In the late 1970s, I worked with others to try to have the actor Paul Hogan removed from Winfield cigarette advertising.1 It was, and remains, the most successful tobacco advertising campaign in Australian history. Hogan had immense appeal with teenagers. This made his role a clear breach of the voluntary code of advertising self-regulation that then operated.2

Our private, polite efforts to get something done about this through the complaints system were virtually ignored until we went public through the media. Ten-thousand-watt lights tend to concentrate the attention of those with responsibilities to act. And so act they finally did. Hogan was removed 18 months after we started complaining.3

I learned a big lesson very quickly: sunlight makes a very strong antiseptic for malodorous health policy. And there is no sunlight stronger than major media attention.

I soon discovered there were remarkably few analytical histories of how either large or small public health advocacy campaigns and policy battles had been won or lost. So I set out to change that by writing books4 and dozens of papers on the process I had often been part of. Today, on the eve of my retirement, I want to give you what I think are ten key lessons I’ve learned repeatedly throughout my career in public health advocacy. There are many, many more. But here are ten which are absolutely critical.

​Lesson 1. Always respect evidence and if the evidence changes, so should you

The granite bedrock of all public health advocacy must always be evidence. Evidence evolves through stages. It starts with hypothesis-generating claims and observations and moves through to the gold standards of large-scale cohort epidemiology and randomised controlled trials in real-world settings. As evidence mounts, things that once looked true or effective can sometimes turn out not to be. We have seen the cancer screening and dietary areas slowly and sometimes reluctantly coming to terms with past doctrines being eroded by the tide of oncoming evidence.

Careers are often built on a lifetime commitment to particular phases of evidence. But if the evidence changes, it is absolutely critical for public trust in the integrity of public health, that we acknowledge – as the economist J. M. Keynes emphasised – that the facts have changed and that accordingly, we have changed our minds too.

It is important to note here that the internet has changed forever the politics of expertise. For a long time, expertise was exercised in forums largely inaccessible to the public and then handed down to the populace in the form of advisories and campaigns. But today access to unprecedented amounts of research and to ways of disseminating it to millions has opened up a kind of anarchy of “expertise” that poses a massive threat to continuing public confidence in public health.

Two illustrations of the advance of junk and low quality science are the resilience and influence of climate-change denialism and the current efforts by e-cigarette interest groups to claim e-cigarettes are so revolutionary in their potential to make smoking history, that unlike all other therapeutic goods, foods or beverages, they should be allowed to stand on their own and totally avoid any form of regulatory oversight. The momentum that the interest groups behind these two major issues are succeeding in building may spread to challenge decades of public health and safety legislation.

Anyone embarking on a career in public health today faces unprecedented challenges to preserve and strengthen public and political confidence in the evidence base for public health policy. Challenging and confronting low-grade and self-interested evidence from such forces will never be more important. It is the very worst time to retreat into the unnoticed and inconsequential debates within the walls of academia. Today more than ever, we need far more of you out there promoting quality evidence and hammering rubbish.

​Lesson 2. Be clear and concrete about what you want to change or support

I am often asked to speak to people who want advice on how to go about building momentum for their concerns. They say, “Tobacco control has done so well in changing policy that has reduced smoking . . . what lessons do you have for our issue?” My first question to them is always what is it that they want to achieve. Almost invariably, they answer with a goal such as reducing obesity or problem drinking. Sometimes, they talk about some important but obtuse value like “reducing health inequalities” or “getting greater attention to the social determinants of health”.

Talk about such complex and worthy abstractions is important and meaningful to small groups of specialists. But this is not how ordinary people talk. Public health is often mired in language that means little to those outside the cognoscenti. A “policy” to most people is what you get in the mail once a year from your house- or car-insurance company. Policy change may well be your goal, but policy will not change unless you can make it crystal clear exactly what you want from policy makers. That’s exactly what we did with plain packaging. Every square centimetre of the pack, the fonts, the colours . . . everything . . . were specified following research with target groups. It could not have been more focused.

Take controls on alcohol advertising as an example. A colleague, Andrea Fogarty, interviewed 28 of Australia’s leading alcohol-policy researchers for her PhD. All offered generalisations about the need for “controls” on alcohol promotion. But once she moved to the next stage and asked about precisely what sort of controls, there was very little consensus. There was no clear, sharp message for policy makers and the public to consider.5

I try to focus colleagues by asking them to pull their attention right into the foreground. What, precisely, needs to happen to reach the broad health goals that are so easily articulated? Precisely what policies, legislation or funding would they like the government to put in their Christmas stocking next year? Once that’s decided, the meat and potatoes work of strategic, policy-relevant research can occur along with the precision “bombing” of false arguments from those opposed to change.

​Lesson 3. “It’s better to be looked over than overlooked” (Mae West)

I’ve never seen the sense in applying for grants, doing all the work with others for several years, and then parking it only in pay-walled journals where other academics are the only ones who can access it. The attitude that expertise carries no responsibilities to ensure that evidence reaches the public and policy makers is bizarre to me.

