples including the garage duo, everyone else was dancing or chatting and having great fun. Perhaps we ought to relax but just keep a look out, we thought.

Then the doorbell rang. It was 9pm.  There stood a man in his mid 40s with his wife behind him. “Is Elizabeth here?” he asked, stonyfaced. “We’ve come to get her. She came here without our permission”.

We didn’t know all the kids’ names, so we invited him inside to collect her. His wife waited on the porch while he and I walked down the corridor. The moment we pushed open the door to the rear living room, a girl hurtled out of the room, through the kitchen, into the garden and then into the garage. Her father quickly followed, as did I.

She’d gone to the back of the garage but found the roller door closed. Our low sports car was in the garage. For about the next 5 minutes, like a cat and mouse cartoon, the father would swiftly move one way toward his daughter and she would move around the car out of his reach. He’d try going in the opposite direction and she’d change direction to counter him. She was in tears. After several bouts of this, I asked if they would both please stop what they were doing as I didn’t want the car scratched or the mirrors damaged. They kept it up.

Finding herself near the garden doorway to the garage on one circuit of the car, she bolted back to the house and rushed into the bathroom off the main room where the dancing and music was on full throttle. Several of her friends raced in with her, locking themselves inside. 

The father began demanding she come out. She wouldn’t. He brought his wife inside to appeal that she unlock the door. Our daughter was now upset. Her first party was facing ruin, she told us. Please ask them to wait outside.

After about 10 minutes of stalemate, Trish and I began trying to negotiate a solution with the parents. “My wife is a very experienced schoolteacher and I am a professor at Sydney University. We are very respectable people and promise you that Elizabeth is safe here. As you can see, our daughter is very upset and feels like her first party is now being upset by what is happening. So can we please suggest that you both go and wait in your car outside? She seems unwilling to come out of the bathroom while you are here, but I’m sure she will come out soon – others will need to go inside to use the toilet. When she comes out, we’ll ask her to join you in the car.”

“No, I want to stay here. She will run away out the back but must come home with us. We did not give her permission to come here. She has disobeyed us and must come. So we will stay here until she decides to come out” he said.

I tried again. “Look, I must ask you to please wait outside. This is very awkward for us all, but as I said, my wife and I are both here, as you can see, supervising the party. We will talk to her when she comes out and send her out to you in the car.”

For some time he said nothing. He then spoke to his wife who left and went out to the car. He remained silent but then said, having seen several of the kids obviously loose with drink and the tongue kissing couples hard at it: “There is alcohol here. Alcohol leads to drugs!”

I tried to explain that some had arrived after already drinking and had hidden their supplies in the lane. We were very disappointed about these kids. As I went through this explanation I could see all over his face an understanding that we were in fact not respectable people at all. No decent parents would ever allow such behaviour, said the body language. I want our daughter out of this Gomorrah.

Exasperated, I then said “Do you drink alcohol?” “Of course!” he replied. “So did it lead to drugs for you?” “Don’t be ridiculous!” he snapped.

So again I suggested, this time unequivocally, that he needed to go out and wait in the car. “Look, you’ve now been waiting here for 30 minutes. No one can use the bathroom. Our daughter is upset. We have asked you very politely to wait outside several times now. It’s not acceptable that you stay here when we have asked you to cooperate by please waiting outside.”

At this he immediately sat down on the floor outside the bathroom.  Trish and I went to another room and decided to call the police.  I went over to him and again, this time very firmly, asked him to stand up and leave the house. He stared ahead, refusing to look at me and said nothing.

So I reached down and gripped his shoulder with one hand and said, come along now, you need to leave now. He immediately fell from sitting to supine and started frantically bicycling his legs upward at me, shouting out. I grabbed both his feet, held firm and dragged him on his back quickly up the corridor toward the front door. The whole party erupted in wild cheering. Half way up the corridor we saw his wife had come inside again. She had her phone out and was shouting into it theatrically “Help! Help! Professor Jones is assaulting my husband!! Come quickly!!” (Our daughter is my stepdaughter with a different surname). I let go of his feet, he got up quickly and they both walked out to their car, saying nothing.

