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Whilst no activity has a total absence of risk, science has to embrace risks and challenges to evolve. The over/misinterpretation of the precautionary principle is often an impediment to progress. Drawing on his experience of working with dependence in other fields, Dr McGovern will examine, in relation to nicotine use:
- How should we categorise/quantify risk?
- Is there a hierarchy of risk(s)?
- What are the consequences of avoiding all risks?
- How can equivalence assist in assessing risk?
- Who should determine the limits of risk – for the individual and communities?
- Are there lost opportunities for tobacco harm reduction to have a significant impact on personal and societal health improvement, due to the inappropriate application of the precautionary principle?

Keynote #2 is also available in Spanish and Russian:
- Spanish:
- Russian:


00:00:06 --> 00:03:02

Sarah Cooney: Well, good morning everybody and welcome to day two of GFN 2024 to this plenary session and our second keynote lecture. I think that there are a few gaps in the audience from the party last night, but I hope it'll be an excellent session. My name is Sarah Cooney. I'm a science engagement consultant. It's my honor to be here with two very distinguished physicians who have devoted their careers really to working with addiction and substance misuse. I'm honored to host this keynote about the precautionary principle and how it relates to nicotine products. And I wanted to provide a couple of brief remarks before handing over to the keynote speaker. The concept of the precautionary principle arose several decades ago in response to really significant environmental concerns. One of the first globally accepted definitions arose from the Earth Summit in Rio in 1992. And the Rio Declaration declares, in order to protect the environment, the precautionary approach shall be widely applied by states according to their capabilities. Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation. So it's not, it's a reasonable principle that governs environmental issues in health, especially when there is uncertainty and there are potentially really significant risks to health and the environment. However, the precautionary principle is really just one element that decision makers need to look at. It's not enough to say there might be risks and so we shouldn't do anything. They need to go beyond this and carry out a proper risk assessment and then present those risk assessments to decision makers who then integrate other factors when coming down to making their decisions. The UK Public Health England agency is a nice example of how this should work. There were concerns about e-cigarettes and Public Health England went out and did the work and evaluated the evidence and their best guess based on this weight of evidence evaluation was that vaping was likely to be 95% less risky than smoking and therefore the benefits outweighed the risks and they were prepared to say so. But it doesn't always work like that. So I'm very happy to hand over to Garrett McGovern, who's going to take us through this in much more detail. Garrett's a GP who studied at Trinity College Dublin, and he's specialized in treating substance misuse since 1998 when methadone became available in Ireland. And currently he's the medical director of a private addiction clinic near Dublin. He was recently appointed clinical lead for the addiction services in the Irish Health Service for a large chunk of the Midlands. He's very, very well qualified and I'm very happy to hand over.

