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Colin Mendelsohn: Okay, look, we might make a start. Here's my wife. We might make a start if people are ready to start listening and getting involved. So I'm Colin Mendelsohn, and I'll get our panel to introduce themselves shortly. For those who are up the back, if you wouldn't mind just pushing down a little bit further outside, that'd be great. So look, this is going to be a workshop in which we'll be making several small presentations and asking for your feedback. So we very much want you to give your thoughts during and after the presentations, between the presentations and at the end. So please feel free to stand up and make some comments and give some suggestions. Vaping has a huge potential for public health, but we have to get the regulation right. And that's a critical element in saving the lives, which is our main intention. In this workshop, we want to talk initially about the Australian model, which is a really good example on how not to regulate vaping. And there are lessons to be learned from that. And we're going to then move on to more general issues around regulation and specifically ultimately about what's an ideal optimal regulatory model. So just to move my slides on, I'm going to talk about what's happening in Australia, what can we learn from it, and why is it about to get even worse than it actually is, which is currently an unmitigated disaster. Carolyn is going to talk about vaping from a doctor's perspective because she's a very involved prescriber of nicotine and has had a lot of experience with vapors and the medical model, which is the method we use in Australia. Alex is going to talk about general principles of vaping, of regulation and the impact of prohibition, which is essentially what Australia is providing. And finally, we'll talk more about what is the best way forward, learning from those mistakes and looking at alternatives from overseas. And that's where we want feedback from people. If you have any suggestions or comments, we'd love to hear. And we want lots of discussion. We want to hear what you have to think. So please feel free to speak up. make your thoughts known. So in terms of conflicts of interest, Alex and I have no conflicts of interest in terms of receiving income from e-cigarette or tobacco companies. Caroline has received funding for attending a conference and she's a KACTH scholar but has no ongoing e-cigarette and tobacco company funding. I'll let them introduce themselves when the time comes, when we're a little bit closer to each of their talks. So the current regulation in Australia is We're the only country that requires a prescription for nicotine. So if you want the vape in Australia, you have to go to a doctor and get a prescription for nicotine. And it's a criminal offence not to have a prescription if you want to import, use... Oh, Mark, I forgot to mention you, but you will be speaking as well. I'm sorry. It wasn't on the original panel, but we'll be talking. So it's a criminal offense to possess, use, or import nicotine without a prescription. The only way to get a prescription or to get a nicotine legally is with a prescription and buying it from a pharmacy or by importing it from overseas with a prescription. You can't buy nicotine from vape shops, from other retail outlets. You can get non-nicotine liquids and hardware from vape shops, but you can only legally buy nicotine from overseas or from pharmacies. And as Carolyn will talk about later, very few doctors will prescribe nicotine. So this is what the government wants us to do. So they want vapers or smokers to go to currently an authorized doctor who he's approved to write nicotine scripts, get a nicotine prescription, then find a pharmacy that will sell nicotine. And there are very few that do. otherwise to import nicotine from overseas with their prescription, which they send overseas and it comes back and then they're a vaper. That's what they think doctor patients are going to do. And because they've said that's the law, they think that people will follow, but of course it doesn't work that way. In fact, what's happening is that smugglers are going to the black market where you basically just hand over your money and suddenly you're a vaper. It's as simple as that. And 92% of purchases are illicit. So, unfortunately, the vast majority of smokers and vapors are purchasing illicit products. There are about an estimated up to 100 million illicit disposables imported into Australia from China every year. They're mostly mislabeled, they've got high nicotine levels, and they're being sold freely to adults and children. And 92% of all products sold are illicit. Only 8% after 18 months of a strict crackdown have a prescription. So clearly this model's not working, which is no surprise. It really is a de facto prohibition. It's basically saying, well, you can have nicotine, but you can't really. So you need to go and do it your own way. So people are buying these disposable products from the black market. They're dodgy. They're not regulated. They just go to the local tobacconist, convenience store, look at the price list, hand over their cash, and away they go. They can get them on social media, such as Facebook, Marketplace or Snapchat are very popular. They can buy them from websites. So it's really not difficult to get dodgy, unregulated products. And of course, we have youth vaping because we have such a thriving black market that the black market, of course, sells to young people. They're not concerned about age of sale. And the schools are struggling. Parents are getting distressed. And of course, we all know it's a big tobacco plot, which, of course, it isn't. But that's one of the main drivers of the anti-vaping argument. And there are alarmist media reports. It's the end of the world as we know it. So there's a new generation of nicotine addicts. We're undoing years of decades of work in tobacco control. It's the biggest behavioural problem at schools. It's an epidemic, etc. Shocking schoolyard vaping incidents. Kids are going from vaping to smoking, of course, which they aren't. It's causing serious lung damage. How are schools responding to this? Well, they're suspending kids. They're installing expensive vape detectors in toilets. They're locking toilets. They're removing toilet doors. They've created misleading public education campaigns. So these aren't working, of course, but they feel they're doing something in response to the moral panic. But in spite of all that, smoke vaping rates are rising sharply since the government got involved. And that doesn't work. So there have been various official government steps taken over the last few years. As you can see, smoke vaping rates have risen sharply. And we now have quite a high vaping rate compared to many countries where vaping is legally allowed. 1.3 million vapers in a country of 26 million people. So it's not only not working, but it's of course creating a black market with illegal and dodgy products. One important issue is that vaping's rising most in the younger population. The grey line shows the 24 to 28 year olds, 24 to, 18 to 24. The yellow lines are 25 to 36. What this graph doesn't show is that the higher Vaping rates in the younger population are associated with a significantly reduced smoking rate. They don't tell you about that. They just say all the young kids are vaping. But for example, in the 18 to 24 year age group, where 19% of kids have tried vaping in the last month, the smoking rate's fallen by 21%. in the over 50 age group where they're not vaping, smoking rates are not falling. So that's a really important message. But as if that's not enough, the government said, well, we're not happy with this. People are doing what we've suggested. We've come up with a fantastic model. The problem is that those really annoying smokers aren't following the rules that we set for them. This is a public health menace, this vaping. We've got to do something about it. So they're going to ban supply. The only way to get nicotine will be from a pharmacy with a script. You won't be able to import it anymore. This is coming up later this year. They're going to ban all disposables. They're going to ban the black market, which is already banned. All these things are banned. They're going to reduce demand by reducing flavors. They're going to reduce demand by pharmaceutical-like packaging. They're going to reduce demand. They were going to reduce the concentration of nicotine. We don't know how much yet. And of course this is only going to be harmful so people are going to go back to smoking. Smokers are going to find it harder to switch to vaping. The products available will be just unregulated. People will keep going to the black market. They'll get dodgy products with lots of nicotine. Young people will keep vaping. So it's a disaster for health, but Al Capone will be pleased. So the criminal gangs will continue to supply these products to Australians. There'll be a thriving black market, which will continue because no one's going to go to the doctor. We're going to criminalize normal law-abiding vapors. We're losing all the tax revenue. It's all going to the black market to fund criminal activities. People have to go to the doctor to get a prescription, which is going to cost them enormous compliance and policing costs, which we can't afford. No money's been allocated for that. So it's clearly not going to work. And perhaps even more importantly, the legal vape shops are going to stop. They're going to close. Yeah, okay, that's the end of my presentation. So that's the situation in Australia. That's what's coming up over the next few months. It's going to get even worse. I'd like to hand over to Carolyn who's going to talk about her perspective as a prescribing GP. So Carolyn has developed an interest in this field. She's developed a special nicotine prescribing business, dealt with thousands of patients now, is involved in teaching and writing. We've written some papers together and has a great insight into how this is working on the ground in Australia. Carolyn.
