Achieving consensus in debates around tobacco harm reduction is rare. This workshop explored how we can effectively build consensus in academic discussions around safer nicotine products, and correct misconceptions about tobacco harm reduction, using the Delphi Approach, a structured communications process. After short introductory remarks, participants engaged in group discussions using Delphi techniques and concepts, finishing with a Q&A and a look towards its future applications.
Transcription:
00:12 - 17:51
[Mohamadi Sarkar]
I know that there are several competing sessions, and I appreciate that, you know, you chose to come here. Rest assured that you made the best decision. This is going to be the best one. And hopefully it will be worth your time. My name is Mohamadi Sarkar, and this session is about a concept that some of you may be familiar with. So maybe I'll start by asking you to raise your hands if you have heard about the Delphi approach. That's good, you know, a handful of people, so hopefully you can keep me honest and if I stray. I also want to ask you a question. How many people in this room, and I'm assuming that I will see several hands raised, how many people in this room would say that adults who smoke but are unwilling to quit smoking should be informed and encouraged to switch to smoke-free products. Excellent. So we are in the company of like-minded individuals. In a way, it's going to be an interesting journey for us. So over the next few minutes, what we will do is we will have three talks. I'm going to make some introductory remarks. And then I'm honored to have Ariel, the recipient of the Michael Russell Award amongst ourselves. She's going to talk about the role of misperceptions in the switching journey. And then Pascal. There he is. We'll share his experiences from running this process in an actual real world setting. And thank you, Pascal, for spending some time from your busy schedule and particularly sacrificing your son's birthday. So we appreciate you being here. So before we get started, let's just step back and think about Why are we here? Right? I think I know why we are all over here, but I'll just remind the audience, what's the problem that we are trying to solve? If you look at the statistics of the prevalence of smoking worldwide, while it is continuing to decline, slower pace in some countries as opposed to others, but nonetheless, there are still a billion people that still smoke cigarettes. One billion people still continue to smoke cigarettes. And an estimated eight million will die a premature death because of continuing to smoke. Now, what can we do about that? Well, the solution is the traditional strategies of preventing initiation and promoting cessation while they are good, but they are not good enough because one billion people still smoke. And that's where the option of getting them to be aware of alternatives that are less harmful and promoting them to switch completely to these products can accelerate and help save their lives rather than continue to smoke. So that's where the harm reduction framework comes into play. And it complements the traditional strategies. Now, what is preventing these individuals from switching? We all in this room would probably are aware and would know that misperceptions are rampant. So I'll just share as background. some level setting. So PATH study, many of you may be familiar, that is conducted in the US by FDA and the National Institute of Health. There's a question in there which asks about the risk perceptions of e-cigarettes to adult smokers. And the findings are just astounding. We looked at the data. over the past decade or so. And this study generates evidence every wave. So if you look at the waves of studies, almost 95%, 95% of smokers believe that e-cigarettes are equally or more harmful. That is just mind blowing, isn't it? Almost all of them believe that e-cigarettes are equally or more harmful. These are current exclusive smokers. And not only that, if you look at the data from the early 2010s, 2013, 14, half of them accurately perceived that e-cigarettes are less harmful. But today, only 6%, only 6% of these smokers believe that e-cigarettes are less harmful. That is just not right. And it gets even worse. people who are dual using cigarettes and e-cigarettes, e-vapor products. In 2013-14, 70%, a majority of them, of the dual users, believed that e-cigarettes are less harmful. And in this short time period of a decade, these trends have exactly flipped. And while now 80% of them believe that e-cigarettes e-cigarettes are equally or more harmful. And this has some serious consequences because when we look at it, and Ariel will share some more data on this, those who have these misperceptions are more likely to regress back to smoking than to switch completely amongst a dual user population. So this is problematic, right? Now, not only are there misperceptions about the differential risks of the products, but there is also widespread misperceptions about nicotine. What I'm showing you here is our analysis, once again, based on PATH. The question was asked, does nicotine cause cancer? Only 7% accurately perceived that nicotine does not cause cancer. whereas a vast majority of them believe that nicotine causes cancer. That's despite the evidence that shows otherwise. For example, IARC, the International Agency for Research on Cancer, has looked at the evidence and concluded that nicotine is not a carcinogen. And then if you kind of follow their switching trajectories, those who have accurate perceptions that nicotine does not cause cancer are two to three times more likely to switch to smoke-free products than the ones that have those misperceptions. And not only that, we then went ahead and modeled this and found that if those misperceptions are corrected, that can result in 800,000 premature deaths awarded. And the corollary of that is that if that misperceptions were to persist, if all the smokers had the misperceptions, then that would result in 300,000 additional deaths. So clearly, these misperceptions can have some profound public health impact at the population level, and correcting them can lead to a public health benefit. So what can we do to correct these misperceptions? Well, it would be great if we had healthcare providers educating them, right? And you may be familiar with this study from Rutgers that showed that 80%, 80% of physicians believe that nicotine causes the major smoking-related diseases, cancer, COPD, and cardiovascular disease. 