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00:00 - Intro with Will Godfrey
00:44 - Dr Sud Patwardhan discusses attitudes towards THR amongst healthcare professionals
02:26 - Impact of medical training on smoking cessation support from healthcare providers
05:06 - Should healthcare providers focus on NRT or vapes when helping smokers quit?
09:44 - India bans vape products, whilst a wide variety of high-risk tobacco products remain available
14:37 - Could medically licensed vape products reassure doctors?
18:25 - Closing remarks



Hello everyone, and welcome to this short gfmtv episode. I'm will godfrey of Filter. And today I'm joined by Dr. Stood Patworth, who's been a fixture on the THR, seen for some years based in the UK, but has done significant work in a number of countries with healthcare providers around smoking cessation and THR, and published a recent paper titled confidence in Nicotine for Tobacco Harm Reduction bridging the Policy Practice Gap. Stood, thanks so much for joining us today.


Thank you so much for inviting me to this bill.


So, going to put a few quick questions to you. First of all, I'm just fascinated to know what is your broad assessment of the level of tobacco harm reduction knowledge among the physicians you've worked with?


I have worked with physicians across many continents now, and there is one consistent theme that seems to emerge. And this I first discovered in 2010, when we first did the survey among general practitioners in the UK and Sweden, where we found that over 40% of those we asked the questions about their understanding of nicotine, responded with statements regarding their perception that nicotine in tobacco products caused cancer, which it does not. Let's get that out of the way first. So that's when we first identified it, I guess that was the first time ever documented through a survey of clinicians that this was indeed an issue. And there have been surveys since by us, by my team in India, in Bangladesh, more recently in Bhutan, there have been similar independent studies done by folks in the US. Which was published two years ago. All of them consistently show the same level of misperception about nicotine among healthcare professionals. I started that work with general practitioners, as I mentioned, in 2010, but then subsequently the same kind of research has been done with other clinicians specialists or family physicians and we find the same level of misperception.


Obviously, that's a huge problem when physicians and health care providers are so misinformed. So what are some of the solutions to that problem?


The fact that they are misinformed, now that we have confirmed it through various studies across the world, that's one consistent finding there. The fact that they're misinformed means that we have to start at where they got this misinformation from. Is it intentional or is it part of how they have been trained or not trained regarding tobacco cessation and how to deliver tobacco cessation to their patients? So we go back to the basics. You go back to medical school and dental schools where clinicians and other paramedical specialities where clinicians are trained. I remember from my medical training back in India that yes, of course, in India, especially if you think of it, india has even today, nearly 300 million people consuming all sorts of risky tobacco products. And we can come back to that later if you want, but the fact that these products cause so much harm, be it oral cancers from the smokeless tobacco products primarily, or the lung diseases and cardiovascular disease from the smoked products. We see that as training clinicians day in, day out, right, left and center. And the message given to clinicians in training is that tobacco causes all these diseases. So advise your patient to quit tobacco and that's it. It just stops at giving that one liner message, say, advise them to quit. If they are brave enough. The teachers will also tell you that, yeah, there are these products called nicotine replacement therapy products, prescribe them to these patients and they should be fine, then they'll quit. And there is no level of training, no level of handholding and proper education on how to prescribe nicotine replacement, how to understand the challenges of withdrawal from nicotine when somebody attempts to quit, how to manage cravings of nicotine that consumers of these risky forms of tobacco have. And there is no understanding of how to deal with these patients as humans and address their problems when they come with these withdrawals and cravings and give them solutions that are sustainable. Which means that these folks who are trying to quit and they have got the message that yes, you should quit, and they say, yes, we're going to quit now, and they end up trying all sorts of products, licensed, not licensed, behavioral support in a very haphazard, disorganized manner, and most times fail to quit. And that just worsens the problem. It doesn't solve the problem and they become even more difficult to find, it more difficult to then quit subsequently because they have not had the right level of support to begin with.


Yeah, regarding nicotine replacement therapy, your recent paper does focus significantly on that, given the demonstrated smoking cessation advantages of vapes over NRT. What's your thinking suit with that emphasis?


