Nicotine wars continue…

E-cigs in China

A study by the Society for Research on Nicotine and Tobacco, and published in Oxford Academic, has found that awareness of e-cigarettes is high among Chinese middle school students, but use remains very low.

The study examined data from the Global Youth Tobacco Survey, which was completed by 155,117 middle school students (51.8 per cent boys, and 48.2 per cent girls) in China.

About 45 per cent of the middle school students had heard of e-cigarettes, but only 1.2 per cent reported using e-cigarettes in the last 30 days. Among those who had never smoked, e-cigarette users were more likely to intend to use a tobacco product in the next 12 months than non-users, and more likely to say that they would enjoy smoking a cigarette.

E-cigarette use was associated with previous experimentation with cigarette smoking, having noticed tobacco advertising in the past 30 days, having close friends who smoke, and thinking tobacco helps people feel more comfortable in social situations and makes young people look more attractive.

The study concluded that e-cigarette use among youth in China remains low, but awareness is high; e-cigarette use was associated with increased intentions to use tobacco; and enhanced prevention efforts are needed to target e-cigarette use among youth.

Chinese youths use e-cigarettes as a tobacco product rather than an aid to quitting. Among never-smokers, e-cigarette users were more likely to have intentions to use a tobacco product in the next 12 months, more likely to use a tobacco product offered by their best friends, and more likely to enjoy smoking a cigarette than non-users.

Plain packs in legal win

Australia has won a landmark ruling on tobacco plain packaging laws, with a panel of judges at the World Trade Organization (WTO) rejecting arguments brought by Cuba, Indonesia, Honduras, and the Dominican Republic against the legislation.

ABC News reported last month that Honduras says it will appeal the decision, claiming that there are errors in the ruling.

The WTO panel said Australia’s plain packaging laws contributed to improving public health by reducing use of and exposure to tobacco products, and rejected claims that alternative measures would be equally effective.

The win for Australia effectively gives a green light for other countries to roll out similar laws. It could also have implications for alcohol and junk food packaging.

Australia’s law goes much further than the advertising bans and graphic health warnings seen in other countries.

Introduced in December 2012 by the Gillard Government, the law bans logos and distinctive-coloured cigarette packaging in favour of drab olive packets that look more like military or prison issue, with brand names printed in small standardised fonts.

Studies have shown that the law is an effective measure in stopping people from smoking.

E-cigs in the USA

An Open Access article published in the British Medical Journal reports that, despite an apparent overall decrease in e-cigarette use in the USA, there are indications that JUUL, a sleekly designed e-cigarette that looks like a USB drive, is increasingly being used by youth and young adults.

However, the extent of JUUL’s growth and its marketing strategy have not been systematically examined.

A variety of data sources were used to examine JUUL retail sales in the USA and its marketing and promotion. Retail store scanner data were used to capture the retail sales of JUUL and other major e-cigarette brands for the period 2011–2017.

A list of JUUL-related keywords was used to identify JUUL-related tweets on Twitter; to identify JUUL-related posts, hashtags, and accounts on Instagram, and to identify JUUL-related videos on YouTube.

In the short three-year period 2015–2017, JUUL has transformed from a little-known brand with minimum sales into the largest retail e-cigarette brand in the USA, lifting sales of the entire e-cigarette category.

Its US$150 million retail sales in the last quarter of 2017 accounted for about 40 per cent of e-cigarette retail market share.

While marketing expenditures for JUUL were moderate, the sales growth of JUUL was accompanied by a variety of innovative, engaging, and wide-reaching campaigns on Twitter, Instagram, and YouTube, conducted by JUUL and its affiliated marketers.

The discrepancies between e-cigarette sales data and the prevalence of e-cigarette use from surveys highlight the challenges in tracking and understanding the use of new and emerging tobacco products.

In a rapidly changing media environment, where successful and influential marketing campaigns can be conducted on social media at little cost, marketing expenditures alone may not fully capture the influence, reach, and engagement of tobacco marketing.

Paris bans smoking in parks

France 24 International News reports that Paris city officials have introduced a new measure to ban smoking in six public parks across the city.

The measure is part of a four-month experiment by the city to reduce smoking in public spaces.

Instead of issuing a ticket or fine, park staff will be tasked with informing tobacco users that smoking is no longer allowed on the premises.

A 2013 study of similar bans in selected parks and beaches in Canada found that, although tobacco use significantly decreased after a 12-month observation period, no venue remained 100 per cent smoke-free.

