I’m often asked “so now that we have plain tobacco packs, with their huge graphic health warnings, what’s next in the marshaling yard to try and drive home the realities of the risks of smoking?”

Canada pioneered graphic health warnings on packs in 2000, and by 2016, over 100 nations required the “see and can’t forget” pictorial warnings. Canada is now actively considering health warnings on all cigarettes (see picture).

One of the most potent of all the graphic health warnings that have run in Australia since 2006 is the one about smoking causing gangrene.

Gangrene (rotting flesh) can occur with peripheral vascular disease. It occurs mostly in the extremities of the body, particularly in the in the feet and toes when insufficient blood supply reaches these areas due to narrowing of the blood vessels. Smoking is a major risk factor for PVD because it is a vasoconstrictor and raises blood pressure.

The first public campaign to highlight gangrene was run in New South Wales in a 1983 campaign for the NSW health department developed by John Bevins.  A TV ad on amputation after gangrene was screened in the years after the gangrene pack warning appeared.

I helped find the lower photograph below of the gangrenous foot that was used in Australia’s first generation of graphic health warnings that appeared from 2006. I obtained it from a surgeon at Sydney’s Westmead Hospital where I worked at the time. He gave me these two photographs of gangrenous limbs of smoking patients. I sent them to the Health Department in Canberra who tested them in focus groups. The first one showing the exposed bone was apparently rejected as being just too confronting.

The huge reaction the gangrene warning and the public discussion the graphic warnings caused got me thinking about how they might be made even more powerful.

In 1981, I saw John Waters’ cult film, Polyester staring the drag queen Divine and Tab Hunter. Waters incorporated “Odorama” scratch and sniff cards into the film. Wikipedia notes that “Special cards with spots numbered 1 through 10 were distributed to audience members before the show (see picture below). When a number flashed on the screen, viewers were to scratch and sniff the appropriate spot. Smells included the scent of flowers, pizza, glue, gas, grass, and faeces. For the first DVD release of the film the smell of glue was changed due to, as Waters states, “political correctness”. The gimmick was advertised with the tag “It’ll blow your nose!”

Gangrene has a very potent foul smell that can be highly distressing to patients and those who care for them before amputation.  When I started being asked the “what’s next?” question, I wondered about the potential of extending tobacco health warnings into the olfactory zone.

I called up a Professor of Chemistry at my university and asked him whether he knew of any chemical attempts to develop the smell of rotting flesh. I explained my interest. Absolutely deadpan and as quick as a flash, he told me that there were two candidate organic compounds cadaverine and putrescine. Putrescine is manufactured industrially. He called me back an hour later, having looked up the costs of bulk supplies of putrescine. I recall it was not off the planet and in any case, would be paid for by tobacco companies if the idea ever progressed.

Australia’s tobacco packaging legislation could easily be amended to allow for the mandatory incorporation of a putrescine scratch and sniff tab on packs carrying the gangrene warning.

In 2015, two psychologists conducted experiments where they exposed subjects to three odours: a neutral smell, ammonia and putrescine. They recorded how long it took subjects to walk 80 metres away from the campus exposure locations after smelling these odours. Those randomly allocated to the putrescine smell walked away faster from the exposure sites, causing the authors to speculate that “the results are the first to indicate that humans can process putrescine as a warning signal that mobilizes protective responses to deal with relevant threats.”

“Heath warnings don’t work”

There is a conventional folk wisdom popular among continuing smokers that tobacco pack warnings have no impact: they keep smoking regardless and just switch off. The companion argument here is that smokers are fully informed about the risks of smoking and so banging the same drum about health risks is a useless strategy.

There are several big problems with these arguments. First, if health warnings were so ineffective, someone needs to explain why  the tobacco industry has fought them tooth and nail all around the world for decades, particularly when they moved from anodyne to explicit, specific and graphic warnings. As recently as December 2016, British American Tobacco’s lawyers were attempting to stymie increased graphic health warnings in Hong Kong and Philip Morris did all it could to prevent Uruguay from implementing graphic health warnings. Companies don’t usually bother attacking policies that are ineffective and have no impact n their bottom line.

Second, it has been repeatedly shown that the overwhelming reason given by ex-smokers in explanation about why they were determined to quit, is health concerns. There is daylight between those concerns and other reasons that are nominated, as shown in the table below. Just where is it that smokers pick up these concerns from? Where would they ever find out or reflect on what atheroma or a brain bleed from stroke looks like if they never saw an image of it? How would they know about a person with emphysema’s constant struggle to breathe if they had not seen vision of it in a health warning ad? People with end-stage emphysema don’t tend to walk around in public very much, because they can’t.

And third, there is a very substantial body of research that examines questions about the impact of pack warnings on smokers’ understanding of risk, intention to quit and quitting behaviour, concluding that warnings can be powerful ingredients in motivating quitting.

Big Tobacco will hate this proposal. And that’s all we should really need to know in deciding that it’s an excellent idea.

 

 

This week, the journal Addiction published a letter signed by 6 high profile researchers, each with histories of working with tobacco companies on putatively reduced harm products. Their brief letter sought to “discuss” the ethical issues, as they saw them, that justified their remunerated research engagement. But it contained little more than several glib assertions.

While 181 nations have ratified the WHO’s Framework Convention on Tobacco Control, with its Article 5.3 setting out guidelines for limiting tobacco industry interference with tobacco control (“There is a fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests”), a small number of researchers apparently believe they  can rise above such concerns.

Their letter comes at a time when nearly all tobacco companies are adding so-called reduced risk products to their product portfolios. Some, like Philip Morris are engaging in “we’re changing” charm offensives claiming they are trying “to stop selling cigarettes as soon as possible”.

Ever since the bad news began rolling in from the early 1950s about the inconvenient problem of the very nasty harms smoking causes (latest estimates are that two in three long term smokers will die of a smoking caused disease, translating to some 7 million deaths a year), the industry has pursued a public agenda of announcing successive generations of allegedly reduced harm products. Unfortunately, every one of these  crashed as false hopes. All were primarily designed to keep nicotine addicts loyal to the companies’ evolving products and to dissuade people from quitting, as hundreds of millions around the world began doing in increasing numbers from the early 1960s, the great majority without any assistance and often without much difficulty.

No need to quit, when you can keep smoking a “reduced risk” cigarette?

No industry likes seeing its longest and most loyal customers dying early. They’d far prefer that they lived to consume and be contributing cash cows for as many years as possible. There is also no industry more loathed and mistrusted than the tobacco industry. Against this, the harm reduction agenda represents a trifecta of hope for Big Tobacco: it’s a kind of perpetual holy grail, never reached but always sought, with the promise of seeing smokers living and consuming longer. It’s also a way of enticing new generations of users into the market who each time swallow the hype about radically reduced risk products. And it carries hope of eroding the industry’s on-going corporate pariah status, with its attendant risks of attracting sub-optimal staff indifferent to working in a killer industry. It’s a virtue signalling cornucopia that keeps on giving.

