Evidence valued and used by health promotion practitioners.

The use of evidence has become a foundational part of health promotion practice. Although there is a general consensus that adopting an evidence-based approach is necessary for practice, disagreement remains about what types of evidence practitioners should use to guide their work. An empirical understanding of how practitioners conceptualize and use evidence has been lacking in the literature. In this article, we explore (i) practitioners' purposes for using evidence, (ii) types of evidence they valued, and (iii) qualities that made evidence useful for practice. 58 semi-structured interviews and 250 h of participant and non-participant observation were conducted with 54 health promotion practitioners working across New South Wales, Australia. Interviews were recorded and transcribed, and field notes were written during the observations; these were analysed using Grounded Theory methods. Practitioners used evidence for practical and strategic purposes, and valued four different types of evidence according to their relevance and usefulness for these purposes. Practitioners' ideal evidence was generated within their practice settings, and met both substantive and procedural evaluation criteria. We argue that due to the complex nature of their work, practitioners rely on a diverse range of evidence and require organizational structures that will support them in doing so.

Relational conceptions of paternalism: a way to rebut nanny-state accusations and evaluate public health interventions.

OBJECTIVES: 'Nanny-state' accusations can function as powerful rhetorical weapons against interventions intended to promote public health. Public health advocates often lack effective rebuttals to these criticisms. Nanny-state accusations are largely accusations of paternalism. They conjure up emotive concern about undue governmental interference undermining peoples' autonomy. But autonomy can be understood in various ways. We outline three main conceptions of autonomy, argue that these that can underpin three different conceptions of paternalism, and consider implications for responses to nanny-state accusations and the assessment of public health interventions. STUDY DESIGN AND METHODS: Detailed conceptual analysis. RESULTS: The conceptions of paternalism implicit in nanny-state accusations generally depend on libertarian conceptions of autonomy. These reflect unrealistic views of personal independence and do not discriminate sufficiently between trivial and important freedoms. Decisional conceptions of paternalism, like their underlying decisional conceptions of autonomy, have limited applicability in public health contexts. Relational conceptions of paternalism incorporate relational conceptions of autonomy, so recognize that personal autonomy depends on socially shaped skills, self-identities and self-evaluations as well as externally structured opportunities. They encourage attention to the various ways that social interactions and relationships, including disrespect, stigmatization and oppression, can undermine potential for autonomy. While nanny-state accusations target any interference with negative freedom, however trivial, relational conceptions direct concerns to those infringements of negative freedom, or absences of positive freedom, serious enough to undermine self-determination, self-governance and/or self-authorization. CONCLUSION: Relational conceptions of autonomy and paternalism offer public health policymakers and practitioners a means for rebutting nanny-state accusations, and can support more nuanced and more appropriately demanding appraisals of public health interventions.

Smoking mull: a grounded theory model on the dynamics of combined tobacco and cannabis use among adult men.

ISSUE ADDRESSED: Australians' use of cannabis has been increasing. Over a third of Australians (35.4%) have used cannabis at some time in their lives and 10.3% are recent users. Almost two-thirds of cannabis users combine cannabis with tobacco. The aim of this study was to understand the process of mulling - smoking tobacco and cannabis together - using a grounded theory approach. METHODS: Twenty-one in-depth semistructured interviews were conducted with men aged 25-34 and living on the North Coast of New South Wales. Interviews explored participants' smoking practices, histories and cessation attempts. RESULTS: A model describing mulling behaviour and the dynamics of smoking cannabis and tobacco was developed. It provides an explanatory framework that demonstrates the flexibility in smoking practices, including substance substitution - participants changed the type of cannabis they smoked, the amount of tobacco they mixed with it and the devices they used to smoke according to the situations they were in and the effects sought. CONCLUSION: Understanding these dynamic smoking practices and the importance of situations and effects, as well as the specific role of tobacco in mulling, may allow health workers to design more relevant and appropriate interventions. SO WHAT? Combining tobacco with cannabis is the most common way of smoking cannabis in Australia. However, tobacco cessation programmes rarely address cannabis use. Further research to develop evidence-based approaches for mull use would improve cessation outcomes.

Priority allocation of pandemic influenza vaccines in Australia - Recommendations of 3 community juries.