[Correspondence] A Brexit miscalculation

I read with concern Nick Fahy and colleagues’ Health Policy (Nov 4, p 2110)1 about how Brexit might affect health and health-care services in the UK. I argue that their Health Policy has a logical flaw and a potential miscalculation (appendix). Fahy and colleagues’ key anti-Brexit argument is that EU membership, protective legalities from the Court of Justice of the EU (CJEU), and free movement, tax, and childcare rights are essential to attract and retain much of the UK’s National Health Service (NHS) workforce.

[Perspectives] Making peace with our faulty hearts

In Margaret Atwood’s Two Headed Poems (1978), two contrasting voices are heard. “The Woman Who Could Not Live With Her Faulty Heart” focuses on a woman who describes her own heart as a flawed and arrhythmic fish mouth yet speaks of tenderly singing to it. “The Woman Makes Peace With Her Faulty Heart” ends with a description of a precarious truce—a conciliation of sorts, as the woman imagines herself and her heart as distrustful co-conspirators.

[Correspondence] Can Shoulder Arthroscopy Work? (CSAW) trial

David Beard and colleagues, authors of the Can Shoulder Arthroscopy Work? (CSAW) study,1 should be commended for completing such a large scale multi-centre randomised controlled surgical trial. However, we are concerned that flaws in the study design compromise the value of its results.

WMA condemns complicity of doctors in Iranian executions

The World Medical Association has condemned state-affiliated doctors in Iran for helping to facilitate the execution of young prisoners in that country.

The strong rebuke follows the recent execution in June of 19-year-old Abolfazl Chezani Sharahi, who was sentenced to death in 2014.

The WMA says his sentence was issued based on an official medical opinion by the Legal Medicine Organisation in Iran, stating that he was mentally mature at the age of 14 when the crime of which he was convicted took place.

The WMA said such complicity of medical professionals is totally unacceptable.

WMA President Dr Yoshitake Yokokura and WMA Chair Dr Ardis Hoven wrote a stern letter jointly addressed to the Office of the Supreme Leader, Ayatollah Sayed ‘Ali Khamenei, to President Hassan Rouhani, and to the Head of the Judiciary Ayatollah Sadegh Larijani.

The letter stated that the involvement of physicians in such a way that ensures the execution of prisoners is in direct violation of international law and their duties as physicians, and is both unethical and illegal.

“Further, physicians have a clear duty to avoid any involvement in torture and other cruel, inhuman or degrading punishment, including the death penalty,” they wrote.

“This is specified in the World Medical Association’s policies and the International Code of Medical Ethics. Doctors who provide ‘maturity’ assessments that are then used by courts to issue death sentences, as do physicians affiliated with the Legal Medicine Organisation, are facilitating the execution of individuals.”

According to Amnesty International, Abolfazl Chezani Sharahi was the fourth individual since the beginning of 2018 to be executed after being convicted of crime committed when under the age of 18. There are at least another 85 juvenile offenders who currently remain on death row based on medical maturity assessments.

“Iran has ratified the Convention on the Rights of the Child, which absolutely prohibits the use of the death penalty against people who were below the age of 18 at the time of the crime they are convicted of committing,” the WMA letter states.

“We urge Iran’s authorities to amend the Islamic Penal Code so as to comply with international human rights laws by abolishing the use of the death penalty for crimes committed by people below the age of 18 in all circumstances.

“The World Medical Association calls for Iranian authorities to acknowledge a physician’s duty to do no harm and to guarantee that physicians are complying with the fundamental principles of medical ethics by prohibiting physician involvement in sentencing individuals to the death penalty or in the preparation, facilitation, or participation in executions.”

In a further letter to Dr Iradj Fazel, President of the Iranian Medical Council, the WMA calls on the Council to publicly acknowledge a physician’s duty to do no harm and to condemn firmly the medical maturity assessments provided by the Legal Medicine Organisation.

“The World Medical Association urges the Iranian Medical Council to speak out in support of the fundamental principles of medical ethics, and to investigate and sanction any breach of these principles by association members,” the WMA said.

CHRIS JOHNSON

Press Club speech calls for better health policy decisions

AMA President Dr Tony Bartone has used an address to the National Press Club to salute Australia’s general practitioners, and to call for significant reform of primary care.

In his first major speech since being elected in May, Dr Bartone said the challenge of transforming general practice was severely underestimated by the nation’s policy makers.

He said the AMA has a plan, but it is one which will require upfront and meaningful new investment, in anticipation of long-term savings in downstream health costs.