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Carolyn Beaumont: Thank you, Colin. So my name is Carolyn. I am a GP in Australia, and it's really, really unusual that we have on this side of the world, three Australians in the same room, let alone the same stage. In fact, four Australians. Welcome to Siona. Looking forward to hearing you speak later on in the week. So before I start, I thought it would be nice to bring a little bit of Australia to Warsaw. I thought about what to best bring. So some of the iconic Australian things, a glass jar of Vegemite, our favourite national spread. I thought the glass might break in the plane. I considered bringing a sprig of gum leaf, one of our national trees. I thought customs might not like that, and it would be frowned upon even more than trying to get vapes through into Australia. I thought maybe I could smuggle a koala in. but they have chlamydia on the eyes and they're actually a lot less cuddly than they look. So I did manage to bring one thing that's in my bag. It is the great Aussie icon and national beer. And in honour of having three Australians on the stage, and I can't tell you how difficult it was to bring this across five countries without any deaths, I present a can of EB. Thank you, Fiona, for laughing. So if you think you're in the Philippines discussion next door, you're not. It's empty. It is empty. Okay. Now I am actually talking seriously. So I considered a number of titles before settling on Australia's Prescription Model Adopter's Perspective or How Not to Do Vaping Policy, which in fact is very similar to Colin's subtitle. And because I've been working with Colin and really under Colin, who has been my mentor for the last three years and has taught me everything I know, I'm not surprised that we come from the same perspective. But there were some other options. A tale of two ciggies? Or with reference to Mark Butler, who only Australians would know at this stage, who is Australia's federal health minister and architect of our disastrous prescription pharmacy model of vaping. Minions, the rise of Mark Butler. But in all seriousness, I'd like to thank these two inspiring men. Apologies to Mark, I didn't realise you were going to be on stage. I'd like to thank these two inspiring men that I've had the privilege of sharing the stage with and learning from. Alex and Colin are true leaders and warriors for tobacco harm reduction, and I'm honoured to have something to contribute to this discussion. Alex, the warrior, this one's for you. and Colin. The resemblance is uncanny. It's no longer Batman and Robin. Fake man and Colin. Okay. Let's move on. So in Australia, because a prescription is needed and the government is proposing a disastrous pharmacy only model of purchasing vapes, this creates significant barriers to accessing vapes for smoking cessation. So I'll be discussing barriers to accessing doctors, reasons why doctors are reluctant to prescribe, and I'll briefly touch on pharmacy issues. But overall, Australia's policy leads to a situation like this. This presentation will look at the barriers that Australians face when trying to access vapes without resorting to the black market. And it is based on my years of experience with patients and is supported by the latest Australian Bureau of Statistics data about health care access, which is released annually. So for an Australian smoker trying to buy a legal vape, the typical journey looks like this. Firstly, you need to find a doctor. who is supportive and familiar with nicotine prescribing. Once those hurdles are crossed, you need to find a local pharmacist who is prepared to stop your preferred brand of vape. Most times you'll give up in frustration and probably either buy a black market vape or return smoking. So let's break down the steps. Firstly, find a doctor in Australia, and there are a number of barriers. The first barrier is based on where do you live and work in Australia. The highest prevalence of smoking is in areas and industries with reduced access to doctors. If there's one word to describe Australia, it's huge. Vastness is a defining feature. Even our national anthem mentions our boundless plains. Australia is bigger than Europe. but with less than 5% of the population. This makes for a very thinly spread country with most of the population along the eastern seaboard. But it means that remote towns can be hundreds of kilometres from medical care, and these towns generally have the highest smoking rates. Some Australian country towns have a single clinic, which may not be open every day. And there are fewer doctors per head in more remote towns. And as already mentioned, these areas have the highest smoking rates. So overall, the situation is that the more remotely someone lives in Australia, the more likely they are to smoke and the fewer doctors per head are available. This is not a great start for trying to get a nicotine prescription. A further geographical barrier is work-related. Australia is rich in natural deposits, and mining, oil, gas drilling and long-haul trucking are a backbone of our economy. People may live in larger towns, but they can spend weeks at a time in remote locations or on the road. FIFO stands for Fly In, Fly Out, and it's virtually unique to Australia. Workers are flown to the site, usually for weeks at a time, and it can be thousands of kilometres from their home supports. These remote work environments are stressful and it may be when the person is more likely to resume smoking. There are plenty of cigarettes to be had, but I don't fancy their chances of getting a vaping script and a good quality vape on location. Moving on from geography. These graphs show the worsening access to health care within just one year. In just one year, more people report waiting longer than they felt acceptable for a GP appointment, up from 16% to 24%. And I don't think people are becoming more impatient. There are many other reasons why they're having to wait longer. Of huge concern is that almost half of those in regional and remote areas can't access a doctor urgently within 24 hours. The cost of seeing a doctor is a huge barrier for many. In the space of one year, more clinics are charging privately. Government rebates have been frozen for years, plus many economic factors are driving up the cost of running a practice. It is becoming increasingly hard to fully access government-funded medical care. More people are reporting not seeing their GP due to the cost. People are delaying filling their regular scripts. And as always, the rural and remote areas of Australia are more affected. And so the barriers to medical access continue in Australia. Negative experiences. These graphs show that approximately one in four people don't have positive experiences with their GP. They don't feel consistently listened to or that enough time is spent. And these figures have even worsened a bit over the past year. So, if you're in an environment feeling rushed and not really listened to, this creates yet another barrier to a successful conversation about tobacco harm reduction alternatives and getting your nicotine prescription. Overall, these