Todd Prochnau presents a pharmacist's review of Canadian guidance on alcohol consumption and how the principles of patient-centred care and informed decision making can be applied to both alcohol and nicotine products.
Transcription:
00:05 - 19:04
[Narrator]
So next person is now, you'll have to excuse my pronunciation of your surname, I'll give it a go, Todd Prochnau. That's perfect. Wow, how good is that? Total and utter fluke. Todd's a pharmacist who currently resides in Sylvan Lake, Alberta, Canada. He's worked as a community pharmacist for over 13 years. He has his authorization to administer drugs by injection and additional prescribing. Authorisation, Todd's also a certified tobacco educator or CTE and has extensive experience running a pharmacist-led tobacco cessation clinic. Todd currently works as a consulting pharmacist in relation to tobacco use and the field of tobacco harm reduction. Todd's also a faculty member of the School of Health and Wellness at the Red Deer Polytechnic. Additionally, Todd served as a board director of the Alberta Pharmacists Association from 2012 to 2020, and is an RxA past president. Todd is also a recipient of the CPHA's Dean George A. Burbage Award. Todd, the floor is yours. Todd's gonna play the video, and then we'll have some discussion afterwards. Hi, my name is Todd. I'm a Canadian pharmacist with 15 years experience running a pharmacist-led smoking cessation clinic. And I am presenting new Canadian guidelines on alcohol consumption and then discussing what this could mean for nicotine. Welcome to Nicotine vs. Alcohol. I think these new alcohol guidelines are extremely well done. They place concepts like patient autonomy and patient-centered care as the primary focus. They acknowledge that people will always make their own choices, but public health and health care providers can support these choices by ensuring that they are informed. In 2023, new Canadian guidance on alcohol consumption was published after extensive review of the literature. These guidelines are unique. They don't prescribe a specific maximum of alcohol. Instead, they inform about risk and provide a risk continuum. What are the health consequences of alcohol consumption? Cancer is the leading cause of death in Canada. And the fact that alcohol is a carcinogen that can cause at least seven types of cancer is often unknown. Cardiovascular disease is the second leading cause of death in Canada. And alcohol is a known risk factor for many types of cardiovascular disease, including hypertension, heart failure, atrial fibrillation and hemorrhagic stroke. And then it's widely known that alcohol use is associated with liver disease and also increases the risk of violence and injury. These guidelines summarize the increased risk of various diseases or injuries based on the average weekly alcohol use, and it is separated by sex. It varies based on the disease, but the pattern is clear. There is a continuum of risk. As the number of drinks increases, so does the risk. These are the public-facing recommendations. So rather than offering a prescriptive maximum number of standard alcoholic drinks per week, It's trying to articulate alcohol risk exists on a continuum of risk. Patients will have no risk if they consume zero drinks per week. They'll have low risk if it's one to two drinks per week. Moderate risk is considered three to six drinks per week. And increasingly high risk will be noted at seven or more drinks per week. So what does this have to do with nicotine? I think these guidelines are great. The traditional mindset in healthcare is very black and white. Don't smoke, don't drink, exercise, avoid red meat. But we know that reality is much more complex. Patients will make their own choices regarding substance use and lifestyle. These guidelines acknowledge patient autonomy and aim to boost informed decision making. And importantly, they embrace patient-centered care, which is considered a gold standard in healthcare today. Nicotine has similarities to alcohol. Risk is highly dependent on how it is actually consumed. The difference with nicotine and alcohol is the risk is not dependent on the amount of nicotine consumed, but more so the delivery mechanism. We know we have reduced risk forms of nicotine, which are shown in the box, and that many people that use combustible tobacco could benefit from switching to these reduced risk forms of nicotine. I propose that we create a similar guideline for nicotine where we classify different forms of nicotine according to risk. If we apply the alcohol categories, this is what it would look like. No risk, of course, would mean no nicotine. Our lowest risk category of nicotine would be transdermal and or oral nicotine products. Our moderate risk category would include vaping, snus, and heated tobacco products. And I do realize there's different levels of risks amongst these device types. However, I've simply grouped them together to try to simplify these proposed guidelines. And our high risk, of course, would be combustible forms of tobacco. Of course, when we actually take relative risk into consideration, we have to change the terminology. So really, no risk is no nicotine, but transdermal nicotine and oral nicotine would be very, very, very low risk. And then our vaping, snooze, heated tobacco category could be classified as very low risk or low risk, depending on your preference. High risk would remain combustible tobacco. As