The policy termites slowly eating out the foundations of smoking

Like a mound of termites, tobacco control policies are eating away at smoking in ways we’re not always conscious of. from www.shutterstock.com

Simon Chapman, University of Sydney

Across 40 years of working in tobacco control, there have been countless times when I’ve been asked “so, has [insert here] policy or [insert here] campaign worked?”.

The question has its roots in clinical interventions where we see what happens when you take an analgesic for pain, get an injection before having a tooth pulled, or apply a fungicide on athlete’s foot. These things work.

So it’s natural we should ask the same about a piece of legislation or a multi-million dollar TV campaign about smoking. Do these things make a difference?

In 1993 I wrote an essay on this issue in the British Medical Journal, Unravelling gossamer with boxing gloves: problems in explaining the decline in smoking.

In the wake of Philip Morris being ordered to pay the Australian government about A$50million in legal costs over the company’s failed attempt to thwart plain packaging, I was asked the question again this week: “Has plain packaging worked?”

So here’s an update on the direct and subtly synergistic ways tobacco control has seen Australia achieve record lows in both adult and teenage smoking.

From a trickle to a deluge

Since the bad news on smoking and health began to trickle in from 1950, then deluged us, hundreds of millions of smokers have stopped smoking around the world, particularly in nations where governments have introduced population-focussed laws and regulations. These include measures like laws, taxes and mass campaigns that reach huge proportions of the population as opposed to dinky little interventions very few people ever see or are exposed to.

When a smoker decides to quit, they will have usually tried before – many with about the same conviction as attempts to exercise more or lose weight. But when they finally succeed, ex-smokers will often nominate a reason “why” they quit.

There is broad daylight between the first reason ex-smokers give about why they quit and all other reasons they nominate. Health concerns are the overwhelming reason for quitting (91.7%), followed by cost (way back at 58.7%); 90% of smokers regret they ever started.

The straw the broke the camel’s back

People also often nominate a recent “straw that broke the camel’s back” as the precipitating reason for the final decision to quit and resolve to see it through.

This can be a symptom they have experienced, an incident like the sudden death of a smoking friend, a particularly poignant campaign advertisement they can’t get out of their head (this classic has few peers), the heartfelt pleading by a child or partner, the sudden realisation very few of their colleagues or friends smoke or the price of cigarettes going through a psychological barrier, like A$40 a pack.

These triggers are known as proximal factors that stimulate quitting: factors easily identified, nominated by smokers aware of their influence, and sometimes easy to quantify with proxy measures like immediate boosts in calls to quitlines.

Background factors that eat away at smoking

But there are also vital distal or background factors that work like hidden termites in a building. These slowly and subconsciously eat away the foundations of smokers’ feelings of being invincible to disease, their apathy and act to denormalise pro-smoking environments. The effect is that smokers get fewer reminders about smoking and a growing awareness smoking is not something the great majority of people do anymore.

Examples of these distal factors are advertising bans, graphic warnings on packs, plain packaging, smoke-free public spaces and tobacco taxation.

Very few smokers tell you they quit smoking because tobacco advertising was banned. The impact of advertising bans instead works in slow-burn fashion, as it has done in Australia since 1993 when the last forms of advertising ended.

With plain packs, some smokers experienced an increased urgency to quit after exposure to the purposefully unappealing plain packs with their goullish (but deadly accurate) large graphic health warnings. But the primary goal was to have whole generations grow up never having being beguiled by the designer edginess of pack livery and noting plain packaging of tobacco products was exceptional among all other consumer goods.

Tobacco is the only product where legislation mandates plain packaging: 17 nations have either implemented, legislated it or announced they will. Tobacco is also the only product that has to be stored out of sight in retail outlets.

All these factors do not act in isolation, but like a constant and unstoppable termite colony, working in synergy to erode the appeal of smoking.

A day in the life of an ex-smoker

In my 1993 BMJ essay, I described a day in the life of a smoker who quit. The smoker woke to news on the radio of yet more bad research news about smoking; lived with disapproving family members who often urged him to quit because they had been educated about the risks; winced every time at the price he had to pay for a pack; was acutely aware of all the places he couldn’t smoke and why those laws had been introduced; was self-conscious about the stench of stale tobacco he carried about; and couldn’t shake some of the powerful anti-smoking advertising that intruded his TV viewing.

A smoker might well nominate just one of these influences when a researcher calls, but all play a part in a comprehensive approach to reducing the world’s leading cause of death, if you exclude poverty.

Humans are not like lab rats who can be artificially kept in strictly controlled environments and exposed to single or fixed combinations of policy variables while isolated from all others so researchers can measure the exact impact of any one factor.

People whose questions are based on that premise need to be gently reminded of that. Male lung cancer incidence rates today were last seen in the early 1960s and women’s seem likely to never reach even half the peak seen at the height of the male epidemic. We need to stay the course and make smoking history.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

Cheaper cigarettes, roll-your-own tobacco slows smoking’s downward spiral

While smoking in young Australians is declining, roll-your-own cigarettes are becoming more popular. from www.shutterstock.com

Simon Chapman, University of Sydney

Yesterday morning, Australia’s tobacco industry woke to the latest chapter in the book documenting its inexorable decline.

The Australian Institute of Health and Welfare released data from its 2016 National Drug Strategy Household Survey, which it has conducted every three years since 1985.

While it was always going to be hard to show even further decline in teenage smoking from what was an already very low level, it’s happened again.

The proportion of teenagers (aged 12-17) who have never smoked more than 100 cigarettes significantly increased between 2013 and 2016, from 95% to 98%. Smoking more than 100 cigarettes in a lifetime has long been used in Australia as a benchmark question to sort curious, experimental smokers from more committed and addicted smokers.

Younger people also continued to delay when they first smoked their first full cigarette. This increased in the 14 to 24-year-olds from 14.2 years in 1995 to 16.3 in 2016 (a statistically significant increase from 15.9 years in 2013).

