The dirty dozen: twelve myths about e-cigarettes

[updated 29, 30 Sep, 15 Nov 2019] Advocates for e-cigarettes often appear to display cult-like adherence to a set of beliefs. Like beings possessed of inviolable truths, they repeat these as often as possible. Here are 12 articles of vaping faith, and why they are highly questionable.

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  1. E-cigarettes are 95% less harmful than smoking

The “95% less harmful” claim was first made in a 2014 report chaired by Professor David Nutt, notable and perhaps unique in publicly declaring that e-cigarettes are “the most significant advance [in medicine] since antibiotics” and would be “the greatest health advance since vaccinations.” Seriously. The report was written by a selected group of 12 individuals who each were asked to estimate the relative harmfulness of e-cigarettes and other nicotine containing products compared to cigarettes. Their Big Number was repeated in a 2014 report by Public Health England, which again endorsed it in a 2015 update where it once again cited the Nutt report as a source, but again provided no transparent workings of how this figure was actually calculated. This is all PHE deigned to tell us in 2015:

 “It had previously been estimated that EC [electronic cigarettes] are around 95% safer than smoking [10, 146]. This appears to remain a reasonable estimate.”

Reference #146 in the above update stated “The precise extent of harm from long-term use is not known but has been estimated at around 1/20th that of smoking tobacco cigarettes (5)” with the reference supporting that statement being – you guessed it – the Nutt report!

In its 2018 updated review PHE nudged the 95% even further toward certainty by slipping in “at least”:

 “Vaping poses only a small fraction of the risks of smoking and switching completely from smoking to vaping conveys substantial health benefits over continued smoking. The previous estimate that, based on current knowledge, vaping is at least 95% less harmful than smoking remains a good way to communicate the large difference in relative risk unambiguously so that more smokers are encouraged to make the switch from smoking to vaping.”

The 2016 report of the Royal College of Physicians had this to say about the 95% less harmful figure:

“An analysis based on expert opinion quantified the likely harm to health and society of e-cigarettes at about 5% of the burden caused by tobacco smoking,(112) and a recent report by Public Health England supported this conclusion.(113)With appropriate product standards to minimise toxin and contaminant exposure in       e-cigarette vapour, it should be possible to reduce risks of physical health still further. It is also possible, although unlikely, that other, unexpected harm from inhaling e-cigarette vapour over the longer term might yet emerge. Although it is not possible to quantify the long-term health risks associated with e-cigarettes precisely, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.” (p84)

“There appear to be few, if any, significant short-term adverse effects of e-cigarette use, but adverse health effects from long-term exposure to constituents of vapour cannot be ruled out. Although unknown, the hazard to health arising from long-term vapour inhalation is unlikely to exceed 5% of the harm from tobacco smoke.” (p185)

Reference 112 cited by the RCP was, yet again, the Nutt report. Indeed, all roads from the 95% estimate since 2015 have led back again and again to the Nutt report, or in the case of the PHE 2018 update, to no references at all tied to the calculation.

But what did the Nutt report itself  say about its now famous number? Critically, the Nutt group conceded that “A limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria”.

In 40 years of academic life in public health, and after editing a research journal (Tobacco Control)  for 19 of these, I don’t ever recall reading such an eviscerating “actually, we have no evidence” caveat about the foundations of a supposed scientific risk assessment.

Despite this most sweeping and fundamental of caveat emptor statements about the lack of hard evidence, a senior Public Health England official told an Australian Parliamentary inquiry in October 2017 that “We are very clear that this is just one of the figures that we have used, and there are plenty more. We say what really matters is the evidence underlying this figure from the Nutt report”. (my emphasis).

So where then, is this “what really matters” underlying evidence which is not cited in the Nutt report nor in Public Health England’s reports? Where can we read and critically appraise the calculations that tipped the figure out into the ether?

Certainly  in this video where Martin Dockrell of Public Health England  explains how the magic number was conjured, there’s no reference to anything  other than the consensus process used by the assembled Nutt meeting invitees, of which he was one.

Interviewer: Describe for us the evidence in the report and what is the science behind the 95% less harmful determination.

Dockrell: “…95% less harmful or 5% of the harm  is a good way of expressing that – that subsequently appeared in the Royal College of Physicians report, It first appeared in a report published in 2014. It was led by Professor David Nutt. And David had done this kind of study before where it was a professional consensus process where you get a bunch of experts in the room. .. and we looked at what data we had for example on fires … we looked at what evidence  we had about cancer risk  and toxicant exposure and we had some data on that. And on the basis of the data we had [describes which nicotine containing products were compared] ..them the computer churns out a figure and we see .. e-cigarettes coming out at 5% of the risk…

Interviewer: You’ve got the 5% of potential harm … how conservative is that? Like if you were to go through everything today would it be the same number?

Dockrell: Well we published that study 5 years ago and now we have 5 years,  more than 5 years more data. We have these excellent biomarkers studies. We know much more about e-cigarette vapour and how that might effect bystanders — not at all is the shorthand for that one.  And so, yeah it would depend on the experts  you got around the table [my emphasis] but I think that looking at the data that we’ve got even it would be less than 5%. It would be substantially less than 5%.”

A factoid is “an item of unreliable information that is repeated so often that it becomes accepted as fact.” The “95% safer” statement is nothing but a factoid that has attained an almost Trumpian-like resonance. It is an emperor with suspiciously few clothes.

  1. We don’t know the long-term effects of vaping but toxicology has advanced massively in past decades, so it’s not too early to now call e-cigarettes as all-but-safe

Cigarette use exploded at the beginning of last century after mechanisation replaced handmade cigarettes, making smoking very affordable. But tobacco-caused diseases didn’t start showing up in larger numbers until 30-40 years later.  The  US surgeon Alton Oschner, recalling  attendance at his first  lung cancer autopsy in 1919, was told he “might never see another such case as long as we lived”. He saw no further cases until 1936 — 17 years later –   and then saw another nine cases in six months. Today lung cancer is (by far) the world’s leading cause of cancer death.

The incidence of lung cancer rose rapidly in the decades 1930-1980 but it was not until 1950 that seriously compelling evidence was published in the USA and the UK that long-term smoking caused lung cancer. Knowledge about smoking’s causal role in other diseases followed.

If any scientist had declared in 1920 that cigarette smoking was all but harmless, history would have judged their call as dangerously incorrect. But this is the doctrinaire call that many vaping advocates are making regularly today, after just 10 years of use.

With vaping only having been around in large numbers for about ten years, it is predictable and unsurprising that we have as yet seen little clinical disease presenting from e-cigarette vaping, although the recent growing numbers of deadly serious respiratory diseases now appearing in the USA may be an early  canary in this coalmine.

The recent New England Journal of Medicine report of serious pulmonary disease in two states in 53 vapers with a median age of just 19, found that 17% of these patients reported vaping only nicotine products. British vape advocates have been quick to point out that none of these cases are occurring in the UK. Oh … wait …  hold the press. Here’s a case-report just in.

When many have pointed out this fundamental “too soon to know” problem, vaping defenders argue that toxicological science has progressed exponentially, with the implication being that we can now tell very early with a high degree of certainty if a drug or chemical is likely to cause disease down the track.

That would be all that advanced crystal-balling toxicology capable of detecting long term risk so brilliantly that between 1953-2014, 462 drugs initially assessed as being likely to be safe and let into the market have been withdrawn with some causing death, or very serious health problems. Remember thalidomide?

A reason why we have Therapeutic Goods Administration drug assessment, scheduling, adverse event reporting and the possibility of recall and bans is because pre-registration drug trials can never provide data on the consequences of long term use. In 2017 vaping activists were jubilant about a 3.5 year follow-up study of just 9 subjects (with another 7 having dropped out) which, hey presto, showed no “long term” ill-effects.  “Case closed: study shows no lung damage from vaping” screamed one report.

This baby-steps follow-up compares with the 30-40 years that passed before the huge upswing in smoking in the first decade of the twentieth century began to show lung cancer in case control studies in the early 1950s.

The recent door-stopper report on e-cigs of the US National Academies of Sciences, Engineering  and Medicine found:

  • There is substantial evidence that e-cigarette aerosols can induce acute endothelial cell dysfunction, although the long-term consequences and outcomes on these parameters with long-term exposure to e-cigarette aerosol are uncertain.
  • There is substantial evidence that components of e-cigarette aerosols can promote formation of reactive oxygen species/oxidative stress. Although this supports the biological plausibility of tissue injury and disease from long-term exposure to e-cigarette aerosols, generation of reactive oxygen species and oxidative stress induction is generally lower from e-cigarettes than from combustible tobacco cigarette smoke.
  • There is substantial evidence that some chemicals present in e-cigarette aerosols (e.g., formaldehyde, acrolein) are capable of causing DNA damage and mutagenesis. This supports the biological plausibility that long-term exposure to e-cigarette aerosols could increase risk of cancer and adverse reproductive outcomes. Whether or not the levels of exposure are high enough to contribute to human carcinogenesis

Reckless calls to just allow unregulated e-cigs to flood corner stores and be promoted with advertising like this promising “risk free” vaping and  within one corker of a self-contradictory sentence, that vapers can “entirely avoid the harm” while “lessen[ing] the possibility of inducing danger on your lungs” is the sort of world we are supposed to embrace by these flatulent arguments.

If e-cigs are so safe and so effective, their manufacturers surely have nothing to fear by applying for registration through the Australian Therapeutic Goods Administration. Why is it then, that no such applications have apparently been received? What might these manufacturers know or fear that the TGA might conclude?

  1. Nicotine is all but benign. It’s cigarettes that cause all the harm

Like pilgrims at a religious shrine, vaping advocates also have cult-like veneration for a statement by the late addiction research Michael Russell who stated in 1976 that “People smoke for the nicotine but they die from the tar”.

Since Russell made that statement a whole 43 years ago there has been  an extensive body of evidence published suggesting that nicotine, while not being carcinogenic, is a tumour promoter. For example:

“Although nicotine itself is regularly not referred to as a carcinogen, there is an ongoing debate whether nicotine functions as a ‘tumour promoter’. Nicotine, with its specific binding to nAChR, deregulates essential biological processes like regulation of cell proliferation, apoptosis, migration, invasion, angiogenesis, inflammation and cell-mediated immunity in a wide variety of cells including foetal (regulation of development), embryonic and adult stem cells, adult tissues as well as cancer cells. Nicotine seems involved in fundamental aspects of the biology of malignant diseases, as well as of neurodegeneration.”