healthcare providers, public health and society, it's time that we follow the lead of these Canadian Alcohol Guidelines and take a more pragmatic, person-centred approach to lifestyle and substance recommendations. I believe these Alcohol Guidelines need to be more widely shared to inform people about the risk of alcohol consumption so that they can make their own informed decision about what is right for them. And we have to follow a similar principle in regard to nicotine. The risk continuum needs to be shared so nicotine users can make their own informed decision and exercise their patient autonomy. Thank you. Thank you. Well done. So Todd's going to discuss further about this. Over to you, Todd. Thanks very much. Great talk. Thank you. So I thought I should put a disclaimer, like why am I picking on alcohol? So to be clear, I drink alcohol. I consumed some last night. So I'm not advocating for prohibition or something here, but I think alcohol is a misunderstood substance like nicotine is. The difference is most people don't appreciate the risks of alcohol, whereas most people overestimate risk of nicotine. So seven cancers are linked to alcohol use. Breast cancer, which is the most common cancer in females, and colorectal cancer, which is the second leading cause of cancer death, in Canada at least. And there's other parallels. There's a massive industry in alcohol. There's flavors like cotton candy vodka, right? And one may question who that appeals to. And there's even an industry, the alcohol industry, that is diversifying and making more and more alcohol-free beverages, right? Reduced risk products, one might think of that. But that's why I selected this. And I do really like these guidelines. The biggest limitation is it's not widely shared in Canada and certainly elsewhere in the world. And so, you know, my dream scenario is if we had, you know, a simple infographic of these guidelines on alcohol, beverages, each packaging, might make a little more sense to people than drink responsibly, whatever that means. And then if we had the same thing for nicotine, I think that that is really what person-centered care is about. Medical students and pharmacy students, other health students are taught today that person-centered care is the gold standard. That is what we should be exercising day in and day out. And this is really what person-centered care is. So thank you. Thanks very much for that, Todd. Excellent. So we're doing really well on the time, I have to say. We're going to have plenty of time in this session. I'm going to open it to the floor for some questions if anybody is... Oh, we've got some gentlemen at the back there. Thank you. Yeah, I agree with you on the importance of stressing the continuum of risk for nicotine, and I particularly like the idea of describing certain products as very, very low risk, but I'm kind of amazed that you're using the Canadian alcohol guidelines as some kind of model because they're absolutely terrible. There is, in effect, a specific guideline, which is two drinks a week. That certainly is at least the implicit guideline. That's certainly what's been reported in the media. It's what it says in the report. There is no, I mean, this is a session on observational epidemiology, right? There is no epidemiology to suggest that two drinks a week is any kind of threshold, not least because hardly anybody actually drinks two drinks a week. You can't separate out between people who drink one drink, two drink, three drinks a week. It's just not enough people to base that on. And there isn't really a continuum of risk in the same way as there is with nicotine. What you see with alcohol is, with regards to overall mortality is a reduction in risk for people drinking at low levels before it goes up in a J curve. So although I agree with your conclusion, I think the idea that we should follow the Canadian alcohol guidelines of all things is wrong. Over to you, Todd. Yeah, I mean, I didn't write the guidelines, so that's the disclaimer. And I mean, I'm not a researcher. I work with patients, of course, but... I think that alcohol risk is underappreciated. You know, the standard one to two drinks per day recommendation, that was something that I was taught when I was in pharmacy school decades ago. And I think, you know, when these guidelines came out in Canada, they were largely laughed about by the public because I think the public just said, well, I don't want to know about risk with alcohol, right? Because it's something that I like to consume. So I mean, again, I'm not a researcher, so I can't argue about, you know, how valid some of their conclusions were or weren't. But it comes with considerable risk. And alcohol comes with risk like violence and injury and sexual assault. That risk is definite and it's known. And when you think about youth using alcohol, for example, it's such a much bigger acute concern than nicotine. And I thought this, I pulled these stats. So, um, in Canada, the legal drinking age is usually, uh, 19 in most provinces and 38% of, uh, Canadian adults tried their first alcohol beverage when they were under the age of 16 years and 82% under the age of 19 years. So I would also argue that alcohol is a much bigger concern for youth than certainly vaping, but perhaps even any other form of nicotine. Thanks for that, Todd. I think, yeah, Norbert, do you want to? Hello, Norbert again. I just want to point out, could you