GFN 2024 Keynote #1 - delivered by Andrzej Fal, response by Michelle Minton - titled "Health and economic benefits of tobacco harm reduction".
- What does the current evidence tell us about the potential health and economic benefits of safer nicotine products? - How should we weight this evidence? - What more do we need to know, what is the prognosis for the future and what are the short and long-term costs of different policy alternatives? - How might legislators and regulators balance health and economic imperatives to achieve positive outcomes? - What factors might make for an effective legislative and regulatory framework? - How should future progress be monitored, and policies adjusted in response?
Keynote #1 is also available in Spanish and Russian:
Spanish: https://youtu.be/hiaqJX4pGmQ
Russian: https://youtu.be/cWAq8Sw9D2I
Transcription:
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Grzegorz Król: And now on to our first keynote. Your speaker is Polish professor Andrzej Fal, the head of the Department of Allergology, Pulmonary Diseases, and Internal Medicine at the Central Hospital in Warsaw. He will discuss the health, and economic benefits of tobacco harm reduction. He will then be joined on the stage by a respondent from the United States, Michelle Minton, a senior policy analyst at the Reason Foundation. Please join me in welcoming Professor Fall to the stage.
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Andrzej Fal: Good morning, everyone. Thank you for this kind introduction. I'm really glad and honored to give this keynote of this morning. Well, we've been discussing the weather outside, and I think it's perfect for a Congress because it's nice weather, but it's not too nice so that most of you chose to come in here instead of visiting the beautiful Warsaw. But the time will come also for the second part. So, uh, Well, bad habits, lifestyle, bad lifestyle is something that bothers us recently in the past years became the leading cause of illnesses, diseases and death, especially in the so-called developed countries. So let me focus this morning on the three words that are in the running title of the conference. So this is economics. health and harm reduction. Well, actually it's four words, but three expressions. It's been well understood, and we still tend to say that the wealthier we are, the longer we live. Well, which maybe is the case when we look at this graph. We see that there is some correspondence between the amount spent on health or the amount earned by the citizens and their longevity. So the more you earn, the longer you live. But as you may also notice, this line, it's not a 45 degree angle line. So it's not a simple proportion between spending and well living or healthy living. Well, if we went back Two centuries ago, the proportion would be closer to this ideal, but still not in point. Why is that? It's very simple. Because there were always wars and plagues. And these cannot be calculated in statistics. And now we have still the NCDs. The NCDs, we all know what they are. but we need to repeat it loud, loud, and louder because most people do not know, do not understand what NCDs are. And NCDs are the non-communicable diseases. In the past four years, we've been focused on the communicable diseases, especially COVID pandemics. But still, for the COVID pandemics, the total absolute death count was around 7 million, let's say. Well, it's a huge amount. But yearly, around the world, due to these five groups of non-communicable diseases, which are cardiovascular diseases, chronic respiratory, cancers, well, whatever cancer, starting with stomach, ending with breast, diabetes, or metabolic diseases, and mental disorders, for these five reasons, 41 million people die prematurely. So they die much earlier than they would have if they were not sick with these diseases. So 7 million in the pandemics versus 41 million every single year dying for non-communicable diseases. This shows the scale of the problem we're facing. Especially when you look at the distribution. Of course, well, the huge numbers of people dying because of non-communicable diseases, these are the low- to middle-income countries. But when we look at the percentage in the high-income and upper-middle-income countries, this percentage, maybe the numbers are lower, but the percentage is 90% to 95% pre-major deaths are caused by non-communicable diseases. So if not these diseases, we would live probably 20 or 25 years longer. Because all the other standards, including living standards, medical standards, are high enough to support us up to 120. And we're losing this extra 25, 30 years because of the non-communicable diseases. Well, and the diseases, well, they have their causes. As I mentioned, it's our unhealthy lifestyle. Risk factors. Every single disease has its risk factors. And somewhere in the middle of the 20th century, the risk factors, the predominant risk factors in the world have changed. The old risk factors that we were once used to, well, they're still present, but they're present in sub-Saharan Africa. They're present in some... not wealthy parts of Southern America or Asia, but they're not very important, I mean, socially very important in Europe or in Northern America. So these are under-nutrition, indoor air pollution, pure water, sanitation, and so on and so forth. Instead, we have the civilization risk factor. Well, inactivity leading to overweight, tobacco, excessive drinking, Well, these are the risk factors of today. When we look at the risk factors, the most important risk factors of today, please pay attention that tobacco accounts for over 8 million premature deaths around the world yearly. So every year, because of smoking cigarettes, 8 million people die. Well, the important message here is that more than one million of them never smoked, so they died because of second-hand smoking. This is the only case where not having a bad habit may cause you to die because some people around you were doing something unhealthy. Well, then we have 7 million dying because of indoor and outdoor air pollution, 5 million almost because of excessive drinking, 3 or 3.5 million for junk food and lack of physical activity. Well, when we divide it into the five groups of diseases I've already talked about, we see that really the leader is CVD, so cardiovascular diseases, but there's plenty of other illnesses or diseases in this group that are really bound to especially the two leaders, so tobacco and air pollution, of the contemporary risk factors. So the approach suggested many years ago and still active is the five by five approach. So we have five leading groups of diseases and five leading risk factors. I've already named all of them for the sake of today's discussion. and today's keynote, I'll focus on tobacco use because it's also a very special one. Because, well, it's the biggest killer, as I said, of 8 million lives a year. This is the toll we pay. It does kill also non-smokers. So not only smokers are endangered, And the addictive substance is not the major harmful part because, well, in alcohol, when you drink alcohol, the more alcohol you drink, well, the sicker you potentially can become because this is the same substance, the one that's addictive and the one that does harm to your organism. And, well, smoking cigarettes you have a little bit different, even though smoking cigarettes is a major risk factor in all the diseases I already listed, but because the addictive substance, nicotine, is not the one that actually poses the biggest health threat. Of course, it does pose health threat. It's called health threat as a decrease in myocardial oxygenation, while leading to sudden cardiac death. It's being arithmogenic. Well, all the smokers know that when lit and smoke two cigarettes very fast, they have tachycardia. They can produce arrhythmias of different kind. So, well, of course, this is a bad thing, but much worse things are those that are long-term acting, and this is the tar, these are the... These are the substances that we still come today many times back to because we know at least 7,000 of them, 92 being defined as cancer organic substances. And it's a very simple thing that is being overlooked, not by the audience of this room, but by many decision makers, by many politicians, even by many, forgive me to say, public health specialists. I'm a president of the Polish Society for Public Health, and we spread the news, and not everybody wants to agree with us, that replacing something that's really bad with something that is bad... Well, it's a good idea if we cannot make people resign. And forgive me for saying so, but I do not remember in the history of mankind, of the homo sapiens history, any culture that wasn't smoking, puffing, sucking, whatever they've been calling it. But, well, we've been always drinking something and smoking something. And I'm... I'm not quite sure that we can stop doing that. So that's why harm