Harry Shapiro is joined by Lindsey Stroud and David Sweanor for this Commentary Team session, filmed at the 2024 edition of the Global Forum on Nicotine!
Transcription:
00:05
Harry Shapiro: Good morning, good afternoon, or good evening, depending where you are in the world listening to this. Welcome to the 2024 Global Forum on Nicotine Conference coming at you from Warsaw. My name is Harry Shapiro. I'm the executive editor and lead author for the Global Tobacco Harm Reduction Report. I don't know the title by now. I've been doing it for long enough and all my ears and things have fallen out on the floor. So we're off to a good start. I've got two guests with me on the commentary team today. I've got Lindsay Stroud. who is Director of the Consumer Centre for the US Taxpayers Alliance, amongst many other tobacco harm reduction hats that she wears. And I've also got David Swenor, who's the Adjunct Professor of Law at the University of London. Ottawa in Canada, who's also got a 40-year career in tobacco control and law and combating the egregiousness of the tobacco industry at various points in his life. So welcome. So 2024 is actually quite a sort of signal year in terms of tobacco harm reduction. As the Beatles once said, it's 20 years ago today. 20 years ago, not necessarily exactly today, but certainly this year when the first commercially available vape hit the streets in China thanks to Honlick's pioneering invention. And in a relatively short period of time, we've got a huge range of products available. We've got an industry worth, market analysts differ, but anywhere between 30 and 50 billion US dollars. We've got upwards of 120 million users of safer nicotine products across the world. Mainly, I have to say, in higher income countries. And that's a serious issue that needs to be addressed. So bearing all that in mind, Lindsay, reasons to be cheerful?
02:36
Lindsey Stroud: Reasons to be cheerful? Well... 120 million people using e-cigarettes is a good reason to be cheerful and hopefully you know the majority of them had been formerly smoking um but 2024 we did have the cops so and nothing got done at cops so that's where i'm cheerful at right now um on that one but i'm coming from the united states where everything's on fire right now in tobacco harm reduction so indeed.
03:02
David Sweanor: Yeah, I think there's an awful lot to be optimistic about That the total numbers of people who are using these products what we've seen happen to cigarette sales cigarette smoking in many of the markets The innovation that's happened if we look at the sort of products that were available that became available 20 years ago compared to now I mean that that piece of change is similar to what we've seen with mobile phones I mean they just a phenomenal difference and we now have categories that didn't even exist then and that were beyond anything that anybody had even thought of at that point. And then we look at the countries that have had major breakthroughs. The biggest declines we have ever seen in cigarette sales in any country ever have happened in recent years and are associated with substitution effects. Exactly what we've seen in so many other products and services. You give people a better alternative, they move to it. And even with all the obstructions, consumers are moving to these products. Even in countries that have tried to ban them and ban them harder, these products are still reducing cigarette smoking. So we're seeing consumers move, the market's moving, and I think it's consistent with what we've seen with so many other areas of technology, that it's unstoppable. You're not going to stop innovation. It's a matter of at what point...
04:18
Harry Shapiro: do countries have enough sense to say we're going to work with consumers with market forces and solve this problem rather than we're going to get in the way and see if we can slow it down right um so we're talking about cop just now um and um you made the point that nothing happened well actually there was one thing that actually would seem quite significant happened that a number of countries uh including new zealand but mainly smaller countries that weren't exactly big players in the tobacco harm reduction world, began to put their finger up and saying, hang on a minute, we need to be talking about tobacco harm reduction, which severely agitated those on what we might call the opposition side. But that felt quite significant. And I noticed some people, you and other people out there, may have noticed the latest WHO tweet on the matter that suggested that vapes were, quote, and direct quote, designed to kill. Now, equating vapes with a high-powered rifle seems to me the politics of the desperate. Do you think and I say we, we are winning the argument that they are getting quite desperate about all of this? Or is this just a bit of kind of loud hail of politics that you might expect? It sounded a bit desperate to me.
