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Episode 4 - Vaping with A/Prof Becky Freeman and Dr Michael Bonning
85 Plays18 days ago
Leading researcher in youth vaping A/Prof Becky Freeman and AMA Public Health Committee Chair Dr Michael Bonning speak with Dr Omar Khorshid and Dr Chris Moy about the scourge of vaping in Australia, including where we are now, how we got to this point, and what more needs to be done.
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Transcript
Australia's Leadership in Tobacco Control
00:00:02
Speaker
You're listening to The Waiting Room, a podcast by Australian Medical Association with your hosts, Dr. Omar Khorshid and Dr. Chris Moy.
00:00:20
Speaker
Australia has led the world in tobacco control in the past and we've all seen the incredible impact that public health campaign has had on our society in so many ways.
Expert Insights on Tobacco Control
00:00:31
Speaker
But big tobacco has hit back and in many countries around the world, vaping levels are incredibly high, especially amongst young people. Welcome to The Waiting Room with me Dr Omar Khorshid. And this is Chris Moy, and I'd like to introduce our guest today, is Associate Professor Becky Freeman, a leading global authority on tobacco control and the commercial determinants of health.
00:00:54
Speaker
Based at the University of Sydney, Becky has spent more than two decades researching how the tobacco and vaping industry circumvent advertising bans to target young people.
Vaping Reform and Health Advocacy
00:01:02
Speaker
Becky is the Chief Investigator of the Generation Vape Project, leading research into how young people are exposed to and influenced by the e-cigarette marketing.
00:01:11
Speaker
We're also joined today by Dr Michael Bonning, Chair of the Australian Medical Association's Public Health Committee and a practicing GP in Sydney. Michael's a leading voice in national health advocacy, known for his work already on vaping reform, cannabis legislation,
00:01:26
Speaker
and the responsible integration of AI in healthcare.
Resistance Against Vaping Initiatives
00:01:30
Speaker
Can I just say straight up that at the very start that we we are very lucky to have Omar starting off this podcast because really ah back in 2021, he was instrumental in really kicking off the the movement against vaping in Australia by really convincing the government to at least start the first resistance against vaping in terms of setting up but the need for prescribing and also setting of standards for the first time.
00:01:57
Speaker
Now, that wasn't perfect, but you know it was to some degree against the stand against the so was to some degree against the the tide at that time against sort of movements in, for example, the UK.
00:02:09
Speaker
But now Australia has actually been progressing fairly well along the way, although there continues to be significant resistance.
Generation Vape Project Exploration
00:02:15
Speaker
So I have a question for Becky. You have played an instrumental role in researching impact of vaping on Australia's youth.
00:02:23
Speaker
Could you give us an idea about how generation about Generation Vape and what the what is the latest eighth wave of data ah telling us? I think, you know, you make a good point how 2021 we had, you know, all these products were flooding the market.
00:02:38
Speaker
um Parents were clueless as to what these products even were. We had teachers contacting, you know, public health groups like the Cancer Council and saying, I found this thing in our students bag. What is it? What are supposed to do with this?
00:02:51
Speaker
um the You know, the commercial side of this arm, you know, knew what the assignment was. It was like, get these colorful, flavorful products into the hands of young people. And on the public health side, we were kind of caught with our pants down a little bit because we didn't have good data. We didn't know what was happening.
00:03:06
Speaker
um Community was crying out. And so Genvape was sort of born out of that need for better data, a better understanding of evidence of where were these young people accessing their products? How much were they paying for them? What did they think about them? What were the social attitudes?
00:03:20
Speaker
And um in just that short period of time from 2021 till now, we've seen incredible changes. When we first started collecting data, you know, vapes were really normalized. They were dismissed as something fun and, you know, that appealed to young people, you know, not your grandfather's cigarette.
00:03:38
Speaker
And now in our latest wave of data, we're hearing from young people.
Youth Attitudes Towards Vaping
00:03:42
Speaker
I'm addicted now. I need this under my pillow at night. This is no longer fun. This is something I thought I would just do at parties. And now I can't think and concentrate in school without one. um I'm using it and don't even realize I'm using it.
