Harm reduction approaches are now an established and fundamental part of the response to drug use. While tobacco harm reduction has an expanding evidence base it is often viewed in narrow terms, as if people who smoke exist in a discrete silo.
This has meant the potential of THR to help communities with high smoking prevalence, such as people who use drugs, remains underexplored – despite the evident harms they experience and their impact on health outcomes.
This session brings a drug harm reduction perspective to THR, drawing on frontline experience across a range of environments and sectors, seeking to highlight what works in terms of harm reduction for individuals and communities, plus opportunities for further development.
Transcription:
00:03 - 05:14
[Tatsiana Pikirenia]
My name is Tatsiana Pikirenia, and I represent here Knowledge Action Change organization. We are happy to have this session at GFN this year. And, well, Knowledge Action Change is a public health organization, and we promote health through harm reduction as a concept. Through the Global State of Tobacco Harm Reduction Initiative, we provide evidence, publications in many languages, country-level information, education through Tobacco Harm Reduction Academy, roadshows, mentoring and support to scholars and communities around the world. You are welcome to scan our QR codes, visit our websites, and use our open access resources in diverse languages. For us, tobacco harm reduction is not only a policy or a scientific issue. It is also about access to information, to practical support. It is about inclusion of communities who support people who continue to smoke and deserve safer options. That is why today's session is so important. So we want tobacco harm reduction to be connected more closely to drug harm reduction, community-led services, and the real lives of people whose needs are too often left outside the mainstream tobacco control. It is my extraordinary pleasure to introduce to you our humanistic panel today who are respectful harm reduction advocates. Please meet Professor Gerry Stimson. Gerry is one of the is one of the leading figures in tobacco harm reduction in history. He is one of the founders of Knowledge Action Change Organization and the Global State of Tobacco Harm Reduction Initiative. a public health scientist with over 50 years of experience of research and advocacy. And he was one of the founders of harm reduction in 1990s, helping to develop and evaluate emerging drug harm reduction programs in many countries of the world, collaborating with the UN agencies and the governments and the communities. Alla Bessonova from Kyrgyzstan is, yes. Yes, they all deserve this. Thank you. Alla is a veteran harm reduction activist. For many years, she has defended access to HIV services, to needle exchange, opioid agonist therapy, and human rights-based services for people who suffer. Her advocacy has been acknowledged internationally. In 2024, Alla was awarded the Jude Byrne Emerging Female Leader Award. Magdalena Bartnik is, one of the leading figures in Polish drug harm reduction and the European drug harm reduction, and the founder of Precursor Foundation, which is a leading harm reduction foundation in Poland. She has almost 20 years of experience in the drugs field and has been a strong advocate for humane rights-based drug policies in Poland and around Europe. Marianna Iwulska is a chairperson of the board of European Network of People Who Use Drugs. She is also active in the Polish network. Marianna is one of the leading and respectable activists in drug harm reduction field in Europe. And David MacKintosh is the director the director of Knowledge Action Change Organization. He has many, many years of experience in alcohol and drug policy, public health, community safety, and institutional work in the United Kingdom. Now, Gerry will present why smoking matters for drug-using community, for drug treatment, for drug harm reduction, and what can be done.
05:18 - 18:03
[Gerry Stimson]
Thank you very much, Tatsiana. Thank you very much for that very kind welcome to a fantastic panel. I'm always overawed to be on a panel with people who actually do things, where I spend my time talking about things and thinking about things. But it's great to be with people who are making the world different. Yeah, I came to tobacco harm reduction from drugs harm reduction, and now I think it's time to take tobacco harm reduction to drugs harm reduction. Tatsiana mentioned kind of my longest history, sort of over five decades of stuff, research and other things broadly related to harm reduction, going back to my... first research work in the 70s, which is on herring prescribing, through work on HIV prevention for people who inject drugs in the 1980s and through the 1990s. And then I sort of moved into advocacy for harm reduction and for human rights. And then, along with Paddy Costell, invented this conference 14 years ago, and invented and founded Knowledge Action Change. long history of work mainly on drugs harm reduction and then from 2010 onwards getting very interested in tobacco harm reduction and really seeing how all the stuff I'd been doing in drugs harm reduction related to tobacco harm reduction. But tobacco harm reduction doesn't figure in drug treatment and harm reduction services at all. We can, I think, on the panel explore the reasons for that, but it's high time that drug treatment and harm reduction services got involved with tobacco harm reduction. And it's important they acknowledge that work. It's important that they integrate that work. But it's also important that by getting tobacco harm reduction into drugs harm reduction services, we've got a grassroots bottom-up way of trying to influence donors, international organizations, and others. Many of us in THR are sort of fed up with trying to battle against WHO's misinformed views of harm reduction and the neglect of tobacco harm reduction. in many UN agencies. You can't keep that battling head-on. I think the way to bring about the change is from the community-based organisations and upwards. Nicotine, very popular drug, and extremely popular amongst people who use drugs. And when I'm talking about people who use drugs, I'm mainly talking today about people who are in contact with drug treatment and harm reduction services. Most people who come to those services smoke. Smoking is a major cause of illness and premature mortality in this population, but for reasons I think we can discuss later, it's pretty invisible. Most services ignore smoking, and I think we can look at that during the discussions today. And there really is a disconnect between drugs harm reduction and tobacco harm reduction. There's a major opportunity to improve the lives of people who use drugs, but I think this is also questionable, where I say tobacco harm reduction is a fairly easy, low-cost intervention, but I realize it's not necessarily a low-cost intervention in all situations, but it's certainly a potentially high-impact intervention. Smoking rates amongst people who use drugs, people in drug treatment, are two to four times higher than in the general population. That comes from a survey of 54 studies, 37,000 people in 20 countries. So it's pretty clear that in most places, people in drug treatment services are smoking at much higher rates than the general population. It can be 70% to 80% in people in opiate maintenance treatment. The average smoking rate amongst people in contact with services is around 85%. And I would hazard that, in fact, nicotine is probably the most popular drug in this population. Death rates are high, several times higher than in the general population. And this study that I made from the slide here, a study of 100,000 people who used heroin in the UK, it's a record linkage study. 63% of them had died before the age of 70 compared with 16% of the general population. But when you look at the cause of deaths, nearly equal numbers of deaths were caused, were related to drug use as were related to smoking. So that's quite an extraordinary finding because we're all aware of drug-related deaths. But there is, and I say it's kind of invisible because most of these deaths from smoking are occurring much later in people's lives when they may no longer be in touch with services. So the deaths we're often concerned about amongst drug users are the ones that are most visible. But the fact that in this population there are nearly equal number of deaths from smoking as from drug use I think is quite stunning. A little closer look at what's going on. We had the privilege of undertaking a piece of work in Kyrgyzstan with Public Fund Attica, with Sergey Basanov and Alla Basanova, because we were interested, Tatsiana is the driving force for a lot of this, and just looking closer at what's happening in terms of smoking in populations who are in touch with harm reduction services. Now, Attica is... Harm Reduction Service Organization, founded by drug users, working with drug users, sees around 2,000 people a year. So, survey conducted in two locations, and very detailed questions asked of people about their use of nicotine. In fact, the study which is yet to be published, it's going to rounds, and Tom Jodinski, sitting at the back there, he's waving his hand, he's one of the authors who's struggling with journals, with publications at the moment, but It is, in fact, probably the most comprehensive bit of work to date on smoking in this community. And I think the findings are actually stunning. Nearly everybody, everybody used nicotine in some form. It was almost universal. 