Government action on diabetes prevention: time to try something new

Diabetes mellitus is the fastest-growing non-communicable disease (NCD) in Australia. Around one in 25 adults has type 2 diabetes, and half do not manage their condition effectively.1 By 2023, diabetes will account for around 9% of Australia’s burden of disease, compared with 5% in 2003.2 Health spending on diabetes has been predicted to rise by 400% between the 2002–03 and 2032–33 financial years, reaching $7 billion.2 The rising burden of diabetes is largely due to rising rates of overweight and obesity, to which poor diet is a key contributor.

In 2013, Australia and other members of the World Health Assembly committed to a range of global goals for reducing the burden of NCDs, including a halt in the rise of diabetes. Achieving these ambitious goals will require a paradigm shift from personal responsibility to shared responsibility, as well as greater accountability from governments and industry.3 Although individuals can take steps to improve their own diets, achieving healthier diets at the population level requires cost-effective public policy measures.

Until now, Australian government action to prevent diabetes has focused largely on encouraging individuals, through education and information, to change their lifestyles. In this article, we propose a new approach. We summarise four regulatory actions that the federal government could take to modify the preventable dietary risk factors of diabetes at the population level. These are:

Implementing a mandatory front-of-pack food-labelling system;
Restricting children’s exposure to junk food advertising;
Strengthening co-regulatory structures for food reformulation; and
Taxing sugar-sweetened carbonated beverages.

Unlike medical interventions, legal and regulatory interventions are rarely assessed in clinical trials. Priorities must therefore be identified according to well recognised criteria (effectiveness, cost impact) as well as other factors that are perhaps less quantifiable, including political feasibility. Each of the priorities we propose is supported by an evidence base and engages with at least one of the three policy domains that have been identified as crucial to prevention: food behaviours, the environments in which we make food choices (including price, marketing and advertising) and the nature and quality of the food supply.4 Importantly, these priorities do not override individual autonomy or personal choice, although they may constrain the actions of food businesses and alter the incentives for individual behaviour. These actions complement education and the provision of information to members of the population — they are not intended to be a substitute.

Unhealthy diets, obesity and diabetes

Overweight and obesity are the most important direct risk factors for diabetes.5 Between 2007–08 and 2011–12, rates of overweight and obesity in Australian adults rose by 1.6 percentage points, reaching nearly 63%.1 Overweight and obesity in children aged 5–17 years exceed 25%.6

Rather than illustrating a nationwide failure of personal responsibility, unhealthy diets and weight gain among Australian adults and children are the result of complex global and local processes. Social, economic and technological changes have profoundly reshaped the food supply, making unhealthy choices easier than healthy ones.7 The processed food industry has been influential, driving consumer tastes and spending patterns towards foods that are cheap to produce, highly profitable, energy-dense and nutritionally poor. The recent Australian Health Survey showed that we consume over 35% of energy as discretionary (or “junk”) foods — foods with little nutritional value that tend to be high in saturated fats, sugars, salt and/or alcohol.6 These dietary patterns contribute to chronic energy imbalances between kilojoules consumed and kilojoules expended at the individual level, and high rates of overweight and obesity at the population level.

The need for leadership on diabetes prevention

Governments have a duty to protect the population from risks that may lead to disability and premature death. Achieving this on a population scale often requires the use of laws and regulations. This is uncontroversial when it comes to infectious diseases and injuries: Australians rarely object to laws protecting them from exposure to asbestos particles, contaminated food, Ebola virus or motor vehicle injuries.

NCDs account for 85% of Australia’s disease burden,5 yet successive Australian governments have been slow to take regulatory action. Government action to improve diets has focused on health promotion and the provision of information, including through nutrition labelling, the Australian Dietary Guidelines and campaigns such as Shape Up Australia in 2013.