reduction are the words that will go with us forever. The problem only is that the reduction of harm can be made only in those who will make harm to themselves. We cannot introduce harm reduction in those who do not harm themselves by definition. So when we look at the most defined substances that are really those who are responsible for the non-communicable diseases, especially the cancer part of it, we see that actually we have 10 or 12 the most active substances, and if we have products showing that the amount of these substances or concentration of these substances is substantially less, well, they are potentially dose harm reducing. Potentially, because we have to prove this. Well, understanding that and knowing that, even WHO, sorry for saying even, because I think that WHO, when fighting with the tobacco epidemics around the world, loses from year to year, but I'll come back. to that in the final part of my presentation. So, but even the WHO says that investing in prevention is the best investment that can be ever made. If I was as a player at the New York Stock Exchange and somebody would tell me that, okay, once you invest a dollar today, you'll get $12, $10, $8 in 15 years. Well, I know, well, here's the man I want to follow. But we already know that investing in prevention, primary, secondary, and tertiary, where harm reduction is part of the tertiary prevention, investing in prevention brings you the revenue of somewhere between 15 and 20%. well, investing at this level should be the thing that we do, but this is not the case. Contrarily, when we look at cigarette smoking, we see that almost 2% of GDP is being lost just because of the tobacco-dependent diseases. So because of that, we smoke cigarettes. The GDP of the entire world, of course, it's different in different countries, in different world parts, but the GDP of the entire world is lower by 2% every year. These are huge money. Of course, our friends from the US, they like calculating, they like estimating the real numbers. For the same year that this analysis is published, they've published the costs for the American industry, which shows that the American industry loses $600 billion a year. And not even half of that are the direct health care spending. All the other are mostly indirect costs because of, well, dropping out from the work market because I become sick, I cannot work anymore. Well, having a health leave because, well, I'm sick, I have the COPD, the chronic obstructive pulmonary disease, I have cancer, so I need a and I cannot work. So these losses are double that that really we spend directly to cure the diseases. And sometimes, very often, we do forget about it. When we look at the total burden of all the five groups of non-communicable diseases that I presented to you, we're talking about billions losses and reducing only by 1% mental health condition, this is the red line, or cardiovascular diseases, this is the blue line, will reduce, will cut the costs in the subsequent years, the cost of healthcare and the indirect cost of the diseases by 10, 20, 30 and so forth percent. So this shows that going this way, trying to reduce the damages, so reduce the harm for the future is the best way not only to improve the health of the society, it's also the best way to improve the state of industry and the budget of the country, because, well, the losses are being paid by the public money. Nobody else pays it. Taxpayers have to finally pay them. Well, and I said that I'll come back to the WHO and smoking. I very regularly visit WHO pages, including the one about the key facts on tobacco smoking, and this is July last year, and there's no newer data on that. Well, this is July last year, showing that we have 1.3 billion smokers, tobacco users around the world. Well, a lot or not a lot, but when we go 10 years back and we look at the same page of WHO and the same messages, the number was 1.1 billion. So in this 10 years, the number of cigarette smokers increased in the world by 250. million people. What tremendous success. Well, I know that the general population of the globe increased, so the percentage, if kept the same, would be higher. But the reason is that the smokers moved from one part of the world to the other. Let me come back to this a little bit later. Last year, the mid-year, the Polish parliament office analysis office asked me to prepare an analysis about the state of the tobacco epidemics in Poland and where to go and how to go. So I sat down. A very good moment and a very good way to express what I know, what I think. I consulted it with my friends and co-workers. So we put together quite a nice analysis showing a lot of facts, especially showing that years of life lost due to cigarette smoking. Oh, it's... For the men, let's say... 250,000 years of life lost in Poland because of smoking. Well, this is a very good population indicator of how serious some risk factor can be, how serious the impact to the population is. Well, there was some economical evidence also attached, and we sent it to the parliament a year ago. I'll be back to that in a while. Also in this document we suggested that the best way out is to put much more stress on prevention. And we just put together all the facts on prevention, showing that prevention It's not what the National Health Fund gives us that go well make your blood test or make your x-ray because this helps us finding your disease earlier. Well, this is secondary prevention. But the basics of prevention is lifestyle promotion is health education. Well, nobody wants to pay for it because the benefit you get from that comes in 15, 20 years. So the political cadence is four years. It comes in four or five cadences. Well, another party will be at the government at that time, so why should we... worry about it. So nobody wants to invest at this level. But then we come to the thing that we will discuss I hope here during the three days. So the three levels of the real prevention. So the primary prevention and we have two very important things that we will address in different sessions. One of them is the fiscal tool. Yesterday we had a very nice discussion about the excise tax and nicotine and cigarettes. And this fiscal tool, the XC, well applied wisely, is one of the powerful tools that can help people quit smoking, but on one condition. They need to have an alternative. It's not only putting the prices of cigarettes higher, higher, higher, and leaving those smokers without any alternative. No. High prices of the cigarettes and much lower prices of several alternatives of proven lower harm, of course. So second thing that we'll discuss are the public bans. Many countries have introduced, most of our countries have introduced, but well, every of these countries at different level, banning smoking in public places, in restaurants, at work, this and that, selling cigarettes at gas stations and grocery stores. Well, these are the public bans. They help a lot because the availability of cigarettes, a lot. in that case of all related products, is lower, and when the products are less available, so they are consumed much less. Well, secondary prevention is something that I already mentioned, so it's very active looking for those who already smoke, despite the primordial and primary prevention. They've started smoking, they already smoke, so we look for the disease related to smoking, to find it and diagnose it as soon as possible. Because the earlier we find it, the possibility that we can prolong the life of a patient is longer. What I'm saying, prolong life and not cure the disease, because by definition, non-communicable diseases, chronic diseases, they are not curable. So we'll live with these diseases till the end of our days. Well, even though they do not necessarily kill us, but we will not cure them. We will have them once recognized COPD, so chronic obstructive pulmonary disease, well, is within us all the life long. So by this definition, they are not curable. So the secondary prevention and finally the tertiary prevention. The tertiary prevention that includes, of course, medical treatment, rehabilitation, but also the harm reduction. Well, the only problem with understanding harm reduction and understanding the need of secondary prevention, so early screening, is that only people who are well educated, I mean health education, not general education, well educated, so they have a very good primordial prevention applied, at the early childhood, they will understand that tertiary prevention is necessary, that harm reduction is necessary where everything else failed, that secondary prevention is necessary if the prevention to smoke or to drink extensively failed. So these are the steps. This is not the pyramids that we apply at one time. No, these are the steps. apply prophylaxis step by step. Well, about 250 million people every day, somewhere in the world, in different countries, are trying or willing to quit smoking. The main goal