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Tag: Tobacco/Vaping

25/03/2022

Vaping- the beginnings of a disease description

25/3/22

It seems that the tobacco industry has won the first major vaping battle. They have succeeded in getting their new product legal, and now they do not have to prove it is safe, the medical world has to prove it unsafe. Progressive elements of the medical profession are describing the diseases caused by vaping. Its progressive practitioners are also aware of the political aspects of vaping’s progress, though their power in this area is not great.

After my last article on vaping Anne Jones, who used to run ASH (Action on Smoking and Health,) sent me a significant lecture by Prof Andy Bush, from the Brompton Hospital. (Brompton is probably the most prestigious hospital for respiratory diseases in Britain).

The 45 minute lecture is quite medical/technical and as such quite hard going, but it is interesting in that it combines very detailed medical aspects with an astute analysis of the political and economic significance of vaping. As a student I was subjected to endless lectures on the harm of tobacco without any consideration of the political aspects of its political cause or prevention. As Prof Bush himself says, ‘Fool me once, shame on you. Fool me twice, shame on me’.

He points out the similarities between smoking and vaping, but also the differences. There is something of a nightmare of acronyms, so I will help where I can.

Currently vaping is being marketed using the same symbols of success as was used before tobacco had any restrictions on it, freedom, rebellion and glamour. The difference is that it now uses social media to market to CYPs (Children and Young People). BAT has spent a Billion pounds on social influencers. Although vaping is supposedly allowed to help people get off tobacco, the marketing to kids is to those who do not smoke anyway, so clearly it either a gateway drug to smoking or an entirely separate habit to be fostered and developed.

He points out that the tobacco industry has taken over the major vaping brands. VUSE is owned by RJR, who were R.J.Reynolds Tobacco. VYPE is owned by BAT, British-American Tobacco. BLU is now owned by Imperial Tobacco, and JUUL is now significantly owned by Altria, the new name for Philip Morris.

If that were not enough, one brand Puffit2 is owned by a company called Discreet Vape Company and the vaping device looks like a Ventolin inhaler! Philip Morris purchased Vectura, a British pharmaceutical company that manufactures respiratory drug delivery devices, in September 2021.

ENDS (Electronic Nicotine Delivery Systems) (= vaping devices) deliver chemicals. Prof Bush points out these chemicals have no information publicly available about their nature and properties. 18 flavours have carcinogenic, tobacco-specific components and there are bacterial and fungal contaminants in a high percentage of vaping products. These contaminants may have their own ability to generate allergic lung diseases, which are similar to emphysema. In one case the nicotine was at 120% of the level stated on the pack.

Passive vaping is similar to passive smoking in that the non-vapers get similar levels of nicotine in their urine to passive smokers.

Vaping is not a gateway to smoking cessation and may even be a gateway to smoking. A study which compared nicotine replacement therapy to vaping showed that while 9% of nicotine replacement patients were off cigarettes after 6 months as opposed to 18% of people using vaping, 80% of the people who had used vaping were still vaping a year later (Hajek et al, NEJM 2019). If Buprion was used with nicotine replacement the quit rate was 25% at 6 months and 20% in a year. Varenicycline achieved 27% (Borelli and O’Connor NEJM 2019). Interestingly, if you pay people to quit, it is a better investment than the drugs!

Vaping has risen rapidly amongst American teens and is currently at 28% and the prevalence of smoking has stopped declining since the vaping rise started.

Prof Bush’s lecture states that the acute toxicity of vaping is actually worse than cigarettes. Researchers always do an immense amount of work, and doctors struggle to keep abreast of it. The effect has been measured on foetal lungs, levels of all kinds of proteins, cytokines, chemokines, enzymes, Cell functions, lung pathology, oxygenation levels and from many areas including broncho-alveolar lavage (BAL), (i.e. washing from lungs). Rat models have also been used to look at emphysema (poor little guys). It increases their alveolar (lung air sac) size and causes a fall in transcutaneous oxygen levels. This may be due to a lipoid pneumonia due to lipid (fats) being leached out of the lungs. The negative effects of e-cigarette vapour condensate on macrophages (the cells that fight infection) were similar with or without nicotine in the condensate. The condensate was also more toxic than the e-Cigarette liquid! (Scott, Thorax 2018).

Vaping has been shown to increase bacterial adherence to epithelial cells which increases susceptibility to infection. It also considerably worsens the effect of COVID infection.

There are case histories of a 16 year old previously healthy boy who was admitted urgently to an Emergency Dept with a lung disease so serious that he ended up on ECMO (Extra-Corporeal Membrane Oxygen- the artificial lung). He had only used OTC (Over the Counter) vaping products.

Prof Bush describes a new disease that has been called EVADI (E-cigarette Vaping Acute Lung Injury), though it would not be medicine if they were not arguing over the new name which some want to call EVALD (E-cigarette Vaping Acute Lung Disease).