00:03:02 --> 00:37:01

Garrett McGovern: Thanks, Sarah, for that lovely introduction. Welcome, everybody. I'd like to thank all the organisers, Gerry, Paddy, Jess and also Alex and Sarah who've been really helpful in the work up to this presentation. I have a number of slides which I have to confess in advance I do tend to go a little bit off piste when I do these presentations. I'll try and stay within within the 25 minutes if I can. But you let me know, yeah? Great, okay. Okay, there's conflicts of interest, none declared. I don't have any ties to any particular organization. My views are fairly solid on vaping, and I think they'll only get stronger the evidence, as we all know, is emerging in terms of the efficacy and the safety of these products. So I'll just move through. Stay with me on this. This is my own definition of the precautionary principle. So precautionary principle is hating a product, in this case e-cigarettes, that you lie to the public, particularly smokers, about the predicted harms of that product, and then you pretend you're gonna invest loads of money into investigating and examining the positive and negative effects. Having sort of researched this area, that kind of sounds a little bit like what the precautionary principle is about. It sort of comes under the banner of let's do nothing. Let's create some sort of panic here and let's put barriers in the way of people and particularly smokers who are trying to quit. And in the meantime, of course... In the meantime, of course, it's welcome to Shawshank. Probably any excuse just to put something from that movie up, but it does feel like that for smokers because it's such a hard habit to overcome no matter what. Intervention you try many many people try every year many many people fail I hate to use the word fail, but they they don't succeed let's say and you know if we're gonna really Tackle the global burden of tobacco related diseases. We have to embrace electronic cigarettes and unfortunately There is a war there's a war out there and we all know what that war is and there's this kind of looks like there's worse to come I'll talk a little bit about that as we get as we go along and This is the Wingspread Statement on the Precautionary Principle. Now, I'm gonna try and read this out, but I do have to say, when I started reading it out this morning, and I've looked over it a number of times over the last few weeks, I did sort of wince a little bit and maybe crack a smile in some other areas, but this is what the scientific version is, and I'm not entirely sure it's more accurate than my version, but that's just my personal opinion. So when an activity raises the threats of harm to human health, so straight away, you can see what's going on there, raises the threats of harm. I don't look at innovative technology like electronic cigarettes as being anything but the threat of harm, it's about reducing harm. But anyway, the precautionary measures should be taken, even if some cause and effect relationships are not fully established as scientifically. In this context, the proponent, us, and people who use electronic cigarettes, the proponent of an activity, rather than the public, should bear the burden of proof. Christ, isn't that true? The process of applying the precautionary principle must be, this is where I started to kind of laugh a bit, must be open, informed, and democratic. and must include potentially affected parties. That doesn't really happen. In Ireland, there was a consultation about electronic cigarettes, and who did they keep outside the door? Consumers. And it must also involve an examination of a full range of alternatives, like we don't know what they are, including no action at all. Now, the principle of the precautionary principle or examples of it, we have many of them. I'm not going to go through all these, but I've put in bold type here a few of the areas of the precautionary principle that I'm familiar with and I have kind of some background in. But there are a lot of different areas. The COVID pandemic is probably the most recent. Blood donor policy is And the precautionary principle, just to be clear, is on the surface very sensible. You know, something comes on the scene and we've gotta make sure that we don't cause harm to people. I get all that. But the precautionary principle, there's times when maybe it is absolutely valid to follow the precautionary principle. There's other times where it's gonna cause more harm. And I think we're all agreed here that with electronic cigarettes, that's what's gonna happen. So a little bit about prohibition of psychoactive drugs. There's a number of conventions, the 1961 convention, the war on drugs declared by Nixon, the 71 psychotropic substances convention, the 1988 UN convention. It was all your usual, you know, control of the trafficking of drugs. You know, none of it really thought about the unintended consequences. And it's not like we don't have, I suppose, when do consequences become unintended when we know after many, many decades of this, we know what the consequences are. So are they unintended anymore? It's hard to Hard to know. This is interesting because I'm not going to go through all this. You can eyeball the slide yourself, but just to talk a little bit about it. In Ireland, heroin arrived in Ireland, we reckon around 1979, probably a little bit earlier. And for 10 years, we sat on our hands, but more, 10, 15 years, we sat on our hands. We just said, oh, this is terrible. Well, it's affecting marginalized communities. Who cares, really? It's not affecting the good people. So, you know, it's a terrible, dirty drug. We'll do nothing. Now, this is, by the way, when in New York, in the States, you know, the whole phenomenon of methadone maintenance treatment and giving people needles was established. And in the UK. But Ireland, no, no, no, no, no, no, no. that's we couldn't have that perpetuating one addiction for the other opiate substitution treatment no no no no no then of course HIV arrived and the politicians started to get uneasy because there was a feeling that ooh the good people might get affected by this. And then of course, there was the whole thing of crime, that middle class, more affluent neighborhoods were getting ransacked, and the thought was, oh, maybe we need to do something about this. And it wasn't until about 1992, so probably, I would say 15 years too late, that we said, okay, okay, okay, we'll do methadone. And it was virtually underground between 1992, more or less, and 1998. There were some clinics, but it was not widely available. And then, of course, we started to do what we should have done 15 years previously, which was develop harm reduction services. So we developed a precautionary principle that, without a shadow of a doubt, cost lives. No question about that. And of course, is there anyone accountable for that? No. The kind of idea is, well, we're doing it now, and isn't that good enough? The war on drugs. I only wish he actually would have resigned before he made that statement. because this has been the biggest disaster of all. I don't know generally what people's view is on the war on drugs, but anyone who's worked in this area knows that the harm of prohibition is far greater than any harm that a lot of the drugs will do. And bearing in mind the drugs in question are illicit anyway, there's no regulatory control, there's no information on dose, and there's no safety advice. So it's pretty predictable what's gonna happen. Medical cannabis is another example. Again, you can look at some of this stuff, but essentially in Ireland, there's a real pushback. It's very like electronic cigarettes. So medical cannabis, and only through the advocacy work of people suffering from pain and a number of other conditions, they put in a real pushback togetherness about trying to get medical cannabis. We were very lucky, we had some really good politicians that fought the case as well. And then they said, right, we'll have a medical cannabis access program. The only problem with the medical cannabis access program, the medical cannabis access program is very analogous to the prescription model in Australia, which is essentially nobody can get medical cannabis. So you have to have a specialist in a hospital who knows, who knows damn all about cannabis, they're not well disposed towards cannabis, and a bit like the prescription model, I think Colin was talking about it last night, if they don't agree with it, then they won't prescribe. That's the first thing, so it's consultant-led, so GPs can't do it, or people with expertise in cannabis medicine. Second thing is there's only three conditions that it could be used for. Childhood epilepsy, a syndrome called Dravet syndrome, which is a really horrible condition. In fact, one of the real campaigners, Vera Toomey, sadly her daughter died last year. She did incredible work. It was powerful. And Alex has always said to me, one good story like that, one human story is worth many, many papers. Public don't really understand research papers, to be quite honest with you. But if you have a story like that, and that definitely... That was the catalyst that allowed this to be available. The only problem is, so that's one condition. The other condition is nausea related to chemotherapy. And then the third condition is MS. If you don't have any of those things, and bearing in mind, it's estimated in Ireland, which I was bowled over by the figure, that about a third of people in Ireland, adults, are suffering from chronic pain. They're not allowed to do it. They won't go near that. They poo-poo the evidence and then, again, a bit like my irreverent take on the precautionary principle, they say, oh, no, we need loads of research, but we're not doing the research. There'll be no research in this country, but we need loads of research. It's the usual BS, really. The opponents of this will say that medical cannabis is harmful and it's a gateway problem. for recreational cannabis use. And of course, I get onto the whole issue of think of the kids, but that's looming large here. So what's the outcome of this precautionary principle? Human