00:03:56
Speaker
and It was really interesting hearing from some of our older participants. So we also interviewed 18 to 24 year olds in addition to that 14 to 17 year olds saying, you know, this is really cringy now. This was something I thought I'd be doing as a teen and now I'm still doing it.
00:04:11
Speaker
And that's really worrying in and of itself. that This is seen as a young person's behavior. um I'm really pleased to say that it looks like teen vaping could have peaked in Australia. I ah hope that I don't regret saying that. In couple of weeks, I'm back here going, well, I was wrong. It's actually gone up again.
00:04:28
Speaker
ah At about 15% of 14 to 17 year olds now are vaping at this time, which is still way too high, but we're not climbing up anymore. and it looks like we're turning the tide. Thanks, Becky. And it's it's due to the work of people like you that we've seen such a rapid turnaround in in the attitude toward vapes from young people. And we only need to look overseas to see how it could have been.
Government Reforms on Vaping Policies
00:04:53
Speaker
Michael, it was pretty controversial that the idea that the GPs might be asked to prescribe vapes. How have you found the government's reforms of the various ways of reform that have come in? How have they affected you in your practice and and and of course your patients? I think in the absence of evidence, we were really seeing some practitioners within that the health space, especially within general practice, you know, kind of mounting a ah real campaign to say this is what we should use in terms of smoking cessation, ah really building up kind of ah nothing empirical, absolutely everything anecdotally based to get people ah to yeah on board with their movement. and And there were a number of people ah who are quite prominent within ah general practice, within Australian public health, who went in that direction,
00:05:48
Speaker
I think as GP, but also amongst my colleagues, what we really felt was this is opening a door to a whole group of people with whom we've done generations over time. We've done excellent tobacco control. We've done good public education.
00:06:04
Speaker
We've been really clear to the point where smoking has gotten to a point where ah young people just weren't taking it up. And this was the next thing that that came along.
00:06:16
Speaker
and And so we Now, much of the work that Becky has done, i think Professor Emily Banks' work as well on giving us a ah strong international evidence base and then distilling it into the Australian context.
00:06:32
Speaker
Most GPs have gotten on board with the idea that this you fourth or fifth line, we saw college guidelines catch up with that as well so that we weren't in this evidence-free zone.
00:06:43
Speaker
And you know I know in most of the practices that where I know people that it it has yeah we've we've disappeared and gone away from ah from prescribing where people were doing it under the special access scheme for a number of years. They were thinking, oh, well, this could be
Comparative Analysis of Vaping Policies
00:07:00
Speaker
ah And yeah it's always been this case that the commercial interests front run the public health.
00:07:07
Speaker
And so those commercial interests, you will sell it in the best way they possibly can. They're much better at selling their message sometimes than we are at unraveling that message and working out what is, know, the right thing to be saying.
00:07:22
Speaker
And so I think that's what left a lot of GPs in the lurch there. One of the things that GPs said very clearly, but actually everyone said really clearly was,
00:07:33
Speaker
getting more advice earlier on about emerging products. And in that case it was vapes, but we can, you know, um, nicotine pouches, sors and all that other stuff that exists out there.
00:07:45
Speaker
Uh, because we know that otherwise it's it's exactly as Becky described it. It shows up in schools or it shows up in a consultation room with a parent handing it to you.
00:07:57
Speaker
You look at it and you have a blank look on your face. And I think that was always the part of this that GPs were playing detective. And from a ah point of view then of trying to understand whether we should be prescribing things, we yeah we were we were caught um short in terms of what our knowledge should be.
00:08:17
Speaker
Becky, could I just ask, when when when the the sort of move there started back in 2021,
00:08:25
Speaker
There was a lot of, mean, we were sitting there, not knowing, you know, the argument oh, look, this is all just harmless stuff in there, you know, we don't, you know, there's nothing in there, despite the fact that we knew there were huge amounts of nicotine, plus God knows what else is in there and what that would do to people.
00:08:40
Speaker
um There was also that emerging evidence, in fact, that it was leading people to become smokers in the end, so they were actually you know becoming smokers, and the evidence for that was, I think, one of the greatest ah and compelling evidence was that the the ah big big the big smoking companies, cigarette companies, were pushing this so hard.
00:08:57
Speaker
But the ah the thing that was very, very tricky in terms of the argument that kept on getting thrown at us was that other countries like the UK were actually going exactly the opposite way. They were actually pushing this as a as a smoking cessation strategy and that was being thrown in our faces all the time.