Minutes later, our phone rang. It was Elizabeth’s older sister. Elizabeth must have called her from the bathroom and given our number. She immediately flooded us with her thanks for how we had been handling the incident. She said parents were suffocatingly strict: ambitious parents who allowed them few freedoms, who punished them for unacceptable grades and controlled them around the clock. Elizabeth was feisty and rebellious, and determined to come to the party. She was pleased we had called the police.

About 20 minutes later a constable who looked about 20 and a wide-eyed student social worker on placement arrived. They firmly told the parents to remain in their car as they were trespassing. Elizabeth came out of the bathroom and they spoke with her in a bedroom. She was then taken to the local police station and the parents asked to make their own way there.

We were never contacted again, and heard nothing of anything that may have transpired.

We’ve all heard stories of parties where internet word spreads, gatecrashers arrive, fights break out, things get smashed. Some parents hire security muscle. But calling the police to get rid of parents? That’s a first surely?

Whenever any of her old friends who were there that night come by, they always recall the night with great hilarity. That was an amazing night, they tell us.

Twenty years later, whenever our daughter comes around for dinner and we open a bottle of wine, one of us will always say as the first one is poured “Alcohol. It leads to drugs.”

Vaping advocates say the darndest things … 2: Tobacco control advocates help Big Tobacco

[this is the second installment in an occasional series on very silly things that are said by vaping advocates. See an earlier one here]

One of the most persistent memes in the vaping advocacy echo chamber is that anyone working in public health and tobacco control who has even a flicker of an amber or red light on their policy dashboard about any platform of vaping regulation, is helping Big Tobacco. In fact, we are probably being paid by them.

Here’s how their argument runs

  1. Vaping is a massive threat to the tobacco industry’s tobacco sales
  2. Any policy or statement that slows or stops smokers switching to e-cigs keeps or returns smokers to smoking benefits the tobacco industry

From this it follows that

  • Any caution or hesitancy about allowing unrestrained vaping in any location, using any ingredients in any vaping equipment helps Big Tobacco
  • Any attention drawn to the growing evidence that vaping potentially has serious health concerns like this, this or this,  and does not match the hype about  e-cigs being exceptionally effective ways of quitting smoking also helps Big Tobacco.

Across 40 years in tobacco control I’ve never encountered a greater piece of  weapons-grade confused stupidity than this truly bizarre claim. Let’s take a look at the gaping holes in what they say.

Tobacco control has blown every cherished Big Tobacco policy out of the water

First, there’s the teensy little problemette of how tobacco control has fought and won protracted battles against the tobacco industry’s efforts to retain tobacco-friendly policies over 50 years. Those working in tobacco control in Australia from the late 1960s have won every major policy battle they ever fought. Here are some highlights:

All this has seen a nearly constant decline in smoking prevalence in adults and teenagers, in the average number of cigarettes smoked per day by continuing smokers and rises in the proportion of people who have never smoked and in public support for tobacco control measures. Only 11% of Australian adults smoked daily in 2019, the lowest figure ever recorded and representing some 100,000 fewer daily smokers in the last three years.  The proportion of young adults aged 18–24 never smoking more than 100 cigarettes in their life has increased from 58% to 80% between 2001 and 2019. These are disastrous numbers for Big Tobacco.

So yes, it’s easy to see that Australia’s tobacco control workers have done everything they can to help Big Tobacco over many years. We are just loved by them. They send us Christmas presents and display our photos in their foyers as platinum in-kind supporters.

If we were helping them, we were very, very bad at it.

And of course, how very stupid of us all to be working for decades to reduce smoking when it’s going to put us all on the dole, as this observer notes.

But what about vaping? Is this so-called disruptor really changing the dance card and seeing Big Tobacco secretly applauding tobacco control because they are now grateful that fewer are smoking?  All major tobacco companies are heavily invested in e-cigarettes and heated tobacco products. The industry business model is not e-cigarettes instead of cigarettes. It is e-cigarettes as well as cigarettes with all the companies doing all they can to maximise sales for both. And as we’ll see below, vaping is holding far more smokers in smoking than it is tipping out of it.

