Despite its aim to reduce global consumption of cigarettes, the impact of the WHO’s Framework Convention on Tobacco Control (FCTC) on tobacco use has been heavily contested, particularly in relation to low-income countries. The panel will assess the effectiveness of the convention as it reaches its 20th anniversary, and highlight areas that need drastic change, if it is to have any future relevance in reducing smoking.
Transcription:
00:11 - 05:34
[Jeannie Cameron]
So firstly, on the far end, we have Tikki Pangestu, who was an advisor on health policy at the World Health Organization, director of research and policy. He's a biomedical and microbiologist specialist, and he is a graduate of Australian National University and a fellow of the Malaysia Academy of Medicine. He's gonna talk about the impact of the WHO's policies on tobacco harm reduction. Next we have David Khayat, who is a professor of medicine and he's an oncologist. He's the past president of the French Cancer Institute and he was also an advisor to the French president. He's going to be speaking about the comparison of the FCTC with the Charter of Paris Convention against cancer. Next we have Asa Saligupta, who is from Thailand, and he's a consumer advocate. He also works in the area of probiotics and herbals, and he is a member of the Thai Law and Regulatory Committee of the Thai Parliament. and he's going to be speaking about Bloomberg and Big Pharma's impact on the role of tobacco harm reduction. And here we have Derek Yach, who many of you will know. He's the former head of the Non-Communicable Diseases and Mental Health at the World Health Organisation, who worked on the beginnings of the FCTC at the World Health Organisation. He's also a past president of the Foundation for a Smoke-Free World. He's an epidemiologist and a swimmer. And he's going to talk about, outline some of the FCTC's history and from the perspective of someone who was there at the beginning and some other insights into the treaty itself. But first of all, I'm just going to speak a little about what many of you probably don't know is that the FCTC Treaty actually wasn't a thought, something that the WHO thought about. In fact, initially the WHO actually said, no, we don't want to do that. But where did it in fact come from? It came as a resolution from a conference in 1994, which is the World Conference on Tobacco or Health. Now, if you look, this particular conference happens every three years. It's happening again this year in June in Geneva. And it started in the 1960s. And if you just plot what is the resolution of the outcome of that conference and add five years, pretty much you get what happens in the world in the terms of policy in this area. So in 1994, in Paris, they said, let's go to the WHO and create a multilateral treaty exercising... Article 19 of the WHO constitution to do that, and that's really how it happened. And as I said, there was a lot of resistance at the beginning to do that. I first met Derek because we both sat through the negotiations from 2000 to 2010. and the development of the FCTC, so we've become quite expert at it. But I think one of the things I think is really important to know is when you look at...consider treaty success, for any treaty, not just this treaty, there's three key things you have to look at. Legal effectiveness, political effectiveness and... objective effectiveness? Did it actually achieve the objectives? On the measure of legal effectiveness, you could say this treaty has certainly met its legal obligations. In the first year it was open for negotiation, 168 parties or countries signed and went on to ratify or accede to the treaty. And that is very, very fast in treaty making. So yes, tick that. When it comes to political effectiveness, that is all a measure of have the countries that were party to the treaty actually done what was in it. You could say pretty much most of them have done a lot of the aspects of it in terms of advertising bans, public smoking bans, packaging and labelling, taxation, all of the things. They haven't done the harm reduction aspects, and that's what we're going to be talking about. But in a sense, most countries have done that. But has it achieved the third measure of treaty effectiveness? Has it met its objectives? And the objectives of the FCTC treaty was to reduce the exposure to tobacco smoke and the reduction of disease, et cetera, from smoking. And you could certainly say that that has not been achieved at all. So that sets the scene for what we're going to talk about and I think I'm going to go the other way now and first ask Derek to give, we're going to have five to 10 minutes each just to speak on issues and Derek will open with the beginnings of the FCTC Treaty negotiation.
05:36 - 14:19
[Derek Yach]
Thanks Jeannie and what a real thrill both to be on a panel with so many colleagues, many going back many years. And we were all 12 or 13 years old when we started this work, I think, if I'm right. And it is interesting to think, I never thought about it before, that so much actually did start in Paris. David will talk us through the charter. And I remember the World Conference extremely well in 94. Ruth Romer, at the time, one of our greatest global health lawyers from UCLA, wrote the book on global health law, saw that treaties were becoming the in thing in international affairs. It was the era of the environmental treaties, the seedbed for the climate change conventions. A lot of the work that today is now underpinning a lot of the work on climate and health, was in vogue. Governments were willing to engage in treaty-related discussions at the time. The geopolitics was much smoother, and countries who had had difficulties during the Cold War had emerged from it and were willing to realize that to address the downside of globalization, we needed to have international norms and standards, particularly to cover those aspects of environmental or health issues that you couldn't control by any individual country alone. And that's the point of a treaty. It's not to drive national policy per se, but to address the transnational aspects. And that was the context that Ruth Romer gave a very thoughtful scholarly address, actually first time a year before, in a meeting I hosted with the then Minister of Health of Zimbabwe, Tim Stamps, in Harare. In 93, we invited her to talk about what she thought was missing from the tobacco control scene with a focus on Africa, recognizing that African legal capacity was very weak in ministries of health to virtually nonexistent, and that there's no ways that they'd be able to write their own legislation and draft it. There needed to be an international framework to give them support. And that was when she said, we need to have an international framework an international legal framework to address the transnational aspects and to build capacity. And remember, this was in Africa. The meeting was supported at the time by the ex-president Jimmy Carter, who many from Africa will know how beloved he was in Africa because of his incredible work. And he sent a video address to all the ministers of health of Africa about the meeting, saying that Africa really needed to lead the way since the smoking rates were lowest. We needed to keep it that way. And that was, again, the context Ruth spoke to it. Shortly after that period of 94, before Brundtland came in, the Canadian government, which was at the time, I would say, the leaders in global tobacco control and chronic diseases, actually, proposed a number of resolutions at WHO that laid the basis for the treaty. What made it possible was that the first resolution on tobacco control at WHO had been introduced in 1970. And for every few years since, many of the national components were being introduced. So there was a general resolution in 1970 saying smoking kills, we better educate the public. By the late 1970s, it had gone towards saying, we've got to restrict advertising, restrict, not yet ban. By the middle of the 80s, there were calls for taxation, and taxation started taking off. And by the late 80s, you had countries like New Zealand, Sweden, the UK, Canada, Singapore, all providing examples of how their national laws and their national approaches were bringing the smoking rates down. And I think that's one of the important lessons, is that the countries who are way out front, already achieving success, like the ones I mentioned, continue to achieve success that probably they would have achieved without the treaty. But they were trying to encourage countries which were so far back to make progress, and I think we still have that gap. So the treaty process went through, as Jeannie said, fairly successfully and unusually. Our mandate in the secretariat was to complete the negotiation before Brundtland left office. Now, if you know anything about international treaties, you usually can't predict when this is going to end because of the vagaries of government and government relations and it gets complex. The second treaty WHO agreed, the pandemic treaty, was much more complex and it's just been approved without the support of some of the most important powers, particularly the US, which means that it's