This 2015 review of research relevant to nicotine and the adolescent brain looked at “how acute exposure to nicotine impacts brain development and how drug responses differ from those seen in adults.” The authors discussed “the persistent alterations in neuronal signaling and cognitive function that result from chronic nicotine exposure, while highlighting a low dose, semi-chronic exposure paradigm that may better model adolescent tobacco use” and argued “that nicotine exposure, increasingly occurring as a result of e-cigarette use, may induce epigenetic changes that sensitize the brain to other drugs and prime it for future substance abuse”.

Those like John Britton still asserting in 2019 that long term use of nicotine represents a health risk similar to coffee consumption might like to dive a little deeper into the toxicological literature on nicotine.

  1. The thousands of flavouring chemicals used in vape juice have all been declared safe by regulators

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There are now some 8000 beguiling and often child-friendly flavours being sold in e-juice [Allen et al, 2016; Barrington-Trimis et al, 2014]. Many of these have been approved for ingestion as food additives, but have never been approved for inhalation.  The U.S. flavouring industry has said about this important difference:

“The manufacturers and marketers of ENDS [electronic nicotine delivery systems], and all other flavored tobacco products, and flavor manufacturers and marketers, should not represent or suggest that the flavor ingredients used in these products are safe because they have FEMA GRASTM status for use in food because such statements are false and misleading”

Science journalist  Dr Heather Goldstone  put it beautifully like this (at 11m10to 24m50)

“It doesn’t take someone with an advanced degree in toxicology to understand that drinking water is different than breathing water”.

So beware of fake news that inhaling #vaping flavourants are benign because many used in food flavouring.

For some flavourants, for example cinnamon, there is already evidence for cytotoxicity [Behar et al, 2014] and for the very commonly utilised additive diacetyl, which produces a pleasant, buttery taste in e-liquid, there is an association with the causation of the non-reversible respiratory condition Bronchiolitis Obliterans [Farsalinos et al, 2015]. The English Cherry flavoured vaping fluids have also been demonstrated, via the inhalation of the irritant benzaldehyde, to be a potential concern for long term users [Kosmider et al, 2016].

Our knowledge of the impact of long-term inhalation, on average 200 times a day (and up to 600) over many years in daily vapers, of vapour arising from the heating of these chemicals is in its infancy.

  1. Many smokers have greatly reduced the number of cigarettes they smoke daily: this is no-brainer harm reduction in action!

If you smoke 20 cigarettes a day, and vaping sees you reduce this by half, surely anyone with half a brain can understand that this means you will have greatly reduced your risk of disease and death from smoking? But counter-intuitive as it seems, this is not what the evidence shows. Cohort studies which have followed large numbers of smokers for years have found that those who cut back the number of cigarettes they smoke but do not quit, experience negligible reductions in mortality.

A Norwegian cohort of 51,210 people followed from the 1970s until 2003 found “no evidence that smokers who cut down their daily cigarette consumption by >50% reduce their risk of premature death significantly.” A Scottish study of two cohorts followed from the 1970s to 2010 found no evidence of reduced mortality in reducers, but clear evidence in quitters and concluded “that reducing cigarette consumption should not be promoted as a means of reducing mortality.” The largest study, from Korea and involving 479,156 men followed for 11 years, found no association between smoking reduction and all cancer risk but a significant decrease in risk of lung cancer, with the size of risk reduction  “disproportionately smaller than expected”.

As illustrated in the table below, when randomly selected groups of vapers are followed up at 12 months, by far the most common outcome is that those who were smoking and vaping at the beginning of the 12 months study period will still be vaping and smoking at the end of the 12 months. That might suggest that the vaping holds far more in smoking than it tips out of it.(2018) colemantransitionssummary


Also, studies of the number of cigarettes foregone by dual-using vapers have shown that compared with smokers who never vape, that average daily cigarette consumption is little different. See for example below:Ecigs-trivial reduction insmoking 2016-02-21

  1. Secondhand vape is harmless and nothing to worry about

Our knowledge of the harms of secondhand smoke comes almost entirely from studies of non-smokers who live with smokers and those who worked in enclosed environments where smoking was allowed. While it is true that e-cigarette emissions are far less than those from combusted tobacco, they are very much not the equivalent of water vapour from a kettle, as a senior Philip Morris official recently tweeted (below). Vape consists of vapourised propylene glycol or vegetable glycerine, nicotine, flavouring chemicals  and often tiny metal particles (chromium, nickel and lead) shed from the heated metal coil in vaping equipment.

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Vape advocates argue, in all seriousness, that we should all be happy to allow vaping in all indoor spaces because this will discourage vapers from going outside and joining smoker where they might relapse back into smoking. As I wrote in a debate

“Another argument used by indoor vaping advocates is that indoor vaping bans will cause former smokers who now vape to go outside, where exposure to sensory cues from exiled cigarette smokers will trigger their relapse back to smoking.   This would be all the fault of non-smokers selfishly putting their own health and comfort ahead of vapers and contributing to their stigmatisation.  By this argument non-smokers should be happy to be exposed to ambient vape in aircraft, workplaces, restaurants and bars (or even sustained clouding sessions) to make e-cig users feel more “included” and in the hope that they might quit smoking.”

Importantly, vapers often gather together in social groups where they billow clouds of vape into the air producing particle concentrations comparable or greater to that found in bars when smoking was permitted. Vaping advocates want to wind the clock back and start fighting the same arguments that were won long ago over secondhand smoke exposure.


  1. E-cigarettes are a very effective way to quit smoking

There’s no shortage of individuals who swear blind that they had tried all sorts of ways to quit smoking until vaping worked for them. This is true for those individuals, just as there are success stories with methods of quitting like acupuncture, and hypnotherapy which have poor outcomes when assessed by principles of evidence-based medicine.  In this recent blog of mine, I summarized recent evidence from randomized control trials, cohort studies and national population data, the three most important sources of information.

In a recent RCT from New Zealand,  after six months 93% of the patches plus nicotine e-cigs group were still smoking; 96% of the patches plus nicotine-free e-cigs group had not quit; and 98% of the nicotine patches group were still smoking. The authors described the impact of the patches + nicotine e-cigs group as having attained “a modest improvement” in smoking cessation over patches alone.

I cannot think of any prescribed drug used for any condition where the condition persisted after 6 month use for 93% of users and where anything but the language of failure would be used about such an outcome. Is there anyone who would hail a 93% failure rate for contraceptives, antibiotics, cholesterol lowering drugs, analgesia, malaria prophylaxis or anything else as even a “modest” success?

  1. There are many smokers who just can’t quit, so we need e-cigarettes to help them

This claim derives from the so-called hardening hypothesis which states that, as smoking prevalence falls ever lower, the remaining smokers will be die-hard addicted “refractory” smokers who just can’t quit. They are impervious to the suite of tobacco control policies and campaigns that have driven hundreds of millions of smokers around the world to quit. It’s time we acknowledged that these smokers just can’t quit and so we are condemning many of them to death if we don’t put policies in place that will help them quit smoking with e-cigs. To do anything else would be unethical, they try to argue.

Aside from the dismal evidence referred to earlier that e-cigs are pretty hopeless in helping people quit, the entire premise of the hypothesis is an evidence-free house of cards.

Whenever this hypothesis has been tested against the evidence it has been found wanting. In nations or states where smoking prevalence has fallen most, one would expect (if the hardening hypothesis was correct) that indices of hardened smokers (such as mean number of cigarettes smoked per day) would be rising because the remaining smokers would be over-represented by heavy, addicted smokers.

Unfortunately for this argument, John Hughes, one of the world’s most respected and prolific researchers on smoking cessation, recently let all the air out of the hardening hypothesis tyres in a paper in Nicotine and Tobacco Research. He reviewed 26 studies on hardening and found:

“None of the 26 studies found that conversion from current to former smoking, number of quit attempts, or success on a given quit attempt decreased over time and several found these increased over time.” He concluded “Some have argued that a greater emphasis on harm reduction or intensive treatment approaches is needed because remaining smokers are those who are less likely to stop with current methods. The current review finds no or little evidence for this rationale.”

  1. Countries with lots of vaping have lower smoking rates than those which don’t. Look at England! Vaping has rapidly supercharged the fall in smoking

As at September 2019, the latest available data on smoking prevalence among five anglophone nations which are often compared shows that Australia and the UK are level pegging at 15.1% as nations with the lowest smoking prevalence.

  • Australia (2017-18 ages 18+): 15.1% (this figure includes cigarette and roll-your-own smokers plus all exclusive users of other combustible tobacco products like pipes, cigars, hookah and shisha)
  • USA: (2017 ages 18+) 16.7% (like Australia, includes all combustible tobacco product users)
  • Canada (2017 ages 12+): 16.2% (cigarettes & Roll Your Own tobacco only)
  • New Zealand (2016 ages 15+) 15.7%. (Māori adults 35.3%) (cigarettes & RYO only)
  • UK (2017 ages 18+): 15.1% (cigarettes and RYO only)

Most recently Victorian data on changes in smoking prevalence in that state between 2015-2018 show the lowest daily smoking prevalence ever recorded: 10.7% (down from 13.5% in 2015)  with falls in the most disadvantaged group down from 16.8% to 13%.

In summary, of these five nations, only Australia and the USA include all combustible tobacco products in their data on “smoking” prevalence, while other nations only include cigarettes (factory made and hand-rolled). The “smoking” prevalence figures from Canada, New Zealand and the UK thus underestimate the true prevalence of “smoking”. Australia and the UK have the same (lowest) prevalence of these nations, although UK data does not include combustibles (cigars, pipes, shisha) other than cigarettes. It is therefore likely that Australia has the lowest smoking prevalence. Yet it has the lowest prevalence of vaping and the most restrictive e-cigarette policies. You can go many days without ever seeing anyone vaping in Australia.

Vaping advocates argue that nations with widespread vaping are seeing their falls in smoking prevalence accelerate because of vaping. Just this month, the UK’s John Britton argued that while “it would be premature to attribute these differences in smoking trends solely to differences in electronic cigarette policy”  that “the figures do suggest that the UK approach of medical endorsement with marketing controls and product regulation has to date succeeded in harnessing the potential of electronic cigarettes to significantly accelerate the decline in adult smoking prevalence.”

