Just when you think you’ve met peak stupidity in the vaping debate, you find a new verse in vaping advocacy theology that makes you spray your coffee.

Here’s a proper doozie that often gets an outing from those with a taste for conspiracy theories. It runs like this.

“The obvious reason why there’s so much opposition among people in public health to all the regulatory reforms being advocated, is that these people are just trying to protect their jobs. Vaping is driving smoking down so fast that tobacco control people can see the writing on the wall. If there are no smokers left, they won’t have any problem left to deal with. So no wonder they are desperate to try slow down the inevitable.”

It’s an argument that some have used for many years

The deranged fraternal twin to this argument invariably then pipes up with “And those working in tobacco control are paid absolute fortunes and massive grants by governments, so they have huge incentives to attack anything which might really drive down smoking.” This recent blog by a Queensland vaper with recent form in getting things completely wrong (see below) ticks both these boxes, and plenty more besides.

I recommend you try to read the blog right through to get a feeling for the depths of claptrap these people can plumb when they let their fantasies off the leash. But let’s here focus on a few passages.

Where to begin with this batty nonsense? First up, if public health workers really didn’t want smoking rates to fall, why have they kept successfully advocating ever since the late 1960s for policies and programs that have caused the brakeless train to head south almost continually for 40 years? Here’s a graph of falling smoking prevalence in Australian adults, from results from two different survey series.

So what’s driving this disaster for the tobacco industry?  Chance? Luck? How about synergies between the full suite of tobacco control policies and campaigns that’s made Big Tobacco long describe Australia as “one of the darkest markets in the world”? Mass reach public awareness campaigns (with beautiful irony, the very same ones that motivated many vapers to try ecigs); tax rises; total advertising and promotion bans; smokefree public spaces, public transport, bars, clubs and stadiums; retail display bans; graphic health warnings on packs; and plain packaging?

The massive Tobacco in Australia website documents the research evidence for all of these across hundreds of pages here.

So the fruitcake wing of vaping advocacy would have you believe that  those of us who across 40+ years have worked to hold high success in achieving every policy and law reform we ever fought for; who saw millions of smokers quit and still more never take it up including record numbers of Australians today who have never smoked ; and who caused smoking to be utterly denormalised from an aspirational, glamourous thing that happened in every setting you ever entered to one where 90% of smokers today regret ever starting; who saw smoking rates fall to where they have never been lower;  and who drove lung cancer incidence rates down to a level  last seen in the early 1960s  …. well, of course anyone can appreciate that we were making all this happen because secretly, we really didn’t want smoking to keep falling.

Secretly, we wanted everything we did to fail because in the words of our incisive, shrewd commentator cited earlier “You see as any shrewd person would realise, if you are getting paid big money for eliminating a problem and you eliminate it entirely, then the job is over, it’s done and therefore you have nothing to justify putting your hand out for.”

Presumably it’s just the same for COVID-19 specialists, those trying to reduce domestic violence, skin cancer, road deaths … in fact anyone trying to solve any problem. We need to understand that none of these problems have ever been eliminated because all involved are busy stomping on the brakes so they can keep their jobs.

Perhaps it’s more subtle than that. Perhaps we all secretly agree that the galloping uptake of vaping will be so furious and so amazingly successful in slashing smoking rates, that the bottom will fall out of all remaining smoking. Conversion to vaping will be all but total. When the miracle of vaping came along, the penny finally dropped and we all suddenly decided that enough was enough, saw the looming unemployment we all faced and called for e-cigarettes to be seriously regulated into prescription status.

But hang on. Neither of those assumptions are true: nowhere has vaping caused major declines in smoking prevalence, and vaping is quite dismal in its effectiveness in  smoking cessation. In England, where vape shops wallpaper high streets and vaping theologists dominate policy forums, the proportion of smokers who vape, according to the latest data summary from Robert West’s Smoking In England project, e-cigarette use in adults has been stable since 2013, plateaued in smokers and recent ex-smokers, and the majority of e-cigarettes users are still smoking (dual users).Vaping may well be holding far more in smoking than it tips out of it.

Smoking seems to have even kicked up a little in the very latest English survey.