These approaches sit comfortably with the food industry, which emphasises personal responsibility for dietary choices. It also prefers voluntary, industry-led approaches to food labelling, marketing and reformulation.8 However, while individual responsibility is critical for individuals to manage their own diabetes risk, it has demonstrably failed as a public policy approach to growing rates of diabetes.7 While the food industry’s desire to demonstrate responsibility is laudable, little progress has been made through voluntary schemes. And although it is tempting to regard dietary risk factors for NCDs as being self-inflicted, effective prevention requires changes that can only be achieved with government action, including public policies to improve the food supply and the food environment.

Time to try something new: four priorities for government action

A mandatory front-of-pack food-labelling scheme

If consumers are to take responsibility for their health, they need clear and consistent nutritional information about the foods they buy.9 Australian law requires manufacturers to disclose the ingredient list and nutrition information panel on food packages; however, this can be time consuming to read and difficult to interpret. A front-of-pack label translates this information into simple visual messages about the quality of the nutrition of the food.9 In January 2015, the Australian Government announced it would proceed with a new front-of-pack labelling scheme, a star rating.10 Companies may implement the star rating voluntarily, and it may be accompanied on food packages by the industry’s preferred label, the daily intake guide.

However, voluntary use of two different labels perpetuates the status quo. Food companies that do not wish to draw attention to products high in sugar, salt or saturated fat are already ignoring the star rating,11 while those that act responsibly bear the cost of increased regulation. In 2011, the Blewett review of labelling law recommended a colour-coded (“traffic light”) front-of-pack label, supported by a comprehensive national nutrition policy.9 Four years on, there is no sign of a national nutrition policy, the food industry has successfully resisted colour-coded labels, and the front-of-pack label-development process has been drawn out and hampered by political controversy.

Time to try something new. It is time for Australia to have a legislated, mandatory front-of-pack labelling scheme, creating a level playing field for companies and clear choices for consumers.

Restricting children’s exposure to junk food advertising

In its 2004 Global strategy on diet, physical activity and health, the World Health Organization stated:

Food advertising affects food choices and influences dietary habits. Food and beverage advertisements should not exploit children’s inexperience or credulity.12

A variety of mechanisms have been adopted in different countries to restrict children’s exposure to junk food advertising.13 However, evidence suggests that government regulation is more effective than voluntary industry measures. A recent systematic review found that

self-regulatory pledges are unlikely to be sufficiently comprehensive to have the desired effect of reducing children’s exposure to promotional marketing of unhealthy food products unless tied to stronger government oversight. [emphasis added]14

It recommended as best practice “comprehensive, preferably statutory measures” including clear definitions of media and audience, monitoring of compliance, and sanctions for non-compliance.

In 2008, the Australian Government considered, but decided against, regulating junk food advertising to children. Instead, the food industry signed up to two voluntary codes of conduct. Empirical analysis has shown that these have done little to reduce children’s actual exposure to junk food advertising.15 This is because their commitments are vague, contain loopholes, cover a narrow range of media, and allow for subjective interpretation by companies.16

Time to try something new. Mandatory targets, broader coverage and real sanctions for non-compliance would significantly strengthen the ability of industry codes to limit children’s exposure to junk food advertising.

Stronger co-regulatory structures for food reformulation

Food reformulation has been described as

a realistic opportunity to improve the health of a population through improving the nutritional characteristics of commonly consumed processed foods.17

Reformulation could involve reducing the salt, sugar or saturated fat content of processed foods, or their portion sizes or energy density. This approach is regarded as cost-effective,18 since it does not depend on individually targeted behavioural changes.19

However, food reformulation in Australia has so far been limited to voluntary, industry-led approaches. Since 2009, the major national initiative has been the Food and Health Dialogue, which convenes representatives of government, the food industry and public health to collaborate on reformulation. The Dialogue sets targets on a range of common foods, and manufacturers choose which ones to implement.