for us should be to support them. One of the supports is using the tools that I just listed. So once again, public banks, fiscal tools, harm reduction. Well, the problem is that I'm afraid this is not the case. We are not doing it properly. And that's why over 60% of those who even in all these trials that we look at, short-term trials, 3, 6, 12, up to 12 months, well, 60% succeeded in quitting smoking. Yes, but when we look at the same group in two years, 60% of this group is back smoking. So it's, well, depending on what time perspective we apply, So the accuracy of this data needs to be verified. Well, actually, the effect of our attitude to harm reduction, maybe not our, but I mean those... tax decision makers and healthcare system decision makers. Leads us to that, as I showed you, the cigarettes have potentially 7,000, once again, and 92 substances, 92 defined cancer organs, and they are the most commonly used nicotine products. in the world. All the others that have less nicotine, more harmful than nicotine substances, they are less frequently used, so it's counter-logic. Absolutely counter-logic. These four conclusions are not conclusions of the talk yet. I'm sorry, I'll take four minutes more of your time. But these are four of the ten conclusions that we gave in the documents written for the Polish Parliament Analysis Office. One of them was that we need to launch prevention clinic in each county, and the clinic has to have two responsibilities, have to have access to all the techniques supporting quitting smoking, including pharmacotherapy, nicotine replacement therapy, and harm reduction products. And these clinics, its workers, should be also responsible for coordinating all the, let's say, information campaigns or health campaigns being around. Because when I look at the campaigns that are being paid with public money even, They are absolutely not coordinated. They are made once a year because this is not Tobacco Day or this is World Health Organization Day. So they're not coordinated. Second thing that we suggested is radically... and progressively increase excise taxes and base the whole system of excise taxes on the less harm, less tax basis. So the less harmful the product is, the lower excise we put on it. It doesn't mean it doesn't have any excise because all these products are harmful. But the less harmful products should have less excise and the most harmful products should have the highest excise. And then there are those saying that we do not have proof that these harm reduction products are really harm reducing. Well, let's put some public money and public supervision, and let's finally do prospective studies showing that. And finally, let's end this discussion, sometimes based on nothing, only on my thoughts or my dreams. that these products are good or these products are not good. Let's prove where they are, where we are using them. And finally, we, at least in Poland, we do not monitor any health system changes, including those concerning alcohol or cigarette consumption introduced. So we introduced a change in the law and after five years we do not know, did it go the right way or it went the wrong way, because in the meantime, And so many factors have changed that we really cannot find the real effect of the one we would like to measure. And this is not the way we can be effective. Well, looking at the politicians, I may say, I don't know. It's not a statement. I just wonder if they do not have some conflict of interest. Well, the one thing is the next year budget. So if we know that, well, we're losing the productivity in direct costs, seven to eight billion, okay, every year it's being calculated in the market, in the industry, fine. But at the same time, on the excess tax and value added tax for tobacco, we can add up to the budget. Well, this 23 billion, it was 2018. Now it's closer to 30 billion zlotys. So the proportion shows that to save the next year's budget, Well, let's wait with the new law reducing cigarette sales until the next year maybe, because this one is really hard. Well, we've observed that in the case of New Zealand, that we are looking so forward to see how it will work, the new law, the new attitude to selling and possession of cigarettes in New Zealand starting 2025. and now we know that it has been postponed, and it has been postponed just because of what is written in this slide, even though these are the Polish numbers. Okay, I was already saying that the number of smokers increased partially because, well... There's one billion people more in this world in the meantime. But secondly, the smokers moved. I mean, now the most smoking countries are, as you see, China, India. I'm not saying in general numbers because this would be obvious, but in percentage of global smokers. So almost one-third of global smokers live in China, 10% in India, and so on and so forth. So please pay attention that big European community, big European countries who not necessarily, at least not all of them, followed the WHO way, the one, well, quit or die, but introduced harm reduction, introduced excise tax, long-term policies, introduced primordial prevention. These countries like Sweden, Czechia, Great Britain, several others, well, have real big drops in the number of percentages of smokers. But, well, WHO responsible for the amount of smokers around the world did not do such a good job as the mentioned countries. So maybe the only word, the only thing I want to say in the summary does not sound very optimistic, but in my opinion, I showed you that we are winning many battles. We learn how to use taxes. We know how to introduce public banning. We know what the harm reduction is. But despite all that, we are losing the war against cigarettes. Thank you for your attention.
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Grzegorz Król: Thank you very much, Professor, for this fantastic lecture. And let me say that when you mentioned NCDs, wars, and plagues, suddenly I'm most afraid of the first one now after your lecture. Let me invite to the stage our respondent, Michelle, please.
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Michelle Minton: Is this guy on? It is. Hi, everybody. I'm Michelle Minton from the Reason Foundation in the United States. First of all, thank you to the GFN for asking me to respond to Professor Fall's keynote speech, which was wonderful. I'm honored to be the respondent to that. If you don't know who I am and what my job is, I mean, honestly, you know, you're asking, you don't understand these politicians. Why are they making X, Y, and Z decision? That's kind of where I come in. My job is sort of an intermediary between the science and the policy analysis and to translate that into policy, or at least trying to translate that into policy by convincing lawmakers that these are wise decisions to make. And you ask, you know, I don't know why. Is it a conflict of interest? I'd say yes. Sometimes conflict of interest, often it's perverse incentives, as you mentioned, in terms of politicians aren't in government all that long. They have budgets that have to be renewed once every year or once every few years. And frankly... Numbers are very helpful, cost effectiveness analysis of certain policies are very helpful for me to kind of convince lawmakers that these are good ideas. And lawmakers love it because even if it never actually has the effect that we say a policy's gonna have or that someone tells them it would have, they still get to kind of implement a policy and then sell it as if it had that effect even though four, five, 10 years down the line, It turns out that policy didn't actually work so well. They still get all of the congratulations. They get all of the media attention. Maybe they get reelected. So it looks very good. But even though I rely so heavily on things like cost-benefit analysis, I can never stop thinking when I look at presentations like this, that we have a hard time actually analyzing the true costs of policies. We talk a lot in tobacco harm reduction about how certain tobacco control policies have negative effects and unintended consequences on people. But I think the actual weight of those costs is very difficult to calculate in terms of something like In the early days of tobacco control, we had a lot of overtly stigmatizing campaigns. That was their job. Their job was to stigmatize smoking and denormalize it. And we said, this is how many people over the 50 years since we started doing that have either not started smoking or quit smoking because of social pressure and because smoking has been denormalized. And that's great. And we have numbers for that. And we could take that to lawmakers and say, You know, if you do this advertising campaign and you ban indoor smoking and make people go outside to smoke, eventually some percentage of people will quit and a percentage will not start smoking. And we do calculate costs, of course, of things like this, of cost