BACKGROUND: Pandemic planning has historically been oriented to respond to an influenza virus, with vaccination strategy being a key focus. As the current COVID-19 pandemic plays out, the Australian government is closely monitoring progress towards development of SARS-CoV2 vaccines as a definitive intervention. However, as in any pandemic, initial supply will likely be exceeded by demand due to limited manufacturing output. METHODS: We convened community juries in three Australian locations in 2019 to assess public acceptability and perceived legitimacy of influenza pandemic vaccination distribution strategies. Preparatory work included literature reviews on pandemic vaccine allocation strategies and on vaccine allocation ethics, and simulation modelling studies. We assumed vaccine would be provided to predefined priority groups. Jurors were then asked to recommend one of two strategies for distributing remaining early doses of vaccine: directly vaccinate people at higher risk of adverse outcomes from influenza; or indirectly protect the general population by vaccinating primary school students, who are most likely to spread infection. RESULTS: Thirty-four participants of diverse backgrounds and ages were recruited through random digit dialling and topic-blinded social media advertising. Juries heard evidence and arguments supporting different vaccine distribution strategies, and questioned expert presenters. All three community juries supported prioritising school children for influenza vaccination (aiming for indirect protection), one by 10-2 majority and two by consensus. Justifications included that indirect protection benefits more people and is likely to be more publicly acceptable. CONCLUSIONS: In the context of an influenza pandemic, informed citizens were not opposed to prioritising groups at higher risks of adverse outcomes, but if resources and epidemiological conditions allow, achieving population benefits should be a strategic priority. These insights may inform future SARS-CoV-2 vaccination strategies.

Effect of prolonged catecholamine infusion on immunoregulatory function: implications in congestive heart failure.

OBJECTIVES: This study sought to characterize the effects of prolonged catecholamine infusion on immunoregulatory cell traffic and activation. BACKGROUND: Immunoregulation has been shown to be partially controlled by the sympathetic nervous system. Although short-term elevation of catecholamine levels is known to alter immunoregulatory cell traffic and activation, the effects of prolonged heightened sympathetic nervous system activity have not adequately been studied. We believe that the alterations in immune function seen in patients with congestive heart failure are linked to a prolonged elevation of circulating catecholamine levels. METHODS: To characterize the effects of prolonged elevation of catecholamine levels, rats received 4 weeks of constant infusion of epinephrine or norepinephrine through implanted osmotic minipumps. Peripheral and splenic leukocyte subsets, T cell proliferation and interleukin-2 receptor expression were quantified. Antibody production to the novel antigen keyhole limpet hemocyanin was assessed over the 4-week treatment period. RESULTS: Both epinephrine and norepinephrine caused significant splenic atrophy and cardiac hypertrophy; both were blocked by propranolol. Epinephrine induced lymphocytosis; both catecholamines caused an increase in natural killer cells. In the spleen, both epinephrine and norepinephrine led to a dose-dependent decrease in total T cells, suppressor/cytotoxic T cells and natural killer cells and a significant increase in B cells. Epinephrine at the low dose enhanced mitogen-induced proliferation and interleukin-2 receptor expression. Norepinephrine at the low dose appeared to diminish proliferation. Epinephrine tended to inhibit IgG antibody production, whereas norepinephrine had no effect. CONCLUSIONS: The results of our study indicate that prolonged elevation of catecholamine levels alters immune cell proliferation and differentiation. These alterations differ greatly from those induced by short-term stimulation but, for the most part, parallel those found in patients with congestive heart failure. We postulate that the shifts in immunoregulatory cell type and function seen in patients with congestive heart failure are due, in part, to longstanding increases in circulating catecholamine levels and may play an important role in the pathogenesis and progression of disease.

Tobacco document research reporting.