Big Tobacco is in total lockstep with vaping advocates’ goals

When extreme libertarian, former Liberal Democrat Senator David Leyonhjelm indulged himself by holding a Senate inquiry into “measures introduced to restrict personal choice ‘for the individual’s own good’, vaping was one of the big agenda items. Few public health agencies bothered to waste time by sending submissions to it, but four tobacco  companies ( Philip Morris Limited, BAT Australia, Imperial Tobacco, Japan Tobacco International ) did, along with vaping advocates – you know, the ones who like to say that tobacco control “helps” Big Tobacco. Leyonhjelm’s party was funded by Philip Morris.

If you read through the linked tobacco company submissions to the inquiry alongside the policy goals of vaping advocates, their hopes are often interchangeable: minimum controls on e-cigs and vaping. Public health agencies want serious controls, and are supporting health minister Greg Hunt’s plan to make nicotine juice available only via special prescription.

Vaping advocates like to present themselves as champions of cottage industry vaping companies, often talking as though these were the equivalent of folksy craft beer companies bravely taking on the majors, chanting anti big business, people-power slogans to make vapers feel all warm inside at their revolutionary zeal.

But many of these warriors are ignorant or naïve about the history of the tobacco industry’s mergers and acquisitions with  vaping companies that they see as additions (not substitutes)  to their cigarette mainstays.(see chart below). Just as successful independent micro-brewers like Little Creatures get swallowed up by global companies, the tobacco industry has swallowed up many government tobacco monopolies over the years, to either get rid of the competition or piggyback on local reputations. Altria in the USA invested $US12.8 billion in Juul, the e-cigarette brand favoured by teenagers in 2018, although this may be going pear-shaped for the company. The bottom line is that Big Tobacco can, has and will eat any minnow vaping company for breakfast anytime it chooses to.

No tobacco company has taken its foot off the floor of marketing and promoting cigarettes where and whenever it can. And all continue to lobby to erode effective tobacco control policies, as I argued here, here and here. Vaping advocates are the ones who are helping big tobacco, while tobacco control is working to stop making all the mistakes with vaping regulation that were made with tobacco by letting the industry do what it liked for much of the twentieth century.

In the 1970s, the Australian tobacco companies quietly groomed an eccentric Bondi GP, William Whitby who wrote two self-published books about how smoking was good for you. They even provided him with media training. Today we have a small handful of doctors in Australia who are doubtless being similarly deeply appreciated by the local transnational tobacco company representatives for all the work they are doing to promote vaping and to attack organisations and individuals working to reduce smoking.

In a recent longitudinal study of US vapers, 88.5% of those who were dual using cigarettes and e-cigarettes at baseline, were still smoking a year later. The industry is well aware of such data and sees vaping as a terrific way of holding smokers in smoking far more than it tips the out of it, while also serving to distract attention from further evidence-based measures to reduce smoking.  The table below shows that for every smoker who had a positive outcome after 1 year using e-cigarettes, there were 4.6 who had a negative outcome (relapse back to smoking, took up smoking instead, progressed to dual use) or stayed the same (smoking and vaping, or continuing to vape).

It is vaping advocates who are helping this process, not tobacco control people.

Loathe Sydney’s Crown Casino tower? What if was owned by a renewable energy company?

I’ve yet to learn of any friend of mine who likes what is slowly emerging as one of Sydney’s  most arresting buildings. After the Opera House and the Harbour Bridge the rising Crown casino on the waterfront at Barangaroo, is unarguably peerless as the most dominant building in Sydney. Nearing completion, it is unavoidable from many vantage points of Sydney’s city views.

The Crown casino plans to allow only “VIP” customers in, have minimum bets and has no plans for gaming machines, the gambling method along with on-line, responsible for bleeding the assets of most who are harmed by gambling. There’s no guarantee that gaming machine licenses won’t be sought and approved down the track.

