This panel explores the future of tobacco harm reduction in Latin America, with a strong focus on Mexico's approach to nicotine regulation, vaping, and public health policy. Experts discuss how prohibition has shaped tobacco control, the rise of smoke-free alternatives, and why evidence-based regulation may be more effective than outright bans.
The conversation examines the historical roots of prohibition in Mexico, the impact of restrictive policies on consumers, and the economic and public health implications of limiting access to reduced-risk nicotine products. Panelists also analyze trends in smoking, vaping adoption, and the challenges policymakers face in balancing regulation, harm reduction, and public health objectives.
Transcription:
Will start with some questions regarding this diagnosis. What's happening in terms of regulation, prohibition, and different approaches to see how we can address harm reduction or the possible alternatives to tobacco control? So in that sense, I would like to start with Aldo. How is Mexico a pioneer in the alternatives to combustible tobacco? Also, as it's one of the markets in the context and in the countries that's most affected by this model and this alternative. Do we arrive there and what's been happening in terms of nicotine in Mexico? Well, thank you very much. Thanks to everyone. It's a pleasure to be here with these specialists on this panel. Mexico is a pioneer in national prohibitionism. Mexico banned cannabis in 1920. And that's 17 years before America, who are the main leaders of prohibitionism, even implied their own. And I'd like to remember something that was said yesterday in one of the panels. And this gentleman remembered how during the vaping ban in Mexico, one of the senators who's an agent of prohibitionism said that, amongst other things, vaping provoked promiscuity, In the same context, the former president, Lopez Obrador, mentioned the use of drugs as deviation. This was in recent years in terms of prohibitionism, in terms of nicotine, and going backwards to where prohibition started in Mexico with drugs in 1920, the state's argument, and it's in the law itself, was that the use of certain plants and substances degenerated the race. see a continuity a repetition recording in progress of these arguments morally through through generations talking about promiscuity things like this and understanding all this makes us understand the nature and the ethics of prohibitionism in terms of of drugs they keep repeating all of this not just in mexico but also wherever you find prohibition, anywhere in the world. So I think it's important to understand the nature behind prohibition, and from that, we can then understand why, and this is something we always ask ourselves, why, if the focus fails and fails over and over again, why is it still being applied? Why do people insist on this? I think the answer is because they think there's a bigger enemy. So when the enemy is promiscuity, when the enemy is the ruining of a race and the other things that people say, the bad results in public politics are irrelevant because they see a bigger enemy. which is a moral enemy for them. So in this sense, I don't talk too much. I think Mexican case is a good example to understand how prohibition is built, the results of it, and also understand why, despite the repetition of bad results, they keep insisting on focusing on this. Thank you very much. Focusing on this, I'd like to ask Fernando, who's an economist, And in this sense, based on what Aldo just said, we're seeing a transition from combustible tobacco to different alternatives. And from data and your experience, how big and how quick is that phenomenon, for example, in Mexico or in Latin America? And also, why is public policy, like Aldo said, a few steps behind this phenomenon in consumption? When we analysed long-term data, and in Mexico, just like in many other Latin American countries, or Ibero-American countries, there's usually health surveys every five or six years, and we can track properly different trends in terms of tobacco, but also the growth in population and things like that. When we see those surveys in Mexico, we see that in the long term, there's not been that much of a change in tobacco consumption. So clearly the tobacco control policies haven't had any effect, but what we have seen recently in the last five or six years, we see alternatives popping up. It's a tragedy that in Mexico, the role of e-cigarette has grew until prohibition set in and then it dropped as we saw in 2024 and 2025. So there's something very interesting as in Mexico, and you can see in the data, There's not many consumers, dual consumers. They usually either consume cigarette or an e-cigarette. There's very little dual consumers. So summarizing all of this, analyzing the data in detail can show a lot to understand the phenomenon itself. Thank you very much. We can see this phenomenon that isn't being answered to by public health, which is growing and prohibition ends up creating barriers. So from a point of view, more of the consumer itself, I'd like to ask Dr. Mariana Ojo, from medical practice and harm reduction, when politics get tougher and don't allow access to these alternatives, what happens to people that smoke? Because the trends continue and the harm isn't reduced as they can't access these alternatives. And also what happens from the point of view of health professionals, of the health system, when they take away, when they set in this stigma due to how medical professionals sometimes speak. Well, thank you, Ale. Well, it's just what you said. Prohibition doesn't take the harm away. It just moves and shifts it. When consumption exists or when these activities exist, the truth is that it invisibilizes from a point of view of politics, but not in clinics. In clinics, we still see that patients still consume or they can still get the products in a certain way. So we either recommend... So what the client ends up doing is go back to combustible tobacco or go to the black market because it covers the gaps in the market. So this becomes very dangerous for their health and for the health system. So maybe that's the way of making them understand everything that's happening through those costs. And secondly... In relation to your second question, the patient ends up moving away from the system because they don't see a solution available. They don't see any alternatives. They don't even make any new questions because they know what answer they'll get. The doctor will simply tell me to stop smoking and that's it. And that's not something I can do. That's not something I want to do. Whatever their answer is. So I think that this barrier ends up being very costful, both the stigma, the lack of information. It's like a regulatory scheme or a fiscal scheme or any sort of scheme that can be set in. When it isn't aligned with the sanitary objectives, it ends up creating a complete disaster, at least from our point of view. Likewise, The stigma is related to the lack of information that exists. I mentioned in another panel, we don't have information as doctors in terms of harm reduction. Most people aren't even familiarized with the concept itself. When I come to talk about this, they ask me, what is harm reduction? I have to explain it. And it's something we actually see