A recent systematic assessment found that, in its first 4 years, the Food and Health Dialogue achieved none of its reformulation targets.19 The authors also found that few targets had been set, and that participants regularly failed to meet deadlines for reporting on progress. Further, evidence from other jurisdictions illustrates how commitments made under industry-led processes tend to be diluted to the point of meaninglessness,20 or simply remain unfulfilled.21

Time to try something new. Food reformulation processes need specific targets and timelines, robust oversight mechanisms, incentives for compliance, and independent review of progress and performance. If self-regulation fails to meet its targets, the government should progressively intervene.22

A tax on sugar-sweetened carbonated beverages

Taxes act on consumer behaviour by changing the cost of different choices relative to one another. If unhealthy foods are cheap to buy, then raising their price through taxation provides a price signal — although without removing choice altogether. A 2012 review of health-related food taxes found that, if carefully designed, these could be effective in shifting patterns of consumption towards healthier foods,23 with a 20% tax suggested as the minimum rate for effectiveness. Excise taxes (taxes levied on a specific kind of product) have been found to be particularly effective and are used to correct for negative externalities (harm to a third party external to the producer–consumer relationship — in this case, social harm) caused by persistent consumption of unhealthy products, such as tobacco, alcohol or unhealthy foods.24 Revenue from such taxes can also be hypothecated towards health promotion initiatives or healthy food subsidies.

Proposals to tax fats can be complex, with unintended consequences for basic products like dairy foods. By contrast, sugar-sweetened carbonated beverages (SSBs) are more straightforward targets. They add little nutritional value while contributing significantly to excess energy intake. In January 2014, Mexico joined 34 US states, Denmark, France, Tonga and several other jurisdictions by introducing a tax on SSBs.

In its response to the recommendations of the National Preventative Health Taskforce in 2010, the Australian government stated it would not be considering taxes to decrease the consumption of unhealthy foods and drinks.25 Since then, however, community support for a tax on SSBs has grown significantly. In 2013, a coalition of non-governmental health organisations (the Cancer Council, Diabetes Australia and the Heart Foundation) launched a national campaign calling on government to explore taxation as part of a suite of policies aimed at reducing SSB consumption.

Time to try something new. Thirty years ago, governments were similarly reluctant to take regulatory action on tobacco. Looking forward 30 years, which Australian governments will be seen as leaders and pioneers in regulating for diabetes prevention?

Conclusion

Individualised, education-based and voluntary approaches have dominated the diabetes prevention efforts of successive Australian governments, and rates of diabetes have continued to rise. Results matter. Dogged commitment to failed policy approaches makes no sense; and accountability for these failures is long overdue.

Using law and regulation, governments can have a real impact at a population level, influencing patterns of consumption and tackling the environmental influences on poor diet, obesity and diabetes. No single intervention will be a silver bullet. Instead, we need a quiver of arrows — a selection of public policies that, in the right combination, can begin to reshape our food supply and food environments in a healthier direction. With an ageing population, new cases of diabetes are inevitable. But these numbers can be reduced if governments take prevention seriously, and are willing to challenge the status quo.

Medical negligence system must change

To the Editor: A recent medical negligence decision of the Queensland Court of Appeal in a case involving damages of $6.7 million1 further supports the suggestion that Australia should follow the example of six other nations and switch to a no-fault medical indemnity/insurance system.2 The case concerned a 49-year-old woman who became severely disabled (blind and deaf) as the result of cryptococcal meningitis. Key clinical questions that the Court of Appeal judges needed to decide included the subtleties of distinguishing neck stiffness suggestive of meningitis from that due to cervical spondylosis; recognition by a general practitioner of other symptoms suggesting the gradual onset of this rare type of meningitis; and the timeliness of their referring the patient to a specialist. This case illustrates the weaknesses of the fault-based medical negligence system, which focuses on assigning blame rather than promptly assisting the catastrophically injured. This approach usually involves inordinate delays, the lottery of the court process, and the waste of valuable resources.

The patient has already waited an unacceptable 7 years for a final decision. The woman’s illness occurred in 2008, but the first court decision (which went against her) was made in 2014, and the appeal decision was delivered in February 2015 (a decision that may be appealed further). To date, the complex medical evidence has been considered by four senior judges, with two finding for and two against the patient, suggesting some randomness and uncertainty in the decision-making processes. The $6.7 million awarded will not be all available to support the difficult life that lies ahead for the patient, as estimates of legal costs are typically in the vicinity of 50% of the awarded sum.2 To that waste of resources can be added the costs to the public purse incurred by the conduct of two court hearings.

