An examination of the health, social and economic costs of prohibition, with a panel reflecting on parallel experiences with illicit drugs and alcohol. The panel comprises politicians, thought leaders from the drug and alcohol fields and a consumer/vape trader perspective.
GFN 2024 Panel Discussion #1 - hosted by Ethan Nadelmann with panellists: Fiona Patten, Lindsey Stroud, Sharifa Ezat Wan Puteh, Harry Shapiro
Transcription:
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Ethan Nadelmann: Seven years ago, I was invited by Jerry Stimson to give the Michael Russell oration here. And it was my first entry into the world of tobacco harm reduction. I paid attention to it for many years and met some of the people. But this was the first time meeting a community of people who were engaged in this area. And I was really drawn to it. And part of my speech at the time of the oration was on this theme. It was on the theme of, well, a related theme, which is what can the field of tobacco harm reduction learn or what perspectives can be gained from the broader struggle for harm reduction vis-a-vis illicit drugs and the broader drug policy reform struggle. And obviously, if you've spent your life focusing on the war on drugs and the harms that illicit drugs can do, especially when they're operating in an illicit market, you understand the risks when you see similar abstinence only ideology and similar ideas of stigmatization and demonization and prohibitionist policies emerging in this area. And for me, the decision after 2017 to become more personally involved in this issue was driven really by a couple of things. One was I simply believe that even with respect to cigarettes, that it would be a mistake to go down the road towards full prohibition, even if harm reduction succeeds. But the other was seeing the harmful consequences and the potential damage that could result from banning harm reduction. To me, it was analogous to banning needle exchange to reduce HIV-AIDS or banning methadone or things like this. So today, we have a very distinguished panel of people from Australia, the US, the UK, and Malaysia. most of whom have some experience in advocacy and analysis vis-a-vis both tobacco harm reduction, and illicit drugs. Now, what I also know is that we don't want to spend all our time here preaching to the converted. I think almost everybody here is a supporter of tobacco harm reduction, and there may be a few secret opponents lurking among us. But I think we're mostly in favor. Most of us understand some of the consequences of what would happen from criminalization in this area, what is already happening. So we'll get into that. But I wanted to take this opportunity to throw out to the panelists as well some of the tougher questions. Are there areas, for example, where prohibitions might be justified in the field of tobacco or nicotine? What do we say to some of the best arguments of our opponents? Where do we think this is actually going? So you have the names. I think you saw the names of my fellow panelists here. But I'm going to start here with you, Harry. I mean, you've been involved in this area. I mean, apart from being a famous biographer of musicians and all this in your other life, you've been involved in also the area of illicit drug policy and harm reduction. And when I asked you, you said there's really sort of three sorts of levels of bans or prohibitions. Do you remember this note you sent me about specific bans and about the kind of soft bans, et cetera? Just if you could, to an audience which is already sympathetic, but get into some of the nuances of what you see as the world of tobacco or tobacco harm reduction prohibitionism going on today.
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Harry Shapiro: Thank you very much for that. Well, I mean, you've obviously got some countries in the world, certainly not as many as the WHO would wish, but you've got some countries in the world that have implemented a total ban. Now, I'm sure a lot of those countries are probably awash with illegal votes, but in terms of the policy, it's a total ban on importation, possession, buying online, the lot. So those are your sort of total banned countries of which there are, it's debatable, but around 30 countries are doing that. Then you've got what I call soft bands or de facto bands, which are those territories which are trying to implement flavor bands, for instance, using the kind of kiddie flavor narrative, forgetting, of course, that everybody likes sweet flavors, and a lot of the reason why adult smokers, which is the option for not necessarily having the taste of tobacco in their mouth. So flavor bans represent a kind of, in some areas, a kind of de facto ban, which has its unintended consequences, as we've seen in some of the American states where cigarette smoking has suddenly gone back up. And then I suppose there's something that's a bit more It doesn't feel particularly nuanced, but when you start getting a kind of a torrent of misinformation that comes out of health agencies, public health agencies, international agencies, doctors, medics, it begins to... build itself up into academics as well. We have journals that are publishing flawed science or even fake science in some cases. And that kind of cascades its way down to health professionals who are very reluctant to suggest to people who come forward for help. And yes, lots of people give up smoking without any intervention from anybody. People who smoke don't regard themselves as sick simply because they smoke. But some people do go to health professionals and nurses and stop smoking services and they want help to quit. And many of those professionals are very reluctant to suggest people switch. Many surveys show that a worrying percentage of doctors think nicotine causes cancer. And then you've got smokers themselves who've been put off by media headlines. that vaping is at least as dangerous as smoking, if not more so. So that, in a sense, prevents a number of people from moving away from smoking. They carry on smoking. So in a sense, that's obviously not... it's not prohibition in the way that we talk about it, but that is what the actual nub of it is. That's what the end result of all that tsunami of misinformation does and prejudice and all the rest of it. It results in a situation where people carry on smoking.
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Ethan Nadelmann: So let me get into a little tricky territory here. The issue of the places where you have full bans or partial bans, and we see illicit markets everywhere, gray markets, illicit markets. But in many of these countries, there's not a lot of crackdown as yet. Right. I mean, there's not a lot of police enforcement. They're kind of being tolerated. I mean, we'll talk about the kind of example of Australia. We're actually seeing some some really violent stuff going on shortly. But, you know, I think about in the area of cannabis where we're now seeing full legalization or in the US, Canada, Uruguay, we're seeing elements of far reaching decrim now in Germany, Malta, Spain, what have you. But it sometimes struck me that When people say what would be the ideal cannabis market and if you're kind of resistant to kind of big corporations multinational corporations you sometimes tend to think of the early years of decriminalization as the ideal period. I think about the Dutch coffee shops in the late 70s, early 80s, when it was mom-and-pop operations, mom-and-pop stores, mom-and-pop growers. Everything was chill. Lots of people were making a little bit of money. No big guys involved. I think about the little neighborhood of Christiana in Copenhagen, which had a similar kind of relaxed cannabis scene. I think about even the early years of medical marijuana in the US, where we had a similar thing like that. Maybe Spain with the coffee. And I said, God, that's the optimal because you get tons of people involved in the market. It's not really being cracked down upon. The police are tolerating it. There's no big business, no advertising, all this sort of stuff. And it seems like almost an optimal middle. Now, it's not sustainable in some sense because eventually the gangsters begin to take over, as they did in Denmark and Netherlands and elsewhere. But it makes me wonder, Are there certain advantages to keeping this stuff in a gray market rather than a fully legally regulated one? I mean, where you now have its, let me throw that one out at Lindsay. Lindsay's, I think, an activist in the US, a taxpayer lion. She's coming from a more libertarian perspective on these issues, which have been crucial allies in the broader drug policy reform struggle for decades. But what's your thought about that?
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Lindsey Stroud: Hello? Yeah, OK, it's on. Sorry. Well, I mean, the United States is kind of in that gray market, if you look at it. And it's always kind of been. And I think of vaping in the United States, it was a lot better when, before the FDA came in with regulations, you could still go to the vape shop and make your e-liquid. And I still don't understand why that's impossible to do, because you could go to a bar and have people mix you drinks and go drive your car and cause way more damage on that. So there are benefits, but I guess, too, The only problems with that is once you start having youth issues, there's no way to, you know, restrict it. And you also, when you start having issues like, you know, the vali epidemic, I think, is a perfect example because it was illicit, you know, THC-containing paper products.
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Ethan Nadelmann: Speak a little bit slower for our international audience.
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Lindsey Stroud: Oh, sorry. Yeah. The vali epidemic, I mean, it was largely attributed to youth.
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Ethan Nadelmann: Just a little bit slower for our international audience. Okay. Take a breath and, yeah, you can do it.
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Lindsey Stroud: I'm used to testifying in two minutes or less, okay?
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Ethan Nadelmann: Oh, my God.
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Lindsey Stroud: I'm not going to. We've got 90 minutes here. So if you guys don't remember, back in 2019, around September, the Centers for Disease Control and Prevention in the United States started warning the public pretty prolifically about this spat of lung injuries that they were seeing in ERs across the country that Everything in common was the person who they had faked. I actually started looking at the state health.