suffering. It's inhumane. And I suspect they kind of don't care. I mean, how could you care if you're preventing people? I've always said about medical cannabis, I'll move off this in a minute, but The worst that can happen with medical cannabis is really that it doesn't work because it's not harmful. I mean, there's very little in medical cannabis that makes it actually harmful. Its side effect profile is pretty solid. This is a bit left field. This isn't anything to do with harm reduction, but I suppose it is in one way. But this was about the golden rice case study, which was scientists in Germany had this incredible way of modifying rice and getting it out to the underdeveloped countries, particularly because there were so many deaths in Europe. children and pregnant women but of course the anti-genetically modified organisms brigade came in I'm going no no no no no no no no that wouldn't be safe you couldn't do that and of course they regulated the hell out of it and of course unnecessary deaths happened and then eventually like all things the truth wins out and what happens we You know, the thing that should have happened many years ago, a bit like my example of methadone maintenance and needle exchange and harm reduction measures in Ireland, eventually it happens. They just get buried into the ground. The evidence will always win. And it's a message, because I believe we will win this. I mean, a lot of people have been pessimistic over here this year about, you know, flavour bans and disposables and the onslaught. But, you know... I think we'll win. Maybe, I believe in fairies, I don't know, but I'm confident that we're not going away. Those guys aren't going away, so we've got to keep fighting for common sense to prevail. There isn't a huge amount of common sense out there, and particularly for people, legislators, that's for sure. And as I said at the end of this, the parallels with electronic cigarettes is striking. You know, cautious, cautious, cautious, without any evidence of needing to be that cautious. Yeah, by all means, study, examine the positive and the negative effects of things, but don't put it in the way of people. You know, move with the evidence, and that's what we should be doing. Sorry. This is just very interesting. I didn't know who, before I prepared this talk, who Sven Ove Hansen was. There's some irony there, but Swedish philosopher, maybe in Sweden with Snus, they maybe took this guy's advice, I don't know. But very, very interesting. He talks about the dangers of the precautionary principle. And So when would you not use the precautionary principle? Well, the trade-offs are substantial. I mean, we know that if we stop people using electronic cigarettes, many of them will otherwise smoke. And we know smoking is deadly. Electronic cigarettes are not deadly. They'll never be deadly, in my opinion. Will we find some harms in many years to come? Maybe we will. But So far, we're over 20 years in and we're not seeing those harms. So when the risks are known and priced in, you need to be open about potential risks. One of the things that really distresses me about this whole polarizing debate is that there's a dishonesty. I mean, I think the whole world of research has been completely brought into disrepute. I mean, the public now probably will begin to think and be forgiven for thinking that can we trust research at all? You'll get someone who'll publish studies that we all know are not very robust about cardiovascular effects. And, you know, we know the whole popcorn lung business and, you know, I'm going to show you some sort of news clippings. We've seen them all before, the kind of sensationalism of it. But it does bring it into disrepute of how studies are peer reviewed, because it seems to me there's a lot of studies getting out there that are just not robust. And unfortunately, for every one great study on electronic cigarettes, you know, for every one horrible study on electronic cigarettes, the 20 great studies will never make the media. The media aren't interested in someone who has a 40 cigarettes a day habit and they overcome it using electronic cigarettes. So what? But if you have somebody whose lungs have exploded, you know... or the claim is that their lungs have exploded, then it makes the headlines. And unfortunately, the headlines get into the consciousness of the public. This is just a little cartoon. It's probably these guys around the table. There's a great acronym by a doctor, an epidemiologist, Tricia Greenhalgh. She calls these guys, these are the policy makers, gobsats, good old boys sitting around a table. And they decide for everybody else. We've a lot of gobsats back home. And, you know, they couch it in the terms that, oh, we have to assess risk. But in the meantime, we'll do nothing. So we let the harm, whatever the harm is out there, in this case smoking, then... so be it, but we need this absolutely perfect, randomized controlled trials, we need it to be perfect, completely harmless, and then we'll let people use it. This is, you know, I just put this definition in, relative harm is harm reduction. This is Russell Newcombe, Dr. Newk, as he's known on social media. He died earlier this year. A lot of you harm reduction guys will remember Russell. Incredible guy. Really just his eye for detail and his common sense. I was very, very saddened. I didn't know he was ill. He passed away earlier this year. As we all said on social media, harm reduction is a man down. By God, he's a big man down, I can tell you. it's estimated that he coined the phrase harm reduction, I don't know if this is true or not, but in 1987. Alex now is around longer than that, so he'll be able to maybe throw some light on that. But the reason I talk about relative harm is because Our opponents don't like talking about relative harm. They like talking about absolute harm, as if this is something that's come on the market. Smoking never existed, and we can't let this out. I'm not teaching anyone here how to suck eggs. You know all this. E-cigarettes, we know what the evidence is. I was just talking to Alex just off before I came on, and I said, you know... We've known from the start that the risk reduction was substantial. We don't need 20, 30, 40, 50 years of evidence for that part of it. But of course, our opponents and particularly legislators want this kind of perfect evidence. I don't think they understand harm reduction. I'll talk a little bit about that. How are we for time, Sarah? Yeah, this is about the scepticism. I talked to Clive Bates about this, actually, I think last year. Well, Clive was actually over in Dublin earlier this year. And I still struggle to know what is this scepticism? Like, why? Is it just ignorance? Is it protecting vested interests? Is it conservatism? Is it just a hardened philosophy that these products are evil or will be evil? Is it because e-cigarettes simulate smoking? They develop clouds of vapour and... they have cigarette in the title is that the reason is tobacco control worried about its fiefdom it's a very i'll talk a little bit about that or will we ever know the reason or is it a combination of reasons i i struggle i don't know many people here and it'd be good to hear people's views when we get to the discussion oh youth vaping we've got to say about this um Yeah. This is the jewel in the crown, really. It's the same argument with cannabis. We can't make cannabis legal because we have to think of the kids. And it is a powerful convince tactic. It really, really kind of gets an emotive response from the public. And I say in there that it appeals to parents, and particularly the non-smoking parents. The reason I differentiate that is that if there's a smoker in a house... who has used electronic cigarettes and has now no longer smoked and is going to their physician and their markers of lung disease and heart disease are reducing and they're living a healthier life, they're probably going to be more well-disposed and a bit less well-disposed with this youth vaping business. They'll understand it, they'll probably educate themselves, they'll read the good stuff. I often call this emotion-based evidence. I remember hearing once somebody called it vehemence-based medicine. You know, you challenge somebody about their evidence and they get angry. And that's really the end of the discussion. I noticed actually the anti-group get angry very quickly. Now, I'm a bit guilty of stoking them up a bit. I've done a bit of radio stuff back home. And I have to say, I do like to have a kick. But then again, they give me great ammunition. They give me such ammunition. I mean, the bullshit that they talk, it's just so good. And there's certain things I look for in those interviews. I just want them to say, and I put my ear out, and I just want them to say, well, it is safer than smoking. And I go, great, that's really good. We got that out of them. Because I realized that when people listen to the radio, I'm thinking of the person who's what we call the contemplator. They're going, maybe I'll... Give up smoking. I don't know. What about these electronic cigarettes? And this is the problem. This is the nefarious side of this sort of consumer denting their confidence in electronic cigarettes. Smokers are in a stage, many of them have tried so much, you know, NRT, Verena Clean, Champix, all those things, and they're in a situation where nothing has worked. And then they hear someone on the radio saying, very authoritative, saying, well, you're no better off smoking. you're no better off using electronic cigarettes than smoking. That's just so, that angers me. And we know that youth use is really rite of passage stuff. It's sort of, yeah, they'll mess around with them. The numbers are low relative to the numbers using electronic cigarettes for smoking cessation. I know I probably shouldn't say this but there's an element of so what there's a lot of things young people do I'm a father myself I'm sure there's a lot of things my kids get up to I know there's a lot of things I got up to that my mother and father never knew about but that's just the way of the world is this the one of