to businesses or lost tax revenue from smoking. The things we have a harder time calculating are what does this stigma do to people who don't respond in the correct way to such policies, right? The woman who has to stand outside of a bar and smoke and is maybe then exposed to some kind of harassment. Well, when you go into the literature and you look and see some of the other determinants of smoking initiation or failure to quit smoking. You know, when we do studies like that, when we try and figure out what the determinants of smoking are, what convinces young people, what are the factors that allow young people to initiate smoking, they're usually smoking-related things. Do your parents smoke? Were you exposed to tobacco marketing? This kind of thing. Are cigarettes cheap enough that a child could afford them? we don't look at things like discrimination or self-stigma or economic stress. But you look at the literature and you see that these things are enormous, enormous determinants of whether or not a child begins smoking or whether an adult refuses or cannot quit smoking. So taking something, our host here mentioned something about pushing the boundaries of what is possible. And so I guess I'm kind of the kook. I'm kind of the weird person. I love doing that. I like bringing in odd parts of the conversation. I think my goal here is maybe to stimulate a different kind of conversation throughout the conference, at least some of you, to really look at what are those factors and policy areas that impact smoking, impact tobacco use, but aren't exactly You know, the way tobacco control does things, it's very vertical. We tax things, we ban things, we denormalize things. But then you look at the literature and you say, okay, so a child who's exposed to tobacco marketing might have twice the risk of initiating smoking. Then we ban smoking, you know, advertising stuff like that. Or we say... Children who are exposed to parents who smoke might be 1.3 times, three times more likely to smoke. So we stigmatize parents and we raise taxes on cigarettes to convince parents to quit smoking so they're not modeling smoking for their children. But what kind of effect does that have when, for example, you ban indoor housing in assisted living? In America, if you're in poverty and the government provides you with housing, we've banned smoking indoors. And that convinces some percentage of people to quit smoking. But what about the ones who don't quit smoking and then who get kicked out of public housing? So then you have financial stress and housing instability for children, plus the modeling of smoking from their parents. Are those parents better off? Are those kids better off from that policy? These are those sub-populations. With tobacco control, we look and say, these policies convince this many people to quit smoking, yay. But for the other percentage of people, the cost for them of these society-wide policies can be enormous and can have effects on smoking. I mentioned housing instability. If a child is living in an unstable housing situation, whether that's living with a friend, which speaks to a high level of instability in their housing, if they're living with one parent, if they're living multi-family housing, the children with the least stable housing, so those living in a car or temporary housing, their odds ratio of initiating smoking can be up to six times higher. Six times higher. That's enormous compared to the tobacco-specific determinants that we normally look at and target with policies. Now, this is kind of crazy, right, because I'm talking about housing. And when you're talking about tobacco policy, it's very difficult to go into a lawmaker and say, you know what would actually be the most cost-effective way to prevent youth from smoking? Just solve the housing crisis. Go ahead. Just solve the housing crisis. It's a hard sell. Even though that may very well be true, that when we're looking at drug using behaviors, you mentioned that people have always been smoking or drinking something. This is true. Why people develop problematic relationships with substances is a difficult thing to suss out, because it's often very unique. And it involves multiple factors, genetics, social environment, lots of other things, socioeconomic status. We can't exactly solve the housing crisis or homelessness, although in America we might be able to if we stopped wasting our money on other things. But with tobacco harm reduction, unlike tobacco control, frankly, you can actually integrate these policies into other programs that target some of these other determinants. So tobacco control, like a lot of public health from the early days, is very fragmented. It's almost, not to use the word, but balkanized, where you have atomized is probably a better word here. where you have a person who has an issue that you care about, and then you look only at that issue and how policies can affect only those determinants and those issues. Whenever I talk about or read about cost-benefit analysis when it comes to tobacco harm reduction or tobacco policies, I often think of this story. I once heard of, not to keep bashing on the World Health Organization, back in the 1970s, the World Health Organization had this ramped up smallpox vaccination campaign in a lot of low and middle income countries. I think the cost was something like $200 million over the decade. And two thirds of that was paid for by the low and middle income countries. And they were extremely aggressive going into towns, knocking on doors, trying to coerce people into getting a smallpox vaccination. And at one point, one of the WHO workers went to a slum, a hobble, knocked on the door, and an old Bangladeshi woman came out, and they said, we would like you to get your vaccination. You haven't gotten your vaccination yet. And she refused. She said, I will not have smallpox vaccination until you give me food. which of course they refused to do. And what she said to them has stuck with me for years, probably a decade since I read about it. She said, if you don't care if I die from starvation, why should you care if I die from smallpox? And that quote really sticks with me because I think that's a fundamental problem that we have across public health, but especially when it comes to tobacco control and tobacco policy, is that we are not looking at people as a whole. And we're not even looking at our policies as a whole and how they fit into people's lives and what they do to people. I think it was Clive Bates recently at the e-cigarette summit who said, we are doing tobacco control to people. And that's not exactly the way to help people. Tobacco control is coercive. It's top-down. It's vertical. And it's not inclusive like tobacco harm reduction can be. Tobacco harm reduction actually fits in quite nicely with a lot of other of our public health initiatives and our attempts to help people. So mental health is one of the biggest determinants of whether somebody is going to start smoking and whether they're going to keep smoking. I saw a recent study. that looked at women experiencing homelessness in the Bay Area, San Francisco, and California. And I think they said over half the women had serious psychological conditions. I think they called it, I can't remember exactly the term they used. But one of the things they found was that the greatest correlate of whether these women would continue to smoke, I think about 75% of the women they studied were smokers. And I think 80% to 90% of them were trying to quit smoking actively. Very difficult. They found the biggest correlate for whether or not these women would continue to smoke was the number of other substances they used. And to go back to the housing example, another recent study, and I really like this one because I think this is helpful for how we talk about tobacco harm reduction, is they looked at men this time, homeless men, about 400 of them living in California and Los Angeles this time, and they studied them for 12 months, and they did three surveys with the men, three months, at six months, and at 12 months. And it was when they were homeless, and then... They know the first survey was when they were homeless, then they were put into supportive housing, and then they were studied for a year to see what happened. And after they studied them, they actually split them up. It's kind of perversely. They looked at the patterns of use over that full year, the smokers who were not smoking so much at the beginning but maybe increased their smoking once they got into supportive housing. The people who were daily smokers got into housing and continued to be daily smokers. And then those who were smokers and then their smoking decreased. And they sort of tried to, it's called, I think about it, repeated measurement latent class. So they defined people by class based on their behavior, based on the trajectory of their smoking behaviors over time. The really interesting result