In social media posts, official speeches, press releases and memorandums, WHO has repeatedly made claims which appear to contradict the evidence available, and which conflict with statements made by reputable public health institutions. Simply condemning the WHO’s science on tobacco harm reduction is not going to shift the dial. The panel will investigate the WHO’s science on THR, and address the organisation’s concerns, bringing objectivity and evidence to bear.
Transcription:
00:11 - 02:51
[Clive Bates]
All right, folks, we're about to get cracking on this session. It's going to be a kind of investigation of WHO science. And we're going to use this format. We're going to try and challenge the idea that WHO is a straight broker on science. And we're going to break it into three sections. First of all, we're going to have opening remarks from the panel. Then we're going to go into, what is the problem with the science here? And it indeed is the problem. And we're going to have a little bit of fun with that, people reacting to statements that WHO has made and whether those are true and fair statements. And they may be, and they may not be. They may be true but unfair. So we're going to try and get a sense of what the problem is. Then, as a group, we're going to try and investigate the question of why is this happening. If we find that the science isn't reliable or is misleading in some way, the question is why? Why would they do that? And I want to kind of crowdsource the answer to that question from this audience as much as from the panel. And then finally... How could this be rectified? How could this be reformed? How could it be changed? And again, I'm looking for crowdsourcing ideas. Is it a matter of governance? Is it a matter of a different form of scientific engagement or what? We're going to spend most of our time on the what part of this exercise, looking at what the problem is. I'm going to come back to that in a minute. But for now, I want to just introduce the panel. Thomas Nahde from Imperial Tobacco. Riccardo Polosa, I think you all know, from University of Catania. Summer Hanna from British American Tobacco, or BAT, I think we now call it. and Roberto Sussman from University of Mexico, who's a physicist and, as you all know, a very effective advocate. So this is going to be our scientific panel, but it needs to have a high audience involvement in this, because we've found in the past that we get the best results when we bring the audience in. So first thing we're going to do is we're going to take some opening remarks on the subject that we are dealing with. We're evaluating WHO tobacco harm reduction science. I'm going to call first for Thomas to give us his sort of opening thoughts. You'll need to pick up a mic, and then we'll go through the panel, and then we'll get on to the what is really going on section of this session. Let's go.
02:52 - 06:30
[Thomas Nahde]
Thank you, Clive. So first of all, welcome on a Friday afternoon. So I'm pretty, pretty happy to see so many faces here. And actually, Clive, let's, well, conscious we are on a Friday afternoon, let's bring in some energy and let's celebrate some of the successes of the WHO, if I may say that. really, and bring in the energy. Actually, when I was asked and invited to this panel, actually, I was remembering a story that my mum once told me. And actually, she said, when I was a kid of about eight years, I got absolutely obsessed about those circular scars literally everyone in the family had on their upper arm. Literally everyone. Everyone had them except me. Even my older brother, he had it, so it couldn't be a generation thing, I thought, as a kid. So I sat like, I was begging my parents to, how can I get that scar? I really want to get that, right? You have it, exactly. So everyone had it. So actually, my mom said, love, don't worry about that. I'm having two of them. So I'm wearing one for you because you won't probably get one. And she was right. So that was okay for me then. What I want to say with that is I didn't get one because as we all know, 1980, the WHO declared the war on the smallpox epidemic to be won and actually to have the end game on the war of smallpox epidemic and having the smallpox eradicated, right? So actually now, 45 years later, we are still talking tobacco control, and I'm emphasizing the control there rather than an eradication. And they are applying the same narrative of a war on nicotine use and a tobacco epidemic. So let's pause there for a moment because smoking is not a communicable disease. It's a consumer behavior, right? So with that, that narrative of a war on a behavior is pretty misapplied, I believe. And I'm very conscious that it's actually like part of the urgency, right? And I understand that. But still, that is demonising smoking and it's actually stigmatising people who smoke, right? And not only that, it is substantially limiting the options if you're using a narrative of eradication rather than control, right? So I believe we need way more consumer centricity And we need to really understand the behaviour of those people who smoke and really dig deep into that. And I'll leave it there for a moment because I was very conscious that Clive wanted us to have very short statements for the beginning. So over to you.
06:30 - 06:35
[Clive Bates]
The guardian of the audience here. Short statements, please.
06:35 - 06:50
[Riccardo Polosa]
I'm glad you started with the smallpox vaccine so there will be no overlap. By the way, I'm very honored to be part of this panel. It's me.
06:52 - 07:00
[Clive Bates]
That's really bad. Any resemblance to an amateur hour is purely coincidental here.
07:00 - 10:27
[Riccardo Polosa]
Okay. I'm very honored. I'm happy to be part of this panel also because it was just about time that we scrutinized why WHO in relation to a specific topic of tobacco harm reduction because it's not true that WHO is doing everything wrong. There are things they're doing wrong and things they're doing in the correct way. But in the Department of Tobacco Control, I think it's doing particularly bad, in my opinion, And particularly the way he's producing, misinterpreting signs and creating misinformation. And let's be clear, unfortunately most of the time WHO is doing this on purpose. It's misleading actively. And how? It's very simple. They select references, they distort evidence, they go through tactful omission, and with only one single objective, in my opinion. The objective is to create their own science, a science that support the abstinence only narrative and paradigm. And this has consequences. This has terrible consequences for millions of smokers that would otherwise switch to much less harmful product. And yes, in the clinical world, this would be called with a single name, negligence. Simple as that. In term of why is this happening, I think we are going to get into this discussion extensively. I think it's a toxic mix of different things, in my opinion. There's not a single reason But it's a combination, it's a deadly combination of institutional inertia, all these bureaucratic organizations just like to operate in their own settings and they don't like changes. It's all about political convenience. it explains by itself, and this is it mainly. At the end of the day, W.E. Joe is stuck in an outdated paradigm which just supports abstinence-only narrative. In conclusion, I think what is really needed is that we have a responsibility as scientists, as researchers, as public health advocate to demand that all the evidence should be subjected to rigorous appraisal and with transparency and should be communicated with clarity and honesty. Oh, you have yours.
10:28 - 12:46
[Summer Hanna]
I like the direction that this is going, that we all thought about this a little bit differently as we were reflecting. As I was preparing for this, I started goofing around on my cell phone and it had me thinking about technology and technology transformation in the last 20 years and how 20 years ago I would have used T9 word to text someone after 9 p.m. when the minutes were free. And there I was, scrolling aimlessly, looking at the whole world. And how, as technology transforms, it challenges our beliefs, our mindsets, and it affects our behaviors. And I believe that the WHO recognized that progress and technology transformation would eventually evolve to really change and transform smokers' lives. And that within that, harm reduction strategies would be the third leg of their approach. And that's why it's reflected in the FCTC. And that transformation and that openness to possibility, what it is is it's the scientific mindset. And it's seeking new data. It's keeping an open mind to new information and a variety of possibilities that challenge your beliefs. And it's actively participating in open exchange on those ideas. And it's not having all the answers, but it's the curiosity and the openness to retest your hypothesis in light of new information. And Article 1D, I think, reflects this. But unfortunately, over the last 20 years, we've seen that scientific mindset and that curiosity erode. And harm reduction strategies have not adequately been explored or addressed. So what's happened now is that we have leading jurisdictions of tobacco control, countries like the UK or New Zealand, with progressive regulatory frameworks and remarkable declines in the rate of cigarette smoking. Meanwhile, the FCTC is still reporting, 20 years later, over 1 billion smokers. And to me, that's a failure of creativity and scientific process. And so while it's clear that there might be many views on the best approach to tackling smoking, it is, in fact, in everyone's interest to be a part of the solution. And that's only possible through open dialogue, a robust scientific exchange that includes all viewpoints, and collaboration to truly end cigarette smoking.