00:09:13
Speaker
um i mean, where are we now a few years on? i mean, because, you know, the the paths have diverged to you know other countries have let the cat out a bag. Australia has really gone the other way.
00:09:24
Speaker
um Where are we now compared to other countries? ah You may have picked up that I have a slight accent. I'm Canadian myself originally. And Canada just um interestingly came out with their cessation guidelines just last week, updated cessation guidelines. And um e-cigarettes are in there as a absolute last line possible for those smokers who voice that they want to use them and nothing else has worked for them.
00:09:50
Speaker
There's a reminder right in the guidelines that these are not approved medicines. Like this is almost identical to what we're saying here in Australia, except we have regulation to back those guidelines up and that, you know, these products are not available in corner shops. Well, they shouldn't be.
00:10:05
Speaker
They're not being sold to kids anymore. So you have this in Canada where they're being sold. Vapes are being sold as a consumer good. to virtually everybody normalized in shops. And yet there their guidelines are saying these really aren't cessation devices. They're they're a recreational good.
00:10:21
Speaker
And so we in Australia have, we have coherence between those things. It's like, we're not saying these are you know, this miracle product that should be freely available to everybody. We're saying, no, these are not great.
00:10:33
Speaker
We appreciate that there may be a very small number of people who will benefit from using them, but we do not want a situation where they're being sold everywhere. But people point to New Zealand that has taken a very opposite tactic to us, promoted them as great cessation products, that they're amazing.
00:10:49
Speaker
Unfortunately, um you look at the youth vaping data in New Zealand, youth vaping rates are a lot higher in New Zealand than they are here. We've also done analysis led by one of my PhD students, Sam Egger, who showed that the introduction of vapes in both in New Zealand and in Australia actually slowed our progress in reducing smoking.
00:11:09
Speaker
And that's because we know that e-cigarettes, are a risk factor for future smoking. In the Genvape data, it was five times more likely to go on to smoke if you vaped first when you're a teen.
00:11:22
Speaker
um Internationally, a meta-analysis of all the studies from all the countries altogether looks like it's about your three times more likely to go on to smoke. So you can see that, you know, from ah a population level, an individual study level, that e-cigarettes are definitely a risk factor for young people to take up smoking in the future.
Public Health and Political Alignment in Australia
00:11:40
Speaker
And this is where the politics gets in the way of it as well. I mean, you know, we've seen different styles of governments want to take on...
00:11:48
Speaker
the challenge of this in really different ways. And ah New Zealand is a really good example because they had gone with pioneering kind of landmark legislation around smoke-free New Zealand and really cutting off access.
00:12:03
Speaker
And then you have ah you have a change of government, you roll that back, money there gets diverted into and tax policy and things like that. you One of the things I think we really benefited from here is that there's been
00:12:19
Speaker
a great convergence across public health, but also broadly across society that it's Both the politics, the public health, the community, all are really lined up around this isn't a ah great idea. And so the people on the other side are generally convenience store owners ah and and and tobacco kind of distributors.
00:12:42
Speaker
And they are you they're pretty easy or they're easier group to demonise and keep on one side of a debate, especially because of how much that was being directed towards kids.
00:12:55
Speaker
yeah And so that's been a, i I think that's been a something that was left and the horse bolted a bit, but that we've been able to rein that back in over time because we've had that, that real ah coalition around people wanting this to disappear from our streets.
00:13:14
Speaker
Chris and I led the AMA at a pretty interesting time in our history with with the pandemic. And, you know, we did get death threats and various ah ah various little missives in the post or on social media as a result of the AMA's position, for instance, on vaccination.
00:13:30
Speaker
But I have to say the strongest attacks that we had during that time were from the vaping lobby, ah from the the activists on social media, from from certain doctors. They really felt strong and pushed hard on social media.
00:13:44
Speaker
um I guess my question to you, Becky, is is where's that up to now? Are they are those people still influential and and how do you tackle their accusations that, for instance, they accused me once of of basically killing Australians by pushing them away from vaping and towards
Challenges from the Vaping Industry
00:14:03
Speaker
smoking? Well, first of I'm really sorry to you hear that. um Health professionals should not be getting death threats for doing their absolute best during a global pandemic. That's horrifying to me.