Bush finally asks that the recommendations of FIRS, (Forum of International Respiratory Societies) be implemented:

ENDS (Electronic Nicotine Delivery Systems) should be considered as tobacco products and taxed and regulated as such.
Sales to CYPs (Children and Young People = minors) must be prohibited and this must be enforced.
All advertising and promotion should be regulated and made inaccessible to CYPs.
Flavourings increase rates of youth initiation, so should be banned in ENDS
Vaping should be prohibited in indoor locations, public parks, and places where children and youths are present.
While their health risks are increasingly recognised, more research is needed
Routine surveillance and surveys concerning combustible and electronic cigarette use should be carried out.

Prof Bush makes the point that they also need plain packaging and health warnings like tobacco products and says, ‘There is no chemical model that shows inhaling hot chemicals is a good idea. You show me the proof that it is harmless.’

We all need to lobby on this. Here is the video of the lecture: https://www.youtube.com/watch?app=desktop&v=yhdiIuz0ec4&fbclid=IwAR2ETBxTR8LD87Nmng54uo_w2xZ6vI7kRmYBqITPOv36R0

20/03/2022

The Smoke Screen Recurs.

20 March 2022

An article in the Good Weekend 19 March notes that screening services such as Netflix have a lot of smoking in their movies.

There was a lot of placement of smoking in movies for many years and in the 1920s and 30s there was more smoking in movies than in real life, which was probably not a coincidence.

Steve McQueen smoked in ‘Wanted: Dead or Alive’ and like Yul Brunner, Humphrey Bogart, Betty Grable, Paul Newman, and John Wayne was in the many Hollywood stars to die of lung cancer.

In the 1950s and 60s tobacco companies sponsored many TV programs, such as the ‘Jack Benny Show’ (comedy) and ‘Gunsmoke’. Walt Disney, Larry King, Moe Howard (3 Stooges), Larry Hagman (Dallas), Chuck Connors (The Rifleman) and Ed Sullivan were some of the TV stars to die of smoking-caused cancers. Some musicians to die were Nat King Cole, Dean Martin, Duke Ellington, George Harrison and Sammy Davis Jr.

The heath activists managed to get rid of tobacco advertising in Australia in 1976, but sponsorship, which was cheaper than actual advertising and got much more coverage lasted until after 2000. In the US activists drew attention to product placement in movies where brands were displayed or whole characters written to publicise smoking and fund movies. Product placement by tobacco was banned in Australia in 1992 and in the US in 1998, unless historical figures were known to smoke.

But now smoking in movies is rising again, and it seems to be worse in streaming services like Netflix. Smoking does not seem to be increasing yet, but with vaping acting as a new gateway to smoking, the battle ain’t over yet.

From the ashes: Smoking’s curious comeback on the silver screen

Once the epitome of Hollywood glamour, cigarettes were all but snuffed out in films and TV shows by the turn of the millennium. Now they’re making a comeback. Plot-driven or something more sinister?

By Tim Elliott Good Weekend March 18, 2022

Smoking has made a furtive, and somewhat puzzling, comeback in recent years, something one US veteran anti-tobacco activist says is not random: “Nothing in Hollywood happens by chance.”

When news broke, in mid-2021, that the cult turn of the millennium TV series Sex and the City was to return, the world’s entertainment media suffered a brief bout of tachycardia, the kind of hand-flapping hysteria that could reasonably be expected to herald the return of another well-known cult figure. The excitement was understandable. The new series, called And Just Like That, promised contemporary viewers everything that had made the original show so effortlessly watchable; cheeky humour, exceptional shoes and a non-threatening dose of prime-time friendly transgressiveness.

Yet there was one facet of And Just Like That which got special attention: one of the lead characters, Carrie Bradshaw (played by Sarah Jessica Parker), was smoking again. “Why, decades after she quit the habit, would Carrie return to it?” asked W magazine. A headline in New York magazine read: “And Just Like That … Carrie Is Smoking Again.” “Carrie’s smoking again!” the Daily Mail yelped.

Such head-shaking suggested not just disapproval but bewilderment. The common consensus was that, thanks to decades of pressure from anti-tobacco groups, smoking in TV and films had all but disappeared. In fact, smoking has made a furtive, and somewhat puzzling, comeback in recent years. Agent Smith lights up in The Matrix Resurrections; Kate Winslet vapes in Mare of Easttown; and Christina Applegate’s character Jen sparks up in the woman buddy show, Dead to Me. There’s plenty of smoking in the Netflix series The Umbrella Academy and in Orange is the New Black, and also in Modern Family and Law & Order: SVU.

Sarah Jessica Parker’s character Carrie Bradshaw resumed her smoking habit in the latest Sex and the City series, And Just Like That.

The fug that all but envelops The Queen’s Gambit, which is set in the mid-1950s and ’60s in the US, could plausibly be excused: after all, in 1954 a full 45 per cent of Americans smoked, that country’s highest level. (Australia reached its peak – also 45 per cent – in 1960). But smoking is also popping up in contemporary films, and especially those aimed at kids: a 2019 report from the US Centres for Disease Control and Prevention (CDC) found that the number of times tobacco use appeared on-screen in PG-13 films jumped 120 per cent between 2010 and 2018.