And check out  from page 8 in our submission to the recent Senate enquiry into vaping, just how very ordinary vaping is in helping smokers quit. Would you take a drug that failed with 90% of users? That’s what the latest Cochrane review concluded about how good e-cigarettes were in quitting in clinical trials.

“Millions upon millions of dollars of grants via the federal department of health”

According to our Queensland blogger, those whose assessment of the evidence on e-cigarettes the government trusts have been rewarded with lavish grants from the Department of Health. This is curious, because it’s the NHMRC which awards research grants to successful applicants each year, not the Department. I stopped applying for grants well before I retired in 2016.  And neither of my co-authors (Mike Daube and Matthew Peters) of the submission to the recent Senate committee on harm reduction which was frequently cited in the published majority report have any recent grants either. Perhaps I should go and check my letterbox or one of my many Swiss and Caribbean secret bank accounts?

But, interestingly, look who have recently been awarded a very large ($2.5m) grant to look at tobacco endgames. Why, it’s a list of excellent researchers which includes several who have often been praised by vaping advocates. So something seems to be not quite right here with the claim that vaping skeptics are being duchessed by the government.

But oh, I forgot. As our Queensland blogger told us, it’s also New York billionaire Michael Bloomberg’s small change via  Bloomberg Philanthropies which is secretly showering Australian vaping skeptics with funds.

ATHRA director Alex Wodak seems to know this too, tweeting this week that the Australian Council on Smoking and Health in Perth (directed by Maurice Swanson) is funded via Bloomberg money apparently routed through “a few [of course nameless] organisations”.  Very odd indeed, that neither Maurice nor Bloomberg know anything about this.

Wodak has previously accused the Cancer Council of accepting tobacco money. When this was shown to be absolute nonsense, he offered no retraction or apology. This is what it’s come to.

Update: Wodak is still persisting with this mendacious nonsense in November 2025

Other blogs in this series.

Vaping theology: 1 The Cancer Council Australia takes huge donations from
cigarette retailers. WordPress  30 Jul, 2020

Vaping theology: 2 Tobacco control advocates help Big Tobacco. WordPress 12 Aug, 2020

Vaping theology: 3 Australia’s prescribed vaping model “privileges” Big Tobacco WordPress Feb 15, 2020

Vaping theology: 4 Many in tobacco control do not support open access to vapes because they are just protecting their jobs. WordPress 27 Feb 2021

Vaping theology: 5 I take money from China and Bloomberg to conduct bogus studies. WordPress 6 Mar, 2021

Vaping theology: 6 There’s nicotine in potatoes and tomatoes so should we restrict or ban them too? WordPress 9 Mar, 2021

Vaping theology: 7 Vaping prohibitionists have been punished, hurt, suffered and damaged by Big Tobacco WordPress 2 Jun, 2021

Vaping theology: 8 I hide behind troll account. WordPress 29 Jun, 2021

Vaping theology: 9 “Won’t somebody please think of the children”. WordPress 6 Sep, 2021

Vaping theology: 10: Almost all young people who vape regularly are already smokers before they tried vaping. WordPress 10 Sep, 2021

Vaping theology: 11 The sky is about to fall in as nicotine vaping starts to require a prescription in Australia. WordPress 28 Sep, 2021

Vaping theology: 12 Nicotine is not very addictive WordPress 3 Jan 2022

Vaping theology 13: Kids who try vaping and then start smoking,would have started smoking regardless. WordPress 20 Jan, 2023

Vaping theology 14: Policies that strictly regulate vaping will drive huge
numbers of vapers back to smoking, causing many deaths. WordPress 13 Feb, 2023

Vaping theology 15: The government’s prescription vape access scheme has failed, so let’s regulate and reward illegal sellers for what they’ve been doing. WordPress 27 Mar 2023

Vaping theology 16: “Humans are not rats, so everybody calm down about nicotine being harmful to teenage brains”. WordPress 13 Jul, 2023

Vaping theology 17: “Vaping advocates need to be civil, polite and respectful” … oh wait. WordPress 3 Oct, 2023

Vaping theology 18: Vaping is a fatally disruptive “Kodak moment” for smoking. WordPress Oct 30, 2023

Vaping theology 19: Vaping explosions are rare and those who mention them are hypocrites. WordPress 17 Nov, 2023

