If expensive cigarettes are driving the Australian black market, why do so many countries with much cheaper cigarettes have thriving black markets too?

12 Wednesday Mar 2025

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Big Tobacco and its errand boys in the convenience store industry are clearly limbering up to try and make illicit cigarettes and vapes a hot button issue in the forthcoming election.

The buttons they are hoping to push are a wind back in tobacco excise, and scrapping of the pharmacy-only regulatory model of vape access. This would allow virtually any registered retailer to sell vapes, something many convenience stores have been doing illegally for years and continue to do so. So a great idea — let’s reward them now for years of ignoring the law, as they clearly have built community trust as responsible retailers!

The main games here, under the cover of raising community alarm about criminality in tobacco and vape retailing, are to remove the exclusive sale of vapes from pharmacies and the forlorn hope that lowered tobacco tax will see mass criminal exit from selling cheap cigarettes. As we will see, this fantasy has all the integrity of a chocolate teapot.

The Australian Association of Convenience Stores which has a long history of tobacco industry support and its chief executive Theo Foukkare who started his career with British American Tobacco, recently publicised its latest commissioned report on illegal tobacco retailing. In a report in The Australian, Foukkare wanted the government to freeze excise on tobacco products for four years. A few days before, he went further “it is time for the Government to seriously consider lowering the excise on tobacco”.

Foukkare, nor any other advocate for lowering excise, ever go beyond this slogan. But as we shall see later in the blog, excise reductions would need to be simply galactic to make legal cigarettes price competitive with illegal duty-not-paid cigarettes.

Two National Party MPs have also called for tobacco tax to be reduced in Australia to make legal, duty-paid cigarettes more competitive. The National Party receives financial support from British American Tobacco and Philip Morris International, which have lost every policy debate on tobacco control since the 1970s when the first pack health warnings appeared.

Both the ABC’s Four Corners and Nine’s 60 Minutes have very recently covered the issue, leading and promoting their programs with memorable graphic footage of standover firebombings of stores, as rival criminal gangs viciously shirtfront each other for greater control of the lucrative illegal market.

Australia currently has the highest retail and among the least affordable prices in the world (see two graphs below), and no one disputes that those who buy cheap illegal cigarettes here, as in every country which has illegal tobacco trade, are motivated alone by lower prices. So would lowering the price by lowering excise in Australia, see those running the many shops selling illegal cigarettes just walk away?

An obvious question

A most obvious question to ask here is “do nations with more affordable legal cigarettes, also have significant tobacco black markets?” If they do, it would be clear that criminals will continue to see large opportunities to sell illegal stock regardless of how high or low the prices of legal cigarettes are. The cut-the-tax house of cards would tumble down in the first breeze of evidence.

The commercially-motivated magic bullet of lowering tobacco tax to lower illicit sales reflects a parochial ignorance of global illicit trade in tobacco, and the lack of a consistent relationship between the operation of that trade and the retail price of legal tobacco. Low income nations (for example) Vietnam, Philippines and Senegal where tobacco is dirt cheap are often also awash with black market cigarettes.

This month, Thai officials arrested 690 vendors in just one week allegedly breaking Thailand’s laws on selling vapes.

Vietnam officials burning contraband tobacco

But what about nations that are more socially and economically comparable to Australia? Before I look at three such countries (USA, UK, Canada), a brief overview of the published literature on global illegal tobacco trade, including in Australia.

Illicit tobacco trade: a very long history

Some commentators on illicit tobacco trade appear to have come down in the last shower. This is a global phenomenon which has a long history. Over 30 years ago in 1994, tracking of European tobacco export and import data  found a 30.8% difference between the number of cigarettes officially exported and imported. The only plausible explanation for these missing cigarettes was smuggling, particularly of expensive premium brands moving from northern Europe into lower income eastern and southern European markets.

The tobacco industry has long been active in supplying cigarettes to the illegal duty-not-paid trade while trying to alarm governments about excise tax losses and lobbying for reduced excise. A 2019 systematic review of 35 assessments of the extent of illegal tobacco trade found that 31 of these reported that tobacco industry estimates of the extent of illegal trade were higher than independent estimates by researchers with no tobacco industry ties. Lack of transparency from data collection right through to presentation of findings was a key issue with insufficient information to allow replication of the findings frequently cited.

The authors concluded that tobacco industry data on illegal tobacco trade are not reliable and are intended to talk up the problem in the hope that governments would hobble policies like tax and plain packaging that have serious potential to reduce smoking.

There has been a long history of illegal retailing of duty-not-paid cheap cigarettes and loose “chop chop” tobacco in Australia, with reports of use back to 2001. Tobacco industry estimates of the proportion of tobacco use in Australia sourced illegally since 2012, ranged from 11.8-23.5%, substantially higher than independent estimates from the Australian Taxation Office’s revenue gap analysis which estimates 5.4 to 14.3% between 2015-16 and 2022-23. The ATO estimates that approximately 18% of tobacco for sale is illicit.

Illicit trade in UK

The graphs above show cigarettes today are cheaper and more affordable in Britain than in Australia. A 2024 report by the UK’s HM Revenue and Customs concluded that the forgone value of the  “illicit market in tobacco duty and related Value Added Tax was £2.8 billion in 2021 to 2022.The proceeds of this crime fund the smuggling of weapons, drugs, and even human beings across the globe. We must tackle the cancer of organised criminal groups as unwaveringly as we tackle the harms of smoking itself.”

Years of effort by UK Border Force “have reduced the estimated duty gap for cigarettes by a third (from 16.9% in 2005 to 11% in 2021 to 2022) and for hand-rolling tobacco by a half (from 65.2% to 33.5% over the same period).”

From April 2015 to March 2023, this resulted in:

  • £10 billion: tobacco duty receipts in 2022 to 2023
  • 10.6 billion: non UK-duty paid cigarettes seized by HMRC and Border Force
  • 1,600 tonnes: non UK-duty paid hand-rolling tobacco seized by HMRC and Border Force
  • 1,571: people convicted of tobacco crime offences
  • 8,000: assessments to recover unpaid excise duty
  • 9,304: excise wrongdoing penalties issued for tobacco offences
  • £298 million: value of penalties and assessments raised

Illicit tobacco trade in USA and Canada

The graphs above show both cigarette prices and affordability in the US are much lower than in Australia. In 2024, the average cost of a pack of 20 cigarettes was $US8 ($AUD12.71) compared with Australia at around $40. Nonetheless, illicit traffic in the US is decidedly non-trivial.

The 2015 report from the US National Academies Understanding the US  illicit tobacco market estimated the total market represented by illicit sales in the United States was between 8.5 percent and 21 percent of the total. It recommended that“research and data are needed about the individuals and criminal networks who traffic in illicit tobacco.”

Comparing illicit trade in Australia with that is the US is difficult, because Australia does not have state taxes whereas the US has a variety of low and high taxing states. Illicit tobacco trade in the US is dominated by illegal movement of cigarettes from lower taxing states to those with higher taxes, including from Native American tax free  zones.  The US federal tobacco tax is $US1.01, with the lowest state tobacco tax an additional $US0.17  and the highest in New York state at  $US5.35. These sorts of differences also occur in Canada.

So like Australia where nation-wide high tax and prices have attracted significant illicit trade, high tobacco taxing US and Canadian states also attract incoming illicit trade from lower taxing states. But the critical point to make here, is that even though cigarettes are considerably more affordable than in Australia, illicit traders still have major involvement in tobacco commerce.

These US and Canadian examples illustrate that for whatever reason, where you have high retail prices, criminals will seek to illegally undercut these, and it doesn’t  matter how low the prices are, they will still try to do it.  New York’s average pack price is $US14.55 ($A23.12) far less than Australia’s ~$40, and far more affordable than Australia’s. And in very low income  countries, dirt cheap legal cigarettes are still undercut by illicits.

Market research firm Circana estimates that in 2024 sales of unauthorised, flavoured disposable vapes in the US amounted to  35% of the $6.8 billion worth of e-cigarettes sold in tracked convenience stores and supermarkets. And this estimate does not include massive on-line sales or those from vape shops. The FDA puts the proportion of vapes being sold in the US which do not have a required FDA marketing order at 86.4%. Vapes are sold openly in most of the US, as they are in Canada and the UK.

Canada

Taxes and prices are also considerably lower and cigarettes considerably more affordable in Canada than in Australia. The Canadian convenience store industry recently stated low-cost tobacco products have become a “major selling feature” for well-known and established organized criminal groups such as the Hell’s Angels. “It is absolutely organized crime at the highest level. It’s a billion-dollar industry for (organized criminal groups). It involves all the levels of violence, and extortion and gangsterism that comes along with it.” ) In Canada illegal sales outnumber legal sales in one province by 52% and 36-45% in three others.

The dramatic data above instantly repudiate claims that open access sales of vapes and cheaper, more affordable legal duty-paid cigarettes prevent or even reduce illegal supply and deter criminal involvement. 

Tobacco control—including tax policy – has driven smoking to its lowest ever level

Both 60 Minutes and Four Corners featured ex-Australian Federal Police and former Border Force Tobacco Task Force head Rohan Pike. Pike was described by 60 Minutes as someone “who now advises the retail sector” and by Four Corners as “a lobbyist for retailers”. But neither program asked Pike whether he was advising the convenience store industry out of the goodness of his heart, or whether he had any financial relationship with them.

Pike told 60 Minutes “excise rates are the primary driver of this problem from the start, we should be looking to reduce the excise rates” and hyperbolically described the illicit trade situation as “This policy is perhaps one of the biggest failures in Australian history, really.” A memorable soundbite, but “really”? Really? Bigger even than the housing crisis? The AUKUS submarine debacle? Indigenous health and incarceration rates? The plight of the Great Barrier Reef?

In the 60 Minutes program, veteran organised crime observer John Sylvester stated  “putting heavy tax on smoking was done for two quite legitimate reasons: to raise revenue and secondly to discourage people from smoking. So governments and authorities would look and go, ‘Wow, our excise is down, that means people aren’t smoking.’”

Well, no. Only the most inexperienced analysts of tobacco and nicotine use in Australia would ever exclaim that a fall in total excise receipts could only be due to a fall in smoking. People moving to illicit duty-not-paid cigarettes would clearly reduce total excise but this would not allow any sensible conclusion about whether smoking was falling or rising.  The proportion of people who buy their cigarettes from illegal supplies is an entirely different question from the proportion of people who smoke. It’s not about how or where you get your cigarettes, it’s about whether you get them at all.

Mark McKenzie, CEO  of ACAPMA, Australia’s fuel industry lobby group, has also swallowed the tobacco consumption is rising argument writing that the explosion of illicit retailers “is clear evidence of a rising tide of tobacco consumption – one that government statistics fail to capture”. No Mark, it’s clear evidence of criminal interests fighting intensely over the shrinking market of smokers.

In a recent blog I showed that data on smoking prevalence from the National Drug Strategy Household Survey collected since 1998, shows smoking is now lower  than it’s ever been, with the most recent fall being the largest seen since surveys began. Smoking by kids is heading toward extinction.

So how low would tobacco excise need to go to make the black market disappear in Australia?

It’s easy to call for “lower” tobacco tax, but how much lower would it need to be to see budget-conscious smokers switch back to buying taxed cigarettes? A common price for the most popular illegal brand of cigarettes in Australia is $15. The current excise rate on cigarettes in Australia is $1.40313 per stick. So the tax alone on a pack of 20 cigarettes is now $28.06.

A common retail price for popular brands of legal duty paid cigarettes is around $40, with the extra component costs ( after ~$12 tax is deducted) being those going to cigarette manufacturers and retailers. Given that tobacco manufacturing and retailing interests are not talking at all about radically dropping their margins to compete with $15 illegal pack prices, are the “cut the excise” voices then suggesting that the government should therefore  “take one for the convenience stores” and give up perhaps all of its tobacco excise ($40-$28 = $12), a price that would certainly blow illegal retail trade out of the water?

We don’t know how low illegal cigarette retail pricing could fall to still remain very profitable to those running it. But by now, simplistic calls to “cut excess” lead us very quickly into this truly absurd territory, when the obvious solution is instead for governments to crack down hard on the illegal retailers. Small cuts would make no significant difference to the large gap between legal and illegal cigarettes. Only massive or even entire scrapping of tobacco excise would bridge that gap.

Recent advocacy by convenience stores to list the river of extra money that the government would receive if excise tax was “lowered” and smokers flooded back to buying legal cigarettes would therefore be conditional on the government removing most or all of the very tobacco tax which the convenience stores say would start pouring again into the coffers.  So how does that all work again?!

Enforcement of the law: the missing elephant in the room

The giant Achilles heel of rampant illegal retailing of cheap, duty-not-paid cigarettes in Australia is its sheer blatancy. Every shop selling them and every on-line ad for courier delivered vapes reaches out to its customers with often unmistakable signage and none too cryptic on-line language (eg: fruit, many varieties). “Here we are, come on in, or txt us a meeting point where we’ll deliver the vapes”. It could hardly be more in-your-face.  I recently counted 22 cheap smokes shops in just two adjacent Sydney suburbs.

