A massive opportunity to reduce smoking-related death is being squandered. In this episode of GFN Interviews, cardiometabolic physician Dr. Rohan Sequeira examines how public health distorts the public’s understanding of nicotine and risk. With South Asia bearing an enormous tobacco burden, he explains why traditional cessation approaches are failing, why safer nicotine products matter, and how misinformation continues to block harm reduction.
Transcription:
00:02 - 01:16
[Brent Stafford]
Hi, I'm Brent Stafford and welcome to another edition of RegWatch on GFN.tv. Tobacco remains one of the deadliest consumer products ever sold, driving heart disease, stroke, cancer, and metabolic disease at massive scale. Yet the public understanding of nicotine and risk has been profoundly distorted. Misinformation has collapsed the distinction between smoke and nicotine, treating all products as equally dangerous. When misinformation replaces medical evidence, smokers lose access to safer alternatives, and the most lethal products remain untouched. Joining us today to discuss the evidence is Dr. Rohan Sequeira. Rohan is a cardiometabolic physician based in India with a career spanning over 25 years in more than five countries. Dr. Sequeira, thanks for coming on the show. Thank you so much, Brent. It's a pleasure to be here with you. Well, let's start with the damage caused by combustible tobacco. As a cardiometabolic physician, what have you seen in your practice and how serious is the damage?
01:17 - 02:35
[Rohan Sequeira]
That's a very good question. I'd like to break it up into two parts. First, what is the damage caused by tobacco, different kinds of tobacco, especially the smoke and the smokeless kind? Well, we all know that the smoked tobacco has got more than 7,500 chemicals in it, of which nearly 3,500 of them have had a direct relationship to causation of metabolic disease, cancers, cardiovascular disease, and also multiple other lung conditions in the world. When you look at the smokeless tobaccos, you have a very high incidence of oral cancers. You have all the issues with your mouth. You have issues with your teeth. And also to some extent with the esophagus, because people swallow the tobacco fluid and that causes some issues over there. But that being said, we have known for decades and I would say even centuries that tobacco in any form is harmful for human consumption. It has got negative effects. People smoke for the nicotine and they get the side effects of all the other causes of tobacco, which causes all the medical issues that we face today. So I think we have a very clear understanding. There's no doubt about it that tobacco kills. And that is something which people know.
02:35 - 02:48
[Brent Stafford]
Now, this obviously is serious business, isn't it? We had this interview scheduled the day before, but because of an emergency surgery you had to do, we had to postpone it to today. Tell us about that case.
02:49 - 04:27
[Rohan Sequeira]
Yeah, it's a very interesting thing last night. I'm really sorry for canceling the interview a couple of nights ago, but during the time we got a call that a young man who, this is the third time this has happened actually. So a young man was scheduled for cardiac surgery today actually, but he came in last night with incessant chest pain and he wasn't able to breathe. And we did a CD coronary angiogram for him about a couple of weeks ago. This guy, this young guy, he's just about 34 years old, works in an ID company. And because of work in the IT company and peer pressure and a lot of other things, he was practically smoking about three packets of cigarette a day for the last 10 years. Now, that's phenomenal. But I mean, it's crazy. That's a lot of cigarettes a day. But at 33, 34, we detected him with multiple cardiovascular blockages in his heart. He had all his arteries were clogged. When we did the angiogram for him, we found that he had about 14 blockages in his three arteries. And that is a lot of blockages. And while we were prepping him up for surgery and all the other things which we were doing to get him on the table and all of that, I was really flabbergasted by the question he asked me while he was on the table. And he asked me, Doc, once the surgery is over, when can I smoke? And my anesthetist and me are just looking at each other and we were like, what's wrong with this guy? He's got 14 blockages at 34 going in for a surgery. And his only question to me is not whether I'll live or die, but when can I smoke? This is where we are dealing with addiction and the negative effects of smoking.
04:28 - 04:34
[Brent Stafford]
You're unable to recommend safer nicotine products to that patient, aren't you?
04:35 - 05:51
[Rohan Sequeira]
Right now in South Asia, especially with regards to India, Pakistan, Sri Lanka, and Bangladesh, this is the zone which we live in, the demographic zone that we live in, the geographical zone that we live in. It has 80% of the world's smokeless tobacco users. And we have a very high percentage of people who also smoke. Now, considering the population-based metrics that if you go onto any Google search, you'll find out that we have about 250 million tobacco users in India alone. That's more than half the population of the United States. And of these 250 million tobacco users, 200 million plus are smokeless tobacco and about 40 to 50 million users are of the smoked tobacco. Now, we also live in the zone where we have the world's largest number of oral cancers. 60 to 70% of the global oral cancers are in this region. So I would say that we are in the epicenter of tobacco harm that is happening. And we see this every day. Every day there are patients walking in with some effect or the other medically with regards to tobacco usage.