going to be pretty toothless as we look forward. I would say the most important lesson I learned was that getting an agreement is one thing, and what we say in simple terms is that law on the books, particularly if the books are in Geneva, doesn't mean law on the streets, particularly the streets of the bustling capitals of India or Bangladesh or Nigeria or the Middle East. It's very easy for bureaucrats to sit in Geneva, even when they come from their capitals, and feel very comfortable about saying, oh, yes, we are going to raise the taxes by X percent. We're going to ban advertising and marketing. We're going to provide cessation services and sign on the line. Well, if you don't have the resources, and you don't have the political will, and you don't have the organizational capability on the ground, and you don't have the legal competence, very little happens. And that was the lesson of the treaty. was that the thought and the intent was great. The funding was zero for many years, zero. There was virtually no extra funding for governments to actually mobilize the support needed at a time when infectious diseases, HIV-AIDS was a huge issue dominating the agenda, thousands of competing priorities. This was not a top priority for most countries, but they needed the funding to do it. The Bloomberg funding did actually provide some support. particularly for some of the more traditional aspects of tobacco control, encouraging advertising bans and so on, but had very little impact on taxation, by far the most powerful single intervention on smoking rates, and of course opposed vigorously anything that even came close to being related to tobacco harm reduction. Our net balance, I think it's important to remember, this is 20 years since the tobacco treaty came into force, which means that countries actually signed on to implement it. I would say that the success rate can be looked at in terms of two measures of outcome that I focus on. Do we have more smokers today than we did in the past? Well, we have 1.3 billion users of tobacco, according to the WHO documents that now are put out. That is a huge amount. Smoking rates exceed 50% in many countries in the world, particularly among men. Excess exceed 50%, for example, in China and Indonesia, it's what, 65%. Jordan, which got a fantastic prize from WHO, smoking rate among men, 57, 58%, not something you should get a prize for. And I could go on. And more importantly, the deaths. When we started the treaty work 25 years ago, we were predicting there were about four, four and a half million people dying a year of tobacco-related deaths. The figure today is about eight and a half million per year, and the figure's likely to continue to grow to 10 million before we start seeing a decline, even if all the measures are put into place. And just to put that figure into context, The official figure of how many people died in the entire COVID pandemic was 7 million over all the years. The estimate is probably wrong. It may very well be 14 million. But compare that to 8 million deaths per year, every year, relentlessly for the next many years, meaning a billion people will die this century of tobacco-related deaths. And staring us in the face is the obvious way to halt it in its tracks that I hope we'll move on to tobacco harm reduction.
14:20 - 14:49
[Jeannie Cameron]
Thank you, Derek. I think it certainly shows that that third measure of effectiveness in terms of the FCTC meeting its objectives certainly has not done that because it has not embraced all of the elements the harm reduction aspects of that treaty that governments have not taken on. I think first of all we'll continue on the WHO side of things before we move to the others and I will ask Tiki to make his presentation.
14:50 - 20:21
[Tikki Pangestu]
Thank you very much Jeannie and wonderful Derek to give us that background to the FCTC. For my intervention, I think basically I don't need to tell this audience that WHO has taken a very strong anti-tobacco harm reduction position. continued along that path. In fact, during COP10 it had actually been strengthened and current indications are it may not change that much with COP11 in November of this year. The main issue that I have, and I think many of you have, is that position has a tremendous influence on policies in lower and lower middle-income countries. Now, why is that? I think, first of all, there is the lack of capacity within many of those countries to independently evaluate their evidence and make their own decisions on policies that are useful to deal with their problems. I come from Indonesia, and many of you know we are number one in the world in terms of prevalence of smoking amongst males. Seventy percent, two out of three of our male adults are smoking cigarettes. So that's one, lack of capacity to evaluate evidence. Secondly is the lack of context-important local research. And policymakers, they don't really look at research in the US or in France or in Japan. What they need is local research, and that is solely missing in many of the LMICs. And as Mark Tindall mentioned this morning, there's apathy within government. So all this means they take the easy way out. Well, if WHO says THR or vaping is as harmful as combustible cigarettes, we'll just follow WHO guidance. Okay, so that's particularly important and you know it's particularly pleasing for me to attend the GFN. I mean you're addressing all the key issues here. There's obviously a very exciting science. There's the exciting highlighting of the importance of communication, okay, be it to overcome misinformation, be it to advocate to consumers and to policymakers, the highlighting of the importance of regulation, for example. So these are all key, key issues in our battle to advocate for harm reduction. But let me give you my own personal view. The elephant in the room is the WHO. As long as that position doesn't change, many countries are going to continue with apathy, many countries are just going to say, we follow WHO. That is the impact. of the position of the WHO on many lower and lower middle income, even middle income countries. So despite all the important things that are happening in the GFN, I still firmly believe that we all need to do our bits to advocate to our governments to take the lead to develop a movement to try and change the position of the WHO. Derek will agree. There's only one thing that will move the WHO. It's when a Minister of Health calls the Director General and says, we want this issue discussed at the WHO. All the experts in the world can send letters, Nobel Prize winners, doesn't make any difference. It's only the countries that can move the organization. It is a politically driven organization. The only members of the board of directors of WHO are sovereign member states. There are no other stakeholders in the governance of the organizations. No industry, no civil society, no consumer organizations. Okay, so, you know, at the end of the day, That's our aim. We need to change this, what I call, pardon the strength of the term, the evidence-blind policy of the organisation. Really, that is the elephant in the room. Any of you, if any of you have been to Geneva, when you walk in the front door of the WHO, you see the mission of the WHO. The highest possible level of health for all people. That's the mission. That is equity, that is social justice, that is human rights. They seem, as far as THR is concerned, they have seemed to have forgotten that mission. Let me finish by saying that despite all that I've said about WHO, I still passionately believe in the value and the importance of the WHO. There's no organisation that can replace it. Thank you.
20:21 - 22:05
[Jeannie Cameron]
Thank you, Tiki. And I think what you just said on the human rights aspect reminds me of the very opening line of the FCTC document itself. It says, and I've written it down actually, the treaty opens with the parties to this treaty give priority to their right to protect public health. I mean, that's how the treaty opens. And the preamble in treaties is always used to interpret them if there's any dispute. So it's very important. And I think another thing that you said, Tiki, which was very important, which a lot of people don't realise, is that it is the member governments, it is the sovereign states that actually have the power to do anything. They The government's created the treaty and the words and the text and everything in the treaty, not the WHO. At COPS, the Conference of the Parties, that are the parties to that treaty, they are all... Now it's up to 183 governments out of 193 in the world that are party... to that treaty, and it is only they that can move on anything. And as Tiki said, one or two ministers of health or the delegations who are speaking at a COP, COP 11 will be later this year, can actually change the direction. But they need to, as was said earlier, have the political will to actually do that. And I think that's where we'll come on to that a little later as well. But I think now we'll move to David, who is going to talk about an analogous sort of multilateral agreement, the Charter of Paris. And over to you, David, to take us through that. Thank you.