12:48 - 12:53
[Clive Bates]
Excellent. Thank you. Roberto? Thank you. Roberto...
12:53 - 16:34
[Roberto Sussman]
Hello? It's difficult to say something that was not said by my colleagues. But I would like to reflect on history, how the emergence of the FTCT. And essentially, we have to recognize the first international treaty on health issues. So it's a great victory at the time, and it's a victory that encodes years of previous struggle against spreading about the word, the scientific research on the harmful smoking. And also at that time, the tobacco industry played a role that is not honorable at the time. And it was a great success. But it was a great success 20 years ago. And things have changed. But the narrative and the paradigm remains fixed. And this is a problem. This is not outlandish. You can see it in many political issues. And here I talk as an amateur political scientist, but as a personal experience, I remember being in Cuba. For us Latin Americans, the Cuban Revolution was also something apocalyptic. It was a small country defeating American imperialism, et cetera. I know that on time, this narrative is also criticized. But at the time, I remember even as a student really believing about the Cuban Revolution, and I'm talking about the 1980s. Now, I'm in Cuba as a visiting professor in 2008, and I hear the same narrative. You know, we defeated the Americans' imperialism, but at the same time I see how the Cubans live in poverty and in oppression. So we have something similar in the case of the WHO. The narrative is of a previous, apocalyptic victory, but the reality is, as people have said here, one billion smokers, and a war, a war mentality, like also the Cuban Revolution had a war mentality. We are defending ourselves from the American imperialism, and people had rational cards to buy food, like in a war state. So here again, it's a war against the industry. The COP meetings are closed because the industry might put some molds there and disrupt the whole... the whole thing that we are doing. So it is a parallel situation. It is an old narrative and a reality that completely denies that narrative and a technocracy that resists the change. And in this resistance there is becoming more and more aggressive what I fear is the insecurity of this technocracy. And my hope is that the market, the increasing market of these products, in spite of all this information, the market is growing. And there will come a point that things will have to change. And that will include also the WHO.
16:39 - 19:53
[Clive Bates]
I'm just going to say I wasn't going to actually make any introductory remarks, but I wanted to pick up something Roberto said, which I do think the narrative has changed. I was involved in 1999 to 2003 as an NGO in the early days of the FCTC. and WHO's engagement is with Derek. And there really was a laser focus on health. It was like, how do we deal with the problem of smoking? Because that is the generator of disease and death. We're talking at the time about a billion deaths worldwide. What can we do about that? How do we generalize good policy around the world? Now, I feel, and this is testable with this audience, I feel it's become a vehicle for resisting innovation. There's been innovation that solves this problem or addresses this problem partially in a way that is unwelcome to many of the participants in this debate. Through reduced risk technologies, smokeless tobacco products, and through policies that basically enable consumers to make these decisions themselves in a you know, a relatively lightly regulated market focused on consumer protection rather than behavior change. That has been unwelcome, and there has been a massive rearguard action against that. And that is now the preoccupation of the delegates, that type of innovation and the companies that are behind it. And I think that's a terrible shame. I think it's squandering an amazing opportunity. It's not inconsistent with the goal of smoking cessation and prevention of uptake. It's an additional third strategy for which there is a very strong scientific evidence base. of which WHO is basically in denial. And I'm going to say that by way of introduction to our next section because we're going to have a little bit of fun here. We're going to try to terrorize our panel because I have extracted over the weekend 37 statements from WHO from their e-cig fact sheet and their world no tobacco days and their 100 reasons to to quit and we now have the 37 statements that we're going to respond to because we can't talk about who and science unless we're specific about what they're saying we can't just talk in generalities about this so this little charine of terror here the the the panel members are going to select a number between 1 and 37 out of this then we'll call the number up and the panel member who picks the number is going to respond. And if you like their response, you can applaud or whatever, or we'll call to the audience for assistance or other panel members or whatever, okay? So it'll probably be a total disaster, but let's give it a try anyway, shall we? Okay? So who wants to go first? Is there any bingo prize? It's like there's going to be bingo prizes, there's going to be everything, there's going to be... Who's going to go first? Right, I'm going to choose someone. Ricardo, go. All right, call out a number. What's the number?
19:53 - 19:54
[Thomas Nahde]
He's drawing one and giving it to you.
19:54 - 19:58
[Clive Bates]
Seven. Tech team, give us quote number seven, please.
20:07 - 20:22
[Riccardo Polosa]
This is too difficult to address. What shall I say? Evidence reveals that these products are harmful to health and not safe. Where shall I start? It's going to take one hour.
20:22 - 20:24
[Clive Bates]
No, you've got to be really fast.
20:24 - 22:10
[Riccardo Polosa]
Very fast. The evidence reveals exactly the opposite. And most of the evidence that is confusing is confusing simply because The population that has been subjected to studies are also previous smokers, so there are confounders effects involved, so many of the negative health effects that have been measured are basically measured because there was a previous history of smoking tobacco combustibles. In reality, to address this question, you really need a completely different approach, which has not been done so far. For example, to study vapors who have never smoked in their life. This is the only way to address the problem of absolute risk, okay? Because, of course, in that department, WHO, is correct, we don't know very much about absolute risk and what's gonna happen in 20, 30 years. Of course, all the toxicology is indicative that, I mean, we are not gonna be developing any major disease in the short term of our lifespan when we switch to these products. But if I put myself in their shoes, I agree this is a sort of question that needs to be addressed. And to address this question, we really need a completely different approach, which has not been produced to date. So there's no evidence.
22:10 - 22:33
[Clive Bates]
All right, okay. Anyone in the audience want a really quick follow-up on that? Can improve on Ricardo's answer? Yeah, someone there. We need to be really quick with this because we've got like a million things to do. Can we get the mic on, please, folks?
22:35 - 22:41
[Martin Cullip]
Hello? Yeah, I'd say nothing is safe and they're talking about absolute risk instead of relative risk.
22:41 - 23:18
[Clive Bates]
Yeah, I think this is one of those cases where this statement is maybe technically correct but misleading because what matters is how harmful and how safe or unsafe compared to the other risks that people bear either as smokers or in society in general. You know, we don't have a zero risk appetite And the evidence suggests that these products are much less harmful than smoking and not particularly harmful in absolute terms. And that is a more accurate and fair way of expressing relative risk. Let's go to the next one. Okay, come on. Speed it up, guys.
23:20 - 23:23
[Summer Hanna]
This is the raffle no one wants to win, to be clear.
23:23 - 23:25
[Roberto Sussman]
27.
23:26 - 23:46
[Clive Bates]
Tech team, give us 27, please. Okay, so heated tobacco products expose users to toxic emissions, many of which can cause cancer.
23:46 - 23:46
[Roberto Sussman]
Hello?
23:46 - 23:53
[Clive Bates]
By the way, you're allowed to say this is totally true, totally fair, and totally wrong if you want. I haven't selected him in that way.
23:53 - 25:02
[Roberto Sussman]
Well, I would say it's very simple. Air, water, food satisfy the same properties. Absolutely. Rice, you have arsenic. And many, air, for example, all carcinogens like metal. Metals don't come from another galaxy. They are natural elements. And the way this statement is produced without any reference to a standard, to a comparison, as was said by Ricardo knows about crime. It's nonsense. It contains, it exposes, well, everything, air, water, does the same thing. So this sentence is essentially nonsensical. I don't think I can say anything more that would involve more technical evaluation. But the way this, what is written here is nonsensical and non-informative.
25:02 - 25:16
[Clive Bates]
That's spot on. A chemical that can cause cancer is present doesn't mean it's present in sufficient dose and exposure to cause cancer when using this product. You're inhaling now. Yeah, we're inhaling stuff all the time.
