The Cochrane Library’s Tobacco Addiction Group has just published its third update of the evidence about the usefulness of e-cigarettes (ECs) in quitting smoking. The update considered 50 completed studies, which together had 12,430 participants. Twenty six of these studies were randomised controlled trials (RCTs). However, just four studies were considered at low risk of bias (such as non-randomization) and these four formed the basis for the report’s main comparisons. They considered only reports which assessed smoking status at a minimum of six months from when the participants started using the ECs

The review concluded that there was “moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.69, 95% confidence interval (CI) 1.25 to 2.27; I2 = 0%; 3 studies, 1498 participants). In terms that ordinary folk might better understand “For every 100 people using nicotine e-cigarettes to stop smoking, 10 might successfully stop, compared with only six of 100 people using nicotine-replacement therapy or nicotine-free e-cigarettes, or four of 100 people having no support or behavioural support only.”

Put another way, if we take 100 smokers participating in an RCT, 90 would still be smoking six months later if they used e-cigarettes, compared with 94 who used NRT, and 96 who just tried to quit alone or got some “behavioural support”.

I’ve tried hard to think about this, but I cannot come up with any drug, used for any purpose, which has any remotely more dismal success rate than e-cigarettes or NRT in achieving its main outcome. If you went along to your doctor for a health problem and were told “here, take this. It has a 90% failure rate. But I’m describing it as successful.” …what would you think?

Well, here’s how the new Cochrane report was reported:

“Vapes more effective to quit smoking than gum or patch, review finds” Reuters

“Updated Cochrane Review shows electronic cigarettes can help people quit smoking” Eureka Alert

“E-cigs better than gum or patches” Hippocratic Post

And below, how indefatigable vaping advocate, Alex Wodak, greeted the news.

But it’s far worse than this. Far worse. There are many reasons why randomised controlled trials in smoking cessation tell us very little about how well these products perform in the real world, away from trial conditions.

And that’s the only world that’s worth thinking about when we ask basic questions about whether e-cigs are game changers in helping people quit smoking.

Problems with RCTs

Randomised controlled trials  (RCTs) are revered in experimental and clinical science as being “gold standard” evidence about whether an intervention (often a drug) makes a difference to outcomes of interest, such as smoking cessation.

RCTs can compare a drug with another drug used for a similar purpose, with a placebo, or with “usual care”. Usual care in smoking cessation RCTs can be the sort of advice that a doctor or other health professional might ordinarily offer to a smoker when they were not participating in a study. Given that such advice is often given, especially when a medication is involved, it is important to assess whether the medication has any additional cessation effect on top of the advice or routines to which smokers would ordinarily be exposed in their interactions with a health care provider or service.

But when smokers access drugs in real world circumstances, they may receive no support or advice (for example, when buying NRT from a supermarket or e-cigs over the internet) or only brief, sometimes perfunctory advice when a health care provider or pharmacist is too busy to spend much time with a customer or patient. A NSW survey of 700 pharmacies reported that pharmacists claimed to spend an average of five minutes discussing stop smoking medications with smokers. meaning that many would spend less time than that.

Once a sufficiently large number of participants have been selected to participate in an RCT, they are randomly allocated into treatment or comparison/control arms of the trial. Ideally, the allocation should be done by randomization software and by someone not associated with the trial but by third parties with no interests of any sort in the outcomes of the trial.

Those conducting RCTs can recruit their participants in a variety of ways, some of which introduce important biases in the study population. In the smoking cessation field, we often see subjects recruited from sources like quit smoking clinics, telephone quitline callers, general practitioner and other primary health care patients, smoking cessation or vaping website and chatroom visitors. With each of these, we need to ask whether smokers recruited in such ways are different in important ways to randomly selected smokers in the population at large. Self-selection bias is very relevant here. We are likely to be dealing with those who are more help-seeking. This may mean they are more motivated to quit than smokers in the general population, and it may mean they are people with lower self-efficacy (lower confidence in their ability to quit unaided).

Often researchers attempt to address this concern by demonstrating that those who have been recruited into trials are comparable to smokers in the whole population on a range of variables like demographics, smoking history, level of nicotine dependency, intention to quit and so on. But, beyond all these comparabilities, in a very important respect they are different: they have often taken steps at help-seeking in their hopes to stop smoking. But the great majority of smokers who quit don’t seek help to do so. So those who volunteer to take part in trials recruited in these ways are help-seeking volunteers.