05:51
Lindsey Stroud: I think they're desperate. I mean, the whole kid argument that they're using now. I knew it was bad when they started turning their eyes towards the UK and New Zealand to go after youth vaping because in the States it dropped. That's when you knew it was really bad. But then, I mean, They are hiding behind the children. That was the thing that the end of COP and the secretariat, the FCTC secretariat, you know, sat there and said that even if one kid gets addicted to nicotine, who cares about the smokers pretty much or the people who smoke? If one kid gets addicted to nicotine, it's not worth, you know, turning 1.3 billion people into former smokers. So I do think there... I think the argument keeps changing, and I think the WHO's got a big case of mission creep. I was going through some readings before the FCTC was a part, and looking at some of the World Health Assembly meetings, and they were talking about smoking, and they're talking about smoking and the harms that combustion did, and then it's completely turned into this whole going after the demonization of nicotine and stuff, and not really looking at getting back to the root of You were in tobacco control. Wasn't that the point? We know smoking kills you, and this is harmful. We should be reducing that. Now it's turned into this mission creep-out. We're going to go after anything that has nicotine in it now, because nicotine addiction is such a problem. It's not the lung disease that you get from combusted tobacco. Right, right.
07:17
Harry Shapiro: On this question of youth vaping, yesterday there was a session on health economics and the fact that there are unspoken benefits associated with tobacco harm reduction in terms of increasing quality of life and so on and so on. And the point was made that there's a feeling that policymakers and legislators don't get it in terms of the benefits and instead just play the what about the kids, teen vaping epidemic and all of that. But you've got a perspective, David, on what they're missing when it comes to thinking that there is, in fact, impacts on young people by a prohibitionist, obstructionist approach. Could you perhaps...
08:14
David Sweanor: Sure, I mean, I think what's happened is that we have people who are very well-funded who are using sloganeering in place of actual analysis. And so it's very easy to say something like, make America great again, or think about the children, or... Use developing brains.
08:33
Lindsey Stroud: Yeah, that's right.
08:34
David Sweanor: So you throw out a slogan rather than thinking. And in this case, if you think about what they're saying... They're saying that all we're concerned about is young people, meaning you're willing to write off the lives of hundreds of millions of adults in order to try to prevent a young person from using nicotine, which itself has very low risk. But even if you're only concerned about the young people, even if we accept that abhorrent view that you're willing to sacrifice the lives of hundreds of millions of fellow human beings, Well, what about the young people? What is the overall impact on them of the policies you're pursuing? So how many of those young people are now going to smoke cigarettes instead of vaping? What impact does that have? How many of them are going to get sick and die because of that? How many of them are going to lose a significant other, a parent, a grandparent, a coach, a teacher, somebody who's really important in their lives, who becomes incapacitated, ill, or dying, or dead, because of cigarette smoking. And what impact, forget about the adult, what impact does that have on a young person? where a grandfather becomes somebody who's in a hospital bed spitting up blood rather than somebody who's playing catch with you. That's huge. What about the impact of their family finances when the parents are forced to buy cigarettes because they're not offered an alternative that would be far less expensive? So they no longer have the sort of disposable income, especially in poorer families, to have the sort of life that that child should deserve. What about the child's exposure to secondhand smoke because the parents are having to use a combustible product? What about the chance of the house burning down? I mean, if you take a look at all of this to say the move to vaping is a huge plus for young people. not to mention just enormous in terms of overall public health. And it's that absence of an analysis, somebody wanting to simply throw out a one-liner, use a slogan rather than thinking, and hope that you can grab people emotionally. We know that the limbic system can work like that, thinking fast, thinking slow, get people to panic about it, and they won't even think. And how long can they maintain something like that before we actually start getting people to think this through, to say what they're saying is absolute nonsense and it's repugnant.
11:02
Lindsey Stroud: I'm going to segue in a little bit. It's also this lifetime addiction. Oh, you're this, you know, that the slogan airing that you call it. But it's a lifetime addiction to vaping, a safer product. Again, we've gotten lost. It seems that we've gotten lost in this nicotine addiction versus the harms. I mean. Yeah, you don't want kids using any of these products, but at least they're using a safer product than smoking cigarettes.
11:25
David Sweanor: If we look at it and say, imagine we found a parallel universe where people get their nicotine in non-combustion forms, but they get their caffeine by smoking tea leaves. And they have all the diseases that we associate with inhaling the products of combustion, all the lung cancer, heart disease, lung disease. And somebody says... My gosh, why don't we go open some Costas or Starbucks in that land and replace what they're having or teach them to brew tea? And people are saying, what about the children? What if a child, like if you tell adults that you can brew tea rather than smoke it, maybe a child will start drinking tea. And there's caffeine in that. You know, my gosh, we've got to save the children. So the first thing we have to do is ban people from brewing tea and make sure it's illegal to open a Starbucks because we have to protect the children. I mean, it's the same stuff. And we would laugh at it. You know, now, if we think about that in terms of caffeine, but that's what we're doing on nicotine.