Catch ‘em young

The tobacco industry knows it needs to attract and addict new consumers to replace those who stop smoking through quitting and death. As a 1981 report sent to the then vice-president of research and development at Philip Morris put it:

Younger adult smokers are the only source of replacement smokers … If younger adults turn away from smoking, the industry must decline, just as a population which does not give birth will eventually dwindle.

Australia’s plain packaging legislation, implemented in December 2012, was aimed at reducing teenage Australians taking up smoking. As the health minister who introduced it, Nicola Roxon emphasised in April 2010 when announcing the policy:

We’re targeting people who have not yet started, and that’s the key to this plain packaging announcement – to make sure we make it less attractive for people to experiment with tobacco in the first place.

As Australian young people have turned away from smoking, the tobacco industry is left scrambling for new ways to addict young customers to nicotine.

Total smoking levels remain level

The proportion of people of all ages who smoke was also not good news for the tobacco industry.

The percentage of people aged 14 and over who smoke daily is down from 12.8% in 2013 to 12.2% in 2016. While any decline is welcome, this was less than it should have been, and the first time in two decades that a statistically significant fall was not recorded.

There are several factors likely to be responsible for the previously brake-less downward slide in smoking.

Long-time campaigners Mike Daube and Todd Harper have set out nine strategies the Australian tobacco industry has used so it can keep earning from the deaths of two in three Australian smokers likely to die from using their products.

Two critical factors here are price discounting and the dramatic rise of roll-your-own tobacco.

How price discounting works

Plain packaging means brand differentiation is gone as all packs look the same, except for the written brand name. So, the ability of branding to convince gullible smokers that premium (expensive) brands are somehow “better” and worth spending more on than cheaper, budget brands goes out the window.

After plain packaging was introduced, there was an industry-wide decision to cut prices to compete with lower priced brands for market share. There were large tobacco tax rises in the run-up to plain packs being introduced (25% in 2010) and a further 12.5% each year from 2013 to 2016.

Again, the tobacco companies cut their margins by desperately trying to keep some brands below A$20 a pack, a price known to trigger quitting.

These practices may see renewed interest in floor pricing of tobacco products, when a price is set below which a product cannot be sold.

Rise in roll-your-own tobacco

Tobacco companies have also aggressively pushed cheaper roll-your-own tobacco by introducing loose tobacco with cigarette brand names. The tax in roll-your-own tobacco will rise from September 2017, which may see a further round of price discounting to try and stop people quitting.

The use of roll-your-own cigarettes has gone from 26% of smokers in 2007, to 33% in 2013 and to 36% in 2016. Lower price is one factor driving this, but so too are the quite erroneous beliefs that roll-your-own tobacco somehow contains fewer additives and is less harmful, an issue I will explore in my next column.

The increase in roll-your-own cigarettes since 2007 has been largest among smokers aged under 40 (increase of 82% for young adults and 70% for smokers in their 30s between 2007 and 2016). Between 2013 and 2016 roll-your-own use in smokers in their 30s jumped from 29% to 37%.

National campaign wheels fallen off

Sustained and adequately funded mass media campaigns are a vital component of strategies health authorities recommended to change health behaviours, like smoking.

And with smoking, one of the most obvious pieces of evidence comes from ex-smokers about why they stopped smoking. There are light-years between the answer that has always been given (concern about health) and everything else (cost, social unacceptability, pregnancy etc).

In this study of smokers in 20 US communities, 91.6% of ex-smokers nominated “concern for your own current or future health” as why they quit compared with 46.5% who nominated “pressure from family, friends or co-workers”.

Without large scale, on-going campaigns that reach large proportions of the population with unforgettable, motivating information about why smoking is so harmful, the core driver of quitting and not starting smoking may wane.

Regrettably, Australia’s world famous national tobacco campaign that started in 1997 and has been used by many other countries, has been mothballed since 2013 when the Coalition government took office.

Smokers still get sporadic small bursts of quit smoking ads on television in some states from state health departments. But they are not getting a fraction of the highly motivating exposures that were a big part of our earlier rapid declines. This absence is almost certainly a major factor explaining the slow down in people quitting smoking.

E-cigarettes

The latest stats show that while around 31% of smokers (ie 3.8% of the 14+ population) had ever tried e-cigarettes, 20% seemed to have done so out of curiosity (once or twice) with only 4.4% currently using them (the remaining 6.8% no longer use them). Just 1.5% of smokers were using e-cigarettes daily (0.8% of ex-smokers and 0.2% of never smokers).

There’s no evidence from these very small numbers that e-cigarette use is contributing to falling smoking in Australia.

Many are concerned that the tobacco industry (which has bought into vapourisers big time) has a business plan to have smokers vape and smoke, not vape instead of smoking. If that plays out, increases in vaping may in fact act to further slow people from quitting smoking. The next few years will provide important information on this important issue.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

Banning early evening gaming ads on TV is like being ‘a little bit pregnant’

While gaming advertising will be banned before 8.30pm, the ban doesn’t extend to perimeter advertising or on-air mentions of betting odds. From www.shutterstock.com

Simon Chapman, University of Sydney

Early this month, Prime Minister Malcolm Turnbull made his family friendly announcement that advertising for gaming, including sports betting, would be banned from television and radio before 8.30pm each night, plainly a message about reducing exposure to children.

The “siren to siren” ban, which will cover all sports broadcasts on TV and radio except racing, will start five minutes before matches start and end five minutes after full time.

We don’t know when this will start, but you can probably get low odds somewhere on implementation taking as long as possible.

Just as you can’t be “a little bit pregnant”, you can’t have a partial ban.

Turnbull’s announcement said nothing about on-ground and perimeter advertising, TV commentators and their guests mentioning betting odds or the many sneaky ways direct advertising bans were subverted by the masters of the art, Big Tobacco.

No kid watches sport after 8.30pm, right?

Just take a nanosecond to think about what has been promised. Yes, the policy will take direct advertising of gambling out of pre-8.30pm sport. But last time I looked, the State of Origin, all day/night cricket, major world events like the World Cup and the Olympic Games, and Grand Prix events all run well after 8.30pm.