Trial exclusion criteria

Those running trials will often exclude people from trial participation for a variety of reasons. Those who have language problems are often excluded as interpreters are expensive to add to study budgets. Those with drug or alcohol dependency, serious mental health problems like depression, psychosis or bipolar disorder can also be excluded, as can those with no fixed address, or who move addresses often, are in prison or who have a serious illness which might reduce their life expectancy (and so participation in the study down the track. Those with low motivation to quit can also be excluded.

One study reviewed 54 RCTs smoking cessation trials for criteria for exclusion and found 25 separate criteria being used across these trials. They then applied 12 of the most commonly used of these criteria to 4,962 adults with nicotine dependence in the past 12 months from a US national survey  on alcohol  use  (NESARC) and to a subgroup of participants motivated to quit. (see table below).

They found two-thirds of participants with nicotine dependence would have been excluded from clinical trials by at least one criterion, with 59% of the subgroup of motivated to quit smokers  also  excluded.

Exclusion variable	Current nicotine dependence (n=4962)	Motivated to quit smoking (n=4121)
Pregnancy	3	3
Cardiovascular disease	7	7
Smoking <10 cigs/day	32	34
Current/past 6m use of any psychotropic medication	NA	NA
High alcohol consumption	14	13
Not motivated to quit	18	0
Use of other drugs	3	3
Current depression	17	16
Current/past 6m use of bupropion and/or NRT	NA	NA
Eating disorder	NA	NA
History of psychosis	2	2
History of bipolar disorder	10	10
Exclusion by any criterion	66	59

Trial subject retention strategies

Those running trials put a lot of effort into maximising trial cohort retention rates. If lots of people drop out of the groups being studied, this can greatly compromise the integrity of trials, as important questions can be asked about whether those who pulled out or were lost to follow-up differed in important ways to those who remained in a study across its entire course.

Real-world studies have found high levels of premature discontinuation of medication use. A four nation study of 1,219 smokers or recent quitters who had used medication in the last year (80.5% NRT, 19.5% prescription only found most (69.1%) discontinued medication use prematurely (71.4% of NRT users and 59.6% of bupropion and varenicline. NRT users who obtained their patches or gum over-the-counter without prescription were particularly likely to discontinue (76.3%).

Lots of wisdom has accumulated in professional trial communities about cohort retention. Strategies include reducing any barriers to participation, efforts to building a sense of community and belonging among trialists, follow-up and reminder strategies, and tracing techniques. Community building strategies can be particularly important and trial staff who have good “people” skills are particularly important. This often fosters positive attitudes and a sense of responsibility among participants toward helping the trial avoid low levels of dropout. They can be made to feel important that they are contributing to the advance of science and the health of communities.

Trial staff often include young investigators whose PhD work is focussed on a trial. They have particularly strong motivation to develop good personal relationships with participants as the work they do will be assessed by their thesis and publication reviewers and major problems like high dropout rates can be fatal to publication. Someone mildly irritated with the on-going demands of a study to complete questionnaires, provide biological samples and keep personal data records may feel a sense of “that lovely young researcher who contacts me every few months would be very unhappy if I pulled out”. Strategies like sending thank you, birthday and holiday cards, trial newsletters, supplying trial logo material like caps and T-shirts are also often used. None of this happens in the real world when people start vaping or using NRT they might buy in a supermarket.

Trialists are often paid and drugs are free

The drugs used in trials are given free-of-charge to participants. Even where governments subsidise the cost of approved prescribed medications, the drugs are never free, and to those on low incomes, can still constitute a significant outlay. This may inhibit them being used into the medium or longer term by those who feel they need to continue using them.

It is also increasingly common for trialists to be paid for their participation in trials. This is intended to act as both fair compensation for their time and any out-of-pocket expenses like travel to the research unit, but may also act as an incentive to continue participation, particularly for those on low incomes or who are unemployed.  In real world, unmonitored or unsupervised quit attempts, smokers are never paid to use quitting aids. These differences may give an extra boost to full compliance across the recommended course of smoking cessation aid use, something that is often far from the case in real world use.