80%. of the physicians believe that nicotine causes these major smoking-related diseases. And as a, yes? Yes, this is from the U.S., but there was a recent survey done by PMI, and there was another survey done that was international by the foundation many years ago, and these data are very similar to what's been seen in the rest of the world. But the data that I showed, even for the smokers, was from the study that is done in the US. But nonetheless, I think that there's enough evidence that these misperceptions are pervasive in other countries as well. So as a side, we did a survey among physicians and asked the same question about NRTs. Well, it's the same nicotine. In that case, they say, oh, no, it does not cause the major disease. Because why? Because in the US, these are drugs that are approved as safe and effective. So there's a total cognitive dissonance on the same nicotine when it's delivered in the form of a smoke-free alternative is perceived as extremely harmful. Now, this is really problematic, particularly if you layer on top of it the fact that many smokers, 86% of them, believe that the doctors are the trusted source of health information. So they're going to the doctors for advice. And if the doctors have these misperceptions, then they cannot provide the right advice to them. We heard earlier in the keynote, both from Dr. Sindel and Callan, that when physicians are unable to provide accurate information, they can inadvertently get people to continue to smoke. So that's what we need to fix. So how can we change the misperceptions? We are all familiar with the Swedish snus experience, right? And that Swedish snus experience was a result of the decades of epidemiology that had been generated on snows. But one of the inflection points of the public health debate was this seminal publication that came out in 2004 where Levy and others had put together a panel of experts. And this panel of experts included, you know, luminary stalwarts in the public health field, Martin Jarvis, Michael Thune from the American Cancer Society, Deborah Winn from the National Institute of Health in the US. And this panel looked at the data and they utilized this Delphi approach and came to a consensus decision that based on their expert judgment of the review of the evidence, snows is about five to 10% mortality risk than cigarettes. So this was, in my mind, the pivot point where there was broader agreement amongst public health about the benefit of snows. So now, I've been talking about Delphi. So what is Delphi? I saw that some people raised their hand. I'll just step back and give you the historical version of the term Delphi. It actually originates from this ancient Greek site which was a seat of the Oracle Parthia, who was consulted on important decisions. So this was the wise priest who opined and provided his opinion on important decisions in the society at that time. And I was just chatting with Farsaninos outside. And I told him, hey, you should come to the session because I'm going to talk about Greece. He said, yeah, I don't know what Patea was smoking. He was probably smoking a lot. That's why he was able to give all these words of wisdom. But nevertheless, this Delphi approach, in my view, may be a valuable tool for us to try to start making an impact on these misperceptions. Look, You know, we can sit in our rooms and talk about this misperception until they turn blue. And there's no action being taken to address these misperceptions. And in order for us to address these misperceptions, We need to build consensus at the grassroots levels amongst various stakeholders, including the physicians who we saw have deeply rooted misperceptions, as well as other health care providers, nurses, dentists, social workers. We know that smoking is widely prevalent in people with serious mental health diseases, psychiatrists. So in order to make that change, I don't think that it's going to happen at the top level for these health or care organizations, American Medical Association, or WHO, maybe you can put that on the side for a moment. But in order to make this a meaningful impact, we can use the Delphi as a means to build the consensus. Let the practitioners look at the scientific evidence. and us talking about it and let them come to their own conclusions based on the judgment of the science. And that's what this is. It's a well-established approach. This has been used widely in other disciplines. And I think that it's time for us to consider, utilize this in harm reduction. And that's how I think we can build the judgment. And the process is pretty straightforward. It involves... clearly defining the goals, engaging the experts, let them take a look at the science and the evidence, and give them the opportunity to develop communications that they are comfortable with, so that we are not kind of forcing things down their throat, but you know, they come to their own expert judgment, and sometimes it may require some iterative process, and at the end of this iterative process, you can generate a precise, a pithy statement, like what we saw with snows. You know, all these experts came to the conclusion based on their available evidence. I mean, another great example sort of is what happened with Public Health England. Public Health England came forward with a statement that vaping is 95% less risky than smoking. That was based sort of on this modified Delphi approach. And then the last piece, which is the important critical thing, is that that information, once it's kind of ingrained in the minds of those individuals who have looked at the evidence, come to their own judgment, that needs to be broadly communicated amongst the smokers, because at the end of the day, Those are the people that matter. Those are the individuals that need this accurate information so that they can make informed decisions. So I'm gonna just, this was just the setup. What we are gonna do is we are gonna have two presentations. Ariel is gonna talk about the role of misperceptions in the switching journey. And then Pascal is gonna share his experiences of running this Delphi. And then we are gonna do an interesting exercise. audience is going to participate in a case study of a mock Delphi. So you get a sense of how this would work. And hopefully, as you kind of experience it yourself, you will see the value in this process. And then you can then share it amongst your colleagues. And we can proliferate and build this consensus groups that slowly but steadily is not going to happen overnight. And mind you, this is not a silver bullet. It's not to use a crass analogy, but it's not the 30,000 pound bomb, cluster bomb that is going to disrupt the nucleoside, but it will slowly make a difference if we do it in the right way.