We sympathise with the judges concerned, as it must be extremely difficult to make decisions on complex and contested clinical issues without specialist medical knowledge or clinical experience. In no-fault systems in other countries, such adverse outcomes — were causation or responsibility subject to dispute — would be determined by expert medical panels. Where questions about the professional performance of a doctor arise, they are referred to the relevant authority.

The Queensland decision makes very interesting reading for doctors. Those who study it should be moved to add their voices to a demand that a no-fault system of medical indemnity be carefully considered by our governments, and sooner rather than later. Such a system is necessary and inevitable — and was first recommended for Australia in 1974.2

[Correspondence] Who will implement WHO’s statement on public disclosure of trial results?

WHO’s statement1 issued in April, 2015, calling for public disclosure of all interventional trials—whether they have positive or negative findings and irrespective of date (present or past)—is laudable. By calling for the public disclosure of past trials, WHO’s statement goes further than existing policies or laws. Ben Goldacre’s commentary2 then effectively outlines how an audit system could serve as a powerful and practical means to put this statement1 into practice.

[Editorial] Will China make the great leap in tobacco control in 2015?

As the world’s largest producer and consumer of tobacco, China is becoming more aggressive in tobacco control this year. In April, China’s legislature adopted an amendment to the 21-year-old advertisement law to ban tobacco advertisements in mass media, public transport, and public spaces. From May 10, China’s consumption tax on the wholesale price of cigarettes was raised from 5% to 11%—the first increase since 2009. On June 1, Beijing’s smoke-free law—one of the toughest tobacco control regulations in China—will come into effect.

[Comment] Tobacco in China: taming the smoking dragon

Beijing’s air pollution makes news headlines around the world: hazy images of people’s faces shrouded in masks and iconic monuments obscured by smog are now as synonymous with the city as the monuments themselves. As expatriate residents of Beijing, our friends and family from home often ask us: “But living in Beijing, how do you breathe?” We hope the answer is more easily after June 1, 2015, when Beijing’s new smoke-free law will take effect.1 Although Beijing’s outdoor ambient air pollution routinely makes the news, indoor air pollution in the city—and across China—is often worse than outdoor air pollution.

The future of electronic cigarette growth depends on youth uptake

Simon Chapman discusses the phenomenon of “e-cigarettes” and the potential risks associated with their use

The New South Wales Government recently announced that it will outlaw the sale of electronic cigarettes (ECs) to minors. For the unfamiliar, ECs are battery-powered vaporisers that produce an aerosol or vapour containing nicotine and other substances, rather than cigarette smoke, which the user inhales. Parallel laws banning sales of tobacco products to children have existed in Australian states since 1900.1 These laws have long been ignored by many retailers2 and are poorly enforced. Prosecutions are rare, with the laws being largely symbolic gestures.

The tobacco industry long ago perfected pious expressions of public concern about juvenile smoking, while knowing how essential new cohorts of young smokers are to its very survival as an industry. Private acknowledgement of its own duplicity was hardly surprising:3

… this is one of the proposals that we shall initiate to show that we as an industry are doing something about discouraging young people to smoke. This of course is a phony way of showing sincerity as we all well know.

Equally, any manufacturer or retailer of ECs wanting to maximise sales appreciates the critical importance of building demand for these products in the young, as well as the social and political unacceptability of being candid about this. Today, an ever-diminishing 12.8% of Australians aged 14 years and over smoke on a daily basis.4 The record low uptake of smoking by the young is most responsible for this. The prospect of the industry reversing this inexorably ruinous exodus has been given a major boost with the arrival of ECs.