Look, nicotine replacement therapy were the first form of tobacco harm reduction. If you think of it in a pure practical sense, this was over 30 years ago when the first forms of nicotine replacement were invented in the forms of the form of gums, then patches, more recently lozenges and mouth sprays and so on. They have finally, after a long time, they have finally been accepted by clinicians in the tobacco control community as a way for smokers and tobacco users to quit tobacco. So nicotine replacement is now, as you know, accepted by the who, the World Health Organization, as part of a model Essential Medicines list. So that's a good starting point. And as I said, the first licensed tobacco harm reduction product in the UK, in fact, was nicotine replacement therapy. So the UK's enlightened view about nicotine, the fact that it's not the nicotine but the tobacco, and the harmful constants of either smoked tobacco or oral tobacco products that cause all majority of the tobacco related diseases, was a very important inflection point in the history of understanding tobacco control and giving solutions to the millions of people consuming these products. So to ask you a question. Nicotine replacement in a broader sense and accepting that as harm reduction is finally accepted by at least the enlightened ones. And I start with UK as an example. I talk a lot about that in my paper, actually, that you referenced, and it's worth going through that at some point now, am I going to draw false dichotomy between nicotine replacement therapy products versus electronic segments or vapes? And I would resist doing that well because I'm not hung up on what product it is. And if it's more efficacious in controlled or even real world settings, that is the one I'm going to offer at the cost of other products. I wouldn't follow that approach. And that's purely, purely because as a medically trained person, I'm looking at the harms that tobacco causes globally. I want to put the consumer of tobacco products at the center of this conversation. I would rather offer that consumer whole range of products, starting from nicotine replacement therapy products, beat gums or patches, lozenges, micro, tabs, mouth sprays, two electronic cigarettes which are properly regulated. In the case of the UK, we fortunately have that situation where the market is generally well regulated. Of course, we have recently seen incidents where companies have finally, after a lot of pressure from various groups, sort of admitted that they were perhaps putting in products with much higher levels of beyond what was accepted by the regulators. And I think these are the issues that still keep on cropping up. So would I say that for a patient coming to me as a patient asking, look, doctor, what should I use for quitting tobacco? I'm not just going to offer him a vape or her a vape. I would say, look, these are the various product options and look, Will, it's not even about just nicotine replacement, right? We should also be ensuring and if you look at the studies, I suspect you're referring to the NEJM paper where Ecigarettes were showed to be twice as efficacious than nicotine replacement therapy products. But do you remember what was the most important common thing across those two arms of the study? And that was behavioral support. So offering the right level of behavioral counseling along with adequate nicotine replacement, and I stop at the word replacement, I do not call it therapy or nicotine replacement. E cigarette give the consumer adequate form of safer form of adequate nicotine for long enough so that they will not, they will manage their cravings, they will not have the withdrawal. And these things don't stop within a day or two of one quitting, by the way. These things take a few weeks or months for the consumer, for the patient in this case, to overcome their urges for nicotine. And if you can manage the nicotine needs adequately for a long time, enough and enough behavioral support to change their habits, their routines, that's increasing the chance of sustainably quitting, which means not relapsing. And so in that case, I would say, look, they need to have all the options available, but properly regulated.


One country where all the options are not available is, of course, India, which has completely banned vapes. Specifically. Regarding your work in that country, could you tell us a bit more about the landscape of tobacco use there and also the situation regarding THR and health care practitioners?


Yeah, so let me rewind a bit in terms of the tobacco use profile in India. As I mentioned earlier, nearly 300 million people in India consume tobacco. Tobacco products come in a whole range of product forms, from combustible tobacco in the forms of cigarettes and beadies and hookah, to oral forms of smokeless tobacco products, be it Kenny, Zerda, marwa, Gudka, and so on, and misery. And there's a whole range of products in between. So the variety of products is massive. There is one common thing across all these products. They're all toxic. I wouldn't start even saying that, oh, one is less than the other. They're all toxic in their own way, and any consumer of these products should be given the help to quit these products in a sustainable fashion, in a sustainable manner. So with that in mind, and of course, let's connect back to the smokeless tobacco thing I mentioned earlier. Smokeless tobacco use in India is the driver of oral cancer. And unfortunately, it makes India the capital of oral cancers. In India, you have a few hundred thousand people dying every year from oral cancer, which is completely unacceptable and mostly driven from the oral tobacco use in that country. So the problem is there. Now, how does one solve, how does one begin to solve this problem? And it's such a complex problem, given the variety of players in terms of manufacturers, the cottage industry making some of the older tobacco products, the much organized industry as well, which makes some of the other old tobacco products, the big cigarette companies and the big manufacturers. So a whole range of stakeholders, the very fact that the Indian government owns nearly 30% in the largest Indian tobacco company, along with another multinational company, ironically. So there's a whole bunch of stakeholders who have a stake in the Indian tobacco landscape, and then you sort of just oppose that with the findings from a paper that we had published three years ago where Indian clinicians are equally having the same level of misperceptions about nicotine tobacco, but more importantly, they have never received the formal training in tobacco cessation. So, as I said earlier, the only thing they advise their patients is to quit. And the poor Indian patient will say to the clinician, yes, of course I will quit. And then they have nothing to take back. That brings me to a point I mentioned in the paper that we referenced, accessibility, affordability of appealing products for adult Indian tobacco consumers is not there. So the the price back of a nicotine replacement gum versus that of a good capac, the gum is ten times 20 times more versus the good capacity the smokeless tobacco pack. So how do you expect that poor patient who is earning maybe RS100 per day max in that case, to be able to buy RS100 worth nicotine gum for their daily requirement? So there's a whole issue with affordable, accessible harm reduction products. Now, I do not want to not answer your e cigarette question. I think in this sort of a complex environment, these products were banned a few years ago and there's a whole bunch of reasons behind it. The fact of the matter is the Indian broader public health and medical community still has the same level of misperceptions about nicotine, which means that landing a product such as an e cigarette completely unregulated is only going to make the matters worse in terms of rampant uptake, potentially. And we do see and hear a lot of anecdotal stuff now about especially young adults in India taking a piece of cigarettes. And that really bothers me. It's a matter of great concern and we shouldn't ignore that situation. Ultimately, prohibition doesn't work. But regulation has to be done in a way that allows current smokers or current users of oral tobacco products the right level of range of options, safer nicotine options and behavioral support, and the right kind of regulations to ensure that young adults and non smokers or non tobacco users do not pick these products up. And that balance, to strike that balance, needs a much refined and multi stakeholder dialogue. That's not happened in India. So I don't want to just give a solution saying oh, they should do this, they should do that. I think it's a matter of really having that level of honest conversation that can lead to the right level of decisions by the government which are suitable for the local population. It can't be a copy paste from the western world either.