If ordinary citizens can locate these outlets with absolute ease, it is obvious that so can those charged with investigating and enforcing the laws. So why are the shops proliferating and prosecutions occurring at dismal rates?  Many of the public are asking this question. Health Minister Mark Butler this week encouragingly announced $156.7m extra for police enforcement.

Those selling illegal recreational drugs do not open shops with signs like “Cheap meth, heroin, ecstasy here”. The government has for many decades “banned” all retailers other than pharmacies from selling prescribed drugs, but criminal gangs have not set up high street shops all over the country with signs “Get your medicines here – no prescription needed!” Neither do we see every second corner shop without a liquor licence selling alcohol.  In both cases, the law would come down very fast and hard.

Australian governments now have national and state laws with numbingly high maximum penalties for selling illegal vapes and duty-not-paid smuggled tobacco.  These penalties are set at levels designed to seriously deter both major a small-level commercial involvement in these illegal sales. 

The fuel industry’s Mark McKenzie,  the convenience stores’ Theo Foukkare and Big Tobacco all have got one thing very right: governments need to act quickly on illegal trade. Illegal and legal cigarettes are both deadly (up to two in three long term smokers die from tobacco caused disease). Legal tobacco retailers, like petrol-driven car manufacturers, DVD hire shops and typewriter manufacturers know they are well into the endgame of having large customer numbers who still want to buy their products.

As with illicit drugs, no government has succeeded in eliminating all contraband tobacco. But some, like the UK, appear to have made major in-roads into the illegal tobacco problem.

Australia’s pharmacy vape access policy together with governments acting against illegal retailers and importers, could feed a global appetite for a template that will make smoking history. So what is Australia waiting for?

Addendum

The Government today announced a huge round of law enforcement reforms to the issues raised above. Plus press conference transcript

Cherry-picking redux: problems in comparing vaping retail regulatory models when only two nations are considered

03 Monday Mar 2025

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Dr Colin Mendelsohn recently published a co-authored paywalled paper in Addiction comparing smoking and vaping prevalence in adults and adolescents in New Zealand and Australia during 2016-2023, when smoking fell in both nations and vaping rose under two different nicotine vaping products regulatory regimes.

Mendelsohn has summarised the paper  here and in an opinion piece in the Sun Herald where he modesty declared the paper to be a “landmark” study. The principal policy question driving the paper is whether countries with more restricted access policies on vapes such as Australia with its pharmacy-only access see different changes in smoking than those with more permissive “regulated market models” (RMMs) such as their comparator case study, New Zealand.

Notably, all but one of the Mendelsohn group authors have histories of often strident public advocacy for vapes to be sold to adults through a wide range of registered retailers. These could include dedicated vape stores and tobacconists and any type of retail business. They have relentlessly opposed Australia’s policy of pharmacy-only access to vapes, including in submissions to governments. This has aligned them with advocacy and submissions from all the major tobacco transnationals, right wing think tanks, the convenience store and tobacco retailing industries, Pauline Hanson’s One Nation and the National parties. It has also set them apart from all major medical and public health agencies, every state and the commonwealth health department and a large majority of Australian researchers and public health advocates who strongly supported the government’s proposals (see table).

Their paper concludes that New Zealand’s greater reductions in adult smoking may suggest a causal relationship between higher rates of vaping with higher falls in smoking, concluding “adopting the New Zealand model for vaping is likely to assist Australia in reaching its [smoking reduction] target earlier.” Below I critique three issues which I believe make this conclusion less robust than it may seem. The concerns are:

  1. Cherry-picking one comparator nation when other RMM nations of equally obvious relevance present far less persuasive evidence
  2. A pollyannish, naïve or ill-informed view of the ability of RMMs to reduce illegal trade in vapes
  3. Use of dated smoking prevalence data in modelling forecasts to declare Australia is likely to miss its 2030 target of less than 5% smoking prevalence

I argue below that Australia’s pharmacy access model preserves access to vapes for adult smokers trying to quit in a retail environment where sales to children are highly unlikely because of professional pharmacist ethics. Illegal sales are widespread in nations with RMMs, while ex-pharmacy sales of prescribed drugs are marginal. Pharmacies have long histories of managing access to narcotics and other drugs with misuse or abuse potential such as methadone and codeine.

  1. Why compare only two nations?

Fundamentally, the stunningly obvious question demanding to be asked is why the authors selected only two nations from which to base their conclusion that a regulated consumer access model is superior to what they call “highly restrictive” models like Australia’s. There are many nations which allow vapes to be freely sold to adults. Three other nations which also largely share the comparable demographic and multi-cultural backgrounds and history of strong tobacco control of Australia and New Zealand justified by the authors for selecting New Zealand and Australia are the UK, the USA and Canada.

Comparing smoking rates between nations is fraught with problems summarised here. These especially include differences in definitions of “smoking” (some defining only cigarettes, others counting any combustible product) and in different reported age ranges (14+, 15+, 18+). Nations like the UK and the USA which count only cigarette use underestimate true exposure to combusted tobacco smoke (smoking), particularly where use of tobacco in water pipes and cigarillos is widespread.

With  smoking prevalence being very low in adolescents in each of these nations, those which include under 18s in their total smoking prevalence data like New Zealand, Canada, and the UK will thereby dilute their total point prevalence figures compared to nations which only count 18 and over smokers of all combustibles. Patterns may also differ depending on whether it is daily, weekly or any current smoking that is being tracked, and whether current smoking includes smoking less frequently than monthly.

Point prevalence of current smoking from the latest available data sets for the five nations are:

Australia (10.5%, 14+, all combustibles, 2022-23 National Drug Strategy Household Survey)

Australia  (11.1%, 18+, all combustibles, 2022-23 National Drug Strategy Household Survey)

Canada (10.9%, 15+, all cigarettes only, 2022 Canadian Tobacco and Nicotine Survey)

New Zealand (8.4%, 15+, all combustibles, 2023/24 New Zealand Health Survey)

UK (10.5%, 16+, cigarettes only. 2023 Opinions and Lifestyle Survey,)

UK (11.9%, 18+, cigarettes only 2023 Annual Population Survey)

USA (11.6%, 18+, cigarettes only, 2023 National Health Interview Survey)

Additionally, in Europe where vapes are often openly sold, average data from all EU member states for 2019 show daily smoking prevalence of 18.4% in those aged 15+.

The margins of error around these numbers, together with them each being obtained from different starting ages and defining smoking differently, make direct comparisons problematic.

With declining smoking being the primary focus of Mendelsohn et al’s paper, why were these other three nations each with permissive retail RRMs not also compared for the lessons they might equally hold for Australia?  With highly liberal vape retail access occurring as much, if not more, in the UK, USA and Canada as in New Zealand, and smoking prevalence in all five nations declining, any putative causal generalisation about the downward effect on smoking of liberal versus restricted retail access becomes immediately contentious. By selecting only New Zealand for comparison with Australia, the authors have cherry-picked a nation to provide a comparison compatible with their previous outspoken advocacy for RRMs.

Similar regulations on retailing vapes in other RMMs

Vaping advocates often describe New Zealand as having the most preferred regulatory model for vapes. Retailers like supermarkets, ‘dairies’ and petrol stations are allowed to sell vapes, but only in limited flavors like tobacco, menthol, and mint.  Licensed ‘specialist’ vape retailers can sell a wider range of flavours. However, in practice New Zealand is little different to the UK, the USA and Canada. All have age restrictions on selling, and unlike Australia, all allow retailers engaged in any type of retailing to sell vapes after simply registering.

UK: There are no restrictions on types of retailers which can sell vapes to those aged 18+ in premises or on-line. All products must comply with the Tobacco and Related Products Regulations by only selling products that are notified and compliant with the Medicines and Healthcare products Regulatory Agency specifications.

USA: Vapes assessed by the FDA as suitable for sale can be sold by any retailer to those aged 21+. Twenty-one of 50 states require a permit or retail license to sell vapes.

Canada: Vapes can be sold by anyone with a vaping product licence. Those eligible need only meet financial transparency and probity criteria.

Australia: While Australian consumers were able until 2021 to import nicotine vaping liquid with a prescription, it has never been legal to sell nicotine vapes in Australia. However this was rarely if ever enforced, with vapes being often displayed and openly sold in shops. COVID caused health departments to reallocate staff to COVID-related duties, severely curtailing surveillance and inspection of illegal NVP selling.  The fact that non-nicotine vapes were legal to sell until July 2024 made enforcement difficult both at the border and at retail. From mid-2023 a trickle of enforcement commenced, but illegal retailing remains widespread. The Government’s 2024 package of reforms to reinforce a pharmacy dispensing model for supply of vaping products in Australia is wide-ranging. It includes

  • Restricting the supply of vaping products to pharmacists, with a prescription required for higher dose products (>20mg/ml <100mg/ml), for people under 18 (and for all customers in Western Australia and Tasmania)
  • Requirement for discussion with a health professional about other quitting options, to counsel against dual use and to encourage cessation of vaping
  • Banning disposable, flavoured vapes that have proved attractive to children
  • Requiring pharmaceutical style packaging to reduce appeal to and risk of accidental poisoning for children
  • Limiting chemical additives to a small range of approved flavours
  • Standards for electrical safety
  • A pre-registration system to allow authorities to investigate suspected instances of failure to comply with standards
  • Enforcing legislation prohibiting sale of vapes from other sorts of retail outlets, including on-line sales

Some of this package will not be fully implemented until July 2025. So what is being compared to New Zealand in the Mendelsohn paper  is not the full Australian model, but rather the very unsatisfactory situation in Australia which preceded it—the situation which allowed widespread sales which is what the very recently introduced reform package is intended to address.

As with pharmaceuticals, alcohol, firearms and explosives, surveillance and enforcement is necessary under every regulatory model. With so many more products needing to be scrutinised and retailers to be monitored, enforcement under a RRM presents far more challenges than a pharmacy-only model.

Pharmacists have long been granted exclusive rights to dispense prescribed and scheduled drugs.  While ex-pharmacy supplies of restricted drugs and supply to those without a prescription are occasionally prosecuted, any non-pharmacist retailer who flagrantly decided to supply prescription drugs to the public would be rapidly investigated, prosecuted and likely suffer severe penalties. This is very much not the experience with the illegal supply of vapes in all the four RMM nations named.

  • Do regulated market models reduce illegal sales of vapes?

A purported major benefit of regulated consumer markets for vapes is said to be that they will reduce illegal trade. Mendelsohn et al state “there is no evidence of a significant organised illicit market for vapes in New Zealand” citing a submission to the Australian parliament by two of their group authors which asserted  “There is little incentive to operate an illicit supply chain at any commercially viable scale due to effective competition from the legal marketplace.”

This pollyannaish, naïve or ill-informed statement sits awkwardly with recent New Zealand government prosecutions for illegal sales and a controlled purchasing exercise where 10% of 600 tobacco retailers were selling to children. Copious international evidence exists of rampant illicit trade in the UK, USA (market research firm Circana estimates that in 2024 sales of unauthorised, flavoured disposable vapes in the US amounted to  35% of the $6.8 billion worth of e-cigarettes sold in tracked convenience stores and supermarkets. And this estimate does not include massive on-line sales or those from vape shops. The FDA puts the proportion of vapes being sold in the US which do not have a required FDA marketing order at 86.4% — see graph below) and Canada where illegal sales outnumber legal sales in one province amount 36-45% in three others. Canada has an RMM. These dramatic data repudiate claims that RMMs prevent illegal supply.

Source

The Canadian convenience store industry recently stated low-cost tobacco products have become a “major selling feature” for well-known and established organized criminal groups such as the Hell’s Angels. “It is absolutely organized crime at the highest level. It’s a billion-dollar industry for (organized criminal groups). It involves all the levels of violence, and extortion and gangsterism that comes along with it.”

This is in a nation where cigarettes that are taxed less than in Australia vapes can be legally sold by anyone with a permit (see graph below).

  1. Will Australia likely  miss its 2030 smoking reduction target?

The Mendelsohn paper concludes by saying:

 “Australia’s current trajectory and a daily rate of 8.3% indicate it is likely to miss its target of 5% daily smoking or less by 2030”. Here they cite two modelling papers which drew on reports published prior to the availability of the most recently data used by the authors in their paper.  Australia’s  2022/23 National Drug Strategy Household Survey reported daily adult prevalence at 8.3%, down from 11% in 2019 (an absolute fall of 2.7% and relative fall of 24.5%). This was the largest decline in smoking prevalence reported in 10 triennial NDSHS surveys since they commenced in 1998. As such, it may represent a step change in the decline in smoking.

Vaping may well be a factor helping adult smoking cessation in both countries, although both nations also have the world’s highest retail prices, advanced comprehensive tobacco control policy and enjoy widespread public support for further government action. Recent data shows 94.6% of New Zealand smokers were aware of the Smokefree New Zealand proposal, with 77.8% of smokers and recent ex-smokers supporting the Smokefree Generation proposal and  73% supporting the denicotinisation of cigarettes.

When the price of cigarettes between the two countries is standardised to international dollars, cigarettes in New Zealand are the least affordable in the world in 2022.  Might not this have had a little something to do with so many smokers quitting in New Zealand?