99% used nicotine in one way or another. And nearly 80% were smokers. And daily smoking was as high for women as for men. Now, for men, the smoking rate in this group was two and a half times the background smoking rate in Kyrgyzstan. But for women, the smoking rate was 25%. times as high as the background rate for smoking in Kyrgyzstan. So that's quite extraordinary, both the high level of smoking, but also the high level of smoking amongst women. Another form of nicotine which is relatively popular is Nasvi. And if you want to know more about Nasvi, you can look at the GFN5 video which Sergei made on how Nasvi is made. It's a small pellet of tobacco mixed with nicotine. ash and water made into a small pellet used orally. Vapes, not really figuring at all. Heated tobacco products, not really figuring at all. And no use of snus or nicotine pouches. In fact, if you look at the little chart there in the gray column, nearly 63% had never even heard of snus or nicotine pouches. So predominantly smoking and Nasvi. Yeah, okay. Why is THR not happening? Well, partly it's a matter of information, low awareness, and inaccurate perceptions of risk of different kinds of product. It's partly about pricing. In Kyrgyzstan, as in many countries, the alternatives to cigarettes are often expensive, and companies making and selling alternatives to cigarettes really need to look at some of their pricing practices. PMI, for example, pushes its price of its products up very high and makes them far too expensive for people in many countries. Services. THR has not been seen as part of the harm reduction offer. Smoke is not really seen as kind of a relevant part of the work in harm reduction services, and we can explore more of that today. Norms about smoking in many services, in some countries staff and clients smoke together. The context of nicotine use, often cigarettes are used along with other drugs to manage cravings and so on. But we need to explore a little bit more today the reasons that THR is not happening. It's really a missed opportunity. Hardly anybody in the people we had interviewed had been offered help to quit. Around 3% had been offered some personal help to quit smoking, and that similar low level of offer of help occurs in other studies in other countries. A few had an appointment to discuss quitting, only two had been encouraged to use nicotine replacement therapy, which is, in fact, not particularly useful in comparison with some other ways to switch away from smoking. So all in all, high levels of smoking, not much being done, and what we found in this study with Attica is what you'd find in most other drug services globally, I believe. So what can be done? That's really for the panel discussion today. I think that overall there's a strong message that for drug treatment and harm reduction services that there's a huge missed opportunity to help people improve their health. I think, and again I might be challenging on this, I think that tobacco harm reduction is a fairly simple thing to introduce into harm reduction services. It's a lot simpler than trying to persuade governments that you want to be prescribing methadone or persuading governments that you want to give out needles and syringes. There's a lot of things that can be done in a very simple way, just talking to people about their smoking and the options and alternatives to smoking. But at the end of the day, I think for me in terms of where I am heading, don't make a joke about that, in terms of where things are heading with tobacco harm reduction, getting interest in drug treatment and harm reduction services and getting interest in tobacco harm reduction in other sectors is really the way forward for change. As I said at the beginning, it's a matter of getting interest at the grassroots level where people are doing things and hoping that feeds up to begin to change donors and funders views of tobacco harm reduction and feeds up to change the whole ecosystem which is predominantly against tobacco harm reduction but I think through this we can have a ground up move to help change the broader acceptance of tobacco harm reduction. So just leaving you with a question and I'm sure the panel are going to be able to answer all the questions about why it's not happening. So thank you very much.
18:07 - 18:38
[Tatsiana Pikirenia]
Take a seat. Take a seat, Gerry. Thank you very much, Gerry. Kyrgyzstan research was, in addition, important because it did not look at people at a distance, but it rather involved people and was done together with the communities. And I'm happy to give the floor to Alla to give us even a deeper insight into the women who use drugs and why they smoke.
18:40 - 27:56
[Alla Bessonova]
Dear colleagues, I also want to represent the result of research which we made in Kyrgyzstan. And Gerry now shows us the landscape, who smokes, how much, and how little support people who use drugs receive. But I want to zoom in one group that is largely invisible in this data. It's women. Our study, which we made in Kyrgyzstan last year, it was a gender study. Fifty-fifth women who use drugs in Bishkek, Osh, and the Chu region, it was not like escape, survive. But it was a close conversation, and what we had matters. Women who use drugs carry what we call a double or tribal stigma. And we talk about this, present the situation in Central Asia two days ago in our gender session. What does this mean? There are women who use drugs, and they smoke. They can be sex workers, and this is a tribal stigma. And if they have an HIV status, it's more stigma. And each of this alone is enough to close the door to help. Together they make help seeking almost impossible in Kyrgyzstan. This is also a psychological dimension that is too often ignored. Smoking describes hormonal balance and reproductive health and raises the risk of cervical and breast cancer. Yet, awareness to this risk does not motivate women to seek medical care, even when access exists. they are likely to face institutional violence also. This is a judgment refusal or humanization based on their drug use. So women who already have symptoms will and all likelihood not to go help. Now I need to say something directly, because it shapes everything else. The women in our study do not just experience stress. They live inside violence. We tend to think of violence as a physical assault, but the reality is far broader. It includes sexual violence, physiological abuse, control, humanization, isolation, economic violence, no money, no autonomy, no exit. and institutional violence. The clinic that turns women away, the law that criminalizes women, the services that demands women quit drugs before it will talk to you about anything else. For women who use drugs, Institutional violence is not an exception. It is the system they navigate every day. In this context, a cigarette is not a bad habit. It is a coping mechanism often they only use one that is immediately available, cheap, and not criminalized. Stress, unworthiness, both drug use and smoking. You cannot address one without addressing the another. I'm also back to data. 77% of women in our study smoked daily. The national rate of women in Kyrgyzstan is 3%. This is perhaps not a question of individual choice. It is a question of the condition people live in. 97% had never privately received any personal support to stop smoking. not had ever seen a tobacco cessation specialist. And yet, when we appeared in interventional competing cognitive behavior therapy, motivational interviewing, and access to alternative nicotine product, 75% reduced their smoking, 20% switched to vaping only. The average daily cigarette code dropped by 45% over three months. Women want support. They respond to do it. They just rarely receive it. Based on our research, finding what we actually observed, this is what we think can improve both understanding and practice in tobacco harm reduction. First, ask every woman about smoking. Make it part of standard screening, not afterthoughts. Second, trust to peer model. This is really work. Women in our study did not trust state services. They trusted NGO workers and peer consultants with lived experience. Third one, put NRT in the basic package. Nicotine patches and gum are legal, affordable, and effective, and possibility-headed tobacco products like IQOS. There are other options that can legally be included in harm reduction programs. Other cigarettes alternatives are banned in our country. Cognitive behavior therapy and motivational interviewing work really well. Without psychological support, behavioral changes does not happen. Our data confirms this. And five, I'm saying this to everyone in this room who talk to donors. How do we integrate tobacco harm reduction into the services of organization working with the most vulnerable population? Because smoking among people who use drugs is causing serious chronic illness and death at rates that may exceed the harms from drug use itself. Tobacco harm reduction through gender responsive approaches is not a separate agenda. It is part of the work and we are already doing. Women who use drugs smoke under condition of violence, stigma, and with no support at all. We will offer real help. They take it. We just need to start offering it. Thank you.