Vaping theology 20 : Today’s smokers are hard core nicotine dependent who’ve tried everything and failed – so they need vapes. WordPress 14 Dec, 2023

Vaping theology 21: Australia’s prescription vapes policy failed and saw rises in underage vaping and smoking. WordPress 10 Jan, 2024

Vaping theology 22: “Prohibition has never worked at any point for any other illicit substance”. WordPress 17 Mar 2024

Vaping theology 23: “84% of the Australian public are opposed to the way the government will regulate vapes” WordPress 2 Apr, 2024

Vaping Theology 24: “Tobacco control advocates are responsible for vape retail store fire bombings and murders. WordPress 27 May, 2024

In November 2020, I was lead author with Emeritus Professor Mike Daube AO and Professor Matthew Peters AM of a 32 page submission to the Australian Senate Committee on Tobacco Harm Reduction. Our submission was cited many times in the final majority report of the Committee. I’ve since received many requests for a copy of the submission which are continuing, so am re-publishing it here for ease of access.

The full citation for our submission is Chapman S, Daube M, Peters M. Public Submission #195.to the Senate Select Committee on Tobacco Harm Reduction. Nov 3 2020 https://aph.gov.au/Parliamentary_Business/Committees/Senate/Tobacco_Harm_Reduction/TobaccoHarmReduction/Submissions

Robert Beaglehole is a veteran public health leader from New Zealand. He was professor of public health at the University of Auckland between 1988-1999, before joining the World Health Organisation in Geneva in 2000, heading its chronic disease prevention and health promotion division until 2007. He started New Zealand’s Action on Smoking and Health in 1982 and chairs its board today.

I’ve known and admired Robert’s work for many years, and have spent some very pleasant time in his company.

But lately, he has become an advocate for vaping and is showing signs of having drunk the movement’s kool aid rather deeply.

One of the most persistent memes in vaping advocates’ creed is the profoundly silly argument that anyone who expresses any scepticism about any of the pillars of the case for vaping is  helping Big Tobacco. I explored this argument in an earlier blog here.

Recently, Beaglehole was interviewed for a short video produced by CAPHRA (the Coalition of Asia Pacific Harm Reduction Advocates).

Australia’s Therapeutic Goods Administration has ruled that from October 1, 2021 anyone wanting to import or purchase nicotine for vaping will be required to have a doctor’s prescription – see here. This is in effect a quasi “license to vape”, that has some of the reasoning in common with that I set out in a paper in 2012 on the idea of a “smokers’ licence”, later adapted by Coral Gartner and Wayne Hall in a paper on a “vaping licence”. The prescription route is now causing apoplexy among those who want to see e-cigarettes containing nicotine sold in almost every conceivable retail outlet (I’ve not yet seen this include crèches, tuck shops or back-to-school sections of stationery shops … but nothing would surprise me here).

Asked to comment on this recent decision to implement what the interviewer  calls “a medical model” for vapouriser access, Beaglehole says at 2m35s:

Well, basically going that route privileges the tobacco industry. By making vaping less accessible and more difficult for smokers who smoke cigarettes and want to quit, making it more difficult for them to access nicotine is privileging Big Tobacco. That’s the last thing we want to do. We should be treating nicotine as a consumer product. Let the market innovate. Let people make their own choices as to what they do.

So, what do the main tobacco companies selling tobacco in Australia and hoping to be able to sell their vapourised and heated nicotine products here have to say about their impending “privileged” position said to arise from prescribed access?   

Imperial Tobacco told the 2020 Australian Senate enquiry into harm reduction:

We are discouraged by recent moves from the Department of Health to ban the import of nicotine containing EVPs [electronic vaping products]… We believe NGPs [next generation products] are more likely to succeed at transitioning adult smokers if they aren’t perceived to be medical treatments for smoking, unlike NRTs [nicotine replacement therapies].

And what about British American Tobacco Australia?

A practical and regulated solution that allows Australian smokers ready access to nicotine containing e-liquids (along with other potentially reduced risk alternative products to cigarettes) without the need for a prescription, is urgently required.