Delivering the nationally televised address during Family Doctor Week in July, Dr Bartone said his overarching concern as a GP himself has always been the patient journey and ensuring that people get the right care at the right time in the right place by the right practitioner.

“The priorities for me are always universal access to care, and affordability,” he said.

“GPs of Australia, I salute you. We all salute you. Your hard work and dedication is highly valued. The AMA will always support you and promote you.”

But he described there being “something really crook” about how GPs have been treated by successive Governments.

“They have paid lip service to the critical role GPs play in our health system, often borne out of ignorance and often in a misguided attempt to control costs,” Dr Bartone said.

“General practice has been the target of continual funding cuts over many years. These cuts have systematically eaten away at the capacity of general practice to deliver the highest quality care for our patients. They threaten the viability of many practices.”

The AMA President said Australia has seen too many poor decisions and mistakes in health policy.

General practice must be put front and centre in future health policy development.

“Despite the Government’s best intentions – and lots of goodwill within the profession – the Health Care Homes trial and implementation failed to win the support of GPs or patients,” Dr Bartone said.

“Instead of real investment, the trial largely shifted existing buckets of money around. It has fallen well short of its practice enrolment targets, and it looks like only a small fraction of the targeted 65,000 patients will sign up.

“But general practice still needs transformation and rejuvenation to meet growing patient demand and to keep GPs working in general practice.”

Dr Bartone outlined the AMA’s plan for general practice, which included in the short term:

significant changes to chronic disease funding, including a process that strengthens the relationship between a patient and their usual GP, and encourages continuity of care;
cutting the bureaucracy that makes it difficult for GPs to refer patients to allied health services;
formal recognition in GP funding arrangements of the significant non-face-to-face workload involved in caring for patients with complex and chronic disease;
additional funding to support enhanced care coordination for those patients with chronic disease who are at risk of unplanned hospital admission – a similar model to the Coordinated Veterans Care Program funded by the Department of Veterans Affairs;
a properly funded Quality Improvement Incentive under the Practice Incentive Program – the PIP;
changes to Medicare that improve access to after-hours GP care through a patient’s usual general practice;
support for patients with chronic wounds to access best practice wound care through their general practice;
better access to GP care for patients in residential aged care; and
annual indexation of current block funding streams that have not changed for many years – including those that provide funding to support the employment of nursing and allied health professionals in general practice.

“In the longer term, we need to look at moving to a more blended model of funding for general practice,” he said.

“While retaining our proven fee-for-service model at its core, the new funding model must have an increased emphasis on other funding streams, which are designed to support a high performing primary care system.

“This will allow for increasing the capability and improving the infrastructure supporting general practice to allow it to become the real engine room of our health system.

“It is about scaling up our GP-led patient-centred multidisciplinary practice teams to better provide the envelope of health care around the patient in their journey through the health system.”

On public hospitals, Dr Bartone said a better plan was needed.

Instead of helping the hospitals improve safety and quality, Governments decided to financially punish hospitals for poor safety events.

“There is no evidence to show that financial penalties work,” he said.

“Public hospitals are a critical part of our health system. They are highly visible. They are greatly loved institutions in the community. They are vote changers.

“The doctors, nurses, and other staff who work in our public hospitals are some of the most skilled in the world…

“Despite their importance, and despite our reliance on our hospitals to save lives and improve quality of life, they have been chronically underfunded for too long.

“Between 2010-11 and 2015-16, average annual real growth in Federal Government recurrent funding for public hospitals has been virtually stagnant – a mere 2.8 per cent.

“The AMA welcomes that, between 2014-15 and 2015-16, the Federal Government boosted its recurrent public hospital expenditure by 8.4 per cent.

“But a one-off modest boost from a very low base is not enough.”

Dr Bartone called on the major political parties to boost funding for public hospitals beyond that which is outlined in the next agreement.

There must be a plan to lift public hospitals out of their current funding crisis, which is putting doctors and patients at risk.

And Governments must stop penalising hospitals for adverse patient safety events, he said.

The wide-ranging Press Club address also went to aged care, with Dr Bartone describing it as “one of the highest profile segments of the health system – but for all the wrong reasons”.

He added that aged care was now emerging as an area in need of significant reform as the population ages and lives longer.

“An increase in funding for GP visits to aged care facilities would result in many savings, including from reduced ambulance transfers to hospital emergency departments,” he said.

“Changes to after-hours care remuneration must consider services that are currently provided under ‘urgent’ item numbers to patients in aged care facilities.

“We also need to ensure that the critical role that nurses play in caring for older Australians is recognised in those facilities.”