12:28
Harry Shapiro: Well, yeah. Although, of course, it's worth bearing in mind that one of the election pledges from one of the political parties in the UK is to ban high-caffeine drinks from the 16-year-olds. It's one of their election pledges. We know that bans always work. Of course. So we're getting around to caffeine in the UK as well.
12:45
Lindsey Stroud: Hey, they're trying to ban 16-year-olds from using social media in the States.
12:50
Harry Shapiro: Well, yes, good luck with that. um so is it the case then that um it's just a political way i mean you interesting you you we were just talking we were talking earlier about the fda i was going to mention the fda um in terms of the wider influence in terms of global policy and and stuff so um And he mentioned EVALI, so this idea that vaping kills people.
13:25
Lindsey Stroud: That's mostly on the CDC, not the FDA.
13:29
Harry Shapiro: So explain a little bit about that.
13:33
Lindsey Stroud: EVALI?
13:35
Harry Shapiro: Just the fact that... What happens, because the FDA, CDC oversee the biggest vaping market.
13:45
Lindsey Stroud: Yeah, the U.S. is the largest illegal vaping market because all its products are illegal, according to the FDA.
13:51
Harry Shapiro: Yeah, yeah. I mean, somebody yesterday came up with some huge figure for the number of,
13:56
Lindsey Stroud: Oh, their numbers keep changing, because Brian King testified yesterday in front of the Senate Judiciary Committee, and now it's 27 million applications. It used to be 26 million.
14:04
Harry Shapiro: But the percentage of technically illegal products in the States, not illegal because they're dodgy or badly made, illegal simply because... The FDA won't author.
14:17
Lindsey Stroud: The FDA never authorized anything before when the vapes first came out. It's like 2014 when they started doing the deeming regulations, 2016 when they actually hit, and then the PMTA process, what was it, 2020 when they actually had to submit their applications. But I think the biggest problem in the States, at least with the FDA, is it's a political appointment. You know, it changes when the administration changes. So that's why we had, you know, FDA Commissioner Gottlieb, who, you know, put up the continuum of harm and looked like he was moving, quote unquote, moving towards, you know, accelerating the access to harm reduction products. And then now we've got Commissioner Califf, you know, that... Honestly, I don't think he's really that anti-vaping, but that's really probably the biggest problem about the FDA. It's not really rooted in science, but it changes literally as the presidents change at this point. But I do think that they have an influence, but I don't think the rest of the world's following them. I don't know any other country that is requiring somebody to do a PMTA to bring a tobacco product to market.
15:19
Harry Shapiro: No, no, no, that's true.
15:22
Lindsey Stroud: That's true.
15:23
Harry Shapiro: But I think, I mean, it's just a question. I mean, there's the EU tobacco products directive as well. They're both, they have frameworks for what you, what we would think of what you shouldn't be doing in terms of tobacco. So what goes on in the higher income countries in terms of policy clearly does have some impact elsewhere. Yeah.
15:47
Lindsey Stroud: Well, yeah, I mean, I'm in the States. We've got five states with statewide flavor bans, okay? And they were about to do the menthol ban, but it's an election year, so that one got shelved. Because we're dealing with millions of illegal e-cigarette products. Let's just go ban one of the third of the combustible products.
16:05
Harry Shapiro: So just talking about the health economic side, David, I mean, I think you made a comment to me earlier, quoting somebody that said you shouldn't mistake malignant intentions with stupidity.
