The story of Dr Nigel Gray vs Big Tobacco: a masterclass in advocacy

Veteran tobacco control researcher Professor David Hill paid homage at the recent 2015 Oceanic Tobacco Control conference in Perth to his former colleague Dr Nigel Gray, regarded by many as the 'father of tobacco control globally as well as in Australia".

Here are excerpts from his tribute speech - it's a #Longread but provides so many great insights into research and advocacy.

Dr Nigel Gray with former Labor Health Minister Nicola Roxon

David Hill tribute speech, October, 2015

It was my great good fortune to work with Nigel Gray for 27 years beginning with his arrival in 1968 at the then Anti-Cancer Council of Victoria (ACCV), where I was already working.

Nigel had just left his previous job as Assistant Medical Director of the Royal Children’s Hospital.

I recall how rapidly his thoughtful analysis of the cancer scene identified tobacco as the pre-eminent target, and how he saw that public information alone would never solve the problem. I don’t recall him actually using infectious disease terms such as ‘vector’ at that time but his way of thinking showed that he knew the tobacco industry was the dangerous vector that had to be dealt with.

So, the story of Nigel Gray versus Big Tobacco began.

'Cancer country'

In his first year at the ACCV we did a survey of TV advertising in Melbourne. We found that evening viewers saw a cigarette ad every 12 minutes. Nigel decided the Council had to go after this vector of tobacco disease, at whatever cost. The contest was to be played out on their turf – commercial television.

And so work began on the 1971 anti-ad campaign featuring British comedy stars Warren Mitchell (aka Alf Garnett) and Miriam Karlin (“Rag Trade”), and local actor Frederick Parslow.

Nigel somehow managed to get an understandably nervous Executive Committee to allocate from reserves $50,000 (that’s $550,000 in today’s dollars), to make and broadcast anti-smoking ads. It was typical of his bold style to simply jump into the task, while trusting in the god of serendipity.

Instead of tedious formalities such as working through actors’ agents, I remember sitting in his office when he picked up the phone; dialled the hotel where Warren Mitchell was known to be staying; was miraculously put through to his room, where Warren miraculously picked up. “Hello, I’m Nigel Gray. You don’t know me. I’m ringing because…(then followed a potent Gravian charm offensive).

Later, after a few drinks at Warren’s hotel it was decided that Warren would recruit Miriam, who in turn recruited Fred to comprise the cast of three for a total of 25 anti-smoking ads to be filmed over two days in a garage in Fitzroy and in a borrowed mansion in Toorak. Most of the ads were scripted, rehearsed and then filmed in a matter of minutes, with very few second or third takes. The young John Bevins volunteered his creative script-writing talents too.

The aim of the campaign was to get federal parliament to legislate against TV and radio advertising of tobacco. Nigel always said that the target audience was actually the 120 or so members of the House of Representatives. The ads were not intended to make smokers quit, which is just as well as research has since taught us that humour is an ineffective motivator of cessation.

Satire was the chosen weapon in this advocacy campaign: as I recall, a couple of Nigel’s favourites were “Alf’s cough” and “Cancer Country”.

Watch them here.

But among the satirical array of anti-ads there was a serious hand grenade. This was Nigel’s idea to have a straight-faced appeal by Nobel Laureate in medicine Sir Macfarlane Burnet calling for cigarette advertising to be banned because it was responsible for recruiting teenagers into a deadly addiction.

When Melbourne TV stations declined to accept bookings of the anti-ads on the grounds they ‘knocked copy’, that is to say denigrated another client’s product, the stations in effect banned a Nobel Laureate from speaking out in the interests of our children’s health.

This outrage then became the story. It ran for days until the stations capitulated and our campaign went to air.

Nigel’s idea to recruit Mac Burnet to the cause was better than cunning… it was sheer genius.

Nigel’s sense of humour, his sense of fun (particularly if it could be at the expense of the tobacco industry) was another defining characteristic of his modus operandi, and it explains much of his success.

