Examining available evidence on the net public health impact of incorporating tobacco harm reduction principles in policymaking, participants discussed the challenges and opportunities to leverage tobacco harm reduction approaches to achieve LMIC public health goals. The aim was to identify the top three priorities as a takeaway for key stakeholders in the audience.
Transcription:
00:11 - 06:51
[Sud Patwardhan]
So welcome all to this afternoon session. This is perhaps always the worst session for anyone to have a lovely lunch and then come into a, people are quite, had a lot of food and a bit sleepy. So we have some plans, but allow me to introduce ourselves first. I am Dr. Sudh Patwardhan. I'm very passionate about low and middle income countries and how tobacco harm reduction And tobacco control needs to be made available for those 80% of users of tobacco products that live in these countries globally. I have a very distinguished and a very global panel, which I'm very proud of. If you look at the conference agenda, you will see that there was Professor Sharon from India who was going to be here, but because of travel-related paperwork, he could not be. But then we were very fortunate to be able to request and get a person who I know it's a big task, but to represent Africa is a big task. So I'll start from the left. Emmanuel Mbenza from the Democratic Republic of Congo, Professor Sharifa from Malaysia, Dr. Hugo Tan from Global Citizen really is, I'll let you look through his CV on the conference agenda, and Dr. Sartanek Muradian from Armenia. But I also have three people who have very, very kindly volunteered to help us run this workshop. So the workshop is, of course, called low and middle income countries communicating the scientific rationale of tobacco harm reduction. And so we thought, if it's a workshop, we need to workshop it out, right? So three people who have very kindly volunteered, again, covering a breadth of the world in terms of representation and also ability and excellent backgrounds. So Dr. Hazel Lindsay Ebenezer, that's there. So she's going to take charge of the flip chart there, and you'll know why in a minute. So Hazel's a PhD in women's rights law. And she's kindly volunteered to take one of the breakout groups that you're going to fall in. The other one is Dr. Pritika Kumar, who is sitting next to that flip chart there. She's a public health scientist, a PhD. And again, in the intervals, you can get to know her more and chat about her career and so on. Very fascinating. And there's Dr. Andrea Constantini from Argentina, who is a medical doctor, but also with specialism in clinical pharmacology and a long career in pharmaceuticals and the tobacco industry now. So the idea is this. For the first 15 minutes, instead of us as a panel giving you our thoughts on what it means to What kind of science is needed in tobacco harm reduction, whether science is needed or not? What is the rationale for that in the context of low and middle income countries? And then how and who should communicate that in those countries and to whom? Is it the policymakers? Is it the medical professionals? Is it the consumers? And or all of them? So a lot of these questions need to be discussed by us, for sure, as a group, really. I've always... appreciated the fact that this conference and the conference organizers I have to give them due credit that on my request over the years they have allowed us to bring this LMIC related session in the conference agenda and some of you I see here who have been part of that panel but also have been in the audience in those sessions have really hopefully allowed us to put a spotlight on the region of the world and the section of the consumers of risky tobacco products globally. And as I said, 80% of the world's tobacco users live in LMICs. To be able to put that spotlight and not forgetting that they also equally need safer alternatives, tobacco harm reduction, tobacco cessation, and a whole range of things that support them on a journey to a healthier, happier, and longer life. So thanks to the organizers, but thanks to you for coming and braving the session at 2 o'clock in the afternoon after a lovely lunch. So without further ado, may I request, what we have done is we have actually designed the audience in three columns slash sections. The flip charts for you guys to now orientate yourselves to. So the middle section, for example, will have to move their chairs to face there. And if you think you want to just go closer to that and just huddle around that sort of section, you get 10 to 15 minutes max. The same with this section. So Peter and people back, Libby, you could all look up this way and perhaps go near to Andrea. So Andrea has raised her hand already. Would you mind sort of moving there? I'm sorry, I'm making you sit up, but this is part of this sort of getting you a bit energized in a post-prandial session as such. And the folks on that side, His is there, so would you mind sort of just inching closer to her, please? And she will wait for you to, each of them will wait for you to give your views on how, so there are three things I've asked them to ask you. One is, is tobacco harm reduction needed in LMICs that you are aware of? And if you're not, that's fine. Somebody else will answer that. If nobody answers that, that's also fine. So is THR needed? The second is, is the science there? Or is there any rationale for tobacco harm reduction approaches in LMICs? And you can specifically talk about one LMIC or a broad range of countries you can think of from your experience. And the third is communication. who, what, and how should be communicated about this topic in your view. So if you don't mind, with your facilitators, while we all just look nice and sit here, but I will also prod you guys. So please, let's start. Thank you so much. Move a bit if you need to. So there are three mics now, one mic coming each to Andrea, to Pritika, and Hazel. I'm so sorry to interrupt. There's a lovely flow of ideas there, I'm sure. First of all, a big round of applause for the three facilitators. Thank you so much. Now that you've got the applause, your task is to summarize what was told to you. So who wants to start first? Want to start from that end, and then we go to Andrea? Sure. Thanks.
06:51 - 08:45
[Attendee]
Our discussion started with the first question of is THR needed in LMICs? And we decided that's a resounding yes. No one is denying that, and we can end our discussion there. But then we went on to talk about how it's good as an additional tool, so something to have in the toolkit, and also how the scientific rationale is really there to support it. So THR is very important for that. And the discussions naturally led to the third question as well, which is about the THR science. So one of the audience members, Sophia, pointed out very well how there's a life cycle of tobacco control and how we may be at the end of the life cycle of tobacco control. There's already all these restrictions, policies being done, but THR can breathe new life into it. and how restrictions are becoming less effective, so there needs to be a revised thinking, and THR provides the sort of revision, which is a very interesting way to put it, so thank you. And then we went, we skipped to our third question with that to talk about it more, and understood that step one is everyone needs to be on the same page that we need THR. After we know that, we can help motivate and educate, and one of the ways to do that is by examples. So to learn from the mistakes of or the benefits of, Ekaterina was mentioning, things like alcohol bans in the past or other restrictions that have happened or other alternatives that have been looked at so we can learn from them. We also, I didn't get your name. Vladimir also shared how decision makers, they don't look at data. They look at their own beliefs, especially using Central Asia as an example. So looking at consumer experience and translating that into decisions would be very important. And the last thing I'll say is another thing Vladimir mentioned is decision makers look at where the money is coming in from. So to show how THR is cost effective, it can help economically, would be a big help. Thank you.
