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0:00 - Intro with Joanna Junak
0:51 - Dr Sudhanshu Patwardhan discusses a recent study looking at marijuana and nicotine use
5:04 - More Americans smoke marijuana than tobacco
7:52 - Nicotine use in the context of other consumable substances
12:51 - Do experts need to be better informed about a holistic healthcare approach?


Hello and welcome. I'm Joanna Junak, and this is GFN News on GFN TV. Today's program: Dr Sud Patwardhan, a UK licensed medical doctor with close personal and professional ties to India, will comment on a new study on using peripheral marijuana together with nicotine. The study examines nicotine use among customers at a medical marijuana dispensary and found that close to 40% of these medical marijuana users also use nicotine. We ask Sud Patwardhan, a UK licensed medical doctor, what he thinks about these findings. Thank you, Sud, for joining us. Can you give us your thoughts about this study?

Sud: Well, look, this is not surprising. It's been very well documented over decades that there is a tendency among those using substances or abusing substances to also use other substances at the same time. So there is no surprise there. And the author has also very clearly acknowledged that. I think the big finding here is specifically about the use of cannabis that's used as part of cannabis used for therapeutic purposes, as they call it, CTP, in this article by Steinberg at all. And the interesting finding there, and I'm going to read from the sort of summary of what they've done so that I'm not missing out on anything, is that users of CTP, the cannabis that's used for therapeutic purposes, are more likely to use nicotine products than the general population. Again, as I said, that's been already known for just cannabis smokers in the past, but in this case now, they documented that for cannabis for therapeutic purposes, users and the route of administration and this is where it gets very interesting. I think the route of administration of nicotine products is related to the route of administration of CTP. So what they're saying is that if aerosolized CTP, which is they're using it as a vape that's being used by them, what does that mean in terms of them using vapes for consuming their nicotine as well? And that makes for a very interesting kind of correlation that they're trying to draw from that, and it makes for some very new insights into user behavior. And also, what does this mean in terms of the staff in the dispensary where the cannabis for therapeutic purposes is administered? What does it mean for them to be able to advise the users or clients in this context from a harm reduction point of view?

Joanna: Does this use of vape cannabis products have implications for current users of combustible tobacco who are looking to quit smoking?

Sud: I don't think they're going into the discussion about whether cigarette smokers, that is, smokers of combustible tobacco should or should not be getting into or should not be using CTP, in this case, cannabis, for therapy purposes, for quitting combustible tobacco. I think the point they are trying to draw it as is about the polyuse or at least the use of different substances by the same user. And here they're saying that if that user has used cannabis in the past, smoked cannabis in the past and is now using cannabis in a vape form, how do you then start drawing parallels in the same user who has been smoking combustible tobacco and now potentially vaping instead of smoking? And that's where the kind of thinking is going in the article, if I was to interpret it that way. So to answer your question, it is not about whether combustible tobacco smokers should be now switching to vape cannabis? Of course not. I think that's not what the article is talking about. As a medical doctor, I would not start getting into this very complex topic by saying that one should be substituted by the other. These are substances that can be used misused and we know the effects of these products. So the point here is that if one is a smoker, as in inhaling combustible form of that product, be it cannabis or tobacco, for sure there is logically, based on the chemical profile of what is being created, if you don't burn it but actually aerosolize it, what is the likely chance of that making it less risky? And in this case they're talking about, well, if a smoker of cannabis is switching to vaped form of cannabis in these clinics, wouldn't it be logical also to support these? If there are smokers of combustible tobacco as well, wouldn't it be logical to support them to also use weight forms of nicotine and not combustible forms of tobacco?

Joanna: According to the results of a recent gallup pool, more Americans smoke marijuana than tobacco. Why do you think marijuana use has overtaken tobacco use in popularity?

Sud: So let me try and answer this with the knowledge I have about this. There was a very interesting paper by Holland Koslovsky a few years ago and I would love to pull it out and perhaps we should have that as a separate conversation. But what it was talking about is how perception and usage, if I was to remember this correctly, perception and usage of marijuana over the decades and the legal frameworks for allowing such use, as we know in many states across the US. More than 20 states, cannabis is now either legal, medically, allowed to be used, or even for recreational purposes. Now this is very interesting in the context of how tobacco control and tobacco use has evolved. And that paper talked about how the trajectories of these products they use, their regulation and public perception has changed over the decades. So to answer specifically on which one is more prevalent now versus 510, 1520 years ago, I think, more importantly, one should understand, and this is where public health, I believe, really struggles globally. So I'll make two points here. One is public health in the interest of public health, in this interest of the health of the public, if I may say, should look at not single drug or substance use and abuse. Poly use of substances has been well documented over the years and people mix and match various substances for various purposes. These are all very addictive substances. Let's not get that wrong at all. Let's not forget that. But they do use different chemicals for different purposes. And we know that reducing one use, people tend to end up consuming the other substance and vice versa. And if you're talking about polyuse, you're looking at a very complex mix of chemicals consumers are consuming to meet their needs. I want to argue the needs are have been created because they're addicted to the use of that chemical. And then over time, the addiction takes over. But the fact remains that people are consuming a lot of chemicals on a daily basis, a whole mix of them. And depending on the societal attitudes towards these substances and the availability, accessibility, and in some cases affordability of these products, consumers behave accordingly. And that's how it evolves. So the US. Is seeing a very interesting spike in the use of marijuana from what you're saying. And I think there's enough data to support that because of the availability of, in the case of many states, medical cannabis and say in the case of many other states, just recreational purposes.