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Ethan Nadelmann: Hold on one second. Is everybody familiar with the whole E-Valley thing in the US 2019 where 70 or 80 people landed up dead and 2,000 hospitalized because of the... Does anybody not know about it? Just raise your hand. Okay, a few of you, but just, I think, enough no that we will go ahead.
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Lindsey Stroud: Well, what a lot of people don't understand is the CDC really wasn't giving us a lot of accurate information on that. They were not warning us that it was, you know, illicit products, and what was actually kind of crazy was the knee-jerk reaction from some of the governors after that was, oh, let's ban flavors now. Yeah, these are all unregulated products. And the eval, I don't know if everybody saw that the study that came out, the most of the deaths, there were more deaths in states that didn't have recreational cannabis. So you did see that there was a direct correlation to where you're more likely going to have illicit, unregulated products and harms associated with them. So, I mean, that's the only part where I would argue for some strict regulation, especially in vaping. Like, if something happened, let's say, you know, vapers were using the vitamin acetate and they're vaping, then it did cause a problem because, you know, somebody thought it was a good idea. You should be able to have a recall system on that. And, unfortunately, we just don't unless you want to recall the 23 products that are legally for sale. Right.
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Ethan Nadelmann: And I think everybody's aware the issue was not vaping marijuana, THC. It was illegally produced THC cartridges. I remember lecturing some of my allies in the nicotine field, always say these were illicitly produced. And as Lindsay's saying, the states where cannabis was being legally regulated, you saw much less incidents in the valley. than in the states where people are more dependent upon the illicit vape market. So that is clearly a cost.
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Lindsey Stroud: Well, vaping cannabis is safer than smoking it. And I think that's really lost when it comes to the e-valley stuff. I think they're also looking at that being a mechanism for cannabis.
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Ethan Nadelmann: OK. So Sharifa, yesterday I was at a presentation about Central Asia. And somebody put up a chart, and just the diversity Full ban, partial ban, this ban, fiber ban, da da da da da ban. Now when we go, I mean you're from Malaysia, I'm curious within Malaysia and more broadly in East Asia, is it the same thing where the degrees of bans vary dramatically from country to country and where the illicit market is pervasive but still not really being enforced?
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Sharifa Ezat Wan Puteh: Thank you very much, Ethan, for the questions, and thank you for GFN for me being here. That's a very good question. In Asian countries, most of the countries would actually sort of allow vape, even though most of the countries actually put some sort of ban on it, either a complete ban or a partial ban. Some are very strict, things like Singapore would put a complete ban, but of course, coming from Singapore with a high GDP, but also a low number of population, comparatively with other countries like Malaysia or Indonesia or even China, where we have a huge number of population, example for Indonesia. And most of the countries in Asia, interestingly, we have signed with WHO and CDC. So in a way, we are sort of bonded with this binding with WHO, and as much as possible, the tobacco control in most of these countries try as much as possible to follow all the articles in WHO FCTC. where they actually put or segregate things like e-cigarettes and vape as a tobacco product. So when that happens, they're going to be saying that you should not be vaping and e-cigarettes and things like that. And many of the countries do so. Some of the countries that actually sort of regulated vape would be Philippines. Indonesia and also Malaysia, we have just recently sort of approved the last tobacco bill in 2023, where we sort of allowed e-cigarettes or vapes to be sold, of course not for minors, but there are very severe restrictions, meaning that you cannot promote, you cannot advertise, things like, it's the same thing with many other countries, you cannot promote, advertise, use, or you can use, but you're not supposed to promote it, and that's where some of the issues come about. where how do you actually do studies on that? How do you actually tell about the benefits of vaping in this sort of restriction? So most of us, we cannot talk about it in an open manner. There's going to be some maybe soft retaliations to us. And what happened is that what we see now, because of the lack of regulation, We see an increment of black market and most of this comes from certain countries which is nearby. Some of them comes from Indonesia but also in China, from China. And we have a huge black market for not only illicit tobacco but also illicit vaping products. So that gives us a lot of scare because how do you say to the public you should vape but then suddenly all the vape products are being adulterated with vitamin E, B, E, A. So how are you going to tell people that you have to choose carefully? How do they actually choose? This creates the problem. So the government last year, what happened is that the Ministry of Health, with good intention, they have sort of promoted or sort of mentioned that all the vape vendors should actually be put in some sort of inventory so we can control what is being sold and things like that. At the moment, there's no standardization. So everybody can sort of buy their own and they can actually do backdoor industry. They can buy things from the bakery and just come up with their own products and things like that. And this is what we are worried as well, because even though it's a good thing, but the effect is that you see increments of lung abscess. lung collapse and cases where they represent things like ARDS coming up to the ER and we don't know what they are vaping or taking. We have a problem with cannabis as well, where most of the vapers now actually use vaping equipment to actually vape substances. And again, how do you actually monitor this? Because even though we are supposed to not do it, but it's in the guidelines, but people still do it. And there's not enough enforcement to go around and look at that. And what happened is that because these are considered black market, and we have certain syndicates doing this, So they sort of get agents to sell this to the youngsters as well. So now this creates a double whammy for us as well. When we advocate for vaping, then it goes into, so how do you tell this to the adolescent or the children or the youngsters? Smoking starts quite early in Malaysia as well. In some cases, you can get, you know, initiation from 10, 12 years old. Probably this comes about because we used to be a tobacco producing companies, and most of the tobacco actually do come into Asian markets, as everyone knows, huge market there. And most of the head of household actually smokes, especially the elders, you know, the male elders.
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Ethan Nadelmann: And is a big part of the tobacco market illegal as well?
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Sharifa Ezat Wan Puteh: Yes, yes. Once the children, they can just buy illicit cigarette, which is much, much cheaper. It is about three quarter, one third of the actual price. And they can buy this in singular, meaning that you can just buy one or two sticks and they can just use it in schools. I see.
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Ethan Nadelmann: So, you know, you're raising this. I was wondering, actually, when I ask, is the illicit or gray market problem issue such a, it's massive, billions and billions of dollars worldwide. But it's, on the one hand, providing some service of making these things available to people who want it, who need it. It reminds me of the concerns around when people would be worried about methadone maintenance programs, and is the methadone being diverted? And then people sort of realize the only people purchasing diverted methadone, they were not young people, naive users, they were people who were addicted to heroin who could not or would not go to a methadone program. But you're suggesting that actually there are some cases of people showing up. I mean, one could see that with all these devices that are unregulated, there may be long-term negative consequences, right? They may show up 20... or 30 years from now, where they'd be more severe in the products that are not being regulated. But there are cases showing up in hospitals of people being hurt by this illicit market product?
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Sharifa Ezat Wan Puteh: Yes, yes, yes. Some of the published reports or some of the statements made in the newspapers and things like that says that they keep seeing cases coming up in the ER from people vaping. So the next question is that what are the type of vape that they use? What was the quality? What was the quantity? Was nicotine added? And things like that, which are really not answered. So the general effect is that vape is a bad thing. You should not be vaping. And this creates a misperception for everyone. And how do you actually promote vaping for people who are actually smokers? So it is an issue. The government is trying to come up with a new regulation, which is more technical and things like that. I doubt whether this will solve the problem 100%. As you know, the black market keeps coming up, especially in Malaysia. We are surrounded by, you know, the waters and things like that. We have even different states that have more severe cases compared with certain other inner states, you know, because states which are more bigger, states which are nearer the borders and things like that would have more... So that's making the case for... So, I mean, Fiona, you know, I say Australia, I mean...
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Ethan Nadelmann: Here, Australia has been a leader on much of harm reduction vis-a-vis illicit drugs since the 1980s, on needle exchange, methadone, a whole bunch of it. Been a little bit slow on cannabis reform, but pretty good. Fiona, for you to know, has been not just an activist, but also an elected official in Australia for many years. Recently stepped down from that, very active in a whole... We last crossed paths in New Zealand at a conference a decade ago about the issue of synthetic cannabis and how they were going to handle that. But, you know, there was a presentation at the E6 Summit in D.C. last month by Ben Udan. Yeah. who's a wonderful researcher, and he was comparing Australia with the other, US, Canada, and especially New Zealand, and the UK. And Australia just, I mean, it just seems absurd. I mean, the most hyper-restrictive, moralizing, you see the personal attacks on probably you, but also Colin Mendelsohn and others. So I'm curious, in Australia, I mean, the first question, of course, is, you know, why is Australia just so utterly, fanatically antithetical to core public health principles when this should, do you have any deeper understanding or insight into why it's worse there than, as bad as it is in the U.S. and other countries, why?
