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Hear how a once skeptical drug policy advocate became convinced about the power of nicotine vapes to help make positive changes in the lives of the vulnerable.

David MacKintosh
Director Operations, Knowledge Action Change
Drug Policy, Tobacco Harm Reduction Advocate
Fmr. Chair of Trustees, Drug and Alcohol Services London


Hi, I'm Brent Stafford and welcome to another edition of RegWatch on GFN.TV.

While it's official, we are now just weeks away from the start of the 2023 Global Forum

on Nicotine in Warsaw, Poland.

RegWatch will of course be there, as will our next guest.

Joining us today is David MacKintosh, Director of Operations for Knowledge Action Change,

the organization responsible for the Global Forum on Nicotine.

David is a long-time campaigner for drug policy and treatment in the UK, where he served as

the Chair of Trustees for Drug and Alcohol Services London, a.k.a. DAZZLE.

David, it's great to have you back on the show.

Thanks for having me, Brent.

Well, I have to say, you quickly became one of our favorite guests when you gave RegWatch

an exclusive, impromptu tour of the Roman ruins underneath the city of London.

Let's take a quick look.

Here it is, the amphitheater that they accidentally discovered, really, back in 1988 when they

were building the foundations for the Art Gallery, which is above.

So, obviously, that's not the ideal thing you want to find when you're looking at a

new prestige building.

So this is actually Roman?

This is Roman.

The deal that was made was that this was made open to the public and preserved, and that

allowed agreement for the Art Gallery above to go ahead.

David, that really was quite amazing, and I think it says something about your position

in London to have that kind of access to such a special place.

How are you so wired in?

Well, I did work at the City of London for 19 years, and I was based in the Guildhall.

So yeah, it was a great place to work in many respects, not least that we had those Roman

ruins and, as something of a frustrated tour guide, I was always happy to take the opportunity

to show people around.

Let's talk a bit about your experience in drug policy and treatment.

I know that it's traversed a lot of levels.

Tell us about that.

Yeah, so I started off working at a national level in the Cabinet Office in the UK Anti-Drug

Coordination Unit at the end of the 1990s, and after a few years there, I went to work

at the London Drug and Alcohol Policy Forum, which was based at the Guildhall, where we


And yes, that involved me working with drugs and alcohol issues across the piece, from

law enforcement to treatment, young people, education, the whole shebang.

So what brought you into tobacco harm reduction?

Well, actually, it was my involvement with DAZL, and the chief executive of DAZL, persuaded

me that we should bid for some funding to undertake some smoking cessation work.

And I have to admit, I was very sceptical at the time, wasn't really sure it was what

we should be doing, where our focus was at, you know, we did drugs and we did alcohol


But I was persuaded, and actually, I'm very pleased that I was persuaded, because it actually

gave me an insight into a much neglected area.

The UK was on a fairly good track in terms of smoking prevalence at a population level


But, you know, there were pockets and there still are pockets where smoking rates are

fantastically high.

So, I mean, if we think, you know, UK prevalence rate is between 13 and 14 percent for the

adult population, there are some populations where the smoking rate is 60, 70, 80 percent

or higher. And drug users and people who have got serious alcohol problems are one of

those communities where you see very, very high prevalence rates.

So the immediate feedback from the people who were benefiting from the smoking cessation

work, which did include switching, was, you know, it was very powerful.

You know, people telling me how they felt good about themselves, how, you know, their

flat smelt better, their children were saying they smelt better, you know, very human

stuff, but with, you know, a great power, you know, and very important for people who,

you know, had some major challenges to overcome.

Now, those that are having problems with drugs, alcohol, maybe homeless too as well,

they're by definition really a majorly vulnerable group, right?

Sure. Yeah. And, you know, a lot of these populations overlap.

There's lots of people who are sleeping rough on the streets, will have drug or alcohol

problems, you know, and it's not a surprise that we see the high smoking rates in these

groups. I guess what we don't see is services being particularly well targeted at these

groups in terms of their smoking.

Do you see a lot of people who are well off or middle class professionals smoking in the

UK? No, I mean, we have, again, some statistics from our Office of National Statistics.

I think with people who have achieved a university degree or higher, we have less than six or

about six and a half percent smoking prevalence rate in that group.

If you look at people who leave school without any qualifications, it's just under 30

percent. You know, it's quite unusual to see people in, you know, the leafier, greener

suburbs of London.

It's quite remarkable, actually, if you see someone walking along smoking now.

It's not the same in the more economically deprived areas.

You will still regularly see people smoking.

Now, those areas, do you think they've become a bit invisible?

The smokers become invisible?

There is a bit of a visibility issue there.