A few years ago, an NHMRC project I led with Wayne Hall and others interviewed 35 Australian public health researchers about why they were influential. They had been voted by their peers as Australia’s most influential researchers working in six fields. Large majorities agreed or strongly agreed that researchers have a duty to increase policy and draw public attention to their work.6

We undertake research and systematically review it to provide evidence that can lever policy change or defend existing policies and practices. But there is only a small number of people who have the power to make action happen – to effect change or defend good policies. The most important of these are politicians. And guess what? They don’t read research journals!7

But over nearly 40 years, I have had countless occasions to speak to prime ministers and health ministers, their Cabinet colleagues, and thousands of influential people in every walk of life. I’ve done this as they lay in bed, as they ate breakfast, drove their cars, sat in their living rooms, and relaxed on their weekends or holidays in their shorts and T-shirts. By contrast, I have had face-to-face meetings with politicians perhaps 100 times in my life. Let me explain.

When I first met former federal health minister Nicola Roxon, many months after she commenced her ministry, we shook hands and I said I didn’t think we had ever met. She replied she felt she had known me half her life. This could only have meant that she had often heard me and read of my work in the news media. She was one of the highly influential people I had spoken to, often without me even knowing. She was already very receptive to various issues I and my colleagues had been emphasising over the years. If you avoid the media, very few will ever learn about your work and what needs to be done because of what we know. You and your research are far less likely to be influential.

If you care about making a difference, you will put aside the regrettably still-prevalent attitude alive in some institutions that you should not “dally with the Delilah of the press.”8

​Lesson 4. Study the media

If you want to be a potent media advocate for evidence and policy change, you need to know how it works and how you can best be part of it. Many of you will have taken days to prepare your 10- to 15-minute presentations for this conference. You may have rehearsed them in front of colleagues and finely manicured your sentences and slides. The really lucky ones will get to speak to 300 or so in a plenary session. Most, though, will address only 40 or 50 in a breakout session.

But a few will be tapped by journalists at the conference and even fewer will try to get in their faces through their own efforts. If you get interviewed for breakfast or drive-time radio, or evening TV news, your message might be heard by hundreds of thousands of people – sometimes millions. To maximise these unparalleled opportunities, you need to understand the medium and the programs on which you are about to appear. On Australian television news, the time that anyone gets to speak in a 90-second item averages 7.2 seconds, with an interquartile range of 4.8 to 9.2 seconds.9 Knowing that, you can plan precisely what you are going to say and emphasise.

When print journalists request comments (and this increasingly will happen via email), I try to drop everything and send a selection of one or two sentence options. This makes journalists’ jobs easier and they appreciate that. Again, knowing about length restrictions, you can shape a message with exact precision. Try to make every quote you send of potential “breakout box” quality rather than some anodyne, forgettable “memo to the public”. This will mark you as someone they’ll note is “good talent” and they’ll contact you again and again.

Above all, be accessible. This should be so obvious. For seven years, I was a regular guest on Adam Spencer’s Sydney ABC breakfast program with a listening audience of half a million. I was curious why and emailed him for this presentation. He told me immediately, “Because you always answer your phone. The number of people we rang and they missed out because they didn’t realise tomorrow morning was their one shot, was incredibly frustrating.”

​Lesson 5: Use “killer facts”

Every year, people are exposed to thousands of facts, claims and narratives about many hundreds of health issues. Much of this is like informational wallpaper that is forgotten moments after it is encountered, contradicted by competing claims and washed away on the tide of tomorrow’s more arresting news. Some issues rise above the rest and compel political action. Many issues plod along unchanging and others sink without trace.

A basic goal in advocacy is to have your definition of what is at issue in a policy debate become the dominant, top-of-mind way that people think about that issue.

Killer facts10 are like musical earworms: once they get inside your head, it is difficult to get them out. They tend to kill off competing definitions of what is at issue. If they employ powerful and repeatable analogies, before and after comparisons, and humour if appropriate, this can really help. I heard one yesterday: “Public health is about saving lives . . . a million at a time”.

Here are some examples:

• “The USA has 13.5 times Australia’s population, 5.9 times Australia’s rate per 100 gun ownership, and 305 times Australia’s gun homicide rate. So more guns make a country safer?”
• “In the 18 years before Australia’s 1996 gun-law reforms, there were 13 mass shootings (defined as shootings that involved five or more deaths, not including the perpetrator) in Australia. There have been precisely none in the 18 years since.”
• “For four of the last five years, quad bikes have been the leading cause of non-intentional injury death on Australian farms. This is unique internationally as in all other Western nations, tractors continue to be the leading cause of injury deaths.”

Every advocate, for every issue, needs to stock up on killer facts for every sub-issue in their field. Plan to use at least one of them every time you are interviewed.

​Lesson 6. Values are everything

I have said earlier that facts and evidence are the bedrock of public health advocacy. But unless those encountering this evidence care about it, they are highly unlikely to pay attention to it, let alone act on that evidence. Caring about something is always a necessary but not always a sufficient precondition for support and action.