While most seven-year-olds may be tucked in bed before 8.30pm, many older kids stay up much later. So picture the living rooms across Australia as armies of parents say to their 12-year-olds, “Look I know it’s the decider State of Origin match and the game kicked-off only 15 minutes ago, but the TV is going off now because the betting ads are starting up in a minute.”

That’s just certain to work very, very well. Perhaps exactly as well as the gaming industry’s public support for the package would predict.

Former Labor front bencher Stephen Conroy, now with Responsible Wagering Australia told Sky News that Sports Bet “absolutely welcomed” the new package.

This should set cynicism meters off the dial. If this move had even the remotest chance of having any impact on the betting industry’s bottom lines, it would fight it tooth and claw, in the way we saw with tobacco plain packaging.

Gamble responsibly

The relentless TV betting ad postscripts that remind us to “always gamble responsibly” are as sincere as Big Tobacco urging smokers to smoke lightly.

The 2010 Productivity Commission report on gambling in Australia estimated that problem gamblers contributed about 40% of gaming revenue via poker machines. The report identified about 115,000 Australians as “problem gamblers” with a further 280,000 people at “moderate risk” of being a problem gambler.

There is no definitive national estimate of how common problem gambling is among people who bet on sports. But a 2014 study in the ACT indicated rates of problem gambling among internet gamblers were three times greater than for gamblers in general and on a par with rates for people gambling on poker machines or on racing.

The bottom line is that problem gamblers are the backbone of the gaming industry’s fortunes. The industry would be devastated if these fortunes somehow dried up.

Incremental tobacco advertising bans

The history of restricting tobacco advertising is likely to point to what’s ahead in reforms on how gambling promotion.

The last time a direct tobacco advertisement was seen or heard on Australian TV or radio was in August 1976. The Whitlam government introduced the policy, which was continued by the Fraser government. Direct cigarette advertising on radio and television was phased out over the three years between September 1, 1973 and September 1, 1976.

The decision was framed as a way of reducing the exposure of children to tobacco advertising. Obviously, the proposition was that kids were a prime target for tobacco companies and their advertising was a powerful way of conditioning interest in smoking in young people.

So, direct tobacco ads on TV and radio could help kids take up smoking. But the very same appeals in ads in print, on billboards, in shops and as sporting and cultural sponsorship apparently could not. This was the bizarre logic in governments at the time banning tobacco advertising in only selected media, but not across the board.

As ordinary commonsense and research highlighted the inanity of this policy, governments incrementally increased the number of media where cigarette ad bans applied. It took from September 1973 until April, 30 1996 (when tobacco sponsorship of cricket finally ended) for all forms of tobacco advertising and promotion to end in Australia. That’s 22 years and 8 months from start to finish.

If we count branded packaging as a form of advertising (as the tobacco industry unequivocally agrees it is) then we need to add another 16 years and 7 months. That’s until plain packaging was implemented in December 2012.

Children seeing sports betting ads can’t participate in online gaming because they don’t have credit or debit cards. But they are a vital audience for the future of the industry. It is in the industry’s interests to beguile them about gaming as early and for as long as possible until the day they can open their first betting account.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

The stampede of wind farm complaints that never happened

Why were so few complaints about wind farms investigated further? And who made these complaints anyway? From www.shutterstock.com

Simon Chapman, University of Sydney

National Wind Farm Commissioner, Andrew Dyer, has just released his much anticipated first annual report.

In its first year of operation until the end of 2016, the National Wind Farm Commissioner says his office received:

• 46 complaints relating to nine operating wind farms (there were 76 operational wind farms in Australian in 2015)
• 42 complaints relating to 19 proposed wind farms
• two complaints that did not specify a wind farm.

The commissioner’s office closed 67 or these 90 complaints, with the remaining 23 complaints still in process.

Of the 67 now-closed complaints, the office closed 31 because the complainant did not progress their complaint. This suggests these complaints were minor.

The office closed the file on another 32 after it sent complainants more information about their complaints.

This leaves only four, which the report describes two as being settled after negotiations between the parties, and two given the ambiguous category of “other”.

These figures are frankly astonishing.

The complaint investigating mechanism was set up after a Senate enquiry report that cost undisclosed millions to deal with a “massive” problem with wind turbines.

But the hordes of people who apparently needed a way to help them resolve matters have now gone shy.

Chair of the Senate Committee on Wind Turbines was ex-Senator John Madigan, a public critic of wind farms.

John Madigan speaking out against wind farms at the National Wind Power Fraud Rally in 2013.

Other members who signed off on the senate inquiry report included Senator Nick Xenophon, another long-time critic.

Senator Nick Xenophon criticising wind turbines on the Seven Network’s Today Tonight in 2012.

Complaints vs complainants

The National Wind Farm Commissioner’s first annual report avoids two key issues.

First, it doesn’t mention how many complainants made the 90 complaints. The anti-wind farm “movement” in Australia is often busy plaguing politicians and the few supportive media outlets that give it time.

One woman from Victoria often sends out emails to well over 100 politicians and journalists. Others join her to try to demonise wind turbines. Those in this small group appear again and again as submission authors to what have now been three senate enquires and two state government enquiries.

This phenomenon is well known in government circles. In the last three months of 2016, just 10 people submitted half of Heathrow Airport’s 25,000 noise complaints.

The second omission from the annual report is any mention of its budget or expenditure. The Office of the National Wind Farm Commissioner is independent and has its own website. But unless I missed it, there are no budget or expenditure figures in either the annual report nor the website. Is this a first for an annual report?

We know that commissioner Andrew Dyer gets A$205,000 a year for his part-time role, on a three year contract. With the numbers we now have about the low number of complaints, this sounds like a tough gig. But what about the staff and office costs, which are nowhere to be found.

No complaints in Western Australia and Tasmania

As I reported in my 2013 peer reviewed report into wind farm complaints, there were no records of complaints for Western Australia and Tasmania.

Of the total complaints about operational or planned wind farms, 40 came from Victoria, and 23 from each of South Australia and New South Wales. Just two complaints were received from Queensland about planned farms.

