John Dollisson, CEO of Tobacco Institute of Australia 1983-87, then with Philip Morris International

I’ve often been asked by journalists, interviewers and friends what it was about tobacco control that kept me engaged and interested in it across the 45 years I’ve been active in research and advocacy for policies capable of driving down smoking and the diseases it causes. Some are probing to see if there was some road to Damascus epiphany I had early in life. The early death of a heavy smoking parent? No. Or perhaps some religious or neo-puritan calling to deny people the so-called pleasures of smoking? Hardly, I’m a very long term atheist, love wine and good whiskey, and like most people of my age, used cannabis for about half my 20s.

Some are keen to steer the conversation to what it is about working in tobacco control that “drives” me. I often wonder if people working in clinical medicine are ever asked the same question (“why have you kept working for so long as a kidney surgeon?”; “You’ve been a cardiologist for so many years, what is it that keeps you at it?”)

The answer to such questions from clinicians is self-evident. People with diseases and injuries that might be cured or alleviated are very keen to come into the orbit of specialists who can help them and are profoundly grateful when they succeed. Clinicians try to help people who want to be helped, so they are seldom asked to account for why they do what they do, unless they have somehow been exposed as behaving unethically or ineptly.

There is some common ground here with smoking. Some 90% of smokers regret ever starting; most smokers want and try to stop, sometimes often; and I’ve never met any parent who wanted their kids to smoke. “Prevention is better than cure” is regarded as a truism because prevention saves suffering from ever occurring. Everyone who has never been seriously injured in a car crash would rather this had never happened than endure surgery and rehabilitation after being injured.  Successful clinical interventions save lives one at a time while successful global public health policy can save millions of lives at a time.

Tobacco control is a multi-disciplinary pursuit. My colleagues over the years have been clinicians, epidemiologists, biostatisticians, social scientists like psychologists, economists and political scientists, pharmacologists, lawyers, mass communication specialists, agronomists, historians, investigative journalists and politicians. This has made it endlessly fine-grained and fascinating work.

But most working in it will readily agree about a factor that turns the temperature right up in motivating public health advocacy for the policies and mass reach campaigns that drive smoking down. The pinguid, dissembling types who do Big Tobacco and (today) Big Vape’s bidding. For over 70 years, the tobacco industry has been represented  by people whose goal has been to use every possible roadblock to tobacco control policies which seriously threatened tobacco sales.

Thankfully in Australia and many other countries, they have lost every single battle they ever fought.

Today, in déjà vu, we see vaping advocates currently in overdrive to cement the narrative that the health risks of ecigarettes are as benign as breathing steam in the shower and the dramatic rise of school vaping is simply a fad like hula hoops and yoyos that we should all relax about, as a leading vape promoter told the Daily Telegraph in 2021. With 13 year olds calling the Quitline for help with their vaping addiction, I may have missed it but I don’t recall yoyo or hula hoop helplines across the country.

Similarly and infamously, Big Tobacco publicly denied for decades that smoking was harmful, that nicotine was addictive and that children were in their marketing and promotional cross-hairs as essential to their present and future customer base.

In 2001, I was awarded a four year US National Cancer Institute grant and another from the National Health and Medical Research Council to sift through many millions of pages of internal tobacco industry documents made public through the 1998 Master Settlement Agreement between 46 US state governments and the tobacco industry. My research group published 38 papers from these grants, 16 here, 13 here and another 9 linked in my CV between 2001-2005 here.

The documents acted like violently emetic truth serum to the tobacco industry. Its galactic public lies across every conceivable tobacco policy area instantly stopped with the revelations about what they had long known to be the truth, now available for anyone to wave in their faces via their very own internal documents. The only one that persists today is their collective hand-on-heart denial that they slaver over the teen nicotine addiction  market, this being the sine qua non of both the smoking and vaping business models.

I’ve often been asked to nominate the very worst examples of this conduct. This recording of a debate I had with John Dollisson in 1984 on (now ABC chair) Ita Buttrose’s Sydney morning radio program on 2UE is very hard to beat. Dollisson was the Sydney-based head of and main spokesman for the fully tobacco industry funded Tobacco Institute of Australia (TIA) from 1983-87. This 2003 paper by one of my colleagues (now) Professor Stacy Carter, describes the history and activities of the TIA. Dollisson was heavily involved in trying to stop the advance of smokefree indoor areas and bans on tobacco advertising. But his bread and butter was attacking claims about smoking risks.

The full transcript of the 2UE conversation is below. The most disturbing part came when a smoker with lung cancer called in and said she believed her cancer was caused by “stress” as she was a highly nervous person, and that if she stopped smoking, she might die sooner. Dollisson told her it was “good to see you have taken an objective assessment” of her situation and that if other factors like genetics, stress, and indoor and outdoor pollution were taken into account, smoking’s role “was virtually removed”. Buttrose’s popular mid morning program would have been heard by tens of thousands of listeners.

Listen to their conversation here.

This figuratively and literally sickening excerpt from an ABC “Pressure Point” TV program also from 1984,  shows Dollisson and Philip Morris’ Bill Webb both faithful to the Big Tobacco script of the day. For those with the stomach, here’s the full 25 minute program.

Dollisson seems to have long moved on from tobacco. Here is his Linked In page which includes his post TIA 4 year stint with Philip Morris and their “Vice President, Corporate Affairs, World Wide”.

To my knowledge, Dollisson has never made any public statement showing any regret about his tobacco industry years. Industry employees often sign non-disclosure agreements. If he’s reading this, I’d be happy to give him space to do so.

About 35 years ago during the Irish ‘troubles’ I flew from London to Belfast and with 40 or so others, took a chartered bus down the east coast  to a convention centre overlooking the Irish Sea. On the return journey a couple of days later, our bus was stopped by the police. There was some sort of security operation going on. It was dark and the bus stayed on the side of the road for several hours with other vehicles till we were given the OK to proceed.

Needing something to help us pass what could have been  a long time in a bus with no lights allowed on, various people told travel tales, tall stories and charades. I  proposed a game that went on for at least an hour to gales of laughter.

Here are the rules. Everyone in the group has to try and think of something they have never done, which they guess that everyone else in the room has done. Absolutely anything qualifies, with the exception of naming places, countries, cities etc where you have never been. For each nomination you make that no one else in the room has ever experienced, you get a point, with the winner the person who has the most points.

The skill is thinking about experiences that you calculate to be widely experienced that makes it likely that your innocence is unique. Not having skydived is unlikely to win you a point, but never having played scrabble may well do so. Common foods and drinks are fertile grounds, as are common sports for the non-sporting, not having read popular books, authors, or seen popular movies or TV series. 

The game can be risky because some will nominate edgy, illegal or reprehensible activities which they guess most will not own up to. The Irish bus was full of public health researchers. Oxford University’s Sir Richard Doll was on the bus with his secretary. She got a highly acclaimed point right out of the blocks by saying she was confident she was the only person on the bus who’d never been to university. I knew that this also applied to at least one other person in the group who chose to keep silent. 

Admitting you’ve never had group sex, smoked dope or gone back to a supermarket and paid for an item that was missed by the check-out staff are all probably likely to produce highly unreliable results, depending on who’s playing the game.

Here are some points I usually score on when I play the game.