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Fiona Patten: A lack of hubris. Lack of hubris. Oh, no, hubris, sorry, hubris, hubris. We... you know, Australian Tobacco Control was so proud of themselves with plain packaging so proud of themselves with their escalating tax scheme, but also proud of where our smoking rates were going for many years. I mean, we've plateaued out. I mean, our smoking rates are just staying pretty much the same now. But we were so overly proud that I think that that is part of the reason for this, and particularly the government that we have today, where they led that plain packaging. They beat big tobacco in the plain packaging. It went all the way to the high courts. It was challenged everywhere and Australia won. And I think that is actually really underlying... where we're going now.
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Ethan Nadelmann: So, I mean, Australia is now emerging bizarrely as the example of where prohibitionist approaches is actually generating real violence and real death with the fire bombings. Just tell us a little more about, I mean, some people will know it, may or may not, about the fire bombings of shops selling these things. And are the gangsters, are they the same gangsters involved in smuggling tobacco or smuggling illicit drugs or other sorts of things?
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Fiona Patten: Yes. Yes, yes, yes, yes, yes. All of that. So in my hometown of Melbourne, I think we've had 80 firebombs of shops that sell tobacco or sell vapes. It's a giant illicit market. For a packet of 20 cigarettes in Australia costs about 30 euros, of which probably 95% of that is tax. So you can see how the black market for illicit tobacco, and remembering that, obviously, as in many countries, people who smoke are generally from lower socioeconomic backgrounds, lower education, lower employment, et cetera, and more disadvantaged communities. So we've seen the illicit tobacco market skyrocket. Now, you would think that an intervention for that would be vaping. That would be a great way to break that market. But, of course, that's not what we did. We went on and banned vaping. And we've... And so we've seen the illicit market in vapes. I mean, you... Well, you can't buy... And you've never been able to buy a vape legally in Australia, except now with a prescription from a pharmacy... But so we had these giant illicit markets, very popular product. For tobacco, you really, it's a tax crime. It's not really a criminal activity. So the risk is low for the importation of vapes. They're such a cheap product. If you lose, you can certainly lose a lot getting picked up at borders. or picked up by police and you can still make a handsome profit on them. So yes, we're seeing crime gangs, we're seeing territory wars around the supply of illicit tobacco and vapes. and there is not a child in Australia that couldn't easily purchase a vape.
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Ethan Nadelmann: So here's a somewhat, I don't know, cynical question. You know, we all agree, it's almost pat, you have to say, that of course we have to keep young people from vaping or obviously from smoking, vaping, what have you. And of course, we need age limits, right? Of course, of course, of course. Now, I know from the cannabis field that banning it for all adults did not keep it away from young people. In fact, the polls show that young people for the last 50 years have had the best access to cannabis. In fact, if one 50-year-old or 40-year-old asks another one, like, how do I get some marijuana years ago, the typical response was, have you asked your kids? I mean, it's just that was it. Do you think that any of these regulations or restrictions anywhere is actually effective at reducing access to young people? I mean, we all have to say it, and we may actually want it to be true, but does it actually?
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Fiona Patten: You know, I think with Lindsay, and Lindsay will probably say this as well, but, you know, when... When you look at tobacco, and when we sort of made tobacco sales restrictive, we increased penalties for selling to minors, you actually did see probably a reduction of access. It was harder for young people to access tobacco when it was strictly regulated and there wasn't this illicit market. So I think, yes, you can through regulation, and I think even Canada is finding that with cannabis, that... that the age of people first experimenting with cannabis is going up. Now, that might be because their parents are doing it. It's no longer cool. Right. But also, I think that regulation is kicking in.
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Ethan Nadelmann: Yeah. Lizzie?
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Lindsey Stroud: Well, I mean, when you ban vaping devices, you do see an increase in smoking. You've seen it in Massachusetts. They've seen it in California in numerous localities. There was just a study done that looked at cigarette sales data. So it's almost like we're losing the message on harm reduction completely when we're so worried about banning vaping that we're not even paying attention to smoking rates increasing. and going after that. So I haven't seen that be successful at all, actually. And even with the bans on places, with some of the vape bans, you can still go get vapes. I mean, you can get them in shops. It's not like in Panama where everyone was selling vapes on the street. There are brick and mortar shops that are selling e-cigarettes that are technically illegal.
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Ethan Nadelmann: Yeah, I mean, it did seem in the cannabis context, in fact, that when it's banned for everybody, the young people have the best access. When it's banned just for young people, there may be some, somehow the adolescent market seems to lose some of its dynamism and maybe some, you know, but Sharifa, so if you look at Malaysia or Asia more broadly, do you see any evidence that young people have less access because of regulations or prohibitions?
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Sharifa Ezat Wan Puteh: At the moment, no. One of the reasons might be because we have not fully prohibited it. Last year, during our release of the tobacco bill, there was a lot of backlash from certain societies saying that why the government actually allows vaping starting from 18 and above. If you're a minor, of course, you can't vape or you can't access vape. But if you're 18 and above, you're considered an adult, you can actually use vape. And this is where they actually access it either online, through friends, buying it from vendors, and so on. So back to your question whether certain countries would actually have a successful prohibition approach, I would see in our region would be probably only Singapore. And that was because they have a very strong tobacco control from the start. Besides that, they have started with a very low number of people smoking. That's the initial, you know, starting point. In many of the countries in Asia, we have a high burden of smokers, like more than 30% many, many years ago, even in Malaysia. At one point in time, about 40 plus percent of our male, 15 years old and above males, are smokers. Now that has reduced, but we have seen that adolescent has sort of a reduction in smoking. So has adults, but we have seen an increment of e-cigarette users. And this is something that I would say that, oh, this is good. You know, people are using something which is supposed to be risk-reduced products or alternative nicotine products. But in the end, there's another way of looking at it is that hopefully all these products are safe. That's the other drawback. Yeah.
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Ethan Nadelmann: Yeah. So, I mean, Harry, probably nobody has a better global overview. Does that one work down there or not? This one works. Okay. Nobody's got, I mean, you've been doing, authoring the global state of tobacco harm reduction report for some years now, so almost nobody's got a better global overview than you do. When you look at, if you look at which countries seem to be doing the best, are they the ones with the most sensible science-based regulation, or are they the ones that are actually just allowing the free market to more or less flow, or what stand out as good examples, and why?
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Harry Shapiro: Best in what respect?
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Ethan Nadelmann: If you had to pick one, say, if I had to pick one from the real world here, the one which is more or less doing best at kind of making the stuff available, fewest people getting hurt, most people benefiting, you know, maybe it's gray market, but there's not a lot of, you know, violence with, I mean, some mix.
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Harry Shapiro: I suppose in terms of
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Ethan Nadelmann: And I should say, Harry, when people ask me, when I think about harm reduction, you think about harm reduction intervention, but for me, when harm reduction applies to public policy, I typically would define it as the optimal harm reduction policy is the one that best does two things. It reduces the negative consequences of the drug itself, and it reduces the negative consequences of government regulatory and prohibitionist policies. And so the optimal policy will be the one that achieves the best mix of reducing the harms of the drug itself and the harms of the government policies. So by that kind of balanced set of criteria.
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Harry Shapiro: Okay, well, I suppose the two most obvious examples would probably be Sweden and Japan, because Japan has seen its... Now, bearing in mind Japan still bans vaping, because nicotine is listed as a poison, nevertheless, cigarette sales have just gone through the floor in recent years, something like 50% in the last very few number of years, which is probably the biggest fall in cigarette sales anywhere in the world. and it's seen a consequential rise in the use of heated tobacco products. Government seems largely to have stayed out of this, to the best of my knowledge, and it's been consumer-driven. For various kind of cultural reasons within Japan, that there's an element of people not wanting to, what's the word, inconvenience other people with smoke. There are various cultural elements going on. The other classic example is Sweden.
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Ethan Nadelmann: Right, and I think almost everybody here knows the Swedish story. So what are the runner-ups?