every day. You start with a base. I think that's where we are right now, trying to change language that we use, remove these barriers without just saying that if a patient doesn't want to do something or he has to say stop consuming alcohol, maybe they can't do it. We have to look at harm reduction. So I think this motivation and this lack of meaning and the fact that it's the only instrument available means that we've ended up with a lot of complex situations with patients. Thank you very much. In relation of this, from the point of view of Realidad and their work, I'd like to ask Diego and his work in the region, if you could show us how open or how closed Latin America is to the access to alternatives or less harmful products, or if you want to share the specific case of Argentina and the news that are coming in from Argentina. in front of this reality that what happens to a person that stops consuming combustible tobacco and has transitioned to less harmful alternatives? Well, the situation of Latin America is fractured, I'd say. There are some countries with a very high index of prohibition. We've seen a lot of examples, Mexico, Brazil, Panama, And then there's a small beacon of hope in other countries. Chile was one of the first. Now Argentina becomes one too. And hopefully, and I think Peru is in that process too. Colombia is somewhere there too. But they don't end up being completely open politics in favor of harm reduction. There's always a small needle in our shoes. With this, Argentina lifted its prohibition. It's partly politics and it's partly administrative. It's not a law yet. So it's still very fragile right now. and every regulation that comes in behind it isn't great. There's a lot there to improve, even though this lack of prohibition, we're trying to install this lack of prohibition and harm reduction, which not only is something that the media don't know, but it's also something that a lot of colleagues don't know. But also, depending on their specialty, everyone actually does harm reduction from a clinic, to a surgeon. All of us focus on harm reduction. But why can't we apply it with tobacco? What's the big problem behind all of this? Falsely, it's nicotine. Everyone focuses on nicotine. But that's not actually the problem. Because nicotine is a substance. The vector of the disease is the combustion. And that's what some people don't understand. The prohibition of Argentina was lifted, and there's a lot of work to do now. Now the regulations that are set in, which aren't even firm regulations, have a lot of points that actually go against harm reduction. One are the flavors, the registration of the products, the quantities. I'm going to give you an example, and everyone here will understand it. that a person that managed to achieve to leave tobacco using a vape, for example, and has managed his transition, they now demand that he goes back to consume the tobacco flavor, which is the only one that's been approved. So this is like making a meeting for former alcoholics in a bar. When someone leaves tobacco, after a certain time, their taste buds recover and they start finding real sense for flavor. And this is a very important factor to keep the patient within this system. There's a fight that is going on throughout the world. It's not just in Argentina. The regulations of Argentina have very positive things and other things that seem to be to have been copy and pasted from other things that are done very poorly. Just like, for example, the flavors like I mentioned. Furthermore, the idea of communicating that we don't have this prohibition opens a whole specter of of possibilities of working with proper information, of fighting for a spot that isn't banned and fighting against misinformation, which is something we're very used to in the media. So the idea is to have access to studies. Before, I couldn't even talk in a university because I was vetoed from there. Now, with this lift of prohibition, we have more chances of having access to those opportunities to be able to inform people and also to get closer to decision makers, to political decision makers who are sometimes colleagues who don't have the whole spectrum of information and for them to be able to listen to us because the reasons are there to be read and it's not just about numbers, it's about saving lives and that's what we want. Thank you very much. It's interesting to see that we're not just talking about prohibition and regulation, but also within regulation, there's a whole specter of issues where it might be fragile or it might be far too strong and it can have positive effects in harm reduction and in public health. So with this diagnosis, I will close up this first this first issue asking dr fernando bueno what the perspective is like in spain look at the panorama and comparing it to to the prohibitionist model in mexico the current model in argentina and the fragmentation in latin america well good evening everyone in spain now we're very aware of public consultation for the new TMZ3, which will regulate in the 27 countries of the European Union, the new tobacco protocols. It's a bit more of the same. Politicians have an ideology that you can't take away from them. Maybe amongst 27 European countries, it might be a bit easier due to the cultural diversities, economic and administrative differences for it to be a bit more of a debate. there's a lot of control and there's a lot of influence from the World Health Organization in these 27 countries with an ideological position. And what I mean by ideological is that they're blinded by, they ignore evidence. And above all, they just ban debates, which is where you can really win in and advance in science. Something I mention very often is that if my positions are wrong, what better than a debate where you show me the true data and expose my information? But that just doesn't happen. And it doesn't happen because those data, the data that are in favor of prohibition, especially in terms of flavors, the rise of taxes, and generic packaging, et cetera, et cetera, is not based on data. It's just based on protecting youngsters, which we're all in favor of, that we have to protect the youngsters. Impossible epidemics take illnesses that are appearing. Right now, they're still talking about E-Valley, when the FDA has explained what actually happened. And it even said that people that stopped smoking and consumed e-cigarettes shouldn't leave the e-cigarettes. In some countries, that translation was ignored. That comment was ignored and it wasn't even shown. So that's why it's important to show our evidence, which is what we're trying to do in Europe, amongst the groups that believe, or it's not that we believe, it's that we've noticed that with the data that they have, the countries that have applied this prohibition, the countries that have applied the measures that we recommend have reduced the number of tobacco consumption. So we have to keep working on this and we have to see what happens in the future. Thank you very much. With this general panorama, I'd like to hear some reflections, not by the abstract world of prohibition, but just in terms of the day-to-day life of consumers. And I'd like to start with Dr. Mariana, asking her that you mentioned that politics is born from an ideology and not from real behavior and not