factors contribute to why a huge number of Australians don't have a regular GP. Official numbers say 20% don't have a regular GP. My vaping patients self-report closer to 35%, but it's unknown how many people from the highest smoking risk groups don't have a regular GP. Those in prisons, hostels, the homeless, the semi-homeless and even university residences. These groups are excluded from the official Australian Bureau statistics. Well done! You've made it into the doctor's office. Now you need to try and obtain a nicotine prescription, but there are further obstacles in your way. To really highlight how difficult the process is, let's compare vaping to safer sex. Stay with me here. So imagine if we expected patients to avoid sexually transmitted diseases by abstaining from sex. And if we discouraged safer ways to have sex. This is what Australian doctors are taught. They're taught that nicotine is something to abstain from. There are no recognition of safer alternatives to smoking as a consumer choice. Now, actually, I had written in honor of this conference a short skit which illustrates this point. It's called Billy Visits the Doctor. But sadly, due to the time constraints, it will have to wait for another time. Maybe during DRIT sometime during the week. Now, moving on to the second major barrier. Doctors generally don't smoke or vape. They don't know the products, the brands, and the strengths. They have an inadequate understanding of smoking and nicotine addiction. They have suboptimal education about tobacco harm reduction. Smoking is taught as an addiction. But the many complex reasons for ongoing addiction aren't really understood by doctors. Vapes are not seen as consumer options but as medicine. Doctors have resistance to prescribing something that's a consumer choice. Australia's official smoking cessation guidelines for doctors put vapes as a second-line option but far below existing therapies. And in my opinion, these guidelines simply don't reflect the lived experience of smokers. Finally, there are administrative barriers for doctors to prescribe. In Australia, the doctor needs to apply to be an authorised prescriber of nicotine. This is a somewhat confusing and time-consuming process. Getting authorisation should be straightforward, but it looks more complicated than it is. The unsuspecting doctor will go online to register and is confronted by many documents. So not surprisingly, less than 5% of Australian GPs are registered as authorised nicotine prescribers. And to create even more access barriers, these authorised prescribers overwhelmingly come from fee-paying private clinics. Doctors are exposed to the usual negative narrative about vaping. Headlines such as, youth vaping crisis, Poisonous vapes, and of even greater concern, vapes are no safer than smoking. And unfortunately, our major medical journals don't provide much balance to this. Colin and I can attest to the huge difficulties we faced in getting even a letter to the editor published. Congratulations, you've managed to get a nicotine script in Australia. Now what? So under the proposed model, to fill the script at a pharmacy only, not many Australian pharmacies stock vapes. Very few brands are currently available. The larger pharmacy chains have preferred products and consumers don't usually like the flavors and strengths of these products, which are actually often too strong. The product is not always stocked as it's too expensive for the pharmacy to keep a product that might expire. It takes at least one day, sometimes longer, for them to bring in the product that the customer wants. And then returning to the pharmacy to pick up the product creates further access issues, especially with remote locations and works. We've reached the final steps in our quest to buy good quality legal vape in Australia. However, unlike Frodo and Sam's quest to destroy the ring, this quest is usually not so successful. It usually ends in frustration and returning to smoking or the black market. How do I know this? Well, I have three years' worth of conversations with over 2,000 adult ex-smokers. I ask them, if you couldn't access liquid nicotine via a script, what would you do? Over 80% of my patients say they'll probably return to smoking. Some say they'll access nicotine via the black market, some aren't sure. 6% say they might try different cessation methods such as patches, and about 5% self-admit to using other drugs instead. And by the way, if this data interests you, I'll be presenting more like this on Friday. Small plug. So in summary, there are many barriers to accessing a nicotine script in Australia. You need to find a doctor who needs to be supportive and familiar with nicotine prescribing. You then need to convince the pharmacist to order in your preferred brand. You'll give up in frustration and buy a black market vape or return to smoking. Recently, though, the government has announced it will remove the administrative barrier of doctors needing to apply for a permit. But that still leaves all the other barriers. It really shows that unless Australia's national health system is completely overhauled, then significant barriers to a nicotine prescription will continue to persist. People will continue smoking and the vaping black market and use access will continue to thrive. Thank you for listening. And on behalf of Australia. Sorry.
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Colin Mendelsohn: Well, thank you very much, Carolyn. So look, I think we've presented basically the disaster from Down Under. And at this point, perhaps we could pause for a while and just get your feedback about the sorts of problems we're facing, which are the difficulties of people accessing these products through doctors, and the obvious and totally expected experience of the black market appearing, and the vaping epidemic that's therefore developed from children who access products through these markets. But any discussions about this kind of model would be very welcome. Or any comments of any kind? Yes, Fiona.
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Fiona Patten: I just... thinking about the outcome of this where nicotine becomes an illicit drug, effectively. Now, we are moving in Queensland to decriminalize the use and possession of illicit drugs. In the ACT, this has already occurred. In other jurisdictions, that's occurring. So now, are we going to see, do we imagine that nicotine is going to be in that perspective? So even though the federal government might say, well, we're going to ban this product, The states are moving to a position saying, actually, prohibiting the use and possession of illicit substances doesn't work. We should take a health model. So we're going in this sort of bizarre circle where you've got the federal government saying, let's ban the possession of this product. And you've got states now saying, banning possession of products such as heroin, cocaine, cannabis doesn't work. So we need to take a different approach And now nicotine will come into that. So in the ACT, for example, if you're caught with an illicit vape, you will come under the decriminalization of illicit drugs.