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Harry Shapiro: Well, UK hasn't done too badly. We've seen steady falls in the numbers of smokers over the years, steady rise in the number of people using various heated tobacco and vapes. A reasonably proportionate regime control landscape. It's gone a bit wonky recently with, you know, talk about banning disposals and smoke-free generation and various stuff like that, which may or may not come to pass because we've got an election going on. But generally, you know, you've got mental health trust, stop smoking services, giving, we've got stop to switch, I can't remember the exact slogan, but actually giving vapes out, switch to stop. Thank you very much, you see. As someone who's not even from the UK, who knows it better than I do.
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Ethan Nadelmann: Harry, what about the less economically advanced countries? If you look at Latin America, Central Asia, Africa, are there places that just seem, whether by chance or accident or purposeful, that actually seem like they're doing a pretty good job in terms of allowing this stuff to be available and people are benefiting and transitioning?
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Harry Shapiro: Well, there have been some, and I don't know all the ins and outs, but there's some recent sort of thumbs up from, say, Chile, for example, which has been kind of definitely moving in the right direction. My colleague Ignacio, who may or may not be in the room, will probably know more about that than I do.
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Ethan Nadelmann: I just heard Ignacio give one of the best talks I've heard at this conference at the previous panel.
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Harry Shapiro: Yeah, yeah, yeah.
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Ethan Nadelmann: And it was included talking about the success stories of advocacy. It was actually quite inspiring in that regard.
00:35:30 --> 00:36:57
Harry Shapiro: Yeah, exactly. I was in the room as well, and I heard that. It was very inspiring. It shows what advocacy can do in the face of some fairly monolithic opposition to the premise. We've heard mention of some countries out in the Far East and in Asia. So So there are pockets. You can say there are pockets around the world where you can say there is some promising developments. Huge swathes of the world where either there aren't any markets... Mm-hm. Africa is a good example. There are some pockets of use. There's a very active African Harm Reduction Association, but I think you're just looking at Kenya, Nigeria, South Africa, one or two countries where there are even any markets where even these products are available. South America is lots of advocacy, but still a bit of a desert when it comes to proportionate regimes. So, you know, it's a very... In all of this subject, everything that we talk about, whether it's numbers of users, products, legislation, everything's mixed. The whole picture across the world is mixed. There's no real homogenous... kind of narrative that you can put around.
00:36:57 --> 00:37:47
Ethan Nadelmann: And there's no trend line globally you think towards, I mean one tends to hope and maybe believe that ultimately the science will win out, ultimately the prohibitionist mentality will begin to fade, ultimately Bloomberg will decide to you know, pulled back, or maybe it'll stop happening, that, you know, and look, I mean, obviously, some of these was involved in, you know, cannabis reform, and in broader illicit drug harm reduction, and we had the dark days in the 80s and the 90s, and we've seen, you know, over time, huge progress, and in fact, we've seen it without there being any commercial interest behind us whatsoever. If anything, now, the commercial interest of big tobacco is a very double-edged thing. They have the resources to advocate for harm reduction. At the same time, their negative reputation is what undermines the advocacy efforts that have nothing to do with them.
00:37:48 --> 00:38:04
Harry Shapiro: Look how long it took to get any chinks in cannabis prohibition. It took decades and decades before you could even begin to see any sort of light if you were embedded in the drug reform movement. And it's different because you started out with an illegal product.
00:38:05 --> 00:38:05
Ethan Nadelmann: That's right.
00:38:05 --> 00:38:58
Harry Shapiro: And now you've got transitioning from one form of legal product to another. And I think the commercial interest in this is very embedded, whether they're tobacco or whether they're non-tobacco. And it ain't going away anytime soon. So I think consumer demand is going to push this forward almost irrespective of what's going on legislatively, whether these products are legal or not. illegal in terms of actually not being allowed in the country they're going to be there they're there already and it's a you know it's a ferris wheel that ain't going to stop turning right so let me press the issue about you know we generally consider ourselves anti-prohibitionists when it comes to tobacco harm reduction products non-combustibles
00:38:59 --> 00:39:54
Ethan Nadelmann: But even within this movement, there's gradations of this sort of thing. And I think we begin probably by all agreeing that there should be a prohibition on sale to people under the age of 18 or 19 or 21, I assume. It's almost impossible even if you don't believe it's true to say it, but I think we generally believe that there might be some benefit to making it legal by banning the sale to young people, even if it creates a de facto illicit market, even if most young people can get it, still, good. Well, what about the issue of, let's start with maybe the other one where we would agree, I think, that there should be a prohibition. But, you know, Lindsay, you dealt at one point with the issue of Juul having to deal with counterfeit products. Oh, yeah. Yeah, so do we agree counterfeiting's a fraud, it's a crime, and it should be prohibited? Or what can you tell us about that Juul experience with counterfeit products? Or is there some nut public health benefit because they were getting things out there?
00:39:55 --> 00:40:03
Lindsey Stroud: Well, the counterfeits, Eon Smoke, and I found out that actually Durbin went after Eon Smoke back in 2014, which was kind of interesting.
00:40:03 --> 00:40:04
Ethan Nadelmann: Durbin, you're talking about the U.S.
00:40:05 --> 00:41:43
Lindsey Stroud: Senator from Illinois who's been a leader in opposing harm reduction. He was testifying yesterday. He sent a letter to some of the major tobacco companies. Laurel was one of them, and then also Eon Smoke was in there. I don't know if you guys are familiar with the Juuls and the pods. There's these little ones. And at least in the States, Juul didn't have very good flavors. They also had very limited flavors. But Eon Smoke made these compatible Juul pods that were really a lot better. cheaper than the Juuls were, and they also came in a plethora of flavors, and they were also terrible products as well. They didn't last. They leaked. I know I used them, but I never really saw a lot of scrutiny when you, you know, there was a kind of a convolution between Eon Smoke and Juul and, like, who really was the bad actor, and again, all these kids were vaping. You were catching them with Juul products. You can see the actual device, but it wasn't like, you know, school teachers were testing it or, you know, Juul doesn't make a watermelon, raspberry, Laffy Taffy, you know, but this is that flavor. So I do think that it is a major issue when it comes to all the regulation and all the new products, too. You know, disposables, for example, are another problem where it's all counterfeits. Elf Bar quit selling Elf Bar in the United States in 2023, but if you go to any gas station or convenience store or tobacco shop, you're going to see products that sit there and say Elf Bar, and they look just like them, and they're not, and there's really just no supply chain oversight. And I think it's just going to get worse with pouches, okay? You're going to see Zin, the next knockout of Zin in a few years, so...
00:41:44 --> 00:41:51
Ethan Nadelmann: Any other thoughts from the other panelists about counterfeit products, whether they are a significant problem or whether they just need to be opposed?
00:41:52 --> 00:42:15
Fiona Patten: Yeah, I think it's about product safety, isn't it? And so it's really just about ensuring that we have a safe product for the consumer. And so, yes, counterfeits inevitably seem to be a less safe product So, yeah, as a minimum, it's around product safety.
00:42:15 --> 00:43:02
Ethan Nadelmann: That enforcement should be there. Well, so on the previous panel, there was... ..which Tommy Chair and Ignacio and others from Thailand and Sweden also spoke. There was the issue about... The issue of whether or not to ban disposables, which seems to be a fairly contentious issue in this community here. And, you know, obviously people make the argument about there's the environmental negative consequences of disposals and how big or serious is it really? There's the issue that young people are very drawn to disposables, older ex-smokers are more likely to use the non-disposables. What are your respective thoughts about whether disposables should be banned or not, or banned today or banned in the future?
00:43:04 --> 00:44:51
Sharifa Ezat Wan Puteh: Can I give my experience from some of the things happening in Malaysia as well? We see that some of the studies show that most of the people or the age category or age brackets that use disposable are the young or adolescent, and these are one of the main reasons because they can purchase this at a cheaper price. We know the youngsters do not have enough money, so whatever budget that they use to buy disposable, which is going to be very small, compared with the money that you actually devote So let's say you buy a pot, you know, it's more expensive, the concentration would be higher, so this is dedicated for more adults, and pots are not sold, you know, just at the corner store. So disposable are very, it's a tacky thing, because not only that they vape sometimes in school, but it's easily concealed. So this is one of the reasons where we, in a way, it's a good thing is that... we plan to ban or there's going to be some plan to ban disposable. I do agree that for adults, disposable may have some use because you have access, you can actually use it once you need it, things like that, rather than pot. But then because of the issue of youth in Malaysia, this is one of the reasons that they plan to sort of ban the disposables, maybe concentrate more of allowing pods or closed system where you have high concentration, but more oriented towards the medically prescribed prescription model as what Australia has done, which is again worrisome as well, because then you see that the trajectory will not be as smooth as in UK and also New Zealand. There's less market for HDP. I'm just saying out loud. There's less market for HDP in Malaysia because one of the reasons is that it's quite expensive. So the market would be more of affluent and so-called high-income bracket in Malaysia.