from the true needs of consumers. And in that sense, the harm doesn't disappear, just shifts. And these decisions even increase harm to consumers and the risks to consumers. So what is something that's focused on people, attention that's focused on people and respecting their autonomy to making decisions and transitioning to other alternatives? Thank you, Ale. I believe that everything's born from something very basic. Sometimes I say to every one of my students, and it's that the people that's in front of you is a psychosocial, spiritual person, a very complex person, and you have to treat them like that. They're not just a number, they're people. with a whole history behind them. And I think the attention must focus on that to see how you can be a tool to guide the patient. You can't just say that it's an authority, that you're an authority and guide them. You can give them information, communicate with them effectively, and empower them in a way to make their own decisions, ones that they decide. I think the system has removed this possibility for them to direct their own goals. So now that's what we should focus on. What's in front of us is our patient and their questions, because we want to reach the patient's goals with information that we have, educating them in a certain sense, adapting our language and our communication to them to be able to see that the message is being properly understood and based on that, see what they want to do with their own lives. Their answer is completely valid and they still deserve our attention and our guidance. For example, with nicotine, we have to make the difference that the issues, the combustion, not nicotine, and why we should transition to less harmful alternatives, showing what nicotine is, how it affects our behavior, without judging and removing the stigma around all of this, because everyone can do what they want with their bodies and with their lives. which is why we want to communicate all of this. And now that we've done it, we can't deny them the different options because of politics or because of our narrative. Because there's a clinical compromise and an ethical compromise commitment that we have to keep our neutrality in our practices. So I think that many of our patients in this sense, nicotine consumers feel abandoned by the system. knowing that the system has a goal in public health but you as a as a professional should worry about the well-being of your patient and as a patient you should know that a doctor should guide you without ideology just based on science instead and evidence hopefully the support of the system of course this humanization and the ethics behind the attention towards people on the behalf of health professionals is vital. But I'd like to ask Aldo, how do we translate this human rights issues into drugs politics, into tobacco politics, and what rights, which Mariana gave us a general panorama, But what are the rights that are being affected right now when there's no access to alternatives? And how could you argue that they're being violated by politics? Yes, Alejandra. I think that regulatory models that aren't based or designed on harm reduction violate a lot of rights. Above all, the harm reduction in our area makes a bit of mistake because they focus on the violation of the right to health, for example, the right to information, which are fundamental. But I think that that's that can sometimes be slightly weak if we don't complement it with a right. That's very important for me or even more important, which is the freedom of choice. For example, in Mexico, you can't freely develop your own personality if you can't choose what you consume. And I think I forgot to say something in my previous answer, because if the enemy is a cultural enemy or a moral enemy, like perversion or the degeneration of the race, as they like to say, which is a bigger a bigger enemy than bad bad results in public health if that enemy is bigger scientific evidence isn't enough so what what's the way of beating this big rival that's what that's what moral that's what ethics should appear I think all of us agree that a person or individual can't be forced to, for example, access certain health services if the person doesn't want. They can't be forced to eat in a healthy way if that person doesn't want to do so. So in this sense, with these examples, you can see that freedom of choice in our modern societies is a moral and ethical right. Likewise, if you give individuals this freedom of choice based, supported by evidence and supported by information, most individuals will make more responsible decisions with better results. And I'll go back to a Mexican example. before I spoke about prohibition, but how did that start being, how is that destructured? It was done through this argument when in 2015, jurisprudence was set for people to be able to use cannabis because the argument by Supreme Court was that the consumption of this substance or this plant doesn't affect, according to evidence, third parties. So there's no way of, so the person could choose what they want for themselves because they're using their body and their mind freely. And this was set in as a jurisprudence in 2019 with cannabis in Mexico. So based on harm reduction around nicotine, we would do so well if we based our arguments with a freedom of choice and the right to freedom of choice. And that's why I focused on that. Thank you very much. In that sense, I'd like to ask Diego, as we're already talking about this intersection between themes of public health and something related to human rights. So I'd like to ask when a state bans or regulates, as you told us, in a fragmented way, or they go backwards on regulations or they're weak regulations. And they go backwards with them. I'd like to know who ends up paying for the cost of all this or how? How is this paid? When the decision making in public health. And I'll I'll reinforce the concept that we're mentioning is based on ideology and not on scientific methods. We're in very deep trouble. Consumption, just like Mariana said, shifts and it shifts to a sector that we don't want, which is the illegal market, the informal market, to be a little bit more correct. And who's the last part of this problem? The population. But not all the population. The low to medium income population are the ones that can't access good quality products. People with a higher income can probably bring in devices that are certified in other countries with more technical rulings or more scientific rulings that we have in Latin America. But low to medium income people will end up asking the most economic device that exists, which often are clones, which often don't have enough quality. Just like smokers access combustible cigarettes of very low quality, which are more toxic than others. So I believe that establishing these parameters and the state must apply a little bit of control. Sweeping rubbish under the carpet doesn't make the rubbish disappear. And a state that bans this ends up doing that. They lose the opportunity of testing, of having serious statistics, and knowing how that consumption fluctuates. So in that sense, we can then talk about what the countries that have been successful have done, and we'll leave that for later. But I think the one that ends up paying is the patient, and especially the