17:52 - 18:49
[Pasquale Caponnetto]
Thank you. Good morning, everyone. I am Pasquale Caponnetto. I am from the University of Catania. As you can see from this slide, this is an Italian study. This study is about the new strategies against smoking, topics and perspectives from experts in the results of the Italian consensus paper. In Italy, electronic cigarettes and either tobacco products are not licensed therapy. We study from about 25 years this approach, but it is not considered an approved therapy. Before to speak about our experience, I wish to show you a little video, three minutes, about the context of where I live and where I work from about 2003. Can we start with the video, please? Hello? We can start with the video?
18:56 - 21:29
[Video]
If you want to become educators or pedagogists, then work in the field of education and training from childhood to adulthood, to provide your service as a psychologist or as a psychotherapist, the Department of Science of Training is located in the historical center of the city, two steps from the most beautiful monuments, the most important archaeological sites of the city. The Sicilian society is in love with smoking. So these 28% of people that smoke, they just love it because it's part of the culture. So you have an espresso, you must have a cigarette. Addiction can be a spectrum of different level of dependencies. And clearly, there's no black and white. These are real people with their real problems, real need. These are not just statistical figures. I was the first one to open the first smoking cessation center in Sicily. Now, this center is one of the most active nationwide. They were really engaging with the smokers and getting to understand, empathize, consider what was it that really would help smokers to actually change their behavior so that lower their risks. The idea is to develop an exciting project related to the possibility for users to monitor their food during the quitting process. One of these is the problem to gain weight because the diet changes in some way because there is some stress, there is some problem related to the abstinence. We receive all the people who want to stop or reduce. Even if I can't stop or reduce right away, we manage to provide a delayed change strategy. And we really hope together, collectively, we can provide the evidence for many governments to base their new regulation about these products. We really believe we can do that together. Something came to my mind that made me decide I don't want to be a slave to that piece of paper with tobacco inside.
21:32 - 35:12
[Pasquale Caponnetto]
At this point, I know that you learned a little bit of Italian. That could be useful, especially during this period in summer. I worked, as I said before, for 20 years at the Smoking Succession Center. And what is the situation just now? 20% of Italians are smokers. Despite the decline in tobacco consumption in 2023, current crucial measures remain insufficient to achieve the WHO goal of 30% reduction by 2030. It is necessary to implement innovative strategies. I work for 20 years and the song remains the same. This means that, in my opinion, This is important to use that they are the novelty. The novelty are the reduced risk products. Why? Because they can be used in the general population and principally for people not motivated to quit. This means that initially they can be not motivated to quit, then they can switch, as I switched with my colleagues just now, and then this could enhance, improve their self-efficacy to change and switch and quit also with the reduced tobacco products. The objective of this consensus paper was to analyze prevention, succession, and harm reduction strategies, evaluate the role of combustion fuel alternatives, and identify areas of consensus and controversy. And so we know that there are three methods that mean that we use these techniques, we involve the 20 experts in different fields, by multiple rounds of anonymous evaluation. The importance of experts' concerns arises from the need to identify combustion-free alternatives such as electronic cigarettes and heated tobacco devices to reduce the smoking of the arms in Italy. In Italy, we have this problem, but for clinicians, the problem of tobacco addiction is not an addiction. And for this reason, we are trying to change the mind of future generations with some action. For example, we are training this year as a first experience, 150 physicians and 150 clinical psychologists to addiction and harm reduction approach. The process of this study was composed of four stages. During the stage one, we involved these 20 Italian experts selected by the principal scientific societies, and we selected these 20 experts because they published a lot in this field, in the field of tobacco addiction, and because they published a lot of work. In the second phase, we used 38 questions by using a Likert scale at 9 points from not agree to totally agree. And we divided this into three macro teams, where each expert expressed his or her level of agreement. Then there was the phase three with analysis of results and review. In this phase, the spirits eliminated the low agreement statements and modified the borderline statements. And the final phase that is named also second round of voting and we maintained that with 80% of agreement. This means that from 38 statements, we maintained 24 statements. What are the three markers? The first one was about the smoking harm and harm reduction strategies. The second one was about the combustion-free alternatives. And finally, about the anti-smoking legislation that is different in different places, also inside Europe. about the other one, that is about the smoking harm and harm reduction strategies. These experts discussed about the main objective that was to prevent smoking cessation and promote cessation. There was an anonymous consensus on cigarette smoking as a public health priority. This is not obvious, because as I said before, there is a problem about the approach of clinicians in Italy. This is different, for example, from