When I ask my friends their opinion of the tower, I’m almost always instantly regaled with venomous, splenetic bile about what an utterly vile excrescence it is. It’s disgusting. It’s vulgar. It’s James Packer’s pecker, isn’t it! It’s funded by the misery and on-going ruination of countless families from Packer’s gambling empire. How could anyone with a shred of decency in them see it as anything but just awful? Is it unavoidably “ugly because its purpose is ugly”?

My question back is to ask whether their assessment of the building would be any different if the building was a public building, funded by government to house (say) various government departments, or cultural collections like art, historical and anthropological exhibits. Or would they feel any different if it was owned by major company earning money from something very important like renewable energy, electric vehicles like Tesla, affordable housing, or fair trade agricultural products?

Can – and should we – separate the origins of the money which is funding a building, a stadium etc, or the politics of an artist or performer from our appreciation of their works? Or once we know about any nefarious connections in the designer, the source of the capital that created something, or the uses to which something will be put, should that cruel any gut aesthetic appreciation of a building?

Debates like this have often occurred about music, art, and literature. Wagner’s music was used by the Nazis. So does that make it “fascist music” and  ruin it for all of us? Rock guitarist Ted Nugent is a Trump fan and frothing gun rights activist. A long time ago I used to like his Stranglehold anthem, but today can’t separate it from his vile politics. It’s gone from my rock Spotify playlist. As I teenager I learned by heart several of Barry Humphries’ Sandy Stone monologues. Lines like “a man doesn’t want a couple of kiddies walking half the beach through his car and scratching a brand new pair of seat protectors” were quite brilliant satirical observations of friends’ families in my early life. I also found Les Patterson hilarious and for years had a life-size cardboard figure of him in my office, souvenired from a Toyota Avalon promotion. But when I learned of his contempt for the Human Rights Commission, much of this soured.

So my personal reactions have been mixed, from ambivalence to disappointment to turning the page.


Vaping advocates say the darndest things!

Example: The Cancer Council Australia takes huge donations from cigarette retailers

It seems that Dr Alex Wodak doesn’t like the Cancer Council Australia very much. Along with the agencies, authorities and  government departments all shown below, the Cancer Council supports strong regulation of ecigarettes in Australia, including health minister Greg Hunt’s plan to enforce the current ban on open retail sale of nicotine containing e-juice by making it only available on prescription from 2021.  This sets them apart from ATHRA who want to see ecigarettes available as widely as possible, with some advertising allowed,  lots of flavours (regardless of whether these appeal to children), and vaping allowed in smokefree areas.

Wodak is one of three directors of ATHRA (Australian Tobacco Harm Reduction Association). ATHRA appears to have no members but accepts donations from supporters. We don’t know how many supporters there are, or how supportive they are. But  in 2019 it sought to raise $15,000  but raised only $1,345 from 38 people, falling 88% short of its modest target.

However, in Wodak’s description, ATHRA received two “piddling” donations from two vaping companies at establishment in 2017  totaling $17,500.

ATHRA also received another presumably equally piddling $8,000 “unconditional” support from KAC (Knowledge Action Change), a private British agency. KAC is awash with  millions in funding from the Foundation for a Smoke-free World, the “fully independent” agency that happens to be solely funded by Philip Morris International. (KAC has also previously received grants from British American Tobacco’s offshoot Nicoventures.)

If Wodak thinks these donations were piddling, I wonder how he describes the rather more modest donations ATHRA gets from its supporters?

Perhaps smarting at journalists who frequently (and appropriately) question potential commercial influences on ATHRA’s policy positions, Wodak has been busy claiming on Twitter that the Cancer Council takes “HUGE donations from major national retailers of cigarettes”. He also retweeted this claim that Woolworths alone had donated $2m. In fact, he has tweeted references  to the Cancer Council takes money from tobacco and alcohol retailers six times in the last nine days.