Enter e-cigarettes

E-cigarettes and heat-not-burn products (ENDS or Electronic Nicotine Delivery Systems) are the latest harm reduction debutantes. The size of the popularity wave they are riding in several nations puts these products in the league of two previous, disgraced heavyweight champions of harm reduction: filter tips and so-call light and mild, cigarettes. Filters are almost universally still used today in cigarettes, but with 7 million deaths a year still occurring, it’s a bit like saying that arsenic is less harmful than cyanide, thanks to filters. Because of compensatory smoking, lights and milds were declared misleading and deceptive descriptors by the Australian Competition and Consumer Commission in 2005 and outlawed. Tobacco companies in the USA are currently running court-ordered corrective advertising, including messages about the lights and milds scam.

The rise of ENDS has been accompanied by a chorus of Big Tobacco CEOs proclaiming that they mark the beginning of the end of smoking. “Look what we are doing.” they gush “We are transforming ourselves into companies that are saving lives! We are investing billions into research, development, production and marketing of these new products.”

With their new health promotion vocation, they have tried to cosy up to governments, the WHO and sadly, to researchers like those who signed the letter in Addiction.

The Jekyll and Hyde defence

The authors of the letter in Addiction state that they “limit our work with the industry to projects involving reduced-risk products.” This argument is a kind of Jekyll and Hyde defence. It invites readers to consider that tobacco companies produce both morally defensible and indefensible products, and that it is ethically unproblematic for a scientist to have supportive dealings with those representing the Dr Jekyll persona, but self-evidently unethical to do anything to support murderous Hyde characters.

The unavoidable, blindingly obvious problem here of course, is that Jekyll and Hyde are the same person. Prisons are full of people who at their trials presented outstanding employment records, character references, and receipts for generous charity donations, but who had feet of clay and committed heinous deeds. In the corridors of tobacco companies there are divisions of both Jekylls and Hydes. The two camps may have little to with each other (BAT’s “science” twitter feed @BAT_Sci daily parades the work of its busy harm reduction product staff, but I’ve never seen mention of what its legions of cigarette division chemist staff are up to).

But on the floors that house those in the executive who pull the strings for the entire companies, they know exactly how the company bread is buttered and what the future vision looks like. And for all the sloganeering about the end of smoking, that future has, as it has always been, cigarettes right at the very front of the business model.

PMI’s global market is dominated by cigarettes.

BAT’s 2018 half yearly report could not have been more emphatic on this from its opening paragraph “Our strategy is to continue to grow our combustible business while investing in the exciting potentially reduced risk categories of THP, vapour and oral. As the Group expands its portfolio in these categories, we will continue to drive sustainable growth.” (my emphases)

A senior Philip Morris International spokesman, Corey Henry, told  the New York Times in August 2018 “As we transform our business toward a smoke-free future, we remain focused on maintaining our leadership of the combustible tobacco category outside China and the U.S.”

Philip Morris USA’s website candidly speaks of “making cigarettes our core product”.

Reduced risk products instead of or as well as cigarettes? 

The Addiction letter authors wrote “If the tobacco industry seeks to make money by making reduced risk products instead of  [my emphasis] more risky products, we fail to see this as a menace to public health.”

Yes, I’m afraid they do fail to see. Put simply, there is no evidence – apart from an incontinent river of public declarations – that any tobacco company is taking its foot off the twin business-as-usual accelerators of massively funded marketing of combustible tobacco products (chiefly cigarettes), and continuing  efforts to discredit and thwart policies known to have an impact on preventing uptake and promoting cessation.

In recent years companies like BAT and Philip Morris have been relentless in seeking to dilute, delay and defeat any policy posing any threat to their tobacco sales. This is not the behaviour of an industry earnestly trying to get all its smokers to quit. Witness their massive efforts to stop Australia’s historic plain packaging legislation. Witness their years’ long efforts to stop Uruguay’s graphic health warnings.  As recently as December 2016, BAT’s lawyers wrote this appalling letter to the Hong Kong administration trying to stop graphic health warnings going ahead. This was from a company which, published in its 2016 financial results statement a call to “champion informed consumer choice”.

Attacking tobacco tax

British American Tobacco’s twitter feeds relentlessly highlight seizures of illicit tobacco. The sub-text for these is that tobacco tax is so high that it is fueling demand for cheaper, illicit tobacco which evades tax. Joining the dots, the proposal here is that governments should stop raising tobacco tax (and perhaps even reduce it) to perversely “help” smokers buy the company’s brands.

In nauseatingly unctuous displays of civic-mindedness, the companies publicly wring their socially responsible hands about smokers having to interact with criminal tax evaders, unknowingly channeling their tobacco purchasing money into terrorism, and depriving national treasuries of much-needed revenue.

All this neatly avoids the public understanding that tobacco companies have used tax rises as air cover to add to their own margins by raising the prices they charge retailers who in turn pass on these increases to smokers. For example, In Australia from August 2011 to February 2013, while excise duty rose 24¢ for a pack of 25, the tobacco companies’ portion of the cigarette price (which excludes excise and GST), jumped $1.75 to $7.10. While excise had risen 2.8% over the period, the average net price had risen 27%. Philip Morris’ budget brand Choice 25s rose $1.80 in this period, with only 41¢ of this being from excise and GST. (see p77 here)

These public displays also keep attention away from the large body of evidence across many years that shows the tobacco industry has long supplied tobacco products to agents in knowledge that these products would enter the illicit, tax avoiding market.

The Philip Morris fully-funded “Foundation for a Smokefree World” has recently awarded New Zealander Marewa Glover $1m to advance harm reduction globally among indigenous peoples. Glover has been a frequent written and vocal critic of tobacco tax, claiming it is ineffective in reducing demand.  This contrasts to the overwhelming consensus of evidence about the role of tax in reducing demand. Price elasticity is why all tobacco companies (just like those in every industry) engage in price discounting: smokers smoke more when prices fall, and less when they rise.

In 2011, BATA’s Australian CEO David Crow told a Senate committee “We understand that the price going up when the excise goes up reduces consumption. We saw that last year very effectively with the increase in excise. There was a 25 per cent increase in the excise and we saw the volumes go down by about 10.2 per cent; there was about a 10.2 per cent reduction in the industry last year in Australia.”