OBJECTIVE: To understand the use of internal tobacco industry documents in the peer reviewed health literature. DESIGN: Interpretive analysis of published research. SAMPLE: 173 papers indexed in Medline between 1995 and 2004 that cited tobacco industry documents. ANALYSIS: Information about year published, journal and author, and a set of codes relating to methods reporting, were managed in N*Vivo. This coding formed the basis of an interpretation of tobacco document research reporting. RESULTS: Two types of papers were identified. The first used tobacco documents as the primary data source (A-papers). The second was dedicated to another purpose but cited a small number of documents (B-papers). In B-papers documents were used either to provide a specific example or to support an expansive contention. A-papers contained information about purpose, sources, searching, analysis, and limitations that differed by author and journal and over time. A-papers had no clear methodological context, but used words from three major traditions--interpretive research, positivist research, and history--to describe analysis. INTERPRETATION: A descriptive mainstream form of tobacco document reporting is proposed, initially typical but decreasing, and a continuum of positioning of the researcher, from conduit to constructor. Reporting practices, particularly from experienced researchers, appeared to evolve towards researcher as constructor, with later papers showing more complex purposes, diverse sources, and detail of searching and analysis. Tobacco document research could learn from existing research traditions: a model for planning and evaluating tobacco document research is presented.

Increased production of antigen-specific immunoglobulins G and M following in vivo treatment with the medicinal plants Echinacea angustifolia and Hydrastis canadensis.

A number of immunomodulatory effects have been attributed to the medicinal plants Echinacea angustifolia and Goldenseal (Hydrastis canadensis); however, little is known about whether treatment with these plants can enhance antigen-specific immunity. We investigated the antigen-specific in vivo immunomodulatory potential of continuous treatment with Echinacea and Goldenseal root extract over a period of 6 weeks using rats that were injected with the novel antigen keyhole limpet hemocyanin (KLH) and re-exposed to KLH after the initial exposure. Immunoglobulin production was monitored via ELISA continuously over a period of 6 weeks. The Echinacea-treated group showed a significant augmentation of their primary and secondary IgG response to the antigen, whereas the Goldenseal-treated group showed an increase in the primary IgM response during the first 2 weeks of treatment. Our results suggest that medicinal plants like Echinacea or Goldenseal may enhance immune function by increasing antigen-specific immunoglobulin production.

Gamma-Aminobutyric acid (GABA) transport across human intestinal epithelial (Caco-2) cell monolayers.

1. Transintestinal absorption of gamma-aminobutyric acid (GABA) via a pH-dependent mechanism is demonstrated in the model human intestinal epithelial cell line Caco-2. 2. Experiments with BCECF [2',7',-bis(2-carboxyethyl)-5(6)- carboxyfluorescein]-loaded Caco-2 cells demonstrate that GABA transport across the apical membrane is coupled to proton flow into the cell. 3. Short-circuit current (ISC) measurements using Caco-2 cell monolayers under voltage-clamped conditions demonstrate that pH-dependent GABA transport is a rheogenic process even in the absence of extracellular Na+, consistent with H+/GABA symport. 4. A range of GABA analogues were tested for their abilities to: (a) inhibit pH-dependent [3H]GABA uptake across the apical membrane; (b) stimulate H+ flow across the apical surface of BCECF-loaded Caco-2 cell monolayers; (c) increase inward ISC across voltage-clamped Caco-2 cell monolayers. 5. Nipecotic acid, isonipecotic acid, D,L-beta-aminobutyric acid, and 3-amino-1-propanesulphonic acid each caused a marked acidification of intracellular pH and an increase in ISC when superfused at the apical surface of Caco-2 cell monolayers. In contrast L-alpha-amino-n-butyric acid failed to induce proton flow or ISC. The ability of these compounds to induce proton or current flow across the apical surface of this intestinal epithelium was closely related to the relative inhibitory effects on [3H]GABA uptake. 6. These observations demonstrate H+/GABA symport and suggest that this transport mechanism may be accessible as a route for oral absorption of therapeutically-useful GABA analogues.

A genetic study of platelet phenolsulphotransferase activity in normal and schizophrenic twins.

In a series of 19 identical and 16 fraternal twin pairs, the activities of the two forms of the enzyme, phenolsulphotransferase, denominated M and P, were investigated in blood platelets. Both were shown to be under a high degree of genetic control. No differences were found between 11 schizophrenic patients from discordant twin pairs, compared with their well cotwins and 12 male and female volunteer twin pairs, for either form of the enzyme.

Platelet monoamine oxidase and phenolsulphotransferase M and P in cancer.