Snow skiing. Never been in an ambulance or broken a bone. Never stung by a bluebottle. Not read any science fiction book. Never worn sandals as an adult. Never voted conservative. Never ordered or accepted a glass of Baileys, Chartreuse, Tia Maria or Benedictine (after having had a previous sip). Never swam in the sea in mid-winter. Never read anything by Tolkein or JK Rowling. Never seen a single episode of Friends, Dallas, Dynasty, Sex in the City, South Park, the Simpsons and a bewilderlingy long list of other US produced TV fare since the 1970s.

My University has awarded former NSW premier Nick Greiner an honorary Doctor of Business (honoris causa) during a ceremony held in New York on  8 October, presided over by the University’s Vice-Chancellor and university President, Professor Mark Scott AO. 

“Across business and politics, Nick’s achievements are remarkable,” said Professor Scott. “Throughout his illustrious career, he has served the nation and helped the community through his work in policy and his environmental efforts. He continues to influence the next generation of leaders, the future of business and the important relationship between Australia and the United States.”

The University of Sydney’s website noted that “Mr Greiner’s achievements in business over the last 30 years have been significant. He has served as Chair or Deputy Chair of organisations including Harper & Row (Australasia), Bradken, Citigroup (Australia), Coles Myer Ltd, Rothschild (Australia), Stockland Trust, QBE Insurance and Castle Harlan Australian Mezzanine. In addition, he was Chairman of Infrastructure NSW and the European Australian Business Council.”

Significant in its absence here is that Greiner was also a board member and chair of the tobacco company WD & HO Wills (later amalgamated with Rothmans to become British American Tobacco Australia – BATA).

Greiner’s own website includes his BATA role, so it seems inconceivable that the University was unaware of this and has deliberately air-brushed Greiner’s tobacco history from its decision and communications.

In 2003, I led a group of academics and health and medical students in protesting the Greiner appointment, then chairman of BATA, to chair Sydney University’s graduate school of government. One senior paediatrician was so incensed he threatened to resign if the appointment went ahead.  I persuaded the University Senate to overturn the appointment. They agreed with me and Greiner resigned from the role. I wrote a detailed account of how this occurred as a case study in public health advocacy at the end of this paper in the BMJ’s Journal of Epidemiology and Community Health.

At the time, the then University Chancellor Kim Santow AO wrote to me that Griener’s appointment had nothing to do with his tobacco industry role but was all about his distinguished career in politics and public administration. This was a version of the Jeckyll and Hyde defense: the upstanding citizen by day, who strenuously denies his evening persona has any relevance to his overall reputation.

In 1982, Sydney University was the world’s first University to formally adopt a policy whereby neither the university, nor any staff member or student could accept any form of support, grant or scholarship from a tobacco company. This was subsequently strengthened in amendments. Careers fairs at the University have long excluded tobacco companies from pitching employment to students. Universities around the world have followed suit, including Harvard and the London School of Economics.

When Nicola Roxon, the former Australian Health Minister and Attorney General was awarded an honorary doctorate of laws in 2019, the then Vice Chancellor Michael Spence AC noted that:

“the honour was also a fitting continuation of the University’s role in tobacco control. The University of Sydney has a long history of engagement in tobacco control and was the world’s first university to implement a policy preventing staff and students from accepting grants from tobacco companies. This has been emulated by nearly all Australian universities and many others around the world.

At the University of Sydney, we share Ms Roxon’s genuine desire to build a better, healthier future for the world and we are so proud when our world-class research is used by policymakers to bring about real change”

Greiner’s parting shot at the University in 2003 was to say that “his departure points to broader problems in the university, including mismanagement.”

“It’s the ultimate sort of inmates-in-charge-of-the-asylum situation and I just didn’t think it was worth the hassle” he said.

To my knowledge, Greiner has never expressed a syllable of regret about his role with BATA. This is important. History records many prominent people who have gone out of their way to express remorse and regret about dark periods or events in their past. Civil society has codified five steps for contrition that we expect people to exhibit before society turns the page:

Greiner openly admits he worked at the very peak of a tobacco company, with his eyes wide open. But he has never taken the next four steps. Draw your own conclusions.

It has been decades since any tobacco executive has been awarded a civic honour like an Order of Australia or knighthood. For such a thing to happen today would be like a rabid dog winning London Crufts dog show. The World Health Organisation’s historic Framework Convention on Tobacco Control has been ratified by 181 nations. Its Article 5.3 precludes governments from any engagement with the industry. Two in three of the tobacco industry’s most addicted, “loyal” smokers die from tobacco caused disease. There are light years between that toll and that attributed to any other industry.

Sydney University’s gesture to Greiner might simply be a case of failed corporate memory in a new administration. Perhaps there is no one on the present Senate which would have signed off on the award who is aware of the history. Or perhaps there is and they didn’t care.

But the omission of his tobacco links from the university statement suggests this was done in full awareness. This is very regrettable.

Following the publication of my new open access book Quit Smoking Weapons of Mass Distraction (Sydney University Press) I’ve been speaking to thousands of Australian GPs at conferences around Australia about vaping. The book includes a 16,000 word chapter looking at hype about vaping. My talk to the GPs focuses on 10 cornerstones of what I call “vaping theology”  – beliefs that all vaping true believers hold to be inviolable. The Medical Republic published a lengthy piece summarising my Sydney talk.

Dr Colin Mendelsohn, or the folksy “Dr Col” as he likes to call himself these days, is Australia’s  Energizer Bunny of vaping promotion. He didn’t like what he read and took to his blog to provide us with a “detailed …more scientific analysis”, giving himself a giant tick.

Let me take apart his sophistry one claim at a time. A warning, this won’t be pretty.

Response: I’m very sorry Dr Col, but it is true. The 2014 paper reported on a consensus of 12 people convened by the hyperbolic Prof David Nutt in 2013. They rated 12 nicotine containing products for harm and judged vaping as having 5% the harm of cigarettes, after acknowledging “A limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria”. Just read that again. Caveats don’t come more sweeping than that. So this was a estimate not worth a cracker.

But I am wrong about the provenance of the figure says Dr Col: he says the 95% figure came from the 2016 report of the Royal College of Physicians (RCP) and the now defunded Public Health England’s (PHE) 2014 report and 2015 update, both written after the Nutt paper.

In this 2019 blog, I forensically searched the RCP and PHE reports for the evidence informing the 95% figure. Nowhere in either report is there any worked calculation of the 95% factoid, which with others I shredded in the American Journal of Public Health in 2020. But in both reports, all referencing roads lead back to the Nutt report. 

Dr Col’s blithe “not the point” dismissal of the lack of precision about the relative toxicity of vaping and smoking would amuse any toxicologist.  Strychnine is less dangerous  than cyanide.  Proximity to sharks less dangerous than sharing a room with someone with Ebola. The point though, is that all deserve the utmost caution, not that we frame the choice as one or the other. How about quitting smoking and vaping?

Response: Dr Col always calls for vapes to be openly sold as “consumer products”, just like ordinary grocery items including cigarettes. With the support of nearly every health authority and NGO in the country, the Australian government has instead commendably restricted legal access to nicotine vapes to those with prescribed authority to access them through a pharmacy.

All new pharmaceutical products are scheduled by the TGA to enable tracking of prescribed use and reporting of adverse events. These reports over the years see drugs rescheduled up or down (sometimes including bans) in response to data on any problems found with short or long term use. Many vaping advocates argue strenuously against vapes being prescribed, invoking the urgent duty to save millions of lives. But advocates for life-saving drugs for cancer, HIV-AIDS and heart disease don’t think their drugs should be available over the counter in corner shops. Vaping advocates seem to think their issue is far more important than any other therapeutic good.

