Today's Science Lab session features presentations from Yusuff Adebayo Adebisi & Gabriel Oke. Presentations highlight the need for inovative approaches to tobacco use in LMIC's and identify gaps in THR research in the global and LMIC contexts. Gabriel Oke shares some statistics on tobacco use, health impacts and understanding of SNPs in Africa.
Transcription:
00:05 - 01:30
[Summer Hanna]
So next what we'll do is we are going to mix it up a little bit and that we will run two of the videos concurrently and then invite the authors to discuss any questions as a bit of a tag team. So first I'd like to introduce understanding research gaps and priorities for tobacco harm reduction and LMICs. Yusuff Adebayo Adebisi and Derek Yach. So Yusuff will be representing the discussion of the presentation. Yusuff is a pharmacist and epidemiologist committed to advancing equitable health research and strengthening responses to health emergencies in low and middle income countries. He now serves as director for research at Global Health Focus, a think tank that builds research capacity across the global south and beyond. Then Gabriel Oke. Sorry. Gabriel is a medical laboratory scientist communications professional with expertise in tobacco harm reduction, research and advocacy, and low and middle income countries. He leads THR Journo, an initiative advancing THR in Africa through research, social media campaigns, workshops, and training programs. And so we will start with the first video, if that's OK.
01:35 - 09:19
[Video]
Hello and welcome. This presentation is on understanding research gaps and priorities for tobacco harm reduction in low and middle income countries. We first discuss the connection of WHO's FCTC harm reduction and research, then how and why we develop draft priorities for THR. Then we look into THR papers categorized using Scopus, and then the research funding landscape between 2014 to 2024, and finally the priorities for private and publicly funded research. At the end, we discuss the proposed priorities for THR research as to our findings. Article 1D of the FCTC defines tobacco control as a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke. The FCTC highlights the importance of research, surveillance and capacity development as essential pillars of effective tobacco control. Article 20 places emphasis on research, surveillance, and exchange of information. Article 21 calls for strong reporting and exchange of information, while Article 22 calls for cooperation in the scientific, technical, and legal fields and provision of related expertise. By these clear directives, WHO has not developed global recognized priorities for tobacco control research, more specifically, THR research, two decades after the FCT's inception. This, in part, informed the need for this paper. At the same time, it was important to identify gaps in research where answers could unblock impediments to progress. To achieve this, the researchers conducted a systematic review of publications on THR from 2014 to 2024. The review focused on gaps in research output in LMICs versus OECD countries and differences between private and public research. THR papers were categorized by product type using Scopus. From this, it was noted that e-cigarettes dominate the THR research landscape, followed by NRTs and heated tobacco products. The USA is the main source of THR research. Sweden dominates source research through the Kalolinska Institute. While Japan contributes to HDP research, The National Institute of Health is the top public funder, while PMI, Swedish March and Graco-SmithKline are the top industry funders. Substantial disparities were found in the citation densities for DHR research. The highest values were seen for New Zealand, the UK and the USA. By contrast, the citation densities in other countries were lower. Public funding for DHR research throughout the study period was predominantly provided by public entities with occasional contributions from charities, especially in Europe. The NIH was the most frequent funder and supporter. However, most countries relied primarily on national funding sources for research. Big funding is directed heavily towards chronic conditions like cancer and the effectiveness of THR products as cessation tools. Privately funded research is focused on demonstrating the safety and efficacy of THR products, particularly as alternatives to traditional cigarettes, and on the biomarker evidence of reduced harm to health. Now, what are these proposed priorities for THR? These were separated into global and regionally specific priorities. Global priorities should be approached with the same rigor as studies on vaccine or medication efficacy and overseen by international advisory boards to facilitate wide endorsement. Draft areas should include long-term effects on health, health effects of nicotine, and relative effectiveness of cessation across OTHR categories, among other priorities. While country or regional specific priorities are needed to address diversity in product use, research capabilities, public health competence, public health priorities, epidemiological realities, cultural attitudes, regulatory environments, and healthcare infrastructure across different nations. Some of these priorities are listed here, including surveillance, THR product trends by age, sex, or amount, healthcare providers' use, knowledge and advice about THR, and youth access trends and intervention impact, among others. LMICs, particularly those in Asia and Africa, face unique challenges and opportunities, but the levels of research in LMICs are lower than those in high-income countries. One of the most pressing priorities is to comprehensively chart tobacco product use, including types consumed, demographic differences and cultural factors. These baseline data are essential for developing targeted, contextually appropriate, and effective interventions. The analysis in this research paper highlights substantial research gaps and the critical need for a comprehensive and nuanced approach to THR research and policy development, particularly to address the unique challenges faced by LMICs. However, it must be emphasized that the current WHO and NIH massive funding cuts will affect all tobacco control research. This is the time to call for a review of priority topics supported based on the needs of smokers and countries. Please read the research paper to get a full understanding of the realities of the gaps in research in LMICs. Thank you for your attention. Goodbye. Thank you.