Phenolsulphotransferase and monoamine oxidase inactivate a wide range of dietary and endogenous phenols/monoamines by sulphoconjugation and oxidative deamination respectively. In this study, both enzymes were measured in platelets from cancer patients and controls. Of the two variants of phenolsulphotransferase, activity of the P form was normal in all groups. Activity of the M form was, however, significantly less than control values in patients with cancer of the rectum and bowel but not in other cancer patient groups. If this finding reflects enzyme activity elsewhere in the body and is not merely a manifestation of an abnormal platelet population, the deficit could expose affected subjects to the action of potentially carcinogenic dietary phenols. Platelet monoamine oxidase activity was significantly raised in the cancer group as a whole, and in all sub-types investigated apart from breast cancer. The increase in the cancer group as a whole was independent of sex, age, drugs, radiotherapy, smoking or platelet count. Its mechanism and significance are unknown but there may be links with the patients' psychiatric state.

Human platelet phenolsulphotransferase: separate control of the two forms and activity range in depressive illness.

Human phenolsulphotransferase exists in two forms, one specific for dopamine and tyramine, termed "M" and one for phenol, termed "P". In this study we have shown that these two forms are under separate control by correlating their activities in different individuals using different substrates. There was a highly significant correlation between the activities with dopamine, p-tyramine and 4-hydroxy-3-methoxyphenylglycol, but no significant correlation between the activities with any of these three substrates and that with phenol. Neither age nor sex had any effect on platelet phenolsulphotransferase "M" or "P" activities. Nor was there any significant correlation between platelet monoamine oxidase activity and phenolsulphotransferase "M" or "P" activities. Human platelet phenolsulphotransferase "M" was found to be unstable at temperatures above 35 degree C and it lost substantial activity when stored deep frozen in isotonic saline. However it was stable for up to four months when stored in isotonic sucrose or 10 mmol/l phosphate buffer (pH 7.4). Phenolsulphotransferase "M" amd "P" activities were measured in platelets from depressed patients of a diagnostic type characterized by low output of tyramine-O-sulphate after oral tyramine loading but their enzyme activities were not different from those in two control groups.

Decreased urinary output of conjugated tyramine is associated with lifetime vulnerability to depressive illness.

In a group of normal pregnant women whose psychiatric histories were unknown, those with the lowest output of urinary tyramine (free plus conjugated) after an oral tyramine load had a significantly higher lifetime incidence of depressive illness compared with those with the highest output. as none of the women were suffering from depression at the time of tyramine loading, it seems likely that this decreased excretion of tyramine is associated in some way with vulnerability to depressive illness, whether puerperal or nonpuerperal.

Cooperation and control: the Tobacco Institute of Australia.

OBJECTIVE: To describe the history of the Tobacco Institute of Australia (TIA), particularly regarding connections between local and international cigarette manufacturers and tobacco organisations. DESIGN: Analysis of 4541 industry documents from the world wide web. RESULTS: From 1978 to 1983 the TIA built strong international networks via ICOSI/INFOTAB and the US Tobacco Institute, and defended existing industry freedoms. 1983 to 1989 was the TIA's aggressive heyday, led primarily by John Dollisson. From 1989 to 1994, following the decision in Australian Federation of Consumer Organisations vs TIA, local and international industry lawyers assumed control. Between 1994 and 1997 a brief revival led into decline and then dissolution, as previously common ground became commercially competitive issues for the manufacturers. The TIA facilitated interconnectedness: between local manufacturers; via individuals who played multiple roles; to international tobacco organisations; through the industry's local and international counsel; and by acting as a conduit for information. CONCLUSION: The local tobacco industry was comprehensively informed on issues including smoking and health, and connected to the international industry, via the TIA. The manufacturers were closely involved in the TIA's activities, and cooperated through the TIA in a manner detrimental to Australian consumers. The TIA's conduct was the responsibility of local and international manufacturers and their counsel.

From legitimate consumers to public relations pawns: the tobacco industry and young Australians.