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Alex Wodak: Sure. Look, let me make a number of points. Before I do, I just want to quote Herb Stein, who was one of President Nixon's foremost economic advisors, and he was fond of saying, things that can't go on forever, don't. And we have to remember these frameworks that are put forward to us like the one that Colin and Carolyn have have dissected for you are really unsustainable. They're nonsense. And they will collapse. And they'll collapse slowly, and then they'll collapse completely and subtly, in my view. I say that because I've been involved in this area for 40 years or so with illicit drugs, and that's really what's happened with illicit drugs. that the same kind of nonsense has been put up that somehow we could stop these drugs. With understandable reasons, people were very apprehensive about the drugs. But at the same time, the process of globalization was occurring, and we had millions of people moving around the world. billions of containers moving around the world and we are meant to somehow search the passengers and their luggage and we're meant to search the containers in Australia. Three out of every, only three out of every thousand containers are searched. This is really nonsense and it's taken a long time for those arguments to get some traction and as Fiona Patton, former legislator, former member of parliament, has just explained to you, this nonsense is finally starting to be understood. But in Australia, so far, not for vaping. The starting point of all this is to be crystal clear about what the objectives of regulation should be. I think it's very important to realize that in a country which makes a complete mess of vaping regulation, the objectives of what the legislation is meant to be about are very unclear. It's not clear that the objectives are the reduction as fast as possible and as complete as possible of smoking-related deaths and disease and other social and economic costs of smoking, which are considerable, which are huge. It's not clear that that's the objective. What seems to be the objective, although this isn't spelled out, is the destruction of the tobacco industry. That's what the Zellop antifabers seem to regard as their number one objective. But we can learn a lot of lessons from countries which make a mess of regulation, like Australia. We can also learn a lot about regulation from countries that do regulation well, and I think of the United Kingdom and New Zealand. They may not be perfect, but they're a lot of lessons for all of us, particularly in countries which do such a bad job of it. So, one of the objectives for me, I've mentioned the paramount objective for me is the reduction of death and disease as fast as possible, smoking-related death and disease, but it's also important, I think, to identify some sort of sub-objectives. And the first one for me is making it as easy as possible for smokers to switch from dangerous nicotine options to less dangerous nicotine options. So for example, in the people who are struggling with problems from street heroin, we make it, we try to make it easy for them to move from the really dangerous option, street heroin injecting, to less dangerous options. such as methadone and buprenorphine. Secondly, it's minimizing the use of safer options by youth who have never smoked. That's important. The public certainly regards that as a very high priority, and I don't think any of us have any objection to that. I hope not. And the third objective, as in all policy, is minimizing the adverse effects of policy. And it's characteristic of the countries which don't do well with regulating that they never consider the adverse, unintended consequences of policy. And policy almost always has some adverse, unintended aspects, and certainly the banning of vaping has, in Australia, has had huge negative consequences. I think it's also important to consider that regulation is better thought of as a dimensional phenomenon rather than a categorical phenomenon. Apologise for these. difficult words, difficult especially for people for whom English isn't their first language. So what I mean by this is that most regulating involves a continuum from zero to 100% and all the steps along there. We often talk about regulating as if it's just one or two or three categories. It's never as simple as that. So to give you an example of that, of how complex the terminology we use are and how confusing it all is, as Carolyn and Colin have said to you, obtaining nicotine for vaping in Australia requires a doctor's prescription. and the vaping opponents fiercely reject us and criticize people like us three when we refer to this as prohibition. If we look at alcohol prohibition in the United States, which went from 1920 to 1933, it was also possible for people to obtain alcohol in that period of alcohol prohibition by prescription, and no less a person than Winston Churchill. when he was visiting the United States during that period, was able to obtain a prescription for whiskey, which he needed to have in large quantities every day, so he could comply with the law. So if that's called alcohol prohibition, there's no controversy about that, and yet people are very unhappy about Exactly the same kind of situation in Australia being described as prohibition or neo-prohibition or quasi-prohibition. So the terminology, these categories are problematic, confusing, and distracting. And it's important to realize the general principles behind it. And if a market is so arranged that 92% of people prefer to obtain their supplies from the black market and only 8% from the legal market, It doesn't matter what you call it. It's the result that really, really matters. It doesn't matter what the intention was. It's the outcome that really matters, and surely that's a terrible outcome. So let's try and get away with these categorical descriptions and use dimensional descriptions. I would say what's important here is that 92% of people in Australia where nicotine for vaping is highly restricted prefer to get it from the black market. So what should we be trying to do? We should, taking a word from the economic language, we should be trying to use regulations to nudge smokers to much lower risk options. And this works much better if the regulation is voluntary, in my view, and has strong consumer support. And that's more likely to happen if consumers and other stakeholders help to decide both policy and implementation. I've had experience of that during the HIV epidemic in Australia and in other countries. where in some countries, yes, but in other countries, no. Consumers were very much involved in policy design and implementation. I can tell you for sure that that worked a whole lot better when consumers were very involved in policy design and implementation. So here I'm talking about men who have sex with men, men and women who sold sex, it's predominantly women, and men and women who injected drugs. And in Australia, they were very much involved in the committees and other processes that went on to design policy and implementation, and it worked fabulously. So let's try and learn from countries that make a mess of regulating, Australia unfortunately being a poster example of that, and learn from countries like the UK and New Zealand that are doing much better, not perfect, but doing much better. Thank you for listening.
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Colin Mendelsohn: Yes, though.
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Anton Israel: Hi, Dr. Anton Israel. My question is, based on the fact that it's prescription based as lopsided, based on the fact that it is lopsided based on a prescription and everything else you discussed as the Australian situation, coming from Israel, coming from the military in Israel, we implemented what we were told was an Australian practice back in the 80s and 90s of telemedicine. We actually have a naval medical program called Protocol, which allows for remote medical services and support. So my question is, why would you not be able to implement the same concept in Australia based on the fact that there's so few practitioners to begin with, let alone those who can deal with nicotine in those underserviced areas. And would that maybe be a, actually the solution is something that you guys came up with and we adopted, maybe it would be able to reinvent the wheel, so to speak, with what already worked in Australia, apparently.
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Carolyn Beaumont: Thank you. Great question. And I talk about it on Friday a bit more. It's absolutely a very logical, reasonable way to be able to bring the medical services to those who need them and easily. We already have telemedicine and that's how I operate because I need to reach a huge country. We still will come across the same issue, though, about doctors not being prepared to prescribe. So whether it's via telemedicine or in person, that is still the issue. There can still be issues with cost. There can still be issues with accessing an appointment for telemedicine, though maybe a little bit easier than face-to-face. Look, I agree. I think it is a way forward, but we'll still have the same barriers about the doctors not being open and prepared to prescribe.
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Colin Mendelsohn: One of the problems in Australia is that doctors are receiving constant negative messaging about nicotine vaping, and they have very negative views. They're being constantly told by the Australian Medical Association, the Cancer Council, the Health Department, that we just don't know enough, it doesn't seem to work, and what about the children? And that's what they read in the newspapers and in the very biased medical press, and that's a very negative attitude that they have. And also, they're being asked to prescribe what's an unapproved medical product, so it hasn't gone through the medical regulator. So they're anxious about prescribing something that doesn't have the high standards of quality and safety proven that medicines have. So even if you have telemedicine, which we have, very few doctors will actually participate. And honestly, patients don't see why they should have to. Patients can go to the next door to the service station and get a pack of cigarettes. Why should they have to jump through all these hoops? And patients have rejected that, and they're continuing to do that.