please point out in your presentations next time that nicotine has no, zero cancer associated with it, in contrast to alcohol. Yeah, absolutely. And I completely agree. I was trying to make the presentation about alcohol for something maybe a little different for GFN. But yeah, that's why I tried to make the point that oral nicotine and transdermal nicotine are, you know, I use the silly term very, very, very low risk, but that's because that's the most accurate way I could describe it. Okay. Carolyn, do you want to just give Carolyn the mic? Just a quick two-parter. One is a comment, one is a question. Just in terms of a comment, I really resonate and support that even though, yes, maybe the guidelines for the alcohol use aren't perfect, et cetera, absolutely, they use very clear symbolism, traffic light system, I mean, you know, the general public health professionals, they're bombarded with very inaccurate but easy-to-remember things, aren't they? You know, vaping is bad as smoking. So you've got to kind of counter it with really, you know, crisp, recognisable imagery, and it might not be perfectly scientific, but I really resonate with that because that's what's going to cut through people, going into their doctor's office, seeing the poster with the traffic light system, Yeah, I think it's great. We can tweak the accuracy of it and the track, but it's just big picture. Vaping and nicotine over there. Smoking over there. Boom. Yep. And what was my question? Oh, shit. Sorry. Sorry. It's slow. Oh, yes. Sorry. Hang on. Coffee hasn't kicked in. So do you think there, you may not know, but do you think there's much suppression by the alcohol industry of the harms of alcohol? Because I think, you know, as med students, we learn, yes, you know, excessive use causes, you know, cirrhosis and that. And a lot of people think, well, I don't, I never use it to that excess. So it's just not that harmful. I just feel there's a big suppression by the alcohol industry. Yeah, and that's a great question. I mean, I honestly think it's partly suppressed by the public because people like to drink. And so I pulled some more stats. So if you look at the last 30 days, 67% of Canadian adults consumed alcohol. So two out of three, right? And when we compare that to smoking, 13% smoked in the last 30 days. So 67 versus 13%. So We've talked a lot about how smoking, there's this stigma. Nicotine use in general, there's this stigma, right? That's kind of been a theme of the conference so far. There's not, at least in Canada, in the same way with alcohol. It's very socially acceptable. People like it. When we talk about youth use, I probably had my first beer at 15 or something. My dad used to buy me alcohol. beer before I was 18, which my province, the legal age is 18. So I think it's, you know, I'm sure the industry is active in their lobby efforts, but I think it's also just that it has a place in society that people like. Thanks for that, Todd. Lynn? Thank you. Lynn Dawkins, Dawkins Analytics, Pinney Associates, who consult for joy. I was going to make the same point as Caroline, absolutely echo that. Maybe the alcohol guidelines didn't quite get it right, but the general premise is there, and that traffic light scheme just resonates with people, and it's so easy to understand. So my question for you, Tom, is, What now? How are you going to get that out there? How are you going to make Health Canada or whoever it is listen to that and adopt that or some version of it? Yeah, that's a great question. So, you know, continue to advocate. I don't have an easy answer. We wouldn't need this conference and these types of get-togethers if I did. But one thing I'd like to point out is Canada actually had Health Canada had vaping messaging ready to go. So it was going to go on cigarette packages to say, basically the essence was vaping is less harmful than smoking cigarettes. So if you're not going to quit, you should switch. So this, I think it was maybe 2018, this was ready to go and it got held up politically. And so I think there are those in Health Canada that are ready for this harm reduction concept to be embraced, but we just have to continue with it. We have a new government, so maybe I'll try to make some friends with some of the politicians and see what we can do, because I think in Canada at least, in Health Canada, I think they are on board with this concept of harm reduction, but we've seen a few examples of where politically it's been overridden, essentially. I didn't answer your question, but I don't have an answer, so sorry. So thanks for that, Todd. Have any more observations, comments, questions before we move on to the next speaker? Oh, we do. We have one more. Let's go to this gentleman here. Hello. from the Consumer Association in France. Just a question, not specifically on your presentation, but the two presentations. turning around the risks of things including nicotine and none were talking about the benefits and I don't mean the benefits itself but just for example I use a vape that makes me far more immune to smoking than not using it. I never see papers highlighting that. Somebody who uses nicotine in a safer way is far more immune to returning to using it in a dangerous way. The same thing occurred when you were talking about smoking. And in America, globally, it's very strange that smoking something else than tobacco seems to be totally fine, which chemically seems not quite right.