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0:00 - Intro
1:03 - Canadian smokers seem to support the idea of lowering nicotine in cigarettes
7:05 - A new study has found that e-cigs are an effective quit aid for Australian smokers
12:35 - China's market regulator has released national standards for e-cigarettes
23:35 - Many doctors have misconceptions about e-cigarettes
24:15 - Brent Stafford of RegWatch interviews Sud Patwardhan
46:06 - Closing remarks


Hello and welcome to GFN News on GFN.TV. I’m your host, Joanna Junak.

In today’s news,

…Canadian smokers seem to support the idea of lower nicotine in cigarettes - We will hear what Canadian expert, , thinks about this approach.

A new study has found that e-cigarettes are an effective quit aid for Australian smokers . Dr Colin Mendelsohn will tell us more.

China’s State Administration for Market Regulation has released national standards for e-cigarettes. Albert Chan from Hong Kong joins us.

Many doctors have misconceptions about e-cigarettes, a study from Rutgers University has revealed.

And after the news, Brent Stafford of RegWatch interviews Sud Patwardhan a UK licensed Medical Doctor with close ties to India.

But first: tobacco use is still the leading cause of preventable death and disease in Canada. A recent study from the University of Waterloo says that most smokers, ex-smokers and vape users support lowering nicotine levels in cigarettes, believing that this would make them less addictive. We asked David Sweanor of the University of Ottawa what he thinks about these findings.

David: I think it's important to understand the social psychology behind the responses we get on surveys and not take some survey results as seriously as some people like to do. So, for instance, we have known for a very long time of desirability bias. People give responses according to what they think they should be saying, what the interviewer would like to hear, because we're trying to present our best selves. So if you ask people about their diet, they will hugely misrepresent what they eat to make it look like they're far healthier. We make it look like we exercise more, that we spend more time with our kids, that we pay attention to important things. So it's no surprise, we've known since the 1970s that Canadians report consuming three times as much broccoli as we grow or import because broccoli is seen as a good thing. We know that when we ask people about their smoking that if you take the total number of self-reported smokers, multiply it by the average number of cigarettes per day they claim they smoke. That in countries even like Canada, which are generally pretty honest people, about half of the cigarettes are unaccounted for. I mean, just massive underreporting because of desirability bias. People are not wanting to say how much they smoke or whether they smoke. When you ask people questions like would you accept these changes in behaviour you run into that or changes in the product, you run into the desirability bias. And people saying of course, I'd be fine with that, but also with what's known as hyperbolic discounting where we're willing to accept changes in the future or claim that we will, that we wouldn't accept now because we discount the future. So if you say, would you like to be doing sit ups every day starting now? Most people say, well, no, not really. If you say starting a year from now, would you accept that you should be doing sit ups like every day? Of course, if you're choosing lunch today, would you rather have the salad or the lasagne? People pick lasagne. If you say there's an event coming up next October, we need to put the diet together for people. What should I put you down for, salad or lasagne? People will say salad because they're talking about their noble future self. So when people say things like they'd be willing to accept these big changes in products or their behaviour, I don't think it means very much. I think that we need to see it in relation to the real world of why people report some of the things they do and will they act accordingly. But in addition, we need to understand that people are making decisions or taking positions on something that they don't necessarily know very much about. And there's a truism in that people can only make as good a decision as the information available to them allows. And if they've been informed that nicotine is this hugely deadly thing, that's what's causing the cancer and the heart disease, and they don't see it as that's what they're trying to get from cigarette smoking, of course they'll say you should remove it. Just like many people think the harm from cigarettes is some sort of additive that cigarette companies purposely put in because they're psychopathic. So we need to understand what do people know about why they would be using nicotine? We would need to understand what are they really willing to do as opposed to what they're saying they're going to do. But perhaps most important to try to understand why would health researchers be focusing so much on something like should we remove the nicotine from cigarettes as this one off Grandiose Masterstroke planned and smoking without putting into context of what do we see from other abstinence approaches to dealing with human behaviour and what are the opportunity costs. So if we try to do something like this, what are we not doing instead? And a classic example of that is the United States Food and Drug Administration's tobacco program, where they've talked about reducing nicotine. It would take them years from the time they start something like that to the time they could finish because of the rule making procedures and the litigation that would ensue. So even if they could do it, which they've not been able to do for twelve years, even if they could start it, which they've not been able to do for twelve years, it would take another decade before they could get anywhere. Contrast that to what could be accomplished if they simply started to tell the American public the truth about relative risk and encourage people who are smoking cigarettes to get their nicotine from low risk alternatives and said what those alternatives are. They could do that today, that could be impacting health by tomorrow. So when we focus on these long term strategies that are probably not even viable, and even if they were viable are going to take years and years and years to do. The real cost is all the sensible strategies, all the things that could really make an impact, all the things that are based on where we've had success to date in improving health by empowering people and understanding where they're coming from, meeting them, where they are. All those things are being lost because of this focus on how are we going to impose our moral views on the behaviour of others, how are we going to force them to change, how are we going to use coercion despite all the evidence that coercion just doesn't work very well?