08:46 - 08:48
[Sud Patwardhan]
Thank you, Hazel. Cheers. Pratika, please.
08:48 - 11:17
[Pritika Kumar]
So we had a pretty robust discussion about the first question is if THR is needed in LMICs. And so some of the points that were raised was that A, we don't really have many options that are available for THR. And that THR is within, it should be seen and it is within the Empower framework. It's not always recognized as harm reduction or as THR. It could be existing, but may not be labeled as such. And that it is needed because it is a cleaner alternative. The burden of tobacco use, as you said, Sud, earlier, is very high in LMIC, which is why it is an option that definitely should exist. And the WHO Empower framework is not always a practical solution. to be applied in every setting, which is why harm reduction alternatives become extremely important to exist alongside. And then the second question was about what evidence we have and why should THR exist as a viable alternative in LMICs, and that is because we see in the space of addictions there's a lot of tobacco use in the space of addictions and so we know that that is a space where we can leverage THR alternatives. One thing is that where evidence can be used against building evidence for THR is where youth use is used as a lever against accepting THR as a viable public health solution. And also illicit markets come in the way of building this evidence of THR because people are using illicit products, we don't really have the data to show how much of a, what scale the impact is of or the favorable impact is or the less harmful impact is of using these alternatives. And finally, we know that NRTs are an alternative but not a very effective alternative. So in that particular case, that evidence does exist. So that makes it even more important that there should be alternatives. And we did not get to the third question.
11:17 - 11:20
[Sud Patwardhan]
That's fine. That's quite comprehensive. Thank you so much, Pratika. Andrea.
11:21 - 13:59
[Attendee]
Well, last but not least, our group. Regarding the first question, is THR needed? I think it was, again, an absolutely yes. Why? Because nowadays, 80% of the smokers, they live in low and middle income countries. And nowadays, the population that is growing the faster is the one that lives in low and middle income countries, which means that in the future, the absolute number of smokers is going to be higher. And it is needed as a public health policy, complementing the tobacco control policies that we already have. Going to the science, yes, we have plenty of science. We all agree on that. But unfortunately, many policymakers believe that the science that is out there at this moment is not relevant for them. So what we need is local science relevant to the reality of the different countries that is meaningful and makes sense for these policy makers. And we need to emphasize that the important part of the science is the quality of the science and not the funding, which is the difference between science coming from the pharma companies to register a medical product and science coming from the tobacco industry to demonstrate that these non-combustible alternatives are less harmful compared to keep smoking cigarettes. And that is also a message that needs to be showcased and there we are going to the last question. And regarding the last question, who, what, how to communicate on DHR We all agree that it is needed to simplify messages to allow policymakers to understand the difference between non-combustible alternatives and combustible products, but also the difference between the different products. And something that was mentioned in some markets, for example, smokeless tobacco is really, really important. So maybe emphasizing on oral products would make sense. Also healthcare professionals need to be involved in this. And something important for low and middle income countries is to showcase, while communicating, to showcase success stories. Markets where THR was implemented successfully and how it helped to decrease the prevalence of smokers. And stop being reactive. So far, whenever we are communicating on the HR, we are more reactive than proactive. So we need to switch to the other mode in order to be successful in the communication. And I think that's it.
13:59 - 15:14
[Sud Patwardhan]
Thank you so much, Andrea. That was an amazing list of things that you've compiled based on a very interactive discussion. I could see that. Sorry we had to stop it at that, but I think this is a whole list of things that we can perhaps weave in into this conversation. So thank you so much. You can take your seats. May I request someone from the conference team to just move that one flip chart chart behind so that it's not in the way for the folks behind it. Just the one in the middle there. Just move it back, please. So thank you so much, the facilitators. And thanks to the audience for giving an amazing range of input. I think you all deserve an applause. So why don't we clap, please? Come on. Thank you. So look, what we had planned and is working out even better than I had anticipated is that now the experts on this panel will give their views. I am going to restrict them from going beyond five minutes, although I said seven. But I think it might be an idea to let them give their views based on what they've heard, but also their own backgrounds, what are they doing in their own country and region, or in their roles, if it's in a company, and what are they doing to address these challenges that some of them have been highlighted. So Professor Sharifa, if you don't mind starting, then Emmanuel, then Saten, and then you go.
15:17 - 22:09
[Sharifa Ezat Wan Puteh]
Very good afternoon and thank you Mr Chairman, Dr Sood, and thank you everyone for coming. The session on LMIC is very interesting because we have the least resources when we talk about resources not only on monetary but also in the sense of numbers and also enforcement, policing and also enforcement. We have the least resource number enforcers and so on coming from LMICs. But we have one of the highest burden of most of the diseases, including tobacco as well. And a lot of us in the low-middle-income countries are also burdened with illicit tobacco, coming from countries that export a lot, or basically produce a lot of illicit or unregulated tobacco. So this comes in the form not only of illicit cigarettes, which are not taxed, but they are found in abundance on our shores, We can just go in one of the markets and just buy one or different brands of tobacco. And they can even ask you whether you want the strong one or the least strong, and they give you options. And these are unregulated cigarettes. But we also have unregulated or illicit vapes. And these products or the illiquids are being so-called manufactured by backdoor companies industries and so forth. So coming from an LMIC background, I'm coming from Malaysia, and of course I do understand that other countries may have different experiences. But in Malaysia as well as in many of the LMIC countries, I think the tobacco control, as has been mentioned by our colleagues in the workshop just now, it's a dying basically a dying cycle. It's very traditional-like, and basically it's a prohibitionist approach, and you basically try to ban everything under the sun, including not only tobacco, but now including alternative nicotine products. What happens is that they are so scared, you know, some of the tobacco control or policies are so scared about using nicotine alternative. One is that, semantically, they also incorporate it as tobacco, right? If you have nicotine, it's considered as tobacco in many of the countries. We are also signatories of the WHO. I think in Asian countries, only Indonesia is not. The rest of us do sign signatories with WHO since 2005. So we consider tobacco and also nicotine as the same. So what happens, a lot of us basically no risk proportionate data are being looked at. We will just lump all of this as tobacco or something which is harmful. And we will say there's no other options except banning and being very, very strict on tobacco as well. So in the end, we have a product which is not only good for the population, and some of us, me, myself, coming from an NGO, the Malaysian Society for Harm Reduction, we try to educate, advocate and all, but most of this falls into deaf ears, and we are being seen as propagators or