22:05 - 33:14
[David Khayat]
Thank you, Jeannie. Thank you. It's a pleasure to be here with you today. I would like to start my talk by asking you a question. And if you can raise your hand. Is that... Who knows why the 4th of February is the World Cancer Day? One, okay. So let me tell you the story. In 1999, we said groups of friends, including Dr. Harper from London, Gabriel Tobagi from the MD Anderson in Houston, we were coming to the millennium and we thought that it was time to raise awareness in the world about the epidemic of cancer and the burden of cancer. And we sat down in different places, in airports, and we wrote that document which became the Paris Charter Against Cancer. These documents, after a preambulance, you have the summary of the charter. under your seats, that document was giving a preamble about the burden of cancer, the stigma, the difficulties to struggle against this disease, the huge cost of money for every nation because of the premature deaths and everything, and then 10 articles dealing with freedom of research, respect of the end of life, empowering patients, and so on and so forth. And the tenth article, the last one, was that all the parties who are going to sign the Charter must make the day of the signature becoming the World Cancer Day. And I came with that with President Jacques Chirac, President of France, and when I explained to him that so many people are suffering because of this disease, because of the stigma around the disease, because of the difficulties to get the CT scan, to get the latest treatment, and to the difficulties of equity and access to the lastest innovation, he decided to sign it officially and he was very rapidly joined by, not WHO, but UNESCO. Question, why UNESCO was signing that? Because if you look at the most important determinants of cancer, it's education. 80% of all cancers in the world are due to lifestyle habits. Smoking, eating, being under the sun, lack of activity, obesity, and everything. And this is education. If we can teach to the kids to do some sport, to eat not potato chips, but tomatoes, to et cetera, all what's called lifestyle medicine today. they won't have the same prevalence of cancer when they become adults. So this is why UNESCO said, okay, we agree, we're going to support that. And on the 4th of February, 2000, at the Élysée Palace, which is the equivalent of the White House in my country, the director of UNESCO and the President Chirac signed that charter in front of all the media from all around the world, 400 million people saw it on the news in their country. And that was the reason why the 4th of February became the World Cancer Day. So now I have been asked by Gianni to make a kind of comparison about what is inside the charter compared to the FCTC. And there are some points that we can discuss. One is that the total difference in terms of tone and attitude toward human beings. If you look at the Charter of Paris against cancer, the first article says cancer human rights are human rights. Because at that time, a woman who had cancer, many times, has been left. When you get cancer, you lose your job. Because you are under human beings. You are not real human beings. And you are not allowed to get the same rights than the others. So this is why we made Article 1. Cancer patient rights are human rights. This is the basis of the charter. We deal with patients, we respect their life, we respect their hopes, we respect their chance to, in case they get a cancer, to be diagnosed as early as possible and get the best treatment. We teach them, we raise awareness to them about the determinant of cancer so that they can do something to try to prevent themselves about that. Whether the FCTC is dealing with the control So we are helping people. They are trying to control people. And that is, I think, the main difference. We are at the level of human beings, dignity of human beings, dignity even at the last week of the lives of these people, whether the FCTC and today the WHO in general, to my point of view, is very far for what is the life of one single person in the world. They don't care about that. And we can see that in a second thing. We are very much in the charter, and I think this is Article Two, working on the stigma. As long as, you know, when I launched the national breast cancer screening program in my country, we found out after three years that only 30, 40% of the women in the age of the program were going to get a mammogram. And when we made a survey to try to understand One-third of women will say, you know, whether I made the diagnosis early or late, I'm going to die. Second-third, they say, it's the mammogram that gives my cancer. And third is that I'm too busy, I'm struggling just to get enough money to survive and give food to my kids. I don't have time to go to a mammogram. So the stigma are a barrier to health. And we are... in the charter, in the essence of the charter trying to work against that. Whether in the FCTC, the stigma is part of the plan. They are threatening the governments about what is there with cancer instead of trying to help removing some of the stigma that are barriers to health. And the last point is that the Charter is very optimist. One day we will defeat cancer. If we work all together, if we put enough money on it, if we commit ourselves significantly. Whether the FCTC is regarding the main cause of cancer, which is tobacco smoking, is saying, you know, You don't want to quit, die. It's quit or die. And we cannot accept that because we are oncologists. We see patients every day in our clinics. And you know, when you see a patient with lung cancer, do you have any idea how many of them are going to continue to smoke after the diagnosis, knowing that they might die? that they are going to suffer radiotherapy, chemotherapy, surgery, and everything, 64% on the average will continue to smoke until the end, which means it's not that easy to quit. So when the only message you have is quit or die, it's not acceptable for a clinician. Now, if you look at the measurement, this is a second way to look at that comparison, the measurements of success. In the chart, the measurements of success is raising the awareness on the disease in the world, is raising the respect of dignity, raising the respect of the end of life, and give some hope to people that are either affected or the relatives of the people affected with this disease. Whether the FCTC, because they don't count on people, they just look at the number of countries who ban tobacco smoking. And the problem is that the third part of comparison is that the Charter is saying, again in its essence, is please take into account the innovation, take into account science, the results, the controlled studies, and try to provide people with the best and the latest improvement in the diagnosis, the treatment, and the prevention of cancer, whether the FCTC is saying we are going to even more than just control tobacco smoking, but also all the alternatives that could give a better outcome for the smokers. So the mistake is that Risk is not binary. It's not you are safe or unsafe. It's not you are drinking or not drinking. I mean, it's a relatively risk. It's not eating meat or not eating meat. It's not binary. The risk is more complex. It's personal. It depends on the way you live. So as long as you are so binary as the FCTC is, you will be wrong and you will not get the results you are expecting, which is a lower number of smokers, which is not the number of smokers, and the lower number of people dying because of the disease related to tobacco smoking. And unfortunately, this has never been achieved. by the FCTC. As Derek said, we had one billion smokers. We still have one billion smokers. And in many countries, in my country, 28, 30% of smokers in France, very rich, developed country, put a huge amount of tax. And did it work? Not at all. The only thing that happened is that the poorest people in my country, and this is not me, it's a study, it's an official survey, the poorest people, in order to be able to continue to buy their cigarettes, either they buy illicit cigarettes, about 45% of the cigarettes sold in France, or, that's more important, they are spending less money in food. for their diet, so they have a poorer and poorer and poorer diet just in order to be able to continue what is not just a pleasure, it's an addiction. You can tell to a drug addict, stop injecting drug, he will continue. You can tell to a smoker, stop smoking, if you don't help him, will not. And here we have a problem of the perception about nicotine, and I think that we will have maybe some points to discuss about that. because there is a misperception about nicotine and cancer whether it's tobacco smoke that gives cancer.