28:01 - 28:21
[Tatsiana Pikirenia]
Thank you. Thank you very much, Alla. This is very, very insightful. And thank you for not only giving us the insights, but also suggesting what needs to be done. And we are over to Magdalena. You're welcome. The floor is yours.
28:27 - 35:50
[Magdalena Bartnik]
Hi, everyone. Thank you for the introduction and for the invitation. I'm very happy to be here. I do believe we can't really talk about harm reduction without tobacco harm reduction. In my presentation, I want to talk about the project that I implemented in Gdańsk five years ago in a COVID pandemic, which was quite challenging. And it was done within Tobacco Harm Reduction Scholarship Program, done with opioid agonist treatment patients. There are 23 participants. So the aim of the... I can't... Okay, so the aim of the program was to determine the possibility and efficacy of harm reduction interventions among this group. And the idea was also to contribute to the knowledge of the interventions in this population and also to promote topical harm reduction approach among services. First, about attitudes towards smoking and safer nicotine alternatives. Smoking is overlooked and never addressed, and that's the case with harm reduction services, addiction treatment services, but even more in researchers. history, like within the history of drug use, using nicotine is never mentioned. And one of our participants said she was never asked whether she's smoking and nicotine use is preceding very often alcohol use. And she said that smoking in a way is common, normal, something that people just do. Nicotine plays an important role in regulating emotions and coping with stress. People were saying it calms them down in difficult situations, improves their mood and motivation. E-cigarettes were perceived as less harmful alternative to traditional cigarettes with expectation of health benefits. Maintaining using nicotine was an important aspect for the participants. They wanted to replace traditional cigarettes but not quit nicotine. And for them crucial was that e-cigarettes provide a similar sense of satisfying nicotine cravings. Regarding barriers to an effective transition to safer nicotine alternatives, people emphasize that switching to e-cigarettes required running correct ways to inhale and that adaptation process was difficult and time-consuming. There were financial barriers related to purchasing and maintaining the equipment. Participants emphasized that cigarettes are a constant part of their daily life. Smoking habits are deeply ingrained, and they reach for a cigarette reflexively, especially in stressful situations. Respondents believe that e-cigarettes do not deliver nicotine in a manner comparable to traditional cigarettes, and they were talking about the need for rush. and all participants were surrounded by people who smoked. Being offered cigarettes by friends made it harder for them to transition, and that would be easier if those around them also used e-cigarettes. The conflicting information media reports were really confusing and respondents stated they lack knowledge about actual harmfulness regarding e-cigarettes, which limited their trust in this form of nicotine use. The conclusions of the project We have a couple of conclusions based on this project. So people experiencing health problems, mental health problems, hepatitis C, HIV, respiratory diseases, for them, it's really crucial to have access to safer nicotine alternatives. Participants emphasise that cigarettes are an important part of their life, a way of coping with stress, so tobacco harm reduction allows for the mitigation of health risks without the need to quit using nicotine. Some participants reduced their use of other substances, for example, alcohol. And this stabilizing nicotine use may facilitate broader health improvements. People are experiencing economic difficulties, mental health crisis, unstable living conditions, and under such circumstances, gradually reducing risks is more realistic and effective. And participants reported improved respiratory functions, reduced coughing, and better overall well-being. To close my presentation, I want to stress that integrating tobacco harm reduction into treatment and harm reduction services is critical. Use of nicotine has to be addressed in the continuum of risk and in the context of polydrug use. We need awareness raising, providing education, assistance and guidance for safer practices, including to people who use cannabis. And we need to provide access to balance and evidence-based information to all safer alternatives. And then provide access to safer alternatives. Within services, we need to change and establish norms regarding safer nicotine use. And that would be it. Thank you.
35:54 - 36:16
[Tatsiana Pikirenia]
Thank you. Thank you, Magda. This is very important. And again, we got the second presentation from the community organization. And we not only get the insights, but we get the way forward. And this is extremely valuable. Thank you so much. Mariana, over to you to your experience.