basically arms of the big tobacco. Most of the research that we produce, even though they are not funded by tobacco companies, but are deemed as tobacco tentacles in the government and so on. So there's less data that's being produced and I do agree with that. I think Derek this morning, Derek Yatch, he shared a data which shows that, you know, comparatively with OECDs of high income countries and also with LMIC countries, these are we have the least number of THR data being produced scientifically for over 1,000 population. That says a lot, meaning that not only is the funding not available for us to do research, but most of the research or the belief that we feel should be advocated is not being transferred or communicated to the public. We do get a lot of questions coming from the media. However, most of the sessions or what has been mentioned do not get properly transmitted for some reason or the other. Either the scientific data is not being well informed to the public, or it has been misconstrued, and in the end, it doesn't reach the population. So in the end, what is being mentioned in the data or in the media, but not all, I do understand that, is basically vape is even, or alternative negative products are even more harmful than tobacco. So what happens? The population gets confused. So then they actually send us messages and questions saying that, okay, where should I get my vape? And we keep saying to them, okay, you should get it from a regulated or a registered vendor. And they say that, okay, where is that? We don't even know. Because at this point in time, the regulated becomes sort of the unregulated as well, and that leads to the confusion to the public, and basically for those who really want to stop smoking or use alternative nicotine products to reduce their smoking habits or reduce their harm, have a lot of problems in obtaining proper or basically regulated vape products. This leads to a problem because then they don't know where they should be going in the sense that we also have HDP as an example for Malaysia, but HDP is actually very highly taxed as well. So with that, the population is not able to access HDP as what Japan is doing. This reduces the options for people to use alternative nicotine products because they are not able to basically buy HTPs or basically ICOS. In Malaysia, it's ICOS. And they are not able to purchase this because of the cost that it costs. So what happened, most of the lay people or the low-income, which are the smokers, the highest burden would actually go for illicit cigarettes, tobacco again, or they'll just buy vapes among all these unregulated vendors. Another problem that I would like to highlight, my last point is that Due to these unregulated forces, most of the vape liquid are being mixed with something else. So this includes opioids, amphetamines, even fentanyl now. And one of the reports from the police saying that 65% out of their product that has been confiscated has opioids, amphetamines, or even fentanyl. And that has very ill effects to the population. They go into seizures, some of them have, you know, disastrous effect to the lungs and things like that. So this is something I think a lot of countries are facing, including LMICs such as Malaysia. Thank you very much.
22:09 - 23:36
[Sud Patwardhan]
Okay, so I've stopped already. Gosh, people are afraid of me. So thank you so much, Sharifa. And look, that was very helpful. In a matter of literally six minutes, you covered a whole range of things. And I want to just point to Empower that was mentioned in one of the breakout sessions. And maybe most of you are familiar with that. But Just to kind of remind everyone that the Empower stands for monitoring, protect, offer, is that, oh, we'll come back to that, warn. enforce and raise. The raise is for taxes. So what you've talked about, Sharifa, is kind of touching on many of these points. They have raised taxes on the safer alternatives. They are not enforcing many things in some countries. Some countries are not signatories. And I would love to pick Dr. Tikki's brains later on in the session, if I can, on why Indonesia has not signed FCTC and does it matter? Has it helped them or not helped them achieve their public health goals and so on? So a very sweeping kind of view of the issues in Southeast Asia. I really appreciate that. Regarding offering help to current tobacco users to quit is one of the six pillars of Empower. And we see that that's perhaps not that practically implemented by those who should be. But anyways, we can come back to that. This Empower framework can also be used for hearing what potentially Emmanuel has to say about the Congo and also the region and, if possible, the entire continent of Africa, which I'm sure is not an easy task. But only six minutes, mate. No more. Lovely.
23:36 - 28:55
[Emmanuel Mbenza Rocha]
Hi, everyone. My name is Emmanuel from the Democratic Republic of the Congo. So it's an honor to be here today and talk about what is happening in the country as an advocate, as a THR, a CEO of the Congolese community. So I'm here by representing the continent. So I would like to start with telling all of you here one thing. And the one thing I want to tell you is that there's hope. There's always hope. And I'm still hoping that great things are coming. So as Dr. Shari was saying earlier on before me, she mentioned about... Things that we face also in Congo, there are many similarities, but the case are completely different because of the context and the continent and everything. Us, we have the biggest problem, we have the biggest challenge we have in the Democratic Republic of Congo in particular and in Africa in general is the issue of data, the data collection. Most of the information that is out there, the fictive information, is not really accurate compared to the reality down in different communities. For instance, for us in the Democratic Republic of the Congo, we have 120 million people. The population is 120 million people. And we have only 25 Congolese that have access to electricity. The 75% of Congolese are in darkness. Therefore, it's not really possible to inform, to create a campaign awareness to reach certain regions, certain areas of the country. So the difficulty will be already at the level of energy. We don't have enough energy to pass on the message. Those are the type of challenges we have. We have a lot of tobacco. We have a lot of plantation of tobacco in the Democratic Republic of Congo, but we do not produce tobacco ourselves. It comes from neighboring countries like Angola, like South Africa, and Kenya. And in those countries, they just produce the tobacco, produce the cigarettes, and they make a very, very low quality for a very low price at low cost that really kills people. And it's accessible to even teenagers, to even young people, and there's no law or regulation at all that is in place to take care of all those things. That's why I'm saying there's still hope because we can still communicate about it. That's the reason why I'm here to emphasize on it. And the case is not only in the Democratic Republic of the Congo. I'm emphasizing on the Congo because I'm coming from there, but neighboring countries are facing the same difficulty when it comes to tobacco. So the tobacco harm reduction, the advocacy we're doing, it's on teaching, on preaching about safer alternatives, safer products that can be used around the continent, around the country. However, the difficulty we'll have, again, is the accessibility and the lack of communication and all that. But we came up with a way of communicating, creating different communities networking because in Congo we have 26 provinces within the 26 provinces we have delegates that are originally from those provinces where we can reach from time to time in different communities like in different churches mosques different type of religion and everything so we kind of collect that's how we collect information that's how we collect data in order for us to have a certain accuracy of what is really happening. And the biggest challenge we have in terms of introducing to them the alternatives for safer alternatives, the difficulty is the product, the lack of product. We do not have all the All the things gather, as you know, as an LMIC, we do not have all the means gathered to split the information, to show them that there's hope, there's a way to transition to cessation. So that's about it.