So what’s going on? “It’s not totally clear, but we’ve got a few ideas,” says Professor Stanton Glantz, a veteran anti-tobacco activist and founder of Smoke Free Media at the University of California, San Francisco, which tracks the incidences of smoking in movies and video. “One thing for sure is, these are not random creative decisions. Nothing in Hollywood happens by chance.”

Cigarettes and movies have been inextricably linked for generations. Ever since the advent of the talkies, tobacco companies have understood the power of film to shape cultural norms. In the 1930s and ’40s, tobacco companies paid Hollywood stars to appear in cigarette ads and smoke on screen. In return, the studios received funding for film advertising. Some actors, including Joan Crawford and Carole Lombard, appeared smoking in posters that promoted both the film and the brand of cigarette.

In the 1950s and ’60s, tobacco companies shifted their focus to television, spending hundreds of millions of dollars sponsoring popular programs such as The Jack Benny Program and Gunsmoke. Steve McQueen smoked in Wanted: Dead or Alive. Peter Gunn smoked. Even the Flintstones smoked. In 1962, the American television network CBS assured tobacco companies that the TV set “is the greatest cigarette vending machine ever devised”.

In the early 1970s, however, regulators in the US and Australia began banning cigarette advertising on TV and radio, prompting the tobacco companies to turn their attention once more to the movies. Product placement became rife, with Big Tobacco paying millions to have its brands on screen.

In 1982, Superman II featured a classic fight scene in which Superman is thrown into a Marlboro truck by General Zod. In 1989, Philip Morris paid $US350,000 ($472,000) to have its Lark brand featured in the James Bond film Licence to Kill.

Some companies were literally throwing cigarettes at actors: in 1984, American Tobacco supplied more than $US5000 worth of cigarettes to the set of Beverly Hills Cop. “I do feel heartened at the increasing number of occasions when I go to a movie and see a pack of cigarettes in the hands of the leading lady,” Hamish Maxwell, then president of Philip Morris, told a marketing meeting in 1983, adding, “We must continue to exploit new opportunities to get cigarettes on screen and into the hands of smokers.”

Such marketing has been phenomenally powerful, not only at creating new smokers but at manipulating reality. “You often hear these days that, ‘Oh everyone smoked in the 1920s and 1930s,’ ” says Glantz. “But it turns out that people back then smoked less than they did 10 years ago. The reason people now think people smoked so much then is that the movies back then had so many people smoking.”

Paying for on-screen product placement was banned in Australia in 1992, and in 1998 in the US. By 2007, according to the CDC, smoking on screen was at an all-time low: virtually the only people you saw puffing away were historical figures whose persona was inseparable from their habit: Winston Churchill, Fidel Castro or King George VI in the 2010 film The King’s Speech, in which he’s frequently depicted lighting up as he struggles with his speech impediment.

But smoking soon rose from the ashes. According to the CDC, tobacco use in top-grossing movies jumped 57 per cent from 2010 to 2018. Meanwhile, in the real world, smoking rates in the US were going in the opposite direction, from 19.3 per cent in 2010 to 13.7 per cent in 2018. The CDC didn’t attempt to explain why there was more smoking in films, but it would be naive to think that Big Tobacco had simply walked away from the movies.

“If you see a pack of Marlboros on screen, someone would have had to approve that,” says Glantz. “It doesn’t get in there by accident. How exactly it gets there, we don’t really know at this stage. There are still product placement companies, but they all deny they work with Big Tobacco. But if you see smoke, there is a fire.” (A spokesman for Philip Morris in Australia said the company does not engage in product placement in movies or on television.)

Streaming services aren’t bound by regulatory agreements, which is how shows like The Umbrella Academy managed to include cigarettes in every scene of its latest season.

Streaming is a big part of the problem, according to Glantz. Every year the tobacco companies must certify to the US Federal Trade Commission that they haven’t paid for their product to be placed in movies, TV shows or video games. But the agreement doesn’t cover streaming content, the enormous quantity of which makes it all but impossible for anti-tobacco groups and regulators to monitor.

“The cynic in me says that tobacco ads have been so curtailed globally that the tobacco industry must have a role in it,” says Becky Freeman, associate professor of public health at the University of Sydney.

“But then, given how many productions are involved and the sheer number of people, it seems unlikely there would be big money changing hands without someone leaking about it.” Freeman believes it’s more likely that streaming services are using smoking “to stand out from the big budget movies, and to appear more ‘indie’.”

Some streaming services are more “indie” than others. Despite a pledge to limit smoking on screen, Netflix remains the worst offender. (According to the Truth Initiative, an American anti-smoking group, scenes involving smoking tripled in the latest season of its superhero series The Umbrella Academy, which managed to include tobacco in every scene.)

The major studios also have policies that aim to restrict the amount of on-screen smoking. The strictest is Disney, which banned it in 2007. Thus its 2021 film, Cruella, which features the ghoulish De Vil without her signature cigarette. But all of the studios – even Disney – make allowances for creative licence and historical accuracy.

Kate Winslet as Detective Sergeant Mare Sheehan vapes in the crime drama, Mare of Easttown.