Source

Collateral damage to youth

There has also been significant collateral damage in the form of re-ignition of nicotine addiction among former-smokers and starting it in many who had never smoked. A recent large (n=31,733) US cohort study assessed smoking and vaping transitions between two waves (2016-2017 and 2018-2019) and found for every beneficial transition out of smoking via vapes, there were 2.1 harmful transitions (ie never smokers starting to vape, exclusive vapers taking up or adding smoking to vaping).  So the net population effect of vaping may well be negative.

Here, teenage vaping data is of particular interest. A New Zealand Ministry of Health analysis of pooled data from 2020/21 and 2021/22 for 15-17 year olds found 76% of daily vapers had never smoked, 18% were former smokers and 6% were dual users [24]. The latest wave of data from Australia’s GenVape study show that 50% of current vapers (last 30 days) had never smoked. (unpublished data provided by GenVape)

When smoking prevalence is very low in youth (as in the five nations discussed above), the argument that high vaping prevalence might be substituting for more widespread smoking is difficult to sustain against a background of plummeting smoking prior to significant uptake of vaping.  Daily vaping rates in 14-15yr Australian, New Zealand and US students are 2.8%, 10% and 3.5% respectively, and in 15 year olds in Canada 8.1% and 10.9% in English adolescents. Daily smoking rates have been below those figures for some time.

Concern about youth vaping has mostly been about vaping priming some for subsequent smoking, as well as about the financial and health burdens of nicotine dependence in itself (eg: on-going expense, social inconvenience, possible neurological and major psychiatric problems and possible cancer promoting action). As 15 presidents of the Society for Research on Nicotine and Tobacco wrote in 2021 “There are no data on long-term health effects, reflecting the relative novelty of vaping and the rapid evolution of vaping products. Determining even short-term health effects in adults is difficult because most adult vapers are former or current smokers.”

Benefits of prescription drug access

Australia’s pharmacy-only access model harnesses the benefits of providing easy access to vapes by adult users and minimising collateral damage to children. Argument that accessing vapes through pharmacies is onerous is particularly silly. Some 5935 community pharmacies are located throughout the country, with at least one in every shopping mall, and in all but the smallest shopping strips in suburbs and in towns throughout regional Australia. In capital cities, 97% of people live within 2.5 kilometres of a pharmacy, and 66% live within 2.5 kilometres in the rest of the country. Over 2000 are open after hours and at weekends. Telepharmacy and postal delivery service those in remote areas. The Pharmacy Guild estimates that in 2022-23 there were 443.6 million individual pharmacy visits. In a population of 27 million, 335.8m prescriptions were dispensed for all drugs. Many more across-the-counter purchases would have additionally occurred, as can occur with 20mg or less vapes now without any prescription.

The prescription model of access to drugs with misuse or abuse potential has flourished for decades  in all but lawless or chaotic nations where almost any drug can be obtained without a prescription. Criminal gangs have not decided that Australia presents a golden opportunity to supply any of the 925 Pharmaceutical Benefits Scheme drugs to millions of people wanting them cheaper and without the inconvenience of getting a prescription.

In Australia, there are black markets for some pharmaceuticals including anabolic steroids, some new and expensive weight-loss drugs and erectile dysfunction drugs, but these are very marginal compared to the overwhelming supply volume via prescription access through pharmacies. A BBC report detailed criminal gangs diverting a range of prescribed drugs in England.  Black markets do exist for prescribed drugs but the size of these are a tiny fraction of those which operate via prescription access.

Are Tesla owners simply “supporting the finance arm of the Nazi party?”

26 Sunday Jan 2025

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Like a lot of Tesla owners, I’m sickened by Elon Musk’s metamorphosis into a mega-funder of extreme right wing political aspirants. Since acquiring Twitter in October 2022, his gleeful unleashing of armies of vile miscreants who had been blocked by Twitter’s previous management policies is rapidly turning it into a toxic sewer.

Like many others, my own Twitter following began haemorrhaging as people bailed in disgust at what he unleashed (including his own rancid posts) and his desecration of the platform’s functionality and culture. Today, I rarely use it, having moved to the fresh air on BlueSky.    

At first many of us resisted the name change from Twitter to X, but we must now acknowledge that Twitter is dead and what remains, X, is a very different beast. To refer to it as Twitter is to deny Musk’s destruction of what was a vibrant town square.

The oceans of money he poured into Trump’s re-election campaign turbo-charged his X disgrace. His fascist-style fist-pumps and salutes on Trump’s inauguration day removed any scintilla of doubt about Musk’s values.

If I ever buy another car, it would certainly be an EV, but not a Tesla. I fully support efforts to raise awareness of Musk’s mendacity and to urge potential EV purchasers to think hard about their choices.

But that said, there’s a good deal of simplistic Manichean thinking being flung about here. And not a little hypocrisy when, as is highly likely, many of the Tesla haters continue to do their bit to fund Big Oil when they continue to fill their fossil-fuelled cars and motorbikes.

So should those who are disgusted by Musk all feel mortified about driving our Teslas? Should we all get rid of them and spread the word? It’s now common to hear people remark that while they understand how excellent Teslas may be as an electric vehicle, they would never buy one because of all Musk stands for. The implication here is that if you have a Tesla, you are somehow declaring yourself as a Musk fan and have lined up with all other Tesla owners to enrich him. You need to feel shameful, apologise and seriously think about selling your Tesla. This video lays out that case.

Tesla also makes Powerwall batteries, with 600,000 sold worldwide by early 2024. Many competitors have now entered the rapidly expanding market.

Tesla also owns Starlink the high speed internet service which is a wholly-owned subsidiary of SpaceX, a major Musk company. Among its many uses, is its ability to provide internet access in remote locations inaccessible to Australia’s National Broadband Network. The Starlink Mini is a compact, portable internet kit. An ocean sailing friend tells me there is currently no alternative for affordable internet access far away from land.

So presumably, those arguing that buying Tesla vehicles helps fund Musk’s agenda would also count purchasers of his batteries and Starlink internet as equally complicit and shameful.

Tesla was incorporated in 2003 by Martin Erberhard and Marc Tarpenning. From February 2004, the PayPal multi-millionaire Musk led fundraising and had been chairman and principal fundraiser for Tesla, then CEO from 2008. Today he’s the world’s wealthiest person.

Teslas have been on sale since 2008. We’d used one on a holiday to France in 2016 and had been immensely impressed but until the Model 3 was launched in 2017, found the price way out of our league. We bought our Model 3 in June 2021 for $AUD52,000 after a $15,000 trade-in on our sedate little Mazda. This outlay was similar to the cost of many decidedly non high-end petrol-fuelled cars.

Three motivations to buy our Tesla

We bought the car to reduce our carbon footprint, to save serious money on fuel and servicing and to enjoy a driving experience that is endlessly wonderful.

Transport vehicles are the leading source of anthropogenic carbon emissions and the only source where these emissions are rising  (see European data below). A typical fossil fuelled car emits 4.6 tonnes of CO2 a year from its exhaust. EVs of course have no exhaust and emit nothing once manufactured.

Like ICE vehicles, EV manufacturing entails emissions. The chart below shows US EPA lifetime greenhouse gas emissions (GHGs) estimates for ICE and fully electric vehicles.

# “feedstock” here refers to materials like liquids, cloth, rubber etc used in manufacturing

So in summary, reducing vehicle emissions is of immense importance in reducing anthropogenic greenhouse gas emissions, and EVs are hands-down winners over ICE vehicles when it comes to emission reductions.

Cost savings

The savings involved in EV ownership can be huge. Our experience of the car has been beyond outstanding. It is a fantastic thing. Our only outlay in 3.5 years has been two $60 wheel rotations. That’s all. No fuel (saving $1500 a year), no servicing and engine part repairs (saving perhaps $2500 in a typical year), 90% of our charging is done free off our solar roof during sunny days, with most of the remainder done during cheap off-peak times overnight.

A recent post on Australia’s Tesla owners Facebook page (81.6k members) from a guy who uses his as a rideshare business and has done 334,893km, explains how he’s still on the original brake pads which are more than 85% of original thickness, thanks to regenerative braking (ie: the electric motor turns into a generator and slows the car — charging the car! — when you decelerate).

This week I noticed and responded to a post on BlueSky

So let me parse the ethical issues involved. Three issues arise here for me.

First, while it is true that Musk benefits directly from every Tesla new car sale, he’s by no means the single beneficiary. The company’s market capitalisation on 26 Jan 2025 was $1.27 trillion. Musk owned 20.5% of Tesla’s stock by the end of 2024. So 79.5% of its global market capitalisation benefits other investors via dividends and stock value increases. With pension and superannuation funds being massive investors, there will be millions of ordinary working people who will be also benefitting beside Musk. Then there are the more than 100,000 Tesla employees. They probably feel good about working for a company that today makes the world’s #1 selling new car (the Model Y) and playing a role in inspiring competition from most other vehicle manufacturers which is seeing massive uptake of EVs. 18% of all cars sold in 2023 were EVs, up from 14% in 2022 and only 2% in 2018.

Ninety five percent of 2023 new EV registrations were just three markets: 60% in China (1 in 3 of all new registrations), nearly 25% in Europe (1 in 5), and 10% in the USA (1 in 10).

This is nothing but a positive development. Whatever Trump might try to do in the US, there is a massive, moving global wall of green EVs, rooftop solar, windfarms, home batteries, new green buildings and city design which is pushing forward hard. Bizarrely, Musk is in the front row in this while his buddy Trump is lining up with oil interests.

The huge curve ball being thrown here, is that Musk/Tesla is a massive contributor and stimulator to efforts by his competitors to reduce greenhouse emissions. But he is at the same time an odious stimulus to politics that may take humanity back to very dark periods.

Second, if I were to sell our Tesla and buy another EV make, I would lose an estimated $25-$30k off the purchase price. Competition since 2021 has seen the new price for the Model 3 fall to be competitive with and burgeoning cheaper alternatives in other manufacturers’ models. So pfft to “retaining value” — few cars ever do that and Teslas are no exception. But Jacoby glibly counsels me here that “progress always requires sacrifice”.

So, if I follow this, I’m supposed to take a $30k haircut in order to achieve …. what precisely?

Sydney’s roads would have one less Tesla reminding people of Elon? Oh wait, no. Whoever bought ours would fill the Tesla ownership gap we vacated.

So I’m left wondering what I asked Jacoby: what possible benefit selling our Telsa could ever be argued to bring?

Third, Jacoby did not answer about his own driving choices. If he drives a non-Tesla EV, great. But if he drives an ICE (internal combustion engine), I’m hoping that he has also counselled cyberspace to put notices under all ICE car and truck wipers to remind them of their moral turpitude in generating CO2.

I put this to one of Jacoby’s other respondents who wrote:

The oil industry spent $US445m in the last election cycle to help re-elect Trump and from day 1, Trump has begun thanking them with his “drill, drill, drill” war cry on the environment.

By the very same argument being used by those rallying against Musk and Telsa, anyone still driving an ICE vehicle is polluting the earth’s atmosphere while lining the pockets of Big Oil which, like Musk, is facilitating the Trumpian politics that will put major lead in the saddlebags of the global race to reduce greenhouse emissions.

To my mind, that’s the first question that anyone trying to shame Tesla drivers needs to answer.      


Selling our Tesla wouldn’t result in any fewer Teslas on the road, whereas buying a new one would. So for as long as Elon is at the helm, I won’t be buying a new Tesla. In the meantime, I’ll keep driving my zero-emissions vehicle… and I’ve ordered a sticker from Etsy that says “I bought my Tesla before we knew Elon was a Nazi.”


Smoking is fast becoming extinct in Australia but spare us from hare-brained extremist policies

10 Friday Jan 2025

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Population-focussed tobacco control in Australia has seen smoking prevalence fall to its lowest ever levels for both adults and teenagers. Teenage smoking is all but extinct – an amazing achievement. This has been driven by 50 years of successful public health advocacy for policies, legislation and campaigns increasing public and political awareness intended to foment declines in smoking. Since the 1970s in Australia, there has been no advocated tobacco control policy that has failed to be taken up by governments. The tobacco industry has lost every battle it fought. All cigarette factories have closed and you seldom see anyone smoking in the street. Smoking is a pale shadow of what it was 40 years ago.

Sitting astride all of this has been the continual and progressive denormalization of both smoking and the tobacco industry. Ninety percent of smokers regret ever starting. There’s no product whose users are so disloyal. All political parties except the hillbilly Nationals refuse to accept tobacco industry donations and would rather be photographed with the Grim Reaper than be seen enjoying  tobacco industry hospitality.

But over the 45 years I’ve worked in tobacco control, I’ve lost count of the number of times people have assumed I would want to give my support to some truly loopy and sometimes unethical policies. Four leap out. I’ll briefly outline the first three, then go to town on the why the fourth – censorship of films showing people smoking – is the mothership of muddled thinking, indeed stupidity.

1: Got some new way to quit? Sign me up!