Response: There is in fact a large research literature about the roles of nicotine in a wide range of disease processes.  I captured some important examples of this here, including disturbing emerging evidence on nicotine as a possible cause of schizophrenia and as a promoter for several cancers.

The role of the vasoconstrictor nicotine in cardiovascular disease has long been known, and with unregulated flavoured disposable vapes flooding many world markets and providing as much nicotine in some vapes as in 9 packets of cigarettes, nicotine is by no means some benign vitamin-like substance that vaping theology insists.

Neal Benowitz, arguably the world’s foremost nicotine pharmacologist, summarised current awareness of nicotine safety risks in a presentation to the annual nicotine/vaping  conference  in Warsaw in 2019 (see his slide below). In only one area (COPD) was there any assessment matching Dr Col’s assertions.

Dr Col has previously pilloried evidence about vaping toxicity from animal studies. But as a prescriber he’d be well aware that the standard LD50 metric (Lethal Dose required to kill 50% of exposed laboratory animals) is used globally to rate the toxicity of chemicals. He’d also be aware of the vast record of animal studies being used in the development of safety and efficacy of many life saving drugs.

Yet when it comes to inconvenient information about possible negative effects on adolescent brain development, vaping theologians instinctively wave the dismissive “pure speculation” flag.

This recent longitudinal study of very young children who used any form of nicotine found, using neuroimaging outcomes, “a significant association was found of early-age initiation of tobacco use with lower crystalized cognition composite score and impaired brain development in total cortical area and volume. Region of interest analysis also revealed smaller cortical area and volume across frontal, parietal, and temporal lobes.” 

Nothing to see there, Dr Col?

Response: Dr Col writes that flavours encourage uptake of vaping “by current smokers” in the same way that they do with NRT gum and lozenges. Errmm … there are two rather large issues carefully omitted here. Vaping involves inhaling vapourised chemical flavours, while NRT flavours via gum and lozenge are ingested. In this blog and my book, I set out in detail why it is that no inhaled pharmaceuticals are flavoured (such as asthma puffers) and why the US flavour and extracts manufacturing industry (which stands to make billions if governments gave the green light to flavours in vapes) has spoken strongly against flavours in vapes.

And then there’s the teensy little issue of the huge attraction of flavours to nicotine naïve children who are flocking to vaping all over the world, and the importance of flavours in predicting on-going vaping. Why did you omit this, Col?

Response: Sadly, Dr Col apparently did not attend my talk, so has completely misunderstood what I actually spoke about here. I showed data from the UK government’s annual Opinions and Lifestyle Survey showing that the average number of cigarettes smoked daily by smokers who vape (8 a day) is almost identical to that by smokers who have never vaped (8.1 a day).

But in any case, his selective summary of dual use is a cherry-picked special.  Dual users are also exposed to more toxins than cigarette smokers and dual use does not predict smoking cessation, as shown in this 4 nation study where “smokers with established concurrent use [smoking and vaping] were not more likely to discontinue smoking compared to those not vaping … it is clear that the rates of transitioning away from smoking remain unacceptably low.”

Response: Again, Dr Col responds to something he’s guessing I was talking about here. What I actually spoke about was the bankruptcy of the so-called hardening hypothesis. Dr Col’s response indicates he’s fully signed-on to the idea that today’s smokers are predominantly those who “can’t” quit. The US smoking cessation maven John Hughes reviewed 26 studies which examined the hardening hypothesis to see if this was true. Hs conclusion? “Some have argued that a greater emphasis on harm reduction and more intensive or dependence-based treatments are needed because remaining smokers are those who are less likely to stop with current methods. This review finds no or little evidence for this assumption.”

Response:  My book has a section of a whole, large  chapter (#2)  explaining why participants in smoking cessation RCTs bear scant resemblance to those from real world longitudinal use. Just to take one example, two thirds of smokers would not be deemed eligible to enrol in an RCT. Reasons here include mental illness, which is much higher in smokers. Such ineligibility will mean that RCTs are likely to be strongly biased to not include many deeply nicotine dependent smokers. My chapter also explores many other issues that differentiate the attention paid to RCT participants by researchers compared with how cessation products are used in the real world.

And yes, meta-analyses of RCTs like Cochrane do find that vaping is more successful than NRT. But the “success” here is utterly, stonkingly dismal. Ninety out of 100 smokers assigned to vaping in RCTs continue to smoke, compared with 94% using NRT. Is there any other drug in the whole of medicine that would attract the epithet “successful” with a failure rate of 90%?

Longitudinal cohort studies of smokers who vape also reach conclusions that vaping is far more dismal than disruptive, with plausible concerns that it may hold more in smoking than it tips out of it. Again, my book discusses this at length.

Response: Oh dear, Dr Col is at it again. He’s using data in August 2022 that is way out of date. In this blog I wrote in April 2022, I explained how the dotted line you see in Col’s graph above for Australia is now down to 11.8% (if we take all smoking …even very irregular smoking … into account) and down to 10.7% for daily smokers. That’s because we have 2021 Australian data, which unfortunately don’t fit Col’s narrative so he leaves it out.  Australia is just behind New Zealand (on just one year’s data), but ahead of the UK and USA.

Response: Debate about whether vaping leads (ie increases the likelihood) to smoking or whether it’s simply a matter of “kids who try stuff, will always try stuff” (dignified as “common liability theory”) will always be on-going because it will of course never happen that children will be randomised to vape or not vape and then followed up for several years. The best we can do is to look at large cross-sectional cohorts and control in analyses for the very factors that common liability theorists say confound claims that vaping leads to smoking.

The best example of this is a paper on the UK’s  huge Millennium Cohort. It found  “Among youth who had not smoked tobacco by age 14 (n = 9,046), logistic regressions estimated that teenagers who used e-cigarettes by age 14 compared with non-e-cigarette users, had more than five times higher odds of initiating tobacco smoking by age 17 and nearly triple the odds of being a frequent tobacco smoker at age 17, net of risk factors and demographics.”

Very importantly, the paper also knocked the stuffing out of the glib ‘kids who try stuff, will try stuff’ common liability dismissal of the concern that vaping acts as training wheels for later smoking uptake. In their analysis the authors controlled for a rich constellation of ‘propensity’ factors that have been suggested to predict smoking uptake in youth. These included parental educational attainment and employment status; parental reports of each child’s behaviour during the prior 6 months using the Strengths and Difficulties Questionnaire, with indicators of externalizing behaviours (i.e. conduct problems, hyperactivity, inattention; and internalizing behaviours (i.e. emotional symptoms, peer problems) parental smoking; whether a child spent time ‘most days’ after school and at weekends hanging out with friends without adults or older children present. Children, via confidential self-reports, indicated whether they had ever drunk alcohol (more than a few sips), ever engaged in delinquency (e.g. theft, vandalism) and whether their friends smoked cigarettes.

The authors concluded:

“we found little support that measured confounders drove the relationships between e-cigarettes and tobacco use, as the age 14 e-cigarette and tobacco cigarette estimates barely changed with the inclusion of confounders or in matched samples. Furthermore, early e-cigarette users did not share the same risk factors as early tobacco smokers, as only half the risk factors distinguished e-cigarettes users from non-users, whereas age 14 tobacco smokers were overrepresented on almost all the antecedent risk factors. If there was a common liability, we would expect similar over-representation for users of both forms of nicotine.”