Joanna: Researchers at the Australian National Drug and Alcohol Research Centre at the University of New South Wales have shown that vaping nicotine may be more effective for quitting smoking than nicotine replacement therapy and stop smoking medications. These findings are consistent with previous analyses of the effect of nicotine vaping on real world smoking cessation success undertaken in the United States and the United Kingdom. Dr Colin Mendelsohn, tobacco treatment clinician, founding chairman of the Australian Tobacco Harm Reduction Association, joined us to explain why this study has important implications for Australia’s policy on vaping.

Dr Colin: Well, thank you for asking me to comment on this important Australian study which examined whether quitting smoking with vaping is more effective than quitting without vaping, and this was in a real world study without support. The study used data from the 2019 National Drug Strategy Household Survey, which is a nationally representative survey conducted every three years and 1600 smokers were founded have tried to quit in the previous twelve months, which is about half of the smoker's question. The main findings were that those smokers who tried to quit with vaping were significantly more successful than smokers who hadn't used vaping. The overall quit rate for the vaping smokers was 68% higher than the quit rate for those who haven't used vaping. The quit rates for those who source their nicotine from overseas, which is how most Australians actually get their nicotine, was 124% higher. So more than double the quit rate of those who didn't source nicotine that way. And that suggests that those smokers and neighbours are more likely to be using nicotine and I think that's why that rate is higher. So overall I think we can say that roughly those smokers who used vaping to quit smoking were twice as likely to succeed roughly compared to those who use other methods. And these figures are in line with the population studies we've seen in the US and the UK. The survey also found interestingly that vaping was the most popular aid for quitting and reducing smoking in Australia, which is interesting because of the very harsh restrictions on vaping in Australia and the difficulty with accessing vaping products. So in spite of that, smokers are finding ways to vape and doing so in spite of all the negative messaging they're hearing. The frequency of Vaping wasn't mentioned in the study, but we know from other studies that daily vaping produces significantly greater quick rates. So we can be confident that people who vape daily would have had significantly higher quit rates. The other interesting thing is that the results from those who are actually better than from all the other quit aides. So those who use pills were about 22% more likely to succeed than those who didn't use pills. But all the other methods actually seem to have reduced quick rates. So people who use NRT had a 25% reduction in quitting compared to those who didn't use NRT. Those who saw their doctor had a 12% lower quit rate than those who didn't see their doctor. And those who used quit line had a 50% reduction in quit rates compared to those who didn't use quit line. The highest quit rates were when vaping was combined with a smartphone app like smoke free, which is a vape friendly smartphone app. And the quick rate from smokers who use vaping and an app was three times that of smokers who use neither. So there was an interesting side message there. But this study is important because as to the evidence that vaping is an effective quitting aid, and this study in particular shows that it works in a real world environment in the way that most people use it without support. And a lower study like this can't prove that they can cause people to quit smoking. It adds to the evidence base that we have. And when you have all the different types of evidence together, such as this kind of population study, randomized controlled trials, observational studies, the decline in smoking rates in countries where vaping is popular, the use of testimonies, when you bring all that together, I think the evidence is now fairly persuasive that vaping is an effective quitting aid.