“Smoking was so widespread in the 20th century that it would be inauthentic not to show it in a drama set in that period,” says novelist and screenwriter John Collee. Collee, whose credits include Master and Commander, Happy Feet and Hotel Mumbai, is writing an adaptation of Trent Dalton’s bestselling book, Boy Swallows Universe, which is set in Brisbane in the early 1980s among working-class criminals and journalists. As it happens, the movie will include a historical figure called Slim Halliday, who was a member of the Brisbane underworld and an enthusiastic smoker. (Spoiler alert: in the film, Halliday dies of lung cancer.)

The problem for groups like the Truth Initiative and Smoke Free Media is that smoking in movies often signifies recklessness, and being reckless is cool.

History aside, smoking holds a strong stylistic appeal in cinema, which, says Collee, uses a “Freudian kind of dream language, where some things signify other things”. In Mad Men, the popular series about hard-living advertising executives in 1960s New York, smoking stands in as moral commentary, a metaphor for lead character Don Draper’s shadowy past and heedless chauvinism.

In the 1999 movie, Fight Club, Brad Pitt’s character, a poisonously disillusioned soap salesman named Tyler Durden, smokes so greedily it’s as if he’s eating the cigarette. “His smoking is like saying, ‘Here is a guy who doesn’t much care for his own survival,’ ” Collee says.

In Mad Men, smoking stands in as moral commentary, a metaphor for lead character Don Draper’s shadowy past and heedless chauvinism.

The problem for groups like the Truth Initiative and Smoke Free Media is that smoking in movies often signifies recklessness, and being reckless is cool. The bottom line, says Collee, who worked as a doctor before becoming a writer, “is that, unlike a public health announcement, a drama is essentially non-didactic. To a certain extent, you have to trust your audience to discriminate between a good thing and a bad thing.”

In the 2012 Judd Apatow film, This is 40, the lead female character, Debbie (played by Leslie Mann), has a sneaky smoking habit, puffing away near the bins out the back of her house. When her teenage daughter Sadie discovers her, Debbie is aghast and promises to give up. Like Debbie, today’s filmmakers have been busted smoking. Like Debbie, they have promised to give up. Like Debbie, their heart’s not in it.

Everyone has different ideas about how to fix the problem. India tried to ban all smoking scenes in Bollywood movies in 2005, but failed thanks in part to opposition from the creative community, which argued that it would curb artistic freedom. Instead, all scenes involving smoking are now accompanied by a caption at the bottom of the screen warning viewers that “Smoking is injurious to health”. In Thailand, meanwhile, the act of smoking and cigarette packs are pixelated.

Stan Glantz has long advocated, unsuccessfully, to have all movies with smoking scenes rated R. But prominent Australian anti-tobacco campaigner Simon Chapman believes this would be a mistake, not only because it’s unfeasible (would a minor character smoking one cigarette trigger an R-rating? What about scenes that depict smoking negatively? And what 15-year-old kid takes notice of movie ratings anyway?), but also because having health advocates dictate the content of movies is a really bad idea. “This kind of approach just seems a bit North Korea to me,” he says.

Some of the most memorable anti-smoking messages have come from within the film industry itself. In 1985, the actor Yul Brynner, who had been a smoker since the age of 12 and was then dying of lung cancer, appeared on Good Morning America, imploring the viewers: “Whatever you, just don’t smoke.”

Some of the smoking scenes in The Queen’s Gambit may not have had quite the effect Big Tobacco was hoping for.

Then there is the hit series The Queen’s Gambit, in which sassy chess prodigy Beth Harmon (Anya Taylor-Joy) rises up the chess world while battling booze and drugs. In one scene, Harmon, hitting rock bottom, stumbles around her house, hopelessly hungover, a cigarette dangling from her lips. She heads to the fridge and grabs a beer, then dances around the kitchen to Shocking Blue’s Venus.

As the song hits full stride – “A goddess on a mountain top, was burning like a silver flame” – Harmon twirls, cigarette in hand, smoke in her hair, and promptly pukes in the sink. Not quite the product placement Big Tobacco might have hoped for.

18/03/2022

Vaping is Now Endemic

18 March 2022

It gives me no pleasure to say that vaping is endemic, or that I told you so.

I spent 20 years more or less full time trying to get smoke-free air, which equated to fighting the tobacco industry, who were dedicated to selling as much tobacco as was possible with no regards for its health effects.

As I attended endless conferences at my own expense, there were parallel better funded conferences on the Quit issue, where a second tier of anti-smoking professionals went to conferences on nicotine replacement strategies.

Some of them ran Quit clinics on the model that people would come to them saying “I have a tobacco addiction problem, please help me wean off nicotine”. The Health Dept. set up and funded quite a number of these clinics. The tobacco industry did not object as they made little difference to the number of people who smoked or the ubiquitousness of the habit, and allowed the government to say that it was doing something, avoid doing something more useful and continue to get the tobacco industry’s political donations. As an enthusiastic smoking activist, I visited these clinics. I was always warmly welcomed by the health promotion staff running them who were always up to date on the latest tobacco control literature and happy to talk. It took me a while and some direct questioning to realise that the model was flawed; very few people came to the clinics and the staff were well read because they did not have much else to do. Eventually the government stopped funding them.