And as for Col’s statement “Most young people who vape have first smoked cigarettes”, I’ll just leave you with this. In the 2019 New Zealand Youth Survey, “More than 80% of ever-vapers (N=2732) reported they were non-smokers when they first vaped, and 49% of regular vapers (N=718) had never smoked.”

Response: Do you all see what Dr Col has done here? He’s highlighted data in Philip Morris International’s second quarterly report for 2022 about the growth in revenue it’s getting from its putative reduced risk products. Premium products have long been far more profitable per unit for tobacco companies than budget products like much cheaper cigarettes. But in public health, we are more interested in how much of which products the tobacco industry is selling, not how much money they might make from each. Col might have missed this graph in the same report.

And from earlier in the year

With this brilliant observation

So, PMI’s much trumpeted drive to reduce consumption of its ultra-deadly cigarettes is, in their word, “recovering”. In Philp Morris-speak, the decline in cigarette use is now reversing at the same time as its pricey heat sticks are increasing. So much then for unsmoking the world, particularly in Poland, Turkey and Indonesia where cigarette shipments are increasing.

Tomorrow, Australia’s state and federal health ministers will meet for the first time since the May election routed the Morrison government. The national explosion in teenage vaping, driven by access to cheap, highly addictive, sickly-sweet, disposable vapes is on their agenda.

As we saw on Four Corners this week, there can be very few schools across Australia not struggling with the growing epidemic of vaping. Australia hasn’t surveyed teenage vaping in schools since 2017 (a new survey is in the field right now), but in New Zealand the government is now desperately trying to put the teenage vaping genie back in the bottle.

Between 2012 and 2015, prior to the widespread availability of vaping in New Zealand, overall smoking fell by 21% from 6.8% to 5.5% and by 37% from 17.7% to 11.2% in Māori teenagers. But after the advent of vaping, the decline in smoking changed to a growth of 9% between 2015 and 2019, with Māori smoking rising 21%. While this was happening, regular vaping was rising dramatically: between 2015 and 2019, the prevalence of regular vaping rose 173% (5.4% to 12%) and by a roaring 261% in Māori teens (5.4% to 19.5%).

In the USA in 2021, 11.4% of high school students vaped in the last month.

I recently asked my 12-year-old granddaughter what she thought attracted some of her Year 6 classmates to vaping. Instantly she replied “You can get lemonade flavour!”  There are more than 15,000 vaping flavours advertised on the web, many of which would not be out of place at a 5 year old’s birthday party.

Australia has 2.7 million people living with asthma. Not one of them uses a flavoured puffer to mask the unpleasant medicinal taste of the salbutamol they typically inhale a few times a day. Why? Because no pharmaceutical regulatory body anywhere in the world allows inhalable flavouring chemicals, with the US Flavouring and Extracts Manufacturing Association warning last year  “E-cigarette manufacturers should not represent or suggest that the flavour ingredients used in their products are safe because they are used in food because such statements are false and misleading.”

Daily smokers pull smoke deep into their lungs an average of about 100 times a day. But daily vapers average 500-600, making a mockery of the bizarre denialism spread by some vaping advocates that vaped nicotine is not addictive. As England’s Professor John Britton has said “Inhaling vapour many times a day for decades is unlikely to come without some sort of adverse effect. And time will tell what that will be”

As Four Corners explored on Monday, today’s flood of cheap, disposable vapes can be traced to former health minister Greg Hunt being rolled by a 28-strong backbench revolt led by Queensland National Senator Matt Canavan. Hunt had announced in June 2020 that any adult wanting to vape would need to get a prescription to do so. He also announced it would be illegal (as it has been since July  2019 with cigarettes) to import nicotine-containing vape products. Canavan’s signatories spooked the government and Hunt withdrew the personal import ban.

But the Canavan pro-vaping cabal has been shredded with the departure of Abetz, Falinski, Laming, Wilson and Zimmerman. Its residuals like Hollie Hughes, Canavan and Barnaby Joyce have been rendered political eunuchs by the May election. Hollie Hughes’ performance on Four Corners is causing weapons-grade levels of amusement on Twitter.

Vaping advocates are fond of arguing that because nicotine is freely available in tobacco products, it follows that nicotine for vaping should enjoy at least the same, if not greater accessibility and be freely sold anywhere as a “consumer good” like milk and groceries. This argument has all the integrity of a chocolate teapot. We made every conceivable mistake by failing to regulate tobacco because governments early last century had no idea of today’s 8 million global annual death smoking health toll that took 30-40 years to emerge. Widespread vaping had only been around about 10 years.

Very few kids import their vapes. Why would they bother when they can just walk into the many shops openly selling them, or buy from entrepreneurial kids who buy them in bulk off sites openly advertising them like Facebook Marketplace (search for “fruit” or “vapes”).  The vaping chain’s weakest links are retailers and on-line wholesalers. Hitting these is essential to seriously curtailing the tsunami of vapes getting kids. All state governments should introduce seriously deterrent fines for importing and any form of retailing.  If corner shops and convenience stores were selling codeine, requiring a prescription, they would be shut down.

Tomorrow, the health ministers should:

1. Immediately add disposable vapes to the Prohibited Import Scheme (PIS). This is significantly more urgent from a public health perspective than attempting to close down the Personal  Import Scheme for Nicotine Vaping Products (NVPs). This could be achieved very quickly with the stroke of a pen and will cause zero political ructions.
2. Harmonise large, significant national increases in fines for commercial quantity importing, wholesaling and retailing of NVPs across all states and territories. These fines and confiscations should be big enough to give serious pause to anyone assuming that their illegal trade can go on, with rare busts costing a fraction of the the profits being earned.
3. Cooling agents should be also be immediately added to the exclusion list in the Therapeutic Goods Administration’s TGO 110 (also achievable with a stroke of a pen). These are being used to facilitate vapers inhaling large, highly  nicotine doses
4. Closing the Personal Import Scheme (PIS) will be a longer game and careful thought should be given to how encouraging the TGA/APHRA/HCCC to focus on telehealth prescription “factories” which are churning out prescriptions often without any acceptable doctor-patient interaction. This could significantly curtail abuse of the PIS by non-legitimate users.

Prescription access via pharmacies selling pharmaceutical grade products can supply adult smokers wanting to switch. Advocates of continuing the open slather access that is now occurring claim Hunt’s prescription access is “prohibition”. By that very silly argument antibiotics, the pill and every other prescribed drug are prohibited too.

Health Minister Mark Butler should seize his first Nicola Roxon moment, and reintroduce the personal import ban. Roxon was lauded internationally for plain packs and Butler can lead the world with workable prescription access not gutted by leaving the front door open to rampant illegal nicotine vape retailing that is addicting a new generation of kids to nicotine who had never smoked.

My new book  Quit Smoking Weapons of Mass Distraction (Sydney University Press 2022 359pp ISBN 9781743328538) was published as an e-book on June 26 and as a paperback on July 1, 2020

You can download a full pdf of the book FREE here OPEN ACCESS e-book or order the book at Amazon here ($AUD40.00 paperback)

Below are quotes from the book that I hope will stimulate your interest.

The core message of the book

“The core message throughout this book has been that the overwhelming dominance of assisted cessation in the way that quitting has been framed over the past three decades has done a huge disservice to public understanding of how most smokers quit. Around the world, many hundreds of millions of smokers have stopped without professional or pharmacological help.”

On the dominance of unassisted cessation in how most ex-smokers quit

“If we were able to estimate the total number of people who have ever smoked and the total number who later stopped smoking completely, the proportion who were assisted in quitting by the actions of any kind of therapist or interventionist, or by consuming a potion, a pill or nicotine replacement (pharmaceutical, or most recently, from e-cigarettes) would be a small minority.”