05:51 - 06:03
[Brent Stafford]
And I think it's important to be clear about the smokeless tobacco. We're not talking about nicotine pouches and snooze. We're talking about something that's drastic. Why don't you fill us in on that?
06:03 - 07:36
[Rohan Sequeira]
We have more than 25 different varieties of smokeless tobacco in India. The age of initiation of smokeless tobacco can be as young as 13 years old. Kids as young as 13 year olds can walk up to a tobacco shop and just pick up a pouch of tobacco. They use it in very different kinds over here. We have about 25 different ways in which they can be used. I'll just give you an example of how carcinogenic some of these methods are. One method, which is the most common, is they take raw tobacco, which is dried of course, and then they mix it with a little bit of calcium hydroxide. Calcium hydroxide, as we know, is an alkali. If you just leave it on your skin long enough, it can burn the skin off in large quantities. But you're actually putting it in a very soft, tender area of your mouth and keeping it there for hours on end. That's one method. The other method is using it, using tobacco with betel nut. Betel nut is another fruit, which is the nut of a fruit which grows in this area of the world. And it's got multiple alkaloids which have been proven to cause cancer. So you're not using one product. You're using two or three different products which have the potential to cause cancer, to cause cardiac disease, to cause cholesterol levels to go up, and all of these other issues. So people are using all of these methods to give them a delivery method for tobacco, but they're getting the raw end of the deal by using other products to use along with this. So the impact is not just tobacco. It's around it also.
07:37 - 07:44
[Brent Stafford]
So how medically important is it that people stop smoking or using those toxic forms of oral tobacco?
07:44 - 09:25
[Rohan Sequeira]
Every doctor, worth his salt, doesn't matter which medical school he went to, knows for a fact that tobacco kills. There's no doctor on this planet, whether he's in any part of the world, whether he's in the US or he's in Europe or he's in Africa or he's in India or even the remotest village of any country anywhere in the world knows that tobacco causes cancer, tobacco causes heart disease, tobacco causes all forms of medical issues that we know. it is absolutely imperative that there has to be a very strong messaging that a product that kills 8 million of its users every year needs to be looked at from a fresh perspective forget your politics forget the you know all the other financial things that you look at look at the healthcare burden And this needs to be addressed yesterday. There is no direct connection between nicotine and cancer as of today. The Cochrane reviews, if you go to a PubMed search, you'll find, of course, you'll find always find two sides of the coin. But as of today, as of 2026, 22nd of January 2026, there is no direct causality between nicotine and cancer. Yes, with regards to the heart, it does cause your heart rate to go up. It does cause you a little bit of vasodilation. A little bit of cognitive issues can happen in the brain, but then that happens with everything. So, you know, I think there has to be a very, very deep thinking process as to where we want to go in the next 10 years from here with regards to tobacco control, because it's not going to just get up and disappear.
09:25 - 09:37
[Brent Stafford]
So obviously we've heard that, you know, nicotine causes cancer. We hear that from tobacco control, public health. We hear that from the World Health Organization. How can they get away with saying that?
09:38 - 10:56
[Rohan Sequeira]
The funny part is when they say it, they do not give any statistics. They do not give any data on which they base their statement. There is no reference. Which reference article are they trying to use? You know, because as doctors, we always have something called this evidence-based medicine. Where is the evidence? Let's see the evidence. If you're saying that all of this, if nicotine kills, where is the evidence? Provide the evidence. They haven't done that so far, right? They're just making innuendos that tobacco kills, and they're using that same parallel to talk about nicotine, assuming both of them are the same thing. Unfortunately, nicotine is an extract from, is a product in tobacco, but there are other things in tobacco which can, you have trans nitrosamines, you have carbon monoxide, you have all the cancer causing chemicals which are released from nicotine, but yet they won't say anything about cutting down on the sale of cigarettes. They'll just talk about taxes. They'll talk about public messaging. Have they ever penalized the country or anyone in the world when they said they're going to sell tobacco? No. So it's a duality of their approach. On one side, they're saying, let's sell tobacco. On the other side, they're saying, let's not allow nicotine, safer nicotine products. So it doesn't make sense.
10:56 - 11:09
[Brent Stafford]
As a physician, Dr. Sequeira, you were trained, as most doctors are, to prioritize abstinence and complete cessation. So in your experience, how well has that actually worked out for long term smokers?