Many assumed that I would want to rush to embrace and recommend almost any agent or process intended to help smokers quit. Rarely did a month pass when I was not contacted by a breathless enthusiast for some new purported breakthrough. These included any new way of consuming nicotine other than smoking (I’m still waiting for nicotine suppositories, but surely it can’t be long); any new drug; any complementary procedure maximally accompanied by soothing, holistic placebo-enhancing mumbo-jumbo and eye-watering costs for consumers; any “professional” intervention featuring the nostrums of doctors, nurses, pharmacists, psychologists and counsellors in clinical, group, on-line or app settings.

A  piece I wrote 40 years ago in the Lancet (“Stop smoking clinics: a case for their abandonment” see pp154 here)  set out why well-intended dedicated quit smoking centres were distractions from the main goal of reducing smoking across whole populations. They were never going to make any serious contribution to reducing smoking nationally because smoking was so widespread and interest in attending such clinics so low, that impossibly massive numbers of clinics would need to open for them to make a difference.

In 2009, again in the Lancet,  I proposed the “inverse impact law of smoking cessation” which states “the volume of research and effort devoted to professionally and pharmacologically mediated cessation is in inverse proportion to that examining how ex-smokers actually quit. Research on cessation is dominated by ever-finely tuned accounts of how smokers can be encouraged to do anything but go it alone when trying to quit―exactly opposite of how a very large majority of ex-smokers succeeded.”

I then quantified this with a look at how research on quitting had become overwhelmingly focussed on assisted quitting, with research into unassisted quitting far less common. This was truly bizarre given that no one disputes that the most common way of quitting used in final successful quit attempts has always been to do it cold turkey.  So why not learn more about that and shout it from the rooftops?

My contributions caused apoplexy and multi-signatured condemnations from those who had tethered their career sails to assisting smokers. My 2022 book Quit smoking weapons of mass distraction looked in depth at why professional smoking cessation was dominated by the tiny “tail” of treatments, while the large “dog” of real world unassisted quitting was often denigrated by tobacco treatment professionals and the pharmaceutical industry, for obvious self-interested reasons.

2. The smoker-free workplace

A second perennial bad idea proposed that employers should be allowed to reject applicants (for any job) who smoked, even if they were completely agreeable with smokefree workplace policy and did not want to take divisive “smoking breaks” not available to non-smokers. Henry Ford pioneered early workplace smoking bans in his car factories  (see photo below) But a century on, some were now arguing that even  if workers smoked entirely in the privacy of their own life, employers could threaten them with unemployment because they smoked.

I made a case against this nonsense in 2005.

Two arguments were typically used by advocates for this policy

1: employers’ rights to optimise their selection of staff (smokers are likely to take more sick leave and breaks)

2: enlightened paternalism (‘‘tough love’’).

The first argument fails because while it is true that smokers as a class are less productive through their absences, many smokers do not take extra sick leave or smoking breaks. By the same probabilistic logic, employers might just as well refuse to hire younger women because they might get pregnant and take maternity leave, and later take more time off than men to look after sick children. Good luck with that argument!

But what about paternalism? There are some acts where governments decide that the exercise of freewill is so dangerous that individuals should be protected from their poor risk judgements. Mandatory seat belt and motorcycle crash helmets are good examples.

It was argued that the threat of ‘‘quit or reduce your chances of employment’’ was founded on similar paternalism. I think the comparison is questionable.

Seat belt and helmet laws represent relatively trivial intrusions on liberty and cannot be compared with demands to stop smoking, something that some smokers would wish to continue doing. By the same paternalist precepts, employers might consult insurance company premiums on all dangerous leisure activity, draw up a check list and interrogate employees as to whether they engaged in dangerous sports, rode motorcycles, or even voted conservative!

Many would find this an odious development that diminished tolerance. There is not much of a step from arguing that smokers should not be employed (in anything but tobacco companies where perhaps it should  be mandatory?), to arguing that they should be prosecuted for their own good.

3. Finish the job … ban smoking in all outdoor public areas

When the evidence mounted in the early 1980s that breathing other people’s smoke was not just unpleasant to many but could cause deadly diseases like lung cancer, bans on smoking followed in enclosed areas like public transport, workplaces and eventually the “last bastions” of ignoring occupational health: in  bars, pubs and clubs.

Some in tobacco control then excitedly began to argue “why stop now? Let’s extend bans to even wide-open spaces like parks, beaches and streets.” The teensy-weensy problem here was that all the evidence on breathing other people’s smoke being harmful came from studies of long-term exposure in homes and workplaces. There was almost no evidence that fleeting exposures of the sort you get when a smoker passes you in the street is measurably harmful.

So banning smoking in wide-open outdoor spaces was not a policy anchored in evidence about health risks to others.

Accordingly, I advocated for smoking prisoners to be allowed to smoke in outdoor areas, for ambulatory patients and their visitors to be able to smoke in hospital grounds if they chose to and for smoking to be allowed in streets.  When I was a staff elected fellow of my university’s governing Senate, I voted against a (failed proposal) for a total campus ban on smoking in favour of having small dedicated outdoor smoking areas (see photo).  I set out my concerns in these papers, here, here and here.

This marked me as a heretic for some. But as I argued in one of these “I have had heated discussions with some colleagues about this who are triumphant that the proposed ban [on smoking in prisons] will help many smoking prisoners quit. I agree that it will, and that is a good thing. But so would incarcerating non-criminal smokers on an island and depriving them of cigarettes. We don’t do that not just because we can’t, but because it would be wrong. The ethical test of a policy is not just that it will “work”. In societies which value freedom, we only rarely agree to paternalistic policies which have the sole purpose of saving people from harming themselves if they are not harming others.”

4. Ban smoking in movies, or slap them with box-office killing R-ratings

But true peak silliness in tobacco control advocacy  arrived when a small number of people began arguing for all movies which depicted smoking to be either banned, or more commonly, slapped with R (18 and over) classifications, known to severely  reduce box office receipts. This threat would see most film producers order their directors to impose on-screen smoking bans.

I first flashed bright amber lights on this idea in 2008. With a US co-author, I followed up with four arguments  against this proposal in this PLoS Medicine paper and this response to criticism that followed. Much of our paper was hypercritical of research that purports to show that there is a strong association between kids seeing smoking in movies and their subsequent smoking. Some – including even the World Health Organization – even tried to extrapolate attributable fraction estimates of the number of deaths down the track that this exposure would cause down the track in what was an uncritical orgy of highly confounded leaping from simple associations to causal statements. The huge number of assumptions and uninhibited reductionist reasoning in this exercise was quite extraordinary.

The main problem here was that when characters smoke in films, they do not just smoke: they bring to their roles a constellation of other attributes that are likely to be deeply attractive to youth at-risk of smoking.

As we wrote: “Teenagers select movies because of a wide range of anticipated attractions gleaned from friends, trailers, and publicity about the cast, genre (action, sci-fi, teen romance, teen gross-out/black humour, survival, sports, super hero, fantasy, and so on), action sequences, special effects, and soundtrack. It is likely that youth at risk for current or future smoking self-select to watch certain kinds of movies. These movies may well contain more scenes of smoking than the genres of movies they avoid (say, parental-approved “family friendly,” wholesome fare like the Narnia Chronicles or Shrek).

Teenagers at risk of smoking are also at higher risk for other risky behaviors and comorbidities. They thus are likely to be attracted to movies promising content that would concern their parents: rebelliousness, drinking, sexual activity, or petty crime. … Movie selection by those at risk of smoking is thus highly relevant to understanding what it might be that characterizes the association between young smokers having seen many such movies and their subsequent smoking. Movie smoking may be largely artifactual to the wider attraction that those at risk of smoking have to certain genres of films. These studies rarely consider this rather obvious possibility, being preoccupied with counting only smoking in the films.

By assuming that seeing smoking in movies is causal, rather than simply a marker of movie preferences that have more smoking in them than the movie preferences of those less at risk, authors fail to consider problems of specificity in the independent variable (movies with “smoking”). It may be just as valid to argue that preferences for certain kinds of movies are predictive of smoking. The putative “dose response” relationships reported may be nothing more than reporting that youth who go on to smoke are those who see a lot of movies where smoking occurs, among many other unaccounted things.”

All this was silly enough, but where the silliness became weapons-grade in its over-reach was the way in which some in public health didn’t hesitate to decide  they had every right to start urging that governments should censor movies (and presumably theatre, books, art, smoking musical performers) which showed smoking.

We wrote:

“most fundamentally, we are concerned about the assumption that advocates for any cause should feel it reasonable that the state should regulate cultural products like movies, books, art, and theatre in the service of their issue. We believe that many citizens and politicians who would otherwise give unequivocal support to important tobacco control policies would not wish to be associated with efforts to effectively censor movies other than to prevent commercial product placement by the tobacco industry.

The role of film in open societies involves far more than being simply a means to mass communicate healthy role models. Many movies depict social problems and people behaving badly and smoking in movies mirrors the prevalence of smoking in populations. Except in authoritarian nations with state-controlled media, the role of cinema and literature is not only to promote overtly prosocial or health “oughts” but to have people also reflect on what “is” in society. This includes many disturbing, antisocial, dangerous, and unhealthy realities and possibilities. Filmmakers often depict highly socially undesirable activities such as racial hatred, injustice and vilification, violence and crime. It would be ridiculously simplistic to assume that by showing something most would regard as undesirable, a filmmaker’s purpose was always to endorse such activity. Children’s moral development and health decision-making occurs in ways far more complex than being fed a continuous diet of wholesome role models. Many would deeply resent a view of movies that assumed they were nothing more than the equivalent of religious or moral instruction, to be controlled by those inhabiting the same values.

The reductio ad absurdum of arguments to prevent children ever seeing smoking in movies would be to stop children seeing smoking anywhere.”

Despotic and fundamentalist religious governments have huge appetites for censorship (think North Korea and Afghanistan under the Taliban). But in the west, there is a long and often disturbing queue of single-issue advocates who would wish to see greater state intervention in cultural expression. Precedents for such doors to be opened should be treated with great caution. If scenes of smoking should be kept from childrens’ eyes, why stop there?

The slippery slope is today well-oiled in the USA where in a growing number of Republican states a large range of books are being removed from school libraries at the behest of Christian family-values activists.

The Google Trends graph below shows that globally the debate about R-rating smoking in movies had a massive rush-of-blood from 2004-2009, with attention waning in the years since.  Advocates for censorship and R-rating have succeeded in several national and global agencies endorsing their calls. But significantly, no nation has legislated to R-rate smoking films.

Even if they did, as far back as 2004,  81% of under 18s were allowed by their parents to view R-rated movies in the USA occasionally, some or all of the time. With all the myriad ways available today to view movies on-line, via downloads, movie swapping and piracy, any thoughts that R-rating would achieve anything look increasingly absurd.

The Tobacco In Australia website has a very thorough section on all the debating points relevant to the whole issue.

Google Trends “smoking in movies” 10 Jan, 2023: 2004-present, worldwide

“Why did you get into this work?” 40 years in tobacco control

27 Wednesday Nov 2024

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Across my career, I’ve often been asked by media interviewers “What got you involved in the sort of work you do? What drives you to keep at it?” Depending on who’s asking, there’s an occasional edge to the questions presaging that a little probing will lift the lid on a deep moralistic busybody, driven by a barely disguised missionary zeal to lead sinful smokers off the pernicious path of self-destruction and into a wholesome life of glistening health.

In the 1970s, when I first started working in health, I’d sometimes sense the same assumptions in people I talked to at parties. When they asked “what do you do?” and I answered that I worked in tobacco control, I’d often sense the hesitancy: he probably doesn’t drink. Never smoked dope. No chance of any fun or sex with this guy. He probably thinks the music’s too loud. Steer well clear.

Early anti-smoking efforts in the years before strong evidence rolled out in the early1950s that smoking was deadly were deeply mired in puritanism and ideas that the body was a temple from which the devil and his work had to be driven out. The evils of drink, smoking, masturbation, temptresses and reading novels travelled together in a morals crusade that extoled abstention from fun and pleasure. Purse-lipped temperance groups picketing pubs, jokes about Methodists who eschewed dancing and the rest, and the way that smoking and under-age drinking were pretty reliable markers of kids who were often more edgy and interesting than their heads-down classmates all coalesced in those early days to make any mention of tobacco control a tad suspect.

When the Niagara of evidence became undeniable that smoking was out on its own as a cause of disease affecting almost every part of the body, the moralists’ chorus was joined by doctors and health authorities who had long also brought us warnings about other dangers that we were thankful to receive. Just as no-one thinks of a lifesaver at the beach warning about sharks or dangerous rips as a moralist or killjoy, the overwhelming evidence that smoking was harmful radically changed the complexion of anti-smoking efforts. This became ethically turbo-charged when strong evidence emerged that chronic exposure to other people’s tobacco smoke was also deadly.

Seventy four years along from these early studies, research has repeatedly confirmed that around 90% of smokers regret ever starting. While some die-hard smokers still want to trot out their favourite talismanic self-exempting beliefs (“plenty of people smoke all their lives and don’t die early”, “everything’s bad for you these days”, “what about all the air pollution we breathe on every day?”, “I keep fit, so get the nasty stuff out of my system”), and some insist that smoking is pleasurable, most smokers today are reluctant, embarrassed and apologetic. A huge majority have tried to quit and I’ve never met a smoker who hoped their children would take it up. There are few — if any — products with such a near-universal disloyalty and resentment among their consumers.