These allegations of outrageous hypocrisy (“double standards”) sounded extraordinary to me. So I asked the Cancer Council if this was true. Here’s what they told me. All supermarkets except Aldi sell cigarettes, but the funding the Cancer Council received in the past from these chains has not been given by the supermarkets as a slice of their income that included tobacco sales. Instead it has been from in-store fundraising collections and the sale of Cancer Council fundraising daffodil pins, supermarket staff donations, the use of in-store community benefit shopping cards and the sale of Cancer Council sunscreen. All of these sources of fund raising have absolutely nothing to do with tobacco sales, as Wodak implies.

They wrote:

“Cancer Council does not take money directly from industries associated with carcinogen production including the tobacco and alcohol industries. We also avoid any donations that might imply or seem to pressure Cancer Council into adopting policy positions in their favour, such as the pharmaceutical industry, as we value our independent voice on health matters. Cancer Council, like most charities, has accepted fundraising via supermarket networks. In Coles, for example, collections bins for Daffodil Day have raised donations from the public but these donations do not come directly from the supermarkets.”

In 2009 Ritchies IGA supermarkets also donated $1.4m provided by its customers via its Ritchies Community Benefit Card charity initiative.

Perhaps though, Wodak is alluding to some impurity of association in these donations? Is he arguing that the mere fact that the supermarkets, with their hands dirty from selling cigarettes, have metaphorically handled the money obtained from in-store collection boxes or pin sales, making these transfers dirty tobacco money?

If so, every time that he or I or anyone buys anything at a supermarket or fill our cars with fuel from Caltex (Woolworths) or Shell (Coles) or buy liquor from Dan Murphy’s or BWS (Woolworths) or Liquorland, Vintage Cellars or First Choice (Coles) are we also somehow soiled with tobacco associations?

By the same logic Wodak uses here, there is no person in Australia who is not in receipt of benefits partly paid for by tobacco sales. The Commonwealth’s estimate of tobacco excise receipts for 2020-21 is $15.61 billion. This represents 3.2% of expected total government revenue of $490.036 billion.  Tobacco tax goes into consolidated revenue along with all government revenue which is used to pay for government expenditure. So every time we all drive on a public road, use a public hospital, send our kids to school, or use any government funded infrastructure, a portion of the cost of those goods and services is funded by smoking. When we get a Medicare rebate payment of say $50, it might even be said that $1.60 of each transfer into our bank comes from tobacco sales.

It does not follow from this that we should all cry and tear out our hair in a moral heap that we are all getting tobacco money. Tobacco tax of course is known to be a powerful factor in driving tobacco consumption down. This 2019 Treasury paper shows  (below) the recent historical relationship between excise going up and cigarette sales going down.  Because of that, I’m more than fine with tobacco tax: it drives consumption down and provides money for essential infrastructure and government expenditure, as it does in every country.

All this is of course far different to an organisation taking funding directly from vaping companies, or from a third party which distributes money from an agency which receives it all from a tobacco company. Which is what ATHRA has done. 

Wodak spent most of his career employed in drug and alcohol services at Sydney’s St Vincent’s Hospital. St Vincent’s Health Australia operates the health and hospital services of the Roman Catholic Sisters of Charity and is part of Mary Aikenhead Ministries. The Catholic church in Australia and globally has of course been the focus of enormous criticism for its record with paedophile priests, for its policies and practices on contraception, abortion, opposition to same-sex marriage and the ordination of women.

On the assumption that Wodak shares the concerns that many have about the Catholic church’s  problems, would anyone seriously argue that he therefore had “double standards” in working for a hospital connected with the church, even though the hospital’s drug and alcohol services have nothing to do with any of those policies?

ATHRA’s objectives are anti-smoking as well as pro-vaping (although you will search for a long time before finding any supportive contribution to anything but vaping on their website).  I may have missed it (although I don’t think I have), but I’ve not seen ATHRA nor Wodak shaming other charities that the major tobacco supermarket retailers support and calling them out for being in receipt of retail tobacco sourced donations. These include OzHarvest, Foodbank, White Ribbon, Redkite, Children’s Hospitals, Ovarian Cancer Australia, Hummingbird House to name a few. Would a little consistency be too much to ask for?