36:18 - 41:09
[Marianna Iwulska]
Maybe I will not stand up because I don't have really presentation. So please let me introduce myself. I am Marianna Iwulska. I am currently chairperson of the EUROINPUT, European Network of People Who Use Drugs. and also I am part of Polish because every input is a network which is associating user organization across Europe also individual user activists and Polish It's POLINPUT, it's Polish branch of EUROINPUT. We are currently in drug policy for over a decade, and there's plenty of research and projects we have done on our page, so I encourage you to go to see it. But first of all, I am here as a representative of myself as a drug user who went through a journey when in Poland I started using when I was 13 and then in Poland there was any harm reduction. There was only abstinence-based approach and total... indoctrination to the people that you have to throw your children from house and completely like against any harm reduction ideals. So I was 10 years in in this treatment, you can say, so I get hurt a lot. I get infected with HIV, my education gets completely lost, and all of this because I get wrong treatment, because I was constantly more harmed than treated. Then, like in 2000, when harm reduction approach came to Poland and substitution treatments, and this really changed my life. And also, implementation of harm reduction, which is user organizing and user involvement, community involvement. I forget to say that I am also a peer worker in a precursor in Magda's association, which is... I think one and only place in Poland which is currently employing drug users who are using like people not with the lived experience. This was I heard from presenters here before yesterday, but also people who are living now with the drug use. And I think it's very important. So I am very grateful that such a place exists in Poland. But it's very rare. When it comes to tobacco harm reduction, I have deja vu. I am seeing the same argument thrown when it was about drug use substitution, opiate substitution, when people were saying it's the same, it's like drug use. You are not recovering at all. Harm reduction and what it's done, it's like meeting people where they are. Not expecting miracles. You have not given condition. You have to stop first, then we treat you. It's like... reducing all harms. And I think it will be very, very beneficial to drug users to implement tobacco harm reduction to the places, to the services of drug user harm reduction. Because we have also special needs connected with nicotine nicotine use like thrombosis, which is very common in drug user spaces because of the veins and injections. And it's really killing people. And drug use is worsening this condition. And doctors are not saying this loud enough. Because in Poland, it's possible to vape, to sell pouches. So there's really a space to do this harm reduction legally. But nobody's scared. Nobody's caring enough. So I am really, really grateful for this invitation and all that I learned on this conference is really giving me a hope that things are maybe not so bad as I thought and it will get better. Thank you and sorry for so long.
41:11 - 41:37
[Tatsiana Pikirenia]
Thank you. Thank you very much, Marianna. It's not at all long. It is very, very valuable. David, harm reduction has always required institutional courage. So would you please tell us more about your experience in that?
41:38 - 48:09
[David MacKintosh]
Thank you. Yeah, I'm going to... A couple of things here. I'm very much picking up on the challenges. And I think one of the things that came out of the harm reduction session the other day is actually all harm reduction remains really quite challenging to sell. And we are selling it. And one of the other things that came out over this conference was a point Mark Tindall makes. We're actually perhaps not selling harm reduction quite as positively as we should. We've got a good story to tell. We should be a little bit more upbeat how we do that. And some of this is going to be my experience as I escaped from being a civil servant to someone who became involved in drugs work, drugs policy, harm reduction work, and then tobacco harm reduction work. But there's a principle of harm reduction that I think we need to remember, not just when we're engaging with the people that we want to work with, the people who we... our services are directed at, but the people we want to influence. So the politicians, the policymakers, in some cases our colleagues and our peers, we need to meet them where they are. We need to spend, because it's very easy, and perhaps we all sit there and we talk harm reduction and we understand the principles. We know it, we get it. We see the human rights angle, the rest of it. We know the science. For a lot of people, it's a very abstract, what is this? And if I think what's worked with me, both when I was a civil servant and my introduction to harm reduction, I'd worked in the Department for Education. One week I'm worried about higher education policy and the number of people applying for university. And then suddenly I'm working on drug policy and meant to know about needle exchanges. And at the time in the UK, is harm reduction really the best approach? And we had some magic fixals that just said, we're just following the evidence, even though sometimes the evidence wasn't that clear or contradictory. What made a difference for me was that people took me out to see services. I was very lucky. A number of people took me out, and I did go to needle exchanges. I did go to prescribing centres. I got to see people who were engaging with very chaotic individuals who, at that time, crack cocaine was the big new kid on the block. And that was incredibly useful. And when we were trying to get people to buy into policy and trying to resource things, being able to say, well, if you see this, I have been there, I have seen it work, that was quite important. What was even more important is when I could take people to see that. You know, I have taken politicians and small groups, let them go and see what these services look like. What is it they actually do? Make it relevant to their interests. And, you know, you can be quite surprised at how keen people will get. People who you would assume sometimes, because of their political background or whatever, are quite hostile. But if you give them the opportunity, you know... you get advocates. There were some times, and I'm not going to go on too long, but there were people that I sometimes think, did I sell that the wrong way? But there was a period around 2010 where the whole principle of methadone prescribing in the UK came under a lot of attack. And I can remember sitting down with someone who was quite an influential policy person in London who was saying, I'm really looking forward, we're going to row back on methadone prescribing. It doesn't work. And I could just tell, you know, there was no point just doing the whole evidence stuff around the medical side of it. They were interested in crime, so I just, you know, If you pushed me, I'd be really hard-pressed to come up with a sort of more effective harm reduction tool with certain cohorts of methadone. Now, a lot of people go, that's not the right way to go. Worked wonders in that situation, because it was like, what do you mean? I said, well, we've got all this evidence, you know, that people, once they go from this, you know, chaotic lifestyle, we get them into a methadone program, we support them, their offending reduces massively. And actually, that was just like, oh, maybe we don't want to start tinkering with that, because we hadn't considered this. Their objection to methadone prescribing was essentially moral. The sudden fear that that might impact on a target that was going to cause them trouble, oh, you did this and crime's gone up, they had a change of heart. And I think whether you're working with national level politicians, public health people, they're going to have their interests. Harm reduction has huge impact across a number of domains. Health, yes, how people feel, social integration and cohesion, which I think is something that we undersell in the UK, actually. Economic impacts for individuals and local communities. All politicians, all policymakers are going to have some interest in some of those potential outcomes. And I think it's worth thinking about what we can deliver on that. And depending where you are, it's very dependent on which country you're in, et cetera. But I think we can all benefit from thinking harm reduction can do wonderful things for the people we work with. We know that. but we also need to get better at selling it to the people who make the policy decisions, and perhaps particularly the people who have their hands on the checkbooks so they can fund services. And if we look at tobacco harm reduction services, again, mainly in the UK, These aren't, you know, tobacco smoking cessation work is not funded by the same people out of the same silo that funds drugs work, but it's actually quite modest amounts of money we'd often be after in those circumstances. There is a case to be made and going out and trying to find those people and meeting them where they are will help us working with the people you are meeting where they are. The end.
48:13 - 49:01
[Tatsiana Pikirenia]
Thanks, David. Thank you. So we have now heard five perspectives of five different people that actually comprise one large story of harm reduction. And now we are eager to open the floor to discussion. And while you are getting prepared with your comments and questions to our panelists, for a start, I would like to ask you all one question. What is one practical step that can be implemented in the nearest six months that would take tobacco harm reduction closer to people who most need it?