patients of low to medium income, which are mainly in Latin America. And with that, and reinforcing this idea and going deeper in terms of costs, I'd like to ask Fernando about that, as well as who's paying for the cost of these decisions based on ideology and not on evidence. This ends up being a problem of social justice, of economic justice, or how do you see this with the costs of the different prohibition or regulatory methods? Well, yes, totally. Most smokers are adult smokers, are adults, and politics ends up leaving them on the side. Current smoker is just left on their own to their luck. So the illnesses that they end up having in the future, they'll have to face on their own, depending on the country. Some public health services are well financed, others aren't, but that'll be a problem for their future. Why is this a problem? Because adult smokers, current smokers, during the last measurement, for example, in Mexico, three out of four, so 75% of them, want to stop smoking. So it's not that they're completely opposed and they'll say, that's the way they are and they'll always be like that. But very few of those, and I'm saying one every 20, goes to pharmacological therapy or support. And the tools that work, the harm reduction tools that work in many cases, they don't even have access to them. And it's impossible for them to access them legally. So without these possibilities, it ends up being a problem that's given to the person without any support, without any information. And eventually it becomes an accumulation with with this economic cost, which ends up being a burden for the whole society or or the person left on their own. So seeing it in this way and seeing the data. It ends up being a problem. That's that's just ignored or left on the side, but it's an ends up being being seen in in data. Thank you to finish off this round. Doctor Fernando Bueno. Let's go back to the perspective as we've we've seen the perspective of rights and of politics of society in general. And we can see that the decisions that affect society. But I'd like to ask you, as a doctor that accompanies true patients, how much of a perspective is there of these rights are being affected by these decisions? Well, patients want to look for a solution. They don't care how the solution arrives to them, whether it's political, whether the system is given to them by public health, like it can be done in Spain. And if not, they'll look for it in other ways. We have to understand when someone's sick due to cancer, which is what I usually treat, is a smoker. which around 70 or 80% of my patients are, when they come to us and you tell them what to do, they'll keep smoking. You recommend that they leave tobacco, which is fundamental for their surgeries. You have very little time to work. When people talk about leaving tobacco, I think it's great because I'd love them to stop smoking, but there's a certain time for that to happen. And there's steps I don't have time to take. If I have someone in chemotherapy, I can't add another drug. If I have someone pregnant, I can't add another drug to their system. If I have a psychiatric patient, I can't add another drug to them. If I have an elderly person, in many cases I can't give them another drug or I'd be taking big risks. So for that group. If I add the fact that the rates of leaving tobacco. In the best cases is around 55%. Let's say 60 is exaggerate. That's an exaggeration. I still have 40% of people that want to stop smoking. have tried it and haven't been able to, and another group of the population that can't receive other drugs. So that's why I ask authorities, what do I do with them? Wouldn't it be better for a patient to switch to vape or to nicotine pouches? because they're still smoking because they depend on nicotine in the worst way possible. And that's the people I want to work with. If the government allows us to make these interventions, ends up covering a good number, you won't reach zero, absolute zero is impossible, but we can reduce the numbers like they have in Sweden, which is around 5% now, which is very, very positive. or rates like New Zealand, who are at 3.4 or 3.3. Let's try and get closer to them. But give me an arsenal of therapeutic options, which I don't have right now, with good information so that every doctor can access them. Thank you very much. And this answer takes me to make a different reflection. It's the fact that often we look for solutions And they don't have to come from just one place. It can come from a doctor. It can come from community. It can come from the same regulation. saying all of this with an initial diagnosis is slightly negative, but I'd like to move on to something a bit more optimistic and something a bit more positive for this reflection. And it's how harm reduction can achieve results in the market, in regulation, in the community, in bars too, in public health, in investigation, in evidence, So maybe the biggest issue is a regulatory frame that allows harm reduction. But while that a lot that happens while we generate more information, while we have all these debates, this decision making can go from ideology to data. to consumers so we can have answers in different places and we won't stop giving them. So in this sense, I'd like to move on to how can we design these measures for Iberoamerica and from those reflections, from the truth of data and all that, the alternatives with harm reduction and how that can affect decision making. you talk a little bit about harm reduction you said that politics have to be different in each country there's no there's no one size fits all for be it for latin america or not so what changes from one context say in mexico to others in terms of harm reduction thank you alejandra yes To be honest, I support the idea, not in terms of harm reduction itself per se, but I refer to the strategies in order to implement this risk and harm reduction. This should be boosted by each community. And I would use certain specific exams in terms of risk and harm reduction beyond tobacco and drugs. For example, the use of condom. we all know that is a strategy to reduce sexual risk and is the more effective but many religious communities do not allow this because there are higher principles to the benefits arising from risk and harm reduction so it's not efficient in for those communities so They don't accept the fact that you can say, well, this is something positive that will help you. But, well, there are higher opinions or regulations, I would say, of premises. But in Mexico, for example, by middle... 