When the activists had reduced the credibility of the tobacco industry to laughing stock, and the deliberately long contracts of the sponsored sports and other apologists had run out, we managed to get rid of the advertising sponsorships and get smoke free air (with a generous definition of ‘outdoors’ to allow smoking in poker machine areas in pubs to keep the money engine ticking over). This was in 2000.

The vaping technology was being improved as part of this parallel Quit universe, and its medical protagonists were grateful that there was less tobacco use and hoped that the world would perceive their Quit efforts as the last stage in mopping up the smokers remaining, and they could take more of the limelight. Seeing the whole world from a Quit smoking perspective and possibly having attended a few well-funded conferences, they concluded that vaping would be good for quitting, and because it was much less harmful than burning leaves, it was a step in the right direction. The assumption that the only use of vaping was to get smokers to quit was naïve in the extreme. Some of the vape makers are the same companies that were happy to sell cigarettes, and now there are as many people starting smoking from vaping as leaving smoking for vaping.

But the key to vaping is that it is a new consumer product, with the potential to do immense public heath harm and to make massive profits. The economic engine is in place, the government apathy continues helped by the naïve abovementioned Quit doctors.

In the fight against tobacco, the fact that the ubiquitous ads affected children was self-evident, but like everything in the tobacco wars had to be proved, so a study was done which showed that the brand preference of kids was not the same as adults, but the brands chosen by kids were the ones most advertised.

But now marketing is much more sophisticated. Social media allows targeting by age, gender, location and even personal opinions and preferences. So kids can be reached without adults even being aware, and this is what has happened. Vaping has become ubiquitous, just as we were achieving a smoke-free generation. Now vaping will have to be shown to be harmful, rather than have to be shown to be safe. So the research will take years, be denied by its industry protagonists, and be subject to the venal indolence of the political process. Inhaling solvents with random additives is likely to be harmful, but this of course is not ‘proof’. The industry should have had to prove it was safe before it being released, but because the Quit people allowed tobacco to be the bar that it had to beat, it became legal without scrutiny, and now has become ubiquitous without being noticed.

I was therefore not happy but not surprised to read a schoolkid talking about vaping, and sadly he was also realistic enough to assume that the government was not likely to be of much help. Here is his article.

Vaping, a constant craving for too many of my school friends

Ari Katz, High school student

March 15, 2022, Sydney Morning Herald p19

It started as a novelty, a bit of harmless fun. The snap, crackle and pop of each nicotine-fuelled hit was exciting, enticing. The headspin was a new experience. We felt rebellious, revolutionary, cool. Vapes then started appearing at parties, the beach, the cinema.

But when friends started vaping regularly in the bathrooms at school, it became clear this device – resembling a coloured pen, bright and slim (concealing the fusion of wires, batteries and chemical compounds) – was here to stay.

During assessment-intensive periods at school, vapes act as a coping mechanism, a seemingly indispensable form of stress relief. Is this really the way we want our youth to be dealing with the challenges life throws at them?

The highly addictive, flavour-filled substances in vapes are engineered by profit-hungry foreign manufacturers who, I fear, pay little attention to the long-term health implications of their product.

What began as youthful self-discovery and experimentation has descended into a state of unfettered addiction among the adolescents – boys and girls – I know, some as young as 12. This is because vapes are too accessible, too easy. For me, having seen this obsessive relationship with vaping in all types of peers, including those who excel in sport or academic work, the extent of the issue becomes overwhelmingly clear. Vape addiction does not discriminate – everyone is susceptible.

So why should you care?

A Victorian father is warning parents about the dangers of having vapes near children after his son was hospitalised with what are believed to be the effects of smoking one.

The full negative health implications of vaping are as yet unknown. But the concern is that the recurrent inhalation of chemicals will do significant damage to the underdeveloped lungs and brains of teen vapers. However, from my perspective, far worse is the impact that this dependency and incessant craving has on the mental and social wellbeing of my peers. Teen brains aren’t prepared for the burden of addiction.

We know adults are largely oblivious to the scale of the problem, so how can we ask for help when we know the first reaction of the unprepared parent is likely to be a reprimand rather than a helping hand?

The cognitive dissonance of knowing vaping is harmful, while not being able to stop, is taxing on the mental wellbeing of adolescents. We have little experience of addiction and are not taught to deal with it. We know it’s harmful, we know it’s toxic, but we can’t stop.

Vaping is no longer a fad; the fun has been over for months now. From what I can see in my circle, few people who vape actually want to vape.

Government education campaigns will be largely impotent against the vape culture because addiction, by nature, does not just end by the push of a button. It takes personalised support, resources and encouragement to curb the dependency. Where is all this when we need it?

Vulnerable, developing brains are suffering at the hands of an insidious device, yet this challenge is only now starting to receive attention.

Seeing friends and peers suffer is shattering. This is Australia’s future we are talking about.

Ari Katz is a high school student in Sydney’s Eastern Suburbs

12/11/2021

Mental Health and Physical Health

11 November 2021

The Health system has a major divide that is not often spoken about- the divide between mental health and physical health.