00:14:13
Speaker
um Yeah, look, I think anyone who's worked in tobacco control for any length of time has encountered people who aren't big fans of the work that you do, to put it mildly.
00:14:26
Speaker
It's, a I supervise a lot of early career people and I feel it's my obligation to try and prepare them for that and shield the best I can. um i think the the the biggest factor that you can do to insulate yourself and help yourself is to have really good colleagues and to have that support base of colleagues who you can check in with and tell you you're doing a great job. Just ignore that.
00:14:49
Speaker
It can be really hard. um I trained under Simon Chapman, who's like made of rhinoceros hide, who like... Everything just like slides off him. So it's kind of like, okay, he can take it. I can take it You know, we can do this. And because the goal is to silence you, right? The goal is to to either one, scare you into thinking you've said something wrong or you're doing something wrong and you should stop.
00:15:11
Speaker
or it's too it's to intimidate you and to make you feel so terrible all the time that you stop. So the goal is to get you to just stop what you're doing. And you have to talk to your colleagues and reassure yourself that what you're doing is right. You check in and make sure you haven't you know stepped over the line and gone for something that makes no sense or there's no evidence to back up what you're doing and you carry on. And um I also like to um you know do some boxing on Friday afternoons. It's a nice way to get some of that that out. Yeah.
00:15:41
Speaker
But I say on that point, though, yeah I mean, you've both spoken strongly about the tactics used by the vaping industry to target our younger people. I mean, what parallels do you see between the strategies used by these groups that have traditionally been used by big tobacco or other than so? it It's a playbook, isn't it? you know, if we're...
00:16:04
Speaker
I always think if we're talking about vapes, we should also be just saying this whole group of whatever the next novel thing is, whatever, unfortunately, Becky's going to have to ask Generation Vape about, i you know, in 12 months or 18 months' time.
Vaping Industry Tactics
00:16:16
Speaker
But it is this, you know association with cool, the Marlboro Man, um Joe Camel ah back, you know, 20, 30, 40 years ago has was just replaced by a whole legion of social media influencers, associations with, know, with sport,
00:16:37
Speaker
for vapes, then the ah the the the ease and availability, so flooding a marketplace, making it that there was always something available. You could pick, you know, and we know people with, you know, just bags of them at schools and you could just sell them and, know, convenience stores where you could walk in and even if you're in school uniform,
00:16:59
Speaker
ah you could you could pick one up. And all of those things come together, ease of availability, um a positive kind of social pressure. Plus, as Becky said before, you know, it's it's not your grandfather's cigarettes. It was something new. It had novelty to it. And then you add to that Nicotine, wonderfully, unfortunately, addictive, and and then add some flavours to it. you know Mango ice or you know and something mint or yeah this, that or the other.
00:17:30
Speaker
um yeah Caramel corn, where we see all of these around the place and And in time, those were things that, they don't appeal to ah a 60-year-old smoker. They absolutely appeal to a 14-year-old.
00:17:43
Speaker
um you You put all those things together and it's it feels like the same playbook just rehashed from modern world, again, where there was no government intervention for the first kind of six, eight years of these being on our market.
00:17:58
Speaker
And I think I would add to that too, like we have, you know, the there's only a few major multinational tobacco companies. There's, you know, they control the vast majority of the market. And um if you look at what British American tobacco is doing in this space right now, we've just published a paper on this. They're flagship brand views, which is their e-cigarette brand.
00:18:19
Speaker
They sponsor Formula one they sponsor music festivals. Like it's like I've gone back to the 1990s when I was like in my undergrad at university and they were doing that with their tobacco products. It's it's like just press repeat. They're learning from what they've done before.
00:18:35
Speaker
And It was so strange to me that people couldn't see that. but It's like, this is the same companies and the same target audiences doing even the same sport they're sponsoring. They're back in motorsport again.
00:18:50
Speaker
And yet we're going like, well, you know, maybe we should just see what the long-term impacts are on these people's health. and And to make, you know, people who are trying to quit smoking guinea pigs for these products and saying, let's just see what happens in 20, 30 years. And in the meantime, they can glamorize formula one.