33:15 - 36:12
[Jeannie Cameron]
Thank you David and I think we'd all agree from hearing that that the Charter of Paris has a much more humanitarian approach than the FCTC. Although the FCTC does have in the preamble various references to human rights One in particular, it draws on the Article 12 of the International Covenant on Civil and Political Rights, which outlines the highest attainment of health as being a right that humans should have. Now, that treaty, and also from 1966... And equally, the other one from 1966, the International Covenant on Economic, Social and Cultural Rights. Both have a lot of human rights aspects that are very relevant here. And one of the things which I'll just mention now before we go to ASSA is both of those treaties have what is called an optional protocol. Now, an optional protocol is in treaty law. It gives... It gives individuals or groups who are affected by their national policy the right to take their case against their government to either of those – against those treaties. Now, most governments in the world are parties to those 1966 – human rights treaties. Now an optional protocol, one group of individuals who wish to vape and their government stops them from vaping can take a case as individuals only to those human rights bodies and take that through. Now the reason I know about this and when it worked was because as you can tell I'm from Australia ...and in 1997 I was working in the Department of Prime Minister and Cabinet... ...on international treaty issues. And it was back then illegal to be homosexual in one of the states in Australia. And two homosexual men took a case personally using... ...invoking these human rights things in these international cases... and they actually won and forced the Australian government to do that. Now, in Article 12, the issue of health is even far more significant and very well spelled out that any individual could take a case using their country's being party to that treaty against the national policy that is inherent in their country. And I think we should all think about that. I did write an article in Filter Magazine last year on it, and no one has yet done that. So I think it's worthwhile to think about. Now, moving on to ASSA. Asa is going to talk to us about Bloomberg and some of the anti-tobacco control and anti-harm reduction areas.
36:12 - 43:10
[Asa Saligupta]
Thank you. Thank you, Jeannie. I'm going to talk a little bit about Bloomberg, not a lot. I don't want to get sued right then. Because I think most of us here already know who Bloomberg is and what Bloomberg Philanthropies does. What they do is they fund anti-tobacco. And we have to look back at FCTC is tobacco control. It's not tobacco destruction. Nothing is completely 100% good and nothing is 100% completely bad. All the honoured speakers had mentioned something or others, and we are going through the end of this year, the WHO FCTC is coming up, and what Bloomberg is trying to do is to get with, the intention is to reduce smoking rate, which we all know that it's not working. And what they are doing or trying to do is they try to limit access to what we know is safer alternatives, something like vaping or snus or pouches. And a lot of countries have banned on less harmful products, like in my country. And in some countries, the ban are really crazy. Like in my country, it's illegal to import and it's illegal to distribute. You think about that, only to illegals. So it's not illegal to possess, it's not illegal to vape, per se. So you cannot import. So it's really weird. Also, they are public confusion. This is one of the confusion, right? And we also heard about the misinformation and all the false information that's going out, spread out. And the local people, the regular people, especially nowadays, you know, the internet and the media, society that we are going through, A lot of people, they just look at their Facebook, they look at their Instagram X and Twitter, and they see whatever jumps up at them in the first glance. And especially older people, they believe what's in there. It's like older generation believe the news, whether it's come from ABC, NBC, Fox News. It's come from news, must be true, and then they just like, so it's this generation, it's going through social media also, so they believe in my country, even though Bloomberg doesn't have a direct impact on the tobacco harm reduction It's not known to the public. There are quite a few local NGOs that play a similar role by pushing prohibition, especially they are ignoring science always. And like I said, they use ideology over evidence like Tiki and David had mentioned before. And I want to also speak a little bit about, there's a lot of people that, I don't know if you're trying to, but I've been trying, wherever I go I try to mention, the other players are big farmers. We started, lately we started to see like, I'm trying to say, like, okay, listen, who's the... Usually I said I don't blame big tobacco as much as big farm, but this is... First, I have to say this is my personal opinion, right? Big tobacco... It's our enemy. Of course, you know, I used to smoke for almost 40 years before I switched to vaping. The doctor said, don't use the word quit. Use the word switch, whatever. So the big pharma, they try to come out with like patches, gums and medications. And it had been said that veroniclein is the best way. It had been proven is the best way to quit smoking. And the second best way is vaping. But veroniclein had been removed from market because of side effects. Of course, all medicines have somewhat more or less side effects, right? And so the big pharmas also, they are opposed to vaping and stools and THR, the tobacco harm reduction in general. They also fund a lot of selective research, selective research, right? And they try to lobby for regulations. Like Jeannie had said, I work with the government. I'm a member of a committee of the government of a Thai parliament, still ongoing, and we are getting that close to legalizing vaping. Right now, the cabinet is taking a break. That's why I could be here, could attend. And then earlier in July, it's going to reconvene, and one of the first things will probably be maybe entertainment complex, and then followed by vaping, if all goes as well as I... I thought. But getting back to what we are discussing, so they are trying to regulate. In many countries, the regulations kind of varies, right? I heard like in Ireland, They kind of want to do simple packaging, plain packaging, maybe flavor band, or maybe not. And in many countries, it's like various kind of band with different level. I don't think they are looking at real tobacco and we had mentioned how many days in Thailand there are at least 70,000 people die of tobacco related each year and we haven't seen even one death case related to vaping. And, you know, so we were going on about tobacco harm reduction, and that would be pretty much unless, you know, like if maybe later if somebody wants to ask something more, but, you know, this is from consumer point of view.
43:10 - 43:39
[Jeannie Cameron]
Thank you, Asa. Now, you've all heard some very interesting commentary from each of our panellists here, and I think I have some questions for them. But first, I'll just take a couple of questions from the audience if anybody has... Oh, I can see one straight away from Martin. Martin, we need a... And if you can say who on the panel it's for or whatever.
43:39 - 43:56
[Martin Cullip]
Yeah, Martin Cullip, Taxpayer Protection Alliance. Derek, you wrote a while ago about the early years of the FCTC Treaty and you said that Gro Harlem Brundtland wanted to hear from all voices, including from industry. Why did that change and what's the effect been?
43:59 - 46:56
[Derek Yach]
One of the things, you're right, she was, just also remember her background. She was the Labour Party Prime Minister of Norway. And often one associates the Labour Party with being antagonistic to the private sector. Well, Norway was not. And she believed that all the complex social environmental health problems of the world could only be solved through private-public partnerships. And she did that as the Minister of Environment. She did it as the Minister of Health. At WHO, we had roundtables with the pharmaceutical industry. We hosted the first and only one with the food industry and even, believe it or not, with the alcohol industry because we saw there were some issues of common ground. On tobacco, we recognized very early on, before the formal negotiations started, that we needed to give them a voice to say what did they think was going to be the way of addressing the health issues. And so we had two public hearings in the WHO building. And the one was where the industry was invited to present them whatever they wanted. They were not alone. We had NGOs, activists. And for two days, we had these public hearings. The major companies, PMI, BAT, Japan Tobacco, all sent representatives, and they all gave speeches. We then had a second meeting, which was the start of what became the Tobacco Regulatory Advisory Committee to WHO, where we wanted them to send only their scientists to answer the question, what did they have in their armamentarium that was likely to advance harm reduction? So what was the research evidence that they had? And for that meeting, again, those same companies took part. And there was a decent discussion. I don't think we on our side were convinced that they had much at that point to offer, which if you look at the evidence, they actually didn't, except for snus. And the end result of that, unfortunately, then was this discussion around 5.3, about the irreconcilable difference between tobacco industry and public health meant that you had an inability to have any discussions anymore with the tobacco industry. So it actually ended by the start of 2000. And I remind people that that language, irreconcilable difference between the interests of tobacco companies and public health, is now belied by the FDA language on appropriate for the protection of public health. If something is appropriate for the protection of public health, you can't have an irreconcilable difference. And the FDA has recognized that and seen that in the case of harm reduction, we should be making more progress.