Physical health tries to be a science and likes to think that its diagnoses and treatments are based on sound experimental evidence. If someone is sick and there are not enough facilities there is a fair effort from the medical profession and relatives to get more resources and they are mostly successful. There is a highly respected system and career structure.

Mental health has similar endeavours, but has less of a scientific base for its diagnoses and treatments. There has been a lot of work on neurotransmitters associated with depression and drugs that supposedly increase the good ones, but no single test is associated with a diagnosis, and diseases are defined. It gives it a lingering stigma of imprecision.

The workforces in mental and physical health have relatively little crossover, even isolated within the same hospital. When I last worked in the health system 9 years ago in a hospital that had both an active ED and a mental health facility, patients were triaged as physical or mental, different teams saw them, and neither team wanted much to do with the other stream’s patients. There was a shared waiting room, but different personnel, assessment areas, practices and wards. Getting one of the other team to assess someone was an afterthought, or only when the pathology was fairly gross.

When I was in tobacco control, there was a lot of reluctance to try to get mental health patients to stop smoking as ‘they needed it’, which was another way of saying that to add the nicotine withdrawal to their generally stressed situation was merely making trouble. But the public health statisticians said that people with mental health problems had a lot of physical problems and died about 14 years earlier (AIHW). So glossing over the physical health of mental health patients is not without consequence.

It was interesting to note recently that a COVID-19 infection in a mental health inpatient went undiagnosed for 4 days, and drew attention to the fact that mental health patients had a poor vaccination rate also.

www.smh.com.au/national/nsw/hospital-patient-s-covid-19-infection-undetected-for-four-days-20211105-p596aw.html

11/11/2020

Medicine, Reality and the US vote 11/11/20

Doctors tend to assume that everyone knows certain things, particularly because everyone they meet usually does. They also tend to think that everyone knows the order of importance of what they know.

Many years ago as I started to campaign against tobacco, Henry Mayer, the first Professor of Political Economy in Sydney, who had a regular column in the SMH told me that the health people were invisible in the media on the tobacco issue. I said that this was ridiculous, it was the most studied subject in the history of medicine, with over 60,000 papers and growing daily. He pointed to a person called Tollison, who wrote in the non-medical media that was read by the business sector. There were no medical responses there. The mainstream also media had relatively little on tobacco, as tobacco advertising was one of the major sources of revenue.

So the harm of tobacco was known, but ignored, like the fact that you are going to die one day.

It came home to me, when I amputated the leg of a smoker for vascular disease. He had bad lungs and a bad heart. I said, ‘Look mate, if you keep smoking, you will lose the other leg.’

To my amazement he replied, ‘Look, all you doctors go on about smoking, but if it was as bad as you say it is, the government would do something about it’.

He had internalised the government’s non-action as being mute testimony to it not being a problem. Doctors are, after all a subculture that claims to have expertise in a certain area, as do engineers, educators, weather forecasters and many other groups. In tobacco, the Tobacco Industry, the Australian Hotels Association, Clubs and Pubs and the advertisers and sponsorship recipients fought like tigers to stop reasonable public health policy. They are probably still retarding it- there has not been a Quit campaign in Australia for over a decade.

Trump’s denial of the significance of COVID19 must have struck a chord with those who knew that in the absence of decent welfare system a lockdown would send them broke. They needed to believe that they could carry on, and he and his denial were their salvation. A lot of business interests supported them- they would go broke too.

So it was interesting that the health facts became politicised, and wearing a mask was as much a political statement as a medical one. Politics was not, and will not be in future a good basis for personal preventive heath decisions. So controlling the COVID epidemic in the US will be harder than here, where mainly apathy and complacency are in the way.

The figures that only 4% of people in the US changed their view on the dangers of COVID goes some way to explaining why Biden did not have a landslide. For many people, COVID was not an issue, Trump’s rhetoric was plausible if you did not fact-check, and the economy had been going OK prior to the epidemic.

SMH today:

Virus neglect didn’t infect Trump vote

Shaun Ratcliff

Since the first person was diagnosed with COVID-19 in the US, more than 10 million cases have been confirmed and nearly a quarter of a million people with the virus have died.

Watching from afar, in a country where the coronavirus has been significantly less lethal, it is surprising the incumbent president did as well as he did.

While the pandemic probably did cost him votes, surveys we have run over the course of the year showed there are strong partisan effects on attitudes towards COVID-19, with supporters of Donald Trump mostly unconcerned about the risks from the virus, and getting less worried as the year went on.

These surveys were run in May and September. Both surveys consisted of responses from more than 1000 Americans.

In May, approximately 40 per cent of all Americans were very or extremely worried about the possibility they or a family member might catch the virus. Almost the exact same number were only a little or not at all worried. According to our data, this level of concern actually declined slightly between May and September.

This was largely a partisan affair. Respondents who said they were going to vote for Joe Biden retained a similar level of concern during this period, with 48 per cent very or extremely worried in May, and 50 per cent in September.

However, respondents who said they would vote for Trump were not very concerned about COVID-19 in May – about 19 per cent reported they were worried about it in the first survey and just 11 per cent of Trump voters reported this level of concern in the second survey.