Our study found records of only 129 people who had ever complained about wind farms since the first one was built in Western Australia in the 1980s.

Three years later, after the door is left open for complaints, a mere 90 are received from an unknown number of individuals.

Wind turbines and sickness?

This is all very awkward for those who argue wind turbines cause illness. How is it that if wind farms are a direct cause of illness, that 67 wind farms around the country (88%) saw not one complaint, about health or anything else across a whole year?

The stock answer given here by wind farm opponents is that wind farm illness is like sea sickness: only a few get it. So in the whole of two states, and across 88% of wind farms, there’s apparently no-one with susceptibility to wind farm illness.

Former Prime Minister Tony Abbott, who described wind farms as “ugly”, noisy” and “visually awful”, threw the senate committee a giant political bone.

The committee, and the Office of the Wind Farm Commissioner, put up their “we’re open” shingle and invited the alleged throngs of suffering rural residents to air their problems.

This annual report shows very few did, and the great majority of “complaints” dissolved by being sent information.

This sorry episode in appeasing the wind farm obsessions of a tiny number of cross-bench senators needs to have its time called, fast.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permision). Read the original article.

Carrots and pumpkin might reduce your risk of cancer, but beware taking them in pill form

A diet rich in fruit and vegetables is more than just a sum of its individual nutrients. From www.shutterstock.com

Simon Chapman, University of Sydney

In February this year, ABC’s Four Corners broadcast a critical and compelling program on complementary medicines, Swallowing it: How Australians are spending billions on unproven vitamins and supplements.

The program certainly tapped into a growing trend. The value of the global vitamins and dietary supplements market is predicted to reach US$59.6 billion by 2020; in Australia in 2014-15, 49% of women and 34% of men had bought vitamins in the past six months. Companies like Swisse and Blackmores have a lot riding on keeping up this demand.

Yet, the vast majority of this mass consumption, often helped along by celebrity endorsement, is just generating oceans of very expensive urine; relatively few people have medical conditions requiring specific nutrient supplements.

So why do so many people waste their money?

Seduced by reductionism

Scientific reductionism is the seductive “mental shortcut” or cognitive heuristic that assumes you can understand complex phenomena by analysing each of its elements: the whole is just the sum of its parts.

In reductionist reasoning, a piece of fruit is nothing more than the sum of all the compounds it contains. So if you don’t have enough time to buy, cook and eat a diet rich in the sources of vitamins and minerals we all need, you can buy a set of pills containing the vitamins and other nutrients that go to make up a carrot, a fish or a banana.

Right? No, actually.

A good example of the simplistic appeal of reductionism is the assumption that because tobacco smoke has over 70 known carcinogens, removing some of them will make smoking less dangerous. A no-brainer?

This is what three major US tobacco companies once tried to imply when they chemically engineered “reduced carcinogen” brands.

But a study of cigarette smoke emissions across different brands concluded that reducing some carcinogens in the smoke mix had two effects – “risk swapping”, when one specific carcinogen exposure was reduced at the cost of another’s exposure increasing, or “risk shifting”, when a specific exposure was reduced at the cost of that exposure increasing within another carcinogen group.

The impact on actual carcinogenic risk remains unknown when tobacco companies manipulate the presence of one or several carcinogens but sell products with all the 68 or so others intact.

Dietary reductionism

Reductionist thinking flourishes most in popular understanding of nutrition and is at the very epicentre of the appeal of complementary medicine. The vitamin and supplement shelves of pharmacies and complementary medicine shops are groaning with single and multi-vitamin and supplement bottles all promising swallowing their contents daily just must be good for you.

Perhaps the most famous of all salutary tales about the folly of reductionist thinking in medicine concerns beta-carotene. Beta-carotene is an organic red-orange pigment abundant in plants and fruits. It is a member of the carotenoid group, the main source of vitamin A in our diets (along with retinol in liver, butter, cheese and chicken skin). Beta-carotene levels in the diet are seen as a good indicator of overall fruit and vegetable consumption. Carrot, orange sweet potato and pumpkin are the richest sources of beta-carotene, with spinach and kale and any brightly coloured fruits and vegetables also good sources.

Studies of the diets of whole populations and their sub-groups (such as vegetarians) had long observed those who ate the most beta-carotene tended to have lower population-wide rates of several cancers.

Could beta-carotene pills prevent cancer?

By the early 1980s, leading epidemiologists like Oxford University’s Richard Doll and Richard Peto were speculating that diets high in beta-carotene protected people from developing cancer. This speculation stimulated several long-term trials of whether taking beta-carotene supplement pills might influence cancer rates.

The most famous was the Carotene and Retinol Efficacy Trial (CARET). In this study, people – including those at high risk of cancer like those exposed to asbestos at work, and smokers – were given daily 30mg of beta carotene plus 25,000IU of retinol and followed for an average four years between 1983 and 1997.

In May 1996, the bombshell results from the study were published in the New England Journal of Medicine. A total of 388 new cases of lung cancer were diagnosed. And the clanger? The study participants randomised to receive the beta-carotene and retinol supplements had a 28% higher incidence of lung cancer than those given placebos. As a result, the trial was stopped 21 months early.

The study provoked intense interest and commentary. In 2008, a meta-analysis of four studies of beta-carotene supplementation involving 109,394 people taking an average of 20-30mg of beta-carotene supplements a day confirmed the CARET results. It found that in smokers, those taking the supplements had a 24% increased risk of lung cancer. Beta-carotene was found in 70% of 47 common multivitamins used by people in the studies.

The beta-carotene supplementation story is a textbook illustration of the folly of reductionist thinking in preventive health. As one letter writer to the New England Journal of Medicine put it:

Beta-carotene was also acting as a marker of increased fruit and vegetable consumption and thus of many other components that have cancer-preventing potential (Vitamin C, folate, other carotenoids, polyphenols, and many plant compounds).