28:55 - 29:54
[Sud Patwardhan]
Emmanuel, thank you so much. That's a very enlightening kind of introduction to DRC and the challenges you face there in terms of what I would say is starting with the fundamental of Empower, which is monitoring. So from what I've heard from you now, as well as yesterday when we talked about this, there is no data on prevalence nationally on how much tobacco is consumed. So pretty much all the components of Empower are kind of not being implemented, and that's a very sorry state for a country of 120 million people, and based on what you said, at least a few million consumers of tobacco, all irregulated or not regulated, and that's a very sorry state. And again, the problem with this conversation, or at least what we are trying to highlight, is that LMICs face the sort of double brunt of almost being pushed into a wider inequity gap because of not being the attention of either funding agencies or even the industry. But I'll come back to that in a minute or a few minutes. Next is if you don't mind picking up, please.
29:56 - 34:46
[Satenik Muradyan]
Thank you very much. It is the greatest pleasure to be here and greatest honor. So me being a doctor, I always focus a lot on other doctors and the healthcare field. So let me start my point from there. In a lot of low and middle income countries, doctors are, at least in some regions of those countries, doctors are still remaining very trusted figures in terms of health care from the population side. But when it comes to how doctors are perceiving the fight against smoking, we learned that a lot of them only know one way, which is quit or die. And I'm saying this based on a lot of things. And research that I did last year in Armenia where I asked a lot of doctors from different backgrounds on, well, have you ever received any training on how to fight smoking, and the answer of over 80% of doctors was no. And then when asking about alternative nicotine products, most of them were thinking that those are worse than combustible cigarettes. Doctors have never been told other way than quit or die but on the other hand why i mentioned that in some regions doctors are trusted because in contrast in some regions they're not and they are viewed as politicized or advertisement driven so even if some do know that THR actually works, they may not be trusted because of these points, because of these views that, oh, doctors are politicized. So that's the point where I think it is very important to also educate doctors on the science behind tobacco harm reduction is that they know from root to top what tobacco harm reduction stands for. And even when being said, oh, dear doctor, you're politicized, they don't just say, no, I'm not. They say, no, I'm not because the science says this and this and that. And a lot of doctors and decision makers in low and middle income countries take their views from different structures, like, for example, WHO. And I love WHO's views on a lot of things. They've done amazing, amazing work on various fields. But let's take the fight against smoking, which usually WHO recommends nicotine replacement therapy, cognitive behavioral therapy, and some medications. But are they, in fact, available in these countries? For example, let's take NRT. Yes, it's licensed in Armenia, in Georgia, in Iran, Turkey, Uzbekistan. It's licensed. But is it there? I can tell for a fact about Armenia that, at least for the past two years, those products are not being sold. They're not in stock. Gums, maybe now and then you could find that at one point or two. And when prescribed, rarely prescribed, for example, nicotine patches, people have to order them from other countries or some online platforms. So first of all, it's physically not there. Let's take CBT therapy. Armenian average official salary is around 200,000 drams. The average cost of one single one-hour therapy with a therapist costs around 20,000 drams, so 10% of the human's average salary. Would a person go once a week to a therapist and spend 40% of their average salary on CBT? I think no. Besides the cost effectiveness also, it is very taboo. Most of Armenian grown men, like over 40 years old men, just wouldn't go to a therapist to quit smoking because of that taboo. So even if we assume that WHO's methodologies work against smoking, which we know that they don't because science clearly says otherwise, they're not accessible for LMICs. Maybe it is for most of the European countries or America, but for LMICs, it doesn't let people even try to see if it works or not. So yeah, if I have more time, I'd also make a little point about science as well, if no.
34:48 - 35:39
[Sud Patwardhan]
Thank you so much. I'm being a very tough taskmaster. I'm sorry. But this was very helpful to get a good view of a range of countries, not just Armenia, but neighboring countries where you have a very good grip on. I think two things came out pretty prominently. One is your experience with clinicians, healthcare practitioners, and their misperceptions about nicotine, safer products, but also the fact that we talk about these things regarding accessibility, affordability, availability of appealing products, and I think it looks like that's not there. And that's, again, one of the issues that we face in terms of, again, why are LMICs disadvantaged even more for all these reasons? And if I may put Dr. Hugo Tan on a bit of a spot by asking, what is the industry doing about it? But before that, of course, I would love to hear about your personal journey as a doctor, and how do you find yourself in tobacco harm reduction?
35:39 - 41:39
[Hugo Tan]
Sure. Thank you very much, Sud, and I'm very honoured to be part of this panel. So, first of all, I must applaud every one of you to choose this session over other sessions with a little bit of competition. It shows that you care about LMIC, it shows that you care about THR, and this topic is very important. And every one of you in this room has a role to play to continue to communicate the importance of THR. And this has been a very personal journey for me where I'm a clinician and I've spent a number of years in the pharmaceutical industry as a medical affairs director before joining the industry at BAT where I work in the research and science. And obviously before joining industry, I thought that There's no research ongoing, but it has really opened up my eyes, and I'm here speaking to you, and I hope to share some of my experience with all of you. Before we talk about communicating THR, perhaps let's put into context, and I'm sure you heard this many times, but I'd like to just recap a couple of things. There are 1.3 billion smokers out there, and annually there are 8 million death due to complications related to smoking. All of us are very relieved post-pandemic COVID and COVID itself amounted to about 7 million deaths. If COVID is a pandemic, it's a public health crisis, what happened to the 8 million deaths every year? So question is, what are we going to do about it? If I could turn back time, I would have said that all this education should have started much earlier. It's embarrassing to note that for many of us here, as doctors, clinicians here, we are being viewed highly by the society as someone who has the best knowledge in science, the latest updates in terms of the knowledge in science. But the reality of the fact is, not too long ago, when I was in medical school, where we were taught about the harmful effects of smoking, we were taught about NRT, but we were never taught of any other signs, information about alternative nicotine products or smokeless products. And for many of us who see patients and counsel patients, stop smoking. Yes, that's the ultimate goal. But the reality of fact is we do not live in an ideal world. And for many of the smokers which I managed to counsel in the past when I was in clinical practice, it's harder to achieve than it is. So nevertheless, stop smoking is still the ultimate goal. But again, This is something which we need a lot of support. That brings me to what I believe are the challenges, and we need to address all this before we could really communicate effectively. I talk about lack of awareness, and hence education needs to be done, to not just the consumer, to even the healthcare providers, public health community, scientists, everyone. So each of you have a role to play. Secondly, in the LMIC's perspective, there is still a lack of local regional LMIC country-specific data to support the importance of tobacco harm reduction as a public health policy. Without this data, government departments, policymakers will not be convinced that this is something important for the respective countries. Thirdly, we spoke a lot about misinformation. In this era where so much of misinformation, fake news, information are widely shared in social media without much substantiation to it. So itself, it's a big problem, right? adding on to all the different agenda, be it political or anti-tobacco. So again, there's still a lot of work that we need to continue to clear the air about misinformation. So lastly, Suits did ask me to share about what we could do, especially in my current context representing the industry in the research and science function is we continue to commit. We wanted to partner with... the researchers to work on generating more data, robust data through clinical trials. Over the years, there has been more interest to generate impactful, meaningful data, which could be used by the regulators. For example, in the past where we have generated a lot of data in showing reduced risk with biomarkers of potential harm. biomarkers exposure now is to really move into doing clinical trials, say looking to reduce the impact of smokeless products in terms of reduction of harm versus combustible secret in clinical outcome like COPD, oral health. So this is some of the areas that we are focusing, especially in LMIC. And with all this, we are very sincere and we commit to partner with all the relevant stakeholders on this journey to communicate THR. Thank you.