Tobacco companies’ investment in e-cigarettes

All tobacco transnationals have invested in ECs, with none desisting from their efforts to attack and dilute potent tobacco control policies nor announcing any phase-out of their combustible products. From this, we can conclude that the companies’ best hopes are for people to smoke and to use ECs or “vape”, not to use ECs instead of smoking. At a population level, this would be harm increasing, not reducing.5 Successful EC start-up companies are being bought up by tobacco companies, so the future of ECs is likely to be in lockstep with those companies’ ambitions, driven by their concern to preserve and grow immensely more profitable cigarette sales and to maximise the hours in a day when their products can be consumed.

Australian data on daily EC use are unavailable, with a 2013 national survey finding that 15.4% of smokers aged 14 years or over had used them at least once in the past 12 months,6 despite sales of nicotine liquid or “juice” being illegal here. In the United States, where ECs are freely available and heavily marketed, rising EC use by youths has now surpassed their falling cigarette smoking prevalence.7 EC advocates argue that there is thus no evidence for any gateway effect where nicotine initiation through vaping predicts uptake of smoking at higher rates than would occur without EC use. But smoking by young people has been in continual decline since 1994 in England8 and 1997 in the US9 and Australia,10 all well before the advent of ECs. Net transitioning to cigarettes or dual use with ECs in minors might be camouflaged by these broader declines. Future research will inform this important question.

Here though, a potential coalmine canary comes from a repeated Polish cross-sectional study, blithely dismissed as an outlier by vaping advocates. It found current use of ECs among Polish adolescents was dramatically higher in a 2013–14 sample than in a 2010–11 sample (29.9% v 5.5%) and that the prevalence of smoking tobacco cigarettes also increased (38% v 23.9%).11

The internet is awash with aggressive advertising for ECs,12 and the wide range of models available13 make them highly attractive to young people acutely hungry for ever-changing technology with edgy semiotics. A website sponsored by cigarette manufacturer Lorillard, which also sells Blu ECs, once stated knowingly:14

Kids may be particularly vulnerable to trying e-cigarettes due to an abundance of fun flavors such as cherry, vanilla, pina-colada and berry.

Many chemical flavourants in ECs have been approved for ingestion in foods, but not for inhalation15 up to 200 times a day, as occurs with ECs.16

The evidence relating to e-cigarette use

The volume and quality of the evidence for ECs being superior to unassisted quitting is small and often compromised by serious selection bias. EC users or “vapers” who have quit smoking understandably like to share their stories. But we have little population data on the extent to which ECs are causing prevarication about quitting, through erroneous beliefs that simply reducing smoking while dual using is harm reducing.17–19 One review concluded that real-world EC use is associated with significantly lower odds of quitting cigarettes.20

A recent systematic review of the evidence on the health risk profile of ECs concluded:21

Due to the many methodological problems, severe conflicts of interest, the relatively few and often small studies, the inconsistencies and contradictions in results, and the lack of long-term follow-up, no firm conclusions can be drawn on the safety of ECs …

Should the many hopes be realised that ECs do indeed pose minimal health risks and significantly assist in smoking cessation, future policy development in Australia will need to carefully consider how adult smokers wanting access to these products can best be facilitated without reversing the decades-long decline in youth smoking.

EC proponents argue that nicotine is almost benign in the doses obtained through vaping. However, there is growing evidence about the role of nicotine in carcinogenesis22 and the International Agency for Research on Cancer has recently prioritised the assessment of nicotine’s carcinogenicity.23

Pied Pipers in the vaping and tobacco industries have attempted to argue that concern about EC uptake in youth who would have never used any nicotine product is nothing but barely disguised moralism, akin to railing against innocuous caffeine. If they are right, those urging caution about soft touch regulation will have simply been wrong. But if the EC advocates are wrong, a less than benign genie with its pharmacological clutches around millions of young people may be extremely difficult to put back in the bottle.

Premium case of diminishing returns

It’s almost five years since it became mandatory for all doctors in Australia to have medical indemnity insurance.

I come from the low tax state, Queensland, where it was never essential to have indemnity insurance, though public Queensland doctors had always had discretionary cover for work performed at a public hospital.