the worst things I don't think so and as I say it's analogous to cannabis they they've gone large I think internationally but in Ireland oh my god the the stuff that's spoken about in terms of, you know, it's really reefer madness, to be honest with you. You'll be all very familiar with all these headlines. I mean, you're never gonna get a headline saying, I gave up two packs a day with electronic cigarettes and now my life is much better and healthier. No, that won't make the headlines. This is interesting because global tobacco control largely have been pretty negative about electronic cigarettes. You can quit, but you're going to do it our way. And maybe it might be electronic cigarettes, but that's down the line and really will discourage you away from that. I mean, in my own country, the health service executive who I work for dismissed electronic cigarettes. I mean, if you go onto their website and you look at electronic cigarettes, there's a little small paragraph. with all the usual rubbish in it. And then it says, we don't recommend electronic cigarettes as a mode. Not enough known about it. Awful advice. And again, sadly, and I won't mention any names, gobsats. There's a few people, very influential, the top of the tree, who hate electronic cigarettes. But is tobacco control under threat? Because what will happen if this... succeeds and we we electronic cigarettes are the premier way in which people get away from from a smoking habit well it's obvious isn't it there's a lot of jobs maybe on the line and there's a lot of activities i mean a lot of people making a great living from laying the boot into electronic cigarettes so that'll all be over and uh you know if you look at the cochran review and you know twice as successful as any other method you know it's i reckon that's only going to go up um So that's a real threat to them. We all know who these are. I won't mention any names. I don't want to get sued, but we all know these. I could add a few, by the way, let me tell you, homegrown ones. I did an interview with the guy in the middle beside Stanton. Oh, shit, I shouldn't mention his name. And he thought that I wasn't going to come up for air, but Unfortunately, I do suffer from the last word syndrome, so he wasn't getting that in Irish on home soil. But he came on, and it was... I mean, you could hear the ambulances outside my clinic window with the moral panic. I mean, it was, save us, we're all going to die in our beds. The youth, our youth. I mean... But anyway, sometimes you just have to keep the message simple. But the damage these people are doing to public health, and many of them are meant to be promoting public health, is astonishing. Again, more sensationalist headlines, more moral panic, and the public, many of the public really, you know, are unfortunately buy into this because they read so much of it. You walk in to a newsagents and you see this. You go online and you see a news piece, and it's got to be negative, which is awful. Yeah, that's what it is. It's harm reduction denialism. And I think we've all been talking about this over the last few days, that harm reduction is the cornerstone of everything we do. In medicine, we don't cure it. There's not very many things in medicine we can cure. Can we cure anything, really? All we can do is reduce symptomatology. All we can do is provide interventions. And in medicine, generally, we shouldn't make that difficult. But with this, for some reason, we're making it difficult. This is a WHO official. While regular cigarettes have a filter, this delivery device, the electronic cigarette, the nicotine goes directly to the lungs. What's that mean? Please. This one really annoys me for many reasons. I've seen this now, and on the campuses back in where I work, there is no smoking, but they have the electronic cigarette where the little symbol is. The other thing here is, which is a bit confusing if you're reading this, includes vaping and e-cigarettes, like they're different. They're two different things, but nobody cares. Nobody cares. Four in 10 smokers believe that vaping is more harmful than smoking. That is horrible, awful. The misinformation roadshow, I call it. Seven out of 10 doctors believe that nicotine causes lung cancer. I did a radio interview with a very well-known lung specialist in Ireland. And I made the point that in all the years in medicine, in all the years working in hospital medicine, in all the years working in general practice, in all the years working in Addiction treatment. I'd never seen a nicotine-causing illness. Never. I'd never seen somebody in... As I jokingly said on the radio, the only time I ever saw someone die of nicotine was in an episode of Columbo. A guy died of nicotine poison. It was injected into the filter of his... He was blackmailing some guy in the show. Nicotine sulfate, which apparently is very horrible stuff. But anyway... I never saw a nicotine causing illness. I stand over that. We know nicotine, a little bit like caffeine, has transient effects on, you know, heart rate and blood pressure and that type of thing. But I'd never actually seen that. And of course, the specialist comes in and says, well, I have, I've treated lung cancer, you know, and he was talking about smoking. He didn't hear the word. He deliberately didn't hear the word nicotine. He heard the word smoke. And I wasn't having that. I said, no, no, no, nicotine. And we know that nicotine is, yeah, it's part of the package of people getting addicted to cigarettes, but we don't really talk about NRT being particularly addictive. Addiction and NRT doesn't seem to be a phenomenon. Popcorn lung, not much more to say about that. Unfortunately, and of course the Avali phenomenon in the US has now been used as a weapon to discourage people from using electronic cigarettes. I think this guy needs a pardon, nicotine. Now I know he was giving cigarettes out, but it's amazing, everybody always calls it a nicotine habit, like nicotine is the problem and the rest of it is not. Here's the great man, it's great seeing the awards for GFN named after his incredible, I mean these guys were ahead of their time really. People smoke for nicotine but die from tar, I mean that'll be etched forever. Last year when I was here actually, Clive did a great talk on nicotine and maybe one of the things that we don't really talk about is the pleasurable effects of drugs. Like whenever we have any policies in my country, it's all about the harms of drugs. You're not allowed, God forbid, you could get pleasure from drugs. That's not allowed. But we talked about nicotine last year and people like nicotine and they feel it helps them. And it doesn't seem to be particularly harmful. But we know in terms of nicotine and cigarettes, we know what the harm is. And I suspect our opponents know what the harms are. But with electronic cigarettes, they like the hand to mouth and the simulation of smoking, which I think is the real gift of electronic cigarettes. And as I say in the last line of that slide, nicotine is very low risk of addiction on its own. So why is there a war on nicotine? I'm giving this fella too much time, really, but I mean, you just only have to read this crapola. When the tobacco industry introduced electronic cigarettes, one narrative they tried to sell is that this is part of harm reduction. I mean... How can a man in a position as important as the Director General of the WHO, the biggest international health authority, health organisation, come out with a statement like that? And I was quite disappointed in many ways when, obviously when I heard this, because the WHO in terms of harm reduction, the wider harm reduction for things like heroin addiction, crack cocaine, they've come out strong. They call methadone and buprenorphine essential medications. And yet here they are coming out, really just completely dismissing electronic cigarettes. So I'm going to finish up. I did well on the time, Sarah, didn't I? I did good. So just a few points. It's meant to, the precautionary principle is meant to protect the public. It seems sound on the surface, but I think you have to look, particularly here, at what's waiting at the pass. What's waiting at the pass is a deadly habit that's going to kill people. It's going to kill half of its users. That doesn't seem like a great use of a principle like the precautionary principle. Unintended consequences, as I say, when do they... When do they continue to be unintended if decade after decade we're making the same mistakes? There's many unfortunate examples, as I've shown, of the precautionary principle that have been implemented to cause suffering and sadly death. The Australian prescription model, which everyone I'm pretty sure here will be familiar with, has been an absolute disaster. And again, I wouldn't call them unintended consequences. We knew that was going to happen. I think the figure is something like 8% of people are actually accessing it on prescription. That is, and I wouldn't mind. Australia authorities are doubling down. They're doubling down. They're standing over this absolutely disastrous policy. We do have some threats ahead with the potential for flavor bans and disposables. And unfortunately, the medical profession, I can't speak, across the world although I don't think it would be probably much different but uh in Ireland we they haven't embraced electronic cigarettes it's difficult to know we have a number we've many thousand doctors in Ireland and very few of them are vocal one way or the other I'm probably a lone voice and there's probably a few voices in the other thing and that's what gets played out in the media um but it's it's it's a real uphill battle um you know when you look at the uh unequivocal support that WHO, it took them a while to get around to supporting drug harm reduction. They just have a very deeply negative stance on electronic cigarettes and I go back to my earlier slide, why? I don't know why. I don't know where this has come from because unfortunately it is increasing the harm to people who smoke and the wider community. I want to thank you all for listening to this presentation.