“the overwhelming majority of research on smoking cessation has always focused on the “tail” of assisted cessation, not on the “dog” of unassisted quitting.”

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

On the medicalisation of quitting:

“Many concerns previously perceived as normal human differences or problems have now been defined as tractable illnesses that can benefit from diagnosis and often lifetime drug taking.”

“It appears that there is no smoker, regardless of how much or little they smoke, and regardless of whether they are not at the point of trying to quit, actively trying to do so or have long stopped smoking, for whom medication and especially NRT is not recommended. It is in the interests of that industry to persuade as many smokers as possible to use pharmaceutical aids for as long as possible.”

On the effectiveness of nicotine replacement therapy

“the best complexion we can put on the question of how good NRT is in keeping smokers abstinent into the longer term (here two years), is to say that NRT fares better than unassisted quitting while it is being used, but that both strongly fade as the months and years go by, to the point that there is no difference at two years. Smokers’ curiosity about whether they will fare better in the long-term with a course of NRT than with unassisted cessation therefore looks like a ‘no’.”

On why results from randomised controlled trials of quitting medications poorly reflect real world use results

 [one review] “found two-thirds of participants with nicotine dependence would have been excluded from clinical trials by at least one criterion … Those in such trials are thus very unrepresentative of all smokers wanting to quit.”

“frequent contact with research staff who are doing their best to ensure low rates of trial dropout, can combine to create an influential backdrop to using a quit-smoking medication or approach which is very different to the way people will use the same drugs or approach in “real-world” conditions outside a trial.”

“Undoubtedly, much smoker resistance to using cessation medication is due to many smokers learning from other smokers that real-world experience of using these drugs does not produce outcomes that remotely compare with benchmarks for other drugs they use for other purposes. Few if any other drugs for any purpose with such abject track records would ever be prescribed.”

“after over four decades of the pharmaceutical industry’s turbo-charged, no-expense-spared efforts to increase physician engagement and erode population resistance to pharmaceutical-based cessation, how many more years can the narrative of getting even more smokers to medicate retain any realistic credibility?”

On the pleasure of smoking

“The argument that smoking and inhaling nicotine is “pleasurable” is a bit like saying that being beaten up several times every day when you haven’t been able to smoke is something you want to continue with, because it feels so good when the beating stops for a while.”

On remaining smokers being “unable” to quit without help

“Those arguing that today’s smokers are increasingly heavily addicted and unable to stop, and therefore need assistance to do so, have very poor evidence supporting their case. Globally, vast numbers of smokers continue to stop or reduce their smoking every year. These include very heavy smokers and … many who quite suddenly stop smoking without making much if any preparation to do so.”

On quitline impacts

 “an estimated 0.87% of all US smokers [ever call a quitline], with the target being 6% or more. In not one year between 2009 and 2017 did the reach exceed 1.19% of smokers, falling some 500% below the minimum target reach set by the quitline consortium management.”

On the unpublicised news that many ex-smokers found quitting easier than expected

“in these striking data about many ex-smokers finding the quitting experience less traumatic than expected, we rarely (if ever) hear comments or see campaigns from those in tobacco control discussing or highlighting this. We very seldom hear any efforts to de-bunk or leaven the “it’s very, very hard to quit smoking” meme by pointing out that many ex-smokers were pleasantly surprised that quitting was not as tortuous as they expected.”

On vaping

“today the dominant narrative about smoking is being undermined by a shift from one about quitting smoking to one about switching to vaping, to the great delight of those in the industries whose very existence rests on the widespread continuation of nicotine dependency.”

“Vaping advocates are fond of arguing that because nicotine is freely available in tobacco products, it follows that nicotine for vaping should enjoy at least the same, if not more accessibility and be freely sold almost anywhere. This argument has all the integrity of a chocolate teapot.”

On vaping safety

“If any scientist had declared in 1920 that cigarette smoking was all but harmless, as vaping advocates insist today about e-cigarettes, history would have judged their call as heroically and dangerously incorrect. But this is the cavalier call that many vaping advocates routinely make, after just 10 years or so of widespread use in some nations.”

“High-quality clinical and epidemiological data on vaping’s health effects are relatively sparse. There are no data on long-term health effects, reflecting the relative novelty of vaping and the rapid evolution of vaping products. Determining even short-term health effects in adults is difficult because most adult vapers are former or current smokers”

“Inhaling vapour many times a day for decades is unlikely to come without some sort of adverse effect. And time will tell what that will be”

“if you both smoke and vape (dual use), you’ll have higher levels than those who only smoke. So if dual use is the Mount Everest of toxicant exposure, then smoking is the K2 exposure, vaping is the Matterhorn and never smoking or vaping is the toxicant exposure at sea level.”

“All tobacco companies now marketing e-cigarettes are delighted to [promote vaping as all but benign], while just down the corridor in their tobacco divisions they continue trying to maximise demand for the cigarettes that will cause the same billion deaths [this century] they claim vaping could prevent.”

“all vaping evangelists believe that no impediment should be placed in the way of their lifesaving work. But medicine of course has a very long history of claims being made by purveyors of a multitude of miracle cures who also believe their crusades are far too important to be regulated.”

On vaping flavours

“I recently asked my 11-year-old granddaughter about what she thought attracted some of her Year 6 classmates to vaping. Instantly she replied, “You can get lemonade flavour!”

“Why aren’t any asthma puffer drugs flavoured? Because the pharmaceutical industry knows it would struggle to demonstrate that inhaling flavours is acceptably safe”

“By 2016–17 [available e-cigarette flavours] had more than doubled to 15,586”

“E-cigarette manufacturers should not represent or suggest that the flavour ingredients used in their products are safe because they have FEMA GRAS status for use in food because such statements are false and misleading (Flavor and Extracts Manufacturing Association (FEMA) 2021).”

“Compare daily inhalation numbers: asthma puffers:4-6; daily smokers:104; daily vapers 500-600 … making a mockery of the bizarre denialism that vaped nicotine is not addictive.”

How good are vapes for quitting smoking?

“17 reviews of the evidence and position statements by professional health associations published since 2017 have concluded that the evidence for e-cigarettes being effective for smoking cessation is inconclusive, insufficient, weak or inadequate”

“But there can be few if any other drugs, used for any purpose, which have even come close to the dismal success rate of e-cigarettes or NRT in achieving their main outcome. If we went along to a doctor for a health problem and were told, “Here, take this. It has a 90% failure rate. But let’s both agree to call this successful,” we would understandably take the view that “success” when used in this context was not the way that it is used in any other treatment context”

On whether vaping reduces amount smoked per day

“Data from 2019 from the UK government’s annual Opinions and Lifestyle Survey also show that the average number of cigarettes smoked daily by smokers who vape (8 a day) is almost identical to that by smokers who have never vaped (8.1 a day)”

Read reviewers’ comments here

On the evening of 10 June, shortly after ABC-TV screened the first edition of its news backgrounding program The Context looking at the evolution of tobacco control, inveterate vaping proselytiser Alex Wodak, cleared his Twitter throat. In prose redolent of Churchill, he advised the world:

Prohibitionism? The overwhelming position of the Australian public health and medical community has been to strongly support the policy introduced by former health minister Greg Hunt who approved the supply of nicotine vaping products (NVPs) to anyone with a doctor’s prescription from October 2021.