Joanna: China's market regulator has approved new mandatory national standards for e-cigarettes, marking another milestone for China's vaping industry. Under the new framework, vaping devices will be developed according to open and transparent rules, which must be adhered to across the whole industry. When applying for a production licence, vape manufacturers should possess the necessary capital, technology and equipment and commit to meeting the industry’s requirements. The new regulations will go into effect on October 1. Joining us today is Albert Chan from Hong Kong, the consultant to FactAsia, an Asia-wide consumer advocacy group promoting adult informed choice. Albert will explain why China has decided to introduce the new national standards for e-cigarettes - and what impact they will have in Hong Kong.

Albert: Okay, perhaps it would be useful to provide a little bit of background to it. The process of regulating what we call alternative tobacco products include vaping products, includes heat not burn. e-cigarettes, et cetera, has been considered by the Chinese government for quite a few years. Meanwhile, a couple of manufacturers have started producing such products in mainland China. And so there was quite a bit of urgency to introduce regulations on these new products. As a matter of fact, at least two companies involved in the production of these products are actually already listed in the stock exchange in Hong Kong. So it's an international market. And so I think investors would be very keen to know the framework going forward. So that's another reason for the urgency to have some regulations. And that's why, in November last year, the State Council of China, which is the highest governing body under the Premier, announced that it will regulate such products and outlining a few main principles. This announcement by the state council, of course, only contains very high level principles. But the announcement is extremely important because it is the first time the Chinese government officially made no decision to regulate rather than prohibit such products. It was very interesting timing because about a month before that, around about October last year the Hong Kong government and the Hong Kong Legislative Council passed a long delayed draft legislation to ban a blanket ban on all types of alternative smoking products including e cigarettes, heat not burn, vaping, et cetera, et cetera. Apparently, I think all of you are aware that Hong Kong, although it's part of China, we operate rather independently in just about every aspect of government. Except, of course, defence matters, military matters and diplomatic matters. So smoking and health, of course, falls under likelihood issues. And therefore, Hong Kong has 100% full autonomy on how it wants to regulate. But it's very interesting because the timing was Hong Kong decided in October to ban it. The Chinese government decided in November to regulate it. So that was the background. The next step after the state council decision was a fairly long process for the Chinese monopoly, the tobacco monopoly in China, to prepare, draft, and issue detailed regulations. In march this year - They worked very fast - In March, last month, in fact, the STMA, the state tobacco monopoly administration, issued several guidelines regarding the licensing of not just manufacturing, but the sale marketing of these new tobacco products. Without going into all the details, there are two very important principles listed. First: They would only allow products which do not have nontobacco flavour. Put in layman terms, they will not allow flavours such as fruit flavours or even menthol in these new products. Secondly, which is universal around the world, is to have strict regulations banning the sale to the minors and marketing as well to minors. So these are the two main principles laid down by the state monopoly, which is, of course, under the state council. So what we would expect to see in the next few months would be a more detailed implementation, guidelines and dates and so on. Because since they are already manufacturing enterprises in China, producing these products, the government decided to give a great spirit before the actual legislation takes effect. So that's the latest development in China. The impact on Hong Kong: As I explained, Hong Kong enjoys a high degree of autonomy in these matters. And also, since the decision of the law to ban the products was only implemented - was passed actually in October, with a six month effective date, which means end of this month. So from end of this month, these products, not just the e-cigarettes or the liquids, but the devices which are used to consume those products, will also be prohibited from import into Hong Kong. Of course, it will be prohibited from marketing sales in Hong Kong. However, the Hong Kong law is interesting in that it allows a little bit of gray area, which is that people who actually consume the products, smokers will not be caught in the new legislation. The law is silent. Also, what happens if a person in Hong Kong is found smoking e-cigarettes on the street? Definitely, under the new law, he is not committing any crime. The law enforcement officers, of course, they have a right to ask the person where the product came from. But it's kind of quite vague as to whether the smoker actually has liability if he is unable to prove the source. Because if the product is illegal, cannot be sold in Hong Kong, the person might have brought it back from overseas, which, in fact, is illegal. But once the product is inside Hong Kong and he is smoking it, the law is rather vague and in fact silent on whether the person is committing a crime. But I believe it is probably not. Of course, we have to wait to see if there's a genuine case of prosecution and the court will decide on this matter. It's a legal matter. I'm not a lawyer, so I can't really make any concrete statement on this. So going forward, I don't think the Hong Kong legislation will be reversed because it will only be implemented effective end of this month. So it will be at least a few years. I'm just speculating before the government or the lawmakers in Hong Kong would reconsider the matter in light of what's happening in China. So that's my, really, summary of what's happening in China and Hong Kong. Final point is, I think, the decision by China to regulate, ride and ban the product carry international and global significance. Because, as we all know, China is the world's biggest market for tobacco products, conventional products, whereas the new products, according to some estimates, it's only taking up maybe 1% of the entire market in mainland China. There is a huge potential for growth, for people to switch from conventional to alternative products. In terms of volume, of course, it's huge. It's the biggest market, biggest country, with the biggest amount of consumed tobacco products. It will be interesting to see what the other countries would have not made a decision on the subject matter, what they will do, and how the negotiations in WHO would turn out in months and years ahead. So I hope that gives you a pretty clear summary of the state of play at present.