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Carolyn Beaumont: So we'll see to the end about that. Um, so actually the, the government do support and they've actively supported telehealth specifically for smoking cessation. Um, when the prescription model came out in, I think it was October 21, the government introduced, um, specific rebates so that patients could access exactly that thing, which is great. We still come across all those same issues of, um, doctor resistance that Colin has outlined.
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Colin Mendelsohn: And now there's a big kickback against telehealth. The AMA saying, oh, well, there are all these commercial organizations that have been set up. There's fragmentation of care. They don't know anything about the patient. It's just a commercial service. And it's better if the patient's doctor does it, but the patient's doctor doesn't know anything. It's not a very satisfactory service. It's about ticking a box. And the purpose of the medical consultation was to give the patient the extra support and medical advice to make the vaping work. Well, the doctors know nothing about vaping, so if they're not getting that extra support, they're just ticking a box.
00:44:34 --> 00:47:37
Mark Oates: We'll not comment on that, but I just wanted to bring in a question and perspective from the United Kingdom. It probably hasn't escaped your attention, I'm not Australian. I'm a POM, as the Australians like to call us. And I'd love to come on here and bash you and have a go for your stupendously idiotic policies, particularly as... Well, I was going to say, particularly as yesterday in the Ashes cricket match, in the first test, we lost. Australia and Britain, we have a love-hate relationship. On this, for one rare thing, I think we are doing better than you. But I suppose I'm a harm reduction advocate. I've been involved in politics for a long time. I've worked on campaigns from legalisation of medical cannabis, say it quietly, Brexit and elections. And what interests me is the cultural and political reasons for how you got to where you are and how Britain got to where we are, because there's a fork in the road, and that's that medicalization of a product or the consumer delivery of a product. And we took the consumer angle. It was a closer run thing, I think, in Britain. There were people calling for the medicalization of the product. doing so makes a deeply unattractive product. And we don't want to make a product attractive to the youth, but the product has to be more attractive in a myriad of ways than smoking. So cost is a perfect example. There's a price elasticity of demand when it comes to nicotine products. And in the UK, the high tax on cigarettes means that vaping is more desirable. And then you want a product that's better. A lot of smokers, 50% want to give up, and struggle and so vaping if they try it is more successful as you know but there's also 50% that don't want to give up smoking which is the elephant in the room and that's where vaping comes in quite well because a lot of people quit accidentally when I quit I didn't want to give up I honestly I knew they were dangerous but I just enjoyed using nicotine and frankly as a 20 year old I had more things to worry about than when I was going to live long you know I didn't want to spend three more years in a nursing home so that didn't matter um how did Britain get to where we are We had fantastic researchers, scientists, professors, academics who have sort of spoke quietly to the government and told them the facts. They were open minded. They were willing to look at this product and see the harm reduction potential. We also had a conservative government who were more liberal minded, more willing to have a sort of free market. If we'd been had a more controlling government, perhaps they wouldn't have taken that route. We had a lot of vapors already, so they were quite powerful. They were getting in contact with their MPs. We had the New Nicotine Alliance Advocacy Group charity. And then the media wasn't as aggressive, I think, as in Australia. So I suppose the question is, in order to know how you guys get out of this situation, how did you get into it? In that regard, were your researchers and academics not as strong? I know your tobacco control field is much stronger than ours, or a little bit. And how do you get out of this situation?
00:47:39 --> 00:49:50
Colin Mendelsohn: I'll just make a couple of points. The one is that we don't need tobacco harm reduction because we're the world experts. So we've been doing it for years. We're the world experts. We know best. You'll all be shown to be going down the wrong path. So that's one thing. Secondly, there's a group of tobacco control experts who have become very connected to our policy makers. They were involved in plant packaging and in high taxes and tobacco control policy. They've all developed a very close relationship, but we don't have a debate anymore in Australia. So when the health minister wants to find out what to do about vaping, he goes to this particular small group of people and they tell him what to do. And the alternative view is not expressed. Well, it's expressed, but it's not listened to. So just to give you an example, the peak health body in Australia which guides health policy, the National Health and Medical Research Council, made a position paper on vaping. And it was really a disgrace. And that was used to guide policy. And Alex and I and a number of other international colleagues developed An article, an analysis we published in Addiction, the leading addiction journal, which basically concluded that this was a flawed, scientifically devised, it had misinformation and bias. We thought, great, this is going to turn things around. No one took any notice. We sent it to all the media outlets, all the members of parliament. It got no publicity. We sent it to the NHMRC and they said, so what? We're the NHMRC. We know best. We've looked at it very carefully. It was co-authored by Anne McNeill, John Britton, Neil Benowitz, Alex. So all the big names in tobacco harm reduction. And it just received, it was totally rebuffed. So the problem is that we have evidence. It's not about the evidence. It's about vested interests, politics, ideology, and I think a close-knit group of tobacco control public health experts who have all banded together and said, this is what we think, and they don't know what they're talking about, and this is the way we want to go forward. And it's very frustrating.
00:49:52 --> 00:51:44
Alex Wodak: Can I just add that I think, and I really appreciate your comments, Mark, I think you're absolutely spot on saying that if you want to figure out what a mess you're in or how well you're doing, you have to, it's important to go back to how it all started. And I think what was important in the United Kingdom, as I understand it, is that your prime minister at the time the decision was made to go down the vaping making vaping easy to get hold of for smokers. Your Prime Minister at the time was David Cameron, who was himself an ex-smoker. And when David Halfon, a noted psychologist, explained to him why vaping was likely to be very, very important in reducing the health and social and economic costs of smoking in the United Kingdom, David Cameron understood that because it was an ex-smoke himself. He knew that the hand-to-mouth movement was important, that the jet of hot gases reaching the back of the throat was important, that nicotine was important. He knew all those things. He didn't really need somebody to explain it all in great detail because he had personal experience of them, that that was terribly important. And really what that strikes home to me is the importance of getting consumers involved in this to become much more activist and explain to their recalcitrant members of Parliament why it's important to them and their family that smokers' arrangements are made so that smokers find it easy to quit rather than difficult to quit.