16:24
David Sweanor: Never attribute to malice that which can be adequately explained by stupidity. We have this tendency to think that these agencies are evil or politicians are only out there to collect cigarette taxes, that's all they care about. And I think an awful lot of it comes down to ignorance and stupidity, that they're being inundated with misinformation. You've got all the moral panic that exists in this field, but I think it's important to understand that this is not exceptional. This is what happens with new technology all of the time. And in fact, if I remember to put it in my pocket, Jume's wonderful book, Innovation and Its Enemies, Why People Resist New Technology. And this is a quote. This was written before anything about vaping came up. But how do you hear this and not think about vaping? Debates over new technology are part of a long history of social discourse over new products. Claims about the promise of new technology are at times greeted with skepticism, vilification, or outright opposition, often dominated by slander, innuendo, scare tactics, conspiracy theories, and misinformation. The assumption that new technologies carry unknown risks guides much of the debate. This has often amplified the levels that overshadow the dangers of known risks. I mean, that's what we're dealing with. But this is what we've always dealt with with innovation. We eventually get over it, but this is a stage that you go through. So nobody should be surprised that we're dealing with this. You know, we've dealt with it, whether we talk about printing presses or farm mechanization or refrigeration, auto safety. I mean, just all areas of innovation as they come up. We're going to have this, and it's going to be influencing politicians, but eventually reality comes through. Like eventually we found out that mobile phones don't actually cause brain cancer, but that was a huge scare at one point. So I think the fact that we're seeing so much progress, that consumers themselves are moving, that the politicians are going to have to follow that because otherwise all they do is lose credibility. The way that's now happening with WHO. WHO is saying nonsense. The result of that is they get dismissed by the public who understand that what they're saying is nonsense. But it isn't that people just say, I don't believe the WHO when they talk about anything to do with nicotine because clearly they're full of crap. They say, I just don't trust the WHO. And then that ends up having a problem when you look at vaccination programs or anything else WHO is involved in. And what we're seeing is a sacrificing of credibility from authorities. The same with the FDA and the CDC in the United States and in other agencies worldwide. And I think that's an even bigger problem. than what we're dealing with on nicotine. People are losing trust and authority. They no longer believe their governments. They no longer believe these institutions.
19:29
Harry Shapiro: Except, of course, in this particular case, you've got the WHO claiming that this is a conspiracy. On the part of Big Tobacco. They have a 25% stake in e-cigarettes. To, you know, addict our kids and get them back to smoking and all the rest of it. Now, I feel the difference here is that Big Tobacco has got a pretty bad legacy. And people are prepared to believe just about anything. about big tobacco so who and others may feel they're kind of onto a winner with this one particularly when it comes to the health of young people which wouldn't necessarily apply with previous opposition to new technologies from other you know from other other sorts of products it feels different It might not be different. But I don't think the WHO necessarily are losing credibility with the public over what they're saying about nicotine because, again, horrific percentages of health professionals still think that nicotine causes cancer. that vaping is no safer than cigarettes. They came at this believing a lot of this stuff in the first place, which is simply underlined by what WHO put out. So it seems like a bigger ask. to bridge that gap between propaganda and reality. Is it a bigger challenge or is it just the same sort of challenge you've been talking about?
21:15
David Sweanor: I think it's the same thing. If we accept a basic premise, which is there is objective truth, And if there is objective truth that the world isn't just whatever you want to believe, then eventually these groups get held to account. And we look to these supposedly authoritative expert organizations as being a source of that objective truth to move us onto something that we didn't otherwise understand, like how do you deal with HIV-AIDS? What's the role of the elimination of smallpox or dealing with polio, et cetera, that they're supposed to be leading us? And in this case, they're not doing that. But this is also happening in an age of internet and social media where people do find out what's going on. So an extraordinary number of people do learn that nicotine isn't what's causing the problem. They do learn that there's huge differentials in risk. And they do learn that these organizations are misleading them. And then how do they feel when they find out that these organizations they'd previously trusted are misleading them. And as Hakutani talked about in her book, The Death of Truth, once people find that they can get better information from an alternative source rather than an authority, it is a very short trip from there to believing all sorts of nonsense because you've given up trust in that authority. And that is a huge cost. And for the WHO to be doing stupid things like saying, we think we're fighting the cigarette companies, giving an award to India for banning alternatives to cigarettes, and seeing the stock price of the cigarette companies in India soar as a result, and think they're doing a good thing to beat up on cigarette companies. You know, this is like saying, I'm so angry at you, I'm going to come and throw gold bars all over your front lawn so you can't cut your grass. I mean, it's stupidity. And I've spent my career actually understanding the cigarette companies so you can successfully regulate and sue and debate cigarette companies. And I'm dealing with people who keep doing things to protect the industry while claiming they're fighting them. So it's these groups that do things like say, let's pass a law that makes it illegal to to tell people the difference in risk between cigarettes and these alternatives. Which is just given the cigarette companies a get out of court free card because you can no longer sue them for failing to inform their consumers about the magnitude of the risk of cigarettes. The cigarettes are an unreasonably hazardous nicotine delivery system because they say it would be illegal for us to tell the truth.
23:53
Lindsey Stroud: I'm going to segue into that, even because when they get the order, all the PMTA orders actually read that, oh, we believe that these are less harmful, but the company can't market that, even though the order that you got, the FDA is sitting here saying this, because you'd have to go pay to do the modified risk tobacco products, so there's just too many regulations.