Joanna: According to a study from Rutgers University, many US physicians incorrectly believe all tobacco products are equally harmful and thus are less likely to recommend e-cigarettes for people seeking to quit smoking. Researchers asked physicians how they would advise two different patients who wanted to quit smoking. The study revealed that physicians were significantly more likely to recommend e-cigarettes for people considered heavy smokers while recommending medications approved by FDA for people considered light smokers. We will discuss these findings with experts in the next episode. And now, we go over to Brent Stafford and his guest, Doctor Sud Patwardhan, a UK-licensed medical doctor with close personal and professional ties to India. In June, Sud will be joining us at GFN22 on a panel discussing the possible benefits of nicotine. In today’s interview, however, Sud will explore how doctors can be helped to provide patient-centred smoking cessation advice. Over to you, Brent.

Brent: Hello Joanna, thanks for that. And hi everybody, I’m Brent Stafford and welcome to another segment of RegWatch on GFN.TV. The unrelenting war on safer nicotine products continues unabated despite growing evidence that reduced-risk products such as nicotine vapes are proving to be highly successful for millions of smokers trying to quit. According to new data published by the Global State of Tobacco Harm Reduction, there were 82 million people vaping nicotine worldwide in 2021, up dramatically over 2020 by nearly 20 percent. Yet, there are still an estimated 1.1 billion smokers across the globe, with the vast majority living in low- and middle-income countries. What obstacles are in the way of THR projects from reaching these smokers? Joining us today to discuss this question and more is Dr. Sudhanshu Patwardhan, founder and medical director of the Centre

for Health Research and Education in the UK. Dr. Sud is a British-Indian, U.K.-licensed medical doctor who is passionate about helping people quit risky forms of tobacco. For the past two decades, he’s lived and worked in three continents, doing senior roles in research, strategy and policy in the pharmaceutical and tobacco industries. Dr. Sud, thanks for coming on the show.

Sud: Brent. Thanks for having me.

Brent: First off Dr. Sud how would you rate the state of tobacco harm reduction globally?

Sud: In one line. It's a very bad shape. It's in a very bad shape.