20th century, I would say there was a community, a community, an indigenous community where women will go to the river to wash their clothing. And that was a risk. There was some environmental impact, but the government decided to set different places, let's say places where people could wash their clothing. But they realized that people were not using this areas, so they would go still to the river. So the consequences of these practices double what had been doing before. So what they did was just try to understand that women didn't want to use that. Because they were just that meant that they had to stay at home and they really enjoyed the moment they had to go to the river, wash their clothing because they would be away from their family. They would enjoy things that they were not able to enjoy at home. So by understanding this, the government set an area with different commonplaces where women could still enjoy the benefits of going to the river without the benefits related to the fact that they would be going to the river. So this could show us that the strategies in terms of risk and harm reduction should be based on a design which understands the culture, the community principles, the society principles and national principles. So I think prohibitionism which is a system which regulates drugs which just deals with illegal drugs is the most expensive policy and the one who has faced more failures and has not worked at all and i think the the reason why they fail is because they thought it would be a model that could be applied to every single area and every single person in spite of the cultural differences. But that was not the case. So we think this is a really negative regulation model. Maybe this could be applied to certain societies, to certain communities. But likewise, I think it's a mistake that sometimes we make in terms of risk and harm reduction because we are really convinced of our arguments and the evidence. And we think this is enough to convince people, to convince communities in order to to make them just carry out different practices aimed at this approach. But I do think that if we reduce the importance we give to this rational scientific vision, and we understand that the different cultures and different social perspectives, that would be great in order to be able to implement these policies. This is so interesting. And I think we should reflect on risk and harm reduction, not only in terms of tobacco, but also in terms of every single substance. So we have to address the cultural, historical, and cross-national approach. We talk about women. talk about different races, different structures, which allow us to implement risk and harm reduction. So as you mentioned, we need to adapt these principles to specific differences. And it's really interesting because we have been talking about this in different countries, which is mainly on the person as an individual, but sometimes it has a more collective approach and community approach. So it's really interesting to see how we have to apply this to different contexts. Diego, in some countries, I think if we try to be optimistic, can you tell us about anything that has been successful? What can we learn as a model? What can be transferred to Iberoamerica? the standard goal would be Sweden. But Sweden manages to be smoke-free and the first smoke-free country with specific strategies. We will be able to achieve that goal in Latin America the same way as in Sweden. Sorry, I'm not optimistic, but no, I'm really sorry. We could try to apply their strategies the ones that have been applied in Sweden, but we are talking about an absolutely different context. One of the strategies applied by Sweden is a confidence of the state and the value of the state in complying with all the single laws. If you just transfer that to Latin America, we have corruption in the government, we have healthcare systems which are not perfect at all. where the population do not believe in the politicians, in people who are running the country. So that's going to be really difficult. But we should adapt, and we will manage to get that. Will the snows or the nicotine pouches be enough or sufficient? No, we need to adapt. Every single country has to adapt. Sweden has been using the snus since the 19th century. That's impossible. Maybe I'm wrong, but in Latin America, we don't have any tradition of oral tobacco consumption, or at least it's not as high as in other countries. So I do believe that the strategy would be to use a more perfect kind of regulation in order to to make the products attractive, not for teenagers. I mean, attractive to adults, where we can avoid illegal trade, which in Latin America represents 40% to 50% of the informal market. So there the state should intervene, not only in terms of regulation according to the products based on the product, because if I have these regulations, the risk and harm reduction problem would be no longer attractive. So we will just help the consumer to switch. So it's going to help because otherwise they would go to the illegal market. So this is really important. We have to work to make them avoid the illegal market because Latin America, we are all different. We're in the same continent. We are all different. so it cannot be controlled as for example we can talk about the Scandinavian or the Nordic area there's so much cultural variety and diversity should use those strategies reduction according to the products especially related to the risk themselves we need to to make it affordable we need to make it possible for the person to have access to this because we are talking about free decision and about free personality development. But if I don't have the right information, I'm not free to choose. I don't have the liberty to choose. So free access to health care doesn't mean that I need to see a doctor when I'm ill. It means that I do have to have access to the right information. This is so interesting and we have to think or to reflect on this. We have so many challenges, but there's a potential here. We have to develop different alternatives because according to the person, to what the person wants to do, if we offer this person different alternatives, he or she would be able to choose the most... affordable for that person so that this person could have access, but we should have the possibility to develop more strategies to cover more people who want to change to safer products. So just following this in terms of designing policies, I would like to ask Fernando. How do you consider evidence and whatever we have been mentioning? How can we just make it just fit our short-term policies? Because we have so many challenges at the moment. But maybe we can do small steps or start having these small steps to allow people to access harm reduction products. We need to start from the public problem. we have to sort out is the harm. So we can say that all the civil society should be aiming at this because which is the cause of this public problem? There are so many, but the main one would be the persons do not have the possibility to assess the risk and harm because there's no one to give them the right information. Maybe the person next to them are given them wrong information. One of the main causes would be that these people want to consume nicotine, but they only have access to not safe products. The reason why this happens is because sometimes there's a bad perception in terms of nicotine. What I mean is we need to understand what people think, how they make these perceptions. So that's really important. We have been working on this for a long time. We need to understand the information. We need to understand the data. We need to understand what people are thinking. Because if we're aiming at them, we need to let them be informed and to make informed decisions. Because that should be changed if they they're able to understand the product what's the role of nicotine they would be able to to take reasonable decisions so in terms of regulation not only in terms of social civility say society sorry but also the government's