here for me was that an extraordinary amount of, this is not surprising, but an extraordinary amount of the men in that study had psychological conditions, PTSD, depression, bipolar disorder, schizophrenia, and there was a high degree of smoking. I think 320 out of the 420 were smokers. And they correlated that, you know, in their study, one of the biggest factors was mental health conditions. And illicit drug use was also a big correlate. But once they got into supportive housing, I think smoking declined by about 30% across all of the subgroups, which is pretty impressive on its own. Illicit substance use decreased by 45%. That was really shocking to me, knowing that housing and substance use, going back to the homelessness study about women showing that just the number of other substances in addition to smoking that they were using was the biggest factor determining whether they were going to continue to keep being smokers. And then you have this other study looking at homeless men showing that without any other type of intervention, just being in support of housing, they almost cut their illicit drug use in half. Even if the smoking among certain subgroups didn't go down all that much because they had supportive housing, their mental health improved, their other substance use improved. And so down the line, and then if you think about their kids, they have more financial stability or more housing stability. Maybe they're seeing their parents model drug use less, so they're less likely to be drug users when they become adults. I guess what I'm saying is I would like for us at this conference, when we talk to each other later, that we should be thinking in terms of how tobacco control or tobacco harm reduction policies fit into the overall framework of the way we're approaching public health, how it fits in with other laws that we have, how it fits in with current tobacco control policies, and specifically, I would like to see policies studied together in the specific environment where they're being implemented so that we can see and subgroup studies because, okay, here's one of the things I think, you know, we're losing the war. And I think one of the reasons we're losing the war with smoking is because we continue to repeat the tobacco control model of sort of like the greatest benefit for the greatest number. And in the beginning, or at least in America in the beginning where education about smoking risk was low, Basically, we were picking off the low-hanging fruit. So we got a lot of return for the investment that we were putting into education. But we're only getting marginal returns now because we're approaching it from this coercive, paternalistic, top-down, greatest benefit for all kind of approach, which results in a greater amount of resources needing to be spent for those efforts in order to get smaller and smaller reductions in smoking. And it also requires greater paternalism. So at the end of the day, I think a lot of these problems would be, I mean, tobacco harm reduction could just easily replace tobacco control in the way that it can be integrated into other things, in the way that its unintended consequences are often largely beneficial instead of the tobacco control where the unintended consequences of stigma, for example, or of people losing jobs or losing housing or being forced out of social engagement because of denormalization. with tobacco harm reduction. You're bringing people, often people who've been pushed out, you're bringing them in. You're giving them support. You're giving them community. You're hopefully connecting them with other services that would help their other determinants that seem to have very little to do with tobacco itself, like mental health or housing.
00:48:55 --> 00:49:10
Grzegorz Król: Thank you very much. And now we got around half an hour to open the floor to questions from the audience, both here in the room and online. Yes, I can see a question at the back of the room here, please.
00:49:13 --> 00:49:59
Bengt Wiberg: I'm Bengt Wiberg from Sweden, doctor from Poland. You were mentioning the direct and the indirect cost of smoking-related diseases. But is there some way, I figure, that the costs are even higher when you consider, for example, a husband and a wife where one is smoking and that person, goes for lung cancer treatments and so on. If this was my case, my productivity and my children's productivity must surely also be affected. Any comments?
00:50:02 --> 00:51:26
Andrzej Fal: Yes, absolutely. As I mentioned, the smoking is the only habit that affects not only the smoker, but also those around him. And of course, these are all estimates, so these are not directly calculated costs. But in these estimates, there is one coefficient always taken, at least should be always taken if they are made correctly. In every country, the exposure coefficient is different. In Poland, the coefficient before public banning was around two and a half. So one smoker influenced two and a half people around. So it was calculated on a basis on several gatherings and so on and so forth. So every country has a coefficient in this statistics. Well, truly speaking, now after banning in public spaces of smoking in most our countries, the coefficient significantly dropped. Of course, we have less knowledge about the exposure at home because most parents declared that even though they are smokers, they never smoke in the presence of children, they go out, but we cannot prove it. It's only declarative way of their giving facts, but I absolutely agree, yes, smoking, once again, is one of the habits, the only one of the habits that affects yourself, your family, and the close ones to yourself.
00:51:32 --> 00:52:05
Grzegorz Król: Thank you very much. And let me just say that I'm most glad that in both the lecture and the response, the problem of vulnerable populations, vulnerable nations, if I may say, as we could describe those most affected like China, India, Indonesia, and vulnerable groups is something extremely important in my opinion. And so I'm most glad that we are including this into the conversation today. We've had another question. Yes, here, please.
00:52:12 --> 00:52:54
Maksym Barabash: Hello, my question is related to Mr. Farah's presentation about the elements which need to be implemented or can be implemented by the government to basically reduce the risk of smoking. One of them was related to fiscal policy of the government. I fully agree that food fiscal policy stimulating the product with lower risk will play an important part. My question is, what would be your recommendation to define what should be the difference of risk? Because across the globe, there is a huge, basically, there are extremes from 70, 80% in some countries down to 10 or even zero. Thank you.
00:52:56 --> 00:55:23
Andrzej Fal: That's a very good question. Well, let's look at this the other way around. When we look at the price of a pack of a product, cigarettes or harm reduction product, And entire taxes, in my opinion, should stand for around 75% to 80% of the price of this, because this is then very influential. But this is not enough. Yesterday, during a very good discussion about excise taxes and nicotine in the afternoon, There has been data shown pointing that in European countries we have different amount of excess tax in euros per pack. This is not the attitude we should, in my opinion, apply because two euros in Germany will mean a little, well, not the same as two euros in Romania or two euros in Poland. This is another part of a percentage of the PAC price, and comparing the mean or average salary in these countries, two euros mean absolutely different things. So when we're talking about excise tax, I will only stress that in my opinion, as every, regulation, it should be high enough to really influence or to really to help us to reach the goal. Because if the tax is even high, but it influences the price by 10 or 15%, nobody will notice it. The price has to be really driven by the taxes, and only in that case we can create a good policy, a good, successful policy on banning or reducing sales of those more harmful and, well, replacing it, or at least partially, with the sales of the less harmful products. But two conditions have to be fulfilled. First, we do have to have these two products. and we do have to have a huge difference on excise taxes, well, somewhere in the back of my mind comes also the question, we need to have the scientific proof that the harm reduction is worth it.
00:55:25 --> 00:55:50
Grzegorz Król: Thank you very much. And let me, if I may add to that equation one more thing, which I believe also will influence the thing, the actual price, different in different countries, as clearly the tax is calculated on top of that price. So if we see significant differences in prices in two, like two EU countries, that will, well, change the outcome. All right, we got another question here from Norbert, please.