49:06 - 50:53
[Magdalena Bartnik]
I think that in immediate terms, I know it may sound as a not big action, but smoking is prohibited in our drop-in centre. That comes also to vaping. And maybe changing these rules and letting people vape in a drop-in centre would be a tiny step motivating to change or to think about it. And I think it's doable. In terms of actions we can undertake to see if we can really include tobacco harm reduction into our service, I guess we would need to reach out to grant owners with this question. With the whole misinformation and distrust towards safer alternatives, among people and also grant donors. It would be difficult but opening discussion with them and naming the safer alternatives as harm reduction tools that they are already providing when people use other substances, drugs, it's a reasonable option for now to see what is possible in this discussion.
50:56 - 50:58
[Tatsiana Pikirenia]
Thank you, Magda. Anyone else?
51:00 - 52:08
[Marianna Iwulska]
Yes. Yes, maybe in some organizations, paying the peers, like the people in cigarettes, they are giving cigarettes sometimes as a support. Maybe giving vapes or pouches will be better. Yeah, I encountered this situation. kind of support from organization abroad and I think it will be and also media campaign and education of course even our president is using pouches and nobody only one newspaper actually mentioned that this is harm reduction all of the others just catch up on him like he did something bad because he was using these pouches during the debate. So maybe it wasn't very polite, but we are losing some opportunities here.
52:09 - 52:10
[Tatsiana Pikirenia]
Yeah, thank you indeed.
52:10 - 52:10
[Marianna Iwulska]
Ola?
52:11 - 53:25
[Alla Bessonova]
Yes, I can add that also what can I see what we could make in our country, in our region. I represent the result that we can be a CBT therapy and motivation interviewing. It's really work for people from Varna Rebel Group. And I think this is the first motivational interviewing, it's the first step which peer consultants can make when people come to NGO. But I don't know what should we do in the national level, I mean what we can do with advocacy. because you some of you maybe can saw yesterday this film about naswai this is absurd that patches is prohibited in kyrgyzstan but naswai is legal and this is really i don't know how we can change the situation uh that's what i think what we can do david any thoughts on this i think in terms of
53:25 - 54:29
[David MacKintosh]
Practical points. I think Magdalene made a really good point. Examples of where people are doing things. And, you know, in the UK, there are settings where clinicians have found it much easier because instead of losing... The patients or people they're working with going out of the building to have a cigarette, they can stay in the building because in the UK you can use a vape indoors. I think it's getting together the different case studies and sharing them because one of the things I'm very conscious of is there actually are little examples, little pockets of good work going on. But we don't really have a mechanism yet for people to share that. And I think, I hope in the coming months that we get more examples of those and that will give confidence to other services to do this. We need to prove you can do it so that people will pick it up. This isn't something that's going to make your service, whatever you do, impossible. So, yeah, we need to share what we're doing and then maybe have more opportunities to talk about what we'd like to do next.
54:30 - 54:31
[Tatsiana Pikirenia]
Thank you. Geri?
54:32 - 55:32
[Gerry Stimson]
Yes, well, you asked about small steps, and I think the first small step is to engage people working in drug treatment and harm reduction services in an honest and curious discussion about tobacco harm reduction to get the people in the team on board for this. And the second simple thing to do is something that Ala mentioned, which is ask everybody who come into contact about smoking, engage in a discussion about smoking. I mean, a lot of things need to follow on from that about what kind of advice you might be giving, access to harm reduction resources, the constraints at a legal level and so on, all the obstacles that are there. The first is to engage the team or the peer educators or the peer workers in an honest discussion, accurate discussion about tobacco harm reduction. And the knock-on effect is you need to start talking to the people you're working with about smoking.
55:33 - 56:12
[Tatsiana Pikirenia]
I totally agree, especially taking into account that thanks to your tremendous work throughout the years, there is already an established infrastructure where peer consultants meet people. And we have to use this infrastructure to deliver the message, to deliver help in terms of smoking. We are now happy to take your questions. Yes, please. Garrett, I see here. I don't see who's there. Oh, it's Mark, okay, sorry.
56:12 - 59:07
[Mark Tyndall]
Okay, I got the mic, so my name's Mark Tinto from Canada, and I really enjoyed all the presentations and all the great work you're doing on the ground for this. I have a little bit of experience with this as far as my first introduction to this really was with a cohort of people that were actively using drugs, about 800 people, and it occurred to me as I was evaluating the annual outcomes that pretty much all the deaths were due to tobacco related illness and we had no more HIV or hepatitis C deaths at this time and the people were quite aware that there was you know big risks in the group from from smoking related but I really, that didn't resonate terribly well, even though you could show people the bad outcomes in 60 years, you know, in the 60, when you're in your 60s. But what was really much more tangible was telling people that I wasn't judging them for smoking, that nicotine is fine for them. I think if they enjoy nicotine and want nicotine, we have an option for them now that is... So the idea, I think we really need to term this as not a reduced risk thing. This is quitting smoking. We want you to quit smoking. We have an alternative for you. It's a good product. You can use it. And even in the short term, don't worry about getting lung cancer in 20 years. You'll feel better in two weeks. And this is a way better thing for you to be doing. And that should be your message. And you have to set yourself up for success. So I think putting in a patch in a kit is a nice thing to do, but it's not going to make any difference of people quitting smoking. And so we need to set people up for success. It means you need funding. to actually give people the products, at least to get them started, to support them through it, and that you can really show that you can stop, you can get people to quit smoking. It also requires longer term support, and that may mean that you need to find funding to make sure that you give out free or very inexpensive vaping products to keep people going. And I think the word could spread there. And I'm not sure, you mentioned, I think you really need to ignore the regulations in the country. So when you say, well, this isn't allowed, that's not, I mean, you're dealing with people that are using totally illegal drugs. And I don't think you should be afraid from challenging the current regulations. regulations in the country and get vaping products to people who need them.
59:07 - 59:11
[Tatsiana Pikirenia]
Thank you. Thank you for the comment. We have here Garrett and then Eman.