25:16 - 25:20
[Roberto Sussman]
Yeah, I'm inhaling something that... Particularly with this audience.
25:20 - 25:26
[Riccardo Polosa]
I think any such statement needs to be compounded by a quantitative risk assessment.
25:26 - 25:30
[Clive Bates]
Exactly. Let's go to the next one. Summer, your turn.
25:30 - 25:37
[Roberto Sussman]
When you pick up a number, pull it out in order to avoid repetition.
25:37 - 25:38
[Summer Hanna]
Absolutely. 16.
25:39 - 25:59
[Clive Bates]
Tech team, give us 16, please. This is a long one, but basically the long and short of this is, are secondhand aerosol emissions from vapes harmful? Okay, and there's a bit of an extension to this, but if you just respond to the first sentence.
25:59 - 26:43
[Summer Hanna]
The question in itself is a book. Secondhand emissions for ENDS. So with secondhand emissions for ENDS, I think what we're really talking about is exactly what we were saying here. It's quantitative levels. and overall exposure. We know that the amount of toxicants within ENDS emissions is significantly less than cigarettes. Their duration in the environment is significantly less than cigarettes. And by way of that, the second hand exposure to those significantly isn't even an appropriate word because I don't have a better word to demonstrate how much less they are than cigarettes. And so for me, this is what it boils down to.
26:44 - 26:49
[Clive Bates]
Roberto, do you want to say anything? Because you're one of the experts on this. That's great. Quick one.
26:49 - 27:46
[Roberto Sussman]
No, just to say that comparing environmental emissions from these products with tobacco smoke is overkill. It's absolutely overkill. We need to compare them with normal aerosols that we see in everyday life, cooking, cleaners, authorizers, and even with pollution. Because you might say that pollution level, let's say in a clean city, is low, but it's constant. You're all the time breathing it. On the other hand, vaping is intermittent. So there is an emission And the vapor is not glued to the device 24 hours, so it's not a continuous emission. And so once you do the right calculation, bearing in mind exposure time, not only the explosion substance, then these aerosols are really, really very, very, very minor pollutants.
27:46 - 27:56
[Clive Bates]
I think I saw one study where it suggested like five orders of magnitude lower risk from vape aerosol compared to cigarette smoke.
27:57 - 28:08
[Riccardo Polosa]
And there is also a reason for that. The main toxicological risk in passive smoking from tobacco combustibles comes from sidestream smoke, which doesn't exist in vaping.
28:08 - 28:10
[Clive Bates]
Okay. Thomas, do you want to pick a number?
28:10 - 28:11
[Riccardo Polosa]
I have it. 19.
28:11 - 28:41
[Clive Bates]
19. Do you want to read it out? Okay, so the question here, this is essentially WHO recommending the ban on the sale of e-cigarettes and strengthen the ban, continue monitoring surveillance. It's not a scientific statement, it's a policy statement. So how do you feel about WHO recommending bans on the sale of e-cigarettes? It's
28:41 - 29:14
[Thomas Nahde]
It's pretty interesting that the WHO is making a recommendation here on the ban of the sale of e-cigarettes. And again, I think it comes back to their narrative on actually eradicating nicotine use and actually the war on smoking and tobacco use. And I think we see it here very clearly that they are talking about surveillance to support public health. They are not even considering e-cigarettes as a part of a tobacco control measure there. So I think And I think something seems to be missing here.
29:14 - 29:18
[Clive Bates]
The sentence is quite weird.
29:20 - 29:21
[Thomas Nahde]
As if something is missing.
29:22 - 29:44
[Clive Bates]
Okay, so the statement was basically really about WHO endorsing bans on e-cigarettes and their advice is to strengthen the implementation of the ban, monitoring surveillance and support strong enforcement. Any views on what's wrong with that or why that might be an incomplete way of discussing that policy with a member state government?
29:44 - 29:50
[Thomas Nahde]
I think also, Deborah touched on that already, so what we see in Australia for example is that there is a
29:51 - 30:21
[Clive Bates]
big shift then towards illicit and and that may pose an even bigger risk then so so it's kind of making assumptions about what the effect of a a regulated ban would actually be and that it would somehow stop the prevent cell any any other question any other thoughts on what's either either what's missing here in this advice or what's wrong about this advice anyone from the audience hang on somebody down there yeah Just say your name, where you're from.
30:22 - 30:39
[Alexander Nussbaum]
Alexander Nussbaum, Philip Morris Germany. Of course, as with all these statements, the context is missing. WHO is asking for bans in countries where cigarettes are sold. So on Mars, where you have no nicotine use, I think this would make sense, but maybe not on Earth.
30:39 - 31:03
[Clive Bates]
Yeah. So there's no call here for bans on the more dangerous products. There's no mention of those. And there's no mention of the interaction between the sale of the safer products and the sale of the more dangerous products. There's missing context. There's missing context regarding unintended consequences. Do you want to comment on this? Okay, down in the far corner over there. And then I'm going to move on because we've got a lot to get through.
31:03 - 32:19
[Alexandro Lucian]
Thank you. Alexandro Lucian from Brazil. I often, when I debate with anti-vaping organizations, I tend to use the following argument. Even if we dismiss all the science, when I started vaping in 2015, we didn't have the demographic numbers of countries that regulate vaping. And we've seen smokers declining and vapors on the rise. And I think we're going to wait a little bit longer, about 20, 30, 40 years, to know the impact on the health, on less cancer, less diseases. But right now, even if I don't use science, I have all the data showing that e-cigarettes works when they are regulated. We had the... diminishing of youth vape on the United States after regulation. So even if we don't count science, the numbers on the society, the real numbers of people stop smoking, It's a gateway out of smoking and not in. So banning the sales of cigarettes, you are increasing the sales of cigarettes. And of course, you are increasing the black market.
32:21 - 32:40
[Clive Bates]
Yeah. And again, that's not mentioned here. I mean, we know, Roberto, from Mexico, that we see there's a constitutional level ban here. But it hasn't stopped the e-cigarette trade at all. People still want these products. We see the cartels getting involved. Do you want to say a few words about that?
32:41 - 33:45
[Roberto Sussman]
Yes. The prohibition, if you want to know details about that, is in my soft stack. But it is enshrined in the Constitution. However, if you land in Mexico, you wouldn't notice that because rapes are everywhere. The grey market has been weakened. The former... a market that existed that was sort of self-regulated. It's weakened but it's still existing and there is an enormous distribution, a huge distribution by the cartels. But when you say cartels, it's not a monolith. There are many cartels of different sizes. And the type of market is different. The cartels mostly sell to lower class, middle lower class, and typically young people. And they are cheap disposables. And the market exists. If you land in Mexico, you wouldn't know that it is in the Constitution. And this is a complete proof of the failure of a prohibition.
33:45 - 34:00
[Summer Hanna]
And that was what I was reflecting on within this is the piece around strong enforcement. I saw a piece of research this week that indicated that it was a piece from Euromonitor that they believed that approximately 80% of the global vapor market was illicit.
34:00 - 34:01
[Clive Bates]
Wow.
34:01 - 34:38
[Summer Hanna]
Yeah. And I was floored that it was roughly 35% in Europe, but worldwide approximately 80%. And what that says to me is that the assumption that enforcement is going to be, like, It's inconsistent regulation and a lack of enforcement that's driven a lot of the problems and a lot of the bad examples in the list of 37 in this wheel of death that we're on right now. But that for me is the real failure in this. It's the inconsistency in the approach that's rapidly closing the door on a sensible and scientific conversation.