00:55:56 --> 00:57:44
Norbert Zillatron Schmidt: Yes. You mentioned the cost of tobacco control measures. And there's one elephant in the American room I wish to mention. The current FDA regulations mean that you have to put an application which costs, according to FDA, about $300,000 to make it. And then if you are really lucky, they approve it. for each individual product and contrary to their initial expectations of maybe a hundred applications they received several million applications and by now they have accepted 23 in total and denied several million applications so Has somebody calculated the wealth that was destroyed by this regulation? My estimation would be you have several millions times 300,000. adding up the shops that had to close, the businesses that went bankrupt, the people who lost their job. Who measures this cost?
00:57:46 --> 00:57:47
Andrzej Fal: I think this one is yours.
00:57:48 --> 00:59:39
Michelle Minton: Yeah, no. Yeah, we do it very backwards in America, where if you're a cigarette company that existed before the FDA was regulating tobacco, you don't have to go through this expensive, lengthy process. But if you're a new product, a less harmful, non-combustible product, you have to basically prove to the FDA that you're not an evil, scary thing that's just going to take over the minds of our children, which is apparently extremely difficult to do. As far as I'm aware, nobody has calculated this cost, even really estimated the cost of the thousands of businesses. And then you would have to go even further and be like, what were the effects of the process on business closures on the people who own those businesses, on their communities, on their families, all of that kind of stuff? As far as I'm aware, no one has calculated that, frankly, because when it comes to the types of calculations, and I'm not talking about academic researchers, but in the policy world, the types of studies we do for that in order to inform policy makers about the wisdom of their choices rarely focuses on something like that. I think someone has calculated how many businesses have closed. We know 99% of the products that were on the market no longer exist now. which is what the FDA estimated would happen before they ever did it, but they just don't care. The sad truth, at least in the United States, is we like to talk about small businesses a lot, but unless it affects the bottom line of very large businesses who happen to give a lot of money to politicians, Or a lot of people are complaining about it, who would maybe choose not to vote for them. They just don't really care. Because at the end of the day, it's much flashier for them to say, I've passed this law. It's going to save children's lives, than it is to say, we're going to do this other thing for 10 years, and it's going to result in a cost benefit. No, we're going to return like $7 on every $1 spent. It's a much harder sell for politicians.
00:59:41 --> 00:59:48
Grzegorz Król: Thank you. Sorry, we've got a question. We've got a question here. Yeah, please.
00:59:54 --> 01:01:09
Flora Okereke: Thank you. Flora Okereke from DAT. Professor, thank you so much for your name this morning. What I heard you in summary was to lay out steps that is a solution for smoking, from education, demonization, taxing, and she says, no, that is not the only way. It has to be an approach that looks at the policies holistically. I would like you to directly respond to that. Do you think she is correct in what she has laid out? And Madam, for you, I think My question would be, you know the way the governments are organized. They have different departments for different policies. They have different objectives and they have different timelines. In a practical way, how do you think that an integrated policy of the nature that you espouse can happen without a total change of how the organization runs? Thank you.
01:01:11 --> 01:02:17
Andrzej Fal: Thank you for the question. I do absolutely agree that we in every action of public health need a holistic approach first. And the holistic approach showing us the way to, and the place where we want to be in 10 or 15 years is the way to follow. But then we need to follow stepwise because, well, we cannot do all the things at the same time and be effective in everything. So following the way that we already know, leading to the place we would like to be in the future, we just follow the steps that I tried to show you, the pyramids. So start with... educating the youngest and also at the same time helping those who already are sick or are less happy or less affected with the policy that we introduced at the beginning. So these two things, so the holistic approach and the step-by-step approach of prophylaxis have to be combined together to reach the goal.
01:02:20 --> 01:03:59
Michelle Minton: And to answer your question, so How this would look is impossible to say. But what I kind of was trying to get at are looking at combined effects of policies. And then for us in the room who advocate for policies, beginning to advocate for combined policies, as you mentioned. You don't raise a tax without making something else available, too. You don't have an educational campaign aimed at children without also having educational campaigns aimed at adults in conjunction with one another. in a perfect world, it wouldn't be so difficult for agencies to coordinate their activities together for the benefit of the population. And in some way, you know, this does happen sometimes where we look at, you know, we're going to talk to the department of, if you look at something like cannabis, for example, we have an interesting situation in the United States where it's still federally, you know, marijuana is still federally legal, but for the last 25 years, a lot of states have had legal markets. And you have governments, bodies that have to coordinate with one another in terms of like the Department of Health has to coordinate with the Department of Justice, and they don't always do it so well. But I mean, I think the beginning step here would be to start studying combination policies to see how they work, to see the unintended negative consequences, the unintended benefits of these policies, how they fit in, and specifically looking at combine policies, this is gonna be difficult to say, combine policies that take into account vulnerable subpopulations. Instead of just one big policy from one agency, it's how do we have a policy that hits all of the different, accounts for all of the different groups with different types of risk factors. I hope that answered your question.
01:04:02 --> 01:04:52
Grzegorz Król: Thank you very much, Michelle. Let me see if we got questions from the far ends of the room. We got one here, one here. Before we get to that question, let me just share a question that I have seen posted online from our online audience. probably from somewhere in India, and the question was whether the introduction of THR policies might rather than help in quitting smoking serve in attracting new users to nicotine. That's an old question, but the reason why I'm actually forwarding this question here in the room is because in many regions of the world, the answer is not obvious. So even if to some of us it might be, may I ask one of you to?
01:04:53 --> 01:06:45
Michelle Minton: Maybe I'll start this time, and then you can correct me. So I think, yes, obviously, right? A lot of people don't smoke. I was one of these people who wanted to smoke but didn't as a kid because, one, it was illegal for me, and then, two, because I was concerned about the health consequences. And if e-cigarettes had been around when I was a youngster, I would have 100%. I would have done that immediately. I would have been an e-cigar. I would have been one of those teenagers they use in all the pictures in the news who's vaping. The thing I think here is that I'm trying to get it, or I'm trying to get it with my response too, is that We can do what tobacco control does, which is play whack-a-mole. Every time a new product comes out, every time something doesn't work, and just keep playing whack-a-mole forever. Or we can try and address why people are having... If they have a problematic relationship with nicotine, why are people... Because this is just... I will probably never be convinced otherwise, but when it comes to substances, especially when it comes to problematic substance use, the substance itself usually has very little to do with it. That it is something else is happening in that person's life or body that they are trying to address and can't address any other way, whether they're trying to regulate their mood or whether they're trying to escape from a terrible financial economic situation, war, Like going back to that Bangladeshi woman, it's really hard. Bloomberg will go to India and say, don't ban e-cigarettes. It's very difficult to convince people to care about their health when they haven't made it past the bottom line of Maslow's hierarchy, when they're experiencing famine or running from war if they feel like their life is in chaos. And you can tax all you want. You can stigmatize all you want. But those folks are still going to find their ways to escape and the substances that make them feel a little bit of pleasure in an otherwise not very pleasant world.