Brent: Why is that?

Sud: How long have you got?

Brent: Well, we got 20 minutes.

Sud: Good. So, look, we can start digging into some of the the sort of factors that play have played over the last few years in in how tobacco harm reduction has been perceived, how products have come to the market, how the market has responded, how consumers have responded on one hand, how regulators have responded, how industries have reacted, and how the tobacco control community has looked at these products with a lot of certainty and uncertainty depending on which part

of the world you are. So you put all these things together and that takes us to what is behind the way tobacco Harm Reduction products have been received or not received. And that kind of leads to the point of and hence tobacco harm reduction as a broader kind of approach to public health is in a bad shape. And you yourself stated that I think I'll just throw back the data at you 1.3 even billion users of risky tobacco forms. So not just smoking, mind you, we're talking about oral tobacco and other forms

of smokeless tobacco, predominantly used in South Asia, for example, in Africa. And you mentioned 80 plus million people using nicotine vapes. And maybe I'd throw in a few more tens of millions using heated products, heated tobacco products and snus. In Scandinavia, you're still not crossing 15, 20% of that otherwise population of risk to tobacco users. So that says a lot.

Brent: Yeah. So if you look at globally the whole issue, would you say then that safer nicotine products have made a dent or are you saying that they haven't?

Sud: The if you look at the glass half full or empty, I think they have made a little, little dent. But I think there's a long way to go. And the work we all do in different ways is trying to address that. Because if you ask me what drives me in this work is simply the fact that consumers should be at the core of this entire conversation. And oftentimes they're forgotten.

They're not given the information. Products are not available or affordable for them or they don't know about these products and those we should be advising them about. These products are either not aware of them or ill informed, misinformed even. And then that takes me to my favourite topic, which underpins the entire tobacco harm reduction problem, and that is the nicotine illiteracy that's prevalent across the sections of the broader stakeholder community, including medical doctors.

Brent: Okay. So nicotine, illiteracy. Did I hear that? Correct.

Sud: You write it is nicotine literacy or illiteracy, depending on what? What you mean here. One is where people understand that are confident about the fact that it is nicotine. That's the addictive substance in all forms of tobacco. Risky or not risky? On the other hand, it is not the carcinogen. It is not the one causing the diseases that are caused by risky forms

of tobacco. I keep on saying risky forms, mind you, predominantly the combustible forms of tobacco, 5000 plus chemicals and so on. But nicotine is not one of them that's causing these lung diseases or heart disease or cancer, particularly. And not knowing this is what I would call nicotine illiteracy.

Brent: Dr Sud, please share with our audience some of your background. I think it would be helpful to have that understanding as we dive into these issues.

Sud: So I am from India. I trained in medicine in India, did my post-graduate studies in California. I was working in Singapore for a couple of years in the pharmaceutical industry, and that's when I saw there was a role to be a role advertised in the UK with a large tobacco company and they were talking about harm reduction and they wanted to establish the

framework for assessing future, less risky products and so on. So I interviewed in Cambridge with British American Tobacco, and I used for my preparation this massive big book called Clearing the Smoke, and that was the Institute of Medicine Report from 2001. And that really opened my eyes myself on what they proposed. And they were talking about how nicotine could be delivered in a safer form. They were looking at how the risk from current tobacco products could be reduced and assessed and then be made available to current users of these products who cannot or will not quit. And that kind of got me into the space of tobacco harm reduction, perhaps much sooner and much earlier than most of the people who are in this space. And I feel very privileged to have been there at that time.

Brent: You founded an organization with your wife, the Centre for Health Research and Education. Tell us about that and the types of projects you work on.