I think it's actually probably quite a good expression.

Again, those areas often have many challenges, and I think the issue around smoking is one

of those that's often somewhat neglected.

These would often be areas where the local authorities and agencies would be hardest

pressed to come up with cash to fund services.

And I'm afraid smoking cessation or switching services have often been, you know, cut in

areas where there's been a shortage of money.

So, yeah, I think there's been a lack of focus for sure.

David, coming up this June 23rd at the Global Forum on Nicotine, 2023, is a panel

discussion that you're hosting titled Inequality of Access.

How do we achieve a level playing field?

This is in regard to increasing access to safer nicotine products.

In your mind, what are the biggest challenges to accessing these products, specifically to

vulnerable populations?

Well, I think one of the things I'm looking forward to in the panel is that we're going to

undoubtedly be touching on some of the issues we've spoken about, you know, homeless

populations, people in contact with the criminal justice system, people in prisons,

another area where we have very high smoking rates.

But we've also, if you like, got a global issue.

You know, there's 80 percent of the world's smokers live in lower and middle income

countries. Now, a lot of those countries don't have well-developed smoking cessation

services. A lot of those countries have very poor access to the safer nicotine products as

well. So, I mean, I think there is an issue that, you know, while there are challenges

around accessing safer nicotine products in a lot of the developed world, compared to the

issues of trying to access any kind of safer product in some of the developing world,

that's a huge problem.

And you can kind of see that that's going to mimic what we were just talking about.

You know, you're going to see big health improvements in the developed world, while in

lower and middle income countries, they're still going to be seeing terribly high and

avoidable rates of smoking related death and disease because, you know, the cigarette is

the unchallenged king there.

So I'm sure that's a topic that we will be touching on in that session.

Often we talk about the there's a litany of kind of issues.

You've got cost, you've got availability.

I think you put it perfectly, it's the three A's, appropriate, accessible and affordable.

Sure. A lot of people, I think, have been put off trying vapes by the initial outlay.

And particularly at one time, you know, you could easily have spent thirty five, forty

pounds on buying a starter kit.

Well, if, you know, at that time, a packet of cigarettes was ten pounds, you're probably

going to stick with spending the ten pounds for something, you know, works for you that

you like rather than perhaps spend forty pounds on something that might not work for you

and you won't like.

And I think, you know, that's a very real problem here.

I think, you know, the acceptability, there's a big cultural issue there, what people are

used to and what people see being used around them.

I think we've now, you know, probably got to a critical mass where there are enough

people vaping, but it probably does encourage some people to give it a go, you know,

because, you know, if it works for them, it might be worthwhile for me.

There is some evidence that a lot of people struggled with nicotine pouches because there

wasn't really any sort of culture about how to use them.

People would put another one in and another one in, which is not the way to obviously

get the most benefit out of using them.

So there are a lot of factors there.

Of course, something which will definitely come up in that session is, you know, in a lot

of places, you've got political barriers, you know, things are made illegal, which, you

know, it's very simplistic, but to me, it's a tragedy for safer nicotine products made

illegal. But everywhere you can buy cigarettes and, you know, that's something we really

do need to keep challenging people on about, you know, this makes no sense.

Whether you're in a lower or middle income country or you're on the streets in London,

right, it's much easier with a stick and a lighter than it is with a tank and a charger,

a bottle of liquid and all that complicated stuff.

Absolutely. You know, if you are, you don't even need to be sleeping on the streets, you

know, if you've got sort of insecure housing or all the kit and gizmos that I know lots

of our vaping colleagues like, but, you know, that's just not going to work for you.

You're not going to be able to say, well, I think I'll take this mod out today or, you

know, I'll try that juice tomorrow.

You're not in that world.

You're not in that world.

So, yeah, there are some very practical challenges there.

And I think for a group, which is often overlooked, I think, is it the older smoker?

You know, some of them aren't particularly keen on new technology.

And as I get older, I also start to understand more about the issues of

pains, not being quite as nimble and, you know,

subtle as they once were, supple as they once were.

So, you know, I think fiddling around, putting in juice, it's not it's not going to work

for everyone.

But of course, there are there are some some products are much simpler to use and, you

know, have proved quite successful with these groups.

Are you speaking of the controversial disposable juice?

Well, certainly disposables have some things going for them for some populations.

They're a lot cheaper.

You know, you know, if you can buy a disposable for four pounds, that's, you know, it's a

lot cheaper than buying a packet of cigarettes.

You know, people might might be more inclined to give it a go.

You know, if you're a smoker, you know, if you're a smoker, you know, if you're a

to give it a go.

And I'm sure for some people that would work and would be, you know, potentially a life

changing event.