Data from the Smoking in England project in the graph below show that the role of e-cigarettes in accelerating the downward trend in England is far from obvious or significant. The dramatic upsurge in smokers using e-cigarettes in quit attempts  using e-cigarettes that commenced in late 2012 and has more-or-less plateaued since mid 2013, does not appear to have had any marked impact on the slope of the historically declining smoking prevalence rate.

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An important report from late 2017 considered the surge in e-cigarette use in England and whether this was reducing the number of cigarettes being smoked at the population level across the country. The conclusions?

“No statistically significant associations were found between changes in use of e-cigarettes while smoking and daily cigarette consumption. Neither did we find clear evidence for an association between e-cigarette use specifically for smoking reduction and temporary abstinence, respectively, and changes in daily cigarette consumption. If use of e-cigarettes and licensed NRT while smoking acted to reduce cigarette consumption in England between 2006 and 2016, the effect was likely very small at a population level.”

Robert West is a world leader in smoking research, and the editor-in-chief of the journal Addiction. He told the BBC in 2016

“[This widespread use of e-cigarettes] raises an interesting question for us:  If they were this game changer, if they were going to be – have this massive effect on everyone switching to e-cigarettes and stopping smoking we might have expected to see a bigger effect than we have seen so far which has actually been relatively small” [my emphasis]

However, if we look at the data on smoking prevalence and changes in smoking affordability in the UK, we can see a rather different picture.

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  1. There are very few health agencies which don’t unequivocally support vaping and “light touch” e-cigarette regulation

Oh really? If you’ve got half an hour to spare, take a tour through this list of 46 global, regional and national agencies who very much beg to differ. The list Includes the World Health Organization, the US National Academies of Science, Engineering and Medicine, and just about every major US and Australian health agency.

  1. Big Tobacco is a minor player in the global vaping business

Vaping advocates like to paint pictures of plucky, noble start-up minnow vaping companies valiantly “game changing” the nicotine addiction landscape. “Big tobacco is not at the leading edge of either product innovation or sales” they protest. And in Australia, they point out that none of the transnational tobacco companies are selling their products here … yet.

The history of transnational tobacco company take-overs of profitable smaller tobacco companies shows us that the transnational companies gobble up all profitable or threatening small companies whenever they can. The same pattern is rapidly emerging with e-cigarettes.

Altria, which sells Marlboro in the USA, has bought 35% of Juul. This article describes the take-over of the e-cigarette market by Big Tobacco. All of these companies continue to resist and attack effective tobacco control policies, while posturing about caring about harm reduction.

  1. Tobacco companies are doing all they can to reduce smoking in concert with their efforts to promote vapourised nicotine products

Philip Morris International currently has a global “unsmoke” campaign trying to convince us all that it really, really wants all its customers to switch from cigarette to its putative reduced harm vapourised product, IQOS. In the tweet below it even profiled Bryan, a smoker who had given up all nicotine too! That’s right. Philip Morris has broken out the maypole and has all its employees and shareholders dancing around it each lunchtime because the company is doing all it can to get all its customers off all its products and publicly broadcasting its success stories!

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But the company has set no targets for its reductions and around the world. It’s business as usual trying to maximise sales of its cigarettes and its IQOS heat not burn product. It has its foot-to-the-floor promoting cigarettes in every market and doing what it can to oppose effective tobacco control which would actually reduce smoking.  Here are ten questions I put to Philip Morris about this sham, their reply, and my response.











Every school principal should write a letter like this



This letter from the headmaster, Michael Parker, of Newington College, Stanmore was sent to all parents and teachers of Newington College, Stanmore on 17 September 2019

The climate strike and our students

Statement from Newington at the end of the article.

Damn these Year Elevens. They come into my office asking me to support the climate strike. They tell me that it is their planet too and that they should be able to protest about what is the most important issue of their lives. They ask whether the school will stand up for them.

I don’t want to catch the political nuclear-grade hot potato that is the climate ‘debate’. I have a strategic plan on education to write and a Council retreat to prepare for. As well, I have always prided myself on being able to teach current affairs without my classes being able to work out which way I would vote in an election. I stay neutral and allow all points of view – sometimes to a fault. And, anyway, I am not a scientist.

But these kids say that they are probably going to live into the 22nd century and they are terrified about tipping points and a runaway greenhouse effect. They say that the climate science is overwhelming. They say that leaders in my generation are not doing anywhere near enough about it.

Heavily I consult my own conscience about climate science.

We teach our kids in Year Seven that the scientific method, whilst not irrefutable, is the best thing we have to work out physical truths about the world. We teach them that when there is a consensus amongst almost all reliable scientists, then they are probably right.

To prepare for the meeting with these Year Elevens, I have read the beginning of the 2014 report of the Intergovernmental Panel on Climate Change (the ‘IPCC’ – a pretty reliable group of scientists). Their chief point is that that human-made effects are extremely likely to have been the dominant cause of the observed global warming since the mid-20th century (SPM 1.2, p4). When they say ‘very likely’ they mean with 95–99% confidence.

Even more strikingly, the IPCC say ‘continued emission of greenhouse gases will cause further warming and long-lasting changes in all components of the climate system, increasing the likelihood of severe, pervasive and irreversible impacts for people and ecosystems.’ That’s severe, pervasive and irreversible impacts for the kids sitting in front of me – as well as my own children.

I think that accepting the reality of climate science is different to expressing political views. It’s a (pretty settled) opinion about a fact, not an opinion of evaluation. The IPCC may all be wrong in some bizarre mass hallucination or corrupt stitch-up job, but I very much doubt it.

But another climate strike?

I ask what’s going to happen when they want to march about immigration or abortion or any other issue. What’s to stop them marching out for that? They say I am committing a ‘slippery slope fallacy’ (damn those critical thinking lessons we teach them) and that climate change is different in kind to any of these issues because it affects the lives of everyone. Anyway, they say, all these other issues have all been prominent since the last climate change march and there have not been any student marches.

I point out the lessons that students everywhere will be missing – that they all need to be in school to get an education. They say to me that the very vision of Newington is for boys to make an active and positive difference in the world. Going on a march for climate fits the school’s vision better than one more regular day around the classrooms, they tell me. (Damn the school’s vision  – I should have seen that one coming).

Why not Saturday? I say. Show your commitment that way. ‘It’s not a strike if it’s on a Saturday’ they say. They get passionate now. They say they have no voice, no vote, that those in power have deserted their generation. They say all that they can do to be heard is to stop doing the thing the government expects them to do that day – going to school.

This isn’t going well. What about ‘slacktivism’ I ask – kids who don’t care and just want to skip out of class. But they are ready for this one too. One of the boys says that he went to the previous march and that everyone he met was committed. Then they say that it is a chicken and egg argument – that going to a march is what will make some kids care passionately and then do more about it. (Damn those critical thinking lessons again). They point out that they have put their own money where their mouth is. They run the school’s sustainability and recycling groups.

They point out that the NSW and ACT Synod of the Uniting Church – the church with which we are affiliated – has supported the strikes. (Hmmm… damning the Uniting Church is going to be tricky). If the church can do it, why can’t their own school? they say.

I’d rather they went away. I’d rather get back to the school’s strategic plan and the Council retreat. But these kids are passionate, they are smart and they have thought it through. They have put their money where their mouths are and they are scared about their future. Students who have shown they care about this should be able to march about it. If their parents have allowed them to be absent to go to the strike, then the least we can do is give them the school’s support too.

Damn these Year Elevens. Because they’re right.


Newington College encourages our boys to act positively through our Sustainability Group and school recycling programs. We engage in sustainable practices such as installing solar panels, recycling, efficient building management systems and grey water reuse. However, there is always more that we can do. We plan to focus on further measures such as food and packaging waste and upgrading plant to more efficient systems in our 2020–2025 Strategic Plan.

Newington College also accepts the reality of climate science. We consider that climate change caused by humans is an urgent issue, particularly for young people. We understand the importance of student critical thinking and student voice in addressing this singularly important issue. We thus support the decision of our boys whose parents have given them permission to be absent to represent their views about climate change at the climate march on 20 September.

Evidence of the effectiveness of e-cigarettes: dismal or disrupting?

[updated 25 Sept, 9 Oct 2019]

Public health professor Kamran Siddiqi from the University of York tweeted today about a conference presentation from Robert West, who apparently was arguing that e-cigarettes “are perhaps the only smoking cessation intervention that has triangulation of evidence of effectiveness from three types of research”” randomized controlled trials, observational studies and population trends.

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Putting aside that there have been many RCTs, observational studies and analyses of population trends which have focused on nicotine replacement therapy and other smoking cessation interventions, what does this evidence of effectiveness show about e-cigarettes?

Randomised Controlled Trials

I commented in an earlier blog about an English RCT where ecigs were compared to nicotine replacement therapy in smokers attending stop smoking services (so a self-selecting group who all also received supportive quit counselling, something that does not occur in real world NRT or ecig use), E-cigs were superior to NRT, but that was not saying much because quit rates in both groups were low.

Very recently a New Zealand study compared 1124 e-cigarette naïve smokers motivated to quit smoking who had been allocated to three arms of an RCT with the principal outcome of carbon monoxide verified continuous abstinence from smoking when measured at 6 months after the trial commenced. The trial compared (1) those given nicotine patches plus an e-cigarette with nicotine (2) those given nicotine patches plus an e-cigarette without nicotine and (3) those given nicotine patches. All three arms were offered 6 weeks of telephone delivered behavioural support (something that only tiny fractions of smokers trying to quit in real-world situations ever avail themselves of) and received a median of 3 such sessions. Analysis was on an “intention-to-treat” basis (ie of all who started the trial, including those who dropped out or were lost to follow-up) not just those who were available for assessment at the end of the trial. All who dropped out were assumed to be still smoking. 

The study found that

“35 (7%) participants in the patches plus nicotine e-cigarette group had carbon monoxide-verified continuous abstinence at 6 months compared with 20 (4%) in the patches plus nicotine-free e-cigarette group (risk difference [RD] 2·99 [95% CI 0·17–5·81]), and three (2%) people in the patches only group (RD 4·60 [1·11–8·09]).”

In other words,  after six months 93% of the patches plus nicotine e-cigs group were still smoking; 96% of the patches plus nicotine-free e-cigs group had not quit; and 98% of the nicotine patches group were still smoking. So the “value added” by using nicotinised e-cigs was just 3%. The authors described the impact of the patches + nicotine e-cigs group as having attained “a modest improvement” in smoking cessation.