Others argued the dose of beta-carotene in the CARET study pill was too high. Others argued the specific form of beta carotene likely used in the CARET trial (all-trans-beta-carotene) was just one of 272 different isomers of beta-carotene and was probably chosen because it was the only one made commercially in large quantities (by BASF, Hoffmann-La Roche, and Sumitomo) and available for purchase. Perhaps the people who conducted the study, they argued, picked the wrong beta-carotene?

All these “what ifs?” may well have substance and we may one day find the holy grail of cancer preventing agents. But when the results are highly unlikely to be much different to the preventive effects of eating a mixed diet emphasising fruit and vegetables, I know which plan to continue to follow.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

Why researchers have a duty to try and influence policy

Simon Chapman, University of Sydney

Very early in my career, I was invited to afternoon tea with the head of the Commonwealth Institute of Health at Sydney University, where I worked. The best bone china was produced and pleasantries exchanged. The agenda soon became clear.

He laboured into a parable about the difference between young and old bulls when locked in a small yard. He told me young bulls run hard at the gate, exhausting and sometimes harming themselves.

But old bulls are generally patient and placid. They always know the farmer will open the gate and they’ll walk out and soon get among the pasture and the cows.

Young bulls should learn from old bulls, he told me.

I knew exactly why he’d called me. For some months, I’d been in the forefront of a small group of public health people who were confronting the advertising industry’s self-regulation body with data about the appeal of Paul Hogan, who fronted the massively successful Winfield cigarette advertising campaign. Hogan’s own TV program had huge appeal to children. The advertising campaign was, therefore, in flagrant breach of the industry’s own guidelines and so needed to be stopped.

After 18 months of trying to ignore us, we won. We quickly discovered while the advertising industry could ignore our letters, going public turned 10,000 watt arc lights on the self-regulation farce. Over that time the media often interviewed us. A headline after we won said our slingshot had cut down the advertising ogre. Hogan said he’d been sent from the field for kicking too many goals. That was in fact our argument.

My “young and old bulls” mentor later told me he’d been tapped by the Vice Chancellor to tighten the reins, after receiving complaints from connections with the tobacco industry.

Then, and even today, there still remain large remnants of the attitude in universities that scientists and researchers should avoid talking to the media. News media are frequently disdained by academics as trivialising and superficial, something from which those with ambitions of gravitas should keep well away.

A long history

The roots of this go way back. In 1905 Sir William Osler a foundation professor at Baltimore’s Johns Hopkins Hospital, warned against “dallying with the Delilah of the press”. More than 100 years later, a 2006 report by the UK Royal Society noted 20% of UK scientists believed colleagues who engage with the media are “less well regarded” by their peers.

Public engagement was something “done by those who were ‘not good enough’ for an academic career”. Those who did so were seen by some as “light” or “fluffy” and, wait for this, more likely to be women. While 60% of UK researchers wanted to engage with politicians about their research, far fewer (31%) wanted to engage with journalists.

The cocooned naivety of this position is quite staggering.

Knowing someone, but never meeting

Early in Nicola Roxon’s tenure as Australian health minister I approached her after a talk she gave at a conference. “I don’t think we’ve ever met,” I said. “No, but I feel I’ve known you all my adult life,” she replied.

This could have only meant she knew me through the media.

There is an abundance of research showing people get a huge amount of their information and understanding of health issues from the news media. Equally, most politicians and their advisors rarely read scholarly papers in research journals. They form their understandings of the issues in their portfolio in a variety of ways. But like us all, they are daily exposed to information and discussion about health and medicine through the media they consume voraciously every day.

I had an instinct about the importance of all this right from the beginning of my career and so quickly took to trying to get my research covered in the media; I gave high priority to making room in my day to provide commentary about the areas in which I worked.

Here, I quickly learned the constraints on time and space meant something richly nuanced and complex always needed to be condensed into just two or three sentences in print media reports, or 7.2 seconds in television news. When I started taking opportunities to write opinion page and feature articles, the access to my work and commentary on controversies in public health rapidly accelerated.

Visibility brings access

The visibility this brought opened many doors to senior policy advisors and politicians. I also frequently had the experience of dozens of people telling me across a day they had read and enjoyed a piece I’d written in a newspaper that morning, or a breakfast radio interview as they got ready for work. Most of these colleagues work in adjacent areas of public health and would have only occasionally read my research work in journals.

My own GP and other clinicians have often told me about patients who brought in one of my newspaper articles to ask about it. This was especially true about pieces I wrote on the risks and benefits of prostate cancer screening. This feedback inspired a 2010 book – Let Sleeping Dogs Lie?: what men should know before getting tested for prostate cancer. Colleagues and I published it as a free ebook and it’s been downloaded over 35,000 times.

My 85 articles in The Conversation have been read over two and a half million times. Just two of them have together been read over 1.8 million times. By contrast, the most read of over 500 papers I’ve published in peer reviewed journals has been read only 150,000 times. Many are lucky to get even 5000 readers. Being locked behind subscription paywalls doesn’t help.

Who are the ‘influencers’?

A few years ago, colleagues and I researched the characteristics associated with peer-voted “influential” researchers. We invited all Australian researchers who had published 10 or more papers in particular fields of public health to name five Australian researchers who were “most influential” in each of these fields. We then interviewed the top five from each field.

Overwhelmingly, nearly all said they believed researchers had a responsibility and even a duty to produce work that might help shape policy and practice. Most of these were very comfortable in actively pursuing media opportunities to bring understanding of their work to the public. Those who weren’t comfortable in the media were very happy for others to do this on their behalf.

This approach started with choosing research questions they hoped would provide strategically useful information to inform policy. Their approach then passed through the necessary steps of grant application craft to best ensure it was funded through the highly competitive National Health and Medical Research Council process that now sees only 17% of applications funded.

These two steps are meat and potatoes for all funded research.

But it was in post-publication behaviour where influential researchers differ. They actively promote their work – not just to other colleagues in seminars and conferences, but to the public and those who might act on it politically.

And after all, isn’t helping evidence-based policy and practice the whole point of wanting to do the research in the first place? Why else would you bother?

Don’t just ‘stick to the facts’

Some critics of researchers with media profiles argue researchers should just “stick to the facts” in media interviews. Our study participants saw this as naïve because “people always want to know what the policy implications are”.