00:51:45 --> 00:53:28
Mark Oates: Yeah, just on that, in a lot of social justice movements, there's a big call for lived experience and nothing about us without us. And, you know, policymakers are often encouraged, and it's vital to have people on the panels that know what it's like. But on this subject, you know, we are just being dictated to by people that have never enjoyed nicotine, that just don't comprehend that desire for pleasure that humans have, and the fact that they will want to consume nicotine, and there needs to be a safer version. And I don't think people have got it into their heads. I don't know a country in the world where they've actually started using nicotine and stopped. And Sweden is a fantastic example, whereby they use a similar level of nicotine to other countries, but they use a version which is vastly safer. And just to make you guys not feel too bad about your politicians, you know, we've made our own mistakes. The ban on snooze in the United Kingdom was an absolute travesty. It led obviously to us encouraging the EU to ban snooze, and that has probably led to hundreds of thousands or millions of deaths across Europe. And, you know, I've been campaigning for the legalization of snooze ever since I tried it on a flight home from Asia, which landed in Sweden in a layover. And I was using snus, but I couldn't get hold of it in the UK, so I was going back to cigarettes. So the UK government was complicit in keeping me smoking. It was only when I switched the cigarettes for vaping that I completely quit. But I've been campaigning for legalization of snus and trying to persuade politicians and policymakers and civil servants that they've made a mistake, that they should withdraw from the route they've taken is, as we all know, a nightmare. You only need to look at the War on Drugs to see that.
00:53:29 --> 00:54:13
Colin Mendelsohn: And just to finish off on this, before I pass to Carolyn, one of the major factors in Australia is very much the war on drugs, the war on tobacco. Many of the people involved in public health and tobacco treatment have gone through the war against the big tobacco companies. And they've been through a very bitter and hostile war where they've been mistreated, there's been appalling behavior. and they're determined to destroy the tobacco companies. Really their priority should be to save the lives of smokers but it's all about destroying big tobacco and because big tobacco has become involved in vaping, vaping has become also the enemy and so now we have the nicotine wars and that's a very big issue in Australia.
00:54:16 --> 00:55:44
Carolyn Beaumont: Thanks. In response to what you're saying, Mark, earlier about why has that fork in the road occurred and why has Australia continued to dig its heels in and want to treat nicotine as a medical model? I can think of a few reasons, but one that really springs to mind is that Australia physically is huge, but we're small. We're small in population and we're small-minded. We have the same number, we have the same small group of researchers, same findings, same enemy That's right. We have probably a small number of major media compared to our population. Again, when you think of Australia only being 3% of the population of a country that's bigger than Europe, the media have a incredibly strong pool and they love terms like the war, the war on drugs, the war on smoking. Now it's the war on vapes, the war against the vapes that are killing our children. And so the media is really important and we just don't have the size and the diversity of voices and research to be able to say, hey, there's another way.
00:55:44 --> 00:55:46
Colin Mendelsohn: Jeannie, did you want to answer?
00:55:51 --> 00:59:12
Jeannie Cameron: Thanks. I just wanted to say, as an Australian, but who's lived in the UK for 20 years and been involved with you, Colin and Alex, for a long time, I actually think there's an extra dimension at play in Australia, and that is what we all know is the tall poppy syndrome, but it's extenuated into this area that There's a, seems to me, and whenever I go back there, there's a fear of, there's a fear dimension that anyone who speaks up, whatever the issue is, Australians are just very ready to sort of cut it off without any discussion. And you almost feel scared to raise things or to say things which are evidence based. And I think that's one thing I noticed whenever I go back to Australia, far more dominant. in a cultural sense than ever existed before. But one of the things I was thinking of was perhaps all the UK scientists and like the Ann McNeils, all of those, and even from the College of GPs and all the others that support vaping in Australia, perhaps it might be a tactic or a something to find someone who would fund to bring a lot of them en masse for a particular conference or something that is set up in Australia, to which all the GP bodies and that in Australia might come to because it's actually people who are, you know, not connected, but are from there and bring them to actually hear from you know, examples where it actually is working. Because I think that's another thing Australians do tend to look to, at least historically, they would always look to, you know, what's happening in other parts of the world. And if you had all those leading experts from the UK academics and others go there for a specific conference, specifically on this, just to bring awareness and it might actually resonate. Because remember the parliamentary thing where Martin Dockrell came in by Zoom or whatever to give evidence at the parliamentary. Those sorts of things were listened to. And at that time, it was pre-COVID, then there's been two years of nothing. Maybe it's time to bring them all back to sort of start the discussion again as completely independent. It might be just an idea because even Simon Chapman, the guy who's one of the ones that the government is listening to. On snooze, he actually published in his book in 2006 and he was what led to it being banned in UK and Europe. He said, I think 30 years on, it was one of my biggest mistakes of having prevented a generation from paying access to A Less Harmful Prayer. It's published in his book. Start bringing those things up again about the people who are now against it and also questioning why they have suddenly changed some of their own published views to now. But I think that fear is what is a cultural thing that is there now more so than I've ever seen, which makes it so difficult. And also amazing Colin, that you and Alex can, and yourself, um, to continue to speak up about it in such an environment, but it's very difficult. And I don't think there's anywhere else in the world that behaves like that with the tall poppy syndrome that we have in Australia.