the UK. I conducted my PhD in the UK, and in the UK, chronic cigarettes is considered an approach, therapy. But in Italy, this is not considered an approach. We use it because we know these effects. And another point of view that is wrong is that many Italian clinicians don't work in tobacco addiction because they consider these aspects and habits as not an addiction. This is a real problem. There is a lot of work to do. Hence, for these experts it was important to invest in scientific information on new products. This means that many, many experts don't know what are these products. how it's functioning. And these are the questions selected for the other one, the disarm from tobacco, smoking, and the studies from reduction. And about the other two, there was a focus on combustion-free alternatives. and particularly about the risk reduction. If you smoke, there is a risk. All know the problem related to smoking-related illness, but experts conclude that chemical toxicological studies and international studies confirm that electronic cigarettes, either tobacco products, produce fewer harmful substances compared to tobacco combustion. And for this aspect, it was important to agree on real-world evidence, the study real-life setting, the long-term monitoring, and verification of effects related to specifically smoking-related disease. And the objective in this case was to understand the real impact on public health about its usage. Particularly, these aspects has been fascinated about the long-term study conducted with the people with the COPD, where people that switched to COPD showed an improvement in COPD assessment to school, six minutes working test, overall quality of life, and the reduction of the exacerbation typical of this illness. particularly they were interested to Ukraine where 56 studies were included and where 29 randomized studies showed that the nicotine electronic cigarettes increased cessation rates compared with the classic and approved lessons therapy such as the nicotine replacement therapy. As a conclusion, for these experts, long-term perspectives are needed to consolidate evidence. Then there was a redundant problem, the problem of yet an accession and smoke-free devices. And our team expressed concerns about two points. The possible role of smoke-free devices in the organization, and there was an anonymous consensus on the need to maintain high vigilance in this sense. And for the panel, it was important to use prospective data and consider two surveys. One Italian survey that has been conducted with people aged between 13 and 15. And this survey showed how during the last eight years, the overall decrease in cigarettes and nicotine use. Then they considered another survey made by European Commission that included the 27 countries and were involved people aged between 15 to 24. And this survey showed that traditional cigarettes remained the most commonly used products. This means that this could, the utilization of smoke-free devices should be monitored but it is not an urgent problem. As conclusion, it is important for these experts the continuous monitoring and a balanced regulation. These are the 19 questions associated to smoke-free alternatives to cigarettes, And the final area, the area three, that is related to anti-smoking legislation, specific for the Italy government. And the experts obtained a consensus on six key statements, particularly about the need for effective policies for risk reduction, the regulatory support for combustion fuel alternatives, and it is important for our experts, the risk proportionate regulation, because the regulation should be based on a specific product's risk profile. And it is important to also use and improve the potential contribution to reducing harm from additional smoking. And also in this case, the final objective was to balance public health protection with harm reduction strategies. These are the 80 questions for anti-smoking legislation. I'm concluding, okay? As I say, my smartphone. Thank you. With this key finding. Just to resume, based on the results, we can conclude that on 38 statements presented, 24 has been achieved consensus. And consensus has been achieved on four point, point one, Arm reduction is a valid strategy, hence the expert concluded in Italy that this approach could be used for this problem. Point two, there is the need for regulation based on scientific evidence. Point three, it is important a clear communication about alternatives. And the last point, it is important to outline how electronic seals and HDP significantly reduce the production and exposure to many harmful substances generated by combustion. As possible, because of this disagreement, there was a complexity of topics and the personal interpretation, but this is obvious. And as conclusion, it is important for these aspects, standard prevention strategies, in order to avoid the smorgasbord, promote tobacco cessation with the new possible alternatives and with the second way that is not only quit but also reduce or switch. And it is important to use these reduced risk products. And it is important, finally, to outline the deaf community because it is a democratic approach, because we use a multidisciplinary team composed by psychiatrists, clinical psychologists, dentistry, experts in public health, cardiologists. because each part of our scientific society can disseminate this information around our country, and this is a step forward for evidence-based regulation. This means that this is the first step in Italy, and we can replicate this approach around the world. This is the study published in Frontiers in Psychiatry, and at this point, I can say to you, thank you for your attention.
35:17 - 35:41
[Mohamadi Sarkar]
Perfect, thank you. Thank you very much. Sorry for the confusion, but the way we had set it up was that I would do the introduction and then Ariel would kind of convince you the reason why this is such an important thing to understand the implications of these misperceptions. So the story is a little bit twisted, but it still sticks together.