The discretionary nature of that cover was tested at times, leading to a bitter dispute between Visiting Medical Officers and Queensland Health.

At that time, I was unimpressed by the disingenuous nature of Queensland Health’s insurance, and ventured onto talk-back radio to vent my spleen.

I was introduced as “Doctor Bruce from the Sunshine Coast”, lest my true identity become known and my employer discipline or dismiss me for daring to speak publicly.

My point back then was that if I wasn’t properly insured, then the patients weren’t covered either.

Next time I’ll have to choose a more discrete moniker because, after getting off the air, I had three friends call me to ask whether that was yours truly on the radio.

I do recall as a medical student being told to never practise without insurance, and it was always my routine to ask colleagues who they were insured with before entering into an on-call arrangement.

As more international medical graduates arrived from countries with differing degrees of litigation, this became a more interesting conversation.

One newly-arrived colleague told me that he was indemnified “by the Church” who owned the hospital that he worked at.

Could there be any better cover than that, I wondered!

It’s hard to imagine how anyone would even dream of practising as an un-insured doctor, but national legislation eventually mopped up the recalcitrant.

In the same breath, it doesn’t make sense to not insure your car, or does it?

Having owned a car that is 18 years old and worth about $3000 (if I’m lucky), I have dutifully forked out $750 every year for fully comprehensive cover.

At first that seemed cheap, when I considered that my car had cost me $68,000 in 1997.

But that $750 has seemed to become increasingly steep as my car drifts further south in value.

Unlike lawyers who have a four-figure excess on their indemnity policies, doctors don’t pay any excess at all, which will always be comforting when that inevitable writ arrives.

I’ve just done the maths with an on-line tool that tells me I have a 42 per cent chance of having a complaint made against me to a regulator in the next two years, which reminds me that I must practise even more defensively.

In my practice, that might mean refusing to see anyone where there might be any risk of self-harm or any possibility of a side-effect arising from the prescribing of complex medication regimes.

It’s a bit like owning a car but never driving it, just in case you have an accident.

Excesses in motor vehicle insurance can be steep. My current policy carries an excess of $600 for myself, and another $1300 if an un-listed driver younger than 18 years crashes my car.

That means I’m paying a premium of $750 a year for a car which, if written off, might return me a payout of $1100.

I’ve done my sums and decided to down-grade to a third party property policy for $150, and to keep the number of the wreckers in my glove box if I have a bingle.

Well done I thought.

There is, after all, no point in paying for insurance you don’t really need.

Now that brings me to reviewing my life insurance.

Do I really need it?

Safe motoring,

Doctor Clive Fraser

Tobacco-free generation legislation

The Tasmanian Public Health Amendment (Tobacco-free Generation) Bill 2014 is vital to improve health in Tasmania

Australia has led many initiatives against tobacco smoking, most recently cigarette plain packaging. Smoking costs this country some 20 000 lives annually, far more than alcohol, illicit drugs and road accidents combined, and indeed almost twice the deaths globally from natural disasters. The need for novel preventive supply-side tobacco legislation is paramount, and such a breakthrough now beckons.

In Golden holocaust, Robert Proctor highlights the insidious psychology used by the tobacco industry of telling adolescents that “kids don’t smoke”, so that they will do exactly that, just to appear adult.1 The tobacco-free generation (TFG) initiative seeks to undermine the rite-of-passage effect by progressively raising the minimum age at which retailers can legally sell people cigarettes.2 Tasmania is the first jurisdiction in the world to craft such mould-breaking legislation, although recent more limited moves in the United States raising the legal age to 21 years have proved highly successful.3

Tasmania’s smoking rates are considerably higher than the national figures, reflecting the state’s low socioeconomic status and historic lack of investment in evidence-based tobacco control strategies.4,5 Tasmania has experienced both the best and the worst of responses to the tobacco epidemic, the latter evident in an industry-orchestrated political corruption scandal in the 1970s, which brought down a government.6 However, more recently, the state has led some notable successes.7