I cannot think of any prescribed drug used for any condition where the condition persisted after 6 months use for 93%  of users and where anything but the language of failure would be used about such an outcome. Is there anyone who would hail a 93% failure rate for contraceptives, antibiotics, cholesterol lowering drugs, analgesia, malaria prophylaxis or anything else as even a modest success?

Observational studies

The most important observational data we have on what happens to smokers who use e-cigarettes in normal conditions of use in the real world comes from longitudinal cohort studies of randomly selected people across whole communities. In an earlier blog, I summarized what two such recent papers told us about e-cig use. I reproduce a section of that blog below.

In 2018, two particularly important papers were published by US researchers using the longitudinal PATH ( Population Assessment of Tobacco and Health) data set.

Let’s take a close look at what they found.

Coleman B et al, Tob Control 2018

This important report on transitions in the vaping and smoking status of a nationally representative cohort of American  adults  aged 18+ who use electronic cigarettes (EC) provides rich data that greatly advances our understanding of the natural history of EC use.

If we examine the report’s data and consider the net impact of vaping on the critical goals of having vapers stopping smoking and vaping non-smokers not starting to smoke, the findings are very sobering and should give strong reason for pause among those advocating e-cigarettes as a game-changing way of stopping smoking.

The study reported on transitions between participants’ responses at Wave 1 and Wave 2, obtained 12 months later. At Wave 2, of the cohort of 2036 dual users (EC + smoking) only 104 (5.1%) had transitioned to exclusively using ECs and another 143 (7%) had quit both EC and smoking for a combined total of 247 (12.1%) who had persistently quit smoking. Of the 896 exclusive EC users at Wave 1, 277 (30.9%) had stopped vaping at Wave 2.

So together, 524 out of the 2932 EC users (17.9%) followed from Wave 1 might be considered to have had positive outcomes at Wave 2 (ie: quitting smoking and/or quitting EC).

The other side of the coin however, shows that of the 2036 dual users at Wave 1, 886 (43.5%) relapsed to using cigarettes exclusively. In addition, among the 896 exclusive EC users from Wave 1, 109 (12.2%) had stopped vaping and were now smoking, with another 121 having resumed smoking as well as using EC (i.e. became dual users). Importantly, 502 of 896 (56%) exclusive e-cigarette users were those who had never been established smokers prior to using e-cigarettes. Alarmingly, of these 502 adults, 120 (23.9%) progressed from using only e-cigarettes to either dual use (54 or 10.8%) or smoking only (66 or 13.2%).

Taken together, 886 dual users in Wave 1 relapsed to become exclusive cigarette smokers in Wave 2, and 230 exclusive vapers in Wave 1 took up cigarette smoking in Wave 2 (dual use or exclusively cigarettes). Undoubtedly, these should be considered as negative outcomes.

The table below shows that for every person vaping at Wave 1 who benefited across 12 months by quitting smoking, there were 2.1 who either relapsed to or took up smoking. Most disturbingly, in this adult cohort nearly one in four of those who had never been established smokers took up smoking after first using EC. Concern about putative gateway effects of ECs to smoking have been dominated by concerns about youth. These data showing transitions from EC to smoking in nearly a quarter of exclusive adult EC users with no histories of established smoking should widen this debate to consider adult gateway effects too.

(2018) colemantransitionssummary

By far the largest proportion of those with negative outcomes are those dual users who relapsed to smoking (886 or 43.5% of dual users). As the authors noted in their discussion, many of these were infrequent EC users, possibly involved in transitory experimentation at Wave 1. If we add the 902 who were still dual using at Wave 2, then 1788 of 2036 dual users (87.8%) in this sample might be said to have been held in smoking (dual using or exclusive smoking) 12 months later compared to 12.1% dual users who may have benefited by using ECs.

Commercial interests in both the tobacco and EC industries would be more than delighted with these findings. However, from public health harm reduction perspective these results argue against EC being a revolutionary effective harm reduction strategy, and point to their far stronger potential to both recruit smokers and hold many smokers in smoking.

Benmarhnia T et al American Journal of Epidemiology 2018 DOI: 10.1093/aje/kwy129

In a second paper using the PATH data, the authors considered persistent abstinence (not using tobacco for more than 30 days). The red highlighted section of the table below shows that those smokers who used ecigs (called ENDS in the table) had the worst persistent abstinence all-tobacco quit rates of any group in the cohort (5.6% of those who were vaping at the Wave 1 survey  and 3.7% of those who too up vaping between Wave 1 and Wave 2). By far the most successful all-tobacco quit rate was for “no aid used” (ie cold turkey or unassisted cessation) with 12.5%.

When we multiply these quit rates by the numbers of smokers using each quit method, the yield of persistent quitters is even starker (see the second table below derived from the data in the table immediately below).

blog table

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So in this major national cohort of US smokers, not only did EC use produce the lowest rate of persistent abstinence from tobacco use after one year compared to all other quit methods, but EC’s contribution to population-wide tobacco abstinence was utterly dwarfed by all other methods (10.9% v 89.1%). The much-denigrated and neglected unassisted cessation approach quietly ploughed on, continuing  its massive historical dominance of how most ex-smokers quit, contributing 1.5 times more quitters than all other methods combined.

Population data

The Smoking in England Toolkit (STS) project (led by Robert West) provides wonderful data on the apparent associations between the downward trend in smoking prevalence in England since the study began in November 2006 through to recent months (see graph below). The dramatic upsurge in smokers using e-cigarettes in quit attempts that commenced in late 2012 and has more-or-less plateaued since mid 2013 does not appear to have had any marked impact on the slope of the historically declining smoking prevalence rate.

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West co-authored an important report in late 2017 where they looked at whether the surge in e-cigarette use in England and whether this was reducing the number of cigarettes being smoked at the population level across the country. Their conclusions?

“No statistically significant associations were found between changes in use of e-cigarettes (â −0.012, 95% CI −0.026 to 0.002) or NRT (â 0.015, 95% CI −0.026 to 0.055) while smoking and daily cigarette consumption. Neither did we find clear evidence for an association between e-cigarette use (â −0.010, 95% CI −0.025 to 0.005 and â 0.011, 95%–0.027 to 0.004) or NRT use (â 0.006, 95%–0.030 to 0.043 and â 0.022, 95%–0.020 to 0.063) specifically for smoking reduction and temporary abstinence, respectively, and changes in daily cigarette consumption.
Conclusion If use of e-cigarettes and licensed NRT while smoking acted to reduce cigarette consumption in England between 2006 and 2016, the effect was likely very small at a population level.”

These findings echoed West’s comments to the BBC nearly two years earlier.


Two of the main pillars of the case made for e-cigarettes by their advocates are that they are a game-changing, disruptive technology which are powerful ways of quitting and dramatically cutting down the number of cigarettes smoked. The evidence above gives a rather complexion to such over-blown hype.

Meanwhile, data on the association between the changing affordability of smoking and smoking rates across the same period that e-cigarette sales have been rising offers a rather different picture, (see for example, UK data below)

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We (also) deny targeting kids: your free guide to playing Big Vape/Tobacco bingo

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For decades the tobacco industry publicly denied that it was intensely interested in promoting smoking by children and teenagers. Any first year undergraduate in marketing  of course understands that any industry professing to have no interest in grooming those who were not yet using its products, but might well do so, would need its commercial head read.

Imagine a Volkswagen executive explaining that VW’s business plan was entirely built on persuading existing car owners to stay with VW or switch to it from their current make of car, and then going out of his way to explain that his company had not the slightest interest in selling cars to first-time car buyers, many of whom would be newly licensed. Major shareholders would run such a person out of the building.

But this has been the stock response always given by the tobacco industry for decades whenever accused of targeting kids. The shaming power of the predatory Piped Piper metaphor, where malevolent figures play beguiling (marketing) tunes to impressionable children, causing them to follow the Piper to their deaths, has always seen the industry, hand-on-heart deny any interest in kids in what is the longest-running lie in the commercial world.

With the tsunami of many millions of internal tobacco industry documents that were released under the terms of the 1998 Master Settlement Agreement, the farcical denials by the tobacco industry about its salivating interest in children came to a public end for more than a decade, when the industry took the decision to rarely speak in public anymore. Instead it lobbied privately and via third party acolytes knowing it would be humiliated publicly by the production of countless of its internal documents that showed it was knowingly lying.

These internal documents were a potent, undeniable truth serum that the industry never expected to be forced to drink in public.

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But today, they are again back in the denial game as they mount a new white horse of harm reduction that they unsucessfully rode in the past with filters, “lights and milds” and “reduced carcinogen” cigarettes. Despite the core twin pitches of ecigarette hype  (that they are all but of benign risk, and that they are spectacularly effective at helping smokers quit), ecig manufacturers still can’t bring themselves to stop saying that ecigs are only for adult consumption.  Along with the independent vaping industry (which is predictably being steadily hoovered up by Big Tobacco companies), we are seeing a near-complete reprise of the oleaginous public   “these are not for children” declarations from Big Tobacco and its new apologists. The only difference is that today it’s the same fake arguments being applied to  ecigarettes.

There was a huge amount of research published about denials about designs on kids in the early 2000s. This powerpoint set of 72 slides by Stacy Carter, originally published on the Tobacco Control journal’s website, is probably the single best catalogue of industry duplicity about kids and smoking that I know of.

Look through it and keep it handy the next time you hear industry employees or stooges assuring interviewers that children vaping is the furthest thing from their minds.  See how many bingo points you can score by matching today’s lies with those the tobacco industry used in public prior to 1998.

Here is a selection of some of these papers on youth by a research group who worked with me on a four year US National Institutes of Health grant (2001-2004) looking at industry document revelations about youth smoking in Australia and Asia.

  1. Assunta N, Chapman S. A mire of highly subjective and ineffective voluntary guidelines: tobacco industry efforts to thwart tobacco control in Malaysia. Tobacco Control 2004;13 (Suppl) 2):ii43–50
  2. Assunta M, Chapman S. Industry sponsored youth smoking prevention programme in Malaysia: a case study in duplicity. Tobacco Control 2004; 13 (Suppl 2):ii51–57.
  3. Knight J, Chapman S. “Asian yuppies … are always looking for something new and different”: creating a tobacco culture among young Asians. Tobacco Control 2004; 13 (Suppl 2): ii22–29.
  4. Knight J, Chapman S. “A phony way to show sincerity, as we all well know”: tobacco industry lobbying against tobacco control in Hong Kong. Tobacco Control 2004; 13 (Suppl 2): ii13–21.
  5. Tofler A, Chapman S. “Some convincing arguments to pass back to nervous customers”: the role of the tobacco retailer in the Australian tobacco industry’s smoker reassurance campaign, 1953–1978. Tobacco Control 2003;12 (Suppl 3): iii7–iii12.