00:19:06
Speaker
I just find that horrifying. ah It's just's not right. It's wrong. There's the marketing side, I agree. And then there's the, the you know, obfuscate, deny, um you know, come up with conflicting evidence, you use selective sources, or all of the things that make it hard in the public health side to get on top of things because there'll always be an argument.
00:19:31
Speaker
And social media has probably made that harder for us. it is, it's not a respectful debate where you cite your sources. Not that it ever really was, but it feels a lot more like a, you know, a street fight these days to work out and work at how to engage with, you with generations of young people who are predominantly finding their information from much broader range of sources.
00:20:02
Speaker
And therefore those sources are you very corruptible by with misinformation, disinformation ah that you know makes it hard for legitimate channels of information to get through to people and their families.
00:20:15
Speaker
Speaking of street fights, Michael, I feel like that's ah that's a great or terrible run into something. Street fights. Can you tell us about what happened? When was the last time you were in a street fight? Yeah, yeah.
00:20:28
Speaker
um We are hearing a lot, though, that it is the ah the importation blocks and the huge excise on tobacco that is resulting in illegal tobacco sales, the black box sales, the under-the-counter sales, and, of course, the violence, the shootings, et cetera, that are going along with that, particularly in some states.
00:20:48
Speaker
So has there been overreach
Illicit Tobacco Market Implications
00:20:50
Speaker
here? Has public health gone gone crazy? and And how would you respond to that allegation? I don't think I can say this more clearly clearly. We are being sold cigarettes that are part of a broad international market.
00:21:04
Speaker
There is a margin on illicit tobacco in low and middle income countries. It has nothing to do, i think, with our excise program, because even if you had ah very minimal excise, Australia as a rich country would still be able to pay more for cigarettes than Indonesia or India, where tobacco companies still make lots of their money.
00:21:29
Speaker
So reducing the excise is not going to solve that problem as some have suggested it may do The other of this is about, and we know that that's a bit of smoke that gets thrown up ah by some elected officials, but certainly by people who push ah the idea that the excise should come down, often representing the tobacco lobby, is that We can't get sidetracked by $6 billion dollars illicit market when there's a $139 billion dollars problem out there and it's still out there and it's still recruiting people to smoke cigarettes every day.
00:22:09
Speaker
The best investment we have is in stopping people from ever taking up smoking. And so the starting point was in you really putting a very strong framework around vapes.
00:22:21
Speaker
It is ah actually, in fact, in using the excise that we do generate to fund vapes primary prevention programs in an education programs for, uh, in tobacco. It's about supporting quit services. It's about making them accessible to everyone.
00:22:38
Speaker
It's about ensuring that there aren't financial reasons or others that people can't access these things. But I would push back in the most, uh, forceful way that I possibly can against the arguments about how the excise, um, is causing all this. so I think if we stand back, ah I've got to say that always put this, the whole arguments against vaping very much in there with the conspiracy theorists the sovereign citizens, which we've we're seeing. I mean, there's been a lot, you know, it's always had a lot of whenever you've had to go up against their arguments.
00:23:12
Speaker
But I think, look, if you stand back, I think Australia really has has almost led the world in the fight back against this, whereas a lot of the other countries really have actually ah let it go. And I think to their great regret now,
00:23:26
Speaker
But can i can I just ask now, I mean, we we have gone a fair way and and we have to credit successive governments for actually beginning the fight and continuing the fight. um I think, you know, there's a little bit of backtracking here and there and there's bit of politics there. But, I mean, the question is, is are we doing enough then and what do we need to do next to to really, you know, continue this and actually, frankly, finish this off, hopefully, as ah as ah as a problem in the
Strategies to Combat Smoking
00:23:50
Speaker
longer term? Yeah, um for me, it's quite striking when you think about how for the vaping, we immediately recognized that easy access and easy supply was a huge problem.
00:24:03
Speaker
And so we don't want these sold in every community and every corner shop oliver all over Australia. We're not there yet with cigarettes. I mean, in my own neighborhood, I live in inner West Sydney and I have a 10 minute bus ride home from the uni to my house.
00:24:19
Speaker
And I must pass literally dozens and dozens of places where I can buy cigarettes. That is just policy incoherence with how dangerous this product is, how highly taxed it is as well.