All but one of the authors of the Addiction letter are from the USA. Professor Robert West, editor of Addiction, has recently drawn attention to the propensity of American researchers for US parochialism. Looking outside of the US border, we see rampant cigarette promotion still happening wherever possible, particularly in low income nations.  A moment’s searching finds examples like the Philip Morris’ controlled Indonesian Sampoerna company, with around a third of the country’s cigarette sales, promoting “stronger” cigarettes on the crest of a 15% industry-wide increase in smoking in the world’s fourth most populous nation. Or evidence of ubiquitous selling of single cigarettes across Africa and promotions near schools.

What could it do?

If Big Tobacco was sincere in its claims it wants to stop selling cigarettes there is much it could do. It could immediately stop all advertising and promotion of tobacco products around the world. It could voluntarily introduce the world’s best practices in graphic health warnings on packs (every company makes decisions every year about how its packaging will look). It could stop supplying illicit trade with tobacco products (currently estimated at one third of all illicit trade), knowing the importance of this in supplying very low income smokers with cigarettes that allows them to keep smoking and hopefully graduate to company brands.

Of course, it will do none of this, continuing instead to endlessly witter its sanctimonious claims about getting out of cigarettes but doing nothing to demonstrate that it is.  What it is doing, is to hide behind the weasel words that it will get out of selling cigarettes “as soon as possible”. That’s about as meaningful as saying “when hell freezes over”.

In this, it contrasts with sections of the motor vehicle industry and some governments over the transformation of motor vehicles from being powered by fossil fuels and moving to electric power, in concert with goals to move power generation to renewables. Volvo has announced that 50% of its vehicles will be electrically powered by 2025. By 2017, 10 nations had set dates for the end of fossil fuel car sales. More will follow. No tobacco company has set any target dates.

Over decades, we have seen Big Tobacco’s response to any proposal that threatens their bottom line. Any government announcing that it would no longer allow combusted tobacco to be sold would see every stop being pulled out by the industry to prevent this. But meanwhile the industry, hand-on-heart, assures us all that it really, really wants smoking to end.

And do they really reduce harm?

And then, at the end of the day, all this requires that we all acquiesce and accept that so-called reduced risk products will, in fact, be found to actually reduce risk after years of use.  The diseases caused by smoking are chronic diseases (pulmonary, cardiovascular, cancer). For each of these, many years pass between the uptake of smoking across a population and evidence of rising disease incidence.

The seminal January 2018 report of the US National Academies of Science, Engineering and Medicine repeatedly concluded that the quality of evidence now available that e-cigarettes actually reduce health risks was either non-existent, low or limited (see health effects conclusions here) because of the insufficient time that large numbers of people have been vaping.

There are many reasons to expect that e-cigarettes may indeed cause less disease than cigarettes. But we know from recent data from longitudinal samples that by far the largest proportion of e-cigarette users continue to smoke (“dual users”); that the reduction in the number of cigarettes that they smoke each day is trivial (see Table 3 here); that reducing (rather than quitting) smoking confers little risk reduction; and that for every one e-cigarette user who has a positive outcome by quitting smoking, more than two continue smoking and vaping, or relapse totally to smoking.

Source: Coleman et al (2018)

Moreover, if we add the dual users who relapsed, the once exclusive e-cigarette users who took up smoking, and the dual users who just kept on smoking and vaping, this important study shows that 12 months on, for every e-cigarette user who benefited by quit smoking and/or e-cigs, 4.6 e-cig users relapsed to smoking, took up smoking or were held in dual use.  Little wonder that tobacco companies are wildly enthusiastic about these products.

The 6 authors of the letter state that they are comfortable in working for the industry because “the FDA  considers the tobacco industry  legitimate, why should we not do so?”  The FDA is not directly funded by the tobacco industry, but is regulating it, so there is a world of difference here. This assertion merely acknowledges that tobacco industry manufactures products that are legal to sell if meeting standards being developed by the FDA.

There is much research undertaken on illicit drugs, but it is not funded by the criminals in charge of the trade. Few sensible people would argue that such research is not very important, but no one would seriously suggest that it would be ethical to accept funding by drug dealers.

Most understand that companies have a corporate interest in funding researchers whose outputs will be useful to them, and not create conflicts with their commercial ambitions. There is a very extensive research literature (eg here) that shows a consistent association between industry funding and research findings that are positive for the funding companies.

This is the reason that all serious journals require full disclosure of funding, and why some journals will not accept papers authored by tobacco industry researchers and why the Cochrane Collaboration insists that a majority of its review authors have no competing interests and refuses to consider reviews funded by commercial interests. For these reasons, mechanisms like mandated hypothecated taxes on the industry to fund external research have been proposed  as a way of better ensuring the independence and transparency of such research.

The concerns I have described should suggest that the opprobrium some of the authors have experienced should come as no surprise to them. I would welcome any of them responding to the issues I have raised by using the comments function on this page.

 

 

Istanbul has wonderful nightlife, although Erdogan’s agenda may soon end much of that. I’ve been there four times and been showered with famous Turkish hospitality. My oldest and best friend there is a senior professor who, last time I was there in 2014, was running a conference at which I was speaking. There was always going to be a great dinner sometime that week. But this one would be unforgettable.

She invited her best friends at the conference to a restaurant about 400 metres from the conference centre in the Taksim district. It was in a quite narrow, newish high rise building of about 10 floors, cheek-by-jowl between other similar anodyne structures. We caught the lift from street level up several floors. There were ten of us: several locals, a French woman, me and my wife Trish, and others I can’t remember. There were three men among the ten. I landed at a part of the table with great conversationalists.

There was feverish talk about the mess Turkey was in. All the Turks at the table were incendiary about the creeping erosion of the secular state under Erodgan. Angry accounts were given about daughters having to wear headscarfs for university entrance interviews or be instantly rejected. About jailed journalists and academics and the small-mindedness of those in power. The women were feisty feminists with commanding jobs in a male dominated culture. They all drank alcohol and bossed the waiters around.

About an hour into the meal, the restaurant was full and people were loose and enjoying themselves. The two women opposite me suddenly said emphatically “Oh. My. God.” They were staring past our side of the table and looking through the restaurant windows into the building next door.

There, not five metres away, was a room with the lights on. A gossamer thin white curtain had been drawn, but with the lights on inside, we could see everything in the room. The curtain presumably prevented them from looking out clearly. A very overweight middle aged naked man and a considerably younger, large breasted and full-bodied woman, also naked, had entered the room, perhaps from the bathroom. They set about their tasks. The quick consensus was that she was a prostitute he had called out to his hotel. If we were wrong about this, the man was punching well above his weight if this was his wife or girlfriend.

Our table had the box seat for the spectacle, but there was no hiding what they were up to from almost every vantage point in our restaurant. Very quickly those on other tables got up, brought their drinks with them and crowded round behind our table to get the next best view. Young couples, small dinner groups, a few elderly couples and the staff all joined the throng.