Regarding that question of regulation and access, you write in your paper, there may be an argument for the medical licensing of ecigarettes and other nicotine products which would instill confidence in physicians and patients alike. That's potentially controversial, of course, when a prescription only model in Australia, for example, has been heavily criticized by THR advocates, and when a commercial consumer driven model where anyone can buy the products has seen large scale switching from cigarettes in many parts of the world. Would you want to elaborate on that?


Absolutely. I'm glad you asked that question and I did not put that line there for no reason. I wanted to ensure that the right kind of conversation happens around the kind of regulation required for future safer nicotine products and their role in tobacco harm reduction, mind you. So let's move away from Australia because that's an easy one to kind of go and say, well, look what happened there and folks are not happy about the very fact that it's only medically licensed. Let me bring you back to the UK. And I would say, look, even in the UK, the fact that ecigarettes and weights have been around, properly regulated to the extent they can be in a consumer goods environment under the TRP regulations. Has UK become smoke free already? Well, it hasn't, yeah. There are still six and a half or 6 million people in the UK smoking deadly forms of tobacco, cigarettes, essentially. So ecigarettes have been allowed in the consumer goods space in a variety of product formats. I mean, you've got a whole plethora of products here that you can buy from the marketplace. It's a consumer's world here, really. In the UK, if you think of it in terms of nicotine replacement, and I use nicotine replacement not as nicotine replacement therapy, but alternative nicotine products, that has not led to the complete switch away from cigarettes to the safer forms as a way to completely stop using nicotine or just completely quit cigarettes, at least. And here is the case, then I would say that if there were medically licensed ecigarettes available as well, and please note the word as well. So I'm not saying it is one or the other. It is not an or question. It's an and situation. I hope happens that will give a lot of clinicians and those who are sitting on the fence about these products confidence that look, the fact that it's medically licensed means that it has gone through that level of scrutiny, that level of critical appraisal by the medical regulatory agency. In the case of UK, the MHRA, and then the prescribing clinician, the pharmacist in the shop will have the confidence to say to their patients, why don't you try this product? This is licensed for this purpose and this is how you use it. And of course, there has to be a lot of education of these health care practitioners on how they give that information as well. But you know what, it's important to understand that there are still people out there who are smokers, who have perhaps tried some of the existing market products, but also have been scared by the scale stories, some true, some not, regarding vapes and what they cause. Having a medically licensed product as well on the market is going to give them that confidence that, look, okay, I am not that risk taking. So I'm not although I smoke, I'm not that risk taking to try this newfangled product in the market, which is just a consumer good. But I know that my doctor is prescribing this Ecigarette for me, if it is available like that, I'm going to give that a shot and then give their best to that. That's, again, increasing the chance of people quitting. Again, I say all I care about is as many people consuming risky forms of tobacco should be given the help to quit. We shouldn't come in their way. I'm giving them an option of medically licensed e cigarettes is one of those ways of doing it.


Great talking to you as ever stood. And thanks so much for joining us today.


Thank you so much. Bill, please.