national government in the they want to to offer different solutions to the problem they should have this information and and all these tools because they need to know what the people are thinking. And I think that would be a great step moving forward. Thank you. And I would like to finish this topic now, just asking Mariana, what should be changed within a health care system in terms of training and How do you think we can change in terms of communication confidence from medical staff? So how can we move to different policies, different references in terms of alternatives and the answer to people who are taking nicotine? Well, if we want to make change effective, we need to support people. and not just make things different or difficult for them. So if we change, we need to change the dialogue, the communication. We need to start from there. We need to know that we have to update, to get informed. We have this huge responsibility. So we see nowadays, Dr. Fernando has mentioned this, People are talking about EVALI still nowadays, but they stop there. They are not committed to knowing what came after that or what can be offered to patients. So that's not optional. The second point would be to improve communication again. No one teaches us how to communicate things, how to deal with this, because we are not taught how to have complex conversation it's only about basic communication if they were talking about a stigma and there's a structure against people who have certain kind of life or style of life the the typical structure of asking about smoking do you smoke yes so you have to quit smoking so that's the only question so it's just protocol but i do think we are basing on this, but we are not basing on supporting the patient. We just want to control or just oversee or take something for granted. We should focus on supporting, as we said before, and as I said before, Anthony, is confidence, I would say. therapeutic alliance is the connection, the relationship you create between the doctor and the patient. So this is built inside the consulting room, but can be destroyed there if you don't use the right words, if you don't refer or address the patient's problems as you should. So we need to be more coherent with the systems in the health care area. And we should give the patient the care they deserve. And I think we have different initiatives, as we have already said, all of us, the ones who are here, that can help us just close this gap in terms of education, evidence, consulting rooms. And I think we have to scale up in terms of this. We shouldn't have these parallel principles. We need to integrate it to make them something comprehensive and a comprehensive system. So I think we should opt at university and in the consulting rooms to address people, to support them, and being able to create strategies based on evidence. There's something we have to take from all your experience, your answers, your investigations, the research you have been doing, not only from the panel, but also from other panels in terms of risk and harm reduction, If we talk about tobacco, we haven't mentioned something that we have been mentioned, which is a huge spectrum in terms of drug risk and harm reduction. what you have been mentioning, it's not only the substance, the risk related or inherent to the substance, but we need to address human rights, institutional violence, exclusion from the healthcare system, address other different services that people need, the users need, apart from, of course, the main point, which is access to different alternatives. So it's interesting to see how this debate in terms of risk and harm reduction in the area of tobacco is being transferred to technology, products, and different environments or other type of strategies supporting because by themselves, per se, the alternative not be addressing institutional problems the human rights and we need to think that tobacco risk outcome reduction also involves a full spectrum as we're talking in the area of drugs so let's give you each of you the opportunity to share say recommendations for people who design strategies or policies regarding tobacco and risk and harm reduction in terms of that what would you advise these people the ones who are making decisions Well, I think I will say the same as I said before. I would like these policies to be aligned with healthcare aims, patient-centered, and I hope we could be able to integrate this and be part of this conversation, this decision-making process, because we are able to contribute to have positive changes. I'd say that you should listen to the wind, not make decisions, unilateral decisions. To have every interested party here, to have producers, to have consumers, to have professionals. Many times decisions are made on a desk without taking into account everyone. Listen to the wind. I'd tell them to review history, to analyze the history of prohibition. It's never had good results anywhere in the world where it's been applied, and especially in most of the situations where it's been applied. And for them to also review history, Those countries that have taken another route and how they performed, if it's been a wrong decision, I avoid it and don't fall over the same stone. But if it's worked, let's go ahead and copy it. And I try and regulate it within cultural context and the economic health conditions of my own country. As Diego said before, Spain or part of the south of Europe can have nicotine pouches or snooze as an alternative. But will it be as accepted as it is in the North? Probably not, or not in the short term. Maybe in 40 years, it will be more used. So you have to adapt ourselves in different ways that interest us. And once you do all of that, you review it, you analyze it again. So don't just... Don't just say that what you're doing is the correct thing. Look at other alternatives. Because other countries also have made mistakes in the past. So let's see why some things work, why some things don't work. Let's see the correct route for us. Adding to what the Dr. Bueno just said, I was going to mention the historic argument too, which is correct, but also add i believe that we should defend the decision the models of free decision making not just because of history but also because it's what's ethically correct that's it for me if i could summarize it in just one phrase it would be understanding the individual i think all of us would that the most important thing in these processes is a focus on the individual. I think it's very important to understand them, understand what information they have available to them, what they believe, how they make decisions, their initial decision, and then their final decisions too, their decision of switching between different products. We have to understand that, and that will help us a lot in terms of public health. but also to reach objectives that we focus as a society in this and in many other topics too, to be able to understand the individual. Thank you very much, so I think there's a lot of different formula. And and recommendations for public health now it's time to find the driver so change change this decision making system and also how we go how we go back on on our human rights, which is another risk that we're facing another reality that we're facing and how that puts pressure on