Sud: So we started the Centre for Health Research and Education in 2019. I left the industry Dr Puja, my partner, she is a practicing physician. We used to argue at home almost every night on the topic of tobacco Harm Reduction, mind you. And that was primarily this is before 2019, because I would come back home over the years of my work and in the in the policy, in the standard space, excited about my discovery that nicotine is not the problem and my new found literacy nicotine. And the argument was not about the facts about it. It was more about, yeah, but this is not being understood by the practicing clinicians that she would see around her. We founded the centre primarily to bridge this gap we felt was very wide. The gap between policy, which is sorted in a way in the U.K. and the practice by clinicians, by other key influences of decision makers and influences of consumers as we like to call them. So we said, well, we have to bridge this gap. We understand the language of doctors. We understand what the policy is saying. Can we bring it together?

Brent: All right. So Dr Sud, let's talk a bit more about nicotine specifically. I wanted to share that. I love nicotine and as a former smoker and now committed vapor, I see nothing wrong with it. Yet it's framed as the demon drug. Why is that?

Sud: That's a great question. And I think if I look at it from my personal experience and I've thought about this and that, my medical education is a good, good point to start. Back in India when I was in medical school, we were taught about tobacco and the harms from tobacco, but it was often interchangeably used with nicotine. So if you think of an equation here, it's like tobacco equals nicotine, equals smoke equals cigarettes equals cancer. And that kind of just they would just clubbed it all together. There was no effort made by the teachers or by us even to disentangle these into their constitution, into their constituent parts, let's say. So we would assume that this is all one thing. So, hey, if somebody is saying nicotine equals tobacco, equals cancer or bad stuff, advise patients to stop it. Now, what worsened is that worsened that was that nicotine replacement therapy products, NRT nicotine gums, patches, lozenges. These products were not that available are still not available in India across the country. And even if they are in textbooks of medicine, you're not taught anything beyond the point saying, yeah, there are some products called nicotine replacement therapy products. You should prescribe them to people who are trying to quit and that's it. There is nothing beyond that. There is no level of handholding, education on how to use these products and so on, but also not giving them that sort of that powerful message that, look, it is the nicotine they smoke for, but they die of something else, which is the in the case of smoked products, the 5000 plus chemicals of which 150 plus carcinogens. In the case of oral tobacco products, the few tens or hundreds of chemicals that they add to make it tasty and attractive, but also with no regulation, no control. So this is never taught. And the doctors are thinking, hmm, I may be able to prescribe nicotine replacement maybe for a few days or a few weeks. No. The way you look at it now, now that I'm enlightened and nicotine literate, as I like to call myself, I see that that demonization has slowly been washed out from my brain because I've thought about it and I look at the evidence base around me and say, I've managed to disentangle the two. I can see that if I can deliver nicotine in its clean, safer form to those who are addicted to nicotine, but are suffering from the consequences of consuming it in a risky kind of package cigarettes or berries or tobacco, I might be able to help them live a healthier, longer, happier life. And then that that is kind of where it comes to me, for me.

Brent: So who is responsible for entangling nicotine with, say, cancer?

Sud: This is a very tricky one, and I don't want to get into a blame game here, mind you. But what I would say is that when communication was done about the harms of tobacco and cancer, obviously one big one or even cardiovascular disease, lung disease, it might have been, I would hope not intentional, but just sloppy communication. Nobody took the effort to say, well, actually, it is not this. That is a problem, not nicotine. That's the the disease causing part. Yes, it is the addictive chemical. I think this nuance is often lost. And look, I think about a communicator trying to communicate this message and I can imagine the challenge they face. I but yeah, but this is the problem. But this is not but this is the addictive substance. You might just jumble folks up. So you want to just keep it simple. Hey, look, it's all very bad to stop using it, but for sure that's not as simple and as easy as we know. Having known the harms of tobacco for the last three or four or five decades in this country, in the UK and at least three decades in India, you still see the millions consuming hundreds of millions in the case of India and they are not stopped and there is a reason for that. They're addicted to that form of nicotine in the way it's delivered, the way it's consumed. And this demonization, wilfully or wilfully, is leading them to not access safer nicotine with confidence.