10:19 - 10:26
[Summer Hanna]
Is there anything that you'd like to add before we move on to questions?
10:27 - 12:58
[Yusuff Adebayo Adebisi]
Thank you very much for the opportunity to share our research. The major thing that I would like to add is that disparity in research between high income countries and low and medium income countries. So the big question is who is going to fund research in low and medium income countries? Is it the government? Is it the industry? Who exactly? Because right now, that question is not so clear. And it's not the tobacco control group, because they're not even interested in THR in the first place. And to us, what we really notice is that most of the time, there's limited knowledge division between high income countries and low and medium income countries. And there's a need to break that gap. There's a need for another sharing platform. And we were even discussing yesterday that if there's no Tuakwa reduction scholarship program, probably some of us might not be able to do anything on THR at all. So I think there's a need for more investment for local research to drive more understanding of how best countries across lower- and middle-income countries can adapt or can even learn from high-income countries to implement THR successfully. But where is the data? I'm not sure presently there's any longitudinal study or any study at all looking at how exactly this product is going to be effective in, let's say, African population. But the question is still that, who is going to invest in that? Is it the industry? Is it ethically right? Some people will say yes, some people will say no. But who exactly? So I think I also throw it open if anyone can share insights on that. Or is it, another major issue here is that most African countries and countries in low income setting, they just rely on button to the top approach in the sense that anything WHO says is what they go with. There's no need for them to do any research. Oh, this product is not bad. It's bad. How do you know that? There's no data. But when WHO says anything, they just adapt. any policy. So how are we going to even drive meaningful research on the continent or in the region? So if anyone can also share insight on that. Who is going to fund research or advocacy efforts on tobacco reduction in low- and middle-income countries? We are also open to questions as well.
12:59 - 15:23
[Gabriel Oke]
Can I also add mine before we now go to questions? Okay, so... I also got involved in tobacco harm reduction because of THRSP, the scholarship program. So we're really grateful to the KSC for that. And for me, in 2022, I was working with an health communications focused organization in Nigeria. And we're doing a lot of videos, animations, writing articles, newsletters. And I was charged to write an article on what, you know, no tobacco day, you know, all those kind of articles you write, you send to, you know, partners and the likes. And then after writing the article, I saw some of his work. And I felt so stupid, you know, because I was like, What's going on? At least if I don't know this as a junior journalist and writer in this organization, my editor should at least correct some of the misinformation I shared in his article. So I felt so stupid. And that was I started doing more research myself to know about tobacco harm reduction. you know, as a concept. And yes, I got into the THRSP program, organized some fellowships to talk to other journalists, emerging public health advocates, to understand what they really know, you know, what are they thinking about this. Because if my editor now, who is a top editor in Nigeria, cannot pick out some of these things, this will continue, you know, while I'm also maybe an editor and I have to work with other journalists as well. So that was the idea of the old fellowship. And as a researcher as well, because I have eyes for quant and qual data, I collected data pre and post the fellowship program I organized. So I was able to get the paper published alongside the program I got in for tobacco and reduction scholarship program. So just building on on what is shared about the scholarship program and also the gaps as well. So the funding, where's the funding going to come from? Who is going to talk about it? Because we have to share the message. Before anything will change, we need us to really get on to both from the government to the users themselves. So I think that's not just one big question. We have many big questions. Many questions. So yeah, thank you. Question.