Describing this as “prohibition” is like arguing that prescribed antibiotics, oral contraceptives or cholesterol control drugs are also prohibited.

Last year, 27 LNP government backbenchers plus legendary deputy prime minister Barnaby Joyce internally rolled health minister Greg Hunt’s accompanying policy of banning personal importation of NVPs. They wanted these highly addictive, unregulated products to be made available for sale anywhere that cigarettes can be sold. And that’s anywhere that includes the many places that are supplying kids across Australia with flavoured, disposable vapes.

When the extent of the carnage caused by smoking was first consolidated in the early 1960s, factory made tobacco products had already been sold openly as ordinary items of commerce for 60 years. Across the next 60 years we saw the glacial introduction of policies that began slowly reeling in that disastrous unregulated free-for-all. Every step was fought hard (and all lost) by Big Tobacco, a fight which it continues unabated today. It’s often been said that if cigarettes had been invented in 1960, with their unparalleled risk profile known in advance, they would have never been let onto the market.

Because of this, governments around the world made every possible ignorant mistake possible in failing to regulate cigarettes, but that’s what let-it-rip vaping advocates want to risk again. By contrast, controlled access via prescription builds a platform that can be liberalised or tightened in light of emerging understanding of the risks and benefits of NVPs.

Vaping advocates  in Australia have always nailed themselves to support from deeply conservative and reactionary political figures.  But since the cataclysm of the May 21 election, they have found themselves in the political wilderness where they are likely to remai for years. Today, their former go-to political besties couldn’t make an impression in a soft cushion. Federally, the Liberal Democrats have long been toast, Fiona Patten’s Reason party got homeopathic level votes in May and Pauline Hanson and her little buddy Malcolm Roberts are impotent in the new Senate. The heroic “I vape and I vote” bumper stickers  generated not  a political bang, but a whimper.

During the last year of the Morrison government, open slather vaping advocates were supported by the 28 LNP backbenchers. With the LNP now political eunuchs and prominent LNP vaping spear-carriers Wilson, Abetz, Laming, Zimmerman and Sharma gone from parliament, vaping advocates have no political friends with any policy influence. Hollie Hughes, Matt Canavan, the lugubrious Senator James Patterson and Barnaby Joyce are the best they have. Just think about that.

On Jun 12, 2020 this rock bottom epiphany saw a lot of people clearly playing with Wodak’s head. In a tweet he pointed at Labor, the LNP and five of Australia’s biggest health and medical NGOs who were “condemning” vaping. In fact, there are a lot more than five (see table above).

Later that day he also tweeted a graph (below) purportedly demonstrating how Australia seems to have choked badly  in reducing smoking compared with three other nations, all with  more liberal vaping regulations than us. Wow, look at how badly Australia was doing!

But there was a teensy-weensy problem here: the Australian data was for 2019 with a number then projected for 2021, while the other nations showed smoking prevalence for 2020 and 2021. Wodak should have known that the Australian Bureau of Statistics published smoking prevalence data for 2020-21  from its National Health Survey  showing that 10.7% smoked daily with 11.8% smoking daily or less than daily. So why didn’t he cite that inconvenient data? I think we can guess.

And there’s another important problem too. As I pointed out in an earlier blog looking at how Wodak’s advocacy mate Colin Mendelson engages in the same exercise, there are important differences in the way that different countries count “smoking”. Australian and US data on “current smoking” include all combustible tobacco (cigarettes, cigars, pipes, shisha) while England and New Zealand count only cigarettes and roll-your own as “smoking”.

• Australia ages 18+) (includes cigarette and roll-your-own smokers plus all exclusive users of other combustible tobacco products like pipes, cigars, hookah and shisha)
• USA: (ages 18+) (like Australia, includes all combustible tobacco product users)
• New Zealand (ages 15+) (includes cigarettes & RYO only)
• UK (ages 18+):(includes cigarettes and RYO only)

A 2017 editorial in Addiction made this same point, when looking at the most recent available data at that time:

it is likely that overall combustible tobacco use prevalence for adults18+ in the United States is higher than 15.1% [in 2015], and somewhere in line or just below the 2013–14 National Adult Tobacco Survey (NATS) estimate that 18.4% of US adults aged 18+ were current users of any combustible tobacco product

The COVID 2020-21 lockdowns saw a lot of smokers exposed to repeated advice to quit smoking. With lungs particularly susceptible to COVID, many smokers heard that message many times. In the first 5 months of 2020, downloads of the government’s Quit Buddy app increased 310%. There are good reasons to expect that the projected downward slope in Wodak’s tweeted graph would have been steeper.

So of the four nations shown  in Wodak’s graph updated for the latest national government data, Australia sits at second on 11.8% smoking at any level, behind New Zealand with 10.9% and ahead of England on 12.1% and the USA on 12.4%.

The disastrous abandonment of Hunt’s planned ban on personal importation of NVPs should be revisited. With massive quantities of totally unregulated, illegal disposable NVPs flooding Australia and driving the teenage vaping surge, the universal support of state and federal health departments to shut this down will offer Mark Butler his first Nicola Roxon moment in prevention.

Roxon’s bold introduction of plain packs, now dominoing around the world, was lauded by the health and medical community. Twenty one nations have now finalised plain packaging legislation. Restoring the ban on personal importation of NVPs and introducing and enforcing seriously deterrent fines for their commercial importers and retailers looks like a very smart move.

The barnstorming success of progressive independent candidates in the May election underlined Australians’ mass scale disillusionment with two party politics. Very importantly, it also shone 10,000 watt arc lights on the huge power of local action to make political change.  Labor and the LNP will be scrambling to tap into that power or will see their voters drop even further.

No issue energized this election as much as climate change and the environment. The huge rise in the Greens vote as well as the teal independents all giving it centre stage are obvious signs.  Many accounts of the growth of armies of volunteers blanketing suburbs with door knocking conversations, local business engagement and packed out meetings full of people hungry to help with change were inspiring.

To try and harness this sort of energy, I plan to soon set up a Sydney inner west local action for the environment page to encourage government policy and practice change at all levels and to promote local initiatives. I hope these will proliferate across the country.

All we are learning about the vital importance of increasing social interaction in people’s lives in reducing isolation, promoting mental and physical health and delaying and minimizing the onset of dementia (the more physical, social and cognitive activity, the better) make increasing local community interaction a no-brainer.

Here’s a start to an alphabetical list of the many things that local action might be aimed at when it comes to the environment. If you can suggest others, PLEASE do.

Abating food waste and building food security

• Explore ways to have more local food businesses donate unwanted stock to food security pantries like Marrickville and Camperdown’s  Addi Road for distribution to those in need
• Organise and promote local monthly residents’ food donation days

Coffee keep-cups and plastic lids

• Encourage expansion of the list of banned single-use plastics to include coffee cup lids. And in the meantime …
• Develop and promote “no plastic lid” requests to coffee outlet
• Survey all local coffee outlets on willingness to fill customers’ keep-cups (some refuse saying they are “unhygienic” to staff)
• Publicise those outlets which actively encourage keep-cup use
• Request council (or coffee wholesalers) to supply “coffee keep cups welcome” signs and stickers. It’s all about normalizing their use.