And Philip Morris International? PMI applied unsuccessfully to have the poisons schedule amended to allow its IQoS heated tobacco product to be openly sold in Australia. But has not submitted an application to the Therapeutic Goods Administration to have it scheduled as a therapeutic good (as has long been the case with nicotine replacement therapy). So it too, does apparently not share Beaglehole’s understanding of how prescribed access would privilege it.

So all three Big Tobacco companies operating in Australia, which are all hoping to market their so-called harm reduced products here, are not exactly popping champagne corks at the thought of how privileged they will become in 2021. In fact just the opposite: they are all implacably opposed to access via a doctor’s prescription.

And what should that tell us?

It tells us that they all know that the “consumer product” classification that Robert Beaglehole supports will see the companies able to avoid any of the controls that therapeutic regulation would bring. For example, very, very few doctors would be willing to issue a nicotine vaping license to a child, while 45% of US vaping retailers​ and​ ​39% of English shops​ operating under a “consumer product” model sell to underage customers. In New Zealand, vaping by kids is booming. And no tobacco company would ever want to see that happen …

Quite amazingly,  at 7m26s into the video, Beaglehole picks up two nicotine delivery systems strategically placed on a coffee table in front of him. One at a time, he carefully inspects them, with the brand names clearly visible. Irony of ironies, the two brands are BAT’s Vype and PMI’s IQoS: the two flagship new generation nicotine products of two of the biggest Big Tobacco companies in the world. You know, the ones that he thinks it’s a bad idea to “privilege”.

He also says that access via prescription will make it “more difficult” for smokers wanting to get vapable nicotine than if these products were sold in shops with open access.

And how enormously difficult is it in Australia for people to access prescribed medications? In 2018-19, in a population of some 25 million, 205.1 million prescriptions for 900 subsidised drugs in 5,455 brands were dispensed via Australia’s Pharmaceutical Benefits Scheme. There can be few people in Australia who, in any year, are never handed a prescription by a doctor.

“All of it is incorrect”

Beaglehole also has some choice words about those who have drawn attention to emerging evidence about harms of vaping. At one point he refers to “the supposed harm of nicotine and vaping”, theatrically gesturing quotation marks around “supposed harm”. He then says “A lot of that information is incorrect. All of it is incorrect. And based on very poor science and vested interests.” (my emphasis)

All of it is incorrect? All of it? So any published evidence that has concluded that there are any concerns about vaping being harmful or not very effective in helping smokers quit is all wrong?  In our submission to the 2020 Senate enquiry, we referenced 11 expert reports and meta-analyses of smoking cessation via vaping published since 2017 which all concluded there was weak evidence that e–cigarettes are useful ways of quitting smoking. We also listed (on pp 23-24 of our submission) a small selection from many recent papers on harms from vaping.

Such categorically dismissive language from a person with a seriously impressive public health background is quite remarkable.

He continues “The misinformation which is coming from a rather limited number of people  with strong vested interests in traditional tobacco control approaches”.

A limited number of people? With “traditional tobacco control approaches?” Perhaps by this Robert means those approaches which no less than 188 nations have signed to support the World Health Organization’s Framework Convention on Tobacco Control – a blueprint for reducing smoking. The only nations that have not signed are Andorra, Dominican Republic, Eritrea, Indonesia, Liechtenstein, Malawi, Monaco, Somalia and South Sudan. Here’s a 2019 blog from me showing a very long list of national and international health agencies who have expressed strong reservations about e-cigarettes.

Speaking for myself, I plead not guilty, m’lud, to slavish adherence to the “traditional” suite of tobacco control policies and practices. I have been persistently critical since 1985 of the very limited impact of stop smoking clinics (see here at p154) and NRT and smoking cessation drugs on reducing smoking prevalence (and am several months into writing a book on these quit smoking “weapons of mass distraction”); of banning smoking in wide-open outdoor areas; of employers refusing to hire smokers; and of R-classifications for movies depicting smoking.

My scepticism of the turbo-hyped claims for vaping is shared by many of the world’s peak health agencies. Here’s how Australian agencies line-up. Notice a pattern?

If there is anyone helping Big Tobacco in the vaping policy debate, it is of course all those who are doing all they can to enable its ambitions to see a repeat with vaping of the disastrous historical failure to regulate tobacco and cigarettes. I’ve never met anyone in health or medicine who thinks it is wonderful for public health that cigarettes can be sold anywhere.  Australia’s decision to require a prescription will put a significant barrier between kids and vapes, but will not constitute a barrier for adults who smoke to access vapourised nicotine under the care of a GP.