46:58 - 47:02
[Jeannie Cameron]
Thank you, Derek. And there was another question here at the front as well.
47:08 - 47:38
[Delon Human]
Thank you. Delon Human, Health Diplomats, and a question to Derek Yach. The FCTC is not silent on harm reduction. Article 1D explicitly acknowledges harm reduction methods as part of tobacco control. So the question is, how did that language get into the FCTC, and what can be done for that language to be elaborated, preferably by a work group? So just a bit on the history and then the way forward, how we can actually enact it.
47:40 - 52:23
[Derek Yach]
Thanks, Dylan. Again, one has to put your mind on to that period of the late 90s. The AIDS epidemic was roaring ahead, needle exchanges, condom use, harm reduction was central to HIV AIDS. It was natural for us to think about how that might apply here. We'd already started doing, WHO had started doing needle exchange programs in Zurich. The German Zurich citizens didn't like it and tried to actually stop the program. This was a WHO program which got led by the then head of the Swiss health department, Zeltner, and led the way worldwide for harm reduction. So it was part of an open understanding that there would be a range of options, and we didn't want to remove it from the list. Just while we're talking about the text, I think the other important thing that came up when David was talking related to really looking at what the objective always was for the Framework Convention. If you read the text, it's very clear that the governments saw the Framework Convention as being successful if it would lower the death and disease caused by tobacco smoke. Reduce the death and disease caused by tobacco smoke. Each word had incredible meaning. First, it meant that success wasn't going to be measured simply in smokers no longer becoming smokers. That wasn't going to be good enough. It had to go all the way through to preventing the cancer, cardiovascular disease, and respiratory disease. And at that time, the leading non-profits, of which Dilan was one from the World Medical Association, along with the International Cancer Society, the World Heart, and the International Respiratory Association, were all very strong voices for their own patients' interests. And they were pushing very hard to make sure that what we did would help patients in the end. And cancer, of course, was a central one. And we've forgotten that. Instead, the debate has moved towards everything to do with kids, forgetting that the real purpose of this is to show benefits to adults in terms of very specific health outcomes. And the last comment I'd make, before I forget, was in response to David's other points about the Elysee Palace meeting. that I was very thrilled to attend, initially illegally, because WHO forbade us engaging with the process, as you'll remember. And I think it took, finally, President Chirac making a direct intervention to say, you've got to have some representative there. So I was then the lowly representative. Sitting on the one side of me was Simone Weil, one of the greatest politicians and thinkers that France has ever produced. which is also ironic to talk about here being in the land of Auschwitz, which she survived. And secondly on my left was Sir Richard Peter, one of our greatest cancer and tobacco epidemiologists. What I find poignant, and again reminds me of how personal this all can get, Simone Weil, in that meeting, I think, or before, announced that she had been treated for breast cancer, something that no senior diplomat in France had ever done before. And it was done, probably with David's support, to destigmatize the issue. On the left of me, we had Richard Peto and Richard was in fine health, but years later would go on to have advanced cancer, which he is successfully treated from and celebrated his 80th birthday last year. And sitting in the middle was me, not knowing that I would land up having three cancers to have to survive, putting all of us in the position to understand that what David's talking about is both personal and professional. And the last point related to it is the reason people are surviving is because of the unbelievable progress in innovation in science and technology of cancer treatment, which is akin to the incredible advancement in science innovation that tobacco companies have practiced in tobacco harm reduction. The treaty failed. to include any mention of innovation, patent protection, the investment in cutting edge science, both to treat, prevent, or diagnose disease. And that is a real big shortcoming that I think the charter could actually highlight going forward. Thank you.
52:24 - 54:57
[Jeannie Cameron]
Before we go to Tiki, because you put it to Derek and Tiki, because I'm going to ask him about COP11, but I would say, in a practical sense, how do you invoke Article 1D of harm reduction? You would do that in the very same way that all the other articles in the FCTC have been invoked at each COP. So for example, Article 8 on environmental smoking bans. During the COP, one country put forward a resolution intervention to say we would like to bring this on for further elaboration and discussion and scrutiny. Another country backed it. WHO and COP is a consensus-making body. No one objected. That's exactly what happened. The next one, a country put forward, we would like to elaborate Article 5.3 on the FCTC. Another country backed it. And they then went on to have a working group to look at how Article 5.3 happened. Every single time, that is exactly how you invoke or elaborate, as it's called, an area of the FCTC. Some years ago, I drafted one to bring on how Article 1D might come. We saw at COP10 that St Kitts and Nevis, one country, kind of did something very similar to looking at that. But unfortunately, there wasn't really any country to back St Kitts and Nevis, we were talking about earlier in political will. So hopefully at COP11, a government backed by another one, And there being no objection, that can actually bring that on for further discussion, elaboration, presentation of the science and evidence to actually bring it about in a very practical way. We have seen COP7, I mean some while ago now, there is language in COP7 in the decisions which actually says something like, if I can remember, If we could fast track and have more people using e-cigarettes or ENDS, we can perhaps bring about a public health benefit and all that. It's quite good because that's what governments were saying at the time of COP7, but none have come back and sort of said that further. So I'll hand over to Tiki because Delon asked him about that, about COP11 and what you think could happen there. I know you have some thoughts on that.
54:58 - 57:10
[Tikki Pangestu]
Yes, thank you for that, Ginny. I think your preamble is very important in terms of a very practical issue. To me, this is a big challenge. And I think there is a very strong ideological divide, as well as what we know as the conflating of arguments between risk to youth and minimizing health risk to adults. That's well known. But the ideological divide is much more difficult, and that is between the public health perspective of reducing harms and the ideological perspective of a nicotine-free society. That's almost irreconcilable. But moving on to COP11, and this goes back to what I said earlier, it's only the countries that can move changes within the WHO position. And I think Jeanes mentioned St Kitts and Nevis example. The Minister of Health, Dr Denzel Douglas, made a very public statement at COP10 that this is a very important public health intervention. But as Ginny mentioned, no other country supported it. But without really divulging any names, I'm aware, because I spent half my time in Geneva, that there are some strong moves to get that second country to support the proposal from St Kitts and Nevis to form a working group. That's the critical point. step. And I'm a little bit concerned. Why is it so difficult to get another country? You know, you have so many countries around the world that have been very progressive in supporting THR. The UK is the obvious one. The Philippines, if you want to talk from my part of the world. I know once again confidentially that St Kitts have been working with a few countries in the Caribbean and hopefully something will happen before November. I'm keeping my fingers crossed.
57:10 - 57:15
[Jeannie Cameron]
David, did you want to comment? Oh, sorry, I thought you were putting your hand up to comment.
57:16 - 57:18
[Asa Saligupta]
Can I say something?