Every new phase of the performance drew gales of laughter. When she took him in her mouth, some cheered and roared. “It’s a wonder she can locate it under all the fat!” “Ah, the first course is now being taken”. When the missionary position changed to rear entry and we saw the man’s thin little bottom gamely pounding away below his considerable back, there were lots of eewws and “oh my gods!” and goodness knows what else being said in Turkish.

This was the first time I had ever watched live sex in a room full of mostly strangers. Or actually, in any context.

I had these thoughts.

First, I’m confident that, presented with a questionnaire on what we would do in such a hypothetical context, nearly everyone in our group would have not hesitated to affirm that, of course, they would have asked for the restaurant curtain to be drawn, or dispatched a waiter into the next building to tell the occupants to please turn off their lights. But presented as we were with the opportunity to watch proceedings – unknown to the performers – no one could look away. The asymmetry of consent between the watching and the watched just flipped the ethical compass for everyone. “They don’t know they’re being watched. We don’t know who they are. We’ll never see them again, What’s the harm?” would have run the rationalisations.

Far more than that, everyone just roared at the spectacle. Far from there being any awkwardness, everyone instantly decided this was spectacular luck we’d chanced on. No one seemed to spend a nanosecond surreptitiously checking non-verbally with others how they should behave. It was uncontrollable, communal, bawdy unity that had been instantly let off its leash.

I wondered too about whether the reaction of the room would have been any different had the performers in our hotel window theatre looked very different. What if we had decided that they were two young honeymooners, with the bridal gown draped over a chair? Or a sweet, long-married couple from the Turkish countryside, in town for a short holiday having saved up for months? Or elderly tourists, lovingly pleasuring each other in the privacy of a hotel room during a holiday? What if the man had been lithe, muscular and handsome instead of fat and out of shape? What if their ages had been similar? Would any of this have changed our response?

It struck me that the essence of the hilarity went something like this: hiring a prostitute is a private and generally clandestine, knowingly shame worthy activity, nearly always done by men with the power to hire women to do something that many people routinely experience as a mutually exchanged gift from someone with love and affection for them. It’s something the man would have probably been hugely embarrassed about, had he known of the audience. Embarrassed about his cover being blown and about his less than film-star like body. So the laughter here was about the combination of the shattering of the man’s hopes to keep his private vices private and the sort of mirth occasionally experienced when we experience or see the wind or a wardrobe malfunction expose body parts in an everyday situation.

His innocent misjudgement about the lighting had transformed him from a man with the power and means to buy sex to an unwitting public cuckold, providing entertainment to a roomful of diners.

Most of our only experiences of watching others having sex is via filmed pornography, occasionally almost unavoidable to anyone using a computer. There, unless the acts are filmed and uploaded without the consent of those involved, the performances are consumed as inauthentic and clearly commercial: they are doing-it-for-money, or purposefully, consensually exhibitionist, in the case of amateur uploaded porn. But here we witnessed a couple in action who were quite unaware that their private, transacted intimacy in fact had an audience.

So public virtues, as might be expressed in a serious-minded conversation about respect for privacy, the ethics of the right thing to do in everyday life or of the case for prostitution took a running jump against the power of private vices – here, the temptation of force-fed voyeurism, of a box-seat on what goes behind closed doors.

I’ve told the story dozens of times, and have even had friends say “I hear that you had an amazing dinner in Istanbul once”, wanting to hear the details for themselves. It seems there’s a little voyeur in most of us.

At a recent dinner, a senior scientific colleague unexpectedly bristled at a comment about anthropogenic global warming, commenting that the world had often seen similar changes to those now being experienced. Four of us in earshot pushed back with attempted jets of cold water, with one saying aghast “you’re sounding like Tony Abbott”.

We all quickly agreed that none of us were expert in all the relevant areas of knowledge and understanding. But this is of course a position that everyone  finds themselves  in daily in regard to any claim in which they are not trained.

So what we all tend to do is to fall in with rule-of-thumb heuristics or cognitive biases that help us make sense of the world. Perhaps the most ubiquitous is confirmation bias  where we seek out, retain and advance facts and assessments  which support our current beliefs.

Anyone with even some elementary scientific background agrees too, that in the evidence pyramid of weakest to strong, the plural of anecdote and opinion does not equal evidence. But when that plurality of opinion manifests as expert consensus, its value is elevated as we see below: here it is reasonable and important to ask how experts across relevant fields view evidence.

Our AGW sceptic that night was convinced he held the knockout punch and the next day sent us a June 2018 swingeing  open letter signed by 25 current Geological Society of London AGW skeptical fellows out of some 12,000, plus another 8 former fellows (with no denominator available to allow a calculation of the proportion). Twenty five of 12,000 is a tiny proportion, heading toward homeopathic territory: 1 in every 480 fellows of the Society. The open letter also referenced a  2010 Royal Society letter of complaint about the RS’s “unscientific” public statements on global AGW. That letter was signed by 43 Royal Society fellows (out of 1600 – 2.7%).

Those derisory proportions don’t say to me that AGW skepticism has much traction in those two most august of scientific communities. Clearly those collecting the signatures would have made efforts to build their lists, yet these small numbers are all they came up with.

In 2015, 76 Nobel Prize winners from across scientific disciplines signed or later fully supported the Mainau Declaration on climate change, which emphasised AGW. The potential Nobel Prize signatory denominator is a much smaller pool, given that the prizes tend to be awarded later in life  and that there are only three categories of scientific prize (physics, chemistry, and physiology or medicine) awarded annually.

Without any apparent self-satire,  the  Geological Society signatories stated “As this letter makes clear [my emphasis] it is not true that 97% of scientists unreservedly accept that AGW theory is fixed, or that carbon and CO₂ are ‘pollutants’ and their production should be penalised.” The authors also asked “how can the primary nutrient in photosynthesis be a pollutant?”  It beggars belief that they could write this when clearly the argument is about the impact of massive rises in CO2, not CO2 itself. Paracelsus’ “the dose makes the poison” is such an elementary principle in toxicology, and it applies to so many exposures and agents.

It’s obviously very far from clear that the arguments of just 35/12,000 geologists destroy the claim that the overwhelming proportion (97%) of climate scientists (working across  many disciplines) accept AGW.

The 97% figure dates from a study published in 2013 of 11,944 abstracts from the peer-reviewed scientific literature on climate change from 1991–2011. The authors wrote:

“We find that 66.4% of abstracts expressed no position on AGW, 32.6% endorsed AGW, 0.7% rejected AGW and 0.3% were uncertain about the cause of global warming. Among abstracts expressing a position on AGW, 97.1% endorsed the consensus position that humans are causing global warming. In a second phase of this study, we invited authors to rate their own papers. Compared to abstract ratings, a smaller percentage of self-rated papers expressed no position on AGW (35.5%). Among self-rated papers expressing a position on AGW, 97.2% endorsed the consensus. For both abstract ratings and authors’ self-ratings, the percentage of endorsements among papers expressing a position on AGW marginally increased over time. Our analysis indicates that the number of papers rejecting the consensus on AGW is a vanishingly small proportion of the published research.”