OBJECTIVE: To document the Australian tobacco industry's activities regarding youth smoking to support tobacco control. METHOD: 492 industry documents from primary and secondary websites were abstracted and analysed. RESULTS: Australian legislation and rhetoric on youth and tobacco has changed dramatically over the last 50 years, from an unproblematic association of teenagers and smoking in the 1960s, through the industry's aggressive attacks and denials in the 1980s, to the 1990s, when industry became newly compliant with "societal expectations" and youth became a dominant bargaining issue in the industry's public relations strategy. The industry's current policy is to simultaneously blame others for underage smoking, frame the industry as socially responsible via voluntary marketing codes, youth access programmes, and school education, and market actively to young adults. CONCLUSIONS: The arbitrary distinction between 17 and 18 year olds is, particularly in Australia's dark market, a liability for tobacco control and an opportunity for the industry, which is attempting to claim the high moral ground traditionally occupied by tobacco control on the youth issue. The current review of Australia's Tobacco Advertising Prohibition Act of 1992 should prohibit all forms of industry communication targeting young people, including retail access and schools programmes and below-the-line marketing. Tobacco control advocacy should highlight the industry's attempts to use the youth issue in its own favour while laying the blame elsewhere.

The Australian cigarette brand as product, person, and symbol.

OBJECTIVE: To examine, for dominant Australian cigarette brands, brand identity (overriding brand vision), brand positioning (brand identity elements communicated to the consumer), brand image (consumers' brand perceptions) and brand equity (financial value). DESIGN: Tobacco industry documents, articles from retail trade publications since 1990, and current brand advertising from retail trade publications were searched for information about Australian brands. RESULTS: Cigarette manufacturers benefit from their competitors' brand equity as well as their own. The industry sees Australian smokers as far less brand loyal and strongly oriented to "low tar". A few predominantly local brands dominate the market, with variation by state. Successful Australian brands exist in one of three categories: premium, mainstream, and supervalue. Their brand identity essence is as follows. Premium: quality. Mainstream: a good humoured "fair go" for ordinary Australians. Supervalue: value for money. All supervalue brand identities also include freedom, escape, mildness, an aspirational attitude, blue tones, and waterside scenes. Brand image and brand identity is frequently congruent, even when marketing is restricted, and brand image is generally more positive for a smoker's own brand. CONCLUSIONS: Tobacco control activities have undermined cigarette brand equity. Further research is needed regarding brand loyalty, low tar, and brand categories. Smokers may respond more positively to tobacco control messages consistent with the identities of their chosen brand, and brand-as-organisation elements may assist. Further marketing restrictions should consider all elements of brand identity, and aim to undermine brand categories.

Going below the line: creating transportable brands for Australia's dark market.

OBJECTIVE: To investigate non-point-of-sale cigarette marketing in Australia, one of the "darkest" markets in the world. DESIGN: Analysis of 172 tobacco industry documents. RESULTS: The tobacco industry has continued to market their products despite severe restrictions on legal marketing activity. They made careful plans to circumvent regulation well in advance. In preparation for bans, they chose and strengthened existing brands to enable their continued success in a dark market and prepared the consumer for bans by increasing their spending on below the line activities. Bans reduced the industry's effectiveness and efficiency. After bans new brand launches stopped: instead key existing brands were strengthened via alterations to the product, line extensions, and stretching loopholes in the legislation as far as possible. In line with the general trend towards integrated marketing, a range of activities have been used in combination, including guerrilla marketing, advertising in imported international magazines, altering the pack, sponsorships, brand stretching, event promotions, lifestyle premiums, and the development of corporate websites. CONCLUSIONS: The tobacco industry acknowledges that marketing restrictions have an impact, validating their continued use in tobacco control. The industry is extremely creative in circumventing these marketing restrictions, requiring tobacco marketing regulations to be informed by marketing expertise, regularly updated, and to adopt the broadest possible scope. Tobacco control advocates, particularly those communicating with young people, could learn from the creativity of the tobacco industry.

New frontier, new power: the retail environment in Australia's dark market.