Abortion in NSW in 1971: a personal account

This week’s debate in the NSW parliament on decriminalising abortion, brought back memories for me of my experience with my first wife Annie in 1971 when she became pregnant at just 19.

We were childhood sweethearts from Bathurst#. We’d both moved to Sydney after finishing school, and having lots of furtive sex, were doing all we could to keep it from her disapproving Catholic parents. Annie had been sent away to boarding school in Moss Vale when a deputation of school nuns intercepted my unrestrained teenage love letters and paid her parents a visit.  Annie was close to her mother and despite school being over, felt it would hugely upset her mother if our carnality came out in the open.

I was a second year undergraduate, living in a $5 a week room in a ramshackle Glebe terrace with four friends. I worked as a car park attendant at Wynyard Travelodge at weekends to get a little money to live on. We got our weekly fruit and vegetables at the market at closing time when they were almost being given away##. I had virtually no money in the bank. Annie was working in temporary typing and shorthand jobs, still living at home.

The tailor-made pill

On campus one day in 1971, I saw a poster advertising a talk about “the tailor-made pill” which would be given by Professor Harvey Carey (1917-1989), Head of the School of Obstetrics and Gynaecology at the University of New South Wales and an early pioneer in the development of the oral contraceptive pill which had fist become available in Australian in 1962. He was recruiting women for his work involved trialing changing doses with a focus on adverse side effects and contraceptive effectiveness as the outcomes of interest. The pitch was that he’d tailor-make a pill for each woman that was effective and would minimize any side-effects. Here (from 24m38s) is an extended interview with him.

Annie and I both went along to the talk, hoping to put condoms behind us. We felt lucky to be able to be in the hands of a leading researcher. It would also be free, a big consideration for us in our penury. Annie signed up and was on the pill for most of 1971.


In November that year, we got married. We were both only 19, full of plans for finishing university at the end of 1972 and then setting out to explore the world. Her parents were very comfortably off and while we felt we were ridiculously young to be getting married, it was likely that a decision to live together would deeply anger them (mine were counseling that we should just live together, something I found out late in life they had always done – they never married). Her father was a self-made, determined man and we thought it possible he might even disown her, and break her mother’s heart. A decision to marry, we thought, might also see some sort of leg-up gift to help us out for a few years until we started earning.

We were married in the registry office opposite St Mary’s catholic cathedral in Sydney at 11am. In keeping with the haut couture of the time, I’d bought a dapper three piece suit and purple shirt and tie and at 9am had gone to a fashionable Italian barber in the Menzies Arcade to have my 1970s hippie tresses washed and blow-dried (picture). Our parents, siblings and her aunt and uncle adjourned to solemn, mostly unsmiling lunch at the Wentworth Hotel in Phillip Street. It felt a little like a funeral, more than a wedding.


Mid-afternoon we went up to the hotel room her parents had bought for us for the night and, quite bizarrely, her father took a photograph of us standing next to the bed.

When he left, we began to get into bed but then Annie realized that her supply of the pill had finished. She had bad tonsillitis with a slight temperature, so called up Carey’s clinic at the Royal Women’s Hospital in Paddington to see if it was OK if I could go up and collect a renewal. So on my wedding day, I splashed out and caught a bus up to Paddington, sat in the waiting room till the tailored pill supply was put together, and then caught the bus back to the honeymoon suite. I’d proudly told the receptionist that it was my wedding day.

Annie took one look at the strip of pills I’d been given and immediately said they were the wrong ones. The colours of the pills, or their sequence was not the same as those she had been using all year. She called up the clinic, but it was too late. They had closed for the day.

A couple of months later, Annie became pregnant. The changed colours of the pills suddenly took on a different meaning. Annie recalled telling the receptionist some months earlier that she was getting married in September. The receptionist took interest in this. Annie recalls her asking about the wedding date and noting it on her file. I had mentioned it when I fetched the new supply on the wedding day.

Carey’s work was very much about finding evidence about threshold doses that effectively prevented conception. He “developed the ‘Roman Catholic pill’ which did not suppress ovulation but rather regulated it to a particular time in the ovulation cycle”, so may have had connections to the church. We heard publicity about this at the time and wondered whether he had taken a decision to vary Annie’s dose from the time that her file would have flagged that her status was now changed to married. If this is what occurred, it was never discussed with her. And of course would have never had her consent.

Getting an abortion in 1971

Barely being out of childhood ourselves, we had no interest in having a child at 19, while still at university, with no jobs, an imminent one-bedroomed rented flat in a Randwick shack, even with $5000 in the bank (the wedding present). We were not remotely ready to have a child, which was why we used contraception. In those days, to get an abortion you had to be assessed by a doctor, an obstetrician and a psychiatrist who together would certify whether there was any threat to the health of the mother. As expected,  the doctor and the obstetrician both said there was no evidence that Annie could not have a baby. So the psychiatrist’s report was going to be critical.

We made contact with a network of feminists who recommended a psychiatrist known to be sympathetic to women seeking abortions. Annie went to see him and explained the circumstances of the pregnancy, our situation but mostly to simply explain that we wanted to make the decision when we would have a child. The psychiatrist, a man, listened to this and then said “I’m sorry but nothing you have told me would allow me to make any recommendation that your mental health was at risk by a pregnancy”.

At this Annie became upset and cried. The psychiatrist then said “ah, that’s what I need. I can now see that you are very upset.” He provided a recommendation and Annie had the abortion soon afterwards. This humiliating farce was what women who were able to connect with such agents had to go through if they wanted a termination. Many without such connections would have had dangerous backyard abortions.

The women we had spoken to were very keen that we raise hell about what had happened. We declined, being apprehensive about the consequences of going public in those very different days. But later told our story on an ABC documentary series [name forgotten but being looked for].

Our fully planned and much loved son Joe was born in 1982 (pictured with Annie and my late parents in 1983).

(1984) Mum,dad,Joe,Annie

footnotes: # See memoir of my first 18 years here. ## See several short stories of my early work and travel experiences (with Annie) from pp12-38 here

Regrets … I’ve had a few. Paul Hogan and his Winfield role.

ABC TV’s Australian Story, will soon run a profile of Paul Hogan best known for his three Crocodile Dundee films, his eponymous television program  that ran from 1973-1984, and for fronting Rothmans’  Winfield cigarette campaign in Australia from  July 1972 until May 1980.

Hogan was spotted by Rothmans’ advertising  agency Hertz Walpole when appearing on Channel 9’s New Faces talent show in 1971. Here’s his first and most famous ad that appeared on Australian television (tobacco advertising on TV and radio was banned from September 1976).

With its budget price and Hogan’s “Anyhow, have a Winfield” sign-off, the brand rocketed to clear market leader. The campaign was revered in the advertising industry as the most successful tobacco advertising campaign ever. The “anyhow …” was a brilliant talisman that worked on multiple levels: (“unemployed or got a dead-end job, no social life, depressed, lonely, worried about all the talk about smoking and disease? Anyhow … have a Winfield”).

Very early in my career, I worked with several others in a public interest group MOP UP (Movement Opposed to the Promotion of Unhealthy Products) to test the tobacco advertising self-regulation system’s willingness to actually regulate itself. We submitted a complaint that the industry’s own voluntary code should have precluded Hogan’s involvement in the Winfield campaign because he had “major appeal to children”, something explicitly forbidden by the code. We’d seen audience data that his TV program was proportionately more popular with children than with adults.

After a saga that lasted 18 months, in May 1972 Sir Richard Kirby who headed the industry’s Advertising Standards Council ruled in our favour, agreeing with our arguments and leaving Rothmans little choice but to pull Hogan from its spectacularly successful campaign.

I wrote up a detailed account of the saga here. The Australian newspaper headlined our victory as “MOP UP’s slingshot cuts down the advertising ogre”

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The late Vernon Brink, then head of Rothmans, also attended Kirby’s judgement. I found myself with him in an adjacent ante-room before entering the room where the judgement was delivered at Sydney’s Wentworth Hotel. We made small talk but after a few moments said to me, cryptically “It’s such pity that you didn’t come and sit down with us and discuss all of this before we got to this point. I’m sure we could have come to some sort of arrangement.”

Regrets, they’ve had a few

On a visit to Australia in 2013, Hogan told the Sunday Herald Sun that one “campaign in the 1970s caused a lot of regret – his advertisement for Winfield cigarettes (“Anyhow… have a Winfield”)”.

Hogan was reported as saying: “Yeah, we were encouraging people to smoke. At the time, 1971 or something, they used to say: ‘Doctors recommend …’ or ‘Nine out of 10 smokers prefer…’ We were all being conned. When they put the medical warning in there I said, ‘I’m going to get out of this.'” He also said  “Young ones were taking up smoking and all going for Winfield. It was a staggering success but I was a drug dealer. But who knew then?” (my emphasis)

His business partner John Cornell said much the same in an interview in The Age “For both Paul and I (the Anyhow campaign) is the sole dismay of our professional lives … when we were selling cigarettes none of the evidence was out about how bad they were and how addictive they might be. When you find that out …” (my emphasis)

The first health warning appeared on Australian cigarette packs from January 1973, just  six months after Hogan fronted his first Winfield advertisement.  He continued in Winfield advertising until May 1980,  nearly seven years after the health warnings appeared. So if Hogan indeed wanted to ”get out of this”  he certainly took his time. The advertising industry magazine Advertising News, reported that there were in fact plans for a major relaunch which had to be scrapped after the Kirby judgement.

“Who knew then?” “None of the evidence was out?”

In fact it had long been common knowledge that smoking was deadly. The first major epidemiological studies were published more than 20 years earlier in 1950 in the British Medical Journal and the Journal of the Amercican Medical Association. The Royal College of Physicians of London (1962)  and the US Surgeon General (1964) published reviews of the evidence. News media gave this evidence huge coverage, motivating many millions of people  to quit. I have a huge folder thick with photocopies of Australian press articles highlighting this information from the 1950s into the 1980s.