00:44:51 --> 00:44:57
Ethan Nadelmann: Right, right. Harry, you've got a global perspective on this. I mean, what do you think about banning disposables or not?
00:44:57 --> 00:46:20
Harry Shapiro: Somebody in that last session that we were both in made a very good point about about the fact that there's kind of the end game on this, is reducing death and disease from smoking and trying to get people who are currently smoking to switch if they can't quit altogether. And every so often, things get thrown in the past in front of people who are advocating this. You know, it's popcorn lung. It's Ivali. And now it's disposables, you know, with the, oh, my God, the young people are using it. And, oh, my God, look at the environment. And the environment is now the latest kind of wagon to which you hitch your objection to disposables because it's what everybody's kind of talking about. So I think we've got to be a little bit careful about kind of rushing to think, oh, yeah, we must ban disposables. I've actually heard... about hybrid products that appear to be sort of disposable but not, so that they are rechargeable, and you can refill them, but only for a certain period of time. So in the end, they become disposable, but initially.
00:46:21 --> 00:46:28
Ethan Nadelmann: So it's possible if you ban disposables, these ones will sneak through by saying, well, we have a rechargeable battery that lasts for a little while.
00:46:28 --> 00:47:28
Harry Shapiro: So there were going to be kind of workarounds as far as legislation is concerned. Much of what we hear about banning this and banning that are what I call foghorn politics. They play well as soundbites and you tick various kind of political boxes. But ultimately, of course, it comes down to enforcement. And certainly in the UK, the police absolutely haven't got... The numbers of policemen in the UK have been slashed by thousands since 2010. So they haven't got time or inclination to go running about and checking whether some shopkeeper down the road has been selling babes. Trading standards are the same. They're the other people with the responsibility. Huge cuts in budgets for trading standards. So if you're going to put this kind of... legislation in place, you've got to have the enforcement in order to make it work.
00:47:28 --> 00:47:33
Ethan Nadelmann: Otherwise, it just becomes... You're just ticking boxes. Fiona?
00:47:33 --> 00:48:47
Fiona Patten: I don't agree with it. I think... But I think there's ways that we can address some of the issues around disposables, so whether that's youth access or whether that's the way they're disposed of. So I know last year there was a number of conversations around what you could make a disposable from and the different materials that you could use. Or there was conversations around recycling and whether we could start seeing recycling models being implemented. You can only do that in a regulated market. You can't do it in an unregulated market. I think for myself, it was a disposable that got me off cigarettes and onto vaping. Now I've moved away from disposables. But it was my introduction to vaping, and I think I'm not alone in that, that for many smokers, that it is an entry point into vaping. So I do think it's an important tool, but I get involved in litter when you go and pick up the trash in parks and things, and we count the number of disposable vapes, and they outnumber the number of cigarette packets now substantially. Right.
00:48:47 --> 00:49:39
Ethan Nadelmann: Right, right. You know, actually, Tommy from Ireland, who chaired the last panel, also made a point I hadn't heard before. It's not just young people who are disproportionately drawn to disposables. He said it's also the quite elderly. They just like the simplicity of it, which is something I hadn't thought about before. Now, what about flavors, right? I think we generally see flavor bands as basically not well, you know, and that basically we know that you know, offering other flavors, non-tobacco flavors, actually helps people quit and helps them stay quit. On the other hand, you know, I've heard people say, well, if you're going to ban anything, at least ban child-friendly names, like, you know, Toadstool Vomitshit, or Captain Crunch, or whatever it might be, and that there might be some limits on the flavor. Any thoughts? Is there any rhyme or rationale for limiting any flavors? Or are there really such things as the super child-friendly flavors, not just names? Harry?
00:49:40 --> 00:51:06
Harry Shapiro: I think the industry has got to look to itself to a certain extent. I mean, there is no real reason for having something called ice coconut explosion or something. I mean, I'm not a vapour, and I don't know about the flavour, but I honestly know whether you can tell the difference between hundreds and hundreds of different flavours. I think... In New Zealand, I think they've come up with about 60 propriety names that you can use for flavours, which includes... Things like cherry, strawberry, vanilla, chocolate and so on. And also names that you can... Descriptive names. So you might have, you know, warm custard or... So a set of descriptions and a set of flavours. And I think that something along those lines... would help to undermine this, you know, this like I've early, what I said earlier about de facto bans, because if you ban flavours, you only allow tobacco and menthol, or you might even only allow tobacco. then you're really cutting the feet from under people who are looking for an encouragement to switch. On the other hand, you don't have to have a company making 500 different flavors, I don't think.
00:51:06 --> 00:51:09
Ethan Nadelmann: Other thoughts from the panelists about the flavor issue?
00:51:10 --> 00:51:57
Lindsey Stroud: I mean, I'm a hard no. I'm an American, okay? We have our First Amendment, right? We can make what we want. That's why we don't have plain packaging, you know, cigarette packs. But I think the bigger question is what is kid appealing? And how do you determine what is a kid appealing flavor? I mean, what do you do, some focus groups and find out, you know, these are adults and these are kids. I imagine you're going to see the similarities of who both found it appealing. It's going to be probably the same. Like, oh, yeah, that sounds really great. That all sounds really terrible. And you also just don't see it in other, you know, adult age-restricted products. I mean, alcohol is probably the best example, especially when you see, I mean, the seltzers or whatever. And you look at the flavors that they have, and those are all sweet, and they're not getting accused of marketing to children at all.
00:51:57 --> 00:51:59
Fiona Patten: They are in Australia, of course.
00:51:59 --> 00:52:01
Lindsey Stroud: Oh, now in the States.
00:52:02 --> 00:52:37
Fiona Patten: Yeah, I think, you know, once... If you have a regulated market where the product is regulated and being sold to adults, then adults should be able to have that choice of flavour. It's right now when it's an unregulated market and it's so accessible to children and there's a perception that the industry is marketing to children. Now, I don't actually think that's the case, but... because we have made it so easy for children to access this product, there's now a perception that we're trying to sell it to them.
00:52:39 --> 00:53:39
Sharifa Ezat Wan Puteh: I think it's the same opinion from my side as well. In Malaysia, most of the youth are really engaged with all the flavors. But we do understand that flavors play a role in smokers quitting, but also staying away from cigarettes. We have samples from our studies showing that they switch to some form of flavors, and once they... sort of switched successfully, they would actually use vape products that do not have nicotine, but do need the flavors to maintain themselves. So we see the role there, but unfortunately, so does the kids. So this trade-off, yeah. But some of the things that the government would actually propose is the restrictive flavors, meaning that you concentrate on the mint, menthol, and tobacco, which is very restrictive, because then you will see, I would foresee that some of the smokers would actually go back into smoking.
00:53:40 --> 00:55:48
Ethan Nadelmann: Yeah. So both, I think a couple of you have mentioned already, either in private conversations or on stage, vaping is not just about nicotine. We know that in cannabis, it's been a huge thing, and certainly we know that if you're a heavy user of cannabis or using it medically, there are good reasons not to smoke it, but rather to vape. I mean, if you're a moderate user, it doesn't make that much difference. We know, in fact, the company that invented Juul initially was in producing cannabis harm products, sort of heat not burn the packs, a heat not burn version for cannabis. But we also, I think, did you mention about vaping, was it ketamine? And then Lindsay, you were joking, half joking about vaping when it comes to fentanyl, which for those of you who don't know, fentanyl and the overdose issue in the United States You know, last year, almost 100,000 people died of overdose or fatal drug use, most of it involving fentanyl. And just to put that in perspective, it's if you add up all of the automobile deaths in the United States of driver, pedestrian, and passenger, and then you add all the gun deaths in the United States, both homicide, suicide, and accident, That still only adds up to about 70% or 80% of all the overdose fatalities in the US. So it's a monumental issue. And there are arguments that, in fact, if you can move towards vaporization, we might be reducing fatalities with fentanyl, and especially if it was regulated. With ketamine, there is a growing evidence about its medical efficacy in helping with intractable depression and pain, but also a growing problematic use issue on the recreational side. There was the intersection with the cannabis thing, right, when E-Valley happened, you know, it was about illicit, tainted THC cartridges, and then governments bizarrely cracked down on the legal, you know, vaping markets, which just seemed about as ass-backwards as one could be. But what are your respective thoughts about how vaping relates to all the other substances apart from nicotine?