41:40 - 43:07
[Sud Patwardhan]
Well, thank you so much. I know that I've seen publications and efforts by the industry to name the company you work for, Omni, and the amount of data you're putting together for public consumption. Other companies have done similar things in the past or are in the process of doing that. And that's very encouraging, because that means that there is an appetite among the industry at least to do the science. Of course, as somebody looking at it from outside, but also talking to the industry, I would say, do more, please. This is a great start, but there is a long way to go. And the research you're talking about, funding there, and conducting local research will be absolutely crucial in informing local policymakers. So thank you so much for sharing that. Absolutely. I've made a few points which I would love to ask the panel. But I'm also conscious that you guys have been very patient for 30 minutes listening to the panel and their expert views. I really appreciate that. Maybe it's a good idea to just get a few lines from the audience. There's one hand raised there. Does anyone? So I would just take a few questions in one go. Do not give a speech. Just state your question. First, say your name, name, affiliation, and a line or two about what your question is. If you want to target it to somebody, please do that. Be kind and polite. So one hand there. Then there is one. Oh, there's quite a few hands there. Okay. There's H there, and then there's somebody here. So let's start with that, and then you afterwards. So we'll come to you in a few seconds. But, yeah.
43:08 - 43:47
[Attendee]
Hello, hi, I'm Farah from part of the Malaysian press corps. My question is this. For a country like Malaysia, we're very much guided by international policies like the FDA when it comes to products like this. So some products are actually approved by the FDA. So what is stopping countries like Malaysia from going to the health ministry and saying that, okay, not only is it approved by FDA, there's also tons, hundreds of clinical studies to support the efficacy of these products, and for it to be sort of endorsed by the Ministry for Use for smoking cessation. Thank you. Thank you. Thank you. Yeah.
43:47 - 43:58
[Sud Patwardhan]
May I just request us to get all the questions, but please do note it. I think it is definitely targeted at you, so you can answer it. But why don't we have H, and then the person here, and then here, please. Thanks.
43:58 - 45:05
[Heneage Mitchell]
Hi. H from Factasia, Southeast Asia. For the panel, I know in Malaysia, for example, over 50% of the tobacco products that are sold there are smuggled, unpaid, untaxed. So significant enforcement problem. I'm assuming that there's similar issues in the various countries represented here. My question is, how and can the... significant black markets that have been created by bands be used to influence policy makers to maybe consider that they've got it wrong. Just one number I want to give you. Australia, just Freedom of Information Act, one out of 1,680 vapes in Australia, one out of 1,680 vapes is sold legally, one. an issue. So does law enforcement have a role to play here? Does security, does the criminal syndicates? Is this something that could persuade governments to be more pragmatic in their approach to THR?
45:05 - 45:06
[Sud Patwardhan]
Thank you, Hedge. Next here, please.
45:08 - 46:05
[Rashidi Mohamed Pakri Mohamed]
Good evening. I'm Dr Rashidi. I'm a consultant primary care physician and addiction specialist from Malaysia. As a term, income, given the greatest importance here, considering the fiscal and public health strategies, so this is for Prof Sharifah, I guess. on high-income countries on tobacco taxation. High-income countries actually managed to get up to 500 billion USD in the past 50 years. How can low- and middle-income countries emulate their approach in leveraging tobacco taxation as a sustainable revenue stream, while simultaneously adopting regulated harm reduction tools? such as heated tobacco products, oral nicotine, or e-cigarettes to reduce the burden of combustible tobacco use. Thank you so much. That's great. The question back there.
46:06 - 46:53
[Kai-Jen Chuang]
Hi, I'm KJ from Taipei Medical University in Taiwan. My question is how do you teach THR in universities in your country. Why is that? I agree with you, quit or die. If you ask students, if you ask experts or doctors from Taiwan, we don't have any course to teach THR in school of medicine or school of public health. So alcohol, betona, tobacco, they only mention as the risk factors in epidemiology or biostatistics. So I was wondering how do you teach students from School of Medicine, School of Public Health in your country to know what is THL and what is tobacco products?
46:53 - 46:59
[Sud Patwardhan]
Thank you. Thank you so much for that question. Any questions at this side? Because we want to just compile them all together. Anyone here?
47:03 - 47:41
[Uladzimir Pikirenia]
Vladimir. My question is about some countries that have not very good in democracy, for example, Belarus, for example, countries in Central Asia. And tobacco manufacture is a property of president or family of president or another, and they have a profit from selling tobacco products. And how we can... push tobacco harm reduction in these countries in this situation? Thank you.