01:06:48 --> 01:09:34
Andrzej Fal: Right, well, in my opinion, this is one of the most important and the toughest question in this area that can be asked because, well, the possibility of recruiting new nicotine users is the biggest and toughest argument against harm reduction that's being thrown by those who are against it. But as I mentioned during the keynote, the harm reduction is possible only when harm exists. So the harm reduction tools and devices should be, in the perfect world, available only to those who are cigarette smokers. So as a medicine, as a drug, it should be given to those who have a disease. So those who are dependent on nicotine, who are dependent on cigarette smoking, should be in the harm reduction technique suggested replacement as a treatment of their habit, as a treatment of their disease, because being dependent on nicotine is a disease. And if it was this way, there wouldn't be any consideration on, whereas this will create a new group of users. But while we know instances, also in my country, we have the cases that new products have been introduced to the market, made available publicly, and sold not to the groups they should have been sold to, and they created now by themselves, or by itself, also a threat to public health. So instead of one threat, we have two threats now. But this shows only that legislation does not follow fast enough the changes in the market. So this is the thing that I wanted also to tell you during the keynote. Well, the politicians need to look more carefully to what is happening and to be a little bit more flexible and willing to understand and cooperate. And well, finally, we need all a little bit more health education to understand what the harm reduction products are. We do not question harm reduction in hard drugs. We do not question harm reduction in diabetes with sugar. So why should we question harm reduction here? But we need to find tools that ensure that this is harm reduction and not harm spreading.
01:09:37 --> 01:09:47
Grzegorz Król: Thank you very much. Let me come back to questions from the room, and we had at least two people waiting. May I ask the gentleman at the far end of the...
01:09:49 --> 01:10:59
Frank Henkler-Stefani: Yes, thank you very much. My name is Frank Henkler-Stefani from the German Association of Tobacco Industry and Novel Products. I found a very interesting discussion. There is clearly a need to have a minimum level for taxes on tobacco to encourage people to smoke. But if I understand Michelle Minton especially correctly, there is also a need for an upper limit. Because if it's too high and we exclude black markets, of course, expenditure, especially in deprived families, would really take away income, which could be spent on education and other issues. So there may also be quite some sensible arguments for a maximum level. And in Germany, we have requests. to put levels up by some people even to just 10%. So that levels could go up to 15 euros, which would be the cost of a bottle of champagne in the supermarket. And the question is really, how would you think a maximum limit would be sensible? How would you fix it? And how would you put it into relation with novel and risk-reduced products? Thank you.
01:11:00 --> 01:11:48
Michelle Minton: I can answer that pretty quickly in that I just don't think taxes should be, this is my personal opinion, I don't think taxes are a good way to affect people's behavior. I think that's a very perverse way to go about it with a lot of perverse unintended consequences, especially on vulnerable groups that are difficult to predict and hard to measure, so we usually don't really think about it all that much. If it's hurting them that bad, they would just quit. So I don't think maximum taxes would be good in the same way that I don't think, I'm fine with the taxes, but I just don't think using taxes as a way to try and modify people's behavior is, I generally think it's much more of a way for government to generate revenue and then it creates the perverse incentive, the conflict of interest where they become reliant on that form of tax revenue.
01:11:55 --> 01:13:15
Andrzej Fal: A short comment on this one. As already mentioned, I think that the excise or any tax put on alcohol or cigarettes must be tested to the market because a different level of taxation will be effective in Germany and a different level of taxation will be effective in Poland in that case. I don't even think there should be a common policy in the European Union because, well, it doesn't work in all the 27 countries. Exactly the same attitude is the first thing. Second, well, when we have a high income on the taxes and excess taxes or value added taxes and we claim or maybe the government claims that they will go to teaching and health promotion, I would love to trust what they say, but I remember for 10 years I was supervising the so-called 0.5% taxation that should have been given to the Ministry of Health every year out of the access from alcohol and tobacco. Never happened. Well, these are the two points in this discussion that I want to stress as far as the taxes are concerned.
01:13:15 --> 01:14:00
Michelle Minton: I want to add one thing to that really quickly. And so first of all, obviously I understand that changing the price of a thing does have an effect, especially on youth, right? But I think it's very difficult, going back to the whack-a-mole issue, it's very difficult to deny the fact that we live in a pretty connected world, especially if you're in Europe, you know, where you have different levels of taxation and different levels of prices. And the response people in the underground industry have is to simply move the products around where they're going to be making the most profit, functionally taking cigarettes from a a country that has lower taxes or where the prices are lower and then moving them into a higher one. And then you have to go, as the enforcer, as the government, you have to deal with this. You're not dealing with the, you have to address the demand, not exactly the supply. Because the market, legal or not, will always find a way to supply.
01:14:01 --> 01:14:59
Andrzej Fal: Well, exactly. I do agree with this one with one but. The but is, well, we're not saying that we need to follow the Al Capone times and ban the cigarettes as alcohol was banned 100%. We try to say that when we raise the taxes, we leave a cheaper alternative, which is the huge difference. And if the, well, the argument of those who are against raising taxes will say, okay, we then have illegal trade, we have illegal production, I will say, okay, we do have services in this country that should take and enforce the law that it's existing. So, well, this cannot be an argument against raising taxes for alcohol or cigarettes that we will create a black market for them. All right.
01:14:59 --> 01:15:06
Grzegorz Król: Well, thank you very much for this discussion. And let me give voice to a lady in the front.
01:15:07 --> 01:16:38
Tatiana: Thank you very much. I'm from Belarus. I've been managing harm reduction projects, but for people who use drugs. And that's why I'm very sensitive to the issues of discrimination. And Michelle, in her keynote, mentioned the importance of creating supportive environments for people who use tobacco. And as we all understand that the nicotine dependence is a disease. isn't it? I would like to draw the attention of this audience to the fact that the most prominent health organization in the world, the World Health Organization, does not hire people who smoke or use tobacco products. Did you know that? I mean, in every job advertisement, the WHO writes that we have smoke-free environment and do not recruit smokers or users of any form of tobacco. So my request is, do you think that this tobacco forum full of esteemed professionals in this sphere and very humane people can make an appeal to the WHO against this ugly discrimination? What do you think?