59:12 - 62:13
[Garrett McGovern]
Yeah, I'd just like to continue on this theme and I absolutely echo what Gerry said. I'm a GP working in addiction treatment, the guts of the last 30 years. And since I've come into the space, I've been in a lucky position that I've been able to talk to patients about smoking. But I had an advantage in that very early on in my journey of this, I was given the best vaping equipment from a vape company. They wanted to do a piece of research and it was just too complicated. But they said, look, keep all this stuff. So I had a room in my surgery, nearly the highest ceiling of vaping equipment. So people come in and I'd ask them questions and go, have you talked about smoking? I'd kind of couch vaping in there. But one of the things that struck me was I would ask them, about vaping, and probably 90% of them thought I would be no better off. And I was able to say to them, look, I can give them some links, I Google my name, because obviously I'm their treating doctor, and it was amazing, within a few weeks, I see these patients every few weeks, they would come back to me saying, I've started using the vaping. Some of them would be continuing to smoke, but they would be using the vapes. And they were getting more knowledgeable about it and said, look, from the links you gave me, I've learned more about this. And I'm infinitely more safer vaping than smoking. And it was really tragic in one case because a lady came to me. She's since passed away, unfortunately. And I've often told this story. in any of the presentations I did, she actually had a lung that had to be removed because it was getting infected so much they had to take the lung out and she'd COPD and she could hardly walk. She was on ambulatory oxygen. And she came into my surgery and she'd been at the... her respirologist that morning and she came in and I said, you're still continuing to smoke, yeah. And she said, yeah, I saw my respiratory specialist. And I said, did he talk to you about smoking cessation? And she said, yeah, yeah, he did. He said, you need to get off those cigarettes. And she herself said, well, what about electronic cigarettes, doctor? And he said, absolutely not. If you're gonna take electronic cigarettes, just keep smoking. And I thought, you know, I was really angry when I heard this because it's just completely and utterly untrue. But in the country I'm in, in Ireland, there's a huge campaign to malign electronic cigarettes, vaping, safer nicotine products, and nicotine itself. And we're seeing it all around the world now at the moment. And this lady, sadly she's since died, was given this information that, you know, possibly could have prolonged her life. And yet the person who should have known best, the person who was really experienced in her spiritual health, gave her information that was just completely and utterly untrue. So as Gerry says and Mark, you've got to have these conversations with patients. It's for far too long. tobacco and smoking has been marginalized within the wider sort of harm reduction kind of sphere and we need to kind of change that. Thank you.
62:14 - 62:26
[Tatsiana Pikirenia]
Thank you, Garrett. This is a very sad story and I believe quite a lot of such stories are happening around the world in different contexts. Eman, you're welcome.
62:27 - 63:58
[Attendee]
Yeah, I just wanted to kind of, when you asked in next six months what are the things that we can do, I think we need to do three things. This is a new space for me, I'm learning about this space, but what I understand from this space is people are finding it difficult to accept what is tobacco harm reduction. We need the acceptance of this word and of this work. And then to make this possible, we need to have the second thing that we need to have a multi-sectoral approach, which means that we need to collaborate with other civil societies, other platforms like social media, youth-led organizations, people that can spread the awareness, information. to other places. And the third thing that we need, I think we should work on something like an emblem, like anything, a right information about what is tobacco harm reduction, what does it mean, what are the things that are there, something like that. Because now when I was coming and preparing for this conference, I found it difficult to find some accurate information because it had multiple people, multiple places, multiple things. And I don't know who is going to take that responsibility of doing it, but I think maybe, you know, this platform could do something on that, or maybe KAC, because KAC itself means knowledge, action, and then change. So, yeah, thank you.
63:59 - 64:19
[Tatsiana Pikirenia]
Thank you. Yes, and the information should be adjusted to different populations of different ages, because Amman represents the youth perspective here at our conference. We had another question from here. Yes, Sergei? Sergei, you would like to ask something?
64:24 - 64:25
[Sergei Bessonov]
Thank you.
64:26 - 64:29
[Tatsiana Pikirenia]
I will translate what Sergei asks.
64:29 - 66:16
[Sergei Bessonov]
Yes, I will add, this is not a question, but probably an assumption on what to do next. That is, after we studied, we also had a problem with information. And just before going here, we had a meeting where Egor came, and we just did training for outreach social workers. That is, I saw that even those people, my colleague, for example, who was an avid smoker and did not take any attempts to move on at all, having met and been convinced of the situation, tried an electronic cigarette, that is, now they are already banned, he found it at his colleague's, and when I left here, he ordered me to bring it to him. The first is information, the second is practice. In our case, no one should be convinced that harm reduction works, that is, our people understand this. After the information, I agree, they offered to distribute vapes. It would be cool to introduce people. But, let's say, Kyrgyzstan can't afford it now, it's forbidden. And on the other hand, people don't have any moral barriers for them to acquire what is forbidden. They already acquire what is forbidden every day. find a way to put it into practice, because for Kyrgyzstan Aikos is a bit of an expensive pleasure. and find a way to help people buy this product so that they try to convince themselves. I think it would be great.
66:17 - 69:11
[Tatsiana Pikirenia]
Thank you. Let me translate. So, yeah, Sergey is a manager of Attica NGO from Kyrgyzstan. So, basically, he was a key person in our collaboration, in our research that we conducted in Kyrgyzstan. And Sergei is suggesting that there are two things that should be immediately and can be immediately done. First is information, so providing information to community, to peer workers, because he has just had this experience in Kyrgyzstan with the help of KAC, Attica's staff and the staff of other friendly NGOs has just been trained within our scholarship program. We have conducted a training. While they were having this training, one person who had ever smoked in his life got interested, and he asked Sergei to bring him from Poland vape, because there are no, I mean, vapes are prohibited in Kyrgyzstan, but Sergei says, there's one feature about drug-using communities that people who use drugs are not afraid of looking for something that is prohibited. So it's not really that height of the barrier to them. So they are eager to look for safer alternatives if they are properly informed that they would be safer and better for their health. And so the second point here is the accessibility and the quality of the safer alternatives they get, right? So it is obvious for people who use drugs, for the community, Sergei says, that when you ban something, people start looking for illicit stuff. And they are used to be looking for illicit stuff. We are talking about the community of people who use drugs. And it creates the problem. So really, access would help a lot. And Sergei says it's nonsense, actually, that in Kyrgyzstan, an illicit, a shadow product as Nasvai is tremendously available while pouches are banned. but they are like the same type of getting nicotine. Any? Yes, yes.
69:11 - 70:15
[Magdalena Bartnik]
I would just have one comment. So harm reduction services in Poland also, but all around the world in different regions are, you know, underfunded, under-resourced and for many it's even difficult to to maintain work, but what we do have, we have established trust. And in this area of knowledge sharing, of promoting safer practices, based on this trust, which is a fundament to really work with people and also to raise awareness among teams, and peers, but I do believe this is the base we can build on. Because people trust us. And we can overcome at some point other barriers.