the. on the regulation of markets. Thank you very much to everyone. A big round of applause to all the speakers. And for going to the questions from the public, I don't know if someone wants to say anything else. Then we'll go ahead to the public. We have some time for questions and answers, so everyone's welcome. More than a question, it's a bit of a comment, which ends up being a question to see what you think about it. At a point, the panel, and I know this wasn't the focus of the panel today, but it's something that I sort of understood that the state in a way pretends that all of the politics are in favor, should be in favor of people. I think one of the problems in the search of change is to keep assuming that this is the truth, especially in the case of Mexico. where there's a narco-criminal state, a violent state that not only isn't interested in the individual, they're not interested in anything rather than just remaining in power and keeping this mafia working. I know this is an extreme case in Latin America, but we see this in many other political parties. Maybe not in the whole state, but we see it in different discussions in the Senate. There are certain parties that that just go against anything that comes in. They're just anti everything, pretty much. So at least for people that don't see it in that way, I think we should be a little bit less naive, because if you think we're going to talk with good people, that won't always work. And in a certain way, I think we've repeated this question, so I don't know how to turn it because we constantly talk about science can do everything, science will always overcome issues. But how do you go against these politics that have no interest in science or in people or in the users or in if people die or not, just like the Mexican state who want their enemies to die or people that aren't their own to die? It's a bit more of a comment rather than a question, and I'm open to your comments too. Well, I'll be brief. Sadly, that's the truth. I think we sometimes base ourselves on ideal scenarios. But given that this factor exists, which is true, I won't speak too much about what I don't know. But at least we can make our small efforts of going to people, educate people for them to be able to make their own changes. And that's why we've seen models and places where people are the ones that start these movements. And when there's a solid community or a strong community that wants something, I think that's at a certain point when it can happen. But maybe I'm far too optimistic. I understand what you say. And I know what you're saying is real, especially here. I know what you're saying is real. To add something else. I made a comment of the Swedish model. And yes, it's based on the trust that people have in their own state and in their political directors and in their public health. And that's part of the state. However, can that be applied to Latin America? I think we're too far away from that. That's true. But even if we're far away, we have to motivate this movement, get as close as possible to it, and it'll be difficult. And why? Because we don't have this tradition, this political and socioeconomic tradition, but we have to set our bar as high as possible to try and make it. From my own point of view, and in And I know this is very far away from reality. There's a long way to travel still, if we're honest. I made an analysis of the Swedish model, but that's far from us. I'd like to thank Ignacio and allow myself to be politically incorrect too. And I agree with you. I think the arguments I presented about the fundamentals of prohibition and the fundamentals against um harm reduction end up in a way being being that the state believes their own arguments so actually I think they're just hiding behind them And this is why I agree with you that their intentions are just control of population because the state has an expansive nature and they like to control as much as possible. So I agree with you. And it's very important to understand that, to point that out. However, the public debate can't be held in those terms. That's why we have to speak about everything else, assuming what you just said, of course. Thank you. reacting to this thought-provoking comment. A couple of months ago, I started to think about where the tax on tobacco came in. What's the first day that people said you want to limit consumption through attacks it happened somewhere in the past few decades but i started wondering this because it results in mexico there's been attacks for a very long time came from 1743 when the monopoly of tobacco was set up and in a certain way there's it's always been a source of income for the state So after searching all of this, the only conclusion I could reach was the true addict to nicotine is the state itself. So this isn't a conspiration. I don't think that everyone that governs is evil. But I think every incentive is put in place to not solve this problem. So the problem of public health is a secondary or third worry for the state. or tertiary worry for the state and those that intervene in this problem. Because they always have this economic incentive to receive taxes, or in a state of total anarchy, well, those actors, apart from the state, they end up receiving more income too. I'd also like to answer to this, and it's true, even though during this panel, I think we've focused on where to go and ideals, maybe. I think it's clear we can't lose track of the risks of the decision-making and states that sometimes for other markets, such as cocaine, marijuana, they've already shown and there's evidence of how violent states can be on this, how violent their decision-making can be. And I don't want to say that they're different markets, that they're completely different for other substances, but it invites to a reflection to see there's enough evidence of what can happen in the decision-making through prohibition in terms of human rights, in terms of lives, in terms of persecution. We have narco states throughout Latin America. We've had them throughout Latin America. So we can't lose sight of all of this, especially in decision-making in the state. can idealize the answer that the state will give, because sometimes the answers should come from other places. Obviously, ideally, there would be a judiciary frame or a regulation that's clear in terms of flavors, in terms of selling. Obviously, that would be an ideal, but we know the issues that the states face. And as we heard from this panel, there's solutions can arrive from other places, from the community, from individuals, from health professionals that go outside of the box to work in a different way. There are investigations that can be done with all the challenges that they can find all the stigma around it, generate evidence that's different. So I agree with the thought provoking message. And we can't pretend that the answer from the state will be perfect. So that's why we go to institutions which aren't perfect institutions either. That's where we can find an answer to harm reduction for people who want to keep consuming nicotine or they can't stop consuming it. The answer doesn't just come from the state, it can come from the industry too. So thank you. Another question? Okay, after listening, yeah, I think there's something that has to do with