On private health insurance, the President said affordability meant very little without value, and that the Government knows the issue is at crisis point.

“Australians want reasonable and simple things from their insurance,” he said.

“They want coverage. They want a choice of the practitioner, and a choice of the hospital. They want treatment when they need it.

“We can’t have patients finding out they aren’t covered after the event, or when they require treatment and it’s all too late…

“Australians do not support a US-style managed care health system. Neither does the AMA. One area we are disappointed with in the recent announcements is pregnancy cover.

“It does not make sense to us, as clinicians, to have pregnancy cover in a higher level of insurance only.

“Many pregnancies are unplanned – meaning people are caught out underinsured when pregnancy is restricted to high-end policies.

“Pregnancy is a major reason that the younger population considers taking up private health insurance.

“They are less likely to be able to afford the higher-level policies. We need to make sure it is within reach.

“And having female reproductive services at a different level to pregnancy coverage is, to us, problematic, and will leave a lot of people caught out.

“There will be much more to talk about as the private health reforms are finalised and bedded down.”

Dr Bartone’s full address to the National Press Club of Australia can be found at: media/dr-tony-bartone-speech-national-press-club

Whatever it takes to clear up ambiguity over My Health Record privacy concerns

During the Q&A segment of his National Press Club address, AMA President Dr Tony Bartone said promised a face-to-face meeting with Health Minister Greg Hunt to gain assurances the Government will take further steps to ensure the privacy and security of the My Health Record.

Dr Bartone said there had been a groundswell of concern from AMA members, the broader medical profession, and the public about the 2012 legislation framing the My Health Record, particularly Section 70, which deals with the disclosure of health information for law enforcement purposes.

“The priority of the AMA at all times has been to support the My Health Record, and its precursors, for the important clinical benefits it will deliver to doctors, patients, and the health system,” Dr Bartone said.

“The AMA has always been protective and vigilant about the privacy of the doctor-patient relationship, and this should not be affected by the My Health Record.

“Given the public debate, I support calls for the Government to provide solid guarantees about the long-term security of the privacy of the My Health Record.

“I will do whatever it takes to ensure that the security concerns are raised and cleared up as a matter of urgency.

“This may involve examining the legislation.”

Mr Hunt contacted Dr Bartone directly after the Press Club to set up a meeting to discuss all aspects of the rollout of the My Health Record.

CHRIS JOHNSON

More than just writing a script

Family Doctor Week
Western Australia – Dr Simon Torvaldsen

Dr Simon Torvaldsen is Chair of the AMA WA Council of General Practice, and he is also one of the owners of Third Avenue Surgery in Mt Lawley, just a few kilometres north-east of Perth’s city centre.

In an area that overall has a somewhat middle-class flavour, his patient demographic is quite mixed.

“It’s mainly mortgage belt and professionals – I have quite a few doctor patients – but also a significant number of elderly, less wealthy patients who have lived in the area for many years, plus some tenants of cheap unit accommodation,” he said.

“We are privately billing, although we bulk bill most pensioners. Our standard appointment is 15 minutes and most doctors see four patients per hour or somewhat less, as we do not discourage longer appointments and have a focus on quality care and patient satisfaction.”

Third Avenue Surgery has 10 consulting rooms.

“The work is so varied. From parents worried about their small children with fevers, to depressed and anxious teenagers,” Dr Torvaldsen said.

“My oldest patient died recently aged 104. I managed the sudden and somewhat unexpected deterioration, counselled family, provided palliative care, arranged nursing support and she passed away peacefully at her low-care aged care facility. It avoided hospital admission, which would have been expensive, futile, and most likely a poor quality, undignified end to a long and worthwhile life.

“Also recently, I had to gently nag an ophthalmologist who came in with wax impacted in his ear, jammed in by his attempts to remove it using various eye surgery instruments. Fortunately, it was easily removed by me. We doctors are not good at self-care, and general practice is a specialty in its own right. He will get me to do it next time.

“It is certainly not all coughs, colds and minor illnesses. Although we see plenty of that and the real skill is in picking the more serious conditions from the minor illnesses, especially as they often present to us in the very early stages.

“So much of what we do in general practice is about ensuring good communication and good understanding. It is not enough to just write the script.

“The reward is in the long-term care and seeing people through all sorts of things, as well as seeing the results of our medical care and the difference we make to people’s lives.

“We sometimes forget the degree of trust they put in us. And for me, the sheer variety keeps the day interesting and the brain nimble.”