70:16 - 71:26
[Tatsiana Pikirenia]
Yes, this indeed opens the doors to any intervention. Yes, yes, I would agree. We got a question from the online, which is about a well-trusted problem that many of the NGOs are facing these days. Someone, thank you, someone for this question. Many drug harm reduction organizations are in fight for survival and rely for funding on a limited range of sources, several of which, the sources these days, are explicitly hostile to tobacco harm reduction. And the question from the person is whether the panelists can suggest constructive paths to dialogue with organizations so that those dialogues do not threaten the ongoing work of the NGOs, so that NGOs do not lose the funding they already have and they are still able to pay their staff. Any thoughts on this, Gerry?
71:26 - 73:41
[Gerry Stimson]
I knew you'd pass it to me, but I wish I knew the answer. I mean, one of the really sad things about... tobacco harm reduction in general is how many people in public health and in some of the big donor and funding organizations in this space are supported of drugs harm reduction. But when it comes to tobacco harm reduction, there's another hat, and there's not only ignorance, but there's reticence and hostility to tobacco harm reduction. And in the drugs field, many of the donors, many of the active funding organisations, Bloomberg, Vital Strategies and so on, they are hostile to tobacco harm reduction. So there needs to be a dialogue. But I think, for me, it's actually getting on with doing it. Disregard the funders, disregard the obstacles, just start doing little demonstration projects. And that, in a way, is the history of... drugs harm reduction. Alex is sort of waving his hand, but he was involved with an illegal syringe exchange program in Australia. Many people around the world were introducing harm reduction where there were laws against needle syringe supply and so on. The first needle exchanges in the UK were done by small little NGOs without any support from government or whatever else I mean it eventually got taken off but it was the doing of it in small little pockets that experience growing which feeds up I don't think I don't think you can really go sort of head to head with some of these organizations because you're just going to get knocked back you know it's like trying to go head to head with WHO on its misinformed campaigns against THR but I think it's It's the grassroots work, which you demonstrate what you're doing. And sooner or later, your funders and donors and your local health specialists will see that, oh, that looks like kind of a good idea, and they will claim responsibility for inventing it. So I think it's guerrilla action. I know there are huge problems with getting funding and all the rest of it, but I think you've just got to get on with doing it.
73:42 - 73:47
[Tatsiana Pikirenia]
Thank you. Alex, yes, yes. We are glad to hear your comment.
73:48 - 76:30
[Alex Wodak]
Thank you. Thank you very much. And yes to guerrilla action, all in favor of that. Sometimes that's the only thing we can do, and we must do it. I wanted just to make a comment, and this follows on from David McIntosh's comments about the selling of harm reduction. There is now a literature, scientific literature, which shows that when drug treatment is given to people struggling with problems from their legal or illegal drug use, and these people also smoke, There is evidence now that we get better results both from the drug treatment if we offer at the same time quit smoking. As you've pointed out, most of these people presenting to drug treatment centres seeking help also smoke, smoke heavily. And the smoking not only damages their health, but further impoverishes a very poor population, which doesn't help them. And so when they are offered drug treatment and at the same time given assistance to quit smoking, whether it is with vaping or other means, they get better results from their drug treatment. So that's, I think, a strong selling point. Those references won't be hard to find by searching the literature. So that's the suggestion I make to you about helping to sell this policy. It's a very important policy that really needs to spread around the world. And we've had experience doing exactly what you said in Sydney with encouraging a drug treatment centre called We Help Ourselves, run by a wonderful character called Garth Poppel. Garth to establish a quit smoking service as part of his drug treatment. They did that and then I visited that centre a few months later and everyone was vaping. Staff were vaping. The residents, as they call them, were vaping. It does work and it will spread to other treatment services as well. This was the first non-government drug treatment service in Australia that started handing out clean needles and syringes way back in the 1980s. Thank you.
76:31 - 76:51
[Tatsiana Pikirenia]
Thank you, Alex. We've got one more question from online. Thank you again, whoever wrote this. How do we know the best methods to help people who use drugs stop smoking when they are often excluded from cessation research? Well, Gerry, I think this naturally goes to you.
76:54 - 80:05
[Gerry Stimson]
Gosh. Well, first let's start with what works to help people stop smoking. And what helps, I think, is helping people to switch. Cessation is too big an obstacle for many people. And we know that continued use of nicotine is not a problem. So kind of frame the approach in terms of switching. And I think that's an important point, because many people want to use nicotine, or they need to use nicotine, or like using nicotine. hundreds of reasons for using nicotine. So don't put an obstacle in a way that you've got to stop smoking and stop using nicotine altogether. Second, look at the best practice evidence about smoking cessation. And it shows that vapes are more effective than NRT, twice as effective as NRT. NRT always seemed to me to be a bit of a con This was the gold standard treatment for smoking cessation, has about a 5% success rate. In any other area of medicine, and people say, well, okay, gonna operate on you, but there's only a 5% chance that you're gonna be okay, I'm gonna give you this treatment, there's only a 5% chance it works. You shouldn't be doing that. But the randomized controlled trials now, the Cochrane review of the randomized controlled trials show the extraordinary effectiveness of vaping compared with other methods of switching away from smoking. Yes, people who use drugs shouldn't be excluded from cessation research, but I don't think in general the issues are any different. They probably are different from other populations, but the basic principles are the same, nudging people. helping people to make that gradual switch away from smoking and doing it, you know, first question you asked was about the first things you do is I said, ask questions, but you know, it's got to be done in a non-judgmental, non-moralistic way. You know, we've spent too many years trying to beat smokers into submission, too many sort of sticks and not enough carrots. And the discussions we've had today and the discussions in the session yesterday, which Dave chaired, I thought there was an exciting new approach to smoking cessation emerging from the experience of NGOs, peer-led NGOs, very different from what we've seen into the formal medical or smoking cessation services. good relationships with people, honest relationships with people, and not trying to sort of say to them, quit or die. So I think there's a model emerging from the NGOs and the experience I heard about yesterday and today, where the whole experience of community-led, peer-led organisations can bring a whole new flavour to how you can help many different populations shift away from smoking.
80:06 - 80:10
[Tatsiana Pikirenia]
Thank you very much. Any reflections on that?