So there are and for other populations, I mean, you know, we've seen in rough sleeping

accommodation, the use of not just disposables, but other quite simple bits of kit.

I'll mention jewel have worked quite well.

You know, they're simple to use.

They're not particularly fiddly.

That's a great attraction for a lot of people in a lot of settings.

So would you classify disposables as a boon for reaching this population?

I think they can be.


I mean, they clearly have advantages for some populations.

But if there are some genuine and understandable concerns around littering, and I can understand

some of the concerns that are raised around disposables, but it's nothing.

What's the expression?

We shouldn't chuck the baby out with the bathwater.

There are, you know, there's a lot we could do to improve recycling and, you know, concern

and, you know, concern about disposal was being bought by people under the age of 18


You know, they shouldn't be.

So there is, you know, the scope there to improve the regulation and the monitoring

of that.

But clearly, for some people, disposables are a great way to switch from smoking.

Let me ask you about priorities.

Should tobacco harm reduction even be considered as a priority when drug harm reduction seems

more immediately important?

As you mentioned earlier, trying to get somebody off of heroin, you know, if they're smoking,

why bug and nag them about smoking?

Opiates don't kill 50% of the people who use them.

Smoking is going to kill 50% or more of the people who smoke.

If we look amongst people who have been in contact with drug treatment, they have tremendously

high rates of things like chronic obstructive pulmonary disease.

You know, this is what kills a lot of them.

That's because of their smoking and, you know, general poor lifestyle.

But there's something we can do about the smoking element of that.

And, you know, we can do it.

And that could be smoking cessation or switching.

But when you start looking at these populations, you know, life expectancy for a rough sleeper

in London is around 45 years of age.

Now, a lot of, you know, that premature death is driven partly by their smoking.

So it should be a priority.

It's not about saying the smoking, you know, tobacco harm reduction is a bigger priority

than the drugs harm reduction or trying to get them into somewhere safe to spend the night

or looking at prisons, you know, trying to stop someone re-offend on release.

But it is a really important part of what we should and can do to help improve

that individual's outcomes and community outcomes as well.

You know, vaping and some of the other safer products are a very powerful additional part

of the arsenal.

You know, they give, you know, it's something else that people can try.

Something else people can feel, you know, it's worth giving it a go.

And you're right for people who have got a particular, you know,

strong desire to carry on using nicotine.

Well, hey, you can carry on using nicotine, but your health is still going to be dramatically


You mentioned earlier in the interview briefly that there has been some good positive response

from some of the clients in the programs that you've worked on.

Share that more detail.

Like what exactly happened, say, in the east side of London?

And what was the response from the clients?

I think, I mean, to be fair, a lot of the clients were probably quite sceptical themselves.

You know, they probably typically had several attempts at giving up.

They've got a lot else going on in their life.

They're going to be focused on trying to overcome their drug or alcohol problem.

And there was a couple of strands to the work.

You know, there was a sort of classic bit.

And this had an impact as well.

Try to get people to realize and see the benefits economically, you know.

So put the money at one side.

And I think sometimes that works particularly well with some of these groups, because these

are people who really do understand the value of a £10 note.

You know, if they saved £10 or £20 over the course of the week, that's a big deal.

You know, that's maybe a treat for them, a family treat.

I think for a lot of them, it was how they felt better in their lives.

And, you know, I think I mentioned, you know, my clothes don't smell.

Where I live doesn't smell.

And, you know, they're very powerful.

My kids say, you know, I smell better.

The flat smells better.

You know, these are huge, huge factors when people are trying to improve their lives.

And one of the, I think, great things about this is it's quite quick.

You know, it's not sort of saying, well, let's see where you are in six months, 12

months, 18 months.

You know, this is demonstrable progress in very real time.

And I think that's what gave me people had a real sense of agency and pride.

You know, I've done this.

I'm feeling much better.

And from the agency point of view, it also helped us because I was very used to walking

up to the front of the service and you'd see quite a lot of our clients sitting on the

wall outside smoking.

And there was a visible reduction in that.

And that used to be one of the bugbears with some of the people who lived, you know, our

neighbours, the residents who lived in that area.

So they were very pleased as well.

But, you know, it was that pride.

And I've done this.

It's in some ways very hard to calculate the value of it, but it's certainly very


Well, and it's something that, as you said, is quick.

It can be quick.

So that's for somebody who's probably not felt that kind of an accomplishment before

when it comes to kind of mastering their will, when it comes to using a substance like

that, that's got to have positive impact in the other areas that they're fighting.

I'm sure.

Yeah, absolutely.

But these were people are people who are quite motivated.