34:38 - 36:03
[Clive Bates]
I think that's a really important point about this statement. So I know we're dwelling on this longer than I'd intended, but when they say strong enforcement, that's a rhetorical gambit because they've not taken into account evidence on how enforcement works. And we've got plenty of that from the illicit drug market. I mean, people are trying to solve problems with a strategy that doesn't work. It doesn't work in Australia. It doesn't work in the United States. It doesn't work for cannabis. If you take cannabis use in the United States, it's been around 20% at 12th grade for about the past 25 years. And there's a lot of effort that goes into enforcement on cannabis. So here is something that sort of has an internal logic to it, but when tested externally against reality, it falls to pieces. So that's another piece of wrongness in this statement. Okay, we're going to go to the next one now. Ricardo, something really scary coming up for you. It's a nine. Nine. Okay. Okay. Right, this is about the long-term, we don't know the long-term effects of vaping, heated tobacco products, pouches, and then there's chemicals that are known to cause, okay? Yeah, if you take enough of them. It's a little bit like the earlier one that we had, but Ricardo, your response to this?
36:04 - 37:47
[Riccardo Polosa]
Yeah, it's similar to the previous one, and basically, There is an assumption here that some of these substances are causing cancer when we know, again, if we refer to quantitative risk assessment, that there's no real reason to fear for cancer in that case. However, I still believe that there are unknown unknowns that needs to be addressed. But this is part of a different approach, which is long-term to vapors never smoked. So again, we are talking about relatively risk and absolute risk. The reason why I'm all in for absolute risk is because I believe that in 20 years, there will be no more cigarettes and no more smokers, more in westernized countries at least. And the problem of absolute risk will be then important, so why not to address it now instead of waiting another 20 years and addressing it now just to reassure the public, to reassure consumers, just to say, look, there is some Nothing is risk-free in this life, of course, but we have made a very precise quantitative risk assessment on these different constituents that we can still measure in the aerosol, including the knowns and the unknowns. I'm referring to untargeted. But in substance, this is really unsubstantiated statement.
37:48 - 39:19
[Summer Hanna]
And before we move on from this, reflecting also on the WHO science machine, we think a lot about FCTC, but we also should think about the other specialist agencies within the WHO that develop scientific insights for their use. And in this one, I think about IARC. So right now, ENDS are listed as a priority for evaluation with the IARC. And so this is a tiny little specialist agency sitting in France that most people don't know much about, but they see the impact of their work quite regularly in the media. So if you think about diet Coke and aspartame causes cancer. Grilled meats cause cancer. Aloe vera causes cancer. Those are all insights from the work of IARC. And what they do is that they do not contextualize the risk of cancer, only the hazard of it. And so the utilization of science in these specialist agencies, uncontextualized but with wildly outsized media and public influence, is also a huge threat to the category and to the public health opportunity within this. And so while we spend a lot of time thinking about these kinds of things like quantitative risk assessment and looking at it, I think, through a very technically appropriate lens, I think it's also appropriate to step a step out of that and bigger into the other pieces of the WHO infrastructure that are also conducting science that's not risk contextualized.
39:20 - 40:31
[Clive Bates]
Yeah. I think there's a disgraceful sleight of hand in this statement because they talk about substances, some of which are known to cause cancer or heart disease, lung disorders, in other contexts, not in the context of being used in an e-cigarette here. And I'm glad Summer raised it, because there's a distinction here between hazard and risk. A hazardous substance is a substance with the potential to cause a risk if the exposure is great enough. And they've lost that nuance here, quite deliberately, I'm sure, to try to link the second clause in the sentence, the cause cancer and heart disease and lung disorders, to the... doubt expressed in the first part of the statement here because we don't know long-term effects in fact we know an awful lot about these products right now from biomarker studies and from understanding the toxicology of the emissions and that's what gives most of us pay attention to the science confidence that these products pose at best a small fraction of the risk of of smoking All right, who's going to go next?
40:31 - 40:59
[Roberto Sussman]
Or do you want to say more? Can I just say, excuse me? Just very quickly that long-term risks, we model them. It is normal in science to do modeling and forecasting. Climate change, we know it's real, but there are many models. And the fact that we don't know exactly what will the temperature be in 50 years doesn't mean we have to keep the status quo.
41:00 - 41:45
[Riccardo Polosa]
Any new drug that enters the market has unknown long-term effects as well. I just wanted to point out a little thing. It indicates toxicants in the slide, but there's something... of a worrying development recently. Even nicotine is being associated with the risk of cancer. And I've been seeing a proliferation of papers, mostly review or editorial papers, stating that nicotine is a promoter, cancer promoter. And this is an area that really deserves a lot of attention and a lot of pushback, in my opinion, from the scientists of tobacco and reduction.
41:45 - 42:09
[Thomas Nahde]
I think, Clive, as we're trying to build bridges here and not burn them further, I think there is at least a call for everyone in the community to think around how can we help and address that first half of the sentence on the long-term health risk. What do we need to do? What is actually the evidence that we wouldn't need to create to be acknowledged by the WHO?
42:11 - 43:18
[Clive Bates]
One of the interesting things about that sentence is there's an implicit demand there for certainty, that you have to know what the long-term risks are. I think, as Ricardo just said, we make a lot of decisions in conditions of uncertainty. Almost every policy decision taken by any government anywhere has uncertainty built into it because we don't know the effects of things. We don't know what's going to happen in the future. Climate change, for example. We don't know what's going to happen in the security environment. We don't know what... you know, President Putin or Trump are planning next, but we still have to do things. And therefore, there's a sort of unreasonable call implicit in that statement that we should know everything before we can do anything, and that's not true. And also, we don't necessarily need to know what's the long-term outlook if we know enough about if we know enough already, like the toxicology, like what's in the emissions and so on, we can project forward based on what we know about these things. Let's have a quick comment here and then we'll move on to the next one. Anyone got a mic? Judy.
43:21 - 43:59
[Judy Gibson]
Thank you. Judy Gibson. Just to say, because it was suggesting, often where they talk about generating emissions, we have found, and I'm sure everybody here has seen it, where this has actually been concluded, the methodology in itself is completely flawed on the basis that poor little mice have been subjected for hours and hours and hours of... And, moreover, the actual power, which would, if you were a vaper and actually used that amount of power, you would immediately stop and say, this is disgusting. And I just think it's a point that's very often a problem.
43:59 - 44:10
[Clive Bates]
So that's a good point, that many of the studies that purport to show a risk are based in unrealistic conditions that would never be experienced by human beings. All right, let's go to the next one.
44:11 - 44:53
[Riccardo Polosa]
I want to move on. I think that Thomas raised a very interesting point. I'm sorry that I have to interrupt you. Do carry on. The one of investigating long-term effects in a different way. For example, looking for early indicators of changes in our biology that they are predictive of diseases. But they can be the predictive of also diseases that we don't even know. Who's saying that an electronic cigarette in 20, 30 years will cause COPD? I'm not convinced. COPD is caused by tobacco cigarettes. E-cigarettes may at least cause some new type of disease that we don't even know. fathom in our mind.
44:53 - 44:58
[Clive Bates]
Right. Next number. No messing, please. Summer, come on. I want to move it along a bit.
44:58 - 44:59
[Summer Hanna]
13.
44:59 - 45:06
[Clive Bates]
13, guys, please. Oh, my God. Ivali.
45:07 - 45:33
[Summer Hanna]
Oh. OK. I mean, where do I even start with this? I mean, it was quite, I mean, I know where I start, but I mean, it was quite clear that in this instance, it was not nicotine-based vapes that contributed to this. It is, in my view, a convenient fear-mongering analogy for something that was an illicit product and not properly stewarded.