35:42 - 45:01
[Arielle Selya]
Okay, there we go. Thank you. So I'm Arielle Celia. Quickly, by way of disclosures, I work for Penny Associates. We consult for Juul, and in the recent past, consulted for PMI. I also consult with Ricardo Pelosa at CoEHAR, and that received global action funding. I present some of that work today in my presentation, but this presentation is my own. Mohamedy set the great stage big picture, Here's some more big picture trends showing changes and misperceptions over time. That's what Mohamadi showed is reinforced by the HINTS data set, where a lot of people shown in gray are just not really sure what's going, they don't know enough about the products. The largest chunk think they're just as harmful as cigarettes. And what I would consider the correct perceptions in green are low and they've been declining over time. And worse, there's an uptick in those who think that e-cigarettes are more or much more harmful than cigarettes. So this is in the US general adult population. Somebody asked about other populations. So here's an example of adults in England who smoke, showing the same trends. And obviously adults who smoke are the ones that it's most important to have correct misperceptions because they're the ones that can benefit from switching to a less harmful product. But we see the same thing, a reduction in what I consider the correct opinion. excuse me, that they're less harmful and an increase in those thinking that it's more harmful. And then Mohamedy covered this too. It's also true in the physician population. Why are misperceptions so common? A couple of big reasons. A valley was one of the initial major reasons that shifted people's misperceptions. This was a lung injury outbreak that was initially falsely attributed to e-cigarette use. And there's some great academic work showing that this impacted people's risk perceptions. And risk perceptions only partly recovered after the correct cause was identified, which was vitamin E acetate in cannabis vapes. And at that point, e-cigarettes should have been cleared as a causal factor, but as some academic co-authors pointed out, there's still confusing messaging from health authorities in the US that kind of allow for the possibility that it might be related to e-cigarettes still. In addition to EVALI, there's also alarmist media coverage. Many of you are familiar with this Mirror article recently, which painted a very alarmist picture. It was not supported by the results, and this was on a study that not only wasn't published yet, but the study wasn't even completed. And there's also been some great work showing how sensationalist or alarmist media coverage can impact people's perceptions of nicotine products. Another factor in my opinion driving misperceptions is that in the research literature on youth use, risk perceptions are seen as kind of a lever to deter youth use. So I'm gonna quote a couple of conclusion paragraphs from studies looking at risk perceptions among youth. Prevention messaging should seek to explain how e-cigarette use is linked to respiratory problems and could affect COVID-19 outcomes. The evidence, as I understand it, is maybe there's mild risk for respiratory problems, but not rising to clinically significant issues. And the link with COVID-19 is very unclear. But the truth of these claims wasn't really considered in this paper. Another one, perceptions of risk significantly increased among teens viewing the Rethink Vape materials, and this was seen as the success of the program. Findings could inform prevention, for example, by developing counter messages for benefit perceptions. So in other words, for youth that perceive benefits from nicotine products, we need to correct those and make them perceive risks instead. And results suggest that the most potent vaping prevention messages for adolescents are those that focus on vape chemicals and the potential of vaping to damage organs and increase disease risk. many other examples of this. The common problem is that many of these messages are not backed by strong science and they lack important context about relative risk. So when you lack important context about relative risk, we're seeing that this is now having harmful effects. This plot shows perceptions of California youth on online exposure to vaping ads, either pro or anti that they've experienced for vaping and smoking. And what they perceived is that even though Overall, the content that they're seeing was perceived as anti-smoking or anti-vaping. There's been a relative increase in the anti-vaping sentiment, and youth are perceiving that it's become less anti-smoking at the same time. The authors had a careful conclusion sentence saying that as cigarette smoking continues to be the most dangerous form of tobacco use, a balance needs to be maintained so that the campaign against smoking is not overlooked. And that's really important to keep in mind. Another example of misperceptions, this focused on youth and young adults who transitioned from one product to another. And unfortunately, there was a sizable subset who changed from vaping to smoking. And the primary reason that they gave was that smoking cigarettes is healthier than vaping, so they thought. This is also backed up from some great qualitative work from out of the UK, including from Lynn Dawkins, a co-author in the audience. And I'm not going to read these quotes in detail, but I think this one is especially enlightening on the right. showing that youth are perceiving and they're picking up all