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Sarah Cooney: Thank you very much, Garrett, for that very thoughtful presentation and handing over to Alex to do the response.

00:37:25 --> 00:46:44

Alex Wodak: Well, thank you. Thank you, Sarah. And thank you to the organizers for inviting me to speak on this subject today. I'm going to quickly race over five questions that I want to put to you and ask you to think about. The first question is, what does the precautionary principle actually mean? Secondly, why did the anti-harm reduction tobacco control, to use the terminology that Ethan recommended to us, why did our opponents take up the precautionary principle? Thirdly, why did our opponents so suddenly drop their references to the precautionary principle? Fourthly, are our opponents well organized? And fifthly, is the anti-tobacco harm reduction, tobacco control movement unique in the way it operates? So let me delve into those questions briefly and then we can all get into some audience participation in this discussion. Let's go to the first question I posed, the definition. I'm sure I'm not alone in saying to you that I struggle with the definition of precautionary principles. What the hell does it mean? I read it over two or three times, my eyes glaze over, and I still don't know whether I'm reading something that says anything significant at all beyond what is commonsensical, that when embarking on a new policy or continuing a previous policy, we're obliged to consider all the benefits, the potential benefits, all the costs, unintended consequences, all of that, surely that's common sense. We don't really need a principle to tell us that that's what we should be doing. So I find the definition elusive and slippery and I'm not sure it really says anything that's of any significance. Secondly, why did our anti-harm reduction tobacco controller friends take up this issue and campaign on it so seriously a few years ago? Now, I think that's an important question. And why did they then drop it only a few years later? It seems to me that this was a deliberate attempt to obfuscate, to delay the discussion about the more important issues It was a distraction. It was all of those things. But it wasn't a serious attempt at policymaking in an area that really is not that difficult, as Garrett has pointed out to you so eloquently. And why did they suddenly drop? Are our opponents well organized? Are they benefiting from well funded, well resourced, well carried out communications research, as I suspect they are. Are they doing focus groups and finding out what really works? How do they manage to have the same kind of discussion against harm reduction, tobacco control in almost all the countries in the world happening around about the same time. Surely that isn't happening by accident. Surely it is well-organised, well-resourced, well-funded. Final question I want to put to you is whether or not this is unique. In the session that Ethan Nadelman chaired yesterday about prohibitions, The point came across to me very strongly that the sort of people who are involved in this issue really fall into two main groups. The majority are people who have spent decades, much of their lives, involved in smoking, trying to reduce the prevalence of smoking. And a minority of us have been involved in smoking in trying to reduce the harm from all psychoactive drugs for a long time. And many of us were very involved in those efforts as they revolved around the control of HIV infection. So we have different experiences. But I would say to you that the patterns that we saw In the various campaigns and issues we've fought for over the years in harm reduction applied to all psychoactive drugs, we're seeing exactly the same pattern in this issue. The issue of gateway drug was used against cannabis to try and stop the inevitable regulation of recreational cannabis. The claim was made that that cannabis was a gateway to heroin use. That claim originated from a very distinguished, highly regarded researcher. Efforts over three or four decades to find evidence to support that contention came up with nothing, and eventually the issue was quietly dropped by the opponents of cannabis regulation. So it's not surprising for me And I'm sure for others who have been involved in drug harm production for a long time to see this issue reemerge in terms of vaping being a gateway to smoking. There are many other analogies. Just think of the children was used. very widely against drug harm reduction, just as it's being used against tobacco harm reduction. But even beyond that, even going beyond the drugs field, I think you can see that elements of what we are facing are not by any means unique to this issue of vaping advocacy, vaping reform advocacy, I should say. In July 2002, Sir Richard Dearlove, who was the then head of MI6 in England, in the United Kingdom, came back from three days he had spent in Washington, D.C., with the then head of the CIA, George Tenet, who was briefing him on the developments to... invade Iraq, which most of the Western world tragically did in March 2003. Sir Richard D. Love, who is known in British official circles, or the head of MI6, is known as C. So Richard D. Love attended a meeting of the War Cabinet in 10 Downing Street in July 2002, and the Prime Minister and the Ministers for Defence and Foreign Affairs and the Chancellor of the Exchequer, all the senior cabinet ministers in the War Cabinet were present. and we have the transcript of what actually happened at that meeting of the War Cabinet in 10 Downing Street in July 2002 thanks to the great humanist Rupert Murdoch who became entangled with the then British Prime Minister and in revenge published the transcript in Sunday Times. And it included a remarkable sentence Now, what on earth could the war in Iraq have to do with this issue? One thing that is common to both is what Sir Richard Dearlove informed the War Cabinet in London of what was going on in the United States. And he said that, and this is word for word from the transcript, but the intelligence and the facts are based on the policy. And surely that's what we are facing, exactly the same issue. At least for our opponents, the intelligence and the facts are based on the policy. And that's why our opponents will eventually lose and we will eventually win.

00:46:56 --> 00:47:30

Sarah Cooney: Thanks very much, Alex. I mean, there's a lot going on here. Before we open it up to the audience, I wondered what lessons you think that work with addictive drugs is going to, how's that going to help with harm reduction? You say we're kind of where we were with tobacco harm reduction, where you were with drugs 30 years ago. Can we speed that up? Can we, what are the lessons from working with drugs that you can take across to THR?

00:47:40 --> 00:50:44

Garrett McGovern: We're gonna learn a lot of lessons, but one lesson we really need to learn is that if we delay, we're gonna increase the risk of harm to people. So that's the biggest lesson. It took a long, long, long, long time for harm reduction to be accepted. There was a sort of moral abstinence ideology for a long, long time, and it still prevails. I mean, it's not gone away. There's still many people in my country that I've heard people call methadone an abhorrence. It's the lesser of two evils. So we still have that brigade. The only thing is we're lucky because, well, you could call it lucky. It was years of advocacy that led to this. but the government has embraced harm reduction. And in Ireland, I'm just speaking from an Irish perspective, we're looking at opening our first injecting center. I mean, I know in Australia and many countries around the world, there's about a hundred of these sites. So harm reduction is accepted, but I just, I think the real message here is that if we delay, we're going to cause death. That's the main message. And we're 20 years in now, 20-odd years in with electronic cigarettes. Nobody's dying. Many people have got benefit. As many people, dare I say it, as I said in my talk, find electronic cigarettes pleasurable. Really, that's what the message is, and there's so many threats ahead. I think, you know, a big theme in this conference has been the threat to flavours, which is, I think we all agree, a de facto ban, and will probably obliterate many vaping... will obliterate the vaping industry. So we've got to resist that, and we just have to keep... Piling out the truth and piling out the good studies and all the things that we know to be true. We just have to keep, we have to stay on our feet. It's very tempting to get despondent in this. But, you know, I'm going to keep going. As long as I'm breathing air and blood is coursing through my veins, I'm not going anywhere. Plus, I enjoy it. There is a part of me that likes the cabaret of having a kick at the other side. I know I shouldn't admit that, but I actually do, because they're easy to pick off. Their arguments are so vacuous that you don't have to say very much for them to make idiots of themselves with some of the stuff they come out with. Unfortunately, I think Alex mentioned it, it's legislators really that are the problem. They're the ones who get their head turned. And many of the people who are anti-electronic cigarettes in Ireland are meeting government officials in secret. It's not... It's not a fair deal. A lot of the influence is the way it's done in Ireland. You pick up a phone and you talk to your political buddy who has the influence. So that's the way I would look at it.

00:50:52 --> 00:54:03

Alex Wodak: The message I want to bring to you is the message of hope. If we just put aside this issue for a moment, and think of the sweeping social policy reforms that have occurred in many issues, including the drugs issue, over the last 30 or 40 years. Sure, I wish it had gone faster, but undoubtedly it's happening. If we look at the drugs harm reduction area in Australia, The United Kingdom under Margaret Thatcher was the first, if not the first, one of the first countries in the world to adopt needle and syringe programs. And there are now between 80 and 90 countries in the world that have needle syringe programs. And that number continues to creep up slowly. Similar for methadone buprenorphine programs. And the smaller number have... pharmaceutical heroin programs, but that number's also slowly creeping up. And these numbers were unthinkable in the 1980s and 1990s when the drug harm reduction movement got going. We can also draw a lot of inspiration from what's happened with gay law reform. In 2001, the Netherlands became the first country to allow marriage equality. And now there are over 30, I don't know the exact number, but well over 30, and the Republic of South Africa is the first country in Africa, and Taiwan, I think, was the first country in Asia. And that's now really starting to spread beyond the high-income European, North American countries. and many other issues that we can draw comfort from. Sure, the pace is much slower than we would like, What are the ingredients for success? Well, clearly, like-minded experts getting together is very important, but that on its own is not enough. Consumer advocacy is incredibly important in all of these issues. On its own, it's not enough. It's really working together, and there's no better demonstration of that working together than the people from diverse backgrounds, from multiple countries around the world meeting here once a year and gathering. And I think through that we can take on issues like the precautionary principle and all the other nonsense that's thrown at us and really make some headway. I think one of the most important things we can all try and do is to meet face to face with our political masters, politicians of all stripes and colors. Meet them, talk to them, tell them your experience. And it's very important that people with lived experience tell what's happened to them. That really makes a big difference to politicians.

00:54:03 --> 00:54:18

Sarah Cooney: I think there's only one working microphone. So thank you very much, and I wanted to open up the floor to questions from the audience. Ariel.