57:18 - 57:19
[Jeannie Cameron]
Yes, of course.
57:19 - 58:51
[Asa Saligupta]
Just to add on. I think one of the reasons could it be the Dirty Estuary Award I mean, like, it's weird, right? I mean, there are a lot of, like, you probably heard of the Golden Orchid Award, you know, like, which two countries that did nothing, and then the countries that did really great on harm reduction, lift the ban on tobacco harm, on vaping. especially because that certain countries had found that there are members, employees of Bloomberg sitting within the health cabinet, within the health department at the Ministry of Health, so it turned around, and that country received the Dirty Ashley Awards. So I would just like to just take real quick for consumers and actually for all of us, you know, to what TK just did, what we could do is we push our government, we ask our government, we put out petition, this is what we did, we had been doing it for over 10 years, and finally, you know, like the government say, and then the representative of what our government will send either from doctors or people in health department as a representative of each country to attend the COP 11, ask them to do what we want them to do. Just be a voice of the people of the country, thanks.
58:51 - 59:24
[Jeannie Cameron]
I think Derek would like to say something just before you do that. I looked at you there and we were both laughing in a sense because when the international negotiating bodies were on between 2000 and 2003, when there were all these antics, the Dirty Ashtray Award, the Mulroman Award, the Good Orchard Award, the Grim Reaper, you know, there was the death clock. There were all these kinds of things that we would be confronted with when you... went into the negotiation area. Anyway, Derek.
59:25 - 62:33
[Derek Yach]
Yeah, and again, it's sort of quite historic, you know, sitting next to Jeannie because she was, you know, from the dark side. And we also learnt in the negotiating rooms that if you go into the conference room, it's got these wood panels if you go down the corridors. And you wouldn't know, unless you really know, that some of them were doors. And if you needed to escape some delegate coming at you, and we had to often escape, you could sneak off and just disappear. And nobody would know where on earth you were in the corridors where the real interesting discussions happened. I just wanted to really go back to the last couple of comments. both Azar and Tiki much earlier, because most of you, or if not all of you, already come from the consumer advocacy, from the activist side, and are not here representing governments. And I just don't want you to think that the only way to change this is going to come through a change in WHO. My own view is that It's long overdue. I don't think we should waste too much energy on WHO now. I think we should be looking at the next director general election, which is only 18, 20 months from now, and make sure that we find the right country to send the right delegate to become the director general. And that will require partnership way beyond tobacco. They're not going to elect a director general based only on whether they're going to support harm reduction. They're going to have to do everything else. But the really important point is to think of many of your careers and certainly my career. I can remember my first success in tobacco control was on the campus of the University of Cape Town where I stopped smoking in our student representative chamber. That was for me a big deal thing. It took an enormous fight. Then the medical school and the professors of surgery were violently against banning smoking in the medical school. That was a real time, I think many of you will know. Well, we succeeded then. And then we tried to ban smoking in the restaurants of Cape Town, which when we first announced it, the head of the major tobacco company said that if we went ahead and the city went ahead, they would withdraw all the money from the city orchestra. Now, you kind of figure out what the link is there. Anyway, he didn't, and that happened, and then Johannesburg banned it, and then we slowly went on. All to say that local activism matters. It builds the impetus, and I don't know what the equivalent is that we need to do. Should we be demanding access to vending machines in universities, if you're sitting on a university campus? I'm sure Sue will agree we should be demanding access to vending machines in mental health institutions and get the mental health patients involved. That would make a massive difference. Should we be making very simple requests for access to nicotine pouches when you get on a plane and you're a smoker to actually reduce your anxiety on a long flight? There are many pragmatic things that we could be doing through activism which means that we don't wait for WHO because otherwise we'll be waiting for the end of time.
62:34 - 63:34
[Jeannie Cameron]
Yes, I said earlier, especially even in these multilateral forums, it's the WHO gets to decide nothing, nothing at all. It's the administrative part. It sets the agenda. It produces papers and background, et cetera. But it does not make any decisions. That is the role of the national governments. So it is, as Derek says, it's so important to educate and have the national governments aware and getting them to take action where possible. And I think, as Tiki said, the governments that we can get to take action, if one... I've seen it before. If one, then another one feels the confidence, then another one. You start to get a little bit of momentum, but you don't therefore get... You know, it's a consensus, the absence of a formal objection. Unless anyone objects, something will go through. So... Do we have any more questions from the audience to our panel here? Yes, Peter, please.
63:41 - 64:48
[Pieter Vorster]
Hi, Pieter Vorster. I'd like to ask, well, whoever wants to answer, but Tiki in particular, you mentioned governments, especially in LMICs, relying on WHO policy because they don't have the resources or there might be ignorance regarding the benefits of THR. Do you think there's an additional issue which is a conflict In terms of tax revenues, Indonesia, for example, I think about 13% of government expenditures funded by excise from tobacco. Do you think it's a convenient excuse for these governments to just say, well, the WHO says this is the... you know, without wanting to think because, you know, there is such a big reliance on tax revenues.
64:50 - 66:29
[Tikki Pangestu]
Thank you, Peter. Excellent point, and certainly economic, political issues are part of the question. You mentioned Indonesia in particular. Derek and I were colleagues with a a lady who used to be Director of Gender and Women's Health at WHO, who subsequently became Minister of Health in Indonesia, Dr. Nafsiah Mboy. And Nafsiah shared with me an anecdote. Well, first of all, you know that Indonesia and the United States are two countries that have not ratified the FCTC. So she shared with me an anecdote. Whenever she got up in front of cabinet meetings during her term as Minister of Health, and whenever she tried to promote stringent control against trying to reduce that smoking prevalence, the first hand that goes up is the Minister of Finance. As you rightly mentioned, it's actually not as high as 30%. The latest I have is about 12% of government revenue comes from tobacco tax. So the Minister of Finance will say, are you willing to give up 10% of government revenue? Minister of Agriculture will say, what are you going to do with the one million tobacco farmers? Minister of Industry will say, what about the one million people working in the manufacturing of cigarettes? So many exigencies, which is political, economic, in addition to what I mentioned before, the lack of capacity and apathy. Thank you for the question.
66:29 - 66:29
[Pieter Vorster]
Thank you.
66:29 - 67:06
[Jeannie Cameron]
Yes, governments are addicted to the taxation, that's for sure. I have a question for you, David. In terms of the Charter of Paris and the FCTC, I would imagine that most of the governments are signatories to both of those multilateral agreements. So how do you think we can educate those governments to actually take more of the approach, the humanitarian approach that they've agreed to on one hand toward the FCTC in terms of going forward to bring out the tobacco harm reduction elements of the FCTC?