00:55:49 --> 00:57:03
Fiona Patten: We've, of course, in Australia, the prohibition on vapes and the importation of vapes has had the unintended consequence of prohibiting medicinal cannabis patients' access to vapes. So we've now, yeah, so we've got this ridiculous situation where we've got medicinal cannabis, and we know that vaping is a great way for medicinal cannabis because of the titration and the very fast titration of that you get from vaping as opposed to edibles or to oral, to other forms of consumption of it. So now we've got medicinal cannabis patients who are being forced to smoke their medicinal cannabis. And as you say, when you're a sick person using medicinal cannabis, this is really the last thing that you should want. And we actually talk positively about vaping when it comes to cannabis. and we talk about vaping as a harm reduction. In fact, some of those same public health organisations that oppose tobacco harm reduction speak positively about reducing harm with cannabis use by vaping. So, yes, we've got a perverse situation now in Australia.
00:57:03 --> 00:57:05
Ethan Nadelmann: Lindsay, thoughts about that?
00:57:06 --> 00:57:37
Lindsey Stroud: I think science is missing out on a very big opportunity to look at ways that vaping can deliver a lot of other things, not just, you know, substances, maybe vitamins, maybe nutrients, and especially, like, you know, in low- or middle-income countries that, you know, might not have access to hospitals, that, you know, you could come up with a medicine you know, back of, you know, vapes and, you know, give these people something. So I think that there's so much hostility towards vaping in general that we're not really looking at the science and how it can be used to actually deliver more than just nicotine or substance, you know, illicit substances.
00:57:37 --> 00:57:39
Ethan Nadelmann: Sharifa or Harry, any thoughts?
00:57:41 --> 00:58:42
Sharifa Ezat Wan Puteh: Same here. Cannabis in Malaysia is considered illegal. It's still considered illegal. There's no such thing as consumerism, cannabis and so on. Of course, there's certain purposes like medical and so on. If you have in your possession more than 200 grams, you're considered pimping and you might actually have consequences such as hanging and so forth. So it's very strict at the moment. So what happens is that some of the very innovative ideas come about where you sort of vape cannabis And they like that because you don't shoot up in your venous system, so basically you're clean, and the delivery system is quite efficient. So it's coming up. We don't really know how big is the problem yet. We assume that this is going to come out higher and higher, and now we have the issues of synthetic drugs as well. Again, we don't really know how big is the problem of use or uses of vaping substances.
00:58:44 --> 00:58:45
Ethan Nadelmann: Harry, any thoughts on that one?
00:58:46 --> 00:59:27
Harry Shapiro: I'm surprised you can actually vape fentanyl. Say again? I'm surprised you can actually vape fentanyl to be perfectly honest. The only reason I say that is because when people tried to smoke heroin in the 70s and 80s from the Bermuda Triangle, not from the Bermuda Triangle, from the Golden Triangle, you'd just finish up with a black sticky mess. You couldn't actually smoke it. It wasn't until the heroin came from the Middle East that you actually... That's chasing the dragon. So I'm not sure how easy it is to do that. Same with ketamine, actually. But, because they're not manufactured to be smoked, to the best of my knowledge.
00:59:27 --> 01:00:07
Ethan Nadelmann: Right. I mean, we'll have to see also what happens with the issue of nasal inhalers, which we're not really doing in the issue But I just had a wonderful ketamine experience not long ago that involved a nasal inhaler. I suppose the other thing to say is... You know that each squirt is like 28 milligrams. You're getting the dose exact. I can well imagine that whether it's vaping or nasal inhaler, that you could get down to a precision of dose which could reduce... not just remove the impurities that you get, and not just remove the problems of smoking or the risk of injecting, but one might think that evolving technology on both nasal inhalers and vaping might actually be a major harm reduction advance with respect to a whole bunch of substances.
01:00:08 --> 01:00:20
Harry Shapiro: But I mean, you would need regulation and controlled medicinal products for that to actually happen, I think, at the moment. As soon as you hear the word vape, it doesn't matter what you've got in it.
01:00:21 --> 01:00:22
Ethan Nadelmann: Yeah.
01:00:22 --> 01:00:26
Harry Shapiro: You know, the hackles rise and people go, oh, no, we don't want anything to do with that.
01:00:27 --> 01:00:45
Fiona Patten: Oddly enough, in Australia, we have two approved medical vape devices for cannabis. None for tobacco or nicotine, of course, but we do actually have two. The Volcano, which I don't know if anyone's seen that device.
01:00:45 --> 01:02:32
Ethan Nadelmann: This is a device created about 20 years ago, I think, or maybe more, by a German firm. It looks like it's actually... large, about this big, looks like a kind of flying saucer. But if you walked into any of the medical cannabis dispensaries, even 15, 20 years ago, they were on every table because heavy users were encouraged to use those and to vape rather than to smoke. Yeah, yeah. Okay, so I have two big final questions and then I hope I'll leave a few minutes for some questions and I'll walk around with the microphone here. So on the issue of prohibiting cigarettes. And I revealed some of my bias before, but it seems to me in the tobacco harm reduction community, there's three views. And by prohibiting, I mean either outright prohibition or the proposals you're now hearing in a number of countries to reduce the nicotine content in cigarettes to so low they're effectively almost without nicotine. So they become of virtually no appeal to most people. And there's one group in the tobacco harm reduction world which says, you know what, they're so deadly, so addictive, just ban them. And then there's a second group which says, don't ban them right now, but as soon as we have enough openness on harm reduction non-combustible products, and as soon as use is getting low enough, banned cigarettes then and that'll help push the remaining people over. And then there's a third group which says even if you have a very smart, progressive, thoughtful harm reduction tobacco policy allowing all of these variations of pouches and snuses and heat not burns and things, still don't ban it because there's always gonna be some people who wanna smoke and the negative consequences of banning that, you have no idea what will happen. So to ask each of you, I don't know how much you've thought about this question, but where do you come down on that, Fiona?
01:02:33 --> 01:03:15
Fiona Patten: No. Prohibition has never worked on anything. So why would we think it would work on cigarettes? It will open up a black market, inevitably. and that will prove to be more dangerous. I think certainly great further restrictions on point of sale and other sort of controls will probably come in, but I can't see why prohibition, and even the New Zealand idea that anyone under 18 today will never be able to buy a suit packet of cigarettes, it will fail.
01:03:15 --> 01:03:17
Ethan Nadelmann: Mm-hmm. Lindsay?
01:03:17 --> 01:04:05
Lindsey Stroud: I'm a big no, no, no, no, no. I've done a lot of work on the proposed menthol ban that they wanted to do in the states. I got shelved recently this year, but the data even shows in the states that have done menthol bans that it hasn't led to a reduction in smoking rates. In California, there was a really good study where they collected trash out of our discarded cigarette packs out of the trash, and it only reduced the menthol incidents by like 12%. Mind you, menthol cigarettes are not allowed there at all, so... You're always going to have a black market and dangerous actors who are going to use this black market. I just can't imagine drug cartels selling cigarettes. It's all started because of the government trying to protect people.
01:04:07 --> 01:04:07
Ethan Nadelmann: What about you, Sharifa?
01:04:09 --> 01:04:50
Sharifa Ezat Wan Puteh: In an ideal situation, I would say that we ban everything and people will listen. Unfortunately, even our own children will not listen to us 100%. So I don't think it will work. It will never work. Even some of the low-middle-income countries, sadly to say, some of the countries that we have approached, I think we went with a few professors as well here, They just mentioned straight out right that we need the tax money. So if the government says that, you're basically, you know, your hands are really tight. You know, how can you say don't smoke or vape when your government says that we need the tax money? It contributes to about 30% of our GDP.