Blindness integrity problems 

In most RCTs, participants are not told whether they have been randomised to receive the active or placebo (control) drug. This is called subject “blinding”: they are blind to whether they are getting the active drug or the dummy, inert, control drug. Sometimes, investigators are also blinded as to whether subjects have been allocated to a particular treatment arm to which each study participant has been added. This is called double blinding and is undertaken to remove the possibility of researchers actively or inadvertently communicating expectations of effects to study participants. A researcher who might have hopes that a particular treatment is efficacious and who knows that particular study participants have been allocated to the active drug, may make comments to these patients that suggest to them it is likely that they are on the active drug. Researchers with expectations that successful outcomes of a trial (ie where the active drug is shown to be far better than a placebo) might lead to valuable, career-enhancing opportunities may sometimes be tempted to compromise the integrity of the blinding of a trial.

Nicotine replacement therapy and vaping are  strong candidates for a failure in blindness integrity. Nearly all smokers have often experienced interoceptive cues that they are craving nicotine. Here, we need only think of the speed with which many smokers light up a cigarette soon after waking each morning, the common sight of smokers rushing to light up after alighting from non-smoking public transport and standing outside office blocks and restaurants. These commonplace sights tell us that smokers are very familiar with sensations that remind them  of their need to re-dose with nicotine and the relief and pleasant sensations they experience shortly after doing this.

So when smokers, who may have had their brains pickled in nicotine for years, get allocated to the placebo (non-nicotine) arm of a trial of NRT or e-cigs, guess what? Many of them very quickly twig that they are in the control arm of the trial: they are not getting the “good stuff” that the trial is testing to see if it is effective. Their body tells them they are not getting nicotine.

 This paper looked at this issue. Of 73 trials it reviewed, only 17 made any assessment of blindness integrity (the others didn’t even consider it). And of the 17, 12 reported that the participants guessed correctly which arm of the trial they had been assigned to.

When considered together, all the above problems make RCTs on smoking cessation a very, very far cry from the way smokers use NRT and ecigs in the real world. But this, as we saw, will not stop the headlines about effectiveness, as if these artificially constructed trials bore any resemblance to the spread and conditions of use in the real world.

When we look at the best of the cohort studies that follow groups of smokers over time, we get a very different perspective of how well these nicotine replacement methods work in reality.

A US paper by Coleman et al using PATH data reported on a 12 month follow-up of 2932 vapers. The table below shows that for every person vaping at the start of the study (wave 1) who benefited across 12 months by quitting smoking, there were 2.1 who either relapsed to or took up smoking. By far the most common outcome was that those who were smoking and vaping at the beginning of the 12 months study period were still  vaping and smoking at the end of the 12 months. That might suggest that the vaping holds far more in smoking than it tips out of it.

Many musicians are doing it very, very hard during COVID19. With venues for gigs around the country having been either fully closed, and seven months on, open only to very limited numbers of patrons, normal full-paying performance opportunities have been as rare as rocking horse shit.

Many musicians are ineligible for Job Keeper, as they have not been in continuing employment for the required lengthy period with the one employer, earning their money from a diversity of opportunities, now nearly all unavailable. Several I know are living off meagre savings and are very depressed about the near future.

Live streaming sites like Sydney Underground Streaming Sessions provide access to gigs for a small charge, most of which goes to the acts. Some artists have done full sets (here’s the inimitable Peter O’Doherty and Reg Mombassa from Dog Trumpet doing a full 75 minute set on September 18, and Terry Serio’s Candelight Sessions, but not charged or asked for donations.

You can run the picture through your TV and turn up the sound system to live gig levels, but the experience is always a pale shell of what it’s like being at a live gig.

House concerts are a wonderful way to help musicians and get your best friends to experience an intimate performance.

Last Saturday night we hosted at out house singer-guitarist songwriter Brendan Gallagher (ex-Karma County, and current Pinks and Dead Marines band member). It was a beautiful night. I’d done it with Brendan a few years ago and had 50 people pay to come, but this time NSW regulations limited us to 20 visitors (including Brendan), in addition to me and my wife, Trish.

Here are a few tips on how to run a good house concert.