11:10 - 15:21
[Rohan Sequeira]
It's a very interesting question you asked me. In fact, I'm reminded of one of my friend's research in the New England Journal of Medicine, where he actually spoke and he identified a gene in human beings. that controls addiction. And it's very interesting. It's a very interesting read. Our addictions are also genetically controlled. There are some people who can give up cold turkey because they have the gene. You know, and there are some people who just cannot give up addiction in any form, whether it's food, whether it's tobacco, whether it's coffee or whether it's tea or whatever, whatever makes them happy. So even addiction to give it up, there is a genetic sequence. Now, not everybody can just stand up tomorrow and say, oh, I'm just going to quit tobacco altogether. Right. But it's very important for as a medical doctor, I would I would categorically state the best situation to be in would be to give it up completely. that would be the ideal that would be utopia that would be medical utopia people just give up smoking altogether right but that's never happened it's not happening and it's never ever going to happen now here is what we call as the bait the switch and bait method right i know it's a very funny terminology it's used mostly in marketing but your view using it in a positive connotation We are switching them to a safer product and allowing them to continue with their nicotine usage. But there's a caveat over here. Nicotine, safer nicotine products are the only proven method to gradually reduce your nicotine usage over a period of time. I have tons of patients. Of course, it's illegal to be prescribed products like THR in India because it's illegal, by the way, but my patients do manage to find them somewhere in the market. It's a big gray market, black market, call it whatever shades, 50 shades of gray, but it's available, right? When you ban something, it's going to be available somewhere or the other. And what I've noticed, I can cite you so many examples. I'll give you an example of one single patient of mine. He was smoking about three to four packets of cigarettes a day because of his stress and everything. I casually mentioned THR to him and he was heavily addicted on nicotine. And this young guy, he's about 40 years old. He works as an HR head. And I started him on nicotine. He purchased an electronic cigarette before the ban came in. This was before the ban in 2019. He purchased an electronic cigarette. He went completely gaga over it. And the funny thing is we started him on 24 milligrams of nicotine. And over six years, I brought him down to zero milligrams of nicotine. He was just vaping polyethylene glycol, PG and VG. At the end of six to eight years, this guy was completely nicotine free. And he was one guy who was doing more than three to four packets of cigarettes a day. So here is an opportunity for physicians to understand that thr can provide you a de-escalation strategy for patients who are addicted to nicotine over a period of time nicotine gums nicotine patches never work the success ratio internationally global success ratios for nicotine gums and nicotine patches has always been between five to seven percent that means for every hundred patients only five would be able to give up 95% would relapse back into smoking tobacco. So this is a very strong message that needs to be, you know, propagated to medical personnel that there is a method in which you can deescalate nicotine addiction. So you're convinced that these products work? Very much. I'm very much convinced that harm reduction products work. And that's the reason why, you know, in spite of all the negative, you know, snidey remarks that we get at medical conferences, when I do try to push in, you know, nicotine replacement and THR products in my medical talks, people come up and say, you know, you shouldn't be talking about that. But, you know, that's the thrill of it, you know, because I'm definitely convinced about it.
15:22 - 15:32
[Brent Stafford]
Dr. Sequeira, you've been involved in tobacco harm reduction advocacy for some time now. What has been the most damaging message pushed by tobacco control?
15:34 - 16:02
[Rohan Sequeira]
The most damaging message that tobacco control has pushed forward is nicotine causes cancer. And that is the single most damaging damaging statement that has deprived hundreds, if not thousands, if not millions of people from the right to choose a safer product that could have given them the benefit of medical benefits.
16:02 - 16:08
[Brent Stafford]
How is it that the medical community seems to be so off when it comes to this information?
16:08 - 17:59
[Rohan Sequeira]
I spend a lot of time discussing this, debating this with my friends who are medical colleagues, and a lot of this boils down to perceptions. We have always grown up with perceptions that certain things are bad and certain things are good. And what doesn't help this open up avenues for doctors to look at it positively is this incessant international pressure that nicotine and tobacco are one and the same thing. And that's been a very strong messaging coming from across the globe. There are some philanthropic organizations like Bloomberg and there are many other organizations that have actively used this as a platform to get THR products not recognized globally. And that's really painful because, you know, if doctors were, because doctors are the people, doctors are the, you know, the last resort people go to when they have a medical problem. They go, hey, doc, you know, I've got a nicotine problem, I've got heart disease, I've got diabetes, I've got cholesterol, you know, I'm going to get my foot cut off. What do I do? He's going to tell you, just stop smoking nicotine. Just stop smoking tobacco. But then if you talk to him and say, why don't you use a THR product, which gives you the same thing without all the side effects? Say, no, no, no, they're all one and the same thing. And that's really, really sad. Because all of these people... One of the main things which tobacco causes is also occlusion of the arteries and the veins in the leg. I mean, you can get certain issues where you get blockages. People have lost their feet because of tobacco. Now, in this kind of an individual, you're going to tell him just to stop. He's going to do that for a month, maybe 10 days, 15 days. But when that issue hits him, when the psychological issue hits him, when he gets that need or that urge, which is triggered by his dopamine need, he's going to go back to a cigarette. And then you have that whole cycle once again.