45:35 - 46:44
[Clive Bates]
Yeah. I mean, this quote actually runs on to say other chemicals may have been involved. And what we get with this, and if you look at that, the sentence includes a common additive in ENDS. Well, ENDS means electronic nicotine delivery systems, okay? So they're kind of taking... a really nasty health effect that was triggered by an additive that can only be added to THC vapes and is only ever used, it only serves any purpose, and they're implying that that could be used in nicotine vapes, okay? And... You know, there's a whole report on this in their Tobreg report, which goes into EVALI, and that's all about tobacco and all about nicotine, not about cannabis. So what they've been trying to do here is link it, link this disease, link this terrible outbreak that we had in the US that was caused by an additive or an adulterant in THC back to E6. Any more thoughts on the EVALI issue?
46:44 - 47:15
[Thomas Nahde]
Not on the Evali issue, but I think on this statement explicitly, I think it's... Because you were asking, is it true and fair? I think at least it's fairly balanced. I think they have even worse statements there. I think there was one before that. I don't know if it was 10 or 12 or 11. I don't know which of those. But I think that was... very, very coloured into very different directions. So I think in this regard, this is way more balanced. So there are examples of where it's more balanced.
47:15 - 47:56
[Clive Bates]
I don't agree with you, Thomas. I think the only thing that would be true and fair to say here is that nicotine vaping was not implicated in EVALI and could not have been. And there's a very, very strong argument to make there that nothing was done to nicotine vapes and EVALI disappeared. We found the causative agent in THC vapes, and that was vitamin E acetate. Once that was removed, the problem basically went away. It could not have been anything to do with nicotine. And that's the true and fair statement to make here, not a balanced statement like it might have been or it might not have been, because that's a merchant of doubt statement.
47:56 - 49:10
[Roberto Sussman]
I would like to tell an anecdote. I was interviewed by CNN in Spanish when it was already known that it was THC, vitamin E. And the interview, I was basically lynched. there are barrage of this and the head of the American Lung Association said this and that and all these youngsters. And then at the end, the only thing I could say to defend myself from this barrage was why not in Mexico? Why not in Nigeria? Why not in Norway? Why didn't it happen there? If it is vaping, And these people raped there, people in all the countries, and they raped the same stuff. Why it didn't happen there? Are American rapers magic? Or they have some special issues in their bodies? That's the only thing, all I can say, but the interviewer was quiet. Because that's the point. If it was related to nicotine, it should have happened everywhere where nicotine vaping was going on.
49:10 - 49:41
[Clive Bates]
And let me just say one thing about this. I didn't put it on the slide, but this is a statement in a fact sheet called Q&A tobacco colon e-cigarettes. So it's very much a discussion of tobacco and e-cigarettes and nicotine. It's not a discussion about cannabis. It's nothing to do with the cannabis parts of WHO's website if they actually have one. All right, let's go on. Let's get another one in. Who's next? Your turn. Okay. Provenance.
49:43 - 49:43
[Roberto Sussman]
Five.
49:44 - 49:44
[Clive Bates]
Five.
49:47 - 49:49
[Roberto Sussman]
Probably something you think.
49:50 - 50:11
[Clive Bates]
Okay, so consumption of nicotine in children and adolescents has negative impacts on brain development, long-term consequences for brain development, learning and anxiety disorders. Okay, so this is the nicotine affecting children's brains story. Is there some truth in this? Is it misrepresented? Ricardo, you have a go at this. Not Ricardo, Roberto, you have a go at this.
50:11 - 51:14
[Roberto Sussman]
Well, just look at major physicists of the 19th century and 20th century. Einstein, Schrodinger, Bohr, all of them smoked and all of them started smoking at a young age. And evidently we know from epidemiology of the 20th century that smoking is connected in a cultural way with a host of diseases. But we don't see a connection with mental disorders. At the level, we have to think of how much smoking was prevalent, and smoking was a delivery of nicotine. But this delivery didn't, we have evidence that it produced a host of diseases. But we don't have any evidence that this evidence should be seen. So to answer this, it is an extraordinary claim would require extraordinary evidence. And this evidence is zero.
51:15 - 51:19
[Riccardo Polosa]
Okay. It's based on animals that have been gassed with nicotine mainly.
51:19 - 52:26
[Clive Bates]
Yeah, these are largely based on rodent studies. And one of the good responses to this was done by the 15 presidents of the SRNT, former presidents of the SRNT, who wrote a kind of essay about the controversy in this area. And what they pointed out is that we've had generations of young people who grew up as smokers, and we cannot find the signs of that kind of brain malfunction in them. The evidence relies entirely on rodent studies, and that may not translate, that we shouldn't rule it out. and that we need to be vigilant, but you can't say anything definitive about it, and there's circumstantial evidence that there's nothing to it. Now, is that, therefore, a proportionate way of discussing the evidence in the same way that the 15 former presidents of the SRNT did? I don't think it is. I think that sounds very confident and very sure, and actually the evidential basis for that is extremely thin. Let's have another one.
52:34 - 52:36
[Summer Hanna]
Number eight. Number eight.
52:40 - 52:42
[Clive Bates]
Okay, I think we've dealt with this one already.
52:42 - 52:43
[Summer Hanna]
I think so too.
52:44 - 52:44
[Clive Bates]
Do what?
52:44 - 52:46
[Summer Hanna]
Yeah, I feel like we have covered this one.
52:46 - 52:53
[Clive Bates]
I think we've covered this one. I'm sorry, there's a bit of duplication. Why don't you pull another one out, Summer? We've talked long term.
52:53 - 52:54
[Summer Hanna]
Eighteen.
52:54 - 53:20
[Clive Bates]
Eighteen. Okay, so there's a Q&A this, so there's a question. What role do ENDS play in smoking cessation? Not proven to be effective at the population level. The alarming evidence of adverse population effects is mounting. We may call for reinforcements on this one. Who wants to have a go at this?
53:21 - 53:47
[Summer Hanna]
I mean, I think this morning, Mariva Glover, she showed some really interesting research on this very thing and the journey over a four-year period that people make with the role of ENDS in smoking cessation. I personally found her work quite compelling. Conveniently, she's in the audience if she wants to talk more about it. It says to me that this statement might not necessarily be the most accurate.
53:49 - 54:06
[Clive Bates]
All right. We're going to go to the audience for this. I'm going to start with the exceptionally clever Ariel Selyer, who's made a kind of career of studying this question. So we've got one of the world experts in the room here. So let's have your response to this.
54:06 - 54:47
[Arielle Selya]
Sure. Yeah, Arielle Selya, Penny Associates. We consult for Juul. I have spent a lot of time looking at population level trends with my colleagues at Penny. And not only us, but other researchers as well have found that the populations that experience the largest uptake in e-cigarettes have the fastest declines in smoking. And this is over and above what would have happened otherwise with smoking, which was already declining. But it declines faster. among the groups, especially younger ages and different, however you slice up the populations, the ones that have higher uptake of ENDS have lower smoking rates. So this is completely false.
54:48 - 54:52
[Clive Bates]
There we go. Completely false, says world expert.
54:52 - 55:28
[Riccardo Polosa]
Perhaps, Ariel, perhaps it's true in the elderly population because the same study that you're citing and quoting, it's the Flo Foxson study, right? When you show the effect on the age range above 55, basically there's no effect. But if you then select the younger population, the decline in the smoking prevalence so accelerated and is parallel but inclined in vaping uptake.
55:28 - 55:51
[Arielle Selya]
Right, and that's the corollary of what I was saying, is that the groups without any substantial e-cigarette uptake have stagnant smoking rates. And, of course, we can't conclude causality with this, but if you look at the same pattern across different countries with different regulatory policies and different age groups, it all tells a consistent substitution story.