00:54:21 --> 00:57:37

Tikki Pangestu: Thank you very much for the wonderful presentation. My name is Tikki Pangestu. For 13 years, I was a director of research policy and cooperation at the World Health Organization in Geneva, Switzerland. I just want to make a point about Garrett's last comment. without in any way sounding disloyal to my former employer. I am personally very disappointed in the stance that the WHO has taken on harm reduction. And I say this because I come from Indonesia, And many of the countries which are low or lower middle income countries look to the WHO for guidance. And this is because they lack their own capability to objectively assess the evidence and make their own policy decisions. In my presence, some of my presentations, I quote Roberto Sussman, I'm not sure he's in the audience, who say that many low income countries look to the WHO as Catholic priests used to look to the Vatican in the past. And that's the truth. And it's very disturbing. My own country in Indonesia say, okay, we've seen the evidence, but this is what WHO says, so we follow them. So that's the reality. So the question is, why is that? And having spent 13 years at WHO, the first thing that comes to mind is that WHO gave birth to the FCTC. So as a parent that gives birth to a baby, they would protect it at all costs. But perhaps more important is the question of resources. WHO has always been strapped for funding. And the TFI and many of the tobacco-related activities is sponsored by a man that Gareth showed which starts with the initial B. So that's the reality of the funding. And I thought about how do we change this? And I can share with you that the only thing that the man in the second last slide that Gareth showed, the only thing that will make him sit up is if the member countries demand change. So I've said this many times, if countries, progressive countries like the UK, like the New Zealand, like some of the other countries, perhaps Japan and many other smaller countries, if they collectively go to the World Health Assembly and say to the Director General, we want a more open, a more objective discussion around this issue. That's the only thing that will make him sit up. That's the reality. WHO is a political organization controlled only by the member countries. And I want to be a little bit optimistic. At the last COP10 in Panama, we are beginning to see some countries agitating for something like that to happen. And I agree fully with Alex that collectively, it's about all of us working together from different parts to sort of move this along to reach that tipping point. Thank you very much.

00:57:37 --> 00:57:52

Sarah Cooney: OK. I have Arielle who had her hand up and then Clive. Or did either of you want to respond?

00:57:52 --> 00:58:41

Arielle Selya: Hi, Arielle Selya. I work at Pinney Associates. We consult for JUUL. I'm channeling my colleague Joe Gitchell for this question. In thinking about the COVID pandemic, I think there's a lot of parallels. So for example, the precautionary principle, I think most people would agree that it didn't make sense to do nothing while we wait for long-term outcomes of the vaccines. And I think there's also a discrepancy with the age groups that are focused on for the two different issues. So for the pandemic, it was pretty well accepted that young people had to make sacrifices like closing schools and for the sake of the older people who were in immediate danger. and it seems the opposite for here. So do you see this as related to the precautionary principle and can you comment on that? Thanks.

00:58:44 --> 00:58:47

Sarah Cooney: Clive, do you want to ask your question and then they can answer both?

00:58:52 --> 01:01:32

Clive Bates: just two thoughts on the precautionary principle and a suggested way in which it can be used in this field. I think it's important to remember where the origins of the precautionary principle came from. It was really used to deal with a certain kind of risks, gigantic risks that were mainly sort of irreversible and had dread consequences. So things like releasing a pathogen into the environment, releasing alien species into an ecosystem, rise in endocrine-disrupting chemicals in the environment. And the characteristics of these risks is that they were like system-wide, and once the sort of genie was out of the bottle, they were very difficult to put back in, okay? So that's the first thing. And really, the risks associated with vaping are nothing like that. They're individual. You could stop at any time. It doesn't persist under its own momentum. Secondly, the precautionary principle, at least in the definition used by the EU, is a symmetric thing. So you have to assess the costs of action and inaction. And that actually gives us the route into my third point, which is how we should think about it in this field. When people apply it and say, you know, we want to ban flavors on a precautionary basis. Okay, the question that we should be, the way we should operationalize this is to say, Precautionary principle is about asking the question, what if I'm wrong? What if my understanding of this is wrong, if something different happens within the realms of possibilities? Now, the people who want to ban stuff say, well, the unknown effects of vaping over the long term are unknown, okay? You say, yes, okay, it's possible something will happen, but we'll probably be able to intervene, we'll be able to find out what the damaging substance is, is we'll be able to control it or modify it and actually people will still be able to quit individually, won't carry on killing people. What if the people who are trying to ban stuff ask the question of themselves, what if I'm wrong? And the what if I'm wrong thing means that more people will smoke and they will definitely get sick and they will definitely die and they will definitely, definitely, definitely be harmed. So changing the precautionary principle into asking the question what if I'm wrong I think gives us leverage into applying it symmetrically in a way that affects the people who are acting recklessly by using the precautionary principle. So that was just some points I'd obviously like you to respond.

01:01:38 --> 01:01:40

Sarah Cooney: Any other questions to come in?

01:01:49 --> 01:02:46

Mattia De Domincis: Matteo Dominici is responsible for innovation in . I joined the industry relatively recently. And the comment for me is quite shocking to see how now illicit is having predominance versus the legal products in the space of harm reduction. So that's, to me, a consideration which is quite staggering, where things are actually not controlled versus things that are introduced with a lot of research and science behind. The question that I have from my side is there is from the authorities of WHO a little bit of a position on the scope of armed reduction when armed reduction is enlarging the population and is actually assessing youth and other things, understandably. Do you see armed reduction as the end game or there is something coming beyond armed reduction?

01:02:55 --> 01:04:08

Garrett McGovern: I mean, there's so many questions. I'll answer yours because it's the most recent. Yeah, I think harm reduction is a perfectly good endpoint. Why not? I mean, medicine, that's what I do every day. I just try and reduce harm. And the more harm I can reduce, the healthier people get. So, yeah, harm reduction is an endgame for me. I mean, I haven't worked in drug treatment for many, many years. It's not perfect, but, you know, it's called harm reduction, not harm abolition. I'm not going to abolish all harms. It's just not possible. So, yeah, I think it's an endgame, and it's a good endgame. And in this case, we're talking about significant harm reduction. It's huge. That's a great point, by the way, about the... the guy from WHO. You haven't burnt your bridges, I hope, in WHO, have you? Do you still have some contacts in there? Oh, good, good, good. Because I think that is an absolutely excellent idea. We need to make inroads there and we need to challenge them. You know, we talk about the precautionary principle and, of course, the proponents, there's the burden of proof. No, the burden of proof should be on them. They're the people who are blocking this. Alex?

01:04:11 --> 01:07:02

Alex Wodak: Can I sadly say to you that I think one of the realisations we have to come to is that we've reached a point in this debate where evidence no longer matters. Surely if evidence did really matter, we would have enough evidence just from the experience of Sweden and the comparison of Australia and New Zealand. Sweden, after all, has had roughly 200 years of experience with snus. During that time, there's been enough research to show that the adverse effects of snus are either minimal or non-existent. The comparison of Australia and New Zealand is also very revealing. if evidence really mattered, we wouldn't need more than these three countries. Australia and New Zealand had virtually identical policies for decades in the tobacco area and very similar outcomes. The smoking rate in Australia was maybe slightly lower than in New Zealand. All that changed in 2020 when the four major political parties in New Zealand got together and agreed that their policy on vaping in New Zealand had to change. And it did change over the next six or 12 months. What also happened is that the smoking rate decline accelerated in New Zealand and smoking rate fell twice as fast in New Zealand as it did in Australia during the comparable period when Australia's policy was tightening and ever tightening and ever more restrictive policies. So that's one thing that happened. The second thing that happened is that New Zealand didn't experience and still hasn't experienced a vaping black market. And Australia has experienced a very flourishing vaping black market, which has now become quite violent and increasingly violent. And the third thing that happened, and others might want to comment about this, is that youth vaping appears to be starting to decline in New Zealand. I don't think there's certainty about that yet. But we can't say the same in Australia with its draconian approaches. If evidence mattered, I think we wouldn't need much more than that. And the what is wrong question, sorry, could I be wrong question that Clive rightly reminded us is behind all this, would surely have to be posed to our opponents and not to us.