Brent: It's interesting because it appears to me both somebody who covers this and also as a layperson, that public health spends millions and millions of dollars more and more time and effort demonizing nicotine, then demonizing heroin. Or other harder drugs.

Sud: Now, let me let me sort of look. I can respond to that. But more importantly, I think what's happened is public health has spent a lot of time trying to ensure, and rightly so, ensure that new users of these products don't emerge in the market. So there's been a lot of effort over the last few decades in terms of all the global tobacco control activity, which is to prevent initiation of tobacco use. Good job where it's really failed. And I can see the effects of that now, not just in India and South Asia and the low and middle income countries, as we like to call the Lmics, even in the UK effort for cessation support or quitting support has either been half-hearted or it's all contingent on funding or lack or availability of funding. So I think public health has failed there. They have not understood that there are existing people who are still consuming very risky forms of tobacco. We're going to lose at least ten, 15, 20, 30 years of their lives prematurely. And no effort is made to invest energy, effort and

messaging on cessation. And before you get too excited or carried away or worried that I'm trying to say cessation as a medical term, please don't misunderstand me. Tobacco harm reduction can be a pathway to cessation, reducing harms from tobacco by switching over completely. The point is about quitting risky forms of tobacco. You call it cessation or I call it cessation. You call it harm reduction. At the end of it, if the consumer is using nicotine in a significantly safer form, that's a good job done for me. And I think that's where public health is failed.

Brent: What is this urban epidemic that I've seen you write about with regards to LMICs?

Sud: The urban epidemic I was referring to, if I'm not mistaken, is a very complex picture. There is a whole new generation of young folks. And I and I don't know if you've been to or if you have seen on television or whatever. If you go to these urban IT parks of business parks and or Bangalore or Delhi or Hyderabad, the folks working in those parks, in those parks will see a lot of them smoking outside. That is their way to get their break. So this is a young, healthy population of educated folks, you would assume, and smoking is pretty prevalent there. But that's not the only problem, mind you. The other one is women smokers. And that that's particularly close to my heart, because I think that there is a whole new generation of of the women population of half the population of a country which is just a young population, a population that has such promise and hope. And they are smoking for whatever reason, be it, for managing their weight, or at least what they think is they're doing is they're managing their weight or appearing to be cool, appealing to be equal to their male counterparts. Then maybe a lot of theories around why they do it, but that doesn't change the problem. That is, they're doing it. And the impact of that on their own lives, their future generations is going to be obvious. And this is not addressed. I don't see this being addressed or talked about apart from the work we did last month on the International Women's Day by actually raising an awareness campaign about break the bias. We said in our communication, we said break the bias about health care practitioners when they see their women patients don't think that they may not be also having a tobacco problem to deal with, offer them support, give them cessation tools, including nicotine replacement. And we were surprised by the positive response we got. Doctors came back to us and said, Wow, yeah, we never thought of tobacco use, especially among urban women. We need to even ask about it. But now that you've raised the profile of the issue and sensitized us to it, we obviously see that that's something we have to address head on. So that's an example of the urban epidemic of tobacco smoking in in countries such as India, which are already going through a massive epidemiological but also population level change.

Brent: So do you think that or does research show whether or not tobacco reduced risk products are top of mind for these people? Do they even have an understanding of what air is and that there's, you know, products available?

Sud: I think they do know that there are products and many of the this generation I'm talking about so we are talking about a very specific kind of subpopulation within a country as vast as India or any other country. And I'm sure you've seen some of the research that's out there, the urban population, those who are well-read, well-informed, do know about electronic cigarettes, for example. Some may have heard about heated tobacco products, depending on how much, whether they travel internationally. They, of course, come out to Europe. They, of course, see that's been used by people in the public and they are curious. They take back products, but there is nothing to buy at the local shop. So again, they are kind of like, okay, fine, I go back to my smoking. And so they are aware they have dabbled with the technology in the product, but when they go to their doctor, I think what happens, an Indian doctor is going to tell their tell their smoker patient. You are not sure about this. These are banned by the government. Right. So I don't think you should even try that. I mean, by quitting your cigarettes. But for sure, don't go into this other new-fangled device. And herein lies the problem.