15:27 - 17:05
[Andrea Costantini]
Hi, hello, everyone. This is Andrea Costantini, Director of Scientific Engagement for the Americas and Latin American region, Philip Morris International. Well, I'm responsible of a huge region, which is low- and middle-income countries mostly, except Canada. And I saw your presentation, Yusuf, and for sure, all the public funding is coming from high-income countries, right? Low- and middle-income countries, we don't have public funding for research since... we have our governments, they have other urgent priorities rather than tobacco smoking and tobacco harm reduction. However, my main concern is, and maybe this is linked to also Professor Poloza's presentation, why we, who are the ones who are supporting and defending tobacco harm reduction, why we are the first one, and I include tobacco industry as well, that we discredit science funded by the tobacco industry. We've seen that tobacco industry studies were not included there. I know that there is... Why? Why? I've been working for the pharma industry for 15 years before joining PMI, and nobody discredits science funded by pharma companies. And many of the local research conducted in pharma is coming from the pharma industry support through grants, through IIS programs, and so on. So I think that my belief is how we can tackle that a disbelief in everything that is funded by the tobacco industry and how we can move to judge the science based on the design and robustness and not where the money is coming from.
17:07 - 18:13
[Riccardo Polosa]
If I can interject on that one, there was an internal choice we had to make in order to make sure that the paper was going to publish very quickly. As you know, there are a lot of editors and reviewers who are stubbornly against this idea that we should or should not include papers from the industry. Let's be clear about this. I very much respect science from the industry. I think it's the best science in term of quality, much better than the academic science, particularly academic science coming from the US. And you know why. Ariel already sketched out the reason why. Because there's a very strong conflict of interest with the NIH, and people are forced to create a drama in order to get more funding, OK? But to reassure the audience, we did a sensitivity analysis, also including the industry studies, and did not change very much the outcome of the results.
18:14 - 20:22
[Konstantinos Farsalinos]
The reason why industry research is being rejected is very simple. It's because in the past the tobacco industry produced a product which increased mortality and morbidity by a huge amount. And that's not only the reason. The main reason is that they did everything they could to discredit research showing the adverse effects of smoking. So they have lost completely their credibility and reputation. In my opinion, science should be approached in an amoralistic way. Amoralistic doesn't mean being immoral, not having morality, but not using morality as a judgment tool or as a critical tool to examine the content of the scientific publication, data or evidence. In science, you need to be open-minded. That means you shouldn't use moralistic and pseudo-ethical judgments of a scientific content when you're looking at science itself. You should look at the evidence. I will agree with Ricardo that the quality of evidence is tremendous, but of course it needs to be verified and replicated independently. but also we need to look at things that companies generally avoid to do. For example, you will rarely see a company comparing heated tobacco products with the cigarettes. Why? Because a company which is mainly focused on heated tobacco products will have to accept that these cigarettes have lower exposure potential than tobacco products. And perhaps that's not a good marketing trick. So the companies are doing a very good job, but they're not going to cover all research gaps because there are other aspects besides science that they need to address in their company. But other than that, I fully disagree. with excluding science. Science should always be published in order to be judged because the publication of any study, wherever it comes from, does not mean that we blindly accept whatever is mentioned. It's being published in order to be critically approached. All of it.
20:26 - 21:49
[Yusuff Adebayo Adebisi]
I also think it is quite important that the industry also make the data open access so that any researcher, any scientist anywhere can look at the data, reanalyze the data. I think that will also build more trust. And I think that is happening already. And I think it should be encouraged that the data should be available for anyone to go through to reanalyze the data, to critique the data itself before analysis. So I think that will also be very important to buy or get trust. in some of the industry's paper. And even as a young researcher myself, we face a lot of rejection from journals. Anytime we find, we do any research and we find anything in support of tobacco and reduction, you reject the paper, even without peer review. So I think that's one of the issues as well with publishing in this space. So there are a lot of research that are unpublished. You might even get tired of, oh, I've been sending this paper out to journals, and this is real, this is what I found. Anyone can access the data and reanalyze the data, but you still face rejection from tobacco control researchers. Oh, reject their paper. They are supporting tobacco harm reduction, or they are finding supported tobacco harm reduction. So there are a lot of bureaucracy, a lot of issues around even publishing tobacco and reduction-related paper. So from the industry, make your data open access, let people re-analyze the data, let people critique the data before analysis, and I think that will build more trust.