47:41 - 48:21
[Sud Patwardhan]
That's a great question. Well, thank you so much. Anyone wants to comment? Anything else before we take it on? So look, there were quite a few questions, Professor Sharifa, that were targeted to you. But please do feel free to address the first one. I want to just make a quick comment regarding the first question about FDA approved. Absolutely appreciate that statement. I would just add that it's FDA Center for Tobacco Products approved. And that's an important distinction to make. We do not want to send a message that is not understood by people. People normally associate FDA with CDER, which is just how it has been so far. CTP is a new entity relatively, so people may misunderstand if you were to just say FDA approved. But yes, that's a great question, so please do answer that, Sharifa.
48:23 - 51:37
[Sharifa Ezat Wan Puteh]
Thank you very much for the first question. I do understand where you come from, because having said that, we keep telling the government or some representatives from the government This is approved by FDA, you have the control by MHRA in UK, you have TPD in Europe, and of course the FDA even in Philippines and also US. But it doesn't really ring a bell for our certain policymakers, given that sample from where we come from, because they follow the WHO. So even though, you know, It has been approved by certain countries and continents and things like that, FDA, MHRA in UK, TPDs in Europe and so on, but they really follow WHO and basically what WHO's, you know, role will play in the Ministry of Health. Hence, even though the general harm reduction is taken very positively, so we have needle syringe exchange program, we have the methadone replacement therapy, we have condoms, we have pre-emptive HIV treatment and so on and so forth. But it's not on tobacco. THR is looked down very badly. There's no opportunity for that. You do understand that with the new act that has come from the government in October last year, Act 852, which controls the public health policies on smoking and so forth, that you could not even say something positive about alternative tobacco products is against the so-called law, so it has become very restrictive. I have not seen any papers on that, meaning that a lot of us have been quite quiet after that law. We can do a scientific discussion that is permitted, but we cannot advocate alternative tobacco products. They have not taken this as part of the tobacco cessation programs. So in a way, there's no regulation as what UK has done. You can use alternative tobacco products to reduce the harm, but it's not available in Malaysia. There's no guidelines for that, and they do not agree to use the UK's guideline. We have proposed that, but they have not agreed to use the UK's guideline. Hence, in a way, we are stuck at what point in time there were quite some leeway. We have made some leeway saying that alternative tobacco products can come into the market, they have already put up tax, excise tax, which is a bit comparable with tobacco. We do remind them it has to be risk proportionate. You cannot tax something which is less harmful, you know, a very high price to tax. And we have seen the tax hikes for tobacco. We've already had three excessive hikes for tobacco. Of course, it's not the highest in the world. I think Australia will have a higher hike in tax. But the tax in Malaysia is quite high as well. It's about 56%. But it doesn't work. It doesn't reduce the consumption because people turn into illicit.
51:38 - 52:22
[Sud Patwardhan]
Thank you so much. That's a great elaborate answer and I appreciate you also then touching upon the need for risk proportionate regulation and taxes have to be commensurate to what the risk of the product is and so on and so forth. May I kind of pivot to maybe, Hugo, if you don't mind me asking that We appreciate that the examples from the US or the UK or other countries who have local research done on these products and who have a better understanding, they have better regulatory frameworks perhaps, that they regulate these products differently and in a disproportionate way. Would the answer for, say, a country like Malaysia or Indonesia or anywhere else in the LMIC world be to conduct more research? And is that something that you or your company or other companies may be doing or would want to do?
52:23 - 53:26
[Hugo Tan]
Most certainly, I think this is something within our focus. As I mentioned earlier just now, that most of the research and the data generated are from the higher income countries, the European countries. But then again, the utilisation of this data, when you go to the LMIC countries, these are not seen seriously or applicable to many of the regulators. So to that context, we are in the planning stage. We can't share much of the details now, but we are committed to running trials in LMIC countries such as Pakistan, for instance, one of the examples where the smoking burden is high, to look at potentially what are the impact of these smokeless products in some of the clinical outcomes such as looking at oral health. Are there any difference if you continue to smoke or you continue using oral traditional tobacco versus the newer oral nicotine pouches?
53:26 - 54:17
[Sud Patwardhan]
That's very interesting. I'm sure the next few years of GFNs will see more data coming from the research you hopefully do in those countries. I do appreciate there are a couple of questions from Edge about the black market by bands and why don't countries then kind of recognize and reconcile that. I would say that although this panel would definitely be able to answer that, again, from a research point of view, just local NGOs and companies should perhaps put that data together and make it available in the right fora, and then use that for advocacy locally, perhaps is a way to say it. I would like to point that question about teaching, the question from back there, about teaching THR to universities, students, experience from other countries, so it may help you in the context of Taiwan. Satyen, you want to answer that? And what you have seen, and what are the challenges you have faced, apart from what you already said? So just maybe a top line answer.
54:17 - 56:59
[Satenik Muradyan]
Yes. So for the past year, almost a year, I've been working on that, not only teaching THR to students, but also doctors as well. So my approach was, while I was doing the research for the past two years, I always asked the question, After asking, have you ever received any training on smoking, which the answer was most probably not, I was always asking, would you be interested in receiving such trainings? And after saying no to the first question, usually people said yes to the second one. And after that, I would collect people's contacts. And after organizing the technical parts of the trainings, me and my team would one by one call doctors and inform them that there is a free of charge training about how to fight smoking. You can come and learn about it. But an important point for me was also not teaching THR. but teaching how to fight against smoking. This was an important point because this helped seem not one-sided. And during the training, I was covering all of the topics, including NRT, including CBT, including medications like , et cetera, et cetera, because doctors don't know about them either. And I was talking about the pros and cons about both WHO-advised methods and THR. pros and cons of both, to give people the chance to think and choose themselves, or at least give them the spark of, oh, maybe I should go and read more about these methods. But besides the individual calling and informing that there's a training, I also went directly to different centers. For example, I recently had a training for one of the biggest psychology centers in Armenia, went straight to the director of the center, told her about the plan, and she was very open to training her professionals about it. Same with university departments. I went recently to the head of the psychiatry department at one of the universities, said, I have a such plan. Would you be interested for your residents and doctors and professors be included in this and they were very open because it's important to show that I'm not one-sided about any specific method. I'm openly talking about pros and cons of all the methods that are out there. So that was my approach and it seems to be working.