80:14 - 81:35
[Alla Bessonova]
Yes, I want to answer this question. How do we know the best method? Take a look at the result of our research. We have a good experience to make methodology for research, for assessment, and we understand how we can find the best ways, the best methods, work with the people from community. And And also, I think this is very important. Again, I want to note gender-sensitive approaches, because unfortunately, harm reduction program for people who use drugs, they don't have gender approaches. But what we can do now, if we make such kind of research and ask people what they want we do with the harm reduction smoking, it will be the answer of this question. Just ask people and involve people who use drugs, NGO, community-led NGO, and the research and study process.
81:36 - 81:37
[Tatsiana Pikirenia]
Indeed, yeah.
81:37 - 82:09
[David MacKintosh]
A very quick point on that. We should build that research evidence. There isn't a lot for this particular group that was mentioned in the question. But what we do have is a lot of evidence that people who smoke in that group would like to give up. There's a big unmet need there that services aren't addressing at the moment, and that's something we should remind. If you ask people in that group, would they like to give up smoking, lots and lots of them say yes, but they need some help to do that.
82:09 - 82:22
[Tatsiana Pikirenia]
Yes, and we have seen attempts in our research in Kyrgyzstan. We have seen that people tried, but as they don't get support in their attempts, they fail, unfortunately.
82:23 - 82:58
[Magdalena Bartnik]
Yeah, I would say also asking people whether they would stop, it's one thing. but acknowledging how important smoking is, or nicotine use, and having this message. You don't have to... It's not about nicotine. Nicotine will stay with you. But appreciating and acknowledging how important nicotine use is in their lives. And I mean nicotine use in the form of combustible cigarettes.
82:59 - 83:17
[Tatsiana Pikirenia]
Yeah, thanks. Um, I got a question to Mariana, Mariana, you because you're sharing personal experience today. So can you share with us please, what exactly made you switch from combustible cigarettes?
83:18 - 84:14
[Marianna Iwulska]
Yes, really it was my health because I feel like my lungs are working better and also economical reasons because in Poland vaping is cheaper actually than normal cigarettes. And I came to this conclusion that I need to start vaping by myself. No doctor never asked me even if I am smoking, really, through my 26 years of substitution treatment in Poland. Yes, thank you for this question, but I really think that we are missing out on this. We have these big substitution treatment centers where they really aren't doing harm reduction that should be done there. So thank you.
84:15 - 85:12
[Magdalena Bartnik]
Yeah, I would just add that personal stories, personal experiences, this aspect of life-changing processes is so important also how, in a way, we talk about the change. Because it is game-changer, it changes the lives and quality of life. I think we need to hear these stories and be open to them within the community. with individuals, but also in general. I was talking yesterday that physicians who switch themselves and understand and experience the improvement are more keen to recommend it to the patients because you have your own personal experience how successful that was.
85:13 - 85:42
[Tatsiana Pikirenia]
Thanks, very valuable. Indeed, well, we are having a large group of people who use drugs who are visiting opioid agonist treatment points, and they meet health professionals there. Do you think that that would help if health professionals working on opioid treatment sites would say a word, would recommend, would ask about people smoking?
85:44 - 87:07
[Marianna Iwulska]
Yes, for sure, because even me, I didn't know. I am more educated that most people are in harm reduction. I wasn't sure is vaping really so safe. I was thinking that some diseases like is also because of vaping. I have to educate myself. And also, maybe people aren't trusting all personnel in the substitution clinics, but they are trusting the doctors. They are trusting, I mean, in the medical field, what they are saying. So any recommendation from the doctor will be very, very helpful. And any knowledge, because there is anything, like... no but nothing that the vaping is better even in the media here it's demonized like oh the youngs are vaping and like it's showing like a bad thing thanks a lot um um we have just a couple of moments for closing remarks from all of you any message anything you would like to say to the wider audience
87:11 - 88:28
[Magdalena Bartnik]
Yeah, like trying to, I mean, harm reduction itself is a concept, a paradigm, which still has an opposition, drug harm reduction in this field. So tobacco harm reduction, this is even bigger challenge. I guess we need to buy alliances, maybe small, tiny alliances with one doctor, one physician at the beginning, the one that is in OET program or someone else. And I really believe that micro-scale actions for now are feasible and planning for broader actions and broader activities. But it is so challenging to really, with this misinformation, with this lack of clear, evidence-based messaging with people being confused, even doctors, it's really difficult to have this message that people should change their behaviors to feel better, to improve their health. Thank you. So it's a challenge.
88:30 - 89:12
[Marianna Iwulska]
Yes, after all these events that I heard, I am just really personally convinced that with little, little effort, the tobacco harm reduction implementation to drug use harm reduction, it could bring really the biggest health improvement since the invention of substitution at all, because Yes, really we have mostly like lungs and thrombosis, veins, diseases, and it's harmful tobacco in this form, combustion is killing us. So thank you.
89:16 - 90:30
[Alla Bessonova]
Two, three years ago, we never paid attention to tobacco, to smoking problem. We just work with people who use drugs and practice drug use harm reduction. But now we can see that this is also a problem for people who use drugs, I mean in terms of their health. And I don't know really how can we... involved this in our daily work in the harm reduction process in our country but I think we should try to make the same step because it's similar with drug harm reduction and try to speak and help people to change their to change their smoking and find something else to save their health and make life more quality for people who use drugs, especially for women.
90:31 - 90:31
[Tatsiana Pikirenia]
Thank you. David?
90:32 - 90:58
[David MacKintosh]
thank you um i think practically we need to build on you know build our networks in this room and outside our room when we can find a good doctor or something we need to share our successes we'll get little case studies and then we can start making real progress when we share those agreed yeah well i'm excited and optimistic i really think we're we're heading into new ground here and uh
90:59 - 92:00
[Gerry Stimson]
you know, as Alice said, you know, just a couple of years ago, they started to think about these issues. It's just a year ago we did this survey. The conference here has never had these sorts of discussions, and we've had three important sessions here on bringing tobacco harm reduction to new sectors. You know, it's early days, and I hope you all look back to this meeting and and the discussion we've all been having and say, yeah, it kind of, it started there. So yeah, I think, you know, this is going to be something that's really going to take off. The advantage that the drugs harm reduction organizations have, and TB and HIV, is that they've already got established networks. You don't have to set up something new. You've already got very important networks of communication nationally and regionally and internationally. So once you start feeding these ideas into those discussions, I think you're going to see a gradual and eventually a big change in approach to smoking in a whole range of different services.
92:00 - 92:19
[Tatsiana Pikirenia]
We needed to hear that. Thank you. Thank you very much. I have nothing to add apart from that our speakers deserve your support now. Yes. Thank you. Thank you all for participating and for sharing. Thank you very much.