this anti-vaping tone in the media from all these alarmist coverage on how it affects organs and that sort of thing, but there's no equivalent messaging to smoking, and smoking continues to be a problem among youth. So this is leading to a lot of confusions. But let's switch now from the harms to the possible benefits of accurate risk perceptions. And this draws on some of my work with JLI. So among adults who smoke who have accurate risk perceptions that e-cigarettes are less harmful than cigarettes, that can possibly benefit several stages of the switching. And we don't know how causal these relationships are, but there is some evidence showing that among those with accurate perceptions, they're more likely to adopt e-cigarettes in the first place, and that's shown in the PATH dataset, whereas conversely, those who misperceive that e-cigarettes are more harmful give that as a reason for not wanting to try e-cigarettes. In the next stage, actual switching from smoking to e-cigarette use, that's also much more likely for people that hold correct perceptions. That's shown in PATH and the dual purchaser study. On the other hand, UK adults who have misperceptions cite this as a reason to not switch completely and to keep dual using cigarettes and e-cigarettes. Finally, once people are switched, those who have accurate perceptions are more likely to stay switched and less likely to relapse back to smoking. And there's some recent evidence. Jamie Hartman Boyce gave a great talk at e-cigarette summit recently on the evidence that she's seeing that people are unfortunately using smoking to quit vaping, which is, of course, up the continuum of harm. All of this is true, including among groups who are likely to keep smoking. So those with a heavier smoking history or who smoke more cigarettes per day, the association with risk perceptions is actually stronger in the JUUL purchaser study, according to what we saw. Older age groups and people with low socioeconomic status also are more likely to hold misperceptions, and possibly changing those misperceptions can aid them in harm-reduced behavior. Wrapping this all up, misperceptions about nicotine and the continuum of risk are common and increasing across many different populations. This likely stems from a valley, alarmist media coverage, and a tendency in the literature to promote increasing risk perceptions to deter youth use. However, misperceptions, especially without counter messaging or accompanied by messaging about relative risk, could promote smoking instead of e-cigarettes in both youth and young adults. On the bright side, accurate perceptions can predict several stages of reduced harm behavior from initially trying e-cigarettes to staying switched. A caveat is that, again, we don't know how much is causal. It might be reverse causality as well. But I think the point is accurate risk perceptions are one possibly modifiable factor. And for some groups that have really struggled with quitting smoking, This might be one of the few modifiable risk factors that we could change in order to encourage more harm reduced behavior. And messaging about nicotine products should include relative risk information. Thank you for your attention and thanks for bearing with us.
45:04 - 49:07
[Mohamadi Sarkar]
All right. So this is the part that I'm sure you were all waiting for. What we will do is Excuse me. Ariel kind of set the stage very nicely because when we talk about correcting misperceptions, there's always this concern about the spillover effect to youth. Whereas what you showed, Ariel, was that trying to dissuade youth from vaping, the spillover also happens amongst adults. which is why I think that it's going to be so important for us to try to get the right messengers, i.e. the healthcare providers, to speak directly to those who are impacted, the adults who come, the patients that they see. So hopefully this exercise will give you a flavor of how this can be effectively used to proliferate in a Pascal did a wonderful job ending his talk where he showed that you can see some evidence-based outcome in one step at a time. This is not going to solve the problem, but it is at least some action that we can take to address these misperceptions. So bear with me. We're going to do a little fun exercise. We're going to divide the room into three groups. And starting from here, Let's just call out, so you'll be one, two, three. Remember your numbers. One, two, three. Remember your numbers. One, just say it, one, three, Scott. One, two, Three. One, three. One, two, three. One, two, okay? So we got this? So everybody remember your number. Here. Yeah, you're one. You're number one. One, okay, so group one is gonna stay here, and I've asked some of my friends to help facilitate, so Elizabeth. Yeah, one comes over here. Elizabeth is gonna be facilitating, and the way this is gonna work, she's gonna explain it, but let me just run this by you. two is gonna come here, and three is gonna be in the back. Okay, so our facilitators are gonna guide you, and basically what we are gonna do is that there are five statements about nicotine perceptions. The group will discuss this, so I'm gonna leave this on the board here. I would like for each group to discuss it, and the facilitator is gonna track the voting. Let's first tackle this, and then in the next slide, we will have five statements on product perceptions. But let's first do the nicotine. So start now, have a conversation amongst yourself, see whether you agree, and if you disagree, Say why.