Currently in Tasmania around 40% of younger men smoke, a proportion that has not fallen significantly for 10 years.8 Their outcomes in terms of mental illness, chronic disease and early death are dire, indeed worse than previously thought.9 The smoking burden to health services in economically challenged Tasmania is huge. In 2014, a novel Tasmanian initiative for adults banned tobacco in state prisons, and was introduced almost without incident. Thus, sensible and practical actions are feasible. The Tasmanian Legislative Council (upper house) has been a prime mover toward a smoking end game. Now, independent member of the Legislative Council Ivan Dean has introduced the Public Health Amendment (Tobacco-free Generation) Bill 2014, with strong public support and backing from a wide spectrum of health and professional organisations.

The TFG concept is straightforward. An under-18 law is presently in force; thus, already it is not permitted to sell tobacco to people born this century. That restriction will currently expire on 1 January 2018. However, with TFG legislation, the restriction will simply continue. Thus, retailers will never be allowed to sell cigarettes to anyone born this century, although the law will be reviewed after 3 and 5 years. Cigarettes will become a “so last century” phenomenon. With each passing year, there will be fewer slightly older smokers as role models and providers, and the “badge of coming of age” incentive (in Imperial Tobacco’s revealing phrase) diminishes in potency. Moreover, TFG legislation sends the important message that tobacco is too dangerous at any age; it could never now gain regulatory approval. Yet, because it is so addictive to young people it is not possible to remove tobacco from the market overnight without denying existing smokers. TFG legislation is the sensible and practical solution to this dilemma. Moreover, its thrust is on commercial agents who purvey tobacco, rather than on punishing their victims.

The TFG initiative has drawn intensive political lobbying by Imperial Tobacco, including closed meetings and meals with decisionmakers, in breach of article 5.3 of the World Health Organization Framework Convention on Tobacco Control (FCTC). The FCTC recognises the tobacco industry and its front organisations as “rogue” entities. So the legislation passes the “scream test”; the tobacco industry is really worried about this precedent. Some state politician objectors buy into Big Tobacco’s “nanny state” cliches, while others focus on allowing the disadvantaged to make their “own choices”. Such political correctness ignores the vulnerable young targets of industry marketing of its highly addictive product.

On 24 March 2015, the new legislation was debated in the Tasmanian Parliament. There was strong support, including from Attorney-General Vanessa Goodwin, for its aspiration, with a committee established to address workability. In fact, the proposal ticks all the political boxes: it is finance free; the machinery needed is in place and working well (98% of licensed tobacco retailers obey the law); 69% of the community and 88% of 18–29-year-olds support the TFG initiative;10 it fits Tasmania’s “clean and green” image; it will have some quick wins, especially among young pregnant women and their babies; and the longer-term gains for community health and government finances will be enormous.

The current Tasmanian Government has declared that it wants the state to be the healthiest in Australia in 10 years — to achieve that it needs the TFG legislation enacted. The rest of world will soon follow another bold Australian initiative against the global tobacco nightmare.11

[Comment] An alternative combination therapy for type 2 diabetes?

In The Lancet, Lawrence Blonde and colleagues1 present data from a randomised controlled trial of the latest glucagon-like peptide-1 (GLP-1) receptor agonist. Dulaglutide has few known discriminating features compared with the other long-acting GLP-1 receptor agonists on the market with full diurnal GLP-1 activity.2,3 Yet, in the present trial, Blonde and colleagues have turned things upside down and tested this drug as an antihyperglycaemic backbone to pre-prandial short-acting insulin and metformin treatment in patients with type 2 diabetes.

[Perspectives] Finding the sweet spot in medicine

Earlier this year, the disputatious Dallas billionaire Mark Cuban stirred controversy when he called for universal quarterly blood testing “for everything available…so you have a baseline of your own personal health”. Around the same time, the US state of Arizona passed a law allowing consumers to obtain any laboratory test directly from licensed laboratories—without a physician’s order. Theranos, a California company pioneering cheap, complete blood analysis with just a fingerstick, has advocated for such laws.