Wodak has often called for civility in the debate about ecigarettes. Vaping advocates have been frequently far more than odious in all this (see this large collection). If he is sincere in this, he should stop and retract his ill-informed and reputationally damaging accusations about the Cancer Council.

The Cancer Council has a very strong reputation with the Australian public as measured by the 2019 Charity Reputation Tracker scoring over 80%. Cancer Council is the most loved brand in the general charity category measured by Kantar and is also highest in terms of trust by the public. The Cancer Council consistently scores in the top three most trusted charities in Australia in the annual Reader’s Digest Awards alongside Guide Dogs Australia and the RSPCA.

I have seen tweets where vapers have talked about urging people to not donate to the Cancer Council. There is apparently no evidence that this is happening but the consequences of reductions in community support for the amazing work that the Cancer Council has done for many decades in prevention, research and patient support would be frankly appalling.

Declaration: was an honorary board member of the Cancer Council NSW from 1997-2006

See also Part 2: Tobacco control advocates help Big Tobacco

The ethics of shaming prominent COVID-19 mask opponents

A couple weeks ago, Oregon haematologist-oncologist, patient advocate and author of Malignant: How Bad Policy and Bad Evidence Harm People with Cancer Vinay Prasad tweeted this

His thread continued: “No physician would dare shame a person who died of lung cancer by sharing a photo of that person smoking in an effort to curb cigarette use It would be despicable, loathsome, & worse; no matter the ‘cautionary lesson’ and yet somehow this idea has vanished for covid19”

And then:

“I understand many are anxious or concerned, and many believe a variety of interventions make sense. But please, doctors do not blame our patients for disease. And, don’t reply to this thread saying ‘this is different’”

Sixteen responded, nearly all agreeing with his views, including some who used his tweet to pile-on the World Health Organization for not having recommended masks earlier than they did.

I posted this in response:

Prasad never responded to me nor to any others. So a few days later I tried again:

Again, no reply. So let’s explore the issues that his tweet raised for me. The argument that a person dead or dying from any disease or trauma should not be shamed or blamed for being a victim of that disease or injury has some obvious ethical and humane merits. But those merits can be parsed.

We rarely if ever see instances of blaming or shaming when the disease involved has important genetic components, when there is an absence of accepted modifiable risk factors for a disease (eg: brain, ovarian, pancreatic cancer), when in the case of traumatic injury deaths, the victim played no part in causing the injurious event, or when the cause of death multi-factorial, with a constellation of contributory issues.

We often though, see comments about the blood alcohol level of someone killed in a motor vehicle, or that someone was not wearing a seat belt. I wrote this piece about the death of Joe Cocker, a heavy smoker, at the age of 70, writing “Confused calls for a cone of “respectful” silence about smoking’s role in cancer and other tobacco-caused disease and for euphemisms about deaths following ‘a long illness’ are forged by the same mentality that thinks tobacco packs should not have graphic health warnings because they might remind people too well about what smoking can do.”

Prasad’s message was directed at his fellow doctors. It was also stimulated by something another doctor had written about someone. If he meant it to apply to all of us as well, he didn’t say so. But it’s worth considering whether the ethical standard he argues for doctors should be any different for all.

His invocation of decency and compassion as reasons for physicians never shaming those who have died go to the widely understood values that it is wrong to speak ill of the dead or to suggest that they had any agency in their fate. The memory of the dead, particularly for those who knew and loved them, should never be desecrated by attempts at shaming them with considerations that they contributed to their own demise.  Irony about a person getting their comeuppance from something that in life they went out of their way to avoid, embrace or proclaim drags in widely invoked metaphors about fools’ errands, tempting fate, hubris and the fall of Icarus for flying too near the sun.

The dead are beyond being harmed by shaming or black humour about them “getting what was coming to them”, but those grieving them are blameless and so we show compassion for their loss and not speak ill of the dead. The idea that those who make the effort to shame the dead are “dancing on their graves” in callous disregard for their loved ones’ grief adds a further dimension to the indecency here.