21:51 - 22:29
[Delon Human]
Thank you, Yusuf. Delon Human, physician and health diplomat. I was concerned about two other stakeholders, and that's WHO and health professionals. From your recommendations, it seems as if WHO is focusing more on old-school tobacco control research, which is questionnaires and then counting bodies. whereas it seems as if the biomarker research is more privately funded. Is this so, and how can that be rectified? And then in terms of health professionals, especially physicians, you mentioned that there needs to be more concerted research by them. What type of research?
22:30 - 25:03
[Yusuff Adebayo Adebisi]
I think for health care providers, I think there's some research that has shown that they have limited knowledge, but I think we still need more implementation projects, awareness projects to raise more awareness among health care providers on what CHR is all about. We have been doing that through the Tobacco Abolition Scholarship Program and many other networks, but we still have a whole lot of work to do because many health care professionals still believe that nicotine is harmful. And the interesting thing is that there are a whole lot of research, even before the advent of tobacco harm reduction products, we have a whole lot of research that has shown that it is not even the nicotine, it is the tar. But many healthcare professionals are still not aware. Though we have the data, but we still need more research. But what is important in the aspect of healthcare provider is that awareness, that education to actually correct misconception and any misperception that they might have regarding tobacco harm reduction. And for the... Biomarker studies. The interesting thing is for many studies in low- and middle-income countries, it's mostly self-reported and cross-sectional studies. So I think there's a need for more capacity building to do more longitudinal study. And one interesting thing that personally I noticed is that In fact, for other areas and across many fields as well, many topics in public health, we are still, many low- and middle-income countries are still at infancy stage in terms of doing sophisticated longitudinal study, biomarker study. So, which I think there's a need for more investment in that area. But the big question is, again, is who is going to support tobacco harm reduction research? That cannot come from the government because governments, as we all know, even for the traditional smoking cessation, they are not doing anything. There's limited efforts in that line. So where is the money? Where is the resources going to come from? So I think for more biomarker studies, we need that on the continent. And we can also adapt knowledge from high-income countries, but where is the pathway? Where is the channel? There are a lot of things that is ongoing with many institutions trying to connect with low- and middle-income countries, but we need more of that so that we can build more capacity in research, and we can do meaningful research that will facilitate the implementation of tobacco harm reduction in low- and middle-income countries. I hope I'm able to answer the question.
25:03 - 26:46
[Gabriel Oke]
Okay, just to add as well, I think another thing that is quite interesting in LMICs where I've worked and all is wherever the money is going really is where governments really support research most of the time. So most government bodies, ministries and even agencies don't want to take initiatives unless there's some money coming in. you know, in that direction. So I think that's a huge problem as well. So let's say the Ministry of Health wants to, let's say they have three or four priorities, and then there's more money coming from here, coming from here, coming from, oh, let's just go with this. And that's why I feel like this research is also very important to really see where the money is going, and when people are funding some of these programs in LMICC, they'll be like, okay, yes, there's a gap here, and we can push more into this area. And another thing that is quite interesting also is, you know, different, countries, different settings need different approach. I think there's another study that probably maybe next year will be shared in Rwanda. For Rwanda now, if you work with community health care workers, because they have a very robust program already in the country, anything you're able to do with community health care workers get to scale easily. So because they go to homes, they work with health care professionals themselves, they work with people directly, and all that. So it's easier to get a lot done when you bind into already established program in a place like Rwanda for community health care workers. In another country, it would be a different approach. In another place, a different approach. So it's quite a huge problem. And we need specific solutions to different settings as well.