Since then there have been two further studies that strongly suggest this ballpark is accurate. One (Verheggen et al, 2014) found 90% of those scientists surveyed who had  more than 10 peer-reviewed papers related to climate science agreed with AGW. Another (Powell 2013) looked at 13,950  papers on  global warming and climate change between 1991 and 2012 and found only 24 rejected AGW.

The coalescence of these research findings and expert views is very compelling.

In the fields in which I’ve worked, I’ve seen many examples of attempts by highly motivated, often credentialed people to wreck consensus using Galilean/Copernican metaphors about their brave, truthful voices standing up against the orthodoxy. These include scientists espousing global epidemics of “electrosensitivity” and WiFi & EMR dangers, and anti-vax and  anti-fluoridation drum-bangers.

When these observations are made, we often then hear conspiracy theories  being invoked (“peer reviewers are too threatened by criticism/invested in their own conclusions” etc).

Very few non-specialists are fully equipped to engage in to and fro discussions about arcane oceanography, geophysics, earth sciences etc. What I do is to look to agencies with processes that inspire confidence in scientific integrity and which are transparent about important issues like any competing interests.

I am a strong supporter of renewable energy. We have solar cells all over our roof. Our next car will be electric. I wrote a book on the nonsense of “wind turbine syndrome”.  The arguments for moving rapidly toward  minimally polluting, renewable forms of energy that are producing huge numbers of jobs are self-evident to me. There seem to me to be no serious downsides in harvesting solar, wind, geothermal, hydro- and tidal energy compared to the very real externalities involved in polluting and resource-intensive forms of energy (fossil fuels, nuclear). A couple of weeks living on the east coast of China or Delhi as I have done is a big reality test about the utter folly of  continuing current fossil fuel burning.

Science is never complete, and debate is virtuous. But when debate stalls action, and the consequences of that are highly likely to be catastrophic, prolonging debate instead of acting is irresponsible.

The efficacy and ethics of fear campaigns are enduring, almost perennial debates in public health which re-emerge with whack-a-mole frequency, eloquently chronicled by Fairchild et al [1].  Supported by evidence-based reasoning about motivating behaviour change and deterrence [2],  these campaigns intentionally present disturbing images and narratives designed to arouse fear, regret and disgust.

Health problems can be profoundly negative experiences unappreciated by those not living with them. Pain, immobility, disfigurement, depression, isolation and financial problems are common sequalae of disease and injury. It is beyond argument that these are outcomes which are self-evidently anticipated and experienced as adverse, undesirable and so best avoided. Efforts to prevent them are therefore, prima facie, ethically beneficent and virtuous.

Five main criticisms

Criticism of the ethics of fear messaging takes five broad directions. First, it is often asserted that fear campaigns should be opposed because they are ineffective: they simply “don’t work” very well. Fairchild et al [1] note that this argument persists despite the weight of evidence to the contrary.

The ineffectiveness argument can be valid independent of the content of failed campaigns: “positive” ineffective campaigns should also be subject to the same criticism. Yet sustained criticism of ineffective “positive” campaigns is uncommon, suggesting this criticism is enlisted to support more primary objections about fear campaigns.

Victim-blaming?

Second, critics argue that such campaigns target victims, not causes of health problems, and so are soft options mounted in lieu of more politically challenging “upstream” policy reform of social determinants of health such as education, employment or income distribution, or legislative, fiscal and product safety law reforms.

It is difficult to recall any major prescription for prevention in the last 40 years not involving advocacy for comprehensive strategies of both policy reforms and motivational interventions. For example, tobacco control advocates target advertising bans, smokefree policies, and tax rises as well as increased public awareness campaign financing. When governments fail to enact comprehensive approaches to prevention, supporting only public awareness campaigns, this is plainly concerning. The resultant concentration of public discourse around the importance of individualistic change instead of systemic, legislative or regulatory change in controlling health problems may lead to public perceptions that solutions are mostly contingent on what individuals do or don’t do(3). This myopic definition of health problems and their solution promotes victim blaming(4), where notions of individual responsibility are held to explain all health problems when any volitional component is involved.

This can be a serious criticism of failed government commitment to prevention, but is it a fair and sensible criticism of public awareness campaigns in themselves? Those making this argument draw the meritless implication that until governments are prepared to embrace the full panoply of policy and program solutions to health problems, they should not implement any individual element of such comprehensive approaches: if you cannot do everything, don’t do anything?

Further, in any public health utopia where governments enacted every platform of comprehensive programs and made radical political changes addressing the social determinants of health, every health problem with a behavioural, volitional component would still require individuals to make choices to act and to be sufficiently motivated to do so.  Campaigns to inform and motivate such changes will always be needed. The reductio ad absurdum of this objection is that attention-getting warning signs and poison labels are unethical.

Stigmatisation

Third, those who live with the diseases or practice the behaviours that are the focus of these campaigns can sometimes experience themselves as having what Irving Goffman called “spoiled identities”(5) and may feel criticized, devalued, rejected and stigmatized by others. The argument runs that these campaigns “ignore evidence that stigma makes life more miserable and stressful and so is likely to have direct health effects.”[6] and fail to recognize that the stigmatized health states or behaviours “travel with disadvantage”. [6]

Criticism of fear campaigns is mostly applied to health issues where personal behaviour as opposed to public health and safety is the focus. Campaigns seeking to stigmatize and shame alcohol and drug-affected driving, environmental polluters, domestic violence perpetrators, sexual predators, owners of savage dogs, or restaurant owners with unhygienic premises are rarely criticized. Some people deserve to be stigmatized, apparently.

Prisoners of structural constraints?

A fourth argument used against fear campaigns, is that many personal changes in health-related behaviour are difficult, requiring physical discomfort, perseverance, sacrifice and sometimes major lifestyle change, often limited by structural impediments like poor access to safe environments, cost, work and family constraints.

But unless one subscribes to an unyielding, hard determinist position that people have no agency and are total prisoners of social and biological determinants, the idea that individuals even in the direst of circumstances cannot make changes in their lives when motivated to do so is an extreme position, difficult to sustain. It is instructive, for example, to reflect that today in many nations, it is only a minority of the lowest socioeconomic group who still smoke.

Is it always wrong to upset people?