55:52 - 56:14
[Clive Bates]
And one of the great ironies here is that e-cigarettes are often... cast as a youth issue, but they're probably having the greatest effect on the youngest users because that's where the greatest uptake has been and therefore the greatest displacement of smoking. What about other forms of evidence that inform this question? Not been proven to be effective for cessation. Any other types of evidence?
56:15 - 56:46
[Thomas Nahde]
I was discussing with Konstantinos yesterday actually on that one, and I think Greece is a good example for that because you can see that the uptake of e-cigarettes in Greece and a decline in smoking rates, again, we're not talking about causality but correlation there, but I think that might be another example. Interestingly, that they are combining here with some alarming evidence on other health effects, and I'm wondering how that should be related to the first half of the sentence.
56:46 - 56:55
[Clive Bates]
Okay. Let's go on to another one. So 15? What was that? 15?
56:55 - 57:04
[Thomas Nahde]
15. Oh.
57:06 - 57:06
[Clive Bates]
All right.
57:06 - 57:11
[Thomas Nahde]
So I would agree with that nicotine is addictive and probably even add it's not risk-free.
57:12 - 57:27
[Clive Bates]
Okay. Nicotine is highly addictive. Anybody want to... That's a very commonly asserted statement, but what does it actually mean? Anybody want to get in the ring on this one? Yeah.
57:28 - 58:04
[Riccardo Polosa]
What's highly? Okay, in my professional life, I've been caring for many, many smokers. And many times you hear stories of people smoking even two or three packs a day. They woke up in the morning and they decide not to quit. They decide just to quit the cold turkey. They don't even suffer from withdrawal symptoms. So my point here is nicotine, is addictive, but not in everybody. So our genetics makes the level of addiction different from one another.
58:07 - 58:50
[Roberto Sussman]
There is a sort of mechanistic understanding of nicotine, like there's a molecule, the molecule creeps up, goes into the brain and takes control of your life. I'm simplifying, but it's a way of thinking of nicotine. It's not like that. Nicotine depends on the way it is administered, depends on doses, and there is individual variation. So to say nicotine is highly addictive is similar to saying there are toxic substances. It is no comparison, no standard, no specific. It is just a bunch.
58:50 - 58:58
[Riccardo Polosa]
And this is nicotine in the smoke that may be highly addictive. We're not even talking about nicotine per se.
58:58 - 59:01
[Clive Bates]
I want to get a comment from Lynn Dawkins. Lynn, stand up.
59:01 - 59:46
[Lynne Dawkins]
Lynne Dawkins, Dawkins Analytics, Pinney Associates, who consult for Juul. Yeah, I was going to raise some of the points that have already been touched upon there. It's just more nuanced than this, and it really depends on how the nicotine is delivered, and in the form of cigarette smoke, yes, it's highly addictive. I would agree with that. But hardly anybody gets addicted to nicotine in the form of a patch, for example. And then there's also the issue of addiction versus dependence that, again, has been touched upon in previous sessions. This addictive is highly stigmatised. Addiction causes harm. Maybe we should be using the word dependence when we're not talking about addiction in relation to cigarette smoking.
59:46 - 60:21
[Clive Bates]
Lynn, before you sit down, because I want to interrogate you a bit more on this, you're drawing a distinction there between a definition of addiction, because one of the key issues here is what does the word addiction actually mean? If you're going to use a language like that, what does it actually mean? You're, I think, drawing a distinction between the word addiction, which is a kind of compulsive behaviour with sort of large amount of collateral damage, with significant net harm, and dependence, which is just a compulsive behaviour. Is that right? Do you want to expand on that and where that distinction comes from?
60:22 - 61:07
[Lynne Dawkins]
Yeah, well, I was making two points, really. The first point was that it depends on the delivery mechanism. The second point is this distinction between addiction and dependence. I think the Addicto Vocab website is really one to go for for this. Dependence, when you're talking about physical dependence, is highly linked to experiencing withdrawal symptoms when you stop. Addiction comes with that unique extra bit about causing harm. But... That's not the way it's used in people in the general public. We did some interviews with young people and they would always use the word addiction. But I think it's the harm that's the key thing there that comes with the addiction definition.
61:07 - 61:39
[Clive Bates]
Okay, so there's a popular definition of it and a professional definition and people in psychiatry, for example, no longer even use that term because of the loaded stigma and the vagueness of the definition. So we're seeing a health body here that's using language that's kind of off the street rather than being precise about the definition and precise about exactly what they mean by this and what the effect is in different contexts. That'd be a fair way of putting it.
61:39 - 61:45
[Lynne Dawkins]
Yeah, and anybody in the general population looking at that would think, addiction, ah, yeah.
61:45 - 61:53
[Clive Bates]
Yeah, good, ah, exactly. All right, let's move on then to the next one. Who wants to pull one out now? Who's not done one for a while?
61:56 - 61:56
[Riccardo Polosa]
Ten.
61:57 - 62:18
[Clive Bates]
Ten. OK. Dual use, okay. Dual use is at least as dangerous, more dangerous than smoking conventional cigarettes or using e-cigarettes alone. What's wrong with that?
62:18 - 63:25
[Riccardo Polosa]
Where does it come from? It's that people don't know very much about dual use per se. It's not a dichotomic, semantical term. Dual use is a range of exposures. So a dual user can be somebody who's gone from one pack a day to one cigarette a day. And to me, that still represents... harm reduction and advantage. However, other form of dual use, when somebody is reducing from 20 to 15 cigarettes a day, of course, because of compensatory smoking, that would be at least as dangerous. So the problem of dual use is that there's very little empirical research showing the difference of the different level dual use. And that allows the WHO and many other scientific society to make very oversimplistic statement about dual use.
63:25 - 63:26
[Clive Bates]
Does anybody else want to go?
63:27 - 63:50
[Thomas Nahde]
And I think it's quite irrespective of consumer behavior, again, because consumers may need to adopt to those alternative products and may need to get used to it. And their experience and journey, and I think this is what we need to respect, is actually that every consumer is different and that it may take a time for them to actually transition away from smoking.
63:51 - 64:10
[Clive Bates]
Okay, I'm going to stand up for WHO for a second. You can try and knock me down. So this argument comes from observations that people who are dual users often have higher levels of toxicants in their biomarkers, in their blood, saliva and urine. Why might that be?
64:11 - 64:18
[Riccardo Polosa]
Because of the compensatory smoking in those who are not minimally dual using.
64:20 - 64:32
[Clive Bates]
Yeah. Does anybody want to have a go in the audience? Oh, here we go. Ariel. Of course, it's useful to have actual experts. Let's go. There's a lot to say about this. It's quite an interesting question.
64:32 - 65:24
[Arielle Selya]
Yeah, this could be an entire panel on its own about dual use. One of the other issues is that dual users tend to be smoking more heavily to begin with. So it's an apples and oranges comparison. There's also a selection bias in a lot of the studies on dual use. Like think of the PATH study in the US where a lot of this comes from. At some point in time, people get surveyed and categorize into whether they're dual users, exclusive ENDS users, exclusive smokers. And that, because the survey takes place at an arbitrary point of time with respect to their personal trajectory of when they started ENDS and where they might be in this process, it drops people that have successfully switched already, because they no longer count as dual users or smokers. So it drops them from the analysis and it produces a negative bias, a pessimistic bias.
65:25 - 65:39
[Clive Bates]
Yeah, exactly right. This is a way of filtering the population into people who generally are more dependent and more intensive smokers. Maria, do you want to say a word on this? I'm going to wrap this section up in a minute because I'm going to run out of time otherwise, but we're doing well.