Brent: You've mentioned this several times now in the interview, Dr Sud, and it seems to be that you believe the biggest problem is with the medical community.

Sud: No, I wouldn't say that. And look, I mean, as my peers in the medical community, I respect the amount of time they have to treat and manage their patients complaints and the symptoms and provide the best health care with a good intention. So that is never doubted. And we have seen that in the COVID epidemic. So I would never say that. But I would say, though, that is are an important component in the decision making process of consumers. The consumers of tobacco, who will come to their doctor as a patient are there and in many cases presenting with a problem that's a result of their tobacco consumption. In many cases, you've come with a cardiovascular condition, you come with diabetes. There's always and if you're a smoker, there is for sure a big chance that that smoking is contributed significantly to that disease outcome or the disease itself. So for doctors to not deal with that is not right is all I'm saying. And then I'm not saying the doctors are not doing it on intention or for no reason. It is because they haven't been given the tools for them to feel empowered and what I like to call nicotine confident for them to say, here's my patient, here is your pill for your blood pressure, but here is also your nicotine replacement therapy. Come back to in seven days and 21 days. And here is the app you need to download to ensure that you will get enough prompts every day. So whenever you feel like smoking, it's going to tell you, actually go for a run and take a sip of water, take your NRT. And that's not what's happening. That's all I'm saying.

Brent: Well, no, but I do know it's important thing, but I think you made it a bit clearer there. So if we were to get more medical professionals to be nicotine confident, then that would make a bigger difference.

Sud: Definitely. Look, I mean, we are talking about 1.3 billion or so people out there who are consuming risky forms of tobacco. You're talking about a few million health care professionals. If you add all the doctors, the dentists, the clinical staff. I'm just looking at it as a problem. Which can I reach to? 1.3 billion people. I wish I could, but I can't. Can I reach 10 million health care professionals around the world? Maybe not. But if I reach a smaller section of that health care professionals, especially their trainers at the medical school level, every professor of medicine of surgery of OBGYNs is churning out over a life span of teaching hundreds, thousands of medical professionals. Same with every clinical profession. If we were to empower these trainers with simple nicotine literacy, nicotine confidence, think of the long term impact of this in terms of their behaviour, how they will address their patients. Real, real needs, unmet felt, but real needs of the patients in quitting tobacco. Of course, this is one of the solutions. The rest of the solutions are then making sure that the products are available and affordable and appealing enough for these people to actually take on and stick to. So but it's an important part of the solution for sure.

Brent: Dr Sud, I know you'll be speaking at the Global Forum on Nicotine Conference in Warsaw, Poland, this June 16 to 18. Why is a conference like CFN 22 important, and what might your message be?

Sud: The Global Forum on Nicotine is perhaps one of the only conferences where over the last decade it has brought together. All imaginable, all possible stakeholders, whoever, whoever role who was taken in the tobacco nicotine conversation, so be it. The industry, which is often kept out of some of these conversations and increasingly so. And by industry, I'm not just saying tobacco industry or one particular part of the sector. I say any industry is welcome and that's what JDRF and does the Global Forum does. Consumers are present in large numbers. And I have said for the last you know, for the entire interview, consumers are often forgotten. This is one place where consumers are not forgotten. They are central to the conversation. It's a it's a time for global forum of on nicotine to really be very confident about its very central role in in in supporting this global consumer movement. Joanna: Thank you Brent and Sud – looking forward to more discussions in Warsaw this summer. That’s all for today. Thanks for watching and see you next time, for more tobacco harm reduction updates and Brent’s forthcoming interview with Michelle Minton, a senior fellow at the Competitive Enterprise Institute and panellist at GFN22. Goodbye for now!