01:07:05 --> 01:08:48

Garrett McGovern: Yeah, I would agree with all that. Just to Clive's point about the precautionary principle, I think we need to redefine the precautionary principle, where it should be applied. And I think the first thing, the first line of the precautionary principle is that we need to establish very early that is the precautionary principle going to cause more harm if we can... if we can establish very, very, very quickly, which we did with electronic cigarettes, they were measurably less harmful than smoking. So I think Alex talked about the precautionary principle has been as clear as mud, and there are different variations of it. I just don't think it applies here. I mean, of course we need to evaluate electronic cigarettes, the negative effects of them. But you have to remember, we found what we were going to find anyway. It's not combustion. It's vapor. It's in much less quantity some of the stuff that's found in cigarettes. We knew pretty much what we know now about the harms of electronic cigarettes. If we're dealing in absolutes, well, then... There's very little we can do about that. Unfortunately, the country I come from, they're dealing in absolutes. I mean, one of the anti-electronic cigarette kind of faction said that, quote, we're measuring electronic cigarettes beside the wrong thing. You're measuring it beside tobacco and smoking. That's a pretty low bar. We need to measure the harms on its own. This is a person who I'm pretty sure is otherwise intelligent, very well qualified, coming out with stuff like that. I mean, what's that? I'm speechless. I'm speechless now just listening to that line. He actually said it.

01:08:49 --> 01:09:30

Sarah Cooney: There are astonishing things, and even in Sweden, where you're almost below 5% smoking incidence, the thing that surprised me the most about the Swedish experience was that public health authorities resent snus. They don't like it. They don't want to admit that that's what has allowed their country to achieve such a low smoking incidence. The only thing that public health authorities did was treat snus differently from a tax perspective, so they provided a financial incentive, but they don't, I mean, I'm sure there's someone from Sweden who knows better, but they don't like snus, and that's a country where it's, I mean, they've achieved what they need to achieve in terms of smoking incidents.

01:09:32 --> 01:10:48

Garrett McGovern: Just to pick up on Ariella's point, the whole COVID thing is very interesting. From how we manage COVID, there was a precautionary principle there. There are many people, sadly, who, from an economic point of view, were obliterated. I think, OK, COVID seemed like a new phenomenon and we were all very cautious about how we treat that. But I don't think we looked at the unintended consequences of COVID. And the most obvious thing with COVID was the vaccine. I mean, the vaccine was hot off the press after 12 months. There wasn't much in the way of precautionary principle about that. Quite rightly so, they said, hold on a sec, this could kill a lot of people, this virus, and particularly vulnerable people. We need to get a vaccine out there. But it's amazing after 20 odd years of electronic cigarettes how we're still crapping on about what the harms of electronic cigarettes are. The vaccine, and I'm, by the way, I'm pro-vaccine, I'm not anti-vaccine by any stretch of the imagination, but it is interesting that policymakers will do things when they want to and ignore certain principles that they will put in place like the precautionary principle for electronic cigarettes and avoid the precautionary principle, you know, when there's something like COVID.

01:10:48 --> 01:10:52

Sarah Cooney: I think Clive has a response to what you were just saying.

01:10:56 --> 01:13:34

Clive Bates: it's really important to understand that the precautionary principle is this symmetric thing where you look both at the consequences of action and inaction. So I think it's perfectly reasonable to say that they took a precautionary approach to the vaccine medication because On the one hand, they had to assess the uncertainties associated with bringing a novel vaccine into the market, and they judged those to be... There were uncertainties, but small. On the other hand, they had to judge the consequences of not bringing the vaccine onto the market and letting a respiratory pathogen run riot uncontrolled and unattenuated by vaccines, and those risks were gigantic. So this is what I'm really saying about the precautionary principle. It's not a one-way bet against innovation. You have to also consider the consequences of not having the innovation. And that's where I think we get to with this, which is if you don't have the e-cigarettes, the low-risk products, because you're worried about residual uncertainties, And there are uncertainties. There may be things that crop up and bite us in the future. Who knows? We won't know that for 60 years. But if you act now on the basis that those uncertainties are so overwhelming, you then have to say, well, what is the consequence of doing that? And you let an epidemic of cigarette smoking going. And if I could just have one final point. this question of whether you should compare to the inhalation of fresh air or the inhalation of cigarette smoke, really that gets down to what you think is the demand for nicotine. If you think the demand for nicotine as a recreational drug in society is fairly resilient and fairly robust, it's going to carry on, like alcohol, like caffeine, like cannabinoids, like basically most substances, then your question is, what are the different ways of using nicotine and what are their respective risks? Because you're not talking about the phenomenon of nicotine use somehow disappearing and everything rebasing to a no substance use, no nicotine use kind of basis, on which case a comparison with fresh air might be... more appropriate. Once it's accepted that there's a persistent demand for nicotine because it makes people feel better, function better, has therapeutic properties, or whatever the reasons for the demand are, you're into comparing different ways of using nicotine.

01:13:37 --> 01:13:46

Sarah Cooney: Thanks, Clive. Are there any other questions in the audience? I see someone at the back.

01:13:51 --> 01:15:23

Roberto Sussman: Hi, Roberto Sussman from Mexico. I participated in a parallel event to the last COP, and something that was very disappointing was the reaction of the British delegation towards not even mentioning harm reduction. It was too mild. And I don't remember exactly the New Zealand delegation, but these are countries that have implemented harm reduction as a state policy. And they should have spoken up. And I think that it is up to, especially people in Great Britain and New Zealand, to press the government so that their delegations would speak up. This is what colleagues said. You need countries to say no. And I think that this can generate a cascade effect. Once countries start, two, three, four countries start saying no, this will generate a crisis because the FTCT is based on unanimity. So break this unanimity, it can trigger a process. So this is very important to bear in mind. Thank you.

01:15:25 --> 01:15:29

Sarah Cooney: Thanks, Roberto. Do we have any comments, questions?