Most occupations and professions don’t attract the sort of questioning I described earlier. I can’t imagine ever saying to an accountant “so what was it that got you interested in accounting when you started?” or asking a dry cleaner “you’ve been doing this for 35 years … can I ask what the fascination is?” We mainly assume that it’s the money, the security and comfortable routine, inertia and the quality of working environments that keeps people in their jobs or attracts them into something else.

We don’t think to ask surgeons or oncologists why they do what they do. It’s obvious that people likely to die from cancer often desperately want to try and avoid that happening, or give themselves some extra time. But it’s also obvious that most people need little convincing that prevention is as, or more important than curing or treating. Yet while the thought of people railing against the work of lung cancer surgeons is unthinkable, all across my career I’ve seen bizarre and sad little pro-smoking and more recently pro-vaping groups form, flutter and fade and heard smokers calling radio programs to whine about feeling under siege.

The “explain yourself” imperative is generally reserved for those who choose to do odd, anti-social, demanding, revolting, seamy or dangerous work: undertakers, midnight to dawn radio hosts, sex workers, plumbers who wade in raw sewage, skyscraper window cleaners. With daily smoking prevalence in Australia down to 8.4%, and 90% of smokers regretting ever having started and often highly supportive of polices that might help them smoke less or quit, we are looking at a mere 0.8% of the adult population who are contented  and committed smokers, with even a smaller proportion of these actively railing against tobacco control. Fringe political parties in Australia which have sometimes run candidates have received derisory public support.

So when I’m occasionally asked the “why?” question these days, that perspective on the likely attitudes of those listening to the interview (it’s usually on radio) guides my response. I’m never tempted to try and repudiate the time-warped, neo-puritanical framing of the question as if it’s a serious, widespread critique. Instead, I steer the conversation over to considering the importance of and challenges in hobbling and discrediting the upstream well-heeled forces that keep promoting smoking and doing all they can to defeat, dilute and delay effective tobacco control policies capable of reducing smoking on a wide scale.

I’ve worked in public health since late 1974. I’ve focussed on a range of issues that extend from tobacco control, gun control, helping people better understand the risks and benefits of adopting (or avoiding) certain medical procedures such as having prostate specific antigen test or getting immunised) or avoiding (or not) exposure to allegedly “dangerous” technology like mobile phones and transmission towers and wind turbines.

The common thread in most of these issues are the efforts of industries, lobby groups and determined, often obsessed individuals to thwart evidence-based public health policy and practice which threatens these industries or the cult-like belief systems of people who eat, live and breathe hatred of a public health strategy. This hatred has a very long history (see below).

A classic analytical matrix in public health (Haddon’s matrix) is the epidemiological triad that was first applied to the effort to understand and then better control road injury and later infectious and vector-borne diseases like cholera and malaria: the agent, host, environment and vector matrix.

In the control of malaria, we put a lot of effort into understanding the agent that causes the disease, the five types of plasmodium parasite that multiply in human red blood cells of humans and in the mosquito intestine. Agent control involves efforts to develop a vaccine which would prevent a person being bitten by a mosquito carrying the parasite from developing malaria. One such vaccine first passed human trials in 2017, possibly indicating a revolution in efforts to control this terrible disease.

Those who are infected with the plasmodium parasite are known as “hosts”. Here, control efforts are concerned with educating those who live in areas where malaria is endemic to take efforts to protect themselves from being bitten by covering-up at times when they are most likely to be bitten, wearing repellent, using insecticides and being diligent about destroying or spraying mosquito breeding water like that which collects inside old tyres, cans, and water storage. These breeding areas are known as the “environments” that need to be mapped, inspected and controlled. A wider definition of environments would embrace considerations of the cultural, economic and political environments in endemic malaria areas. If local health authorities had no funds to support malaria control, this would be importantly identified in a malaria control analysis and efforts taken to raise such funding and support.

Finally, the female anopheles mosquito is known as the “vector” responsible for the plasmodium parasite agent entering the bloodstream of hosts. Vector control starts with studying the life-course and behaviour of these insects in attempts to wreck their efforts to bite people.

Big Tobacco: the global vector for lung cancer

In tobacco control, the vector whose every waking moment is concerned with maximising the number of smokers (hosts) who consume tobacco (the agent) is the tobacco industry. So a large part of my work across 40 years has been involved in exposing and shaming the industry, its acolytes and those in politics who take its donations and hospitality, oppose or water down potent legislation and collude with its ambitions to keep as many people smoking as possible.

The “what has kept you going in this issue all these years” question is easily answered in two ways. First, smoking rates in both adults and kids are at all-time lows, and showing no signs of not falling even further. Lung cancer, a rare disease at the beginning of the twentieth century, rose to become the leading cause of cancer death by the 1960s. But in Australia, male lung cancer rates stopped rising in the early 1980s and have continued to fall, some 30 years after we first saw large-scale quitting happening about the huge publicity was given to the bad news about health. Female lung cancer rates look to have plateaued at a level that makes their peak just a few years ago reach only half the peak rates that men reached over 30 years ago.

Continually falling disease and death rates from tobacco caused diseases have made tobacco control the poster child of chronic disease control, envied by people working today in areas like obesity and diabetes control. It’s been such a privilege to have contributed to many of the major policy developments that have happened since the 1970s: advertising bans, the highest priced cigarettes in the world, large scale quit campaigns, smoke free legislation in workplaces, bars and restaurants, plain packaging, graphic health warnings on packs, bans on retail displays of tobacco products, and a duty free limit of just one pack.

Second, the mendacity of those working in the tobacco industry throughout my career has strongly motivated me to keep hard at it. In the decades before the evidence on tobacco’s harms were established, anyone working for the tobacco industry might have as easily been working for any industry. They were selling a product with strong demand and surrounded by convivial social rituals. The companies employed many people and contributed to communities via sponsorships and benefaction. What was not to like?

But with the advent of the bad news, the industry rapidly descended into decades of the very worst of corporate malfeasance. Those who stayed with the industry or came into it did so with their eyes wide open about what they were being rewarded to do every day and so were open game to account for their actions and the consequences. In the face of all they now knew, the industry doubled down. It conspired with other companies to deny the harms, it lied that nicotine was not addictive, shredded oceans of incriminatory internal documents, corrupted science through tame consultants and scientists, bribed politicians, promoted pro-smoking doctors to the media, donated to political parties likely to support its goals, bought up community support via vast sponsorship of national and international sport and culture, chemically manipulated cigarettes to make then more addictive, researched and targeted children in its advertising and promotions, relentlessly attacked any tobacco control proposal that threatened in any way to harm its bottom-line, cynically supported limp tobacco control policies that it knew were useless but made it look good, and supplied products to agents known to be involved in illicit, black market trade while unctuously railing against that trade in public, posturing as good corporate citizens.

The industry has long been peerless in occupying the tawdry throne of corporate ethical bottom feeders. This popular and political understanding is now so pervasive that its conduct has become an almost universal comparator for corporate pariah status. Big Tobacco is the index case here.  If you google “just like the tobacco industry” you will be deluged by a rogues’ gallery of other industries that have lost public trust. The industry acknowledges that it today has serious trouble attracting quality staff.

Shining 10,000 watt arc lights on that conduct has been of immense importance to tobacco control. It is rare today to find a politician is who happy share a photo opportunity with any tobacco company. When I interviewed Australia’s former health minister and attorney general, Nicola Roxon, for my book (with Becky Freeman) about Australia’s historic adoption of plain packaging, she emphasised that “everyone hates the tobacco industry” and that this understanding had steeled the government to proceed and  brace against the industry’s best efforts to defeat the legislation. That public revulsion did not develop out of nowhere – it was an important enabling objective for many of us in tobacco control in our advocacy for policy change.

All companies today are engaged in high profile rebirthing displays where they openly acknowledge that smoking is deadly and argue that they want to do all they can to encourage smokers and future smokers to switch to electronic vapourised nicotine products like e-cigarettes. After around 12 years of widespread use, they have declared that consensus already exists that these products are all but totally benign. More and more authoritative reviews of the evidence on this show this consensus is very far from the case and that they are far from magic bullets or “Kodak moment” game changers in helping smokers quit.

While spokespeople working down one corridor of tobacco companies extol the virtues of these new products and megaphone the transformational role they will play in the tobacco industry, those working elsewhere in the building continue to do all they can to attack proposals for effective tobacco control policies and legislation wherever they can. In recent years all the major companies have mounted huge efforts to try and stop plain packaging, graphic health warnings, increased tobacco taxation, retail display bans, and flavour bans. If they really wanted to see an end to smoking, they would aggressively advocate for all these policies. So go figure.

This blatant duplicity is stomach-churning. The industry’s clear goal is to not have its customers abandon cigarettes and use e-cigarettes instead. It is to have these customers use both products (known as dual use), to tempt former smokers back into nicotine addiction and to reassure teenagers that these allegedly safe as you can get products hold none of the threats that smoking holds. They cannot believe their luck.

The evidence is mounting that this scenario is exactly the way things are playing out. E-cigarette users are in fact less likely to quit than smokers not using them. And dual use is the most common pattern of use, often lasting years.

Every single policy in tobacco control that has ever been advocated by those of us working in this field around the world has been adopted in many nations. In Australia, the tobacco industry has lost every policy battle it ever fought. As a result, we have been able to get where we have in dramatically reducing smoking to the lowest levels ever recorded. Teenage smoking is almost extinct in Australia and several other nations. These are fantastic outcomes.

“It’s got a lot of community with a capital C”: the Stanmore Music Festival, 2024

19 Tuesday Nov 2024

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This wonderful photo from 2022 by Neil Bennett of two Batacuda Funk dancers ordering drinks in the Salisbury hotel while a disbelieving regular from the front bar adjusts his glasses to make sure he wasn’t dreaming

On Saturday from noon, the 4th Stanmore Music Festival rang out in the streets, schools, the library park and the Salisbury pub until 10pm. This year a record 77 acts involving more than 1000 participants took part. Choirs swelled that number. Some 165 acts had applied for the 35 minute performance spots available on 11 stages. Like the three other previous festivals, over 40 volunteers worked across the day and earlier, setting up tents, chairs, banners and stage managing, after earlier programming the event, designing the website and a multitude of other tasks.

Police estimated the 2019 crowd across the day at 5000. This year’s looked comparable.

I and photographer neighbour Tony Egan directed the first two festivals in 2019 and 2022. Covid caused a two year pause in 2020-2021,with the third held in November 2023, directed by a volunteer stalwart Jan McClelland, who also steered this year’s event.

The Stanmore Music Festival was modelled on the French Fête de la Musique, held on the June 21 summer solstice across France for 42 years since 1982.  Today the festival is held in 700 cites in 120 countries. We initially dubbed it the St. Anmoré (pronounced St. Ann-more-ray) music festival as an affectionate nod to its French inspiration.

We’d lived in Lyon in 2006 and one evening we stepped out into our street leading down to Lyon’s old town and unknowingly walked into the Fête in full swing. We’d not even heard of it, but it was unforgettable. Just quite stunning. I remember seeing Django Reinhardt trios, Malian kora players, jazz bands, string quartets, rappers … every kind of music. It was fantastically festive, communal and participatory. Families, friends and workmates circled performers, along with thousands of local residents till late into the evening.

Our local friends told us that while big name acts occasionally appeared on a main stage – always free of charge —  the overwhelming  emphasis was on musical performances by local residents: people who did not make a living from their music, but who just loved performing. One said to me “You’d be amazed about the extraordinary talent you find living behind many ordinary front doors – former professional musicians, immigrants bringing rich cultural musical traditions from their home country, young prodigies, choir members, instrumentalists whose music has been mostly private but who are very impressive and bathroom baritones and sopranos.”

Years later back in Sydney, I sensed our suburb suffered from a rather anodyne reputation compared to our surrounds. Wedged between Sydney’s Portuguese and Italian quarters (Petersham and Leichhardt) and adjacent to the inner west’s hipster trifecta of Newtown, Enmore and Marrickville, poor old Stanmore needed something to loosen it up a bit.

I approached nearby neighbour, conductor and musical educator Richard Gill about an approach to the local Inner West council for support. Richard and his family had lived in Dijon and needed no persuading it was a good idea to try and have a French-style festival. After some bureaucratic stonewalling by the old Marrickville Council, Inner West mayor Darcy Byrne backed the concept.  Sadly Richard died before he could see the Festival launch. It’s now been anointed as an annual festival in the Inner West’s cultural calendar.

A truly community festival

Most music festivals are commercially driven with professional acts attracting crowds. Performance fees are paid via ticketing, merchandising and catering. Pubs and other music venues also often have ticketed entry to pay musicians. The next step down are suburban non-ticketed music events where outside food and drink vendors pay big money for catering rights to local governments and deep-pocketed corporations pay sponsorships in return for publicity and promotional opportunities. A limited number of performers are generally paid.