24:10
Harry Shapiro: Hang on, let's get this one clear. And I think this actually plays wider, because I've... spent probably too much time looking at WHO submissions to COP around what they call electronic nicotine delivery systems and stuff. ENDS. ENDS. Hey, an end to smoking.
24:32
Lindsey Stroud: And...
24:36
Harry Shapiro: And some of those papers sort of, you know, grudgingly admit that these products may well be safer than... Dr. Brian King mentioned it yesterday.
24:46
Lindsey Stroud: He actually sat there and said, straight from the guy's mouth, these are less harmful.
24:50
Harry Shapiro: So therefore, we leap from... Yeah, all right, OK. They're likely to be safer. We still want to tell people that they're safer, but they might be. But, hey, we've got nicotine addiction, so therefore that gets us, you know. And I've kind of always felt that addiction is such a loaded term. In the public mind, you immediately think of the worst ravages of heroin and crack and crystal meth and all the rest of it. Fentanyl. Fentanyl, yes, certainly. And also, you know, alcohol and even gambling, you know. All these terrible things have horrible impacts on people. And of course, as soon as that becomes a narrative, it's like, okay, but it might be safer. But hang on, guys, you've got nicotine addiction to deal with. And so therefore, I think what you were saying about moving away from cigarettes to the attack on nicotine is in a sense a kind of acknowledgement, although they wouldn't admit it so much, they do in print, that these products actually are safer, but we still can't deal with this because of the whole addiction problem, and of course that relates back to young people.
26:03
Lindsey Stroud: I just don't get why there's all the vitriol against e-cigarettes, especially coming from public health. Let's say e-cigarettes were just as harmful, but how do you deny all these people who've been able to quit and move over to these products. You've never seen anything like that with any NRT. And why aren't we studying that? But it's kind of the same way with COVID. When you started seeing the people who smoke were not dying from COVID and the WHO and the CDC, I know they all started to bury all this stuff. And it's like, again, this is something, people are dying and you're seeing that something is happening. It's all related to smoking. And yeah, we just got this up in arms that anything related to smoking has to be bad.
26:45
David Sweanor: Well, indeed, the worst things are things that are like smoking but aren't causing the harm. I mean, if we look at the history of these moralistic campaigns to change behavior, the view that there's people who want to use the power of the state to impose their moral views on the behavior of others. And I've dealt with many of these people all through my career. Republicans. They're trying to dictate what others can do, that the last thing they want is a safer alternative. So if our job, we've taken upon ourselves to get people to stop using caffeine, somebody selling radioactive coffee isn't a problem for us. Because that's gonna kill people and convince them they shouldn't be drinking a caffeinated beverage. But if somebody opens a Starbucks, that's a problem. If somebody's selling Diet Coke, that's a problem because that's not going to kill them. So it's what we saw with the prohibition in the States. There was great acceptance of things like Jamaican Jake because it killed people. You know, if they drank alcohol, they get paralyzed, they would die. That'll teach them. The people who thought AIDS was God's retribution for sinners. You know, that was a good thing. But my gosh, if you can engage in sex or you can drink alcohol or you can use caffeine in ways that aren't going to kill you, that's the problem.
28:05
Harry Shapiro: Go after the safer things. Yeah. So really, the idea of trying to get the argument across about the health benefits of allowing these products to be available, accessible, promoted, advertised, and all the rest of it, is is problematic even if they admit the health benefit as was discussed yesterday about quality of life about people not being off work because you know they've got lung problems and all the rest of it um the the social cost the health costs of of smoking I don't know, but it feels like this doesn't come into the equation. They don't think along those sorts of lines because it leads them down a path where they really don't want to go. And it sort of feels like they don't care.
29:05
David Sweanor: I think if you're talking about people who have an abstinence-only view on nicotine, that's absolutely true. That's not true for true public health people who are sometimes missing in action in this field. But particularly, it's not true for consumers. The consumers themselves are moving. They're learning about this. They're seeing the benefits personally. So they're way ahead of where many of the anti-nicotine people are. And that's no different than what we've seen on other areas like illicit drugs or dealing with HIV AIDS. You know, so many other campaigns where it's consumers themselves that are in the lead. They're the ones who push for the change. They're the ones who see the benefits. And that eventually pushes the powers that be to start to pay attention.
29:46
Harry Shapiro: And I think that is an absolutely perfect point at which to end this very interesting discussion to kick off the conference. So I'd like to say thank you to Lindsay and thank you to David and thank you to everyone who's been tuning in. And I hope you enjoy the rest of the conference. Thank you so much.