01:04:51 --> 01:05:03
Ethan Nadelmann: Yeah, I guess that's part of the bizarreness of China where the tobacco industry is what, the second greatest source of government taxation revenue even today. And anyway, we'll leave that for another panel. But Harry?
01:05:04 --> 01:05:10
Harry Shapiro: I think Bhutan is the only country in the world that's ever tried to ban cigarettes and smoking.
01:05:10 --> 01:05:12
Ethan Nadelmann: And they reversed that recently, right?
01:05:12 --> 01:05:38
Harry Shapiro: Of course they have, yes, because people either went across to neighbouring countries and brought it back, or it was just smuggled in. I mean, already the global illicit market in tobacco is huge. I mean, there are some countries where nearly all the cigarettes that are coming in are either illegal because they haven't paid the tax, or they're just kind of, I think they call them whites, they're just kind of knockoffs that look like real cigarettes.
01:05:38 --> 01:09:58
Ethan Nadelmann: Yeah. I have to say, I've heard people say, well, if we can get smoking down to under 5% of the population, then why not then? And the point I make to them is if you look at the global illegal drug market, the one that explains these vast levels of crime, violence, and corruption in so many parts of the world, and the violations of human rights, and the mass incarceration in the US and other countries, that apart from the marijuana issue, which accounts for a lot of arrests, but not that much incarceration, that almost that entire problem is generated by barely 2% or 3% of the global population consuming heroin, cocaine, methamphetamine, fentanyl, what have you. So even a very small percent of the population desiring global commodity that is illegally produced and marketed can generate a vast terrible problem and then I think the other thing that could I could well happen you know the United States where you know we have almost as many guns and automatic weapons as we have citizens but one could really imagine that if you went to prohibiting cigarettes one could well imagine a a lot of these paramilitary, right-wing, Trumpist groups basically beginning to see trafficking in cigarettes as not just a lucrative source of income, but as a moral cause against the paternalistic government taking away my right to put in my body what I want, and if I'm gonna traffic it, so it would be combining, for them, a moralistic cause with which many other Americans might agree on the core principle, and then with a huge source of revenue that could be remarkably destructive, which leads to the last question. Part of what drew me to this was the connections that I saw between the whole drug policy reform movement and illicit drug harm reduction and this area. And to some extent, my own view that I was gonna be damned if after having played a major role in helping to legalize cannabis in the US and some other countries, I was gonna go to my deathbed seeing a whole new global war on drugs directed at tobacco and nicotine products, right? narcotraficantes replaced by tobacotraficantes, and the DEA replaced by the TEA, and massive surveillance and drug testing and all of this sort of stuff. But I've also just noted that if you look at some of the people involved, it's not just myself who's been involved in drug policy reform and harm reduction since the 80s, But you look at the founder of the International Harm Reduction Association, Pat O'Hare, his successor, Jerry Stimson, who founded this organization, Alex Wodak, the founding chair, I believe, of International Harm Reduction Association, which is now called Harm Reduction International. You look at David Sweenor, who came into this area. You look at Clive Bates, who was on the advisory board of the British Reform Organization, Transform. You look at Mark Tindall in Vancouver doing cutting edge harm reduction and all of a sudden coming to the field of tobacco harm reduction because he realized he was helping to keep people from dying of HIV or Hep C or overdose and they were ultimately going to die of cardiovascular disease or lung cancer related to their smoking. So there's been this connection and some of you have been part of this. At the same time, one sees, especially among the younger generation of harm reduction advocates, a reluctance to engage with tobacco harm reduction, in part because it's big evil, big tobacco, and therefore they shut their eyes, in part because the issues of racial injustice, which are so prominent in much of the drug war in the US and other countries, are not present here. but I'm wondering in terms of your own interactions. We look in Australia where there's been a movement against the drug war in favor of harm reduction, but less on cannabis. In the UK, which was a leader on some harm reduction, but also like Australia, slow on cannabis reform. Malaysia. which until some years ago followed Singapore, but now has discussions around the decriminalization of drug possession and some harm reduction, the US which is so mixed. What are your own experiences and thoughts about the relationship of this tobacco harm reduction movement to the broader movement for drug policy reform and harm reduction?
01:09:58 --> 01:11:33
Fiona Patten: You know, we hosted the International Harm Reduction Conference in Melbourne last year. And we tried to get tobacco harm reduction onto the agenda without luck. No one was interested. And then, you know, I'm on the board of the supervised injecting room in Victoria. Now, 80% of our clients smoke. You know, we're talking, you know, we'll prescribe the methadone. We're talking about trying to prescribe hydromorphone. Do you think I can convince the doctors around prescribing nicotine? No. No. You know, so we try and say, just say no to smoking to our clients who we are readily trying to find other opioid replacements or other ways to treat their other drug use. So it is, I don't understand, well, I mean, I do understand, but it is so frustrating. You know, I was around in the 80s as well, you know, on working in, volunteering in needle exchanges and working on sex work reform. But we cannot seem to have that conversation about tobacco in the harm reduction field, and it's really frustrating. And even, you know, I was speaking to one of the heads of a harm reduction organisation before I came, and he has been involved in harm reduction for decades, also was part of international harm reduction. But we'll not talk about, we'll not have a conversation with me about vaping. Wow. Lindsay?
01:11:34 --> 01:12:23
Lindsey Stroud: I call it the harm reduction hypocrisy, actually, is what it is. That you can have harm reduction for a lot of things that we recognize it, you know, with, you know, heroin, especially in the United States and certain parts of it. But, you know, Seatbelt is a harm reduction product that we, you know, don't kind of factor that in. and what we do to make our risky behaviors less risky, but I do think it kind of does come from this vitriol against big tobacco, but more so the people who smoke. They just don't seem to have any love in the world at all, and I think that comes from the World Health Organization, and they underscored it very well this year at the end of COP 10, where the secretariat was like, you know, the interest of even the people who smoke should not come over one child becoming addicted to nicotine. It's just harm reduction hypocrisy pretty much and just not caring about the people who smoke.
01:12:24 --> 01:13:45
Sharifa Ezat Wan Puteh: Same situation in Malaysia as well. Harm reduction has been supported in a way for Malaysia medical harm reduction things like IBDU users, needle exchange program, even the pre-exposure prophylaxis for HIV patients and LGBTQs and so on, but not on tobacco. It's even seen as something more sinful. We had a harm reduction conference and we sort of have to hide the tobacco harm reduction into it, even though most of the findings are actually presented by scientific prominent leaders in their field. I think this is seen as something sinful because nicotine is supposed to be addictive. But if you look at the spectrum, and we keep repeating that, you know, this toxicology report, the spectrum analysis, how compared, you have to compare the combustible secrets, but it's an uphill battle, but we have to start somewhere. And I think Dr. Alex Wodek sort of gave me and a few of us motivation, saying that you have to start somewhere. This is what happened with us during the methadone replacement therapy. So don't give up, you know, it's going to reach somewhere someday, you know, but until that fine day, you know, some of us may have retired and so forth.
01:13:45 --> 01:14:43
Harry Shapiro: Harry? I agree with Fiona. It's immensely frustrating and tragic in many respects because Lindsay said that seatbelts are an example of harm reduction. I kind of disagree. Yeah, it's more an example of health and safety. As far as I'm concerned, tobacco harm reduction, drug and HIV harm reduction are all of a piece because it's all about civil liberties and human rights. And that's why these interests should come together. And the main problem, stopping it from a tobacco point of view... is the link with the tobacco industry. I don't think there's any doubt about that. I mean, if the main drug harm reduction intervention had been safer heroin from a Mexican drug cartel, I kind of feel that probably drug harm reduction wouldn't have taken off either.