Stanmore is different. It is free to all and no performers are paid, in keeping with the communal philosophy of the event. We always explain the communal objectives to applicant performers. It was a vision that drove Richard Gill, to whom we dedicated the Festival. Richard worked for decades with the cream of Australian classical and choral musicians. But it was his work with inspiring children and their musical educators from which he never strayed. One of our selection criteria is whether a performer or group had any connection with Richard. A surprising number do.

At the second festival, we received a curt “no thanks” when we approached a well-known inner west band. We were told that no other occupation group is ever expected to provide their services free and that our festival risked publicising amateur acts who were prepared to play for nothing. Pubs and cafes might decide this was a better deal for them than paying full professional fees to performers. So they declined, clearly letting us know they disapproved of the whole thing.

We replied that we fully agreed that professional musicians needed to be paid particularly when people were profiting from the crowd they pulled, but were they seriously arguing that eight choirs, each with 15-50 members should only be able to perform in public for 25 minutes if each and every member was paid full professional fees? Or that a 14 year old guitarist, a local folkloric dance group, a dad-band playing rock covers, a group of young high school jazz students or an accordionist playing Italian folk tunes should all stay out of public performance until they decided to go professional?

Dog Trumpet, legends in the Inner West, played for free at the pub at the first festival. When we sent a questionnaire to all performers asking for 3 good points and 3 “need to fix” suggestions, their Peter O’Doherty wrote back that they had enjoyed the vibe so much, they would be happy to even play in the pub toilet the next year.

The Stanmore festival zone is not fenced off, outside food carts are banned and moved on by the Inner West Council if they turn up (as are those trying to selling any merchandise or services). Local cafes and delicatessens and school parents’ BBQs and food stalls instead reap all the catering income. Several of these local businesses donate raffle prizes at two fund raisers. Including the 18 out of maximum 19 hatted SixPenny restaurant.

My highlights

This year I did a 3 hour stage managing shift in the pub, time-keeping and introducing four bands. One, the House of Monkeys, played as school kids at the first festival and at all three since. I’ve watched them change lineups and grow in both confidence and chutzpah. They played some standard covers well like Beds are burning and Nutbush, but just blitzed the Rolling Stones’ peerless Can you hear me knockin’ with its unmistakable open tuned G power riff that has had millions of people rise to their feet on hearing it since it was released in 1971 on Sticky Fingers.    Last time I saw them play, their savant guitarist Jack Covell, was too young to order a beer.  Here he is at 16. Now here he was leading them through this demanding piece, joined beautifully by a young sax player for the long solo.

Another, Amy and the Grey Zone had a singer with a voice you’d cross the country to hear. Her whole family watched on proudly while the room swayed to their sound.

A third, Redundant Technology came off stage after a blistering set. I commented on how well the guitar and bass worked together “we should do .. . we’ve been playing together since the 80s!” said  Simon Ward, the guitarist. A little community within our community that day.

I saw the sublime Inner West Voices open with Judy Collins’ Both Sides Now, local veteran icon George Washingmachine, and a performance from the local Flamenco School.

At 4.20pm, one of our volunteers overheard  someone say “It’s got a lot of community with a capital C”.  A stranger told me in the park today that he could never imagine Stanmore without the festival. It’s here for keeps. 

Only 12 months till the 2025 return.

Thanks especially to Jan McClelland,  Phil Goldstein, Rebecca-Camille Niumeitolum, Ray Schembri, Tony Egan and Matt Crane and all the other volunteers.

My grand daughter Florence sings at the inaugural festival, 2019. Photo credit: Tony Egan

Are smoking and vaping now endangered public sights?

30 Wednesday Oct 2024

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Only 8.4% (and falling) of Australians over 18 years now smoke daily. Just three percent (also falling) of senior high school students at least smoke weekly, a similar situation that exists in the USA, the UK  and Canada. A recent editorial in the American Journal of Public Health stated “By any measure, youth smoking [in the USA] has nearly ceased to exist”.

Smoking has long been banned in Australia on all public transport, in indoor workplaces including bars, clubs and restaurants, many stadiums and an increasing number of outdoor café dining and coffee areas do not allow smoking. The map below shows a tiny percentages of Australian homes allow smoking inside.

Proportion of non-smokers who report living in a household where: a smoker smokes inside the home; a smoker smokes outside the home; or there is no smoker in the household, 2019, by state/territory. Source

Some local governments have banned smoking in outdoor shopping malls. Smoke-free stadiums are now commonplace. I went to an open-air night time Paul Kelly concert 10 years ago at Taronga Park Zoo where stage announcements directed smokers to go to a section way up the back and away from the crowd. I took a look and it was empty.

In 2008, I co-authored a highly accessed and cited paper on markers of the denormalisation of smoking and the tobacco industry. In it we catalogued a wide range of ways that the identity of smokers has been spoiled from the days when smoking was considered convivial, sophisticated and dripping with the multitude of positive semiotic signification purposefully bestowed upon it by marketing, advertising and smart packaging. In 1992, the single most common feature sought by those advertising for housemates was being a non-smoker. In 2004, only 2% of people using Australia’s largest dating site declared they were smokers.

Denormalisation works ‘‘to change the broad social norms around using tobacco—to push tobacco use out of the charmed circle of normal, desirable practice to being an abnormal practice’’. When smoking loses its public and political charm, when most people don’t smoke, when 90% of remaining smokers regret ever having started and when parents who hope their kids will grow up to smoke are as rare as rocking horse shit, governments know they have a huge mandate to introduce policies that will drive it down, as has been happening since the 1970s.

Rise and fall of vaping?

Over the last few years, I’ve often heard people remark that they seldom see people smoking these days. In recent years vaping seemed to be something we saw much more often, mostly because of the ostentatious look-at-me clouding plumes and the frantic rapid hand-to-mouth frequency of puffing. But after October 1, 2024 when the Commonwealth government outlawed vaping sales from anywhere but pharmacies, vape prices skyrocketed and many small illegal retailers have likely been understandably fearful of the large fines. Many “recreational” vapers may have reduced or stopped smoking. I pass 22 tobacconists and “convenience stores” on my daily walk. Last week I saw not a single customer in any of them on four walks.

No airline allows vaping on board, and train stations make regular announcements warning about platform vaping being banned. Most Australian governments have banned the use of vapes in all areas where smoking is not allowed by law.

So the last bastions of public smoking and vaping today remain some open air spaces like streets, parks, beaches.  But how often now do we even see smoking and vaping these days? Curious about this, for three consecutive mornings this week I set out to count how many people I saw smoking or vaping while I walked through two inner west suburbs.

On each of the three walks, I walked around 12,000 steps from around 7.45am -10am.  I wanted to quantify a strong impression that we don’t often see people smoking or vaping in public these days.

In each hand I carried a thumb-click mechanical digital counter. One for people smoking or vaping and the other for people not doing so (see photo below).

My route took me through the hipsterville shop, restaurant and café high streets of Enmore and Newtown at a time when many were on their way to work, waiting at bus stops, entering Newtown railway  precinct, having their morning coffee or like me, walking for exercise. Those with nicotine dependence can often be seen dosing before getting on trains and buses and lighting up immediately on alighting. So I spent 30 minutes counting commuters entering and leaving Newtown station, wanting to include what I predicted might be a visibly higher rate of smoking or vaping there.

It’s easy to see someone smoking. They are either actively drawing on a cigarette or holding one in their hand or lips. Vaping is similarly easy to spot, although if someone is hiding a vape in a closed hand or keeping it in a pocket between pulls, this would cause underestimates of its prevalence.

But I was not trying to estimate smoking or vaping prevalence. My objective was to try and count the prevalence of actual smoking and vaping in an outdoor setting in the way that an ordinary person might observe people around them as they moved normally on their passage through streets. I was not in any way trying to count smokers and vapers (so including those who might have vapes in their pockets), but rather active smoking and vaping.  Where I came to a situation where a group of people were gathered such as at pedestrian crossing or a bus stop, I stopped too, to carefully check each person I could see. I did not count children in school uniform on the way to school, or infants with parents.

In total I saw 3529 people over the three days observations. Of these, just 38 (1.1%) were smoking.  I saw just 3 (0.09%) people vaping. Only one was smoking at a table outside a café. Those smoking or vaping were so scarce that some small patterns could be discerned. With few exceptions, those smoking looked 70+. There were two spots on my route where I saw at least one smoker on each day. Some at those spots were also begging for change.  Of the very few younger people (teens, 20s) who were smoking, nearly all had “attitude” (goths, punks). Several were south and east Asian men.

These data are only a street epidemiological snapshot of what was happening in two Sydney suburbs on three (sunny) mornings across two hours. But the daily percentages were very similar. My thumb clicking the “not smoking” counter risked giving me repetitive strain injury, while my thumb recording smoking and vaping nearly went to sleep. Smoking and vaping have not vanished from public sight, but they both look decidedly endangered.   

I’m planning to gather the same data across different locations and at different times to see if there is a range.

What can atheists say to the dying?

22 Tuesday Oct 2024

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It’s often said that the devil has all the best tunes. But when it comes to supporting and comforting those facing imminent death, those with religious faith have a huge walk-up start on us non-believing atheists in the trove of things that you can say to a dying person or their families afterwards.

This was first driven home to me when a close colleague in the US started up a blog to keep his many friends informed about the progress of his advanced cancer, which took his life about nine months after diagnosis. He was Jewish, but in the years I knew him I sensed he  was not very observant.  Every post he made on the blog attracted many responses letting him and his family know that people were praying for him, that God would surely show mercy and give him strength and so on.

These people were telling him they were going well beyond just being concerned about his progress, or that they held him in their thoughts; that they knew he was courageously “fighting” his disease, or was showing enormous character in writing the blog in the face of his illness. In praying they were somehow suggesting that this news would be received as helpful. The subtext was  that their prayers might somehow turn the progress of the cancer around. They were offering hope against hope that their prayers would not only bring comfort but would work.

There are many who seriously believe that if they and others pray for a sick or dying person, that this will actually make a difference. They have faith that the power of prayer is real and consequential.

A Cochrane systematic review of trials of intercessory prayer’s impact on health outcomes completed in 2009 reported on:

“whether there is a difference in outcome for people who are prayed for by name whilst ill, or recovering from an illness or operation, and those who are not. Both groups of people still received their usual treatment for their illness. Ten trials were found which randomised a total of 7646 people. The majority of these compared prayer (for someone to become well) plus treatment as usual with treatment as usual without prayer. One trial had two prayer groups, comparing participants who knew they were being prayed for with those who did not.  Another trial prayed retroactively, randomising people a month to 6 years after they were admitted to hospital. Each trial had people with different illnesses. These included leukaemia, heart problems, blood infection, alcohol abuse and psychological or rheumatic disease. In one trial people were judged to be at high or low risk of death and placed in relevant groups.

Overall, there was no significant difference in recovery from illness or death between those prayed for and those not prayed for. In the trials that measured post-operative or other complications, indeterminate and bad outcomes, or readmission to hospital, no significant differences between groups were also found. Specific complications (cardiac arrest, major surgery before discharge, need for a monitoring catheter in the heart) were significantly more likely to occur among those in the group not receiving prayer. Finally, when comparing those who knew about being prayed for with those who did not, there were fewer post-operative complications in those who had no knowledge of being prayed for.

The authors conclude that due to various limitations in the trials included in this review (such as unclear randomising procedures and the reporting of many different outcomes and illnesses) it is only possible to state that intercessory prayer is neither significantly beneficial nor harmful for those who are sick. Further studies which are better designed and reported would be necessary to draw firmer conclusions.”

So what can those of us who cannot with any sincerity say that we are praying for a dying person or believe in any sort of afterlife say that might be welcome and comforting to the dying and their loved ones? When I’ve had occasion to write or speak to a friend who is dying, I’m terribly conscious that they might be clinging to even thin threads of hope that they will miraculously survive.  So that last thing I’d want to do at such a moment is to callously assume the dying friend should, however irrationally, abandon hope.

On the night my own mother died, her last words to me and my father gasped through her feverish hypoxia from cancer in her lungs, was that she would tell her GP the next day that she wanted to take a final chance with a new drug trial. To pull that last hope from her would have been unspeakable. (see p69 here)

The imminence of a person’s death makes me always think about what I imagine they might like to hear from those who are important to them. When they are gone, we do this in absentia at memorial services and wakes which can be very emotional and cleansing. I always think, gee, wouldn’t it have been lovely for them to have attended their own memorial and heard people say all these heartfelt things when they were alive.

What I wrote to a friend

On June 28 this year, we lost a beautiful friend, Euan Tovey, to pancreatic cancer.  Late in 2023 when it seemed likely that he might not even make Christmas, his family contacted his best friends and asked them to make a contribution to a book they would assemble before he died. I thought this was a brilliant idea where all those important to him would tell him what he had meant to them. He lived to read the book.

We had spoken at length in his months after diagnosis about his prognosis. He knew he would die, but wanted to live as comfortably as possible for as long as he could. We discussed voluntary assisted dying. He too was an athiest, so our conversations were devoid of all you would expect.

I wrote the following for the book to underline the boundless affection I felt for him across our friendship.