00:24:31
Speaker
You know, it's it's it's it's not something that anyone can, you know, just sell. it's You need to be an incredibly responsible retailer in order to sell this product, right? And so to me, the next step, and then we've shown we can do this with vaping, we can address supply.
00:24:47
Speaker
We need to do this with cigarettes as well. And we have an oversupply of cigarettes in Australia. We have way too many places selling them. They're way too easy to get your hands on.
00:24:57
Speaker
And if we want to crack down on the illicit market, that would be the most sensible place to to start. If not every other store is selling cigarettes, it's going to make enforcement a lot easier too. How would you score, um I guess, in a sort of balanced scorecard approach,
00:25:12
Speaker
ah the current and perhaps previous government's efforts in this area. You know, we have seen huge public health campaigns in the past, probably not so much anymore, but good, you know, still good um efforts in exercise obviously now in in vaping control.
00:25:29
Speaker
So have we dropped the ball a bit with some of the the public health messaging? And I think you've already suggested a way forward on on the retail shops. is there Is there anything else that needs to be done? Are we missing something else, Michael?
00:25:43
Speaker
Customs and Border Protection have their hands full. They have lots of things to do. This is one. And if you talk to someone from there, they will often say to you, I'm having to make choices about stopping cocaine or stopping cigarettes.
00:25:58
Speaker
And one of the things... we have certainly heard is about how enforcement works. So I think you you do come back to there should be far fewer places where you can buy, know, cigarettes, them and nicotine in its in you in pouches in its leaf form.
00:26:20
Speaker
ah the the The approach should really also be that, we recognise that illicit tobacco is a funding mechanism for organised crime.
00:26:33
Speaker
And so in that setting, we might also think about how important this is as a way to fight a bigger concern in our community because most people will...
00:26:49
Speaker
get to that point of saying, oh, well, it's just some cigarettes. You know, I want i want the police over there doing something else. But if in our, know, in our process ah to think about prioritisation of resources,
00:27:03
Speaker
that we can link those two things together. I think we'll do better, ah going forward. I think if you had to ask this side of this government, I think it's probably a seven and a half on, um, on the scorecard and the, the room for improvement is around,
00:27:21
Speaker
ah the enforcement side. It's around how do you put in place the structures that mean we don't see it on, you know, we don't see all this tobacco. You know, I can't, I'm not being sold a single ah cigarette in my local corner store, which now I see happening, unfortunately, regularly.
00:27:38
Speaker
ah How do you get strong control back in place. Um, and everyone on the same page that that's a valuable thing to do. And it's just as valuable as some of the other crime fighting things that we do. And I would just add, like, we are very lucky in that we have a minister right
Bipartisan Support for Tobacco Control
00:27:54
Speaker
now. um Mark Butler, who has prioritized vaping and tobacco control.
00:27:58
Speaker
It's fantastic. And I would also give credit to previous governments, Liberal and Labour. This is a cross-party supported issue. I mean, might surprise everyone to know that Tony Abbott was the one when health minister bought in picture warnings on cigarette packs, credit where credit's due.
00:28:15
Speaker
and And so there's no need for this to make this a left or a right side of politics. Everybody wins in public health when we all prioritize um reducing smoking.
Conclusion and Acknowledgments
00:28:25
Speaker
And with that, I'd like to close by thanking all three of you. i mean, we've acknowledged the the governments and I think we will say Greg Hunt prior to the current government and Mark Butler now for continuing the fight and being strong in this topic.
00:28:39
Speaker
But I think people like yourselves and I include there Omar, Becky, Michael, I mean, ah people, I think to some degree, will be you know people will be forgotten about this one day, but they will take that a lot of people hopefully in turn the tide against it and hopefully not not let this get out of the bag like in other countries.
00:28:58
Speaker
And I think that's a wonderful thing for Australia. and And hopefully um people will maybe be able to recognize that one day. But with that thought, thank you to all all of you for coming along and and and giving us your insights into this incredibly important topic. Thanks so much. It was great to be here. Thanks, Chris. Thanks, Chris. Thanks so much.
00:29:16
Speaker
Thanks for listening to The Waiting Room.
00:29:20
Speaker
Learn more about the AMA, including how to become a member, ama.com.au.