Hogan was not the only Australian celebrity to help promote cigarettes and then express regret. The late urbane actor Stuart Wagstaff helped Benson & Hedges with the “when only the best will do” pitch to frame the premium brand as way that wannabes could signal their aspirations after outlaying a few dollars.

Wagstaff told the Weekend Australian’s Amanda Meade in 1997 “One thing that concerned  me deeply in light of what we know today is that I might have been instrumental in people starting smoking.” But he said he never “endorsed” smoking and added that he continued to be paid for his advertising work for the brand until the early 1990s, long after the campaign ended.

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Comic Grahame Kennedy advertised Wills Supermilds, and Tony Barber advertised Cambridge cigarettes before getting his big TV break with Sale of the Century.

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Sportspeople in on the act included tennis player Roy Emerson (1960s), and then many cricket, rugby league, and motor racing identities who willingly allowed themselves to be used to promote Winfield and Benson & Hedges and speak out against any calls for banning tobacco sports sponsorship before it was finally banned in 1992.

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Rock musicians got in on the act too, playing on Philip Morris’ 1986 Peter Jackson Rock Circuit before bands like Midnight Oil, the Diviynls, the Hoodoo Gurus, and Hunters and Collectors showed leadership by boycotting it and explaining loudly why. The promotion was rapidly axed.

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“While money doesn’t talk, it swears

Obscenity, who really cares

Propaganda all is phony”

Bob Dylan: It’s all right, ma (I’m only bleeding)

When should researchers collaborate with industry, and when should they not?



This week the Lancet published an extended piece by Boston University’s Sandro Galea reflecting on a new bioethics book by Jonathan Marks, The Perils of Partnership: Industry Influence, Institutional Integrity, and Public Health.

Galea commences with a truism: “those of us who make a living in public health, be it in the academic world or in practice, have a near reflexive suspicion of working with the private sector. We come by that suspicion honestly. There is abundant research, evidence, and experience of how some industry practices have harmed the health of the public.”

And abundant research is almost an understatement. In medicine, the debate about the ethics of the cash register arises most often over drug company money. Here, the research evidence is clear: those who take pharmaceutical research money tend to not bite the hand that feeds them.

A 1998 New England Journal of Medicine study reported that 23 of 24 authors (96%) defending the safety of calcium channel antagonists had financial ties with manufacturers of these drugs. This compared with 11 of 30 (37%) who were critical of their use.

The University of Sydney’s Charles Perkins Centre Professor Lisa Bero is perhaps the world’s leading authority on competing interests in science and the way that engagement so often evokes the tale about those paying the (research) piper, calling the tune. Bero and others’ 2012 Cochrane Collaboration review investigated the association between pharmaceutical industry funding and research conclusions favourable to the companies funding the research.

Bero’s paper with Jenny White on corporate manipulation of research across five different industries (tobacco, pharmaceuticals, lead, vinyl chloride and silica) is another classic paper in the field.

Several research journals refuse to consider papers for publication which are authored by anyone with tobacco industry financial ties. Their reasoning? As the editors at PLoS put it in 2010:

“We remain concerned about the industry’s long-standing attempts to distort the science of and deflect attention away from the harmful effects of smoking.

That the tobacco industry has behaved disreputably – denying the harms of its products, campaigning against smoking bans, marketing to young people, and hiring public relations firms, consultants, and front groups to enhance the public credibility of their work – is well documented.

There is no reason to believe that these direct assaults on human health will not continue, and we do not wish to provide a forum for companies’ attempts to manipulate the science on tobacco’s harms.”


Tobacco Business Ethics

As PLoS journals charge authors a fee to publish, they also did not want to be accepting money obtained from the sale of tobacco and the millions of deaths involved in those sales.

Tobacco-funded research and the conduct of the industry which oversees it has arguably the worst of all reputations. This explains why that industry is unique among all others in being barred from funding research and scholarships at many universities. My own institution – the University of Sydney – was one of the first to do this in 1982.

Bero’s contributions have been supplemented by Nicholas Freudeberg’s Lethal but legal (2014) and a book by the University of Auckland’s Centre for Addiction Research Peter Adams, Moral Jeopardy: Risks of accepting money from the Alcohol, tobacco and gambling industries (Cambridge University Press 2016).

Adams sets out with enormous erudition and many examples, the conduct of the three industries on which he focuses (alcohol, tobacco and gambling). He describes risks to reputations, governance, scientific neutrality, relationships and even to democracy when the corrupting influence of money from industries whose commercial well-being depends on successfully resisting any policies, laws and regulations that threaten their profitability inhibits those developments.

The main focus of his book is the ethical and moral questions which arise for health-care providers, researchers, universities, journals, and communities when such engagement occurs. The book has extensive sections elaborating on inventories of questions that all organisations contemplating accepting funding from these industries should ask themselves.

Manichaean simplicity?

All universities encourage their staff to engage with industry. But academics lamenting the decline of government funding for universities have often been scathing about this development and mocked industry-sponsored chairs. I recall one in “structural clay brickwork” was mercilessly pilloried. But why? What exactly is the ethical problem with assisting in advancing the quality of commercially made bricks? Or of improving steel through the University of Wollongong’s  BHP funded chair?

Bricks and steel have innumerable uses which enhance human life and well-being. Life would be unarguably worse without them.

Sandro Galea’s Lancet piece notes that a central argument of Marks’ book is that

“Given that private-sector actors inevitably have their own commercial interests as one of their priorities, it is …impossible to maintain institutional integrity when one partners with actors whose mission is misaligned with one’s own.”

But Galea, who highly recommends the book, concludes by disagreeing with its main “disengagement” conclusion

“Simply put, I do not think it is possible, nor desirable, for public health to disengage from corporate sector partners; the public–private relationship is here to stay and we should be using Marks’s work to thoughtfully inform such engagements, not as a guide to disengagement”

My own view on industry engagement runs like this.

There are some industries which make and promote products or provide services where the net consequences of consumption are sometimes hugely negative. My personal list here includes fossil fuel industries, the nuclear power industry, tobacco, firearms, gambling, any industry with a track record of exploitative labour practices, irredeemable environmental pollution, or unsustainable pillaging of forests, land or oceans.

Then there is a huge middle group where simple Manichaean (good or evil) categorisations cannot easily withstand even basic scrutiny, and where significant negative and positive consequences of consumption cannot be ignored. Most people who drink alcohol do not harm others because of their drinking, but derive obvious pleasure from it. They may increase their risk of dying from some diseases and shave some months or years off normal life expectancy, but prefer to take that chance. But alcohol causes massive harms across populations.

I am of course not the only person grateful for the pharmaceutical industry as I reflect on drugs and vaccines I have taken to prevent or manage serious health problems, ameliorate pain or induce anaesthesia in surgery.

The cars, motorbikes, buses, trains and aircraft I’ve used, and electricity and gas have all used polluting fossil fuels. Many hope desperately for the rapid uptake of electric transport powered by renewable energy. Unlike the dilettante tobacco industry which refuses to stop making and promoting cigarettes while trying spread nicotine addiction with ecigs and posturing about its responsible rebirthing, major vehicle manufacturers are setting targets for complete transition away from petrol and diesel powered options.

My kitchen pantry is filled with grocery items that I select to consume, and not being heavily into hypocrisy, I don’t gag with ethical confusion when I eat them, despite some being produced by heinous transnational food companies . Instead, I am grateful that these companies are able to manufacture food items that I’m pleased to buy and eat. I can exercise my personal ant’s worth of consumer power by selecting product formulations and companies that tick all the important boxes. I can megaphone the availability of powerful apps like Cluckar (for boycotting misleading “free range” egg brands) and the George Institute’s Food Switch (which provides comparative ingredient information tens of thousands of  grocery items) which help immensely with this.

So with all these examples, only the most doctrinaire or extreme will argue that these profit maximising industries are pure evil and have nothing to contribute to global health and well-being. Here, research engagement between the industries and university researchers is therefore common with constantly evolving effort to ensure research integrity is protected in areas like transparency and full declarations of competing interests.  Researchers should engage with their fully-honed sceptical facilities on open display, as should always be the case in any research engagement.

When collaboration is urgent

Then there is a third category of industry where public health and industry are in all but total lockstep.  Obvious examples here are renewable energy, vaccines, condoms, bicycles and with fruit and vegetable growers (and retailers).

When public health researchers working toward ways of reducing reliance on fossil fuels try to produce breakthroughs on renewable energy costs and efficiencies, they want their work to be commercialised so that it proliferates as fast as possible. That is the whole point of what they are working toward. The dire, accelerating existential threat posed by global warming makes the partnerships between the research and commercial sectors extremely urgent.

When communicable disease researchers produce new vaccines for self-evidently potentially catastrophic diseases like ebola, or partner with vaccine manufacturers in the common goal of maximising distribution, cold-chain standards and intelligence sharing, what’s not to like?

The pharmaceutical industry has more than once engaged in despicable price maximisation at times of communicable disease crises. It is reasonable to fear that specialist researchers affiliated in good faith in partnerships with such companies might self-censor concerns to condemn such practices, not wanting to bite the hand that has been feeding them. But to move from evidence of such conduct to a conclusion that there should be no collaboration in common, important purpose seems disproportionate.

When the world urgently needs to see significant uptake in use of commercially manufactured products, a chorus of criticism that inhibits the sharing of effort between researchers, these industries and government can be very myopic.

Banning smoking in wide-open public spaces goes way beyond the evidence and is unethical

North Sydney local Council has voted unanimously to ban smoking in all public areas under Council control. These include parks, streets and plazas and outdoor footpath dining areas of cafes. The move follows similar bans in other local government areas and the receipt of over 600 submissions from local residents and workers, the overwhelming majority of which (80%) urged the Council to adopt the policy.

The Council has no plans to fine smokers, and it is not clear if the policy will also apply to vaping. It believes that community education and signage will be enough to ensure the policy succeeds. Good luck with that. Fines have been necessary to support every other restriction on smoking.

Throughout my 40 years in tobacco control, I’ve advocated with many others for polices and campaigns designed to reduce the uptake of smoking, to encourage quitting and to protect people from the known risks of exposure to secondhand smoke. The triple, inviolate bedrocks of all these policies and campaigns were that there needed to be evidence that each policy would likely achieve its goals, that the measures posed were proportionate to the problem being addressed and that they were ethically justifiable.