Pick a musician you and your friends will like

It’s best to make direct contact with the musician, rather than go through their management or a house concert organising site. Both of these will be wanting their cut, so less of the money you raise will go directly to the musician. Most musicians have web pages with contact buttons, or Facebook pages you can message. Really big name acts will cost far more than you’ll be able to pay, unless you are loaded.

Acts with multiple members will usually cost more than solo acts, which will have budgetary implications.

Negotiate the fee you’ll pay

Ask the musician what they will charge to play. They’ll quote you the minimum price that’s worth their while. You’ll then know what to charge each person. We decided to think what our friends were likely to pay for an intimate concert with dinner when you were asked to BYO drinks. We thought back from typical dinner + gig + bar price drinks for a few hours would cost for a name act like Brendan, and thought there would be little change from $50-$60 a head.

We were not wrong. The price we settled on saw 20 friends snap the tickets up in the few minutes after my group email went out.

Make sure people pay you in advance. This is important because everyone says there will always be no-shows, if it’s cash on arrival and then the kitty is caught short.

Sound gear

We had amplifiers and a microphone from our band days, but if you don’t, most musicians will have these and be happy to bring them.

Food

Finger food is strongly advised. If you try for a plated food night, there’s seating needed, the limited seats you’ll have then needing to be moved before the concert, mess to clear away, and an overloaded dishwasher. We put on homemade gourmet sausage rolls (these vanished instantly),  a big range of good cheeses and dips, sushi and shrimp toast, and lots bite-sized cakes (all whooshed up). We set up a large iced esky for people’s bottles. A few guests insisted on bringing their signature finger foods and a generous neighbour ran up mini citron tarts.

Seating

We planned to hold it in our back garden, but the night turned out to be windy and chilly, with firepit smoke whipping around. So we moved it into a large living room which comfortably took the 22 people who were there throughout the two sets. We supplemented the available lounge and dining chairs with some camping chairs. If you plan to run it outdoors, let your neighbours know they may hear some sound bleed.Ours were all totally cool with it.

The 19 friends who came were enraptured, gushing about what a great idea it has been. We’ll definitely be running more.  If you’ve held any yourself, please comment on how it went.

Here’s Brendan, backed by Trish, doing Absolutely Away

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So let’s look at the latest data.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Here’s how their argument runs

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

From this it follows that

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

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

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

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

• Four generations of pack health warnings starting in 1973, all resisted tooth and nail by the industry
• Complete indoor workplace smoking bans, including on all public transport,  and in all restaurants, clubs, bars and pubs. Workplace bans reduce number of cigarettes smoked over 24 hours and were responsible for about 22% of the total decline in tobacco consumption in Australia between 1988-1995 when they were being introduced
• Total advertising and sponsorship bans
• Unique among all general retail products, retail display bans (all stock kept out-of-sight)
• Introduction of world-leading mass reach public education programs
• Globally unique plain tobacco packaging commenced in Australian in 2012, starting a global domino effect that now sees 17 nations having implemented or legislated for their introduction, with more on the way. The industry invested  many millions to stop this, but always lost
• end of all tobacco growing in Australia (this let the air out of the industry’s tyres to lobby via growers in the few electorates where tobacco was once grown)
• end of all tobacco manufacturing (BAT and Philip Morris products are all now imported). This benefits tobacco control because there’s now negligible local industry employment and all profits are repatriated, a disbenefit to the balance of trade and therefore an incentive for governments to reduce smoking further)
• world’s highest retail price of tobacco led by tax policy and the industry using tax rises as air cover to raise their own margins
• ban on personal importation of cigarettes by mail
• Import duty free limit of 25 cigarettes in an open pack
• The Liberal, Labor and Greens parties all refuse tobacco industry donations, unique among all industries
• No university allows staff to accept tobacco industry grants or students to take scholarships
• Only far right fringe of politics would ever be seen in a photo opportunity with tobacco or vaping interests.
• Big Tobacco ranks (way) last as the industry with the lowest reputation (see chart below)
• Widespread denormalization of smoking
• The industry understands that all the above make it an unattractive employment choice which creates staff quality problems

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

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

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

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

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

Big Tobacco is in total lockstep with vaping advocates’ goals

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

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

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

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

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

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

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

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

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?

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

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

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

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

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

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

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

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

They wrote:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

See also Part 2: Tobacco control advocates help Big Tobacco

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.