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.

Views?

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

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.

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

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

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

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

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

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

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

The slide collection is here (in powerpoint form)

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

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

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

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

It started with this from an “Iris Reed”

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

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

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

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

Twenty minutes later the indefatigable Macie was back:

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

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

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

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

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

sprayCoffee

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

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

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

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

Iris now kicked this one upstairs to the top brass.

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Mr Williams got back to me immediately.

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

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

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

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

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

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

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

Four lessons

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

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

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

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

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

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

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

Australia’s achievement is simply remarkable

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

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

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

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

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

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

Self-exempting beliefs about smoking

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

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

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

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

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

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

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

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

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

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

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

Self-exempting beliefs about COVID-19

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

Some I’ve noticed include:

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

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

Respectful communication is critical

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

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

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

Apposite analogies

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

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

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

non-smoking section

Peeing v non-peeing

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

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

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

Freedom to vs freedom from

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Source

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

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

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

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

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

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