18:00 - 18:30
[Brent Stafford]
Well, and what we've seen in our coverage and heard from many people involved with THR products is that in some cases, it can reverse some of the damage that's been caused by decades of smoking. I know that Dr. Peloso's work out of Italy has shown that. I mean, so what about that? I mean, we know that millions of smokers have switched to safer nicotine products. So doesn't it run against medical ethics to deny harm reduction options to patients?
18:31 - 20:06
[Rohan Sequeira]
It does it very, very strongly. It does. And what you said really makes a lot of sense to a lot of people who are going to be listening to this. And when you spoke about reversal of some of the effects, there is a molecular reason why this happens. And it's very important that you know a little bit about the science. I'll try to share it in layman terminology so people don't get confused. But when you start smoking or using products like tobacco and all of that, People who tend to get diabetes, heart disease, cholesterol issues, and all of these strokes for that matter of fact, or blockages in the arteries, they have a condition called as a pre-inflammatory state. Most of these people, if you check their inflammatory markers in their body, they have inflamed. They have some form of inflammation in their body which is going on somewhere. Now, when this kind of an individual in a pre-inflammatory state is smoking or using tobacco, it accelerates the inflammation. Now, whenever there is inflammation, your body is not going to be healing. And when you reduce the inflammatory agonists or things which cause inflammation, you're allowing your body's immune system to get activated. And that goes ahead and causes some of the healing processes that the body really needs. And there is a reversal. We have found patients who have had high cholesterol levels, stop smoking and using NRTs or using vapes or using tobacco pouches. Suddenly, all of a sudden coming down, the cholesterol level comes down without any active medical intervention. Unfortunately, in my part of the world, even research in THR products is banned.
20:07 - 20:15
[Brent Stafford]
How much of an impact did Bloomberg and his NGOs have in India fostering this 2019 vape ban?
20:16 - 22:36
[Rohan Sequeira]
So I have no direct data about this, but a lot of information has been floating around that there have been direct involvements. For example, the campaign for tobacco-free kids has been directly implicated with funds which have come in from Bloomberg and organizations. I do not have the data yet, but I know that there are people whom I trust who have spoken to me about this. And there have been direct involvements of agencies like these, which have been trying to propagate the ban in 2019, right? Now, if you look at it from a different point of view, India was in a fantastic situation to turn around a lot of lives. And I do understand, I definitely do understand the reasons why they, because I went through the ICMR report, the Indian Council of Medical Research, I went through the report and I do understand the reasons why they went with a ban overnight, but there should have been a clause where they said, let's revisit this at a later date to see how we can implement this effectively. And one of the reasons why the ban came into place was electronic cigarettes were widespread being sold everywhere without any age ID, without any requirements, without anyone proving their age. And unfortunately, you know, kids like to experiment. A lot of young kids just saw this as the next to-do thing. It was Instagrammable and a lot of things were happening around that. So I do understand the government was very concerned about young kids getting into e-cigarettes or whatever it is. And I would be completely against that either. But... there is the other 200 million people who used oral tobacco. And that, I think, needs a very positive approach from governments in this area, because kids do not get attracted by pouches in the mouth, right? It's not something they consider cool, you know? Hey, look at me, you know, I have a pouch in my mouth. But when you have vapor coming out, hey, look, I feel cool. You know, the old 1970s ads, people standing with cigarettes like the Fonz and all of that, you know how it was. But the impact here, from a healthcare point of view, is the oral tobacco users. And I think nicotine pouches should be looked at very, very positively because that for all of us right here in this country is the low hanging fruit that we can actually address.
22:37 - 22:52
[Brent Stafford]
Well, considering the message that's out there in the media that's pushed by tobacco control and major public health organizations like the WHO, is it just a simple matter of them being misinformed or are they lying?