prohibition, ideology, and it's a fact that Latin American states and Spain depend on the Marco framework, which has established certain certain rules, certain prohibitional rules. So how can we, from Latin America, or what's the vision that you guys have from the States in front of the Maraco framework? I talk about the case of Colombia, who signed this framework in 2006 or 2008, if I'm not wrong. But that was just the start of it, but that's why they didn't sign the changes that appeared later. So it doesn't really link them to it because the changes haven't been approved. But health ministers are very much in agreement with the Marco framework and the WHO, even though even though their decisions aren't based on evidence and they don't even talk about harm reduction. But what do you guys think? about how the Marco framework has been generating this prohibitional environment in the different countries of Latin America who don't have the political strength and are very much dependent on that framework. Okay, Pancho, Argentina is in the same way. We haven't ratified it yet. We're using that same framework. What has Sweden done? They put traditional control methods and they use Article 1 where they talk about harm reduction. So with the same tools, we can advance without having a complete and total 180 degree change. So I think we can use that little window in Article 1D to advance in the implementation different harm reduction tools with the same rules that are imposed or that they try to impose through the Marco framework. Luckily, Argentina is no longer a part of the World Health Organization. I believe that the Marco framework is applied in the way that they want to apply it. Sometimes it's done well and it's marvelous, and other times, like, I can apply it and it'll just be useful to silence people. To have an opinion outside of a usual one demands a lot of strength and a lot of courage. And usually people don't have that courage. For a politician or a regulator to go out It demands a lot of courage and a lot of strength. First of all, it demands that they study. Secondly, it demands that they understand. And once they've done that, which in some cases is asking too much from politicians for them to be able to read and understand properly, you then have to ask them to be courageous. Most of them think they'll be there for four years or eight years. so and they'll think that who cares about smokers they do it because they want to no one forced them to smoke that isn't applied to alcohol that isn't a lie to addicts to to gambling but the smoker isn't treated in the same way There's millions of examples. Why is it that the same situation is applied to tobacco? Because there's a group and an important lobby that wants to have control, that when I'm at the reins, if I leave my seat, someone else will take it. But they forget that there are people. We forget that there are also people, they also have their own interests. As Nacho mentioned before, they have their interests, whether they're legal or not, or valid or not. So until you arrive at solution, you have to work hard. That's why groups exist. That's why meetings exist. That's why actions exist. to be able to explain it as many times as possible to then end up reaching a solution. Yes, I think the answers given by my colleagues are great. I'd like to add something to the example that Diego introduced. An example of Sweden, but I'm going to talk about Uruguay in 2013 when they leave the international treaties in terms of drugs. because Uruguay violated the international treaties when they legalize the cannabis market. All of the countries are forced to ban the cannabis market. They violated this system, arguing that there's other international systems which are more important, which are above above this, which are the human rights ones. And they said they'd leave it because these treaties violate other more important treaties, which are the human rights ones, which could be a good way of leaving them for us too. Briefly, I think the world's changing very quickly. I think the World Health Organization and the Marco framework but the result of human efforts after the fall of the Soviet Union, trying to look for world governments, allowing experts to meet, allowing to talk about politics, to then implement them in the member states. But those were processes from the 90s and from the end of the 80s and the 2000s, but we're in 2026 and everything's changing now. So I think the World Health Organization has stopped having a global legitimacy. And I don't think that it's wrong. I think it's a forum where experts meet, which is well financed by the member states, should be something very, very valuable of how within the rules we can keep working on these issues. But what we've seen in terms of tobacco, I think we'll end up motivating new things because that method of world governance has ended, I think. I don't think it will happen right now, but I think in the next five or ten years, interesting things will happen in this. Yeah, there's been great advances recently because it's not a normal phenomenon in cops and in diplomacy and in the UN methods and I think that warning of not losing the international stage is important as they're advancing very quickly in decision making and wrong decision making and then going back on that same scheme is something very slow. I think you brought an example of how a country found a way of legalizing marijuana or leaving or interpreting the international framework in a certain way. But I don't think it's easy. And I think this invites us to think as if we allow the World Health Organization to advance and implement whatever they want. It's very slow to then go back on them. An example of this, even though Another example of this where diplomacy is too slow is the exit of controlled substances on the coke leaf. We've worked on this for over two decades and the last year they should have taken a decision and the World Health Organization delayed it and gives it a negative concept. within this list. So to summarize this, even when there is a multilateral crisis and many countries are leaving these scenarios or these governance scenarios, I think there's a different panorama too, but if decisions are made there, it'll then be very tough within that multilateral agreement and consensus to go back on them and go back against the prohibition in tobacco and nicotine as we're seeing. Yeah, just to add something quickly. What we're seeing from this side, talking about the clinical side and following what the World Health Organization says, what we're seeing at the end of the day is numbers that with these strategies, there has been no changes in the last decades. We're at the same percentages right now over here, and we've seen other countries that have followed the World Health Organization's methodologies didn't have any changes until they took their own decisions and then they saw a difference in numbers. So I think it's a very tough place to battle where there's different motivations in place. And I think that's where we are right now. Okay, I think that's where we close our Spanish panel. Thanks for having these Spanish panels at the GFN. Thanks to all our panelists here for your interventions, for your comments, and hopefully you keep enjoying the GFN agenda. Thank you very much.