Perhaps the most common argument though, is that we should always avoid messaging which might upset people. This argument has two sub-texts. First, an assumption is made that how people feel about something ought to be inviolate and to challenge it is disrespectful. But we all have our views challenged often on many things, and some of those challenges motivate reflection and change, and in the process make us sometimes feel uncomfortable. Why is the goal of avoiding any communication which might make people feel uncomfortable or self-questioning, self-evidently a noble, ethical criterion in the ethical assessment of public health communication?

Here, feelings about desirable health-related practices often reflect powerfully promoted commercial agendas to normalize practices like over-consumption, poor food choices, and addiction.  The notion that such agenda should be not challenged out of some misguided fear of offending those who are its victims would see the door held open even wider to those commercial forces seeking to turbo-charge the impacts of their health damaging campaigns. If a smoker gets comfort and self-assurance from inhabiting the commercially contrived meanings of smoking promoted through tobacco advertising, should we suspend strident criticism of tobacco marketing because it might be disrespectful of smokers?

It is a perverse ethics that sees it as virtuous to keep powerful, life-changing information away from the community simply because it upsets some people.[7] Should we really tip-toe around vividly illustrating how deadly sun-burn can be through fear of offending some of those who value tanning? While rendering vivid the carnage and misery caused by speed and intoxicated driving may upset some who are quadriplegic, how do we balance the support for such campaigns by others now living that way and evidence that fear of public shame and personal remorse works to deter both?  And if ghoulish pack warning illustrations of tobacco-caused disease like gangrene and throat cancer render the damage of smoking far more meaningful than more genteel explanations, whose interests are served by decrying such depictions as being somehow unethically disturbing?

Some in the community do not like encountering confronting information that challenges their ignorance or complacency, but public health is not a popularity contest where an important criterion for assessing the merits of a campaign is the extent to which it is liked.

Fairchild et al’s paper [1] is a superb contribution to our field’s confused thinking on fear appeals in public health and deserves wide discussion.

References

1. Fairchild A, Bayer R, Green SH, Colgrove J, Kilgore E, Sweeney M, Varma JK. The two faces of fear: a history of hard-hitting public health campaigns against tobacco and AIDS. Am J Public Health 2018;108(9): 1180-1186.
2. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet. 2010;376(9748):1261-71.
3. Bonfiglioli CM, Smith BJ, King LA, Chapman SF, Holding SJ. Choice and voice: obesity debates in television news. Med J Aust 2007;187(8):442-5.
4. Crawford R. You are dangerous to your health: the ideology and politics of victim blaming. Int J Health Services 1977;7(4):663-80.
5. Goffman E. Stigma: notes on the management of spoiled identity. Englewood Cliffs, N.J.:Prentice Hall, 1963.
6. Carter SM, Cribb A, Allegrante JP. How to think about public health ethics. Pub Health Rev 2012;3(1):1-24.
7. Chapman S. For debate: the means/ends problem in health promotion. Med J Aust 1988;149(5):256-60.

This is a pre-print of an editorial published in American Journal of Public Health 2018:1120-1122.

In the next weeks, I’ll be publishing 20 short stories on work and travel experiences I’ve had. I’ll be publishing several in advance here. Here’s one as fresh as if it happened yesterday.

In 1973, at the ripe old age of 22, my then wife Annie and I took the fabled overland trip from London to Australia. We’d been living in London, where I worked as an accessions clerk in the library of the Natural History Museum and Annie worked temping as a typist.

After getting the ferry to Dieppe, in France, we hitchhiked to Brindisi in southern Italy,  took a ferry to the Peloponnese in Greece, a bus up to Athens, a cheap flight from Athens to Istanbul, and then got local buses through Turkey, where we spent nights with monstrous bed bugs in Sivas and Erzurum in the east of the country. The buses then continued all the way across Iran, Afghanistan and Pakistan, with third class unreserved trains from Amritsar to Delhi, Agra and then to Calcutta in India. After losing perilous amounts of weight to travelers’ diarrhoea, we surrendered to a cheap flight to Perth and took a bus across the Nullabor plain to Sydney, our home.

We were  adopted by a beaming Iranian girl, Farah, on a bus in Turkey, returning from au pair work in Germany. She insisted we stay with her family in Tehran. It was  during Ramadan.  On the first full day with them, they prepared vast quantities of food for us and watched us eat lunch. We repaid them by blocking their squat toilet with toilet paper, necessitating the arrival of a plumber and an assembly of curious neighbours. We traveled down to Isfahan to marvel at the turquoise mosaic covered mosques. We lived on pomegranates, pistachios, lamb kebab and pilaf, crossing the vast Iranian plains toward the magnetism of Afghanistan, a place that had fascinated me as a boy. We were warned by police to not go into the very fundamentalist Mashed, so changed into another bus at a station on its outskirts and then moved onto the border with Afghanistan.

We had arrived at the Iranian side of the border about 2pm. It would close at 4pm. With about ten minutes to go, baksheesh negotiated and eventually extracted by the border guards, we were let through and into the no-man’s land between the Iranian and Afghan border.  Because the Afghan side of the border also closed at 4pm, this meant we were obliged to stay in the only hotel in the no man’s land. This cosy arrangement, presumably benefiting all parties concerned, was known to every traveler on the route. The travel writer Paul Theroux, wrote about it in his 1975 book, The Great Railway Bazaar. (see extract below)

Boys who looked about 10 swarmed all over us offering palm-sized black hashish for a dollar. While we had both smoked dope in Sydney and London, we were wary enough to avoid it here. We had crossed the border with some German guys and a Yugoslav woman about our age. They had all immediately bought hash and sat in the garden smoking it before dinner. Shortly after, the boy who had sold it to then arrived with several Afghan border guards, pointing them out. They confiscated the Germans’ passports, saying that they would be returned after they paid ten per cent of the amount of money each border crosser had been obliged to note in their passport as we crossed on the Iranian side of the border.

The Yugoslav woman was taken away by the guards to a nearby garrison building. When the Germans went over to buy back their passports, they saw she was being raped by the men from the garrison. We were all helpless. We didn’t even know her name. There were no phones, no Yugoslav or Australian embassy in Kabul (which was weeks away for us) and the rapists seemed to be a mixture of border guards and soldiers who might have been the only authorities to contact. God knew what might have passed for police in such a place.

Welcome to Afghanistan.

Extract from Paul Theroux’s 1975 book The Great Railway Bazaar, describing the no-mans-land hotel

The next day we went onto Herat, 300km from the border. It was a dusty town with tree lined streets. We stayed for a week, the start of a month in that unforgettable country, then still a kingdom.  Our hotel had no bathroom, but there was a pit squat toilet that smelt so rank, you had to hyperventilate before going inside so that you could hold your breath for the minute needed. With the state of our bowels, that was easily time enough. There was a public bathhouse in the main street that had a women’s night once a week. However, the boss man there allowed Annie and I to go in together on a men’s night and have a private room that you could lock from the inside. We scoured the walls and door for any peepholes, but found none. The water was hot and the floor tiled. It was bliss.