49:20 - 51:40
[Attendee]
excellent i will go ahead and kick things off group one was fantastic we had wonderful discussion i'll start kind of overall one of the things that i observed is that the first page of statements so those around nicotine were a little more challenging because it requires some level of medical understanding of the effects of nicotine, which not everyone felt comfortable either agreeing or disagreeing with. So I think there's an opportunity there. But in general, what our group agreed with was that nicotine does not cause cancer nor emphysema or COPD. Things got a little more diverse as we moved to cardiovascular effects and harm to baby. One of the things that we discussed was the need to expand on terms like effects. What effects are we talking about? And that, I guess, dimension to the statement could help others get on board with agreeing with the statement. And there was a general consensus that there is no direct evidence that long-term use of nicotine irreversibly damages the human brain. Now, when we shifted to perceptions, things were pretty much consensus across, although I did want to call out two pieces that were a little bit interesting. So the fourth one, which focused on the role of healthcare providers, There's a little bit of nuance there. Someone in my group raised that well, it really depends on the health conditions of the patient as to whether or not somebody should be referred to smoke-free products. And additionally, there was a desire to know more about the effectiveness of smoke-free products in switching adults who smoke to noncombustibles. And then lastly, around correcting the misperceptions, there was some conversation of should that can actually be a will, so correcting those misperceptions will accelerate complete switching. And lastly, I just want to raise the importance of the proof points. So we were all at the benefit of the earlier presentations. And so having those in the pocket when discussing these topics would be quite helpful. So anything that I missed, team, that you would like to share?
51:41 - 51:51
[Mohamadi Sarkar]
Okay, fantastic. All right. A lot of applause for this team. Will, after we're done with the presentation,
51:52 - 55:02
[Ian Fearon]
report out by the breakout leads will have a chance to discuss amongst themselves so hi everybody uh ian firan thanks muhammadi for asking me to to do this so uh in terms of nicotine perceptions uh we all definitely all agreed on number one and number two nicotine doesn't cause cancer nicotine doesn't cause COPD, and these are common misperceptions of nicotine. In terms of the cardiovascular effects, we all agreed, apart from one person who disagreed, it is a vasoconstrictor, and it does elevate blood pressure and heart rate, and does that as a kind of an indirect consequence translate into increased risk of heart disease, so that was why they disagreed and queried that. Nicotine use during pregnancy, we had a kind of a mixed bag here. Four people agreed, one disagreed, seven abstained. And I think the reason for that confusion was just the conflicting evidence and maybe a weak evidence based on kind of dissecting and disentangling nicotine from smoke. and not fully understanding it. And then no direct evidence that nicotine irreversibly damages the brain. Eleven agree and one abstain. And I think, again, people question, well, we hear this all the time about nicotine damaging kids' brains and rewiring them and so on. And so at different ages, does nicotine do good things or bad things? And so that, I think, was... causing a bit of confusion. Much more agreement on the smoke-free product perceptions questions. All agreed that cigarettes are the most harmful. All agreed that complete switching is the best thing to reduce exposure. All agreed that smoke-free products are less harmful than cigarettes. All agreed that health care providers should advise people to switch if they're unable or willing to quit. A bit of a disagreement on the final one, correcting the misperceptions about dual users, a couple of abstainers. And I think the reasons for that were, what is a dual user? If they're smoking 10 cigarettes and using one iCostic a day, or if they're using 10 iCostics and one cigarette a day, will understanding their misperceptions help them switch? And the other thing was, what are the reasons that they're dual using? So maybe it isn't a misperception thing, maybe it's actually more convenient and I can actually use my ICOS in the car, but I won't smoke in the car. And maybe there's other reasons. So we weren't quite sure that correcting misperceptions. It probably would, but there might be some focus that it doesn't promote switching because there are other reasons that they're dual using and not just because of the risk perception. And that was it from my group. Thanks to everybody who contributed. Really appreciate it.
55:08 - 56:07
[Mohamadi Sarkar]
Before we go to Chris, I'll just add one anecdote. I don't know whether people in the audience know about the ABCD study, which is a study that's being done in the US, the Adolescent Brain Cognitive Development. And recently, there was a publication that showed that the impact of substance use in general actually does not seem to manifest. Those individuals who initiate on substance use, kids who initiate on substance use, their brains are already different and they were already altered before they initiated. So the question now becomes is whether that leads them to initiate substance use. Now, specific data for nicotine use needs to be disentangled, but I think it was very, very informative. And I was just at the Alida meeting, and this was discussed extensively. So more to come on this.