65:41 - 66:34
[Marewa Glover]
Hi, the term dual use is also part of creating a narrative and another label that can be stigmatised, can stigmatise a group. It's actually... What about the people that have access to a range of nicotine products and they use more than two different products? So I think it particularly was created... to stigmatize people who vape and smoke, but there are people who vape. They might occasionally have a cigarette if they're out partying. They also use oral nicotine pouches or snus. And when there's a wider range of nicotine products, we'll have multi-use. It's just rhetorical creating labels.
66:34 - 67:22
[Clive Bates]
I think one other quick thought on dual use is that unless a smoking cessation method is 100% and immediately effective, people will go through... Going from exclusive smoking to abstinence or pure vaping, people will go through a period of... abstinence, smoking, abstinence, smoking, and they will effectively be dual using through that period as well, and that smoking is never really thought of as dual use. It's just in series rather than in parallel. I'm going to move on. I want one more, and then we'll go into the why is this happening, and I'm going to get views from the audience on this, so get your thinking caps on. Why is this happening? Is it as bad as I'm making out as well? Yeah. Worse.
67:24 - 67:37
[Roberto Sussman]
Thanks. Come on! 25. 25. Oh, here we go.
67:39 - 68:12
[Clive Bates]
So this isn't a scientific statement, but, well, it is in a way. It basically asserts a principle. This is from guidelines to the implementation of Article 5.3, but it basically makes an assertion that nothing that's in the interest of the tobacco industry can ever be in the interest of public health. Is that factually correct? Is there actually a zero-sum game here between health and the tobacco industry, yes or no?
68:12 - 68:40
[Roberto Sussman]
Well, this is very similar to what I said in my first intervention. It's freezing a narrative that could have had valuable elements in the 1990s, and it is frozen now. It is like Fidel Castro in 2006 glorifying the Cuban Revolution when not noticing that things have changed.
68:43 - 68:48
[Clive Bates]
All right. Does anyone else want to comment? Anyone from the industry?
68:48 - 69:29
[Riccardo Polosa]
I may comment about the irreconcilability. Because things have changed from the last century, I think. And now the tobacco industry is actually producing... nicotine delivery systems, they are far much safer than the existing tobacco cigarettes. So I see these as a reconcilable aspect of the story rather than irreconcilable. The irreconcilability, I think, it's in the head of public health people that they want the status quo.
69:30 - 71:30
[Clive Bates]
I remember when this was agreed in 2008, and I remember at the time Who's thinking about the snus experience? By then, we had a tobacco product made by a tobacco company was responsible for the lowest rate of smoking in Europe, if not the world, and then a measurable impact on cancer and so on that was much lower in Sweden than it was in the rest of the European Union where these products were banned. I'm like, well, doesn't that clash? If you have a principle and you say it's fundamental and irreconcilable, What happens when you have a counter case like that? What happens to the principle? You need to change. You know this from the laws of physics. If you find an observation that defeats general relativity, it's over for general relativity. You've got to think about this when you make a bold claim that it's a principle or a fundamental idea. What happens when that is defeated? It's timeless. It's a timeless statement. It is frozen. Yeah. And since that was agreed, and it was agreed at a time that we had the snus experience to draw on, obviously we've now generalized that idea, the proof of concept in Sweden, to vapes, to heated tobacco, to pouches, which could all have the same sort of effect. So now they're focused on maintaining the truth of that idea, when actually it's defeated endlessly by, for example, the points that Ariel just raised, that you can pull the rate of smoking down by switching to smoke-free products. So, any more thoughts on this? Norbert, did you want to say something? Yep, there. Okay, down here, quickly. It needs to be really quick.
71:30 - 71:43
[SPEAKER_04]
Yes, sorry. H-Fact Asia, Hong Kong. I think this statement could actually be very, very accurate if you replace tobacco industry with FCTC. All right. That's a cheap shot. Okay.
71:43 - 72:01
[Martin Cullip]
And I think this kind of dualistic statement can also be used to our advantage. We just need the tobacco industry to produce the contrary of what we want.
72:02 - 72:02
[Clive Bates]
Yeah.
72:03 - 72:07
[Martin Cullip]
and they have to follow their own advice.
72:08 - 73:23
[Roberto Sussman]
But it's part of the combat narrative, war narrative. When you are in war, the enemy is bad. It is irreconcilable because it's the enemy. And so today, being more pragmatic, the industry should be part of the discussion. It cannot be excluded. And to keep this as a timeless, eternal, absolute, thundering proposition is, in the end, is self-defeating. Because also the industry is not the same. It's not the same. The industry has evolved, and also the conception that these type of statements have of the industry is like a monolith. And finally, which industry? What is the biggest of biggest of big tobacco? Is it Philip Morris, BAT, Japan? No, it's the Chinese industry. And the Chinese industry is not alluded here. The Chinese industry... goes into the COP meetings and sits down there, and nobody says anything, and this is the real big tobacco.
73:24 - 73:44
[Clive Bates]
There's a really good point there. I thought it was really important that the industry isn't one monolithic thing with a single controlling mind, and that there is differences between companies, and frankly, there are differences within companies about their view of the future, and that's something that's often forgotten when people just lump them all together as big tobacco.
73:44 - 73:56
[Riccardo Polosa]
But the point is public health policy interest is now shifted into nicotine eradication. In that case, the conflict will be irreconcilable.
73:56 - 74:27
[Clive Bates]
Yeah. If you're focused on abolition and eradication of nicotine, then obviously it's a fundamental problem. But that's not where this came from. I'm going to move to the next stage now. We don't have very long. So could we just go to slide 38, please? I want to now ask for views on why we're in this situation. We've done the what. We spent a lot of time on that. Appreciate that. But I think it was interesting. Some good points came up. Why is this happening? Would anyone like to venture a theory on that? Yeah, Derek. You should know.
74:31 - 75:48
[SPEAKER_07]
I would just give one of probably many interpretations, and I'd ask people to look at the arcane eighth report of the WHO expert committee on tobacco products regulation. That's where you'll find the origins of many of the statements. That is an expert report of WHO. It is supposed to be an independently written report by experts. It was funded by Bloomberg Philanthropies and acknowledged as such in the text. at exactly the time that the funder had a very clear interest in ensuring that tobacco harm reduction never took off. That is both a conflict of interest under US IRS law, and it also represents a violation of the WHO principles of not allowing the funder to have an influence on the process. It should have been funded by government. And the proof of that was when I was heading the non-communicable disease program there were efforts to fund the changes to the hypertension guidelines by the pharmaceutical industry. And they thought that if they have five pharmaceutical companies, it'll mean that it won't be a conflict of interest. Well, obviously it would because they would all benefit if the guidelines change. And we stopped the whole process because it was a conflict. This is exactly the same conflict and it besets the process.
75:49 - 76:22
[Clive Bates]
Okay, so there's a big point there which is sort of biased scientific advice, but it's not accidental. They've purposefully seeked out experts that will give them that advice that supports a certain narrative, and that narrative is coming from outside WHO potentially. Is that a reasonable way? Okay, any other views on where this kind of... Why would they want to do this if you agree that these things are bad? Why would they wish to do that? Does anybody have a view on that?
76:23 - 76:32
[Riccardo Polosa]
Because they're worried. If smoking tobacco endgame is going to happen, they will be rendered useless.
76:32 - 77:05
[Clive Bates]
Okay, so this is the point that if there isn't a lot of harm, if there isn't death and disease and really bad things happening, there's no real role for a control-based effort because there's nothing to control. There's a reason we don't have coffee control. Is that essentially what you're saying with that one? Okay, so there's a sort of institutional bias in favor of finding harm because it's part of that organization's mission. Okay, any others?
77:06 - 77:31
[Thomas Nahde]
And I think the point goes really back to the narrative. We're not talking about a narrative of control. We are talking about a narrative of eradication and an endgame. So there is not much of an option. So the only option... is to actually drive consumers into the abstinence. There is no other option there, and I think that is going back to that.