00:59:12 --> 01:05:27
Colin Mendelsohn: Yes. I might just jump in now and just finish off our presentation, last presentation, which is just now an overview of what we would regard as the best model for nicotine vaping. And this is based on an article that Alex Nye and Wayne Hall wrote recently about how nicotine should be vaping in Australia. And it applies to other countries. We regard this as the ideal model, but we're very open to any suggestions on how to improve this model. So we're looking at what we think is the best way to regulate vaping is with an adult consumer model like they have in New Zealand and the UK, where nicotine liquids are sold at licensed retail outlets. So this would reduce access and appeal to use, because these premises would have careful age verification, and along with that, severe penalties for breaches of age verification, loss of license, which would obviously be of significant value to the business, maybe even closed circuit TVs, which is, I think, a bit of an overreaction, but it's another way of saying, we're serious about this. Because we think these products should be at least as easily available as cigarettes, and not harder to access. And of course regulations should be proportionate to risk, and I'll come back to that. There will need to be some policing and enforcement of course, because not everyone's going to comply, but there will need to be some with severe fines. And the public supports this model. So in a survey recently, 73% of the public support sale by licensed retailers similar to tobacco. So the public recognise that this is the appropriate way to go. And that's why we're optimistic that there may be change in Australia. And amongst papers, 79% said they were more likely to purchase from a legal market. So if this model is introduced, we would hope to see the black market would gradually diminish and be replaced by a legal market. So there is support out there in the community. And just quickly, in Australia, this will involve making nicotine liquid a consumer product, not a medicine. That can be done at the federal or state level. And we think a reasonable limit's 50 milligrams per mil free-based nicotine. And that would be regulated by the consumer regulator, not the medicines regulator. So there are changes that can be made at federal and state parliaments to make nicotine available. And this picture has far too many words, but it's basically a policy framework. So it's all the sorts of things that you would know about that we need product standards for quality and safety manufacturing ingredients in these products. Regulations for containers and labelling, what's in the bottle, is it childproof, and appropriate health warnings. So, for example, this product may be addictive but is far less harmful for adult smokers. So not, this product is addictive. In other words, something with a bit more context that's of value. What else in the policy framework? Yes, flavours. Well, I think there should be flavours available, but not silly flavours with fancy names that appeal to young people and images and unsafe flavouring chemicals, obviously. Public messages should communicate the absolute as well as the relative harms. So not this product is not safe. That means nothing. This product is far safer than smoking. And if you're a smoker, of course, this could help you improve your health. I think there's a place for restricted advertising to encourage smokers to take up vaping, but obviously not advertising that's promoted to children. You need a system of monitoring for unsafe products, and you need a proportionate taxation model. But of course, you also need strategies specifically for restricting youth vaping, because that is the driving force in this debate. So that would involve selling these products from adult-only licensed retail outlets with strict age verification, as I mentioned before. Online sales would require third-party age verification. No marketing to adolescents. Banning flavours that appeal specifically to adolescents. Accurate information. Unfortunately, a lot of the information the kids get is misinformation. And I think there may be a place for increased... I think we think there is a place for increased taxation for disposables to reduce access to children. And so we would hope that over time, the black market would be largely replaced by people going to the legal regulated market. We've taken all the hoops, all the barriers and the hurdles. So hopefully people would go to a regulated market and there would still need to be some policing of the black market, but it would gradually, we think, be diminished. And finally, I've just put a list of issues there which you may want to bring up. I mean, what's important to me is how do we change policy in a hostile anti-vaping environment? It seems that everything we do, no matter what challenge we come up with, what evidence we produce or what evidence is produced, unfortunately it seems like there's an invisible wall around the policymakers. How do we get through? And then there's all the questions about youth vaping, how we're going to deal with disposables and flavors, what nicotine concentrations are reasonable and so on. And of course, prohibition doesn't work. And how do we address that? So be open to any questions or comments or anyone from the audience, the floor like to, this floor here, like to comment, Alex, on any of that.
01:05:28 --> 01:06:54
Alex Wodak: Just make one brief comment, and that is to say, if you look at the UK and New Zealand, one of the differences between those two countries, which regulate much better than Australia, is the difference in the availability of data on smoking and vaping. and Australia has very high quality research on the prevalence of these mood-altering drugs, but the problem is that research is only available once every three years, and it takes a year after gathering the data to publish the results of that. New Zealand and the UK come out with data at least annually, and there are more than one group that produces acceptable quality research in both countries. So there's a lot of data. It's very recent data. Maybe some purists might argue that the Australian data is better quality, but I think having that come out so infrequently is a real problem. So, I think the take-home message, whatever country you come from, try and get smoking and vaping and other relevant data much more frequently, even if the cost might be some reduction in quality.
01:06:56 --> 01:07:01
Colin Mendelsohn: Would you like to comment on any of that? Anybody else in the audience like to pass this around?
01:07:01 --> 01:08:18
Attendee: I hear a couple out here. Just now, Kennedy just mentioned a lot. Very few smokers will see doctors because of barriers, difficulty of them to see doctor because of some barriers and difficulties. But some people argue that now is the time for doctors to be proactive. It is not the smokers who try to see doctors, but it is the doctor himself who tries to find these smokers. I think it is in line with the five A's major steps in quit smoking that we learn. So if doctors are more proactive, then the numbers of smokers who take vaping or any kind of smoking cessation, it will be more in numbers. So what is your comment on it?
01:08:23 --> 01:10:02
Colin Mendelsohn: Thanks Alfin. Yeah, look, I've actually been involved in training thousands of Australian GPs on smoking cessation and I'm pretty despondent about it. Unfortunately, the research shows that although they regard that as a priority, in fact, in the real world, they don't have enough time, they don't get paid enough, It's really frustrating because there are such low success rates. Patients rarely ask doctors for advice, so the doctor has to bring it up and usually there's a shopping list of medical problems, so there just isn't time. And doctors get very little training in smoking cessation. So in the real world, it just doesn't seem to happen. And of course, now they've all been discouraged by failed attempts at quitting over the years, even with the best possible treatments, that they kind of lost interest. And now that vaping has come along, Well, they just haven't become engaged with it. So my experience in Australia is that, yes, at the workshop they might sort of show some interest temporarily, but it's never sustained. And the research shows that Australian doctors miss many opportunities to ask about vaping, smoking, and to offer intervention, and in fact, have very little knowledge. And in Australia, there's very little in the way of smoking cessation clinics like there are in the UK and New Zealand, for example. So there's very little in the way. They can only refer to Quitline, and less than 2% of smokers seek Quitline every year. So unfortunately, there's not a lot else going in terms of traditional treatment.
01:10:07 --> 01:12:11
Carolyn Beaumont: Um, so I guess we can't understand what we don't see and the same applies to doctors. So, uh, doctors generally don't hang around smoking communities and we don't really see them and talk to them. Um, so that's. That's just going to be the way it is. I mean, I'm a very clean-cut, non-smoking, non-vaping person, and I really had no idea whatsoever until three years ago. what this whole vaping, smoking community is. I had no idea. And I had finished all of my general practice training exams and I'd gone through all the modules on smoking cessation and there were the five A's, can't even remember what the five A's, something about ask, assess, advise. Something, something. I was just looking through those notes the other day and I realized just how poor they are and they just barely skimmed the surface of why smokers smoke and why they might want to change. And I've just learned through talking. talking to smokers, but not every doctor will set up a business talking to 3000 people. So, um, I just learned by talking and being open to them and I don't know, I think, um, maybe we can get, get, um, smokers to the doctors, get them turning up to education sessions and, I remember as a, um, a trainee GP, we had one session that really stuck in my mind and it was to do with heroin use. And there was one ex-user who turned up and spoke to us and it was incredibly powerful. And that was just one person, but we never, ever, ever had one heavy smoker turn up and talk to us as trainee GPs about their real struggles. So even I, I like to be practical and optimistic. Um, So even something like that could really help.
01:12:15 --> 01:13:05
Kgosi Letlape: Thank you. My question is about restricted marketing that you talk about in the context of the internet, social media. So what would you really suggest? Because in my country, one of the things that get used is that these things are being advertised to kids. And maybe in the same vein, you could talk about the issue of flavors. What should we actually do? Because if there's no discussion around the issue of flavors, it will always be used as youth baiting. and poison the discussion. And lastly, the issue about physicians, where I come from, people will say the WHO says. And once you still have the WHO saying what it is saying, you won't get physician uptake. So how do we deal with the misinformation coming from the WHO?