A total of 94% of those we interviewed disagreed with the view it was inappropriate to express opinions in the media about public health policy. Journalists might begin with a research finding or an expert clarification of a new report. But they invariably then asked what needed to be “done” about the problem, typically by government.

Journalists and audiences would meet with incredulity any researcher who tried to end an interview when there were questions about policy reform “oughts”, or claimed to have no opinion on what should be done. We expect those who know most about health problems to have views about what should be done to solve them and the courage to put these forward, even if they imply criticism of governments or powerful interest groups.

Speak up, speak up

Trump’s recent gagging of all government environmental agency staff is surely the start of a process that will spread to government funded universities in the USA. There has never been a more important time for researchers all over the world to speak up about their work, it’s implications and how societies and governments should act on it.

I’ve just published a collection of 71 of my essays and op eds across a large variety of public health issues. Like this column, the book is called Smoke Signals, and is published by the Sydney University Press imprint, Darlington Press. It’s available in paperback or as an ebook.

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This article will be the subject of ABC Radio National’s Ockham’s Razor on Sunday, February 26, 2017 at 7.45am.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

On the pleasure of smoking

Simon Chapman, University of Sydney

Repeatedly, studies have found a large majority of smokers regret ever starting to smoke: 85% in this study, 90% in this four nation study. Each year, some 40% of smokers make an attempt to stop, with most relapsing within weeks.

Many fork out considerable money in pharmaceuticals along the way in the attempt to shake their smoking. Snake-oil, evidence-free quick-cure merchants advertising on telegraph poles for “laser therapy quitting” happily make up to A$500 from the more gullible.

With 12.8% of Australians aged 14 and over smoking daily, and 90% of these regretting they ever started, today just 1.28% are contented smokers. Recent evidence shows 55% of young smokers now approve of plain packaging with their ghoulish, unavoidable picture warnings. Can there be any product that enjoys less consumer satisfaction and customer loyalty?

One of the most common taunts pro-smokers hurl at tobacco control advocates with great relish is the claim they are enemies of pleasure: they just can’t stand the thought or sight of people taking pleasure from smoking. Perhaps they are right. Airport smoking rooms strike me as about the most fun and pleasure you could get. The queues of non-smokers you see waiting to get in just to experience it all pretty much clinch that argument.

The picture being painted here is of elegant smokers, hand gesturing and exhaling as in Richard Klein’s Cigarettes are sublime constantly pleasuring themselves in a way denied to non-smokers who have not woken up to the joys of nicotine.

But what is it that nicotine addicts like about pulling the chemical deep into their lungs some 90,000 times a year?

In 1994, the New York Times published the ratings of two of the USA’s most renowned addiction specialists, Neil Benowitz and Jack Henningfield, on the relative addictiveness of nicotine, caffeine, heroin, cocaine, alcohol and marijuana (cannabis). They rated each of these on a scale of one (most serious) to six (least serious).

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Both rated nicotine higher in dependence than all the other drugs. By “dependence” they meant how difficult it is for the user to quit, the relapse rate, and the percentage of people who eventually become dependent.

Nicotine withdrawal also rated high (third behind the often discussed agonies of alcohol and heroin withdrawal). Both experts rated nicotine fourth behind cocaine, heroin and alcohol when it came to reinforcement (essentially, the pleasure given by the drug). But both rated nicotine last on intoxication, behind even caffeine.

Taking all this together, a picture emerges of nicotine dependent people regretful they started smoking, living in full knowledge of their high dependency, experiencing often unpleasant withdrawal symptoms when they have not been able to smoke for a while, and being relieved of this unpleasantness quickly when lighting up another cigarette.

Nicotine withdrawal symptoms include headache, nausea, constipation or diarrhoea, fatigue, drowsiness and insomnia, irritability, difficulty concentrating, anxiety, depressed mood, increased hunger and caloric intake and of course, constant tobacco cravings.

Smokers know from the earliest days of their addiction these feelings can disappear within a few seconds as the nicotine is rapidly transported from their lungs to their brains where dopamine is released and experienced as pleasurable.

Smokers often insist the pleasure from this release can somehow be experienced independently of the pleasures of the nicotine withdrawal symptoms rapidly dissipating.

So what is the “pleasure” being experienced here? When you have a toothache and this is relieved by a strong analgesic, your mood can quickly elevate as the codeine begins to work.

The argument that smoking and inhaling nicotine is “pleasurable” is a bit like saying being beaten up every day is something you want to continue with, because hey, it feels so good when the beating stops for a while.

Holiday periods like the upcoming Christmas break are time-honoured opportunities for smokers to make quit attempts. I used to smoke (in late school and to my mid 20s). I thought smoking was a great way to make a statement about myself that would impress those I cared to impress and irritate those I cared to irritate. But I always thought it tasted disgusting, was a stupid thing to continue and threatened to limit my early career opportunities.

I recall just drifting out of smoking, a pathway common to many ex-smokers. And like many smokers, I recall it being anything but difficult or torturous. This is one of the best kept secrets in tobacco control. While there are many smokers who struggle to quit and fail many times, there are many more who found the experience easier than they expected, sometimes far easier.

There are many more ex-smokers in Australia than smokers. The common narratives of quitting smoking ushering in the pleasures of tasting food and drink better, feeling physically better and of course the pleasure of having more disposable income can be compared with the supposed pleasures of smoking. Good luck if you are planning to quit. It’s the single most important thing you can do to improve your health.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

If smoking doesn’t kill, Mike Pence, neither does the plague

Simon Chapman, University of Sydney

US Vice President elect Mike Pence (who has been the recipient of funding from Big Tobacco) once famously wrote:

Time for a quick reality check. Despite the hysteria from the political class and the media, smoking doesn’t kill. In fact two out of every three smokers does [sic] not die from smoking-related illness and nine out of ten smokers do not contract lung cancer.