You know, they're engaging with treatment, you know, and they are keen.

But, you know, it was a great success.

I went from being sceptical.

I was delighted to be proved wrong quite quickly.

David, I want to return back to disposables for a second, because I know there's more

to that story around the positive impact that disposables may have had for clients during


Tell us about that.


So I was involved in a very small way with the response to getting our rough sleepers


It was called Everybody In at the start of the COVID epidemic in London.

Now, it was quite a remarkable time, actually, because in the space of a very few short weeks,

there's something like 1400 people were taken off the streets of London and found

secure, safe accommodation, shouldn't say secure, not prison, safe accommodation within


Now, a lot of these people had drug issues, alcohol issues, as we've already said, majority

of them smoked.

There's a pandemic.

We don't want people mixing.

We don't want people going out on the street to smoke.

What are we going to do?

Other things were put in place to deal with people's drug issues and the alcohol issues.

And smoking, suddenly we had this, well, what can we do?

Well, let's see what products we can get hold of.

And yeah, things like Jool worked very well.

You know, people did give them a go.

There was some training for the staff working in the hotels.

There were some people who were going in to work with the residents who'd explain how

to use things.

And I think we were all quite pleasantly surprised at the uptake, the positive response.

I mean, you know, people knew it was going to be very difficult to smoke.

They risked getting thrown out of the accommodation if they smoked.

So actually, in a way, the provision of those products did help make that scheme a success.

It was, there was a lot of harm reduction across a range of issues done very quickly.

But there was some great clinical support.

Some people probably deserve medals for the work they did.

And, you know, some people were really surprised.

I mean, you know, I was involved in a small way, say, with some of the commissioning and

people going, this is going to be a disaster.

You know, we're going to, there were some problems.

Some people did still get thrown out for smoking.

But for the vast majority of people, it worked very well, actually.

To me, I think that says something about just the power of safer nicotine products to

replace tobacco when you can take a vulnerable population that does, you know, their use

is a bit rough, you know?



I mean, yes, a lot of these people, you know, would have been smoking cigarette butts left

by other people.

I mean, that was that population.

I think there's a whole heap of learning.

I think it probably worked better because people were in, by and large, quite nice accommodation

compared to what they were used to.

And I'm sure that that helped.

And I say there was a whole suite of support available.

But, you know, the fact is, it worked very, very well.

And we had far less problems than we were expecting.

Did the anti-vaping campaigners get their, you know, knickers in a knot over that?

I think because it was sort of an emergency situation.

And it all happened so quickly.

I mean, it was, you know, it was a very demanding, very rapid period of work.

There really wasn't much opposition to it.

And, you know, I think it's very difficult to insist, well, all these people who've been

smoking for, you know, the very worst, heaviest smokers, we'll just tell them to stop.

It's, you know, I don't think there's actually that many people who would have thought there

was a lot of alternatives, to be honest.

And it's, I'm sure afterwards, there's a lot of people who shouldn't have done that.

But I think it was, you know, it wasn't a planned experiment at all.

But I think it actually has had some positive effects in that lots of the agencies who work

with these populations have seen it.

Oh, actually, that does work.

These people will switch if we can support them, or some of them will switch if we can

support them.

I'm quite, in quite a short period of time, really, you know, some of this work has become

quite mainstream with the agencies that work with homeless people.

David, as mentioned, you will be hosting a panel titled Inequality of Access.

How do we achieve a level playing field?

At the Global Forum on Nicotine, the annual conference on safer nicotine products and

tobacco harm reduction.

GFN 2023 starts on June 21st and runs to the 24th.

If you can't attend, you can watch online.

Please go to to register.

David, final question for you.

Let me ask you, why is an event like GFN important?

I had the opportunity to first go to GFN before I'd really got properly involved in

tobacco harm reduction to an extent, but I wanted to find out a little bit more and I

was incredibly naive about a lot of the kit and products that were available.

And I think one of the things that first struck me and stays with me about GFN is the energy.

It's not just a conference.

There's a slight hint of a festival about it in that there's a lot of people sharing


There's a lot of positivity despite the challenges.

And I have no doubt this year people will be coming against some of the obstacles that

we face in trying to deliver tobacco harm reduction.

But it's the range of information that you can get at GFN.

You know, for someone like me who hasn't got a science background, you know, it's always

interesting to hear the scientists.

I'm very much looking forward to the session on the potential therapeutic uses of nicotine

in connection with brain disorders.

It's obviously a huge, huge issue, particularly where we've got an ageing population.

But GFN is very good, I think, addressing the major issues and actually helping people

to come together to help overcome them.

So yeah, part conference, part festival.