Update 20 Feb 2021: two excellent investigative pieces published this morning in the Australian Financial Review, on how two tobacco companies (BATA and Philip Morris) have been lobbying to stop the “prescription” regulatory model.

https://twitter.com/NeilChenoweth/status/1362881988382715910

https://twitter.com/NeilChenoweth/status/1362887736923889666

See also in this series:

Vaping theology: 1 The Cancer Council Australia takes huge donations from
cigarette retailers. WordPress  30 Jul, 2020

Vaping theology: 2 Tobacco control advocates help Big Tobacco. WordPress 12 Aug, 2020

Vaping theology: 3 Australia’s prescribed vaping model “privileges” Big Tobacco WordPress Feb 15, 2020

Vaping theology: 4 Many in tobacco control do not support open access to vapes because they are just protecting their jobs. WordPress 27 Feb 2021

Vaping theology: 5 I take money from China and Bloomberg to conduct bogus studies. WordPress 6 Mar, 2021

Vaping theology: 6 There’s nicotine in potatoes and tomatoes so should we restrict or ban them too? WordPress 9 Mar, 2021

Vaping theology: 7 Vaping prohibitionists have been punished, hurt, suffered and damaged by Big Tobacco WordPress 2 Jun, 2021

Vaping theology: 8 I hide behind troll account. WordPress 29 Jun, 2021

Vaping theology: 9 “Won’t somebody please think of the children”. WordPress 6 Sep, 2021

Vaping theology: 10: Almost all young people who vape regularly are already smokers before they tried vaping. WordPress 10 Sep, 2021

Vaping theology: 11 The sky is about to fall in as nicotine vaping starts to require a prescription in Australia. WordPress 28 Sep, 2021

Vaping theology: 12 Nicotine is not very addictive WordPress 3 Jan 2022

Vaping theology 13: Kids who try vaping and then start smoking,would have started smoking regardless. WordPress 20 Jan, 2023

Vaping theology 14: Policies that strictly regulate vaping will drive huge
numbers of vapers back to smoking, causing many deaths. WordPress 13 Feb, 2023

Vaping theology 15: The government’s prescription vape access scheme has failed, so let’s regulate and reward illegal sellers for what they’ve been doing. WordPress 27 Mar 2023

Vaping theology 16: “Humans are not rats, so everybody calm down about nicotine being harmful to teenage brains”. WordPress 13 Jul, 2023

Vaping theology 17: “Vaping advocates need to be civil, polite and respectful” … oh wait. WordPress 3 Oct, 2023

Vaping theology 18: Vaping is a fatally disruptive “Kodak moment” for smoking. WordPress Oct 30, 2023

Vaping theology 19: Vaping explosions are rare and those who mention them are hypocrites. WordPress 17 Nov, 2023

Vaping theology 20 : Today’s smokers are hard core nicotine dependent who’ve tried everything and failed – so they need vapes. WordPress 14 Dec, 2023

Vaping theology 21: Australia’s prescription vapes policy failed and saw rises in underage vaping and smoking. WordPress 10 Jan, 2024

Vaping theology 22: “Prohibition has never worked at any point for any other illicit substance”. WordPress 17 Mar 2024

Vaping theology 23: “84% of the Australian public are opposed to the way the government will regulate vapes” WordPress 2 Apr, 2024

Vaping Theology 24: “Tobacco control advocates are responsible for vape retail store fire bombings and murders. WordPress 27 May, 2024

Offer of reply: I offered Robert Beaglehole an opportunity to respond to the points made in this blog on 16 Feb 2021. He replied on 19 Feb accepting the offer. As at 24 Oct, 2021 he has not submitted a response.

Following the development of a cluster of COVID-19 cases in late December 2020 in Sydney’s northern beaches region, the NSW government introduced a requirement for mandatory mask use on all public transport, retail shops, cinemas and theatres from midnight on January 2, 2012. Fines ranged from $200 for individuals, $1000 for small businesses and $5000 for corporations.