77:32 - 77:59
[Clive Bates]
Okay, so I think a really important point here is what is the actual goal? Now, it may not be explicit, it may be implicit, but if your goal is implicitly a nicotine-free society, you react to tobacco harm reduction differently than if your goal is to reduce disease and death at the greatest possible rate, and they are not the same goal. Any further thoughts? And also from the audience, please.
77:59 - 78:31
[Summer Hanna]
Well, one of the things that I reflect on a lot is I'm not confident how many of the people who are working in this space actually personally know any smokers. As smoking becomes less of a middle class or upper class phenomenon, the people who sit in learned institutions do not ever interact with these people. in their personal lives. And so they become an abstract entity in the same way that the tobacco industry becomes a monolith. The smoker also becomes a monolith in this.
78:31 - 79:24
[Clive Bates]
I think this is such an important point. And I think there's a kind of lack of empathy with the people who are at greatest risk here, partly for years of demonising and stigmatising the fact that stigma and denormalisation is a tactic in tobacco control, the fact that there are origins of tobacco control in non-smokers' rights movement, like get your smoke out of my face kind of thing, and a sort of visceral disgust about people who smoke in some quarters. And not meeting those people and not conceptualizing them as real human lives of people with tough lives often and big struggles has allowed them to be cast in an abstract and dehumanized way. And I think that's quite an important part of this. Any other thoughts from there? There was one there.
79:26 - 80:22
[Alexandro Lucian]
Mark? Yes. In Brazil, often I debate with anti-vaping organizations, and less frequently than I wanted, because sometimes they can't argument with the science they have to attack me in person, and et cetera, and paying by big tobacco, et cetera. But I often think if they are being paying, and they know the science, they know they are wrong, and they're being paid to say otherwise, but sometimes I really think they believe. They are working this for several years, decades often. And then, for example, in Brazil, a big shot in anti-vaping organizations said that when you switch from smoking to vaping, you are not stop smoking. It's still smoking. And it seems they believe in that. And maybe 30, 40 years in the work of this field, maybe they believe that.
80:22 - 81:15
[Clive Bates]
I think this is a really important point, and I think it's important to think, remember, most people, including in WHO, including in the industry, do not get up, go to work, and say, I'm going to tell lies all day. What they mainly do is... form a set of beliefs that are reinforced by the influences around them. One of the reasons why there's so much exclusion of people who are interested in tobacco harm reduction and exclusion of consumers from the FCTC is they don't want these dissonant views in the room. because that kind of breaks the bubble of thinking. But I think most people are trying to be honest and have formed a view that is reinforced by everything around them. But it's not an excuse. As a professional, you have to get out of the bubble and listen to other points of view, otherwise you're going to miss things.
81:15 - 82:15
[Roberto Sussman]
There is a Spanish saying that all you need is to pierce a little hole in a sardine can to get the whole thing rotten. Maybe some people that are running the WHO really know that all these things we are saying are wrong, but to admit that is a hole in the sardine can. They are afraid because rigid systems, once they start to be reformed, they become unstable. We see the Soviet Union. And I think that there is a fear that recognizing that they are wrong in science and in many other assumptions... could lead to instability of the whole enterprise. This happens in very rigid governments and structures.
82:15 - 82:53
[Clive Bates]
Right, I'm going to wind this section up now. I've deliberately compressed the last two to the end to give us lots of time to discuss the what. And I want to just get to the how. What should happen? I'm going to ask each of the panel to give me a view on the kind of things that could put this right. What would change things? Not necessarily things that we could do, but what would change the way, you know, WHO and the kind of satellite organisations and the hive around WHO approach these issues? So who wants to go first? Riccardo, why don't you go first?
82:55 - 83:13
[Riccardo Polosa]
I truly believe that reforming in science is necessary. And this is the only way we can have a balanced discussion. If they start to understand what we understand, maybe things will change. OK. Thomas?
83:13 - 84:07
[Thomas Nahde]
Yeah, I think there's actually a couple of things we might want to consider. First of all, address the consumer in the science, right? And try to really address the consumer behaviour. So let's understand what is actually missing, right? If we think of, can we really tap into the real world data and the real world evidence even more? Can we tap into epidemiology even more? really understanding what is missing there. So is there something that we can actually address? And maybe, because I think this is coming up so much that they are really talking about the absolute risk. Maybe we can try and shift our views in that and talk about the epidemiology and trying to really understand and find those biomarkers of early indicators of health impact risk and really trying to identify those and come up with the according evidence.
84:08 - 84:13
[Clive Bates]
So you think evidence might work? Okay.
84:14 - 84:16
[Thomas Nahde]
I'm believing that. I'm a believer in evidence and data, yeah.
84:17 - 84:22
[Clive Bates]
That's good. Okay, so let's get a comment from Summer on this.
84:22 - 84:43
[Summer Hanna]
I agree that evidence is critical, but we have to consider all of it and the sources that it comes from all have to be included. So as one of the industry representatives up here, I have to say that the inclusion of industry evidence in the scientific assessment is also critical.
84:44 - 84:48
[Clive Bates]
Okay. Roberto, then I'm going to go to the audience to get you thinking.
84:48 - 86:20
[Roberto Sussman]
Markets, markets, markets. This is what is going to change. Because I see it in Mexico, prohibition, top level, price from the WHO. We see the market increasing. Market increasing is everywhere. And it is a gradual process. Let's think in 10 years when, for example, Take Mexico, now we have between 3 and 4 million consumers. What will happen when we have 20 million consumers? And put this in all the countries, because consumption goes on. We already know why there is supply, illegal, semi-illegal, etc. And also, as the market grows, the same illegal market will diversify. This is my view. There will come a point when the markets... will make the switch. We don't know how exactly, but I think this is your, because I don't think they Once this very rigid structure, they really don't care about the evidence. How much evidence we have shown them, etc. But the markets will... And also, finally, the sleeping giant, China. China makes manufacturers... At one point, they will see that there is a huge market of more than one billion people that can consume these products. And this might change also. So I think the answer is markets.
86:21 - 88:38
[Clive Bates]
I think that's a really, really important observation. We have to remember that this is happening anyway. It doesn't matter what's being said in Geneva. It doesn't matter what's being done with regulation. People are adopting these products as nicotine users in their own interests, at their own expense, on their own initiative, through markets. increasingly, unfortunately, illicit markets, and then you then get back to, well, what's WHO's role in this? If it's becoming irrelevant because these processes are just leaving it behind, what is it there to do? And it's actually going to be about reasserting lawful markets, creating regulated markets, creating safer products, not trying to stop people getting the products that they actually want to get. And I think that a new mission for WHO in this, which is to kind of get a grip on what's becoming increasingly lawless And we've got the poster child of this in Australia, where everything has gone wrong, and yet you have the strongest regulation, you have the most muscular regulators, you have tough guy policemen everywhere, and it's still a total mess. So how do you re-establish control like that, get a grip again? And I think that's part of the solution here. Back by evidence, I'd add one further thing. We're not going to have time to go to the audience. One further thing, consumers have got to tell their stories. We've got to get the empathy back. And as Summer raised this, get the empathy, get the human stories back in play, because that moves in a different part of the political brain. That helps to get people interested, and then you can follow up with strategic reasoning, the studies, the odds ratios, the randomized control trials. You've got to get people interested in the human story first, and that's where we need to start. Engage and then explain. Everyone, I'm going to draw it to a close now. I want to thank the panel. Great job, particularly under the stress of a random statement generator. And thank the guys at the back there for speedily turning over the numbers. And that's it. We're winding up for the day. Thanks very much, everyone. Enjoy the evening.