67:08 - 69:01
[David Khayat]
It's not easy for them because FCTC is based on the idea that we can prevent disease and death due to a lifestyle habit. The problem is that the political clock has nothing to do with the health clock. If a given government is going to invest a huge amount of money to try to improve prevention on cancer, for instance, is not going to get the profit, the benefit of the better outcome, which will happen 20 years later. And I was the advisor of Jacques Chirac for five, six years, so we had to discuss this with the parliament, with the Minister of Health, and so on. The idea is that they spend money on treating disease, although they are called Minister of Health, but it's disease policy, not health policy, because does not include really significant amount of investment and commitment in prevention. So the problem is that if you put money to try to prevent a bad habit, you are going at the same time to continue to pay for the people who didn't have that attitude 20 years ago, before, and are going to have the disease at the time you are working, you are in charge of the government. It's only 20 years later, so 10 governments later, that they will see less lung cancer because less people were smoking. or less colorectal cancer because less you try to transform food access and so on. So that's the point. You can say everything you want, but at the end of the day, even Tiki said that about tax, it's the question of money. They have budget, they are government, they are in charge of the country, they need to check about what they spend, and spending on prevention, for them, at the day they spend the money, is not profitable.
69:03 - 69:05
[Jeannie Cameron]
Do you want to say something, Derek?
69:05 - 71:05
[Derek Yach]
I think this issue of the importance of the money has never been more critical. Many of you are probably aware that we're now seeing, for the first time in 30 years, a significant decline in spending in global health. The period of the Framework Convention was also the start of the greatest expansion of funding and institution building. Gates hadn't created his foundation, just as one example. He then went on, and Gavi, the Global Vaccine Initiative, the PEPFAR, many of these programs got created. Now they've been cut by billions, a mixture of US policy, but the Germans, the Brits have also made massive cuts, and the result? In tobacco, I don't think we fully understand, but it's meant that global surveillance, youth tobacco surveillance, is no longer supported from the CDC as it was. Many researchers from the NIH, the FDA, CDC have been cut. Massive programs have just been stopped. The Office on Smoking and Health no longer exists. The tobacco-free initiative of WHO is no longer visible on the org chart. The replenishment funds required for the pandemic are struggling. All to say that you can look at this with despair and say, oh my God, where's the money going to come from? And this is where I think we need to recognize that the private sector does need to step up at this time in dramatically bolder ways. Ideally, it would be very nice if the philanthropic sector also would, but it's unclear that there's going to be much more money there. and be bolder about doing a couple of things. Number one for me would be to invest heavily in scientists and researchers in low- and middle-income countries, because without those scientists and without their research and their voice, we won't have the passion needed to drive their policymakers to go to WHO and say, we want tobacco harm reduction.
71:06 - 71:27
[Jeannie Cameron]
Thank you. Now, I'm going to ask each of the panellists to have a final minute. But before we do that, I would like to see if there are any more questions. Yes, I can see two here in the front. We can take both of them. One from Norbert and then the man in front of Norbert.
71:33 - 72:18
[Norbert Schmidt]
Hello. My name is Norbert Schmidt, consumer from Germany. And I have a question specifically to people who were instrumental in the creation of the FCTC. When this was created, what was the thought process behind Article 5.3, and how do you feel how this is abused today for atonement attacks on everybody who disagrees with people?
72:20 - 72:35
[Derek Yach]
I'll just be very brief. First, I think one has to read the text of 5.3, not the elaboration by the Secretariat. The actual text is fine. I don't have a problem with it. It basically says... I can read it if you like.
72:36 - 72:52
[Jeannie Cameron]
Okay. In setting and implementing their public health policies with respect to tobacco control, parties shall act to protect these policies from the commercial and other vested interests of the tobacco industry in accordance with national law.
72:53 - 73:57
[Derek Yach]
It basically means declare conflicts of interest, which is pretty sound. The problem is that there were guidelines attached to it not to... voted on by the member states, but it's developed by the secretariat. That's where the prohibitions and bans, and it's then become part of folklore that 5.3 says ban people from meetings, from conferences, journals should restrict them. Well, journals are not privy to, they're not part of the framework convention. That should be challenged. That's also where I think the activist community should read this text carefully and challenge the the British Medical Journal and all the journals banning this, the conferences that forbid it. And the good news, of course, is that we were talking earlier about the e-cigarette summit in the US just two weeks ago, where one of the most eminent people in tobacco control research, Robin Mermelson, said, isn't it time to reconsider this and have the SR&T meetings, for example, allow scientists on the same platform as public health people. So I think there are ways to challenge it. And the thinking at the time was to have a good conflict of interest protection in the text.
73:57 - 76:01
[Jeannie Cameron]
It's all to do with interpretation and government interpretation as to what they meant in that. And I remember, I recall very distinctly at the World Health Assembly meeting when the FCTC was adopted in 2005, I remember the government of Bangladesh, of all things, it said, we agree to the Article 11 packaging and labelling, health warnings, etc., etc., that were in there. But they said, in our case, most consumers don't actually see the packets because it was to do with graphic health warnings and things like that. Most of our consumers don't see the packets because they're sold in a different way. But we'll agree to it, but we're not necessarily going to do that. And I think that's where that whole interpretation thing of governments and how they shape that interpretation. And Derek's absolutely right. It is far overstretched. It has got even to the stage in some counties in the UK that I understand where the police aren't even allowed to go and look at illicit tobacco products because they're invoking Article 5.3. They can't even address it. I mean, this is absurd and ridiculous. So I think definitely that area of interpretation and getting governments to be more pragmatic about it. The German government where you're from, they actually sat in the public gallery for many parts of the outside the negotiating room because they didn't agree to a lot of the things that were going on. So governments have taken stands. Cuba always takes a stand. You know, they do things on various issues. They just need to be pushed. Anyway, there was a question in front of you, Norbert. The next, yeah. Oh, you don't want to have it. Sorry, it's very hard to see you because the light. Does anybody else have a question? We have one over in the far corner on the...
76:04 - 77:09
[Mark Tyndall]
Hi, I'm Mark Tyndall from Canada. The way these policies work at the WHO are fairly blunt with banning everything, and obviously prohibition is not very successful in many ways, and many countries already are feeling the legal push to get these products into the country. Canada is a good example, Australia is a good example, and already half of tobacco sold right now in Canada is from the illegal market in a country that's fairly wealthy. And vaping products, the problem of banning them is that they're going to continue to get in there and it's going to just cause havoc for communities. And do you think that, I'm just wondering if there's, kind of such a blunt response from WHO and all this talk about prohibition and banning will backfire and governments will find that it's impossible to ban these things and it would just cause chaos.
77:10 - 77:12
[Jeannie Cameron]
Tiki, do you want to take that? Or Derek?
77:16 - 77:53
[Tikki Pangestu]
Derek? Thanks, Mark. I mean, I think that is a classical example of unintended consequences the minute you ban sort of a product. It's becoming a problem in many countries. You've already mentioned Australia where people are actually firebombing pharmacies to get access. Singapore is another country where there's a total ban. We have endless problem with smuggling from neighboring countries in Malaysia with the smugglers coming up with very creative ways of smuggling these products. So yeah, absolutely.
77:54 - 78:08
[Jeannie Cameron]
I saw this morning for Australia, 1,700 to 1 illicit products in Australia being consumed from official record out today.