Pence is referring here to what epidemiologists call the “case fatality rate”: the proportion of deaths from a smoking-related illness to the number of new smoking-related illnesses diagnosed. According to him, the case fatality rate for long term smoking was “only” one in three, meaning only one in three long-term smokers die from a smoking-related illness (such as cardiovascular and respiratory diseases, and smoking related cancers), which somehow meant to him smoking doesn’t kill.

By Pence’s reasoning there are many other diseases that “do not kill”. This extensive list of various diseases’ case fatality rates shows many well known highly fatal diseases with case fatality rates lower than 33%.

These include oropharyngeal anthrax (anthrax that manifests in the mouth and throat), yellow fever, treated bubonic plague, diphtheria, meningococcal disease, legionnaires’ disease, dengue fever and untreated typhoid. The 1918 Spanish ‘flu which was estimated to have killed 50-100 million people globally, had a paltry case fatality rate of around 2.5%.

Pence was also wrong about the rate at which smoking kills. A landmark study of over 34,000 British male doctors (females were excluded when the study commenced in 1951 because there were insufficient numbers of women doctors at the time) has long been the benchmark for the risks of long term smoking.

When the study reported its 50 year follow-up of the cohort, it found “the eventual risks vary from about one half to about two thirds” of all doctors who had smoked had died from a tobacco-related disease.

An Australian study of 204,953 people also confirmed the two in three death rate from smoking.

Today smoking kills some six million people a year globally, and will kill one billion people this century if present trends continue.

The US is the only significant country to have not ratified the World Health Organisation’s Framework Convention on Tobacco Control (the US tends to not sign global treaties). Under a Trump administration, will we see the end of regulation and strict marketing protocols? Will the US be the only nation to ever see a rise in smoking rates after decades of continual falls?

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

Alan Jones goes after wind farms again, citing dubious evidence

Simon Chapman, University of Sydney

Last week, Sydney radio announcer Alan Jones lambasted those concerned about climate change and what he called “renewable energy rubbish”.

Jones has been loose with the facts in the past, having been Factchecked in 2015 after confusing kilowatts with megawatts and quoting a cost for wind power he later confessed “where the 1502 [dollars per megawatt hour that he stated] comes from, I have absolutely no idea”.

Jones, who chaired the much hyped but poorly attended 2013 national rally against wind farms in June 2014 (see photo) told his listeners last week wind farms are “buggering up people’s health”.

He also said “harrowing evidence” had been given by sufferers to the 2014-15 Senate Select Committee on Wind Farms chaired by (now ex-) Senator John Madigan. He along with Bob Day, David Leyonhjelm, Chris Back and Nick Xenophon have been vocal opponents of wind farms.

Their report predictably savaged wind farms, while Labor Senator Anne Urquhart’s minority report was the only one I found to be evidence-based.

Jones then went on to interview Dr Mariana Alves-Periera, from the private Lusophona University in Portugal (world university ranking 1,805, and impact ranking 2,848) whom he described as a distinguished international figure.

She was “recognized internationally” and had published “over 50” scientific papers over 30 years, something of a modest output. Jones, who may or may not have read any of these publications, told listeners her findings were “indisputable”, there was “no opposing scientific evidence” and again in emphasis, “none of [her papers] have been disputed” to which Alves-Periera agreed instantly “no they haven’t”.

This is an interesting interpretation of the scientific reception that has greeted the work of the Lisbon group on the unrecognized diagnosis of “vibroacoustic disease” (or VAD), a term they have made their own.

I first encountered Alves-Periera when she spoke via videoconference to a NHMRC meeting on wind farms and health in 2011. She spoke to a powerpoint presentation which highlighted the case of a schoolboy who lived near wind turbines. Her claim was the boy’s problems at school were due to his exposure to the turbines, as were cases of “boxy foot” in several horses kept on the same property.

Intrigued by this n=1 case report, I set out with a colleague to explore the scientific reception that “vibroacoustic disease” had met. We published our findings in the Australian and New Zealand Journal of Public Health 2013.

We found only 35 research papers on VAD. None reported any association between VAD and wind turbines. Of the 35 papers, 34 had a first author from the Lusophona University-based research group. Remarkably, 74% of citations to these papers were self-citations by members of the group.

In other words, just shy of three quarters of all references to VAD were from the group who were promoting the “disease”. In science, median self-citation rates are around 7%. We found two unpublished case reports from the group presented at conferences which asserted that VAD was “irrefutably demonstrated” to be caused by wind turbines. We listed eight reasons why the scientific quality of these claims were abject.

In 2014 Alves-Periera and a colleague defended their work in a letter to the journal and I replied. They described themselves as the “lead researchers in vibroacoustic disease”. But as we had shown, they are almost the only researchers who were ever active on this topic, with self-citation rates seldom seen in research.

Other experts have taken a different view of the group’s work. One of the world’s leading acousticians Geoff Leventhall who also spoke at the NHMRC’s 2011 meeting, wrote in a 2009 submission to the Public Service Commission of Wisconsin about the Lisbon group’s VAD work.

The evidence which has been offered [by them] is so weak that a prudent researcher would not have made it public.

Another expert said:

vibroacoustic disease remains an unproven theory belonging to a small group of authors and has not found acceptance in the medical literature

And most recently, the UK’s Health Protection Agency said the:

disease itself has not gained clinical recognition.

Leventhall concluded his review by saying:

One is left with a very uncomfortable feeling that the work of the VAD group, as related to the effects of low levels of infrasound and low frequency noise exposure, is on an extremely shaky basis and not yet ready for dissemination. The work has been severely criticised when it has been presented at conferences. It is not backed by peer reviewed publications and is available only as conference papers which have not been independently evaluated prior to presentation.

Jones told his listeners the reason wind turbines are not installed on Bondi Beach, down Sydney’s Macquarie Street or Melbourne’s Collins Street was because governments “know they are harmful to health”. His beguiling logic here might perhaps also be the same reason we don’t see these iconic locations given over to mining or daily rock concerts. Most people would understand there are other factors that explain the absence of both wind turbines, mines or daily rock concerts in such locations.