26:47 - 30:13
[Baharudin Abdullah]
Hello, this is a very fascinating discussion. I'm from Malaysia, auto-renewable oncology physician. You know, talking about the link between research and industry, I've worked a lot with the industry as well. And I think industry has driven a lot of changes and shifts in terms of the approach to the management of our patients, as well as the betterment of human life. When we talk about publication, I think there is always a scrutiny in terms of academic evaluation by the reviewers as well as the editor And I find that even when I want to publish papers, I understand the pain of being rejected without peer review because the editor sometimes has their own bias I think we cannot exclude that because As human beings, we always have different levels of bias It's just that I think they look at... because I wear several hats I'm a clinician scientist, I'm also a reviewer, I'm also an editor Editor, we always try to assess that we don't release all those negative or those without proper evidence for doctors to, you know, for the others to read and learn from. So probably in that sense, they are trying to their best to make sure wherever it's being published is the right sort of, we have the sort of evidence and the sort of authority. But then again, it's not perfect science. You know, we cannot say that whether they reject is the right decision, whether they accept is the right decision. It's just that I find that Especially when the evidence is coming from industry, the scrutiny is higher. And that's coming from the pharma industry, not tobacco industry. But probably when we are going against what is understood and been accepted, probably the bar will be even higher, and the scrutiny will be even higher. And especially so when it comes from those countries not being perceived as an authority in this sort of area of research. And that is why sometimes I believe, and I also work with others, not only from my country, I work at the regional level with my colleagues. So then when we publish anything, it will seem more credible. And I would say that if probably we can look into this as something like we can have some expert sort of grouping that can advocate towards this sort of approach in terms of addressing you know, this very difficult area for us to talk on. And especially as a physician, even in my country, we cannot talk this freely because there is some sort of censorship, there's some sort of, you know, in terms of the authority trying to filter this sort of information from reaching other people. And I understand the challenges being faced by everybody here, but then again, We need probably to work harder and also probably work together with the same sort of information that we would like to give to others. Thank you very much.
30:14 - 31:50
[Konstantinos Farsalinos]
Allow me to disagree with you in what aspect? It is unacceptable to use personal bias in order to prevent research from being published. Personal bias can be used to agree or disagree with your conclusions, with your methods, or identifying gaps that you haven't addressed in your research. Preventing a study from being published because you have a personal bias as an editor is unacceptable and you shouldn't be an editor. It's been done. I agree with you that it's been done. But this is politics and it has nothing to do with credibility. I have faced the same thing after having published more than 110 studies on the subject. And I'm not from a low and middle income country. So it's not a matter of the country not being credible or anything. And I have published repeatedly. I imagine for someone who is relatively new in this field, it's going to be even more difficult. But this is completely unacceptable. You can't use your personal opinion in order to judge the publication or the censorship of research. You can disagree with the conclusions. You can disagree or ask for more data or ask to study something different. Yeah, okay, that's acceptable. But censoring research because you don't like tobacco harm reduction is not the editor's job.
31:52 - 31:57
[Baharudin Abdullah]
I totally agree with you. I'm not saying this to defend the editors.
31:57 - 32:05
[Konstantinos Farsalinos]
We shouldn't use it as a justification. I agree with you that it's pure politics in many journals.
32:05 - 32:18
[Baharudin Abdullah]
Definitely. I totally disagree when they reject my paper. But then again, there's no argument about it because it's final when the decision is being made. I totally agree with you. There's a lot of bias.
32:18 - 34:20
[Konstantinos Farsalinos]
I'll give you one example. There is a study right now from the University of Mexico where the researchers, professors in chemistry, didn't know that in order to convert ppm values to mass, micrograms per liter, you cannot simply multiply the ppm value by 1,000. There is a specific formula which takes into account the molecular weight. This is secondary school chemistry knowledge. It took us three months for our letter to be accepted. The authors were saying that e-cigarettes emit more benzene than tobacco cigarettes and than environmental safety, occupational safety limits. The true results were that the levels in e-cigarettes were 30,000 to one and a half million fold lower And still, today, after our letter was accepted, the journal denies to retract a paper which is a complete rubbish, and they still don't retract it. If it was my paper presenting something positive for harm reduction products, it would have been not only retracted, there would have been headline news that a study that was positive for THR was retracted. And they don't retract a study with an error that a secondary school student can identify. And one of the authors was the secretary of the Ministry of Health of Mexico. And Mexico has recently introduced a constitutional ban on e-cigarettes. Can you understand how much politics this is and how science is being embarrassed by that? And the journal participates into this embarrassment.
34:21 - 34:34
[Summer Hanna]
So I think we could go probably for two more panel sessions on this topic. Or more. And we may have a couple of panels later today that actually touch on some of this.