The partisan differences, and the declining trend in Republican concern about COVID-19, are largely the product of the extremely polarised media and political environment in the US.

Trump voters are less trusting of information on COVID-19 from medical experts than Biden supporters, and between May and September a quarter of Republican voters became less likely to trust information from these experts.

This difference may, in part, stem from the media through which they obtain information. Those with the lowest levels of trust tended to rely upon more conservative cable and online news like Breitbart and Fox News, for instance, which have played down the risk posed by the pandemic.

Republicans who rely more on these conservative media outlets were more likely to have lower levels of trust in medical experts, even after controlling for demographic differences between Democrats and Republicans. They were also as likely to trust Donald Trump as medical experts for information on the coronavirus.

In this polarised environment, very few voters abandoned Trump between May and September (only about 4 per cent in our data), and hardly any shifted to support Biden.

Trump supporters tended to align their position on the coronavirus with their political allegiance. Relying more on media that downplayed the significance of the coronavirus, and taking cues from Republican leaders, they decided the pandemic was not a significant threat.

Our data indicates Biden was able to win over a small number of voters who supported neither candidate at the start of the year. It was enough to win in the end, but not enough to deliver the predicted landslide.

Shaun Ratcliff is a lecturer in political science at the United States Study Centre, University of Sydney.

10/06/2020

Vale Trevor Morling – the Passive Smoking Judgement of 1991, 10/6/20

Judge Trevor Morling has died at the age of 92.

He was the author of the famous ‘Morling Judgement’’’ which sent a shock around the world in 1991 as it stated that ‘passive smoking was potentially lethal’.

This has to be put in context if its significance is to be duly recognised. The seminal article about smoking causing lung cancer had been written by Doll and Hill in the British Medical Journal in 1950, and many articles followed in the 1950s linking smoking to a great many diseases.

In 1961, the Royal College of physicians, concerned that the UK government had not done anything to curb smoking, commissioned their landmark report ‘Smoking and Health’ in 1962. The US Surgeon-General did the same, resulting in a similar report in 1964.

The tobacco industry had to decide whether it would scale down its production, or tough it out and take the money. It did secret research which confirmed that burning tobacco produced carcinogens and other harmful products which could not actually be removed. There was a change of personnel and ethos. Prior to 1950, tobacco was a legitimate product like anything else. After the research was confirmed, the decision to keep selling and to deny the effects and hinder government action was the strategy that everyone working at the top of the tobacco industry had to accept.

Tobacco use was mainstream. 45% of all US adults smoked in 1954 (Statistica- Gallup) and consumption peaked in Australia in 1963. People smoked everywhere. There were no smoke-free areas in bars, restaurants or anywhere else. It was normal for house guests to light up and then ask ‘where is the ash tray? The Tobacco industry was keen to maintain this situation and talked of the need for ‘courtesy and tolerance’ between smokers and non-smokers, which was code for ‘doing nothing political’. Smokers all ‘chose to smoke’, which of course meant that they had voluntarily (and knowingly) assumed the risk and consequences of their behaviour. The tobacco industry also gave money to political parties, just asking for a secret promise that there would be no legislation against them before the next election. The medical industry were unaccustomed to this, and kept giving advice that was ignored, with a few significant voices such as Dr Nigel Gray of the Victorian Anti-Cancer Council and Dr Cotter Harvey of the Thoracic Society doing what advocacy they could.

Non-Smokers Rights groups were the main driving force for change in the US in the 1960s and 1970s arguing that people had a right not to breathe smoke. The health charities, Cancer Councils, Heart Foundations were very keen to be non-political as their core business was raising research funds. Real activists soon discovered that their opponents were not the smokers, but the industry, who claimed that there was no proof that passive smoking was harmful, and that courtesy and consideration was all that was needed. Their public stance was referred to as the ‘tightrope policy’. They had to admit that many people believed that tobacco was harmful, as they had to contend that the smokers knew the risk that they were taking and hence could not sue them for deceiving them. But they also had to claim that they did not know that smoking was harmful, so that they were no liable for selling unsafe goods. It was absurd, but it continued.

The tobacco industry as well as being very politically active were the major advertiser, tobacco being second only to food. This meant that the media were more reluctant to run stories that would affect their advertising revenue. Outdoor advertising was also ubiquitous with over 50% of billboards being for tobacco, reminding people to smoke, and especially plastered all over convenience stores where cigarettes were sold.

In 1981 Prof Takeshi Hirayami published a seminal paper showing that non-smoking wives of smoking husbands got more cancer than wives of non-smokers (Br Med J (Clin Res Ed) 1981;282:183). At last there was substantial medical evidence of the harm of passive smoking.

In Australia the medical groups had done quite good advocacy and in NSW a Transport Minister, Pat Hills, simply banned smoking on buses and trains in 1977, but pubs and clubs knew that smokers drank and gambled more than non-smokers, so they took the money from the tobacco industry and lobbied hard against smoke-free indoor air. The restaurant industry followed them, somewhat lamely.