OBJECTIVE: To investigate the role of the retail environment in cigarette marketing in Australia, one of the "darkest" markets in the world. DESIGN: Analysis of 172 tobacco industry documents; and articles and advertisements found by hand searching Australia's three leading retail trade journals. RESULTS: As Australian cigarette marketing was increasingly restricted, the retail environment became the primary communication vehicle for building cigarette brands. When retail marketing was restricted, the industry conceded only incrementally and under duress, and at times continues to break the law. The tobacco industry targets retailers via trade promotional expenditure, financial and practical assistance with point of sale marketing, alliance building, brand advertising, and distribution. Cigarette brand advertising in retail magazines are designed to build brand identities. Philip Morris and British American Tobacco are now competing to control distribution of all products to retailers, placing themselves at the heart of retail business. CONCLUSIONS: Cigarette companies prize retail marketing in Australia's dark market. Stringent point of sale marketing restrictions should be included in any comprehensive tobacco control measures. Relationships between retailers and the industry will be more difficult to regulate. Retail press advertising and trade promotional expenditure could be banned. In-store marketing assistance, retail-tobacco industry alliance building, and new electronic retail distribution systems may be less amenable to regulation. Alliances between the health and retail sectors and financial support for a move away from retail dependence on tobacco may be necessary to effect cultural change.

"Avoid health warnings on all tobacco products for just as long as we can": a history of Australian tobacco industry efforts to avoid, delay and dilute health warnings on cigarettes.

OBJECTIVE: To review critically the history of Australian tobacco industry efforts to avoid, delay, and dilute pack warnings on cigarettes. DESIGN: Systematic keyword and opportunistic website searches of tobacco industry internal documents made available through the Master Settlement Agreement. RESULTS: Four industry strategies and six recurrent arguments used by the industry are described, which were used to thwart the passage of three generations of health warnings (implemented in 1973, 1987, and 1995). These strategies are shown to have been associated with major delays in the implementation of the warnings and in keeping them inconspicuous, unattributed to the industry and non-specific, and particularly in delaying the use of warnings about addiction. The industry today continues to oppose warnings, which might "repel" smokers from tobacco use. CONCLUSIONS: Efforts by governments to introduce potent health warnings will be resisted by the tobacco industry. Tobacco control advocates should anticipate and counter the strategies and arguments used by the industry, which are described in this paper if they wish to maximise the use of the pack as a vehicle for raising awareness about the harms of smoking.

Smoking, disease, and obdurate denial: the Australian tobacco industry in the 1980s.

OBJECTIVE: To contrast the Australian tobacco industry's awareness of the diseases caused by smoking with their aggressive public denial on the relation between smoking and disease in the 1980s. DESIGN: Analysis of 325 industry documents from the world wide web. RESULTS: In the 1980s Australian cigarette manufacturers were informed constantly by the international industry of the medical consensus that smoking caused disease. In addition Philip Morris (Australia) Limited received reports of Philip Morris' international biological research programme and visited its Richmond research facility; and WD&HO Wills part funded, co-managed, and contributed research to the British American Tobacco groups' biological research programme. Despite this knowledge, the Australian manufacturers had a policy of arguing to their employees, decision makers, and the general public that questions of smoking and disease were unresolved. The industry catalogued the literature, developed arguments against the main claims made by health groups, and attacked public health advocates who made statements linking smoking to death and disease. Industry studies suggested that a 20-30% minority of the Australian public agreed with the industry on smoking and disease, diminishing across the decade. CONCLUSION: Australian manufacturers were clearly negligent in the 1980s, deliberately working to undermine Australians' understandings of the diseases caused by smoking despite their own private knowledge. Continuing scepticism about smoking and disease, corresponding with the industry's deceptions, exists in Australian smokers today, suggesting that their actions may have slowed the rate of decline in smoking prevalence. These revelations provide important evidence for Australian litigation and advocacy.

"Australia is one of the darkest markets in the world": the global importance of Australian tobacco control.

"Australia is one of the darkest markets in the world... it probably is the darkest, I mean ourselves and Canada fight every month for who's got the darkest conditions to do tobacco manufacturing and marketing. And one of the things we can offer the world is what we do best, which is how to work, maximize, proactively drive our market position in a market that's completely dark. Now that takes a different skillset... a different type of learning. We need to export that... we know we have a lot of expatriates who come down to Australia for learning. they can come here and learn these techniques and take them back to Europe or Latin America or to the United States or to Africa... But the other thing that is really good for us is that we are also a huge net exporter of Australian talent. about 30 or 40 people currently off-shore... We do things really differently here than most other BAT organizations." David Crowe, Marketing Director, British American Tobacco (BAT) Australia(1).