01:15:30 --> 01:20:11

Alex Wodak: I'll just add to that, if I may, and that is in the 20, 30 years ago, I was very involved in international efforts to accelerate the uptake of drug harm reduction to control HIV among and from people who inject drugs. And it was a common experience to go to, say, Kuala Lumpur in part of an international delegation And to hear, and I'm just using Kuala Lumpur as an example, to hear Malaysian officials say, well, why should we do that when Singapore and Jakarta aren't doing that and when Hanoi is not doing that? So there's no doubt that countries follow... minutely, very, very closely, meticulously, what their neighbours are thinking and doing. As we all do as individuals, it shouldn't be a surprise. And there is, as Roberto just reminded us, a kind of a cascade effect. And we saw that also with the example I gave of marriage equality. If you look at the timeline of when countries started accepting marriage equality, particularly in Western Europe, you see the Netherlands was first, and then it was a few years before some other country, and then maybe only one or two years before the next country. And the speed of adoption has accelerated. We're seeing that again with the regulation of recreational cannabis, that Uruguay was the first in 2013, and then that was a staged approach, and then Canada was the next in 2018. and now that process is clearly well underway, particularly in Western Europe, and will clearly spread around the world. Now, that's only looking at national adoption, and, of course, we should also look at the adoption at the state or provincial level. Another thing that's worth thinking about is that, particularly in countries that have got federal structures, like the United States, Germany, Australia, The way this happens plays out very differently from more unitary governments like, say, France or China, where in the federal governments, Adoption often starts at the municipal level and then goes to the state or provincial level, and then it goes to the federal level. Can I just finish on one other point, and that is... We should always be mindful of wild cards that no one anticipates things coming out of, apparently, out of the blue. The country with the most smokers in the world is China. The world's biggest tobacco company is the China National Tobacco Corporation, with something like 40% of the world production of cigarettes. And China is... anti-tobacco harm reduction, but yet vaping is not uncommon in China. And also the China National Tobacco Corporation has the world's largest collection of tobacco harm reduction patents. Now, acquiring that portfolio must have cost billions of dollars, and that couldn't have been done without the cooperation of the Chinese government. with the approval of the Chinese government, which is the 100% owner of the China National Tobacco Corporation. It only needs a decision in Beijing to switch from official anti-tobacco harm reduction to pro-tobacco harm reduction, and this debate's over. So remember also that when we're thinking about precautionary principles, often things come out of the blue, or apparently out of the blue. Who would have ever thought that Prime Minister Thatcher's decision to close coal mining in Britain was one of the best things she could do for climate change, which at that time she was very worried about and later changed her position on that. But anyway, so think of wild cards as well.

01:20:13 --> 01:20:50

Sarah Cooney: Well, and thinking about that wild card, when you think back to decision-making and precautionary principle being one element, and as Clive was talking about, risk assessments, but also weighing up the greater good, weighing up political and economic and other factors, China could easily flip overnight. And when they see that the public value, when that equation on public value changes, it could easily flip overnight. That would be a very interesting day. So are there any other questions or comments from the floor? Over here.

01:20:50 --> 01:21:43

Tikki Pangestu: I just want to quickly add to what Roberto just said and Sarah that you alluded to. At a session yesterday on consumer influences in tobacco harm reduction, a lady from Sweden, which has been highlighted, is probably the best success story for tobacco harm reduction. She mentioned actually that the Swedish delegation at COP and at the World Health Assembly actually was not interested in actually even raising the issue. And that's what you said, that the public health authorities, policy makers actually don't like it. So I think it's incumbent upon all of us to work on those people that actually have influence on the WHO to try and slowly shift that needle. Thank you.

01:21:46 --> 01:22:16

Sarah Cooney: I think you're absolutely right. It reminds me of something that Alex was saying recently about the importance of bringing advocates with you. And I don't know if you want to, well, bringing advocates and bringing stories of real people to politicians, because that's much more compelling than data on a page. Are there any? There was a question over here and then over here. Okay, you've got better eyes than I do.

01:22:21 --> 01:23:55

Bengt Wiberg: Bengt Wiberg from Sweden. I can just concur what Sarah said about Sweden. We have a government, we have a parliament majority for tobacco harm reduction, especially supporting snus and nicotine pouches. But then, when it goes to action, We have this social department, health department, where the majority of the people are anti-all nicotine. So it comes down to persons. The Swedish parliament demanded a year ago an investigation comparing the relative risk between different nicotine products. What came out was nothing. They didn't care. And I think one thing which is very difficult to deal with is that if you have the wrong person with his own or her own mindset sitting in positions for like Dr. Tedros, is in for the eighth year now. I mean, presidents are elected for four years. If you have the wrong person, we will never get anywhere. So I concur with you. Let the small countries, the successful countries, speak up. Thank you.

01:24:00 --> 01:24:03

Sarah Cooney: Is there anybody? All right.

01:24:05 --> 01:25:07

Rachel Jia: Thank you. I'm Rachel from China. So when we are talking about China, I just feel obligated to add one comment, that actually if we recall China's position on last COP, they have actually firmly requested more scientific study on novel tobacco products. So I think he's made not a conclusion to say that China is anti-tobacco harm reduction. It is just not provoking enough on that regards. And about the tobacco harm reduction actually in China, they have been, advocate for tobacco harm reduction for years. However, I would say they may not in the right path in the past decades because their idea is reducing the tar. However, if we look about the recent patents that the Chinese tobacco monopoly are applying, they have also done a lot of studies on HTP and e-cig. So I just want to share this progress of China. Thank you.

01:25:11 --> 01:25:17

Sarah Cooney: But they're continuing to review the evidence. That's a good thing. And waiting for the right moment to make a decision.

01:25:18 --> 01:27:11

Cecilia Kindstrand: Hi, I'm Cecilia from Sweden, from Swedish Match. I think this is not only a problem within this field, and I think it's due to the political system. We have engagement from voters every four years, or every three years in some countries, and then it's up to the politicians and the civil servants to push agendas. And there's so many examples in the European Union, for example, where Everyone went around the Green Deal, we need to do something, and the Commission came out with an enormous amount of proposals because we had to save the environment without any considerations or unintended consequences. One is the proposal to ban combustion engines in cars, which is interesting because the car industry is the biggest industry in the EU. And we're not that strong in electric vehicles. There is no electric grid if the entire car park would be changed. But just imagine what would happen if the... What would happen with a lot of unemployed people that couldn't work because the combustion engine was... was banned, and at the last minute, of course, Germany came in and said that, well, it might not be a good idea, but it went almost to a decision. It had been a decision in the Parliament, but at the final moment, the Council said, we're not going to go there. So there's an awful lot of decisions being taken when no one is looking. And I think we should also remember that it was very close that e-cigarettes would have been banned when the Commission came out with its proposal 2012. Can you imagine how many non-ex-smokers we would have had today should they have been successful? And it was only because you had some initiatives from the consumers.

01:27:15 --> 01:27:27

Sarah Cooney: Thank you. Thanks, Cecilia. So we're almost out of time, and so I just wanted to, I don't know if you want to say a final comment, Garrett and Alex, before we finish up?

01:27:30 --> 01:27:34

Garrett McGovern: Down on the precautionary principle. That's my final comment.

01:27:35 --> 01:28:25

Alex Wodak: Move on, nothing to see here. Well, my final comment to you is that to have more hope. I think if we look around at similar issues across the whole world, reforms like the reform we all want do happen, but they happen very slowly. And they only happen if a lot of people work very hard to turn things around. But they do turn around. So we need to keep on meeting like this. We need to keep on working together. And we need to promote consumer advocacy. We need to... promote expert to expert discussion and expert to consumer advocate discussions. But we'll get there.

01:28:26 --> 01:28:35

Sarah Cooney: Well, thank you very much, Gerard and Alex, and also the questions and the discussion. And I'd like to close this session and see you all in the break.