We also stayed a week in Kandahar, a place that would decades later headquarter the Taliban. One afternoon and policeman told us to turn away from the market we were heading for. “Tribal people are there. They will cut your throat”, he told us. The capital Kabul, with its Chicken Street mecca for western travelers, sold lapis lazuli jewellery, wolf skin fur coats and leather horsemen’s knee boots.

This was in the days well before the internet, cell phones, fax machines and credit cards. You carried cash and travelers’ cheques, and picked up mail poste restante  at the post office. Some sold their blood at local hospitals, where you were invited to push your arm through an elasticised hole so they could take whatever they wanted. We gave that a miss.

Part of the adventure was to do it all as cheaply as possible. An old diary I found shows what we paid for transport from Istanbul to when we entered India: about $25 each in 1974 prices (see table below). A mud floor and wall ‘hotel’ in Herat in western Afghanistan cost 15 Afghani a night, with rats, a horsehair and straw paillasse  mattress, and complimentary hashish or opium, usually smoked with the hotel owners who liked to play the travelers at chess.  There were 40 Afghani to the US dollar.  The decrepit buses we traveled in regularly broke down, till the driver’s clanking under the bonnet for an hour got them going again.

Herat street scene                                              Kandahar

Journey	Duration	Cost per person
Istanbul-Erzerum	24h	85 Turkish lira
Erzerum-Iran border	8h	30 lira
Border=Tehran	14h	350 Iranian rials
Tehran-Mashed	24h	200 rials
Mashed-Afghan border	14h	100 rials
Border- Heart	4.5h	50 Afghani
Herat-Kandahar	7h	25 Afghani
Kandahar-Kabul	14h	25 Afghani
Kabul -Peshawar	8h	400 Afghani
Peshawar-Lahore	9.5h	18.5 Pakistan rupees
Lahore-Indian border	2.25h	1.75 rupees
Border-Ferozopore	0.5hr	0.4 rupees

We finally we took a bus from Kabul through to Jalalabad, then through the Khyber Pass and into the even more lawless North West Frontier region of Pakistan. All day long we saw wild looking Pashtun men on small horses and camels, swathed in bullet belts with ancient looking rifles slung on their backs. Urchins and mangy dogs ran alongside the bus. When we stopped, small crowds would gather around in silence, utterly expressionless, staring at us without ever smiling or trying to touch or speak with us. It was unsettlingly eerie.

Peshawar is the first city you come to in Pakistan after passing through the Khyber Pass. The Australian cricket team played a test match and one day game there in 1998, but security has since stopped further international cricket there.  It was an unprepossessing place with a chaotic, unmemorable downtown area with shops selling the same cheap plastic junk, cloth and drab furniture that held no interest. After an hour or so of wandering about and being stared at still more, we were persuaded by a taxi driver to spend the rest of the day with him for about $3 in his deteriorated Morris Ambassador. He would show us the sights, where the people lived and some nice countryside near the town.

It was all dreary beyond imagination, with more unremitting staring all day, few trees and people eking out a living sitting all day next to a rag in the dirt displaying a few onions, fly infested goat meat or metal bric a brac, like locks, buckets and engine parts.

Late in the afternoon we unexpectedly came upon a circus tent pitched in a dry, featureless park.  In the hour that followed, I saw what my life might have been.

We got out of the taxi and made our way to a series of wagoned cages constructed of iron and hardwood. They looked like pieces out of a Frederico Fellini set from Satyricon in ancient Rome. Some housed monkeys and depressed, mangy bears, but one  had a liger, the result of a male lion mating with a female tiger to produce some of the biggest large cats known. But it was the young foreign couple who were the most exotic creatures to what rapidly built to another silent crowd of well over 100 men and boys who surrounded us, all utterly expressionless. No women were to be seen anywhere.

Within minutes we saw a  turbaned Sikh making his way through the crowd to us. He carried a splendid carved walking stick topped with gaudy coloured cut glass. He introduced himself as the circus owner and invited us to his personal tent for tea. There was no refusing. The crowds parted before the exotic entourage.

Glasses of tea and sweets were brought and we answered his enthusiastic questions about where we were from, what our occupations were (we had long learned to not say that we had no jobs or were students, which brought either consternation or obvious thoughts that we must have very rich parents). We were ‘teachers’. Then a litany of calibrating questions came about the price of various  goods in Australia, and the inevitable benchmark question: “how much does an engineer earn in your country?”

It was then that the conversation changed. I remember every word. It went like this.

“Do you know modern dancing?”

Modern dancing?  We looked at each other. What did he mean?

“You know, like cha-cha-cha?”

Well, yes, we did. I’d had a particularly progressive teacher who took dancing at school and daringly went beyond the barn dance and the Pride of Erin.

“And do you have bathing costume?”

Well, yes, we had those too. This was very much the right answer.

“Well, I am making proposal for you to join our very good, most famous circus. The best in all Pakistan. We travel all over the country including to the most famous and beautiful Swat Valley!”

We would have our own tent and we would dance the cha-cha-cha in our bathing costumes at each performance. This would be to audiences that we didn’t need to ask about but who would be all staring, silent Muslim men.

I had instant visions of my rapid disappearance, with Annie becoming the exotic consort of the sikh or traded to a local warlord in some valley in the ungoverned north of the northwest frontier.

We said that he had given us much to think about and we would need to contact our families and employers in Australia before committing to this tempting offer. We would send him a telegram with our answer as soon as we heard.

The next morning we got the bus to Lahore, where a solicitous, effusive businessman seeing us studying a town map, insisted on taking us to a cinema where an English language cowboy film was being shown. In the darkness he surreptitiously began to start his grope at Annie’s breasts. We got up and left, with the man following us back to our sub- one star hotel where he tried to force himself into our room.

Dancing in my swimming trunks in a traveling circus in Pakistan was not the life for me.

* the 20 short stories have now been completed and are here

Dr Joe Kosterich, a Perth GP and a director of the Australian Tobacco Harm Reduction Association, recently argued in WA Today that e-cigarettes should be seen as  no-brainer, common-sense harm-reducing equivalents of seat belts or condoms for smokers. And we should not dither around: there were no randomised controlled trials needed when car seat belts were made mandatory nor for condoms when they were put in the forefront of HIV/AIDS prevention, he argued.

He repeated the factoid that e-cigarettes reduce harm by 95%, said there was “absolutely no evidence” of e-cigarettes being  gateways to later uptake of smoking in teenagers and boldly claimed that “dual use [smoking as well as vaping) is still better than only smoking”. And he claimed that the fall in smoking has stagnated in Australia, while falling faster in nations where vaping is widespread.

Each of these claims is highly contestable. Let’s go through them.