With the ebbing of cases, this requirement was narrowed a few weeks later, with masks remaining mandatory on public transport and in close-contact occupational settings like hair salons, barbers, massage parlours and nail bars.

Throughout 2020, the government had resisted extensive and often impassioned calls from many public health experts, the state political opposition and many members of the public for masks use to be mandatory in public indoor settings and public transport.

Well before masks were mandated, on July 28, 2020 I spent 90 minutes on the platform of my local railway station between 7.15am-8.45am observing the prevalence of mask use. I used two mechanical thumb tally clickers to count both use and non-use on people on the platforms both waiting to board and alighting.  With mask use being voluntary, I found 54 (7.2%) wearing masks and 695 (92.8%) not.

On February 3, 2021 after 17 consecutive days in NSW without a locally acquired COVID case  and when the law still required those aged 12 years and older to wear masks on platforms and in trains, I repeated these observations for two and a half hours between 7.00am-9.30am on a platform of Town Hall station, one of Sydney’s busiest stations located in the downtown central shopping district. From an unobtrusive seated observation point, I counted all use and non-use in those on three clearly visible railway platforms, those visible in the stopped carriages immediately adjacent to my observation point and on two stairwells leading onto the platforms. I did not count any children in school uniform as discerning their age was likely to be unreliable.

Across the two hours, I counted 2758 people with masks (96.6%) and 96 without (3.4%).

The Council on Foreign Relations reported in August 2020 that “more than half” the world’s nations had mandated either total public space mask use or use in certain areas or circumstances.  In view of this, I searched PubMed and remarkably, was unable to find a single observational report of mask use prevalence for any nation or region, post the advent COVID-19, with usage data reports being based on self-report (for example here). Given the volatility of the debate about mandatory mask use in some nations, social desirability bias is likely to cause reliability problems in self-reports of mask use.

These “citizen epidemiological” easily conducted and unambiguous observations of mask use are possibly the first time the impact of legislation on mask use has been reported by actual counting of mask use. Masks are accessible, cheap and most critically, a vital component on COVID-19 risk reduction recommended by the World Health Organization. The data in this small observational study should encourage those advocating for masks to be made mandatory in relevant crowded circumstances. 

Having traveled often on public transport during January, the counts I tallied are consonant with my  experiences of seeing almost everyone masked during this time. Future research could examine whether my tallies are also occurring across the greater Sydney rail network at different times and days of the week.

At different times during the COVID-19 pandemic, Australian states and territories have mandated mask wearing in various public settings. As I write this on Feb 1 2021, my own state of NSW currently mandates masks in the Greater Sydney region (including the Blue Mountains and Northern Beaches), the Central Coast and Wollongong). Masks must be worn on public transport, for staff in hospitality settings (bars, restaurants, cafes), in hairdressing salons and barbers, beauty parlours and nail bars, massage parlours, tanning salons, on planes and in airports, and at places of indoor worship, weddings and funerals. 

Those breaching these rules can be fined $200 (individuals), $1000 for small business owners not enforcing mask use and $5000 for corporations.

During most of January, this list also included all shops. The future may see changes to these rules, depending on infection rates and locations.

Health workers and many citizens were vociferous advocates for masks to be made mandatory from the early days of the pandemic. But without their use being mandatory, voluntary rates of adoption were depressingly low. In late July 2020, out of curiosity I took myself off to my local railway station for 90 minutes in the morning commute period with two hand counters, clicking with one hand all those boarding or alighting wearing masks, and with the other, those not wearing masks. Nearly 93% were maskless.

When Sydney’s northern beaches experienced a significant cluster which threatened to spread beyond the locked down peninsula, the state government relented and rapidly mandated masks in all indoor settings and on public transport from midnight on January 2, 2021.

It was obvious to all that there was an immediate, almost 100% compliance that lasted until the relaxation announced several weeks later.

As I blogged earlier, this was almost entirely predictable, mirroring the 100% compliance with a restaurant indoor smoking ban when it was first introduced in time for the Sydney Olympics in 2000, compared with the situation in Melbourne which at time still allowed smoking in restaurants.

There is a huge, unassailable lesson in this. Public information and persuasion campaigns designed to motivate people, manufacturers and the service sector to  voluntarily adopt behaviours or changes in the way they manufacture or provide good and services will get you only so far.