Jones has given air time to a Victorian woman who is a serial complainant about her local wind farm and who has written:

Around the Macarthur wind farm, residents suffer from infrasound emitted by the turbines, even when they’re not operating.

At a time when we are seeing unparalleled increases in renewable energy and reductions in fossil fuels all over the world, one wonders why this is still public discussion in Australia.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

Mobile phone health alarmists bereft of credible arguments

Simon Chapman, University of Sydney

In May this year, I led a paper published in Cancer Epidemiology, which looked at the incidence of brain cancer in Australia between 1982 and 2012.

The first mobile phone call was made in Australia in 1987 and today their use is all but universal.

Cancer is a notifiable disease: all newly diagnosed cases are gathered from doctors by state cancer registries and nationally aggregated by the Australian Institute of Health and Welfare in publicly available data.

I summarised our study in this column, which to date has had more than 44,700 readers.

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New study: no increase in brain cancer across 29 years of mobile use in Australia

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We found that with extremely high proportions of the population having used mobile phones across some 20-plus years (from about 9% in 1993 to about 90% today), age-adjusted brain cancer rates have flatlined over nearly 30 years.

There were significant increases in brain cancer incidence only in those aged 70 years or more. But the increase in this age group began from 1982, before the introduction of mobile phones in 1987 and so cannot be explained by it.

The most likely explanation of the rise in this older age group was improved diagnosis that happened with the introduction of imaging machines that (for example) could more accurately diagnose some strokes as brain cancers.

In the days and weeks after publication, our paper received massive global news and social media attention, achieving an Altmetric score of 835. On the basis of the most media-covered research in all fields in 2015, this would have put it just outside the 100 highest Altmetric scores if we’d published it last year (2016 figures are published early next year).

It also drew the ire of the close-knit international network of mobile phone and wifi alarmists, who are utterly convinced mobile phones are deadly and won’t hear otherwise. Their opening salvo was to accuse me of being an undeclared phone industry stooge.

In 1997 I had been given a small grant by AMTA, the Australian Mobile Telephone Association, to conduct a national survey of how many mobile phone users had ever used their phone to call emergency services such as ambulance, police and fire. Large proportions of people had done so, probably saving many lives by alerting these services far more quickly than when having to find a landline.

I didn’t report this because I got the one-off grant 19 years ago, and all reputable journals and research agencies rule that competing interests are not lifetime but extinguish typically between one and three years after such support has expired. The grant also had nothing to do with cancer.

I also got a series of mostly verbally incontinent email. One from an excitable correspondent in Swaziland, insisted that I answer his many eureka moment insights into why what we had published was wrong in every respect. We should withdraw our paper, he demanded and tell the world we were wrong.

Predictably, several wrote to Cancer Epidemiology, setting out a litany of our egregious errors and failures to understand that an epidemic of brain cancer, comparable to the deluge of smoking-caused cancers, was just around the corner. Three of these were published this week with our response (open access until October 20, 2016).

The three letters were written by five individuals, three of whom are affiliated with a non-accredited Environmental Health Trust, headed by Dr Devra Davis, the alarmist doomsayer who featured in the much-criticised ABC Catalyst program which has now been withdrawn.

Assuming they got their heads together to rain blows on our heretical findings, it was amusing to see the barely audible blanks they decided to fire.

Their main arguments were:

‘It’s too soon to see an epidemic of brain cancer’

One argued several decades of widespread phone use were needed before increases in cancer might be seen. She seemed intent on diminishing the number of years that large numbers of Australians have used mobile phones, in order to preserve her argument. She argued that only the last nine years of data since 2001 when mobile subscriptions reached 50% of the population ought to be considered in any analysis. And nine years was not nearly enough.

But by 1996, some 20% of Australian adults (some 2.9 million) were using mobile phones. Apparently we ought to have joined her in seeing this as a trivial exposed population, unworthy of consideration. Quite obviously, there’s no alleged carcinogen where 20% of the population is exposed where any credible scientist would seriously maintain such widespread exposure should be ignored in assessing population attributable risk.

Further, in one of the studies cited in a review published by our critics, excess risks of brain cancer from mobile phone use are argued as occurring following exposures of as little as between five and ten years of mobile phone use. These critics even suggested in the same paper that the international INTERPHONE study may suggest a cancer “promotion effect”, with use as few as one to four years being dangerous.

We concluded that:

This therefore looks like an argument trying to walk on both sides of the street: if a short latency period show excess risks they are deemed to be credible, while if they show no excess (as with our study) they are to be dismissed.

‘Various case-control studies show evidence of increased risk’

Case-control studies in this field have been criticised because they rely on users’ recall of the extent of phone use going back many years. Just try recall your own mobile phone use in, for example, 2003 and you will immediately understand how data obtained this way are hugely problematic.

Moreover, people with brain cancer often have memory loss. And if you have brain cancer, are part of a study considering its cause, and have been exposed to frequent claims about the hypothesis that mobile phone use causing brain cancer, the likelihood of recall bias resulting in recall of high mobile phone use is probably going to increase.

The strength of our study was the ability to look at all cases of brain cancer in Australia in the 29 years since the first call was made here. The inconvenient fact for the alarmists is that there has been no significant increase in brain cancer in either men or women compatible with the mobile phone hypothesis.

‘Decreased use of X-rays is masking an increase in cancers caused by mobiles’

Perhaps the silliest argument thrown at us was an unreferenced hypothesis that “discontinued or reduced use of established carcinogens such as X-rays” may have reduced the incidence of brain cancer from such exposures while, simultaneously, the rise of mobile phone use would have replaced those cases, thereby explaining the largely flat line incidence across our data period.

This hypothesis would need to account for how reductions in a very uncommon radiation exposure (full head X-rays) could ever possibly produce the exact same decreased incidence of brain cancer that they claim arise in daily exposure to an alleged carcinogen by most of the entire population would add to that incidence.

Our Swaziland critic finished one of his missives writing that “it behooves you, as a scientist, to take note of fatal errors in your work.” It would “behoove” mobile phone alarmists to stop unnecessarily alarming people with their weak arguments.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.