Seatbelts and condoms for smokers?

Seat belts and condom use prevent unwanted adverse outcomes from driving and sex, but do e-cigarettes do the same by reducing harm?

The fact is we do not know. The average vaper bastes their mouth, throat and lungs with vaporised nicotine and chemical flavouring nano-particles and propylene glycol 200 times a day – over 73,000 times a year. Diseases caused by smoking typically take 30-40 years to be diagnosed. Yet vaping has only been in common use in some nations for barely 10 years.  So if we are comparing the health risks of smoking with vaping we have no direct evidence of what might lie down the track. This is why the prestigious US National Academies of Science, Engineering and Medicine (NASEM) declared in its door-stopper 680 page review of the evidence on e-cigarettes in January 2018 that “There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans. This holds true for e-cigarette use compared with use of combustible tobacco cigarettes and e-cigarette use compared with no use of tobacco products.”

A 2017 review of the emerging evidence on pulmonary effects caused by e-cigarette use provides many causes for concern:

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5582932/

 

Are e-cigs 95% safer?

This figure started out as simply a guess made by a group of 12 people hand-picked for a process led by huge fan of e-cigarettes, David Nutt, who has since declared publicly that e-cigs are the most significant advance in medicine since antibiotics.

Public Health England has also used the 95% figure as a robust estimate of comparative risk, with Prof John Newton of PHE telling an Australian parliamentary committee that “We say what really matters is that evidence underlying this figure came from the Nutt report.”

However, the Nutt group’s report made the extraordinarily frank statement that  “A limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria.” Limitations don’t get much more fundamental than that.

There were no randomised controlled trials for seat belts or condoms

Correct. And neither were there for parachutes  saving lives of people jumping from planes. Indeed, there are another 50 routine and important medical interventions where no RCTs have ever been conducted, for good reasons. But these are the exceptions: there are an estimated 80,000 medical interventions which have been trialed and evaluated.

If someone megaphoned they had a new substance that cured cancer, asthma or HIV and argued it was simply too important to tie their miraculous new breakthrough up in regulatory red tape and that they should be allowed to sell and promote it everywhere immediately, they would be laughed out of the room and told firmly to do what all drug manufacturers have to do: have their claims evaluated through official, independent drug regulation schemes like we do in Australia with the Therapeutic Goods Administration. What have vaping manufacturers to fear from the normal regulatory processes if their products are as safe and effective as they say?

Is dual use better than just smoking?

In England today where vaping is widespread, 61.3% of adults who vape also smoke (see slide 8 in Powerpoint set dated 10 Apr 2018 here).  If you smoke 20 a day and reduced to 10 a day, it’s beyond argument, surely, that you will have reduced your risk? Sorry, but that’s not what the evidence shows. A Norwegian cohort of 51,210 people followed from the 1970s until 2003 found “no evidence that smokers who cut down their daily cigarette consumption by  more than 50% reduce their risk of premature death significantly”. There are several more large longitudinal studies showing the same counter-intuitive outcome. Stopping smoking altogether is the only sure way to reduce risk. We do not know if reducing smoking by also vaping reduces long term health risk.

But emerging evidence already suggests it’s unlikely to. This graph from a 2018 study in JAMA shows dual users (smokers who also vape) had a higher prevalence of six pulmonary symptoms than smokers who did not vape.

There’s no evidence of gateway effects with kids

Kosterich was unimpressed with a health minister’s statement “The overwhelming medical advice and evidence is that it’s likely to lead to the uptake of smoking…”.  He called it “disgraceful” that the minister  should have been “so badly advised”, stating “There is absolutely no evidence anywhere in the world that vaping leads to the uptake of smoking.”

Apparently in all seriousness, Kosterich also argued  that “The public understands international data better than the medical establishment.” 

We can take Joe Kosterich’s word for this, or we can read and acknowledge what the US  NASEM report expert panel concluded about the evidence here: “There is  substantial evidence that e-cigarette use increases risk of ever using combustible tobacco  cigarettes among youth and young adults” and “moderate evidence that e-cigarette use increases the frequency and intensity of subsequent combustible tobacco  cigarette smoking.”

Has the fall in smoking stalled in Australia?

Vaping advocates keep claiming that the fall in smoking in Australia has stalled, as a pretext for declaring it’s time to open the floodgates to e-cigs here. They base this on the fall  between just two data points (2013 and 2016) not reaching statistical significance in national survey by the Australian Institute of Health and Welfare (AIHW). But they are silent on the largest and longest running survey of smoking in Australia which shows nothing of the sort. The Roy Morgan Research company has collected monthly data on smoking rates around the country since 1974 (see Figure 1.3.3 here), selling this information to tobacco companies. Each year, over 50,000 people are interviewed for these surveys and the latest available data from August 2017 show a rolling average below 15% for Australians aged 18 for every month of 2017, compared to the latest data from the UK where 15.1% smoke and vaping widespread.

Like all population surveys, the AIHW data on smoking prevalence in Australia often cited by vaping advocates  has margins of error. The AIHW’s table of relative standard errors and margins of error indicates for example, that the prevalence of daily smoking among people aged 18 years and over in 2016 was somewhere between 12.2% and 13.4%.

Very recently, Philip Morris International’s 2018 second quarter report stated:

“The estimated total market in … Australia decreased, notably due to the impact of increased tobacco tax and retail prices:

• Australia, down by 11.7%, primarily reflecting the impact of excise tax-driven retail price increases in 2017 and in the first quarter of 2018; [my emphasis]”

Kosterich told a conference in Poland recently that “It is in some respects a game that we are playing … we are not actually playing a scientific game. If it was about the science, there’d be no debate. There would be no debate. But there is a debate because it’s not about the science. It is an ideological warfare and particularly in Australia.”

The NASEM report reached 46 conclusions about the available evidence on e-cigarette safety, effectiveness and uptake. In 29 of these 46 conclusions (63%), NASEM labelled this evidence moderate, limited, insufficient or non-existent. This is not remotely a situation where there is “no debate” about the science, as Kosterich asserted to his audience.

Finally, his statement “there was one case where an e-cig exploded” sits awkwardly with data reviewed by the US Fire Administration which found 195 cases between 2009-2016. They noted  “The combination of an electronic cigarette and a lithium-ion battery is a new and unique hazard. There is no analogy among consumer products to the risk of a severe, acute injury presented by an e-cigarette” . For those not squeamish, here is a showreel of some e-cigarette explosion incidents.

We all know that genies are hard to put back in their bottles. If they are good, benevolent genies, they can be a force for good, but if they turn out to be evil genies, letting them out can be disastrous. That happened with cigarettes. We need to learn from past mistakes and take a precautionary response with e-cigarettes, as all Australian governments are doing.