An example is this quip about tobacco company chairman, Sir Ronald Irish. Nigel was widely reported as saying, in the midst of some illicit drugs hysteria of the day: “It seems you get a jail sentence for pushing marijuana but you get a knighthood for pushing tobacco”.

I can still see him chortling through the media furore that ensued.

But the anti-ads were better than fun, they kick-started public and parliamentary debate which,within three years, saw the Whitlam government legislate to phase out TV and radio advertising of tobacco in stages over three years.

However, the dismissal of the Whitlam government came before the phase-out had been completed, and we were querulous. Then about six o’clock one evening in 1975, as we again chewed the fat in Nigel’s office, the phone rang:

“Is that Dr Gray? It’s Malcolm Fraser here. I just wanted to discuss what you think about my government completing Labor’s phase-out of tobacco advertising”….

Blessed moment!

And it showed how quickly Nigel had moved from being a hospital doctor to being a trusted ‘go-to’ advisor at the highest level of government.

The potent tool of sound data

Who was it who said: “All public health is politics”? Of course Nigel understood this better than anyone, and he always worked hard to achieve effective relationships with governments and oppositions.

Word of Nigel’s acumen was spreading, and about 1976 the UICC (Union for International Cancer Control) asked him to invent and lead an international effort to advance tobacco control globally.

Those who know me would expect me to have a bias towards population data on smoking… so of course I think I can make a good case that the commitment of our field to the collection over time of sound data on smoking prevalence has been a potent tool of the trade.

The first scientific paper on Australian smoking prevalence reported in the Medical Journal of Australia on a national sample survey done in 1974. The paper’s lead author was Nigel Gray and the work was funded by the Cancer Council, which continued to conduct and publish prevalence studies until its series was made redundant by the Commonwealth’s National Drug Household Survey. The surveys were commissioned from the same market research company that sold its services to the tobacco industry, a fact which could be turned to strategic advantage in neutralising industry criticism of the accuracy of the prevalence estimates.

The other great big-data resource has been the tobacco consumption records arising from the collection of federal excise duty. Excellent use has been made of these data by very able Australian researchers, who have quantified the relationships between price and consumption in the context of other interventions that also put downward pressure on smoking rates. This has enabled arguments in favour of tobacco control measures to be (almost literally) sugar-coated with revenue raising prospects for governments.

High quality tobacco control research conducted by a number of star Australian researchers has been a consistent feature of our landscape, and I am sure it explains many of the successes. Just as the practical problems and opportunities for tobacco control research emerged over time, so did the research findings that justified the new policies and programs along the way. A number of our tobacco researchers are among the most highly-cited in the world, and there have been a number of other internationally recognised Australian leaders who have followed Nigel Gray.

'Useful-but-not-used syndrome'

Yet sometimes we seem to suffer from UNU (“useful-but-not-used syndrome”), that is, failure to implement findings of research that have been shown to be beneficial. I was close to one example of this. In 1999 Penny Schofield published a paper in an international journal showing that if smoker status was recorded at point of admission to a public hospital and smoker patients two weeks after discharge received a letter and pamphlet advising quitting signed by their consultant, the biochemically validated smoking prevalence was lower than otherwise in the patients receiving the post-discharge mail-out. So far as I know, hospitals in Victoria have never adopted this cessation strategy.

There are probably other examples where simple, cheap, and effective interventions are not implemented because to do so disturbs spurious bureaucratic or system obstacles, such as changes to forms used to collect data before admission to hospital. My guess is that even now there are many missed opportunities to implement research knowledge…knowledge that is there for the taking.

Regrets….we've had a few

Turning from things we could have done but didn’t, were there things we did but shouldn’t have? A very early mistake made by Nigel Gray, together with me and others, was to pursue that illusory safe (or at least less dangerous) cigarette. Given the established dose-response relationship between tobacco smoke exposure and lung cancer risk, it made a lot of sense, of course, to conclude in the 1960s that reducing the total particulate matter (tar) measured by a smoking machine in cigarettes would reduce the risk to smokers. The Cancer Council was first in Australia to advocate for and indeed undertake at Monash University measurement of tar delivered by different popular brands.