Perhaps the most protracted struggle in all of tobacco control was efforts to  reduce exposure to other people’s tobacco smoke. In NSW, these started in 1976 with the ban on smoking on government buses and trains was introduced by transport minister Peter Cox. In the longest ever saga of half-pregnant policy, it took a full 34 years until the Northern Territory, the last bastion of smoking inside pubs, finally joined every other state and territory in introducing that policy.

Pubs were the last setting to go, while they rationally should have been the first if intensity of exposure was the key criterion. Bar staff’s occupational health was relegated to a secondary consideration in industry  campaigns promoting the freedom of smokers to ignore these workers’ health because it was argued it was the birthright of any Aussie to have a smoke, a beer, a meat pie and a bet in a pub and bar staff should just have to suck it up.

Today, it is only high roller rooms in some casinos which still allow smoking. This is because of the little appreciated fact that tobacco smoke from wealthy gamblers’ cigarettes is apparently, unlike that from everyone else’s, not toxic to other people.

While the evidence for the harms of exposure to other people’s smoke has long been voluminous and overwhelming when pooled in reviews, that evidence has been almost totally based on chronic exposures occurring over many years in homes with smokers and to a lesser extent, in smoky workplaces.

This brings us to outdoor smoking and policies like that just adopted by North Sydney Council.

Here, there are some important differentiations to make. Outdoor settings can include the sardine-can like proximities to others we often experience in sporting or concert stadia, where in the past, if you had the misfortune to be sitting or standing next to smokers for many hours across a day’s play in the cricket or at a music festival, you copped a lot of their smoke point-blank.

Similarly, when smoking was banned inside cafes and restaurants in NSW in 2000 (thank you then Premier Bob Carr and health minister Craig Knowles), many smokers simply moved to the outdoor, al fresco tables. There you could find yourself in their haze across an entire meal. It was manifestly unreasonable that smokers should be rewarded with access to prized seats in the outdoor sun, so arguments for amenity carried the day on smokefree outdoor eating and drinking in many jurisdictions.

There was some evidence that acute (ie short term cigarette smoke exposure) can be detrimental to people, especially those with respiratory problems (and there are many such people in any community). For example, acute exposure to ambient smoke in healthy young adults has been shown to be associated with dose related impairment of endothelium dependent dilation, suggesting early arterial damage. However, the transitory and fleeting exposure to others’ smoking in open outdoor settings is not remotely comparable to that experienced in confined indoor settings such as were involved in the study I just cited.

When we reviewed the research literature in 2012 about studies assessing particle concentrations in outdoor smoking settings, there were very few available. And predictably, these mostly showed that the concentrations even in close proximity to the smokers were negligible.

This was always going to be obvious. Smoke particle concentrations in enclosed spaces, often with lots of people smoking, are clearly going to be far higher than in any outdoor setting where the smoke is diluted by the boundless surrounding air and dissipates rapidly in the slightest breeze.

In some Japanese cities, smoking is banned on streets except for designated smoking hubs which can get very crowded. The reason for these street bans is that the density of pedestrians can be so great that burns quite often occur to clothing and flesh from carried lit cigarettes.  Yet, bizarrely, Japan still allows smoking inside restaurants.  Smoking bans in very crowded outdoor shopping precincts like Sydney’s Pitt Street Mall can be justified on similar concerns.

So the key evidence needed to underscore any policy seeking to reduce significant risk to the public in wide open spaces simply  does not exist. Yet this week I have heard North Sydney Council spokespeople saying that passive smoking is harmful to others. Yes it is: but in indoor settings, particularly with long term exposure, not in wide-open spaces like parks, car parks, typical streets and on beaches. Conflating the evidence on passive smoking hazards between indoor and outdoor locations is simply ignorant. All occupational air quality standards for any potentially noxious agent differentiate between indoor and outdoor settings set different standards for both.

Other arguments

The ethical justification for restricting where smoking can occur derives entirely from the Millean principle of preventing harm to others. There are also important collateral benefits of banning smoking in workplaces: smokers reduce their daily consumption by about 21% when they cannot smoke at work and more importantly many quit, welcoming the bans as a form of imposed self-discipline on a behaviour that 90% of smokers regret ever starting. Smoking bans fomented a rapid denormalisation of smoking: venues associated with relaxation, pleasure and conviviality like restaurants, bars, cinemas have no smoking, while smokers excuse themselves to go outside to footpaths in any weather  or sit morosely in the fug of smoke in those desperate airport smoking rooms, wondering  about how much they really enjoy smoking.


An enticing  smokers’ lounge at an airport

The proliferation of smoke free areas certainly contributed to reducing both the frequency of smoking and the proportion of people who smoke. But so would forced incarceration,  forfeiting smokers’ rights to health care or other draconian strategies too tame for the Ottoman Sultan Murad IV who had smokers executed in the sixteenth century. Very obviously, the ethical test of any policy is not only its efficiency in achieving outcomes. We don’t try to reduce smoking by any means possible. We interrogate a policy for its ethical considerations and reject those where  the breaches are unjustifiable.

Because outdoor smoking ban proponents cannot point to any robust evidence to support claims that the fleeting exposures we might occasionally get from a passing smoker in a park or street are meaningfully harmful, they often reach beyond that evidence. The momentum to outdoor bans has incorporated three arguments that go well beyond evidence of direct health effects. First, large majorities of the population do not like being exposed to any tobacco smoke. Outdoor bans premised on communities’ amenity preferences are not about public health but akin to ordinances about playing music in parks, bans on public nudity and littering. Outdoor smoking bans based on amenity should not be dressed up in the language of public health.

Second, cigarette butts and packaging constitute a significant proportion of  litter. North Sydney has named litter reduction as a justification for its policy, but it has not banned single use plastics for example, so its selective concern for one litter source might be questioned.  Local governments wanting to abate this relentless litter source should not appropriate public health arguments in justifying their decisions but be upfront about the litter problem and ideally consistent in their concerns across all litter.

Third, some have invoked the virtues of shielding children from the sight of smoking as worthy evidence in this debate. They may concede that smoking in wide open spaces like parks and beaches poses near homeopathic levels of risk to others, but point to indirect negative impact from the mere sight of smoking. Kids see smoking and this can sometimes make it look intriguing and attractive. This line of reasoning is pernicious and redolent of the worst excesses of totalitarian regimes’ penchants for repressing various liberties, communication and cultural expression not sanctioned by the state.  North Koreans are routinely subjected to such fiats, but many would recoil at the advance of such reasoning elsewhere. If it is fine to tell smokers that they cannot smoke anywhere in public view, why not extend the same reasoning to  people wolfing supersized orders in family fast food outlets, to name just one example?

Coercing smokers to stop smoking in settings where their smoking poses negligible risk to others is openly paternalistic. Well-intentioned advocates for such policies argue, as paternalists always do, that such actions are for smokers’ own good, that many will be sooner or later grateful (which is often true). Paternalistic for-you-own-good laws about seats belts and motorcycle helmets involve trivial restrictions on liberty. Telling smokers they cannot smoke in public sight is a restriction of a different, worrying magnitude.

Finally, of all the factors which have been identified in risk perception research as tending to increase public outrage, risks which are imposed rather than voluntary explain much of the variance in public perceptions. Passive smoking represents a quintessential imposed risk and, together with the possibility of dreaded outcomes (like lung cancer), often incites public demand for zero exposure. This explains why many will get incensed about exposure to a mere whiff of tobacco smoke in a park, but will not hesitate to sit around a romantic smoky campfire where they will, by choice, be exposed to a large range and volume of carcinogenic particulates and gases for sometimes hours on end.

My university, the University of Sydney, has long banned smoking in all indoor areas, and more recently in outdoor areas like those in front of coffee shops and the iconic front lawn. But it provides small designated outdoor smoking areas, well away from buildings and heavy pedestrian areas.  North Sydney council would do well to follow suit.

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African music for beginners 6: Madagascar



I’ve had a passion for contemporary African music since the early 1980s, when I bought my first LPs by South Africa’s (late) Hugh Masekela and Cameroon’s Manu Dibango, went to my first African gig (the Congolese superstar Sam Mangwana and the African Allstars, at London’s Dominion Theatre near Waterloo). In the years since I’ve collected 1000s of LPs, cassettes, CDs and MP3s.

Before traveling to any city, I look up where its African quarter is and try to get out there to see if there are any music shops and bars.  Music shops are very sadly becoming a thing of the past as people move to digital access. I spent many lunch hours listening to music at Stern’s African Record Centre in Whitfield St just behind Tottenham Court Rd in London when I was studying there between March 1984‑November 1985. They are now an on-line shop and also have a blog.

I subscribe to the monthly email from Alastair Johnston’s invaluable Musikifan record review page, buy lots of books on African music, and maintain an ever-expanding Spotify African page. While for some artists it can be very patchy, Spotify has a delightfully vast range of African music, including a lot of very obscure archival music, sometimes replete with scratchy sounds from the old LPs from where it has been digitised.

I have recently started a Youtube page with live African music concerts.

Over the next months, I’ll post country-by-country blogs with lots of recommendations for those starting out to explore the vast catalogue of African music. I’ll only be including those that I like, with links to the tracks on my Spotify page or to Youtube when they are not available on Spotify. These are just a taste that I hope might infect you in the way I was.


1.Senegal selections here

2.Zimbabwe selections here

3.Mali selections here

4.Nigeria selections here

5.Ghana (Highlife) here


The Canadian canary in the teenage vaping coalmine



A recent paper published in the British Medical Journal contains alarming evidence that upswings in vaping by teenagers can see significant parallel rises smoking. The researchers looked at large samples of 16-19 year olds in the USA, Canada and England, and reported changes in vaping and smoking between the years 2017 and 2018.

They summarized their findings this way:

The prevalence of vaping in the past 30 days, in the past week, and on 15 days or more in the past month increased in Canada and the US between 2017 and 2018 (P<0.001 for all), including among non-smokers and experimental smokers, with no changes in England. Smoking prevalence increased in Canada (P<0.001 for all measures), with modest increases in England, and no changes in the US. The percentage of ever vapers who reported more frequent vaping increased in Canada and the US (P<0.01 for all), but not in England. The use of JUUL increased in all countries, particularly the US and Canada—for example, the proportion of current vapers in the US citing JUUL as their usual brand increased threefold between 2017 and 2018.

The Canadian data were particularly alarming. There has not been an increase recorded in teenage smoking in Canada in 30 years. The data on vaping and smoking on 15+ days a month saw a 71% increase from 2.1% to 3.6% for vaping, and a 54% increase in smoking from 4.8% to 7.4%. This was no mere rise in casual experimental vaping or smoking.