Euan, my dear friend

I knew of you before I met you. My best recollection of how we finally met was that we both quite often seemed to be in need of coffee around the same time. So it was one day in Ralph’s café at the university that you introduced yourself as we waited.

You must have known of me too and seemed as curious as I was delighted. We get instant impressions of some people, while others need to percolate across many encounters before any sense of who they are begins to form.

You are one of the instant category. If a Martian asked me to explain what a “transparent person” means, I would walk them around to your place, knock on the door and introduce you.   You are so much of an open book, and it’s that which I think is both the foundation and the glue that has bound us these past years, opening up all the enchanting things that I’ve found in you.

Please spare me from stitched up people for even a moment longer than circumstances sometimes necessitate. But your voice on the phone or the thought of a night out with you and Lib has always put a big smile on my face.

Your candour, friendliness, sparkle and warmth were there right from the start. I knew pretty much immediately that I liked you.  You would be someone who if we passed on campus or in the street, I’d always want to stop for a chat.

Those brief encounters at Ralph’s went on for a few years before we began seeing each other in the way we do now. When I retired in 2016, I sensed that your proximity a few streets away would foment us seeing each other more and more.

It didn’t harm things that Trish was all a-tremble with excitement at getting to know your very famous wife. But you quickly became the icing on that wonderful cake for her. As gigs followed dinners, we seemed to enter your inner circle of special friends, being invited to your end-of-year drinks and even deeper into the rituals of your family on-line quiz during COVID. We were very touched and delighted by all this.

You rapidly became a couple we wanted to share around too. I recall directing you to Martyn and Mim’s house at Rous Mill in the hinterland of Lismore. Martyn called me right after you left and said “wow, what beautiful people those two are.”

The Friday walkers reacted the same way. Everyone felt you both were such a perfect part of the group. Everyone was so pleased Lib could come to the dinner on Saturday. You were very missed.

Trish quickly added you to her very short but highly esteemed list of ”real men” who can make and fix stuff.  “Why can’t you be more like Euan, Simon? He’d know how to fix this.”, she’d regularly say or imply, with her withering accuracy.

When I had COVID in December last year, you thoughtfully dropped off an air purifier you had knocked up with a few sheets of plywood, some industrial strength rubber bands and god knows what other gadgetry inside. We marvelled at your home recording studio, your mask prototypes and of course your retro-fitted round Australia HiAce shaggin’ wagon.

Here, we also noted more than once, your allusions to your private ribaldry. “That pair!” we’d say with huge affection.

It wasn’t all good. I confess to being very disappointed that your Kiwi accent is barely noticeable. I am a bit of a chameleon with accents, quickly adopting the accents I’m in conversation with. The south island Un Zud accent is particularly infectious.

I am also very envious of your luxurious mane and your bold shirts.

But what I will miss about you more than anything Euan, is that I know I will have lost what I unequivocally feel is a man who is one of my very closest friends. I have many female friends, but not so many males I feel very close to.

I’ve sometimes been asked  by interviewers doing profile pieces “if you could change anything in your life until now, what would it be?” I often answer that I so regret not starting to watch AFL and my beloved Swans until about 20 years ago. I wasted 30 years watching the sporting equivalent of hillbilly music in following rugby league, when I could have been watching the balletic spectacle and poetry of AFL.

But I know with absolute certainty that I will from now often say that I lost all too early a very dear friend with whom I had a near-perfect rapport, tastes and love of conversation. He could even cook superbly. We only knew one another well for about 10 years.  I will miss you deeply, my dear friend. I so wish we had met 20 years ago. I feel cheated.

Trish and I hope you will take lots of comfort from knowing that we will fold Lib closely into our lives after you are gone. We have loved our growing friendship and count you both among our dearest friends. 

I came home yesterday from tennis to find Trish sitting on the lounge sorting through her recordings of her singing lots of songs with her uke. The one that was playing as I entered the room was Aretha Franklin’s I say a little prayer.  Listen to it here.

 We both have no time for religious malarky, so you know I have not been beside the bed praying for you. But the religious imagine they have a direct line to the fixer man, and so are doing something actively virtuous.

We’ve been saying our little secular prayers for you, so Trish’s song seemed apposite (of course, extend the sentiments in the words wider than it being a romantic love song).

I’ll end with the (English) words to a Herman Hesse poem, Bein Schlafengehen, that Richard Strauss set to music in his incomparable Last Four Songs. This Elizabeth  Schwartzkopf version is the best.

We played it at my mum’s funeral. The words and music always bring me to tears of sadness and joy at my many memories.

Going To Sleep

Now the day has wearied me.

And my ardent longing shall

the stormy night in friendship

enfold me like a tired child

Hands, leave all work;

brow, forget all thought.

Now all my senses

long to sink themselves in slumber.

And the spirit unguarded

longs to soar on free wings

so that, in the magic circle of night,

it may live deeply, and a thousandfold.

Hermann Hesse (from Richard Strauss’ Last four Songs)

Euan Tovey

Memorable journeys: Riding the Marrakech express

21 Monday Oct 2024

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Throughout my life, there are places and cities that have hypnotized me with the mere sound of their names, their history and promise. I’ve been to a few: Bali, Paris, Salamanca, Granada, Barcelona, Paris, Iceland, Khartoum, Herat, Kandahar and Kabul, Istanbul, Urbino, Naples, Luang Prabang, Hanoi and Lijiang, Yunnan are some. 

There are many I’ve not managed to yet visit: Senegal, the Congo, Mali, Trinidad, St Petersburg, Zanzibar, Samarkand, Kyoto and Mexico City.

Then there is Fes in the north east of Morocco. When I first heard the name as a boy, I went straight to the encylopaedia and drank in the information. Imagine a city named after a hat, or was it that the hat was named after the city?

We were having a holiday in Italy and needed to go to Barcelona where I’d been invited to give a lecture. So let’s fly from Rome to Fes, take the train to Marrakech and then fly up to Barcelona! It was all about to happen.

Our flight went via Casablanca. Mid flight Trish read in the guide book that hotels were known to refuse couples with different surnames a shared room. Oh dear, that was us. We composed a text to the kids back home, describing where they could find our marriage certificate. Send us a photo please. We sent it from the transit lounge at Casablanca and received the photo as we disembarked at Fes about an hour later. The reception desk guy at the beautiful, secluded riad where we had booked a room just within the walls of Fes’s old town (the medina), could not have cared less, so we kept the marriage certificate photo to ourselves.

We arrived in Fes after dark on November 12, 2004, the day after Yasser Arafat had died. It was also about a week after the revelations of widespread torture by allied troops in Abu Grahib prison in Iraq had rocked the world. And it was the day before the end of the Islamic holy month of Ramadan. And amid all this, here we were: two infidels in Fes, one of the more conservative cities in Morocco. We sensed that this confluence was not exactly propitious for our time in the city.

The next morning after breakfast in the marble courtyard of the ancient riad, we walked the 300m to the huge gates leading into the ancient labyrinthine souk. We passed coffee shops filled with men talking and playing cards and dominoes. There were no women in these. None. As we approached the gate about 15 young boys aged about 12 to 16 surrounded us, all trying to get our custom as guides around the vast souk.

We’d both been in many tourist places where you are pestered continuously by shopkeepers, massage services, cafes, guides and taxi drivers. You refine strategies for declining and then are generally little bothered by their efforts. But Fes was like nothing we’d ever experienced, till then or since. The boys were absolutely insistent that we select one of them as a guide. This looked like a recipe for interminable visits to their many ”uncles’” shops for tawdry souvenirs with zero appeal and massively inflated prices for gormless tourists.

So we held our ground, slowly moving in the centre of this swarm of touts, who rapidly became more than insistent: they began firmly grabbing us both by the arms and clothing, as we clutched our day bags for dear life fearing an imminent robbery. We soon turned and strode back toward our hotel. Trish was quite shaken  demanding that we  get out of there.

Back at the hotel almost as soon as we’d left, the concierge calmly tried to have us see that what we had experienced would instantly disappear if we simply chose a guide. The others would melt away and there would be no further harassment. We were not going to spend days in Fes without exploring its fabled souk, so we relented. I went straight up to a boy who exuded street smarts and toughness. The concierge had told us to pay no more than $25 for half a day in the vast market. Our guy agreed immediately.

We set off and just inside the gates of the souk, he led us into what looked like an abandoned old building of four or so stories (see photo). There was no one to be seen in or outside it. We crossed the dilapidated courtyard with a waterless fountain, following him as he headed to an internal staircase. Two flights up and not seeing daylight above, things started quickly feeling ominous. We’d seen no one since entering the building. What a perfect place for a hand over of your bags in a money ambush by his pals we’d yet to meet. Maybe worse, given the week’s events I described.

Abandoned house we were drawn into in Fes

We stopped going up the stairs and he came back down a flight for us. “What are we doing here?” I asked. “Beautiful view” he pointed above us. We sheepishly continued expecting any second to be surrounded by a bunch of brigands. But we emerged from the stairs on to the roof, to see an astonishing panoramic view of the roof of the souk, the old town and much of the new, more modern city in the distance.

He was starting our tour with a jaw-dropper, and one that we sensed would be nowhere to be found in guidebooks or brochures for tourists. We immediately relaxed.

The souk seemed unending, with endless rug, pottery, leather, pouffes, dates, butchers, basketry, spice, lamps, locks and hardware, clothing, body oils, barbers and cafes. We sampled plump, succulent dates of various colours and saw several severed camel heads swinging on steel hooks in butchers.  It was permeated with cooking smells and the stench from open air leather curing ponds. We were unavoidably steered into rug shops by the most polished salesmen I have ever encountered. They seemed to read our tastes by our gaze on particular rugs and our cost pinch points. We left with two which we later regretted and sold on eBay.

The Blue Gate, Fes
The Blue Gate
Camel head with banana, Fes
Trish with teacher & class in madrassa, Fes
the fragrant smelling tannery, Fes

More than one shop keeper, seeing my hairy forearms, gripped me and looking at Trish knowingly declared I must be a virile “Berber man”. The greeting has secured its place in our house in the years since.

A chameleon on the Berberman’s arm

One evening we shared a table in our riad with an American couple. They invited us to share the cost of a day trip in an ancient large Mercedes to the small city of Meknes and the nearby ruins of Volubilis, inhabited for 600 years from 300BC till 300AD. Ruins are mostly low on my travel priorities, but the many extensive Roman mozaics were quite wonderful. Do not miss them if you’re ever out that way.

Volubilis

The next day we boarded the train bound for Marrakech. It would take us through Meknes, Rabat and Casablanca and was amazingly cheap.

An enduring memory was that across almost the entire trip, it seemed obvious that local people used the area on either side of the rail tracks as a place to dump their rubbish. It was an 8 hour almost continual ride through a narrow dump, but averting your eyes upward was often a treat.

I texted dozens of friends “Do you know we’re riding on the Marrakech express?” with a link to the Crosby, Stills and Nash classic.

We shared our small compartment with two elderly men, who wore garments that suggested they were Muslim clerics. The two of them almost constantly fingered prayer beads across the whole trip, talked very little to each other and avoided eye contact with us.

At Casablanca, a young woman probably in her early 20s joined our cabin. I saw her struggle to lift her suitcase into the luggage rack and immediately helped her up with it. As she hoisted it up, her shirt rode up revealing her stomach and back. The clerics did not avert their gaze. She spoke English well so chatted with us as well as in Arabic with the clerics, listening to music through her ear pieces and reading western fashion magazines. Here was a small microcosm of the old and new of Moroccan society, seemingly mutually tolerant.

We stayed in a small riad in a laneway just off Marrakech’s main Jemaa el Fnaa square and market. Across only two days we skimmed the surface of what was a fabled, exotic city from our childhood reading.  A few photos give some glimpses. A vivid, unforgettable trip.

The imminent death of teenage smoking

15 Tuesday Oct 2024

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[extra material added 17 Oct 2024 — see Dai et al below]

By any measure, Ken Warner, Avedis Donabedian Distinguished University Professor Emeritus of Public Health at the University of Michigan, is one of the giants in the history of tobacco control. I have known Ken since the  early 1990s, after he editorialised one of my earliest papers. We were both 2003 recipients of the American Cancer Society’s global Luther Terry Medal and have had decades of mutual respect.

He has written a glowing endorsement for one of my books and references for promotions and awards.  When I retired from the University of Sydney in 2015, my head of school invited me to select a global figure who could be the main speaker at my festschrift. I didn’t hesitate to name Ken, who gave this lecture after which we spent a few great days on the NSW north coast.

Ken Warner 21 May 2015, Sydney University

At that time Ken was showing early enthusiasm for the promise of e-cigarettes as a major new weapon in reducing smoking and the diseases it causes. I was far more circumspect, having provided one side of a debate in the BMJ in 2013 and a crystal-balling piece on the promises and threats  in 2014.

In the years since, I’ve seen him rapidly firm in his positive views about the public health importance of vaping,  In 2018, an internal document  from the vapes manufacturer Juul Labs included Ken’s name on a list of ratings of 18 “collaborators” ranking him 7 out of a maximum 10  and noting that he was “positive on all scenarios” about vaping.  I was listed as one of 10 “current opponents”.