Public health issues often feature in the news because they richly illustrate narratives about values: mini-dramas and secular parables about adversity and the solutions that are needed. These include the humane imperative to reduce early death and suffering; the injustice of inequitable distribution of disease and access to services; and stories about those who put financial gain ahead of population health.

So after you’ve filled your kit bag with killer facts, you need to take an inventory of the values which make these facts even more compelling. For example, killer facts about tobacco-industry expansion in nations with low literacy are powerful because they evoke eons of examples of the Pied Piper mythology: wolves in sheep’s clothing who lead the vulnerable into illness and death. Your facts and evidence should be anchored firmly to the values that will make them resonate with what George Lakoff calls “moral politics”.11

You also need to take an inventory of your vulnerability to opponents framing your position as embodying negative values and then seek strategically to reframe these as positives. The “nanny state”12 epithet, for example, can be easily reframed positively by pointing out all the benefits caused by regulations and standards we all take for granted as we go about our daily lives. As I stood in my narrow hotel shower recess this morning, I whispered a silent “thank you” to the public health nannies who insured that if I slipped, the glass would not shatter and cut me to ribbons.

​Lesson 7. Experts are fine, but they are not “a living thing”

A journalist once said this to me,13 and I’ve never forgotten it. People who live with the diseases we try to prevent appear more often in news media coverage than experts or politicians ever do.14

When an expert speaks, we may admire their coherence, their grasp of the issues involved and their ability to explain complexity simply. But if a person suffering a problem speaks and does the same thing, it can be doubly powerful. Ordinary people can make amazing advocates and we should work with them far more. They bring a compelling authenticity to an issue.

​Lesson 8. Use social media. A lot.

The internet has utterly revolutionised all our lives. And it has utterly transformed advocacy. There are simply massive global participation rates in social media. Anyone in public health who is not part of this, is the equivalent of a scholar in the Gutenberg era who declined to show interest in the potential of books.

I’m a heavy Twitter user. If you are like I used to be and thought that Twitter sounded like some sort of time-wasting indulgence for vapid twits, you may have already pulled the shutters down. But look what you are missing out on. Let me give you three examples.

The paper I published that has had the most downloads looked at the impact of the post–Port Arthur gun-law reforms on multiple killings and total gun deaths.15 It has had 120,600 downloads since 1996, with 86,000 in December 2012 after I tweeted the link following the Sandy Hook massacre in the USA. It has been cited 102 times.

A preprint of my much-tweeted paper on the nocebo effect and wind farm health complaints16 is the most downloaded item in the entire University of Sydney’s eScholarhip repository and featured in this video, which has been viewed 3.659 million times.17

My most retweeted tweet was one I sent after Treasurer Joe Hockey’s public remark about wind turbines being an ugly blight on the landscape.18 It has had 2,289 retweets, meaning that probably well over a million people have seen it.

​Lesson 9. Successful advocacy takes time

Much public health research focuses on proximal associations19 between interventions and outcomes – weeks, months, sometimes a year or two. But advocacy’s dividends can often take decades to deliver their benefits.20

Smoking was first banned on public buses and trains in New South Wales in 1976. It took until 2006 – 30 years later – before such bans extended to the working environments where the problem was worst, and where in a totally rational world, smoke-free areas should have started. Even today, high-roller rooms in some casinos allow smoking. It’s a little-known fact that second-hand smoke from wealthy gamblers is unique in not posing health risks to others.21

If you are serious about being a potent advocate, settle in for a long and often frustratingly slow, but immensely rewarding, career.

​Lesson 10. Grow rhinoceros hide

Finally, unless you are an advocate for an utterly uncontroversial policy (I was going to say “for a mother’s milk policy”, but of course even breastfeeding still gets attacked in some contexts), as soon as you start to become a potent advocate and your work threatens any industry or ideological cabal, you will be attacked, sometimes unrelentingly and viciously.

I’ve been called a veritable sewer of names on social media, often by anonymous trolls and tobacco-industry-funded bloggers. I’ve also been attacked in the coward’s castle of parliament under privilege, slandered on the Alan Jones radio program (and received a written apology and my legal costs paid), falsely accused of being an undeclared paid advocate for the wind and pharmaceutical industries, and sent white feathers each year on the anniversary of Port Arthur. My university administration is regularly deluged with orchestrated complaints. Yet I’ve had nothing but total support from my university and colleagues in the face of this. In all this nastiness, I take deep satisfaction and pride in having worked with colleagues who are lifetime friends to help make Australia’s smoking rates the lowest in the world today.22

Many of you are doing fabulous work to achieve similar goals in your areas. Clinicians are thanked everyday by grateful patients and relatives for their skill in saving lives and limbs. In public health, we don’t have people come up to us and say, “I’ve not been killed or injured because of your advocacy for road injury reduction policy”, or “I’ve not got diabetes, and I put it down to you.” But our achievements can be seen in many areas of declining incidence of disease and injury. We do fantastically important work and I’ve been blessed to be part of it for almost 40 years. Thank you for all you do.