The results were published, with noticeable impact upon brand sales. In fact, so successful was our advocacy that it became an official duty of the Australian Government Analytic Laboratory to test and report on tar content of all brands. Eventually it was mandated that tar and nicotine levels be included on cigarette packs for the information of smokers.

Well, it seemed a good idea at the time but…

We now know, and the tobacco industry almost certainly then knew that smokers can get just as much nicotine and tar from a low tar cigarette as a high tar cigarette by sucking harder or more frequently. And this is what smokers do, unconsciously, to obtain their usual desired dose of the drug nicotine.

We had naively gifted to the tobacco industry a new market segment which it disdainfully referred to as the ‘hypochondriac’ market.

There are moments in public health when the precautionary principle – acting judiciously in the absence of all the evidence you might like to have – should be applied. But mostly it is dangerous to hasten before evidence exploring all the possibilities has been collected. We should have paused to do naturalistic studies of how smokers actually used these low tar variants. We would have discovered, as the industry already had, the flawed logic in promoting low tar cigarettes.

That parable may have present-day relevance, as we consider the advent of the e-cigarette.

Luck, opportunism, intrigue, inventiveness, surprise, religion

The greatest example of tobacco control innovation that precipitated cross-border conflagration was the Victorian Tobacco Act 1986. In this Nigel Gray was absolutely pivotal, although there were crucial players from outside the public health sector who made it happen. While he is best known internationally for his pioneering work through the UICC, he is best known here for the Victorian Tobacco Act and the early years of VicHealth.

The Act levied a state licence fee from tobacco retailers, some of the proceeds of which were hypothecated to the new Victorian Health Promotion Foundation (VicHealth) to spend on health promotion, particularly but not exclusively on tobacco control. Soon, advocates in other states were lobbying for the same thing – with signal success at least in Western Australia and South Australia.

The planning and passing of the Bill is a wonderful tale not only of clear-sighted strategising but also of luck, opportunism, inventiveness, intrigue, surprise – even religion!

As well as its revenue-raising provisions, the Act created VicHealth and charged it with providing funds to sport and the arts to effectively buy out the tobacco companies which had been so heavily funding them. It was arguably the most significant piece of state tobacco control legislation ever enacted in Australia.

They were exciting times and many people (most of whom I won’t mention by name) worked towards its success. What explains the success? Are there still lessons for today?