Dumped rubbish

• Encourage rapid reporting to council of dumped rubbish

Front fence book libraries

• Help others make these proliferate by sharing construction, decoration and mounting tips and moving your unwanted books to them

Electric vehicles

• Identify more large carpark sites for EV charging stations (eg: in the Inner West Leichhardt Market Town, Norton Street shopping centre) and lobby management to install them
• Petition shoppers to sign appeals to shopping centre management about charger installation
• Survey local interest in potential EV purchasing and identifying lack of local charging as a possible barrier
• Prepare and share templates for assisting strata building residents to make the case for unit block charging points
• Investigate challenges and potential solutions for community street charging in areas where many dwellings have no garages or other off-street parking
• Lobby local and state government council for pilot community street charging
• Build purchasing pools of local residents to lever EV retailers to offer discount for bulk EV purchasing

Litter patrols

• Promote local litter abatement by having each block’s residents “own” their block’s litter
• Promote and normalize litter removal as a routine part of local walking
• Ask council to supply or subsidise litter pick up tools

Native bird nesting houses

• Encourage and assist residents to install bird nesting houses (eg: help with construction and installation)

Plastic bags

• Note any businesses still using single-use plastic bags
• Gentle reminders to these about the new law
• Reporting any shops continuing to supply them

Recycling bins

• Build volunteers to conduct sample surveys of yellow bins to determine the extent of and the most common examples of unacceptable content that ruin recycling collections
• Circulate (letterbox, local social media) survey results highlighting common problems
• Encourage council to introduce rejection notices on yellow bins containing unacceptable (contaminating) material
• Encourage councils to expand acceptable green bin content to include the many things shown here

Solar energy capture

• Encourage reform of local government planning regulations to maximise incorporation of solar and battery installation in new building construction and relevant renovation

Street lights left on in daylight

• Encourage reporting of faulty street lights which remain on during daylight (these are easily rectified)

Stormwater drains and mulch

• Build networks of local residents to “adopt a drain” which clogs with leaves and soil after rain. These can be notified to council or easily cleared by local adoptees, with cleared matter making great mulch
• Identify suitable locations for locally depositing mulchable material (gutter leaves, lawn clippings)

Tool and labour sharing

• Set up local tool and labour sharing networks on social media. There are millions of rarely used tools sitting in sheds and cupboards out there. Let’s share them around. Need a neighbour to help you with a small lifting, fixing, clearing or IT job? A pool of community reciprocity would do wonders for community building

Tree planting

• Promote local government tree planting by assisting councils to identify houses and public spaces wanting extra trees

With the long overdue and very welcome passage in the NSW parliament of independent MP Alex Greenwich’s bill to legalise voluntary assisted dying, all six states have now legislated to allow the option of medically assisted death to those who are eligible and wish to die at a time of their choosing.  Estimates are that the NSW law will be implemented within 18 months.

Australia’s new Labor government will be quickly lobbied to allow the A.C.T. and Northern Territory governments to do the same. These jurisdictions are still without these laws and were destined to stay there had Morrison remained in power.

With those two gaps inevitably closing, Australia will have closed the book on medically assisted dying for all those who want it, right?

No, far from it. Eligibility criteria rule out large numbers of people who might want medical help to end their lives.

All Australian state legislation is broadly similar in its provisions. The Victorian legislation, which has been in place the longest, has this to say about eligiblity:

“They must have an advanced disease that will cause their death and that is:

• likely to cause their death within six months (or within 12 months for neurodegenerative diseases like motor neurone disease) and
• causing the person suffering that is unacceptable to them.”

The second dot point about unacceptable suffering gives sovereignty to the applicant’s tolerance for suffering, although this needs to be assessed and ratified by medical assessors. But the six and 12 month limits mean that a suffering person who has a disease judged by the medical assessors as unlikely to kill the applicant within those times will have their request denied.

The obvious problem here is that there are many thousands of people living with chronic, incurable and progressive diseases which cause them profound suffering – including mental and existential suffering – and whose suffering is likely to go on for longer than six to 12 months. If they apply outside those time limits, regardless of the strength of their desire to die sooner, they are likely to be refused.

Parkinson’s disease, emphysema and dementia are three important and prevalent examples of many more.

Parkinson’s disease

In April 2022, Former NSW Deputy Premier John Watkins wrote a harrowing account of his life with Parkinson’s disease in the Sydney Morning Herald. He was diagnosed 12 years ago in 2010. 70,000 people live with Parkinson’s in NSW alone. He described his life this way:

“a chronic, degenerative disease [which] continues merrily down its chosen path, dragging me behind it. In recent months, I’ve found greater impacts on my psychological and mental health, my speech and cognitive ability. That leads to self-doubt, depression, uncertainty, awful loss of confidence. How long it will torment me in this way before moving on to other things, I do not know.

The challenge of PD has changed my life like nothing else. I never expected it and I know I’m not dealing with it very well.

Me, you, none of us can escape the inevitability of life-changing challenges that are rolling down the years towards us. They make and too often break us. Parkinson’s did that for me. I have hoped over the years since that it would stir a stoic resolve, a capacity to bear the strain, and to move on, despite the weight. Rather it has left me feeling bereft, and hopeless.”

Watkins wrote nothing about wanting to end his life early. But many living in such a way might want to. One of my dearest colleagues took that step several years ago, surrounded by his family after a last meal and his favourite music. He was a doctor who had access to nembutal.

Emphysema

Emphysema is another very prevalent disease, with 4.8% (about in in 21) of those aged 45 and over living with it, sometimes for up to 20 years. It is progressive and incurable, with medication capable of only slowing progress and partially alleviating symptoms. In the final stage, which may sometimes last for several years, quality of life can be abject. It can be an exhausting trial to walk even a few steps, with stairs being very challenging. Those living like this are often housebound and so socially isolated.

I will never forget a woman who called me at work about 15 years ago.  “I’ve smoked for thirty years. I have emphysema. I am virtually housebound. I get exhausted walking more than a few metres. I have urinary incontinence, and because I can’t move quickly to the toilet, I wet myself and smell. I can’t bear the embarrassment, so I stay isolated at home. Smoking has ruined my life. You should start telling people about the living hell smoking causes while you’re still alive, not just that it kills you.”

Some living like this may want to end their lives. But again, they would be ineligible under the current legislation’s time limits until they were as assessed as being six or less months before death.

Dementia

When it comes to dementia, Andrew Denton has said “This is a much longer, and more difficult, conversation … [dementia] is the single most common question I have been asked over the last 6 years – what about people with dementia?”

The Victorian rules say this about those with dementia:

“Having dementia is not sufficient reason for a person to access voluntary assisted dying (the same as disability or mental illness), but a person diagnosed with dementia may be eligible if they meet all of the conditions, including having decision-making ability throughout the entire process.  (my emphasis)

When dementia affects a person’s ability to make a decision about voluntary assisted dying, they will not meet the conditions to receive assistance to die.”

When it comes to dementia, this catch 22 is both cruel and iniquitous.

Those of us who have completed living wills (advanced directives) and lodged them with our GPs and next-of-kin, have done so recognising that there may come a time near our death when we are unconscious and so unable to affirm to medical staff looking after us about what we want to happen. While next-of-kin can over-ride or fail to disclose a living will when a person is dying, this is far less common than them affirming a dying person’s known expressed interests.

So when a person is unconscious, medical and hospital staff cannot check with a clearly dying, terminal patient that they indeed still stand by their written, dated and witnessed preferences to not be given life preserving measures like resuscitation, assisted beathing or tube feeding. The medical staff instead check with next-of-kin what the patient’s wishes would be. Here, an advanced directive produced for corroboration would be of critical importance. Medical staff will generally then respect the past written words of the dying patient, in addition to the assurances of the next-of-kin that hastening death by withdrawal of life support is what the dying person would want.