01:16:40 --> 01:18:15
Michelle Minton: We've been trying for years on that. I honestly, as long as tobacco control remains the dominant paradigm, I frankly think no. When we call something a disease, I actually take issue with that nicotine addiction isn't a disease because the things that we decide, whatever dependency we decide becomes a disease is very political, frankly. We don't usually talk about caffeine addicts as having a disease of a caffeine addiction because... I mean, well, it doesn't cause as many problems as tobacco, for one. But also, it's a socially accepted behavior. And I think the reason that places like WHO have those policies and continue trying to force those hiring policies on other businesses. We have businesses in America, I think U-Haul, for example, that has the same policy. They will not hire drivers who smoke or use nicotine, even if that's the patch. And I think the reason for this is demonization. It's part of the denormalization campaign, but it's also part of an anti-compassion campaign, where if you say, we will not hire a person who does X, you're functionally turning them into a monster. It assigns all of these other... features to the person who uses nicotine. Why are you not a good hire just because you use nicotine? I think the reason, frankly, is the WHO, or whoever decided to put that policy in, doesn't want people coming in to the WHO who have knowledge about what life was like using tobacco, and therefore compassion for the people who continue to use nicotine and tobacco.
01:18:16 --> 01:19:48
Andrzej Fal: I absolutely agree with that one. And one more comment. We have a big campaign in Poland for the work givers that complain that those who smoke, their employees who smoke, use at least one hour daily to go out for a cigarette. So actually, if they work for 250 days a year or 300 days, they lose, they are being paid 300 hours yearly Well, just for smoking, cigarettes, and work. And that was a very huge problem. So we even suggested the work givers to the employers to support alternative tactics for those who decide to try to switch. And there are several places in Poland where we, well, I wouldn't say introduced this regulation, but many, many employers went this way. For me, it's unthinkable that a public institution could say that I will not employ you because you're a smoker. No, I have to try to help you find a way out of your smoking habit, but I cannot tell that I will not employ you. Of course, you cannot smoke and smoke among those who are not smokers. This is pretty obvious. But it's not that you'll not be employed. I mean, for me, it's unthinkable.
01:19:49 --> 01:19:59
Michelle Minton: It also really betrays a lack of confidence in their own abilities to help people quit smoking. You would think, if you're a smoker, come in and we'll immediately help you quit. But no, just go away. We don't even want to talk to you.
01:20:01 --> 01:20:10
Grzegorz Król: Thank you very much. I hope that answers the question, although the question was actually to all of the audience to think about. Next one from Jerry, please.
01:20:15 --> 01:22:06
Gerry Stimson: Coming. Thanks. Gerry Stimson from KAC. It's a question about using the return or calculating returns on investment and using the return on investment argument. When I was involved in drug harm reduction in the context of HIV prevention, HCV prevention and so on, one of the big problems was sprayed in governments to spend money on undeserving populations why should i spend money on needle exchange or why should i spend money on methadone for the this this population so we often use the return on investment argument because the prevention of hiv has a greater social benefits and work with the world bank for example who was trying to lend money to poor countries to do hiv prevention and convince them that if they borrow that money, it's a positive effect on their economy. But when you come to tobacco harm reduction, there's an interesting methodological question and also an interesting argument for governments because it doesn't cost governments anything. It's one of the few public health type interventions with a small p small h where you don't actually have to spend any government money to do it because the costs are borne by the consumer who's paid money not to buy cigarettes but pay money to buy a safer alternative So there's an interesting methodological issue there, because how do you calculate a return on investment when the government doesn't have to invest anything? So you've got almost an infinitesimal return on investment. But secondly, it's often a point I think not picked up by governments. This is one of the very few areas where you can drive a public health intervention without actually having to pay for that intervention. I wonder if you have any thoughts on that.
01:22:08 --> 01:23:00
Andrzej Fal: Well, actually, I'd say that the income on the excise on cigarettes that the government has now is for sure. When we start thinking of changing it for other products, first, the excise is different. The amount of those who switch, well, maybe some of them will quit in the meantime. so the excise income is not so sure for the coming year. And maybe that's, well, they simply, being afraid of changes is very typical for a human being, maybe for a politician too. So maybe, well, changing the excise taxation and the product that has to be taxed, makes them a little bit unsure of the real income that they will have in one or two years. I think so.
01:23:04 --> 01:23:22
Grzegorz Król: Thank you very much. And concerning the costs, let me mention a question raised in an old, it was 1990s American article. What will we do with all those poor pulmonologists and cardiologists if suddenly everybody stops smoking?
01:23:23 --> 01:23:52
Andrzej Fal: Well, that's a good question. That's why I'm also an allergist, and the allergy, as you know, is developing, so I'll find my way through that. But, well, being more serious, of course, as I said, I do not believe that we'll stop drinking and smoking in the nearest future, so in the two, three generations, so we'll find a way to survive. I mean, the doctors.
01:23:53 --> 01:24:46
Michelle Minton: Yeah, and I mean, there's the perverse reality here, too, that a lot of people don't like to talk about, especially when it comes to something like smoking, is the Progressive Policy Institute in D.C. They did a study, I think in 2018, 2019, of looking specifically at e-cigarettes and the effects on health, on smoking, and on health expenditures. And what they found was that by their predictions, because e-cigarettes helped people live longer, health expenditures actually increased. The cost of the government in terms of Medicare and Medicaid and stuff like that actually would increase because people would be living longer to get those types of diseases that tend to cost a lot of money in older age, like Alzheimer's and diabetes and other things. But this is made up for in terms of, well, one, lives, so who cares? But then also in terms of productivity, overall lifetime productivity for people who don't die in their 60s of smoking-related disease and suffer for years ahead of that is much greater.
01:24:48 --> 01:25:10
Grzegorz Król: Thank you very much. One last final quick question, and I will ask for a quick answer because we're over time. Coming online, a lot of money is spent on campaigns that end up stigmatizing people who smoke as part of the process of denormalizing smoking. Do you think stigmatizing people who smoke is an effective method of getting people to stop smoking?
01:25:11 --> 01:25:52
Michelle Minton: This will surprise to get my answer. Yes, it is effective for some people. For some people, it is a very effective method, but not for everybody. And then, again, this goes back to what I was originally saying. We don't often think about, for the people it doesn't work for, what is that doing to them and their kids and the people around them, and what effect is that having generally? I think stigmatizing people, if you look, for example, at specifically in America, black pregnant mothers, or black mothers, excuse me, when they're exposed to stigmatizing messaging about their smoking and their kids, their response is that they want to smoke more. they internalize the stigma, they feel bad, and then they want to smoke as a coping mechanism. So that doesn't help them, and that definitely doesn't help their kids.
01:25:54 --> 01:26:27
Andrzej Fal: Stigmatizing a person for any reason is not the proper way to go. It leads us nowhere on the long-time basis. stigmatizing to have, well, good result because he stops smoking tomorrow because he's afraid of showing that he likes smoking. This is only creating a cycle, well, it's serious problems in the future. That's for starters. And secondly, we do not have right to stigmatize other people, at least I think so.
01:26:27 --> 01:26:27
Michelle Minton: Great.
01:26:29 --> 01:26:43
Grzegorz Król: Well, thank you very much. And let us all thank with applause our two heroes of the morning session. And let me ask to continue the conversation in a choir during the morning coffee break. Thank you very much.