1. Luck helps. Nigel Gray was calling on the then Health Minister David White to pitch for funding of screening mammography when just as Nigel was about to leave the room, the Minister unexpectedly asked what the government could do about tobacco. It soon became apparent that Minister White was driven to make an impact on tobacco because his father had been killed by a tobacco-related disease.
2. Be ready when opportunity knocks. Nigel, though not expecting this opportunity, was ready for it. He didn’t miss a beat presenting a few options to entice an interested Minister. But Nigel was far from prescriptive – rather he sensed that David White’s appetite was for something innovative and bold, and so was begun a collaboration… or, as the tobacco industry would have said, a collusion.
3. Inventiveness. David White had in his office several extremely talented advisers who, with input from the Cancer Council, developed a proposal that was both technically and, more importantly, politically gifted. The Tobacco Bill would raise revenue under powers then available to the state (that is, licence fees); it would spend money on programs to reduce the risk smoking (particularly it was cleverly emphasised, the risk of your kids smoking); whilst it did not promise motherhood, it did promise to fund the next best thing - medical research and health promotion more broadly; whilst it would not (and probably could not) attempt to ban tobacco advertising and promotion outright, it would provide the funds to outbid the tobacco industry in its support of sport and the arts. In a stroke, this converted nearly every community sports and arts organization in the State from being opponents into allies of tobacco control.
4. The Premier of the day, John Cain, was not at first keen on the idea, so the early intrigue required winning over Premier and Cabinet. I am not privy to much of that but I did get a glimpse of the politics during an interview with Bob Hogg who was the government’s most senior adviser. The Cancer Council had done a public opinion survey to test public response to the kinds of measures being contemplated, which was generally quite favourable. I was called to Bob Hogg’s office to explain and elaborate. I remember being both stunned and impressed by Mr Hogg’s knowledge of survey methodology, his attention to detail, his nose for bias, and his challenging stance. There was no way he was going to rely on flawed survey data to support this legislation and expose his boss to political risk. Fortunately, our survey (a legitimate example of advocacy-driven research) passed his test.The next level of intrigue involved getting the Liberal Opposition on side. We had a foothold in that Mark Birrell was the Shadow Minister of Health. Mr Birrell, had, as a Monash University student member of the Young Liberals, proposed to State conference a policy to ban cigarette advertising (of course it had not succeeded). Nigel acted as the trusted go-between, apprising Mark Birrell of the proposal for a Bill, relying on him to keep confidences, and to start to prepare the ground among his Parliamentary colleagues. Liberal party support was essential since the Coalition controlled the Upper House. This was how bipartisan support for the Bill was built, and bipartisanship has carried on into the life of VicHealth to this day, with MPs from both sides sitting together on its Board. I am sure that the fact that VicHealth can be seen as a creature of Parliament accounts for much of its stability and durability.
5. Surprise was also important. Everyone on the inside was well aware of the lobbying power of the tobacco industry and its ability to mobilise certain sectors in its support. So the plan needed to be as well-advanced as possible before the industry got wind of it. Which is what happened. A powerful element of success was The Age, whose then Editor Creighton Burns was persuaded to run a series of five feature articles on tobacco over five successive days. The tobacco companies must have thought all hell had broken loose.

1. Religion came into it too. Just to make sure all the bases were covered, Nigel, who was not religiously aligned himself, used his network of influential people to ensure that both the Catholic and Anglican Archbishops were briefed, were onside, and most importantly communicated their view to the political leaders. For example, he spoke to a palliative care colleague, who spoke to her husband (who was the head of major corporation and was a leading lay Anglican), and he spoke to his Archbishop.

All in all it was a meticulously planned and executed piece of public health reform, implemented against a powerful and wealthy opponent. Could we do it that way again if we had to? Probably not. Those were simpler times, and it is much harder for governments to achieve bold objectives. And the tobacco industry is even more vigilant, aggressive, litigious, and egregious than it was then.

After the Victorian Act was passed, VicHealth had to be bedded down and to learn how to wisely spend its $22 million (worth $50 million in 2015). Nigel cleverly declined to take the role of Chairman of VicHealth and instead persuaded the impeccably-credentialed and articulate Sir Gustav Nossal to take it on. It was a master stroke to bring such a prestigious basic medical scientist into the fold, just as Nigel had done with Burnet in 1971. It is always a good strategy to keep tobacco control closely aligned to basic medical science, as well as with clinical medicine.

In a sense, the final phase of Nigel’s career at the Cancer Council was the bookend to match his work in achieving the ban on broadcast advertising of tobacco in the early 1970s. I refer to the stunningly successful work done both within and outside government that led to the Tobacco Advertising and Promotion Act in 1993.

Merely a few years before its passage, to ban all forms of tobacco advertising and promotion was unthinkable, seen as a bridge too far. But the rapidity of this change belies all the strategising, the patience and persistence, attention to detail, and the high level of politico-bureaucratic intelligence that under-pinned it. Compared to the 1970s, tobacco control was a far more highly-developed field of public health with a much larger and more sophisticated workforce engaged in it. Credit for the TAP Act is shared among many, some of whom are in this room. (They will know who they!). And those people will remember Nigel Gray’s ongoing wise advice and occasional strategic interventions to get the federal legislation through.