22:53 - 23:33
[Rohan Sequeira]
Oh, they're definitely informed. They're definitely, if anything, they're anything but misinformed. They know the facts. They know everything. They know it. That's why we have so many THR advocates now who are ex-WHO. We have people who cannot sleep with the fact that they're talking a lie that they have now switched over. And they've now started talking on THR and how it benefits them. They're the ones who are pointing out loopholes in the WHO policy now. And the WHO is all up in arms because they don't know how to stop these people because they were one of them and now they're one of us. So, you know, it always reminds me that truth should set you free, but it's taking its time, but it is working out there.
23:34 - 23:51
[Brent Stafford]
Rohanda, WHO's Framework Convention on Tobacco Control just held its COP11 in Geneva, and you were there to attend the Taxpayers Protection Alliance's Good COP 2.0. What did you take away? What did you think of the FCTC, and what are your thoughts on Good COP 2.0?
23:53 - 25:05
[Rohan Sequeira]
The most wonderful thing that I took back from the FCTC was there are still some countries with a spine who have the ability to speak to the WHO and tell the WHO that we will decide what's right for our people. We are convinced of the facts that tobacco harm reduction is better for our citizens. We are convinced that tobacco harm reduction brings medical benefits, if not benefits, at least prevents patients from getting into serious medical problems. Every life on every citizen of our country is important to us, and we do not want to listen to a wrong narrative that you're giving us. That's the reason why New Zealand got the Dirty Astray Award. That's the reason last year Philippines got the Dirty Astray Award. And that's the reason why this year at the COP meeting in Geneva, there was a whole group of countries which actually tried to get the issues tabled with regards to THR, tobacco harm reduction. So the ball has started rolling. It started to gather moss. And it will take some time before that momentum causes all the others to see where we are heading with this thing.
25:07 - 25:34
[Brent Stafford]
Dr. Sequeira, the 13th edition of the Global Forum on Nicotine, the annual conference on safer nicotine products and tobacco harm reduction, takes place again this year in Warsaw, Poland, from June 3 to 5, 2026. The conference theme is Prohibition and Public Health. In your mind, what are some solutions to address how prohibitionist thinking has come to dominate public health policy around nicotine?
25:34 - 27:30
[Rohan Sequeira]
The entire prohibitionist and the negative regulation has been built around one single theme point and that theme point is tobacco and nicotine are the same and i think one of the ways in which we can look at it at the gfn this year is try to come out with a strategy for medical harm reduction advocates i'm not talking about those when regulation or those because i'm a doctor so i'm going to look at it from a medical point of view you know it doesn't make sense to me look at that side but from medical point of view something which i found to be really effective among my peers and my colleagues is providing them the right medical evidence and saying, see, this is where, you know, the research talks about nicotine not causing cancer. And I've had friends who are hardcore anti-tobacco, you know, speakers, when they heard what I had to say with them and they listened to it from a very open mind, it's like, dude, I was wrong. I mean, you know, THR is got something. And then they went back and started reading and now they converse with me. So the messaging which I would like to give the GFN is to come up with a strategy where advocates can reach out to local doctors and in the medical community and try to disprove these myths, kind of like a literacy campaign. two medical professionals that look this is where you got your information from we'd like you to look at the other side of the coin the problem is most of the doctors i mean you could talk to your own family physician he would not know much about nicotine because that's not something they read but when they want to oppose tobacco, everybody wants to look like a hero. Say, no, no, we don't want tobacco, right? And at the same time, they say, we don't want nicotine. But if they have the truth about nicotine, if they have the truth about how difficult it is to give over an addiction, they'll understand why THR has its place in medical science.
27:31 - 27:37
[Brent Stafford]
And finally, what would you say to all those harm reduction advocates out there who are worn down by this fight?
27:40 - 29:04
[Rohan Sequeira]
I remember I spoke about this at the TPA meeting and I said, you know, it's like we always say, sometimes I like to use this analogy from Star Trek and say, we are the Borg, you will be assimilated. So it's, I mean, of course the Borg lost, but I like to use the line from there. At certain points of time, you are going to find that fighting this kind of a fight is going to be very difficult, very hard. very morally downgrading because you will be ridiculed. People will talk about all of these things and say all of that. And even though I'm not a very religious person, I like to give a religious analogy to this. And I try to say to my friends who are in THR and who feel very down, nothing's happening. They're stuck. We've hit a hard line. We've hit a wall. There's nothing happening, I always say. Well, THR advocates are like the 12 apostles. They got persecuted, they got hung up, crucified upside down and everything, but in the end, it just took an interpersonal relationship and continued doing what they did because they believed in it, right? And the same way as THR advocates, we have the belief, we have the science, we have the evidence. Don't give up. It's going to happen. It's right around the corner. You never know when it's going to happen. But the darkest night is just before the dawn. So just keep fighting there.