56:59 - 58:12
[Sud Patwardhan]
That's a great answer and I would like to kind of also add my experience from working with clinicians in the UK and in India that exactly that agnostic approach, product agnostic, we are about the patients, this is patients who are asking for support and we need to help them in their journey to be smoke-free, or in the case of India and Pakistan and South Asian countries, smokeless, tobacco-free as well. And the way to do that is to offer a whole range of products, talk them through it. Of course, in the case of some countries, the evidence is not there, or the products' evidence is not there. And that's where companies have to increase the amount of evidence available. And then that has to feed into the regulatory sort So it's a whole cycle there. But of course, as clinicians at least, they have to give fair, balanced, objective advice. And that seems to resonate, because then it's not a company-sponsored thing. I think there was an earlier question about it's coming across as a sponsored thing and not as a fact that is scientifically accepted. Hopefully that's answered your question. We can always talk offline. Any other questions on this side? I know I had mentioned that I would love to hear from Tiki. If I may, Tiki, put you on the spot, but nothing, just a very quick, maybe a couple of lines, if you don't mind, please, on Indonesia, why they haven't signed FCTC, and has it mattered in terms of tobacco control and related outcomes?
58:13 - 59:38
[Tikki Pangestu]
Of course it matters, we have the highest smoking prevalence amongst our males, but as I mentioned in the panel this morning, it's very difficult to push through promotion of this harm reduction products. Ten percent of government income comes from tobacco tax. We have one million tobacco farmers, and we have half a million people working in the manufacturing of cigarettes domestically. Just one final comment, because I've heard a lot of comments about the frustrations with policymakers. Sharifah mentioned, we present all these FDA, WHO, nobody listens. When I was at WHO, I worked for 13 years with policymakers in LMICs. And I'd like to quote for you something that comes from Professor Sir Michael Marmot, who was chair of the WHO Commission on Social Determinants of Health. And what he said may put the policymaker in the right perspective. And this is what he said. Science does not engage with blank minds that get made up as a result. Science engages with people who have very strong views about how things are and how they should be. So I have some sympathy for the policymakers.
59:39 - 61:00
[Sud Patwardhan]
That's a very profound statement, and it also reminds us the challenge we are facing, as I would say, as a medical doctor or people who are here in various capacities in their role in tobacco control and tobacco harm reduction. It's not an easy one, but I think no one assumed it's going to be easy, right? So I appreciate your comment. I think it also, two things you mentioned perhaps answer a question Vladimir asked about the state. It was not about state monopoly, but the states or individuals owning companies in countries. And it's not very dissimilar to state monopolies or oligarchs ruling some parts. They're having a huge stake in the business of selling toxic tobacco products. You mentioned Indonesia where millions of people are employed in the industry. So there is a whole vote kind of voting and the population is impacted economically but also they vote for change and they will not want anything that ruins and puts them out of their job. So there's always this sort of additional components that have to be factored in and it's not that easy to sort of find the way through that. I had something else that was brought up just at the beginning of the session, and it's important. I don't know, Andreas, if you want to say something about Hungary. Just a single line, because I want to bring that into the conversation regarding smokeless. So if you don't mind just introducing yourself and also what was the issue you mentioned.
61:01 - 61:24
[Attendee]
Well, just that there are a lot of countries, including Hungary, very difficult to speak about or write about. I'm a journalist. To write about tobacco harm reduction because of regulations. And it is very difficult to talk with the public. And I think this is also a problem in many countries. So I think we should also think about how to change this if it is possible to change.
61:25 - 63:30
[Sud Patwardhan]
Okay, look, I mean, that's the theme of the entire conference is around how to kind of clear some of the miscommunication, misperceptions. One of the things that I have found, and speaking to you, I realized about Hungary, for example, and the incidence of smokeless tobacco use there as well. and the fact that it leads to oral cancers. I find it very interesting. This is my personal statement, mind you. I find it very interesting that always the discussion is about a smoke-free future or beyond smoke and so on. And these are important things for companies to kind of sign up to and galvanize their forces. I think the challenge is that they often forget that there is a huge chunk of tobacco user populations globally And not just in South Asia or Southeast Asia, but also you mentioned Hungary, a lot of European countries have oral tobacco which causes harm. And oftentimes in this conversation about making the world smoke-free, people forget that even making the world free of harms of smokeless tobacco is equally important and not miscommunicate that. Because the moment we start saying that, oh, smokeless is all right, that sends the wrong message because they refer to their own people in their own country and say, ah, that's not true. We see people with oral cancers from smokeless tobacco. So we have to be nuanced in how we communicate about the nicotine tobacco harm reduction. And that's been my learning. But look, it's not about me. We've got 10 minutes. If you have any questions, we can take them now. Or I would actually like to give two minutes each to the panel experts to kind of wrap up. So any questions? Anything to say? Or you had enough of LMIC for now? Thank you so much. But I want to start with Emmanuel. And Emmanuel, I would focus your, and everyone in fact, focus your minds on one question that you can answer or one thing you can mention in those two minutes. And that is, going back from here, what are you going to focus on in your capacity as an advocate, not just in Congo, but in the entire continent of Africa? What are you going to focus on that will move the needle for making tobacco control, because that seems to be a much bigger need in Congo than just tobacco harm reduction, but also tobacco harm reduction accessible to those who really need and deserve it. And the same question applies to you, Sharifa, in your role. You go, and you can have the last word among you.
63:32 - 65:26
[Emmanuel Mbenza Rocha]
Thank you so much, Doctor. Once again, I would like to thank you for the opportunity given to me to to face this audience, and thank you for your attention. As I'm going back to Congo equipped with a lot of information that I received here and with the ideas we have to spread the news, So what we're going to do, like I've mentioned earlier on, is to gather all our team members because we have a board membership with a few members that are part of the East, the West, the North and the South. But we have a big issue, a big problem at the moment. The east part of the Congo is not controlled by the government currently. So that's the difficult part we'll be facing in terms of communication. We have those delegates that are already in those different zones, in those different provinces that we communicate with. What we want is to collect more data to know how to help, how to get the right information about tobacco harm reduction. Because before we help, it's like, let me put it this way, is when you're lost, the first thing you have to know is to get your location, to know where exactly you are. So the first thing to know is, what is the real problem in the Congo? We have to look at the real numbers of people that really, really need help. And that's where we take it from. So it's going to be all about data collection.
65:27 - 65:43
[Sud Patwardhan]
Emmanuel, thank you so much. If I was to summarize that, basically, if we use the M-Power framework, you want to definitely go and start focusing on the M part of it, monitoring use of tobacco. And I wish you best luck for finding the resources to do those surveys and bring that data to our attention next time you're here. So thank you so much. Sharifa, your approach?