There is also a further consideration. There are very few causes of death which do not display an inverse socioeconomic gradient: the lower the socioeconomic status, the higher the incidence of disease and deaths. Analysts of this have long agreed that this is explained by social, economic and educational disadvantage. If you are little educated and poor, there will be many choices you cannot make as easily as those who are better educated and can afford many options in diet, housing, transport and occupation.

So if those less educated make more unhealthy and dangerous lifestyle choices, much of this can be explained as a consequence of intergenerational poverty and disadvantage. If most people in their families smoke and eat poor diets, an individual growing up in such an environment lives through more unhealthy influences than wealthier, more educated people. If they have little understanding of how to assess quack claims or rubbish being promoted about health risks, they may be far more likely to suffer the consequences. Shaming people in such circumstances can be deplorable victim blaming.

So the ethical imperative to leave the dead in peace enjoys widespread support, particularly when those who died are ordinary, little or unknown people. Those seeking to use their ill fate to advance various public health messages, are seen as vulture-like, runs the argument.

Is it different if you are a public figure who megaphones dangerous nonsense?

But as I read Prasad’s tweet, I immediately thought of many instances of powerful and prominent people who have made pernicious, life-endangering contributions to public health. All of these people have faced widespread incendiary criticism whenever they megaphoned their dangerous and irresponsible views. Think of anti-vaccinationists, politicians enabling the tobacco, fossil fuel, gambling and alcohol industries. Think of those actively trivialising COVID-19 risk, opposing social distancing policies and masks. There is a very long list of such people who have used their prominence in these ways, often undermining public trust in science, thwarting policy and legislation that could save uncountable lives.

Just as anopheles mosquitoes are vectors for malaria, it has long been argued that the corporations and senior executives of tobacco companies are vectors for the diseases caused by smoking predicted to kill a billion people this century. Those currently aggressively opposing the mandatory wearing of masks in crowded areas are today’s equivalents to the editorial writer at The Times in London in 1848 who fulminated against public hygiene efforts to prevent the spread of cholera

My question to Prasad was whether we should extend the same compassion to influential public figures who might suffer cruel ironies as we would to some unknown individual such as the young person that stimulated his tweet. Brazil’s president Bolsonaro reportedly mocked mask wearing with the homophobic slur that they were “for fairies” prior to acquiring COVID-19 himself. Would Prasad argue that these two facts should go unremarked out of a sense of decency for Bolsonaro and his family?

Brazil has had 2,348,200 COVID-19 cases with 85,385 deaths. It ranks second worst in the world for total cases numbers after the USA. Is it unethical to use Bolsonaro’s illness to highlight cases of  people like Bolsonaro as COVOD-19 super spreaders because of their policies and statements like the one above, or should  doctors (and everyone) stifle any criticism of him because he has acquired the deadly disease his policies have enabled the spread of and is thereby off limits?

I’m in no doubt that in such cases, the power of cruel irony can instantly and powerfully be penny-drop moments in public understanding. This in turn might play a role in (here) accelerating mask adoption and social distancing, self-evidently good things.

In 1982, the late Nigel Gray AO, a pioneer of Australian and global tobacco control, told two tobacco industry executives on national Australian television “I actually think that the responsible policy makers in the  tobacco industry should smoke a lot. I think that would be good for society.” (the link shows him making that statement)

This was both an amazingly cruel but also powerful way of pointing to a core hypocrisy that abounds in the tobacco industry where many senior employees and directors do not smoke but spend their days devising promotions and appeals to get as many people as possible to do so. Doubtless they would argue that they choose not to smoke. While the male head of a lingerie company would not be expected to “choose” to wear women’s underwear, smoking is a choice open to all. It is scarcely imaginable that the chairman of Ford would drive a Toyota or the head of the Meat Marketing Board would be a vegetarian. Such lack of personal confidence in their products would probably see them not long in their jobs. The tobacco industry does not seem to mind such an irony.

As Nigel Gray did in that interview,  there are times when we should rub the faces of such people in these ironies.

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.