Joanna: So where does nicotine use fit in this context?

Sud: Thanks to the great effort of tobacco control folks over the last few decades, cigarette smoking has significantly gone down but not completely eradicated in the US. We still know that there are 20 to 30 or 40 million people smoking cigarettes even today in the US. And now put that in the context of the availability of reduced risk products, alternatives that offer nicotine in a much safer delivery format, and in this case, let's focus specifically on electronic cigarettes. Now, the way ecigarettes have come to be regulated in the US. The uncertainty around them, the valid concerns about youth uptake, but the missed opportunity in offering ecigarettes as a very clear acceptable form of tobacco or smoking cessation in the US. And the missed opportunity there of giving that off ramp, as some would call it, from smoking into lesser risk in nicotine products has been pretty much missed by public health. And so that sends the wrong message to consumers, right? Consumers will smokers, in this case, smokers of combustible tobacco, to be very specific, smokers of combustible tobacco will not get that message that there is something less risky available for them to continue using nicotine in a safer form. But they will, of course, see a whole parallel track of products being made available, in this case medical cannabis. And they think this means that regulatory wise, these are perhaps more okay. And that may just be a perception that may be sort of trickling into the masters and they start believing that this may be perhaps okay. The good news about this article, let's kind of zoom out a bit, if I may. The good news from this research group, dr. Steinberg and company at Ruggers. I think they're doing some phenomenal research. If you look at the work they've done in the last few years, I think this is groundbreaking in so many ways. They are not looking at the users of these various chemicals, psychoactive substances in isolation. They're looking at the use of these risky products as a whole in a sort of more holistic fashion. And they're also then sort of overlaying that on what is the role of healthcare providers or service providers, in this case, the staff at the clinics where medical cannabis is available? What is the role of service providers, healthcare practitioners, in advising their users or clients or patients on what choices to make? And so this sort of reminds me of another paper that Dr. Sein bugen company did last year, and that was a validation of what we found in our work, what I've done over the last decade in the UK, sweden and India. And that paper was talking about perceptions about misperceptions, rather about nicotine among healthcare professionals. And it highlighted that between 70% to 80% of the doctors that they had surveyed in that study and thousand plus people that I looked at thought that nicotine in tobacco products causes cancer, which it doesn't, as you know. But that very fact that there is such level of misperception among experts means that they are not in a position to advise their patients or their customers, their clients, whatever you want to call it, in the context of where they're operating. It is difficult for them to give proper advice to their patients or to their users. Now this we found. I want to then connect this to what we are doing in India recently, where we're working with mental health professionals and there is a huge problem with substance use, mostly opiate related problem in the northern parts of India. And I was working with some of the psychiatrist work, psychiatrists working in some of these clinics. And we wanted to raise their understanding of tobacco cessation, tobacco harm reduction. And repeatedly we would get pushed back by then saying, you know what, but tobacco use is not the problem, the problem is the opioid use. And we said, yes, of course, if that's what you're there for, you will focus on that. But let's not forget that many of these users are also tobacco users. And as we know, mental health patients, for example, in the UK, we know those who consume tobacco, they die ten to 15 years earlier than the general population, not because of their mental health condition, they die sooner because of their, in many cases, tobacco related diseases and harm. So not acknowledging and not addressing tobacco use in those who abuse substances such as opiah is a missed opportunity. And the work that this paper that you're referring to, and the group that's doing this research is trying to kind of zoom out of single use issues, but also sort of saying, what does this mean for the patient for the user. And let's not think about our own personal ideological agenda. It's about can we help and benefit the user to live a healthier and longer life? Isn't that what it should all be about anyways?

Joanna: You mentioned misinformation around the health impacts of vaping. Do you think experts need to be better informed so they can accurately advise patients?

Sud: Absolutely. Experts need to be informed with the right scientific evidence. And some of the research that's now coming from the group such as Dr. Seinberg and some of these groups is hopefully putting a spotlight on the need to not think of single substance use as the only problem. It is definitely an issue and it's a public health issue for sure. But many times real patients or real consumers, real users, present with more than one issue that they are trying to sort of grapple with. And if you're trying to address only one of them, most probably something else is going to go wrong somewhere else. So unless you look at as a person as a whole, you're going to miss out on really making a tangible difference to their longterm health outcomes and then that's a massive missed opportunity. So hopefully some of this work will put a spotlight on that. We'll make people aware and people hopefully will incorporate that into their daily practice. Now that's a massive leap to make. Now this is research. Then it will have to kind of make to policy and to guidelines for healthcare practitioners or service providers. And then there should be some training of these health care providers and service providers to actually incorporate into their daily practice. And then we'll start seeing some real benefit to the users of these services and these safer products out there.

Joanna: Thank you, Sud. That's all for today. Tune in next time here on GFN.TV or on our new podcast for more tobacco harm reduction updates. And on Thursday, Will Godfrey of Filter will tell us about a recent speech by Brian King, the day director of the Ata Center for Tobacco Products. Thanks for watching. I'm listening. See you next time.