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The four invoilable articles of faith that form the vaping advocacy creed are that

  • nicotine is all but benign
  • inhaling micro-particles of propylene glycol, nicotine, flavouring chemicals approved for ingestion but not inhalation, and metals an average of 200 times a day deep into the lungs (73,000 times a year) is all but inconsequential
  • ecigarettes are highly effective at getting smoker to quit and preventing relapse and
  • vaping by non-smokers (especially kids) will not be followed by any uptake of smoking by the previously nicotine naïve (often called the “gateway” hypothesis).

I’ve taken a skeptical look at several of these before (see the links above), as have at least 45 major health and medical agencies around the world whose policies urge precaution.

Ecig apostles will rush to point out that the US — also awash with large increases in vaping (a 46% increase in past month and a 66% increase in past week) — did not see any increase in teenage smoking, and that the increase in smoking in England was only “modest”. These differences are interesting and deserve greater analysis. But they cannot paper over what has happened in Canada nor provide any assurance that as ecigarette manufacturers salivate over the massive potential of the teenage market becoming addicted to nicotine and play their Piped Piper marketing tunes to ensure this, that the Canadian results won’t consolidate and appear elsewhere.

Gateway concerns  were strengthened with the publication of a meta-analysis of longitudinal studies showing that e-cigarettes can serve as a gateway to later cigarette smoking among some nicotine naïve youth and by the 2018 report of the National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes, which concluded that such studies provided “strong evidence of plausibility and specificity of a possible causal effect of e-cigarette use on smoking…” with the Committee “consider[ing] the overall body of evidence of a causal effect of e-cigarette use on risk of transition from never to ever smoking to be substantial” [p16-32].

Gateway hypothesis critics have relied on several arguments in their dismissals. I coauthored a critique of these in Nicotine & Tobacco Research in 2018. Here’s an edited version of what we wrote.

Are downward trends in adolescent smoking are incompatible with a gateway effect for e-cigarettes?

Several prominent harm reduction proponents have argued that the gateway hypothesis is incompatible with population trends in the USA and UK of declining adolescent smoking. Their argument here runs that vaping has been rising while smoking continues to fall, so vaping cannot be causing smoking to any significant degree among adolescents.

In both nations, declining trends of smoking among youth were apparent well before the introduction of e-cigarettes. Moreover, associations in population trends are known to be prone to the ecological fallacy; i.e. what is true at the population level may not be true at the individual level, especially when other population-level attributes are not considered (e.g. effective tobacco control policies).  Specifically, the ecological argument relies on an assumption that the population net impact of any putative gateway effect of e-cigarette use would be larger than the combined net impact of all other policies, programs and factors which are responsible for reducing adolescent smoking prevalence (e.g. tobacco tax and retail price, measures of the denormalisation of smoking, exposure of children to adult-targeted quit campaigns, retail display bans, health warnings and plain packaging). This is an extremely high bar that gateway critics demand that anyone suggesting gateway effects needs to jump over. The combined impact of such factors in preventing uptake could, thereby, easily mask considerable smoking uptake that might not have occurred in the absence of e-cigarettes.

With smoking prevalence at record lows in the US, England and Australia, only adequately powered longitudinal studies, which control for factors known to be associated with smoking uptake are vital to examining potential gateway effects. Nine such studies were included in the 2017 meta-analysis. Adjusting for demographic, psychosocial, and behavioral risk factors for cigarette smoking, the odds of subsequent cigarette smoking by non-smokers who had any experience of vaping more than tripled among e-cigarette users compared to those with no vaping experience.

Common liability rather than gateway?

One of the main criticisms of the gateway hypothesis lies in the difficulty in excluding other mechanisms for the observed relationship between vaping and later cigarette smoking. The most commonly proposed alternative explanation is based on the “common liability theory”, which emphasizes shared predisposing characteristics among multi-drug users. According to this hypothesis, a “propensity” for drug use predicts multi-drug use. Interestingly, however, several longitudinal studies have reported the strongest association between e-cigarette use and smoking initiation among youth with the lowest risk of smoking. Moreover, recent evidence using national data from the US shows that a third of youth who start with e-cigarettes have risk profiles that make them unlikely to start with cigarettes.

Rather than being mutually exclusive, the gateway and common liability hypotheses are likely to be complementary. Common factors will explain the use of drugs in general, and specific factors will explain why young people use specific drugs and in what contexts. This dynamic perception is in line with contemporary models of behavioral change being dependent on the balance between intention and ability. Intention implies individual factors including any propensity for drug use. However, such factors are contingent on environmental conditions, such as access and feasibility of drug use for intentions to be materialized.

Indeed, most tobacco control successes were the result of targeting those potentiating environmental factors rather than some innate propensity to use drugs. The salience of these environmental factors is also evident from societal trends of smoking propagation in response to tobacco industry marketing and obstruction of tobacco control policies, as well as declines in smoking in response to successful implementation of effective population-based policies.

The wide availability and intense marketing of e-cigarettes, and their putative low-risk appeal may coalesce to increasingly make e-cigarette delivered nicotine the likely first drug on a multi-drug cascade. But, rather than be alarmed, e-cigarettes proponents use this to argue against a specific temporal sequence needed to establish causality. For example, Etter argues that “The temporal sequence argument would not hold if the ordering of product use was explained solely by the ordering of opportunities to use the products, rather than by some inherent capacity of vaping to cause smoking”.  In reality, things are far more complicated, and relationships between risks (causes) and outcomes are complex, nonlinear and multi-directional. For example, obesity leads to joint stress, and joint problems also potentiate obesity through reduced movement. Which of these comes first and how they interact at different stages, ages, and contexts is dynamic rather than static relationship.  A recent study applying a prospective design and causal analytical framework found a bi-directional association between e-cigarette use and cigarette smoking among 11-18-year-olds in Great Britain, yet the association was stronger from ever e-cigarettes use to cigarettes initiation. So if e-cigarettes are a gateway into or away from other drugs/tobacco in different situations that does not constitute a basis to refute causality in both directions.

A recent NEJM review of the molecular basis of nicotine as a gateway drug by the founder the gateway hypothesis (Denise Kandel) and her husband (Eric Kandel, 2000 Nobel Prize winner in Medicine for neurophysiology) concluded that “nicotine acts as a gateway drug on the brain, and this effect is likely to occur whether the exposure is from smoking tobacco, passive tobacco smoke, or e-cigarettes”. Although the biological basis of nicotine’s gateway effect on the brain is likely to be consistent across different delivery means, the manifestation of nicotine dependence can vary according to different nicotine delivery methods (e.g. sensory cues in e-cigarettes can be different from those of traditional cigarettes).

A gateway out of smoking, but not into it?

E-cigarette proponents often assert that vaping is demonstrably a reverse gateway out of smoking for those who quit, while being scathing about suggestions that it could ever be a gateway into smoking  have been repeatedly used as debate enders. Any cessation researcher offering the equally trite “smokers who will quit, will quit” as a serious contribution to understanding the complexity of transitioning out of smoking, would be rightly pilloried for their primitive understanding of the complex processes that can culminate with permanent smoking cessation  Yet, with e-cigarettes, all that is apparently required to be said about anyone who smokes regularly is that that they had a propensity to do so. If this hard determinism was all that was needed to be invoked in understanding smoking uptake, how then do we explain the dramatic falls in uptake that have been seen in nations which have robust, comprehensive tobacco control programs? What eroded the “propensity” of all those who never took up smoking? Nicotine liability may well be a predisposing factor, but what of the known tractable reinforcing and enabling factors that tobacco control has so successfully identified and addressed over decades?

The implausibility of experimental vaping transitioning to smoking?

Another salient argument used by e-cigarette proponents is that studies showing a gateway effect do not differentiate adolescent experimental vaping from more regular use, so “any vaping” is treated the same when the association between vaping and later cigarette smoking is assessed. Etter argued that it is “hardly plausible that a simple puff or a few puffs on an e-cigarette can cause subsequent regular smoking”. But of course every regular smoker started with a “simple puff”, nearly always in adolescence. They then typically progress through more regular use to daily smoking. Birge et al recently reported that over two-thirds of smokers who tried as little as a single puff became, for a time, regular smokers.

Moreover, the assertion about the implausibility of experimental e-cigarette use leading to regular smoking in youth contrasts with an important body of evidence regarding the high susceptibility of children and adolescents to the psychotropic and addictive effects of nicotine. For example, Fidler et al and others have highlighted that children only require a very minimal exposure to develop an important and identified “sleeper effect”: a vulnerability to smoking after trying just a single cigarette, that can lie dormant for three years, or more: “From a neurobiological viewpoint, neural reward pathways might be changed as a consequence of a single exposure to nicotine, thus potentially increasing vulnerability to later smoking uptake”. Others have referred to an established body of evidence relating to youth nicotine exposure; “Importantly, several studies support that a single drug exposure can lead to changes in synaptic strength that are associated with learning and memory. The high susceptibility of children and youth to the “neurobiological insult” of nicotine was recently been highlighted in the US Surgeon General’s report on the potential risks of nicotine and electronic cigarettes to youth. Ultimately, these cellular changes could underlie the long-lasting effects of drugs”.

McNeill, who has been persistently critical of gateway effects  co-authored two heavily cited papers one of which noted that “The first symptoms of nicotine dependence can appear within days to weeks of the onset of occasional use, often before the onset of daily smoking”. Moreover, in a 30-month follow-up of the same subjects, it was noted that “Symptoms of tobacco dependence commonly develop rapidly after the onset of intermittent smoking, although individuals differ widely in this regard. There does not appear to be a minimum nicotine dose or duration of use as a prerequisite for symptoms to appear. The development of a single symptom strongly predicted continued use, supporting the theory that the loss of autonomy over tobacco use begins with the first symptom of dependence”. The clear contrast between the well-established understanding of cigarette smokers’ rapid onset of symptoms of nicotine dependence with efforts to trivialise concerns about initial infrequent use of e-cigarettes is therefore noteworthy.

The NASEM report  emphasizes that  because the e-cigarette phenomenon is relatively recent, “the majority of studies … lack sufficient duration of follow-up to study the naturalistic cigarette smoking progression sequence, which can involve a lengthy period between ever use and reaching daily smoking.”  Emerging longitudinal data should provide greater clarity on the extent to which “ever” smoking after e-cigarette uptake converts to daily smoking.