78:08 - 80:06
[Derek Yach]
Just a historical thing as well, Mark, and warm regards from Peter Singer, by the way. One of the curious things about the Framework Convention process that not many people may know is that in 2002, Alcohol, Tobacco, and Firearms Division of the US government approached us formally at WHO to host a meeting on illicit trade in tobacco at the UN. And at the time, they not only approached us, but they said they'll fund the whole thing. Now, anybody who knows the US government knows it's extremely odd for the US government to fund anything in the UN anyway. And they weren't going to be signatories in the end, so we knew that. So why on earth did they do this? And it was the time when the smuggling case had been detected where cigarettes were being smuggled from North Carolina to Canada, and you can see the price differential, and the proceeds were going off to fund Hezbollah. This was the first terrorist case that eventually made it to court and a conviction. I mention that because people don't realize that illicit trade is not just something that gives cheap cigarettes and robs governments of taxes, but is also used not only to fuel criminal element, but to fuel terror around the world. I know that the tobacco industry look at this very carefully, but they don't have the right fora to talk about it. The World Customs Organization was very involved. If I'm right, they were actually stopped from participating in WHO Framework Convention meetings. Interpol as well. Yeah, Interpol. Can you believe Interpol and the World Customs Organization are not permitted to formally be part of the WHO meetings because they work with the tobacco industry, which is kind of obvious. They have to.
80:07 - 80:32
[Jeannie Cameron]
Yes, some very bizarre things. Although when you look at the US, it is, in fact, from what I've been reading, the fact that there is so much illicit vaping and not FDA-approved vaping going on in the US, it's actually responsible for what's bringing the smoking rate down. So, oh, we do have time for one more question and then I'll come to everyone to sum up. There's one here in the front.
80:32 - 83:12
[Marcela Madrazo]
Thank you. More than a question, it's a comment. I want to share with you two thoughts. I'm from Mexico, first country in the world that bans vaping in the Constitution. I would like to share two things. One, you spoke about FTC and that the parties should have like an office for tobacco control. In America, there were no resources to create these offices, and they were financed by PAHO, but the real financer was Bloomberg, through PAHO. So in my region, there are not many health ministers that would come up and go against whose lineups, because they are being financed by Pajo, but with the money of Bloomberg. And that's a reality mainly in Central America and the Caribbean. Okay, one side. The other one is please make of Mexico a study case. The banning came in the beginning of this year. We don't have secondary laws. We don't know how wide the banning is going to be. There's people that have been extortioned by policemen because they have a vape with them. They're not vaping, they just have a vape with them. We don't know how wide this is going to be. But what I can say is that before it was banned in the Constitution, there were four decrees of the president to ban them. And the prevalence of smoking in Mexico was 16.8% in 2020. Now it is 19.6, and it was not yet banned in the Constitution. So I am saying this in a very formal way. I mean, really study what's going to be happening in Mexico, because after the banning, the prevalence is going to rise. And it's going to give not only the momentum, the data, that you need to have to tell who, look what's happening in a country that even got an award because we granted, they gave us an award because we banned them. And I don't know, three, four, five years from now, the effect is going to be the contrary of what is suspected.
83:12 - 84:08
[Jeannie Cameron]
I think that's very significant and it would be interesting to see whether Mexico, which I'm probably sure it is, was a signatory country to either of those 1966 conventions that I mentioned because that gives Mexican citizens, Mexican individuals, the right to take a case under that treaty against their government policy. And as I've said, I worked on that in Australia in 1997 for the case. It can work. It needs to be very, very well organized, very legally done, et cetera, to ensure that the individuals who take it do the process correctly to stop it. So maybe it's a sort of a global effort in Mexico to make this happen, to enable that to pass. And anyway, it's something we can talk about later. But I agree that you've made some very significant points.
84:09 - 84:13
[Marcela Madrazo]
Mexico was the first country to endorse FCDC.
84:13 - 84:19
[Jeannie Cameron]
The first country in the world. Yes, so it's a very significant thing. And you know why.
84:20 - 84:26
[Derek Yach]
Julio Frank had been the Minister of Health and he was in the cabinet with us, so it was no surprise.
84:26 - 84:39
[Jeannie Cameron]
Frank, I remember him as well. We're just finishing up here, so I'll give each of you please just one minute. Tiki, would you like to start just to say your final comments?
84:40 - 85:33
[Tikki Pangestu]
Just a final comment to support what Derek had mentioned earlier, and that is for more research to be done in lower and lower middle income countries. And I would like to salute in particular Ricardo Pelosa. I don't know whether you're in the audience, Ricardo. doing some amazing collaborative research with Indonesia. My second comment is a quick one, that I do have sympathy with policymakers who make policy on these issues. Indonesia, as I said, smoking is almost part of our culture, so it's difficult for our policymakers to make policies that are going to attack that sort of almost daily habit. And I think there's a saying that what is popular is not always right, and what is right is not always popular. So that's my sympathy for the policymakers.
85:33 - 85:35
[Jeannie Cameron]
Thank you. Thank you, Tiki. David?
85:36 - 86:05
[David Khayat]
Just a very short comment. I am a clinician. I see patients every day with cancer. And it is obvious that we are facing an issue with lifestyle. We know that most of the cancers are due to the way you live, the way you eat, the way you behave. So we have to invest more money, more commitment in governments, in universities, in research labs on this issue related to lifestyle.
86:06 - 86:08
[Jeannie Cameron]
Thank you. And Asa?
86:08 - 86:36
[Asa Saligupta]
Yeah, I'm going to say as a consumer, right, we need a right as a consumer to be given the correct information, like, you know, everything we consume, you know, water and everything, that should be labeled, and it should be not misinformation, it should be correct information directly from the government. So please, you know, just work together, and this is a shout-out from the consumer to the government, to the health department. Thanks.
86:37 - 86:40
[Jeannie Cameron]
Thank you. And finally, Derek.
86:40 - 88:19
[Derek Yach]
First, I would urge people, look at a LinkedIn thing I put up with a link to Yusuf Adebisi and our article on the size of the gap in low-middle-income to high-middle-income companies with regard to investing in tobacco harm reduction research. As I say, without this, we won't make progress. I saw the difference when this started to shift for AIDS. Suddenly you didn't have people parachuting into African countries doing work. You had indigenous African scientists carrying out research which changed policies. And then another thing for you all to look at is a book by Margarita Melillo, and I can give it to you later. who wrote a book on the Framework Convention. She did a PhD in Italy on this, but then wrote the book and she was at Georgetown. It's the only time I've seen an international legal opinion on 5.3 lay out the dangers of it from a precedent-setting approach across the UN treaties in general. And those people interested in 5.3 should take a deep look at the text. And finally, my last comment is just to re-endorse what Tiki and all of us have been saying about the emphasis for change must come from where the smokers live, which are low-middle-income countries, and don't be drawn by the research agenda of what happens in the US or the UK, where the smoking rates are basically gone. Yes, they can fuss around a little bit of flavors here and there, but basically they're gone. Whereas in places where the smoking rate are 50% plus, that's where 80% to 90% of the deaths are going to come. That should be 100% of our attention. Thanks.
88:19 - 88:25
[Jeannie Cameron]
Thank you all. And will you help me in thanking the panel for their wonderful comments?