CHRIS JOHNSON

AHPRA complaint story leads to doctor’s petition

Last month we wrote about AHPRA’s new policy with regards to its publicly accessible register of medical practitioners. This register will now link individual entries to court and tribunal rulings on complaints about doctors – even if the doctor in question was found to have done nothing wrong.

Our story was read by Victorian radiologist Dr Steel Scott, who was prompted to set up a petition to call for a stop to linking unfounded complaints on the AHPRA register. The petition has clearly hit a nerve with Australia’s medical community, with well over 11,000 people signing the petition at time of this publication.

In an update, Dr Scott says he has sent letters to AMA Victoria, the RACGP, Avant Mutual and to Federal Health Minister Greg Hunt. AMA Victoria has referred his letter to the national office, and the RACGP has responded to say it is preparing a communication to AHPRA to raise concerns on the issue. Avant says it supports the petition and further action, while Greg Hunt and AHPRA have yet to comment.

Dr Scott says that linking to rulings with no adverse findings is effectively tarring the innocent with the same brush as those who have been found guilty.

“With the dramatic statistics relating to medical practitioner mental health and suicidal ideology, and having first hand worked with colleagues who have sadly committed suicide due to the stress of our profession, it is clear that we need to help protect our fellow practitioners reputations and mental well-being,” Dr Scott writes.

“As such, it is crucial that we protect our colleagues from having the negative stigma, stress and violation of practitioner privacy, which will result from having our innocent colleagues tribunal results listed in perpetuity.”

But Dr Scott stresses that he supports adverse tribunal results being documented and registered against a guilty practitioner’s name, as this is in the best interests of patient safety.

The petition has prompted hundreds of written responses.

“There are already supports being put in place to assist doctors with the mental stress/anguish of having an AHPRA complaint put against them and yet here we are having to fight for the unfounded complaints to be stricken from our registration record,” writes one doctor. “How many doctor suicides does the board and AHPRA need to take this seriously? As a governing body for doctors there seems to be no advocacy for the rights of the individual doctor.”

Another writes: “This means anyone unlucky enough to come across an unreasonable patient would have his/her name stuck with mud. For such a complicated industry that requires extensive knowledge that hardly seems fair or helpful for anyone. A perfectly capable doctor might be avoided for all the wrong reasons.”

You can read our original story here, and access Dr Scott’s petition here.

California takes an unhealthy step back

California has passed a 12-year ban on any city imposing a sugar tax on soft drinks.

The bizarre and retrograde move has sparked a backlash from healthcare groups across the State, who are now campaigning for a sugar levy to form a major platform of the 2020 election battleground.

The health groups want to see a soda tax initiative on the ballot that will help pay for public health programs. They are insisting the initiative should also enshrine in the State’s constitution the right of any local government to impose their own sugar taxes.

Chief executive of the California Medical Association Dustin Corcoran, who is behind the initiative, described sugar-induced obesity as a health crisis that needed to be urgently addresses.

“This initiative gives voters a real opportunity to do that,” he said.

“Big soda has been a major contributor to the alarming rise in obesity and diabetes.”

The proposal is for a two-cents-per-fluid-ounce tax, which would translate to an extra 24 cents onto the cost of a 12-ounce can of soda, or an extra $1.34 for a two-litre bottle of soda.

It could raise up to $1.9 billion annually.

The battle between healthcare groups and the soft drink industry is now in full flight.

The American Heart Association has vowed to have the new law rolled back.

“We were disappointed that the American Beverage Association and their member companies went to such great lengths to take away the right of Californians to vote for better health,” chief executive Nancy Brown said.

“We will be relentless in our work with communities across the State to improve public health through a statewide tax, and to restore the rights of Californians to vote for what they believe best supports health in their State.”

Health professionals are describing the antics that led California legislators to hand soda companies a 12-year reprieve as “extortion” from the powerful soda industry.

And they have promised to rain on the parade.

A statement from the California Dental Association said: “Big Soda may have won a cynical short-term victory but, for the sake of our children’s health, we cannot and will not allow them to undermine California’s long-term commitment to health care and disease prevention.”

CHRIS JOHNSON

[Comment] Retraction—Tracheobronchial transplantation with a stem-cell-seeded bioartificial nanocomposite: a proof-of-concept study

Following our Expression of Concern1 we have now received further information about the conduct of the study by Philipp Jungebluth and colleagues.2 In letters to The Lancet, the President of the Karolinska Institute has sent the results and conclusions of the final investigation that has identified serious flaws in the conduct and reporting of this study. The report concludes there was scientific and ethical misconduct and requests retraction of the paper. The Lancet is therefore retracting this research article from the scientific record.