01:14:44 --> 01:17:11
Ethan Nadelmann: Yeah, no, it really does. It even seems to me that it's not just that this tobacco harm reduction has to really be as proactive as possible. And obviously, many of those of us who have crossed over can play a leading role. But it's not as if the international harm reduction movement is that powerful, but it's gained traction over 25 or 30 years. And the notion that when you have an international conference on drugs or AIDS, the slogan, nothing about us without us, is being used by the activists and others to say we're part of the conversation. But you can go to the COP, what's it called, COP 10 or the Panama meetings, the others, and there's no activists there. That resistance of the international harm reduction folks, that needs to be overcome. I think also as Harry is saying that a lot of times defined, what is harm reduction? One definition of harm reduction is where public health and human rights intersects. It's at that intersection where lies harm reduction. And I even think that given, I look, for example, at the way in which there's been reductions in funding for harm reduction programs around the world, as George Soros' Open Society Foundation, which was the major funder private funder of harm reduction around the world putting in hundreds of millions of dollars over the last 30 years as They're pulling back because to focus on the greater threat to open societies Pat you know presented by authoritarian regimes and right-wing populist movement But it almost seems to me that one should make the pitch to the big tobacco companies you want to start paying for a harm reduction not just with tobacco pay for in other areas as well and And if you look at who are the highest rates of smoking, Fiona you just said this, here's the average population of many countries in the developed world at 12, 14, 15%, in Asia at 25, 40, 50%. But if you look, obviously it's lower income people, and then you get indigenous people, And then you get people with mental illness, neurodivergent people. And then at the very top are people who are going to harm reduction programs, illicit drug users at 60%, 70%. So the argument for introducing tobacco harm reduction in illicit drug harm reduction programs is overwhelming. And so I think we really need to go to a greater unification here. Now, we have a few minutes left for questions. So I'll see if you have a question. Just raise your hand or try to make your way to the aisle. And just say your name and where you're from. I'll hold it. Stand up.
01:17:11 --> 01:17:29
Rebecca Taylor: Hi, Rebecca Taylor from the UK. I just wanted to ask a further question about the enforcement issue, because it's definitely a problem in terms of disposable vapes, because a lot of the ones that they want to ban are already illegal anyway. It's nonsensical.
01:17:30 --> 01:17:31
Ethan Nadelmann: Yeah, go ahead.
01:17:31 --> 01:18:04
Lindsey Stroud: If you're following the United States, they're having a major problem with enforcing it. The FDA just launched a multi-agency task force on Monday to working with the DOJ, a couple of other things. I think they're trying to get the DEA on it for some reason to really go out and attack them. All they've been able to do is really issue penalties, civil monetary penalties. That comes after warning letters. They've only issued a few injunctions, but I do know that they're discussing, I guess the DOJ is discussing criminal penalties on retailers or manufacturers of the illegal vapes.
01:18:05 --> 01:18:40
Fiona Patten: Fiona? In Australia, it is illegal to possess nicotine without a prescription. and less than 10% of the 1.7 million vapers in Australia have a prescription. And I mentioned, I spoke to the police about this. I spoke to the head of the police association a few months ago and said, you know, every single person you pass in the street is committing a criminal offence. They're in possession of a Schedule IV drug and there actually is penalties that include jail penalties for it. And he shrugged his shoulders. So we're not seeing that enforcement.
01:18:41 --> 01:18:50
Ethan Nadelmann: I imagine the real issue will be if they start creating dedicated police agencies to focus on this, then you'll see people with an institutional interest. Yes. I'll hold it.
01:18:51 --> 01:19:23
Riccardo Polosa: Riccardo Polosa from Italy. I think the case of Bhutan, it's really interesting. It's a reversal of a ban, and I think there's a lesson to learn. Lesson to learn for those who have banned vaping in their own countries. Question, is anybody actually tracking the smoking prevalence and the vaping prevalence in this country that they actually banned the vaping? Because I think they'll be ready for surprise in there.
01:19:24 --> 01:19:25
Ethan Nadelmann: Harry, do you have an answer to that?
01:19:30 --> 01:20:41
Harry Shapiro: Well, yeah, I mean, I'm sure if you look at global burden of disease, WHO statistics, you can identify the countries that have banned vaping and have a look and see what's happened to the... smoking rates in those countries what's a lot more difficult is to um is to get data on the number of people who are actually vaping I mean that that is that is a big problem it's something we talked about in a previous session um because in order to make the case in terms of advocacy you've got to have some pretty good statistics about the numbers of people who are who are vaping I mean there's an estimate for Thailand of about one and a half million people Quite a complicated methodology, I think, around that. But you need those kind of statistics in order to try and make the case if you've got legislations that are looking to ban or looking to overregulate. But the smoking statistics are definitely out there, and you can match those up against countries that have banned vaping.
01:20:42 --> 01:21:07
Fiona Patten: Just quickly, Australia's plateaued as a result, so our smoking rates are not going down like our brothers and sisters in New Zealand have. There's an online question here. The Taiwan government is discussing to make vaping at level three narcotics. And that was in yesterday's news. So another country bites the dust. And I think probably they're asking for our comments on that.
01:21:07 --> 01:21:09
Ethan Nadelmann: Yeah. OK, last question.
01:21:11 --> 01:21:53
Marewa Glover: Thank you. Professor from New Zealand. I would like to know what you and the panelists think. There's this latest sort of narrative that is flooding the tobacco control literature from pro-prohibition, anti-vaping authors. And they claim that the term harm reduction is a tobacco industry strategy. Tobacco harm reduction. And, you know, harm reduction. is a strategy. What's your comments and suggestions on how to respond to that?
01:21:54 --> 01:21:55
Ethan Nadelmann: Thanks, Maria.
01:21:55 --> 01:22:48
Harry Shapiro: Any comments from the...? I think my comments are probably unrepeatable. I mean, that is just rubbish. I mean, I think... I mentioned earlier, I think, that the WHO had come out with a tweet that suggested that... vaping was as dangerous as guns because both are quotes designed to kill, unquote. This is a tweet this week from the WHO and I think this sounds to me like the politics of the desperate. I think they're losing the argument all the way around and to suggest that Harm reduction is an industry construct. It's just plain daft. I mean, you've only got to look at the history of drug and HIV harm reduction and actually read the literature to see that there is this continuity thread between the lot, and it makes sense. So I would...
01:22:52 --> 01:23:11
Lindsey Stroud: I mean, I just think it's a sad state of affair when it's the tobacco companies who are actively working and spending millions of dollars to make a less harmful product and to help people quit smoking, and it's the World Health Organization that is blocking them from doing that. So it's just a sad state, and I do think they're getting super desperate as well.
01:23:11 --> 01:23:57
Fiona Patten: And it's politically popular, as you know. I mean, if you can put big tobacco into the sentence, everyone, you know, it's a very simple, disingenuous way of minimising tobacco harm reduction. And we see it constantly in every sentence by our health minister, you know, he puts big tobacco in every single sentence when he's talking about vaping. And even if big tobacco, certainly in Australia, I mean, Philip Morris actually is involved in the vaping industry in Australia, but they're the legal product that the government approved. So the government approved the big tobacco's vaping product. It was everybody else's vaping product that they banned.
01:23:58 --> 01:26:13
Ethan Nadelmann: I think those are all powerful points. And look, the fact of the matter is, for those of us who have been involved in harm reduction for decades, just standing up and saying, we defined that term, and we are saying tobacco harm reduction is part of our world. And when you, who are pursuing the nicotine abstinence-only ideology, start making things like saying, well, something's not safe when harm reduction is all about being safer, you're being disingenuous and hypocritical. So I just want to say finally, as somebody and as many of us coming from the broader drug policy reform movement, I very much hope that all of those of you who are solely involved in tobacco harm reduction will please make those efforts to reach out and to see yourself as part of the broader drug reform harm reduction movement and to avoid in your own advocacy distinguishing or saying critical things about what's happening on cannabis reform or other areas of illicit drug policy reform. It's important to see that we're all part of a common community committed to basically the principles of harm reduction and to minimizing the harms of drugs and the negative consequences of the policies themselves. It's also to be said that in using our language, our rhetoric, I never refer to our opponents as the tobacco control folks and us as the harm reduction folks. In my view, we're all about tobacco control. We're all. But they're the abstinence-only tobacco control folks, and we are the pro-harm reduction tobacco control folks. Remember that tobacco control is a positive phrase. People, the general public, like the notion of something that they see as dangerous being seen and being controlled. Therefore, let's own tobacco control, but we are the true tobacco controllers because we embrace the full spectrum and include harm reduction. We are not the ideological abstinence-only ones. Finally, come back here at 6 o'clock for the Michael Russell oration. Cliff Douglas, my fellow American, who has just taken over the organization that was called the Foundation for a Smoke-Free World, now called Global Action. He should give a very good talk. Thank you, Fiona, Lindsay, Sharif, and Harry.