The NSW Department of Health’s advanced care directive  that I have completed lists six “values” (see below) for the signatory to complete, as well as a number of explicit medical procedures that should not be attempted to prolong life.

If these directions are followed by medical staff, they will actively be failing to take actions in the knowledge that these omissions will cause the death of the person, as they wished in their advanced care directive.

But when it comes to a person with dementia who is legally judged as not being capable of requesting voluntary euthanasia, no such corroboration from proxies or living wills is allowed.

Front and centre of the assessment by those assessing the request that a person with dementia should be assisted to die, is the active, witnessed wishes of the person concerned. But if, while sentient, that person was to provide detailed specifications about when they would wish to be assisted with their suicide, they will have their wishes denied even if, when those conditions apply, they have ticked all the boxes at a time when they were sentient.

The glaring iniquity here is that anyone dying of any disease other than dementia, who either prepares an advanced directive or applies successfully for assisted dying, will have their wishes respected. Even if they are unconscious and cannot give final consent to actions being taken which will speed up their death, they will have their wishes respected.

But anyone seeking to ensure that their wish to not live with advanced dementia is respected (and assisted) will be side-lined and refused. They are destined, against their wishes, to live on for perhaps years in the twilight zone of total isolation, intellectual and sensory deprivation and unable to perform the most basic human functions by themselves.

My father had dementia and died in his sleep with it, not from it, at 89. He never expressed any wish to have assisted suicide and his quality of life, while a pale shadow of his younger self, was dignified and often contented (see my account of this at page 347 in this collection of writing).

But had he lived when voluntary assisted dying was legal, and when fully sentient, specified for example, that he did not wish to live when he could not recognise his own children, could not feed or toilet himself and answer the simplest of questions about his surroundings or circumstances, humane law on voluntary assisted dying should allow his wishes to be respected.

The situations I have described cannot be swept aside as too-hard-basket exceptions not requiring amendments to the various state laws. Certainly, the cardinal principle of sentient consent will be challenging here. But that principle is already considered where advanced directives are respected for terminal unconscious patients.

The challenging difference of course, is that when advanced directives are respected, life-saving medical procedures (CPR, tube feeding, renal dialysis, continuous administration of a drug) are not given. Steps are omitted that will result in death.  With voluntary assisted dying, a commission occurs: the active administration of a drug that will quickly cause death.

But when the intent in both cases is to accelerate death, acts of omission and commission both achieve the same result, albeit at different speeds. The outcomes for both here are the same, but the speed of death different. But why should the speed of accelerating death be at all relevant?

Instead, the respect for the wishes of the person who will die are different. In the case of an unconscious person without dementia with an advanced care directive, medical staff can hasten death by active decisions to not prolong life. They do not say among themselves “but we can’t check with the dying person if they earlier stated wish to die is still their wish – so we must prolong life, not end it”

Yet with the person with dementia who has actively taken steps to ensure they do not live in a state in which they desperately do not wish to live, no such respect is given.

That cannot be either just or right.

A final word to Andrew Denton “I also harbour concerns about asking a doctor to end the life of someone who can no longer competently request that act. I’m not sure an advanced care directive, no matter how meticulous or frequently updated, can fully answer a doctor’s reasonable concerns. That being said … regardless of our existing VAD laws, this conversation will continue.”

The Coalition of Asia Pacific Tobacco Harm Reduction Advocates (CAPHRA) is a vaping lobby group most Australians have probably never heard of. But on 6 April it issued a press statement trying to warn our political parties that if they did not liberalise access to vaping products, perhaps “millions” of voters would turn against them.

That’s right folks. Forget political parties plans to address climate change, the death of the barrier reef, fires, the worst floods we’ve ever seen, asylum seekers being left to rot for 10 years in offshore detention, failure to introduce a national anti-corruption commission, failure to address violence against women and many more big issues. It’s more freedom to vape that CAPHRA thinks will decide our election.

Besides having problems even spelling “cigarettes”, grammatical problems and getting more than all of 138 hits on its latest riveting video published 26 days ago, CAPHRA doesn’t seem to mind publishing easily fact checkable out-of-date nonsense on how badly Australia is allegedly doing in reducing smoking.

Source

Its press release quoted the irrepressible Australian vaping advocate Colin Mendelsohn:

The two national government data sources on smoking prevalence are the Australian Institute of Health and Welfare’s triennial National Drug Household Survey (NDHS) and the Australian Bureau of Statistics National Health Survey.

Here are the data on daily smoking prevalence

2013:(14+): 12.8% (AIHW)

2016:(14+): 12.2% (AIHW

2018 (18+): 13.8% (ABS)

2019 (14+): 11.08% (AIHW)

2021:(18+): 10.7% (ABS)

AIHW source: Australian Institute of Health and Welfare (2020c). Table 2.3: Tobacco smoking status, people aged 14 and over, by sex, 2001 to 2019 (persons). In Chapter 2: Tobacco smoking supplementary tables, National Drug Strategy Household Survey 2019. Canberra: AIHW.

Mendelsohn’s words quoted by CAPHRA appear in his March 15 2022 submission to the Australian Health Department’s National Tobacco Strategy 2022-2030. Strangely, nowhere in his submission does he cite or quote the ABS’s 2021 data which was published  on December 10, 2021, three months before he finalised his submission.  In his submission he compares the average annual falls in smoking prevalence in Australia, England and the USA writing “The annual rate of decline in smoking since 2013 has been 0.3% in Australia, 0.7% in England and 0.8% in the US”.

Had he looked at the average annual decline in Australia across the 4 years 2018-2021, he would have had to write that Australia’s rate declined by an average of 0.775% per year – a figure inconvenient to his “embarrassing failure” narrative. His forecast that it’s “highly unlikely that Australia will reach the ‘new’ target of <10% daily adult smoking by 2025” – in two and a half years from now – will put egg all over his visage if recent declines continue.

Mendelsohn should also have been aware that the way “smoking” is counted in England is different to how it’s counted in Australia. Australia includes cigarette and roll-your-own smokers plus all exclusive users of other combustible tobacco products like pipes, cigars, hookah and shisha, whereas England only counts cigarettes and roll-your-own as “smoking”. England’s full combustible tobacco smoking prevalence will therefore be higher.

The booming use of disposable vapes by Australian school kids which is alarming school principals, parent groups and those in public health seems certain to trigger major revisions to the regulation of vaping products in Australia later this year. If state and territory governments significantly ramp up fines for selling vapes without prescription and put far greater effort into busting and publicising raids on sellers who are currently banking on COVID19-depleted low priority for this, many small businesses will not risk it.

Lesson from New Zealand

New Zealand, following an unsuccessful 2018 challenge by the Ministry of Health over Philip Morris International’s plans to sell the NVP HEETS product, the government was forced to allow the marketing of NVPs, including no age restrictions for purchase, no advertising constraints and no accountability for retailers.

The graph below, using data from New Zealand Action on Smoking and Health, shows what has been occurring with 14-15 year olds’ regular smoking and vaping prevalence in New Zealand. Between 2012-15, overall smoking fell by 21% from 6.8% to 5.5% and by 37% from 17.7% to 11.2% in Māori children.  But after the advent of vaping, the decline changed to a growth of 9% between 2015-19, with Māori smoking rising 21%. While this was happening, regular vaping was rising dramatically: between 2015-2019, the prevalence of regular vaping rose 173% (5.4% to 12%) and by a roaring 261% in Māori children (5.4% to 19.5%).