We have rarely exchanged views on the issues in the nine years since his trip to Sydney, although I have received comments from friends of him eye-rolling when my name has come up. He’s a true believer in vaping, while I’m a sceptical apostate in circles he frequents.

Warner has just published a piece in the American Journal of Public Health titled  Kids are no longer smoking cigarettes: why aren’t we celebrating. It’s generally excellent, celebrating the near-to-zero high school smoking rates in the US, and principally attributing the declines to the unabating massive cultural denormalisation of smoking (“The principal answer is a major change in social norms”) This was set in motion by the application of evidence-based policies about what would drive youth smoking down across whole populations.  He’s incredulous – as am I – that not more prominence and celebration has been made of youth smoking all but having disappeared.

He declares, and I again agree, that “By any measure, youth smoking has nearly ceased to exist.” The nearing extinction of youth smoking has confirmed tobacco control as the poster-child of chronic disease control. The achievement is precious silverware that has been hard fought for and needs vigilance against both predators and complacency to ensure that it will never rise again.

Warner wonders whether the tobacco industry “may be giving up their age-old pursuit of ‘replacement smokers’”, its coded euphemism for recruiting new teenage smokers. Is there anyone who believes that they would find these developments a bitter, force-fed pill that they would dearly love to reverse?

Here are the US data on 8-12th graders’ 30 day smoking.

Source

We have a very similar situation in Australia (see chart below), with smoking in the last week falling between 1999 and 2022-23, the latest data year available. The US has seen senior high school prevalence drop like a stone from 36.5% in 1997 to 1.9% in 2023. Australia has seen the same age group’s weekly smoking rate fall from 30% in 1999 to 3% in 2022-23 (monthly smoking is 3.4% (12-15y) and 5.2% (16-17y). The US is thus a little ahead of Australia with teenage smoking, with both nations seeing smoking spiralling toward tiny proportions.

Source

However, there are several points in Warner’s paper which require comment when it comes to some of his assertions about vaping.

Warner’s presentation of the US data frames teenage vaping as predominantly a phenomenon of kids who smoke also vaping. He writes that:

“In 2022, 9% of never-smoking high school students had vaped in the past 30 days, 3% frequently (≥ 20 days). In contrast, 54% of ever-smoking students had vaped in the past 30 days, 34% frequently. Still, that 3% of never-smoking students vape frequently is a legitimate source of concern.”

Here, highlighting the much larger proportions of smokers who vape gives the impression that it’s overwhelmingly school students who have smoked who dominate teenage vaping in the US, with those who’ve never smoked, being comparatively less likely to be vaping.

But looking at the numbers  behind these proportionspaints a very different picture. 

With never-smoking youth being (by far) in the majority, even small vaping participation rates among them could translate to greater numbers of vapers than among the much smaller proportions of youth who smoke. So here’s how the numbers fall.

The table below constructed from the dataset here  by colleague Sam Egger shows that of 15884 students, 1265 vaped in the past 30 days who had never smoked, compared to 931 who had ever smoked. In other words, in terms of sheer numbers, the problem of vaping is worse for the never-smoker group compared to ever-smoker group.  So if you saw random student vaping in the US, there would be a 58% (=1265/(1265+931)) probability that this vaper would be someone who had never smoked compared to a  42% probability that it would be someone who had ever smoked.

When it comes to more frequent vaping, this situation is reversed with 58% of those who vaped on ≥20 of past 30 days being ever-smokers (=583/(583+425)) compared with 42% who were never-smokers.

This way of looking at it presents the situation in quite a different light. Focusing on column percentages in the table below frames the situation as very much it being a case of smokers doing the vaping. But  focussing on row numbers  demonstrates that vaping is very much a more comparable phenomenon between ever- and never-smokers when it comes to actual numbers of youth who are vaping.

In Australia (see Figure 16), more than two-thirds (69%)  of 12-17yo school children who vaped  “reported having never smoked a tobacco cigarette before their first vape. One in five (20%) students who had never smoked prior to trying an e-cigarette reported subsequent smoking of tobacco cigarettes (i.e., at least a few puffs).”

Vaping by US high school students, 2022 in National Youth Tobacco Survey

 Never-smokeEver-smoke
 (n=14164)(n=1720)
Vaped in past 30 days
No12899 (91.1%)789 (45.9%)
Yes1265 (8.9%)931 (54.1%)
Vaped on ≥20 of past 30 days
No13739 (97.0%)1137 (66.1%)
Yes425 (3.0%)583 (33.9%)

Frequencies are weighted by weights provided by NYTS to account for the complex survey design and to produce nationally representative estimates. Excludes n=234 with missing data on vape or smoke variables

Is vaping by kids all but benign?

Warner’s paper emphasises that vaping is far less dangerous than smoking, and that nicotine in itself in the doses obtained through smoking or vaping is likely to cause inconsequential health problems, apart from the non-trivial economic costs of nicotine dependence.  I have several caveats about his summary.

There is no shortage of evidence that vapes deliver often far less of key carcinogens and toxicants than do cigarettes. This evidence includes biomarker research showing that vapers have less of these nasties in their bodies. Warner summarises this as: “In fact, smokeless tobacco products sold in the United States create substantially less risk than does smoking”

But vapes and cigarettes are very different beasts: cigarettes are the Mt Everest of risk but vapes contain chemicals that cigarettes don’t contain, and the puff parameters for vaping are very different from those for smoking.

“the contention that nicotine can damage developing adolescent brains or harm health in other ways”.

Here Warner argues “Most research regarding brain effects is based on animal models but with potential relevance for humans.” Prominent vaping advocates have often ridiculed the relevancy of animal studies for humans, elevating this to meme status in true believers about vaping.  But “potential relevance” is surely a huge understatement. Of the 114  Nobel Prize winners in  medicine and physiology between  1901 and 2023, 101 (88.6%) used animals in their research.  Now what would such eminent researchers know that vape advocates seek to dismiss?

Warner continues: “the lack of evidence of brain damage in previous generations of people who smoked mitigates this concern.”

This is quite a sweeping statement, unreferenced.

It’s been frequently noted that smokers are increasingly concentrated in less educated, economically disadvantaged  sub-populations.  Low education and low IQ are clearly correlated, so it’s unsurprising that cognitive concerns may be more prevalent in smokers. But there is also significant evidence that smoking may also be causative for cognitive and psychiatric problems.

For example, in this cohort study of over 20,000 Israeli military recruits, analysis of brothers discordant for smoking found that smoking brothers had lower cognitive scores than non-smoking brothers.

This prospective cohort study examined the association between early to midlife smoking trajectories and midlife cognition in 3364 adults  (1638 ever smokers and 1726 never smokers) using smoking measures every 2–5 years from baseline (age 18– 30 in 1985–1986) through year 25 (2010–2011). Five smoking trajectories emerged over 25 years: quitters (19%), and minimal stable (40%), moderate stable (20%), heavy stable (15%), and heavy declining smokers (5%). Heavy stable smokers showed poor cognition on all 3 measures compared to never smoking. Compared to never smoking, both heavy declining and moderate stable smokers exhibited slower processing speed, and heavy declining smokers additionally had poor executive function.

In this Finnish longitudinal cohort twin study data (n=4761) from four time points (for ages 12, 14, 17, and 19-27 years) “were used to estimate bivariate cross-lagged path models for substance use and educational achievement, adjusting for sex, parental covariates, and adolescent externalizing behaviour.”

Smoking at ages 12 and 14 “predicted lower educational achievement at later time points even after previous achievement and confounding factors were taken into account. Lower school achievement in adolescence predicted a higher likelihood of engaging in smoking behaviours … smoking both predicts and is predicted by lower achievement.”

In a cohort study of 11 729 children with a mean age of 9.9 years at year 1 Dai et al used structural magnetic resonance imaging measures of brain structure and region of interest analysis for the cortex, 116 children reported ever use of tobacco products.  Here’s an edited version of the results and conclusions.

“Controlling for confounders, tobacco ever-users vs nonusers exhibited lower scores in the Picture Vocabulary Tests at wave 1 and 2-year follow-up. The crystalized cognition composite score was lower significantly lower among tobacco ever-users than nonusers both at wave 1 and 2-year follow-up. In structural magnetic resonance imaging, the whole-brain measures in cortical area and volume were significantly lower among tobacco users than nonusers. Further region of interest analysis revealed smaller cortical area and volume in multiple regions across frontal, parietal, and temporal lobes at both waves. In summary, initiating tobacco use in late childhood was associated with inferior cognitive performance and reduced brain structure with sustained effects at 2-year follow-up.”

Nicotine not a culprit?

Warner states that “nicotine per se is not the direct cause of the diseases associated with tobacco. Rather, it causes persistent use of the products that expose users to the actual toxins.”  This proposes that nicotine is not a health problem, only a benign vector for health problems.  

In 2019 I compiled this selection of research about concerns with nicotine  published in notable journals including Nature Reviews Cancer, Lancet Psychiatry, American Journal of Psychiatry, Mol Cancer Res, Critical Reviews in Toxicology, Carcinogenesis, Mutation Research, Int J Cancer, Apoptosis and  Biomedical Reports. These concerns are seldom mentioned by those who recite Michael Russell’s dictum that “People smoke for the nicotine but they die from the tar” as a talisman against any expressed concerns about nicotine.

I’ve also listed numerous recent reviews of the emerging evidence about vaping and precursors of respiratory and cardiovascular disease. This evidence hardly describes an assessment of vaping as a benign practice akin to inhaling steam in a shower or having a couple of cups of coffee a day,  analogies I’ve  heard used by vaping advocates.

Importantly too, there is no mention in Warner’s paper about two key ways in which vapes importantly differ from smoking.

A: Flavouring chemicals in vapes

Flavours are a leading factor that attract and keep people vaping: the beguiling cheese in the nicotine addiction mousetrap. But as has often been pointed out, none of the many thousands of flavours available in vapes have ever been assessed as safe for inhalation. Many of the chemical flavouring compounds in vapes have GRAS (Generally Regarded As Safe) ratings as food and beverage additives for ingestion. But it is elementary in toxicology that different routes of consumption (skin, inhalation, ingestion, rectal insertion) have different risk profiles.

Tellingly, no flavoured inhaled asthma or COPD medicines (used by hundreds of millions globally) have ever been approved by therapeutics regulators anywhere in the world, yet vaping advocates typically shrug dismissively about possible risks in the intensive inhalation of flavours in vapes.

Dow Chemical, a major manufacture of propylene glycol (the most common excipient in vape liquid) in 2019 explicitly named PG in vaping devices and accessories as a “non-supported application”.  With the vast earnings potential for Dow in embracing PG in vapes, clearly the risk exposure to the company in doing so must have been assessed as massive.

Warner cites several examples of the public and health professionals holding clearly incorrect views about particular dangers of vaping, as if the jury is already in on the net effects of harm into the future – the whole point with chronic disease control. Yet he sensibly agrees that it is too early to know if there will be any long-term health problems that might arise from vaping.  The median age for diagnosis of asbestos-caused mesothelioma is between 75-79. For lung cancer, it’s 71. If putative health problems from vaping have similar latency periods from first exposure to diagnosis, we may have a long wait before this issue is settled.

B: Inhalation frequency

The average daily smoker in Australia in 2022-23 smoked  15.9 cigarettes day and a typical puff frequency per cigarette in leisurely situations is 8.7, giving 138 puffs per day. Observational studies of vapers show that average daily puff frequency on vapes is likely to be north of 550 times. In one study (2016), researchers observed vapers using their normal vaping equipment ad libitum for 90 minutes. The median number of puffs taken over 90 mins was 71 (i.e. 0.78 puffs per minute or 47.3 per hour). Another (from 2023) found those using pod vapes took an average of 71.9 puffs across 90 minutes, almost identical to the 2016 study number.

But of course vapers do not vape across only one continuous 90 minute period each day. No studies appear to have calculated average 24 hour vape puff counts. But if we (conservatively?) assume 8 hours of sleep and 4 waking hours of no vaping, then a person vaping for 12 hours a day at this 47.3 puffs per hour rate, would pull 568 puffs across a 12 hour day deep into their lungs, 207,462 times in a year and 2.075 million times across 10 years.

This compares to daily smokers taking 138 puffs a day, 50,405 times a year and  504,050  times in 10 years: 4.12 times less. Cigarettes and vapes are very different products, but the almost frenzied puff frequency we see with daily vapers where each puff sees excipient chemicals like unapproved flavourants and PG pulled deep into the lungs throughout the day should raise red flags.

Australia’s approach to vaping regulation which I have strongly supported has landed at access by adults only via pharmacies, a ban on the importation of vaping products other than those destined for the pharmacy channel, and truly weapons-grade deterrent penalties for any person or corporation breaching these laws.

This has been the approach governments have long used to regulate access to methadone and other narcotics used in pain control, medicinal cannabis and every prescription pharmaceutical. Despite the demand for these products, no government is planning a free-for-all for these products in corner shops. It is very early days, with major busts of flagrant selling likely imminent. Australia has pioneered several tobacco control policies which have dominoed globally.  I expect to see the same happen with our vaping regulations.