When you face deadly serious threats to large numbers of people, and voluntary appeals are not translating into widespread adoption, legislation backed with fines can make a huge, sometimes instant difference. Harvard University’s David Hemenway documented many examples of this in the injury and violence prevention in his 2009 book While we were sleeping: success stories in injury and violence prevention.

And the view from behavioural science research?

I was motivated to write this blog after reading a paper by a group of English behavioural scientists “Interventions to increase personal protective behaviours to limit the spread of respiratory viruses: A rapid evidence review and meta-analysis”. They have put it out for open review: anyone can publish their comments on the open-access website.

I could scarcely believe what I was reading  as I made my way through their painstaking analysis and synthesis conducted between July-December 2020. They gathered studies examining how “interventions” affected  changes in hand hygiene, avoiding touching the ‘T-Zone’, catching droplets in tissues face mask use disinfecting surfaces and maintaining physical distancing.

Here, I’ll just focus on their mask wearing results. They located just 12 studies examining what happened when people are exposed to interventions intended to increase mask use. Their conclusions? “mixed results, with three studies reporting positive effects, two studies reporting no difference, one study reporting negative effects and six studies with indeterminate results.”

And their concluding implications?  The few and often low quality of the studies suggest “a missed opportunity for harnessing techniques indicated by relevant behaviour change theory and evidence. We encourage policymakers and healthcare practitioners to work collaboratively with behavioural scientists to incorporate techniques that theory or evidence predicts are effective for enabling personal protective behaviours, such as techniques targeting motivational or self-regulatory processes.”

So all clear, are we, about what behavioural change research offers policy makers hungry for information about how to increase mask use?

It appears that the authors made a rod for their own back by limiting what “interventions” they should include in their review. Call me picky, but to my mind a law requiring everyone to wear a mask at risk of a fine, combined with the massive news reportage that invariably accompanies the introduction of such laws, ubiquitous posters reminding people about masks and frequent railway station platform announcements, might just count as an intervention a tad more important than some little study of what happens when some university students were sent free masks to prevent acquiring influenza.

In an August 2020 publication by the Council on Foreign Relations, “more than half” the world’s nations had mandated either total public space mask use or use in certain areas or circumstances. A graph in the report (below) showed very wide differences across nations in those self-reporting that they had worn a mask outside the home on the last seven days. Self-reported data on an issue like masks that attracts sometimes significant opposition is unlikely to have high reliability, compared with direct observation of mask wearing rates.

It is likely that there are widespread cultural differences that are highly relevant to mask use, which go beyond simple questions of whether masks are mandatory or not. Many Asian cultures have a long standing tradition for those with respiratory symptoms to wear masks. Differences in enforcement rates will also be important, as will those in a nation’s overall tendency in its citizenry to obey public laws.

This law in NSW produced a blindingly obvious, nearly universal uptake in mask wearing in all areas which required it. So the absence in this review of even a mention of such massive impacts on mask use was startling.

I searched PubMed for studies on the prevalence of mask wearing during COVID. I found many papers reporting and reviewing experimental evidence on the reduction of aerosol from mask wearers, and some papers comparing COVID 19 incidence rates in states and districts which mandated masks compared with those which didn’t (see here for example). But I found no papers showing time-series data comparing the prevalence of mask wearing before and after the introduction of mask laws.

Observational data like this are commonly collected and published in the monitoring and evaluation of the impact of a wide variety of public health laws and regulations like restaurant smoking, car roadworthiness, seat belt  and infant restraint use in cars, blood alcohol and cannabis levels in drivers, helmet wearing by motorcyclists and cyclists, cockroach and rodent infestation in restaurant kitchens, and indoor air quality in workplaces. These are just a few examples.

If I’m right that there are few or no studies of mask uptake after the passage of laws mandating this, the researchers whose paper I described above could be forgiven for not including any in their review. COVID-19 is the largest health threat that all alive today have ever faced. All governments urge their citizens to wear masks, yet many still do not mandate it. Data clearly in plain sight for all of us to see that mandatory masks massively increase mask use could very easily be “upgraded” in evidence status by properly conducted surveillance studies. Such data would be invaluable in levering tardy governments into mandating their use.