56:09 - 60:21
[Christopher Russell]
Thank you very much. I am Christopher Russell. So we had pretty broad consensus over the first three statements. First of all, agreement that nicotine does not cause cancer. And several in our group were saying Several people pointed out that there's good, solid evidence that inhalation of smoke causes cancer, emphysema, COPD, and CVD, but there's no evidence, long-term evidence, that nicotine decoupled from smoke causes those outcomes. So, keenly discriminated between the actions of nicotine decoupled from smoke compared to nicotine delivered via smoke. The group was also careful to point out that there is some evidence that nicotine use can cause some short-term outcomes, have some acute effects, but those acute short-term effects don't necessarily translate into long-term disease outcomes. So again, being careful to say that, yes, nicotine can have certain effects that if they were to evolve and sustain could lead to the onset of disease, but that the evidence only supports that it has those short-term effects and doesn't lead to the long-term disease outcomes. When it comes to nicotine use can harm the baby if used during pregnancy or by nursing mothers, I think there was again general consensus that nicotine is a toxin and can have harmful effects. We sort of thought about this statement in the context of the advice to pregnant women who smoke, but also thinking about pregnant women who have never smoked and what would we say to them about nicotine. So acknowledging that there's a risk reduction that can come from switching from smoking to vaping, but that there would be some harmful effects to women who don't smoke or use nicotine in any form. And lastly to the statement, there's no direct evidence that long-term use of nicotine irreversibly damages the human brain. I think there was general consensus on this. I think there was a couple of abstentions, just purely not knowing the evidence well enough. And I think actually for all five statements, there were some people who, although we, from what we've heard and heard our colleagues speaking about, Some of us are not experts in the questions that are being addressed. And so we're going on trust of our colleagues, trust of certain reports and institutions that have said things. that's what our sort of agreement or abstention is based on here. We debated these five statements so heavily that we didn't get to the other five statements, so we may have a side discussion about those. But generally, there was consensus. One other interesting thing about the fourth statement about nicotine use can harm the baby, we pointed out that Whereas the first three statements were framed as nicotine does not do something. And then statement four was nicotine does something. And we debated what if we were to reformulate that statement as nicotine use is harmless for pregnant women. Would any of us feel comfortable in saying that? And I think the consensus there was we would not feel comfortable in saying that nicotine use was harmless for pregnant women. So ipso facto, nicotine use does have some harms. Yep, that was our thoughts on all of this.
60:22 - 61:05
[Mohamadi Sarkar]
Thank you very much. I know we are over time, but maybe we can open the floor for any comments or questions from the audience. The whole idea of this exercise was to raise awareness on the application of this methodology and hopefully, you know, you've seen that it's possible to implement it in a relatively easy format, just assemble a group of experts and you know, get them to have the conversation because that's what is missing is that people are not talking about this. You know, people have this preconceived notions that stays in their brains and nobody's kind of questioning that paradigm.
61:08 - 61:46
[Attendee]
Thanks, Mohamed. This was a great, great session. I think not to use the word bias here, but I think this exercise is so much colored by the people who are in the room. And I think if you get a different, the opposite set of people, WHO, tobacco control people, they would probably come to the exact opposite. So it's so important to bring different coloured people together with different opinions there, right? Because otherwise we would always have, this is our outcome, this is their outcome. We need to bring that together, right?
61:46 - 63:14
[Mohamadi Sarkar]
That's a great point. And which is why I think in order for us to successfully implement this, it would require us to inform people if we bring in an outside group of stakeholders, let's say healthcare providers, we need to provide them with the science and the evidence. For example, we did one kind of mini Delphi approach in our company where we had physicians and we gave them only one statement about what FDA says on its website. That in itself, had a profound influence in for them to pause and correct their responses that they'd given to the misperception question before. It's just that one statement. And it was not us saying, it was an FDA statement that says that e-cigarettes have significantly lower exposure than cigarettes. Not even about the risk, just reduction in exposure to harmful chemicals. So you're absolutely right. But I think, I hope that, you know, we all feel that, you know, we have some first-hand lived experience of how to use the Delphi approach. Now we are all experts on the Delphi methodology, and we can then find the oracle who is going to be sitting and making these decisions and getting them. You had a question?
63:15 - 64:23
[Attendee]
I'm just commenting because I'm a pulmonologist and I can see that this nicotine thing for the people, normal people or my patients, they think that the nicotine is the most big problem that they're facing. Actually, it's maybe the big problem in not knowing how to stop, how to quit. But actually, the main rising issue for any smoker is coughing, sputum production, COPD, wheezing chest, breathlessness. When the patient, this patient, is going to a tobacco-free or just a nicotine pouch or something like that, and just nicotine replacement therapy, in a few weeks, maybe a few months, he will lose all of these symptoms in a big way, actually on scientific basis, the pulmonary function test, six minute walk test and all that stuff. So that's my concept as a pulmonologist. That's what I mean.
64:25 - 64:38
[Mohamadi Sarkar]
Thank you. Thank you for keeping an open mind and coming to this conference. I'm going to ask Ariel and Pascal to make any final closing remarks before we let the group go.
64:40 - 65:04
[Pasquale Caponnetto]
Thank you for this opportunity and I hope that you will use this approach in your country with your colleagues because it is necessary to disseminate these messages in order to improve the quality of life of many people and to work in order to improve the health everywhere. Okay, thank you.
65:10 - 65:28
[Arielle Selya]
So when Mohamedy asked me to participate in this, I was not familiar with the Delphi method. I think it's really valuable, though. And we had a conversation about how everybody in this field pretty much knows that misperceptions are a problem. But what do we do about it? So I like the action-oriented solution here.
65:32 - 65:34
[Mohamadi Sarkar]
Thank you.