But a breakthrough came in 1979 when 3 activists, Bill Snow, Ric Bolzan and Geoff Coleman formed BUGA UP (Billboard Utilising Graffitists Against Unhealthy Promotions). Coleman had studied political economy, and saw the issue as the tobacco industry killing people for money. BUGA UP saw irresponsible and misleading advertising as the major vehicle for the promotion of products that had no intrinsic worth, tobacco being the leading example. They wrote on billboards, changing the wordings in satiric and humorous ways, and signed their work, BUGA UP, which was an invitation for all to copy. They also did street theatre, often concerned with disrupting tobacco promotion activities in supermarkets or malls. This had an immense direct effect as the billboard posters were only being changed every 3 months and the leaflets and street theatre were amusing. There was a lot of popular support as most people saw that smoking was harmful, and governments were too craven to act. There was also a lot of publicity when Coleman and Neville Biffin were arrested in 1981 and charged with defacing a billboard. They were convicted in 1982 and fined, but praised by the judge (Daily Telegraph 26/2/82) and given a light penalty, which sent a strong message. It also sent a shot around the world by making all other tobacco activism seem moderate by comparison. Australia’s activism was seen as more direct with a ‘Robin Hood’ flavour, but was also more conspicuous because it was against the ubiquitous tobacco billboards, and targeted the industry directly, rather than the more subtle and legalistic approach of the non-smokers’ right groups who had previously been the front line against the industry. It might be noted that at the 5^th World Conference on Smoking and Health in 1983 there were no scheduled sessions on political action or advocacy, and the first meeting was convened by renowned Californian activist Prof Stan Glantz. The presentation on BUGA UP had to be repeated as the room was not large enough for the people who had wanted to attend. The medical system was becoming energised.

The tobacco industry was very demoralised by this. They had set up a lobby group, pretentiously called the ‘Tobacco Institute.’ But this was re-energised by John Dollisson who was there from 1983-87.

In 1983 the Western Australian lower house supported a private member’s bill by Dr Tom Dadour to ban tobacco sponsorship of sport, but an energetic campaign led by Dollisson and using sporting bodies who received money from tobacco, defeated this in the upper house (Musk, BMJ Vol 290 25/5/85).

After his successful Industry fight against the WA Dadour bill, Dollisson’s feisty style set the tone for the tobacco struggles of the 1980s. He was physically strong and in debate would cram a number of aggressive arguments into each sentence, such as, ‘You are treating the smoking causes disease hypothesis as fact, then want to even say that passive smoking is harmful, and smoking is addictive and the advertising get the kids and then you want to tell people how to live their lives and trample on their rights and then you want the government to enforce a nanny state for you.’ (This is not a direct quote, but an example of how his speech was structured). Assuming that he was interrupted at this point, as he would not stop if he were not, the tobacco control advocate would then be able to only answer one of the points already raised. But Dollisson’s aggressive style eventually got him into trouble, with the Trade Practices Commission, prohibition of ‘misleading and deceptive conduct’ being used against one of his advocacy ads. Then the Australian Federation of Consumer Organisations bravely took him on. The story is told by Stacey Carter (Tobacco Control- BMJ Issue 12 Suppl 3):

In July 1986 he [Dollisson as CEO of the Tobacco Institute (TIA)] placed an advertisement in the national press entitled “A message from those who do…to those who don’t”²⁹ in which he claimed “there is little evidence and nothing which proves scientifically that cigarette smoke causes disease in non-smokers”.³⁰ Early in 1987, Dollisson placed a “followup” ad for the TIA, as demanded by the Trade Practices Commission, which among other things stated that the TIA did not accept that their original advertisement was misleading.³¹ This action triggered a six year legal war between TIA and the Australian Federation of Consumer Organisations (AFCO), at substantial cost to the TIA.

On 7 February 1991 Justice Morling decided that the TIA “had engaged in conduct that was misleading or deceptive” and banned the TIA from speaking publicly on ETS.^40,⁴¹ On appeal the injunction was lifted, but the court granted a declaration that the advertisement was misleading and deceptive contrary to the Act and the TIA were ordered to pay a large proportion of AFCO’s costs.

The ‘Morling Judgement’ as it was termed was the first time in the world that passive smoking had been held by a court to be harmful, and this rang around the world.

Dollisson left the Tobacco Institute and went to Philip Morris where he helped the campaign against the Victorian Government’s Tobacco Act of 1987, which raised the State tobacco tax and replaced tobacco sponsorship money as well as promoting health (which replaced tobacco advertising from the advertisers point of view) and also funded medical research. The Victorian legislation, effectively paid off the tobacco industry’s bought acolytes, and the aggressive approach to advocacy by Dollisson in Australia was seen as backfiring.

The decision also set the precedent for the test case Scholem v NSW Dept of Health, where a psychological counsellor successfully sued for workplace tobacco smoke exposure in May 1992.

Australia has been drifting in its tobacco control endeavours of late, but Trevor Morling will be remembered for his contribution, as well for the many other achievements cited below.

www.smh.com.au/national/chamberlain-royal-commission-judge-was-a-lawyer-s-lawyer-20201006-p562hk.html