65:44 - 66:22
[Sharifa Ezat Wan Puteh]
Yeah, thank you very much for the opportunity. I think there's a lot of failure stories, but a lot of success stories as well on the use of alternative tobacco products or nicotine products all over the world that LMIC can actually emulate. So I think success stories from, let's say, Japan or UK or Australia or New Zealand or some other countries that have already used A&P can be used. And of course, we do look at data and I think this is very important for us to look at the success but also some of the failures and try to follow the best.
66:23 - 66:51
[Sud Patwardhan]
Thanks for the very philosophical answer. And I think I like the optimism there. I would also request you to go back. And I think there was a question on taxes and revenues earlier, which we couldn't address properly. But I would request you to, with your vocabulary and what you've learned here, take it back in terms of your engagement and see how that can allow us to have the right level of risk-differentiated regulation to ensure that it's, again, part of this Empower framework. But the raised tax cannot be a blunt instrument that can be used for every product. Well, thank you so much, Sharif. You go.
66:52 - 67:51
[Hugo Tan]
Thank you. So allow me to say I really enjoyed the discussion today, really good questions, and I hope to be invited for next year's conference. We will see. Just two take-home messages. So number one is each one of you are a THR ambassador here. So I don't believe that one party can do everything alone. If we join our effort together, we can achieve more. Secondly, the world is evolving, it's changing, the industry is changing. I could speak from perspective of the BAT where we're also evolving, we're changing, we're definitely committed to THR. What you could also see, there are many more professional scientific experts, clinicians like myself who have joined the industry because we believe in the science, we believe in the cause, right? And do not afraid to engage us, do not afraid to speak to us. We are here to work with you. So we look for a continuous collaboration with all of you.
67:52 - 68:27
[Sud Patwardhan]
Thank you so much. I'm sorry, I should have answered properly. You're most welcome for the next time. If I'm allowed to host a session, you'll be part of that. But look, the Empower framework. Now, I think what the company should be definitely involved in, apart from offering the products, is to monitor, to also protect those who should not be consuming the products. So that's adolescents, those underage, or those who are not supposed to be using the products. and also warn about the harms and the risks of products in a very proportionate and sensible way. So I think there's a lot of burden and responsibility on the shoulders of the industry, but I'm sure they will rise up to the challenge. Satin?
68:28 - 70:35
[Satenik Muradyan]
Thank you very much. I learned a lot from each and every one of you. Once I'm back to my country, I will for sure continue doing my work of educating different professionals about methods of fighting against smoking because in my country, the legislation around smoking cigarettes and safer nicotine products isn't too different from each other, so they are available for consumers, but the knowledge is what's lacking. But I also would like to talk about something that most of you will most probably not agree with, which is understandable from my side, but I'd like to point this out. We keep talking about how data is missing from LMICs. Yes, of course. And data is important, I agree, but what data? research what, let's spend one and two and three more years on researching the fact and coming to the conclusion that tobacco harm reduction is good. If we test, like in LMICs as well, what method is working, what is not, we will have the same conclusion. Tobacco harm reduction works, some methods do not work as good, et cetera, et cetera. And trust me, as a geneticist, It doesn't matter if you're Armenian or French or Chinese. Tobacco kills people, nicotine doesn't. And that's the conclusion that we will always have. And if we spend one and two and three years on researching this topic, instead of focusing on making the product accessible, we will just spend one and two and three years on thousands of people dying because of tobacco. So in my opinion, we should focus on, for example, countries like Turkey, Iran, where these products are absolutely banned. Let's make them accessible. And yes, at the same time, do the research. Research is important. But if we spend time on a research that will give us the information that we already had, we're losing time and losing people's lives. So if you don't agree, I will understand that. But that's the point I wanted to make.
70:35 - 71:09
[Sud Patwardhan]
You've spoken like a true, compassionate and passionate doctor who is action-oriented and wants to get the job done now. And I respect that. I'm sure everyone's going to agree on the need for getting on with it. I think there was also a comment earlier in Andrea's breakout session about youth studies or case studies. And I think it's important also for us to have not just a Sweden and a Norway to point to or a UK and a US, but oftentimes people do need some more locally relatable information. example, which is where that is coming from, perhaps. So it's not necessarily a black and white answer, but completely respect the approach. Diki, a very quick one minute, not more, please.
71:10 - 71:31
[Tikki Pangestu]
Satyavik, Sharifa, and Emmanuel mentioned data. Okay? We need more data. I'm reminded of a saying. What can be counted is not always important. And what is important cannot always be counted. So collect the right data.
71:31 - 73:31
[Sud Patwardhan]
Thank you so much. And look, this is very helpful to have that level of involvement, literally 30 seconds, if you don't mind. Your name, affiliation, and statement or question, but just be very clear, please. Thank you. Yeah, yeah. Oh, no, no, no. You sort of said, I want to say something. You agree with him. This man agrees with Tiki. That's good. Phew. Look, I get the privilege of closing this. I always take pride in finishing things on time, although we started five minutes late. A huge thank you to this panel and the three amazing facilitators who made it happen. My takeaway from this... is incremental. Every year we do something on LMICs, we are kind of moving the needle slowly but surely in the right direction, raising it in people's minds and the profile of the issue. And Derek Yak, who earlier in the session mentioned it, brought also the publication he wrote, which was published last month, about again, data about how the amount of research is not there from LMIC's recently published paper, should check it out, is again highlighting the need for us to kind of be a bit more aware of the world and not live in our own little cocoon as such. One final takeaway for me, if I may, is that the lifecycle of tobacco control was mentioned earlier in one of the breakout groups. I find it very profound. It's a very visual way of depicting tobacco control, the way it's come from. We talked about 20 years of FCTC earlier today. And this is that lifecycle thing where tobacco harm reduction, call it a consumer movement, call it other companies, tobacco companies, really not relevant in the discussion. It's about there is a breath of fresh air, a bunch of new solutions as a part of the toolkit that are available for current adult tobacco users to find a safer way to get out of their habit and live healthy, happy, longer lives. And that's a promise there. And how do you make it happen is everyone's responsibility. You go back and do your things. These guys, I'm going to hold them to account next year. They come here and say, what have you actually done when you said you're going to do that? Thank you so much. A big round of applause for them and them.