01:13:09 --> 01:14:10
Colin Mendelsohn: Yeah, look, I think you have to be very careful about the advertising. You need to frame vaping as an adult quitting aid. It has to be seen very clearly as an adult quitting aid, not for children, but that won't stop some of them. I think it has a place at the point of sale. So places where smokers go where they see cigarettes and they can see an alternative, I think there's a place for it to be seen there. Unfortunately, we have enormous problems stopping it from access from the internet or on social media. But if there is going to be advertising through mainstream media, it needs to be placed at times and in a way that protects young people. So not to be presented in a way that appeals to young people. And I didn't catch the point about your doctor. Doctors, you mentioned, what did you mean by that?
01:14:10 --> 01:14:35
Kgosi Letlape: What I mean by that is that, you know, particularly in low middle income countries, what the WHO says is gospel. What the World Health Organization says is gospel. So now that they are on the wrong side of the gospel, how do you deal with that? Because if you don't deal with that, it's going to be difficult to influence training of doctors and what happens in health systems.
01:14:35 --> 01:14:39
Colin Mendelsohn: The World Health Organization is enormously influential, and I think I'll hand that one over to Alex.
01:14:41 --> 01:18:33
Alex Wodak: Well, just to remind everyone, 25 years ago we were in exactly the same position with the World Health Organization opposing the distribution of sterile injecting equipment to slow the spread of HIV among and from people who inject drugs. And we, the International Harm Reduction Association, for that reason, organized for its annual conference to be held that year, I think it was 1997, in Geneva, so that we could engage in some kind of dialogue with WHO. WHO's response to that was to send a memo to all its staff saying that the staff were not allowed to attend our International Harm Reduction Association meeting, Geneva, on their doorstep. So I was president of the organization at the time and we wrote to World Health Organization and said that this was, we thought this was wrong and unacceptable and we wanted to have a meeting to discuss it. They were generous enough to provide two senior staff members who listened to our complaints. I'll never forget that meeting. It was very polite and respectful on both sides. The result was that a year later, when we held our annual meeting in one of the Channel Islands in Jersey, I think, WHO and UNAIDS sent senior staff to that meeting and Peter Piot, who was then president of UNAIDS, I'll never forget he stood up and he said, I am with you individually and we are with you organizationally. So, they did reverse their position, which had been, WHO turned out had been forced to adopt an anti-drug harm reduction attitude because of pressure from the United States. And that's what happened. So I think the lesson I drew from that is when you think a terrible wrong is being done to you and people you represent or people you work with, you're obliged to complain. That's the only way the system can be corrected. So I think what we really need to do is try and get WHO to receive a delegation, predominantly I would hope, with most of the members from low and middle income countries because that's where 80% of the smokers in the world live in low and middle income countries. And it'd be very difficult for WHO to decline meeting such a delegation. They may not agree, but I think that's what we should try to do, and I hope, rising out of this meeting this year here in Warsaw, that that's what will happen. And it may be we will need several meetings of that kind before WHO might reconsider its position. But their objections are nonsense and we have to keep reminding ourselves that the opposition to tobacco harm reduction isn't reasonable. It's not evident based on any sensible evidence. It doesn't stand up to any kind of scrutiny. So I think that's what we should do.
01:18:40 --> 01:19:54
Anton Israel: So when I look at the list, there are two points that I feel that are missing. Number one is health economics, and number two is the loss of revenue for the country. Reason is because almost all other points are, I feel, I think, I wish they can go that way. And the last of the ones I discussed are just factual. They're numbers. So for Israel, for example, it's just recently started in Israel that they are recognizing that they're losing two billion shekels every year due to lack of revenue because they're not enforcing what is legal. Number one. Number two, black market. is bringing in devices that cause EVALI. We've just had a death of a young person due to EVALI in Israel just recently. And in turn, that affects the health economics. How much will it cost us to treat those who switch versus those who stay? So that's one of those cyclical discussions that actually I find ATOs and public health in Israel have a hard time dealing with and really try and run away from because they don't have a good take on data. They have a good take on feeling. So from that standpoint, I always feel that that's a really important part of the discussion. It's actually been evaluated in the military as well. It's a whole different discussion in and of itself. So that's the only question is, do you put it in there? And if so, in what frame?
01:19:59 --> 01:21:25
Dwain May: Yeah, thanks. The panel, this is a great discussion and obviously it's worldwide in terms of its effect. I'm going to speak a little bit from a Canadian perspective. I'm a research associate, a long-term market access professional in Canada. And in Canada, they're taking a bit of a different approach in terms of how to deal with smokers that can't quit or aren't able to quit. And the pharmacist has gained popularity in terms of trying to be the point of contact for those patients because the Canadian law and Canadian health care coverage allows the coverage for nicotine replacement therapies through the pharmacist on a prescription basis. In Canada, however, the role of the pharmacist has actually grown substantially because of access to physicians has fallen off. Telehealth is becoming very, very popular now with physicians. but the scope of practice for pharmacists in Canada has expanded now that they can actually prescribe. And in Alberta, where I'm from, they have the largest scope of practice in terms of what they're able to do and act on as a pharmacist. And Todd Procknow, who is around here, and Carolyn has heard Todd speak on tobacco use disorder and what needs to be done from a pharmacist perspective in order to try and adopt some of the principles of tobacco harm reduction. So, I'm just wondering, the panel, what their comments would be in terms of the role of a pharmacist and how that can be expanded.
01:21:36 --> 01:22:26
Carolyn Beaumont: I'll just touch on. Okay, sure. Thanks, Dwayne. Yeah, great to hear the Canadian perspective. Yeah, look, I think that's definitely got a lot of merit. Certainly politically, the Pharmacy Guild and the General Practitioners Guild might have to go in the blue and red corner to battle that one out. Um, but yeah, I mean, as I've said many times in my presentation, the barriers to accessing a doctor for their nicotine script are not going. They're complex barriers. They're deeply entrenched in our economy and our culture. Um, so I, I do see that, yeah, having, expanding the role of the pharmacist could be a really logical step.
01:22:31 --> 01:22:33
Kgosi Letlape: So, yeah.
01:22:33 --> 01:22:41
Colin Mendelsohn: So look, it's one o'clock. We probably should stop there, but I just want to thank the panel very much and thank you all very much for your involvement and for asking questions. Thank you.