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David MacKintosh: At the time we better begin because I hope that this is going to be a very dynamic session and that there's going to be lots of questions from the audience. I'm David McIntosh from KAC. I was particularly pleased to get this opportunity to host the Inequality of Access session. How do we achieve a level playing field? Because this really goes to one of the main reasons as to why I got involved with tobacco harm reduction, a background of working with groups which traditionally had been neglected in a variety of ways in terms of access to services. But yet, some of the greatest potential in terms of what could be achieved through tobacco harm reduction in terms of personal improvements in health, but also benefits for community and social benefits. Now, there's been, I think, I see the session really in two parts. I will introduce and you will hear from the participants on the stage and in California at a very, very early hour. And I think we're going to outline some of the barriers that exist and some experiences. But I'm very keen that towards the end of the session, we look at how we can improve the situation and how we can reach out to allies. And there's been some hints and suggestions in some of the earlier sessions on that. But just before I hand over, I think, you know, we often get very hung up on national prevalence rates. You know, in the UK, for men, prevalence rate's around 15%. You know, generally tracking down and people would say, well, it's slowly improving. But then we start looking at different communities and groups within that figure. And actually, it's shocking, you know. If we look at a very simple measure, people's employment and educational attainment, we see that something just under a quarter of people in manual occupations in the UK smoke, whereas only 9% do in professional occupations. But that disparity and imbalance is compared to nothing when you start looking at some other populations. Homeless populations, rough sleeping populations, the official figures say 80% of people smoke in these groups. Whereas I can say from when I was working with people who did outreach with those, they couldn't think of anyone they'd ever found who didn't smoke. There's also something like 80% of people entering UK prisons smoke. The world I used to work in, drug treatment, 60% of people entering treatment for opiate issues smoke. So there's, in some communities, smoking still was a norm. And the potential benefits of helping people move on to safer product is enormous in many, many ways. But there are some very significant barriers. And of course, mustn't overlook the fact that another 80% figure, 80% of the world's smokers live in low and middle income countries. and there's big challenges faced there. So that's enough from me for a moment really, but I will now very briefly introduce the panel. I'm not going to read out all the bio because you've all had access to that, but we have a very distinguished panel. all the doctors, two of a clinical background, two of research backgrounds. We have Cheryl Olsen joining us from California and Cheryl does deserve a medal for being up at what I think is not quite three o'clock in the morning.
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Cheryl Olson: Exactly.
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David MacKintosh: Dr. Michael Kariuki, who's joining us, who is a doctor, a pediatrician by background and working in Kenya. Dr. Li-Din Fong from I'm sorry, Vietnam, who I should, if you get the chance, or you haven't seen his short video, it's available, should be winning the title for the best titled video from ICU intensive care unit to GFN, describing his journey into tobacco harm reduction. And then my colleague at the end, Dr. Kasia Kowalicz, who has got tremendous knowledge of NGOs and a lot of background in mental health practices in not only Poland, but elsewhere in Eastern Europe and Central Asia. So, I will now I think it's only right, Cheryl, seeing as we got you up so early, that we'll start with you. So, a brief sort of overview of how you see the key issues, please.
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Cheryl Olson: Oh, the reason I'm here today is because of research that I did on people in custody. One of the things that I realized, I come from a public health background and I spent a number of years in academia at Harvard doing research, and I find that most of my colleagues in public health There's a lot of people are stuck in, they're in journals, they're among their colleagues, and I think they think in public health that they might be more worldly somehow, but they're really not. I was shocked when I started to do the background research for these studies. The studies that were for a specialty vaping product with the lovely name e-cig for inmate. A sheriff named that. And when we did the research, we asked, recently incarcerated people, what they liked about this product, the name was the thing that they most liked about it. They said, it sounds like it's for us. But I was just so struck by the massive need. David, you mentioned in the UK that the smoking rate's around 80%, and that is the rule of thumb I'm hearing in the U.S. prisons as well, when they order these. vaping products. They say estimate about 80% of your people are smokers. And when I look at the research that's out there in the literature, it talks about people on the low-income health insurance program in the U.S., Medicaid, smoking rates absolutely stagnant, haven't changed in years. People who have disadvantages, low education, low income, mental or physical health challenges, job challenges, their rates are stagnant, and the more disadvantages, the worse it is. But if you don't know to look in the research literature, you don't know about this, and I think When people look at the bigger picture in the U.S. and they think, oh, smoking rates used to be so high and now they're so low and we have nicotine replacement therapies and why don't these people just quit? There's not an understanding of look at the data. If they could have quit, they would have quit by now.
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David MacKintosh: Thank you very much. Next, Dr. Feng.
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Le Dinh Phuong: As you can see in my profile of the GFN, I am the doctor, and my journey from the ICU to the GFN is a long story. I spent very first 12 year in the ICU, where I have to take care of the patient with end-stage COPD, a lot of disease related with the smoking. And at that time, I never pay any minimal attention on the smoking, with smoking concern, because we are very busy, the patient is very severe, and they still live at the last moment of their life. But after 12 years, I move into the internal medicine department and I provide the healthcare for the patient with the heart disease, lung disease, diabetes, and I recognize the consulting for quit smoking is highest priority for the internist, for the own doctor. But I reveal 70% of my patient have willing to quit But 90% of them failed. And even national program of anti-tobacco reached a modest achievement. Only 5% of the smoker can quit within the six months. And after this, majority of the mystery labs is more available. But you know, in my country, we have a very interesting national program. I think it's the very first time reduction program in Vietnam. They supply the methadone, a least toxic for the patient abuser of the heroin. Every day, the drug abuser has to come to the health station, receive a methadone, and take it in the supervision of the healthcare worker. And it's very successful. And my question is, why methadone can be used for harm reduction, why cigarette cannot be, HTP cannot be the alternatives for harm reduction for my patient. That's why I do a lot of research, I do a lot of study on the medical paper, and I see a lot of evidence base proven the HTP can reduce the risk of COPD, can reduce the risk of the cardiovascular disease, and I totally convince it. And that's why as my duty of the clinician and the lecturer, I try to spreading the idea of harm reduction for my young doctors, for my college, and for my patient. And initially, the perception of of the audience is very, very different from the authorities of the Ministry of Health. You know, at Vietnam, the Ministry of Health follow the guidance of the WHO, and they send the warning letter for my health, send a complaining letter for the director of my hospital, and they interfere about my public media talk about the harm reduction. But from the side of my colleagues, my doctors, and my patients, they are very, very highly appreciated. I am the witness, the happiness of my patient. Cannot quit smoking with a severe heart disease, hypothyroidism, depression, and after transfer into the HTP, she is very, very happy. Energetic, happy, not fall into the attack of panic and the anxiety or depression, and her general well-being is big improvement. And from my college, I detect their awareness about the HTP is nearly zero. They are very surprised when I talk about nicotine is minimal toxic on the body. They still think nicotine is toxic and never use it. But after I show them the details of the HTP and the minimal toxicity of nicotine, a majority of them ask me how to buy the HTP product. I think that's why it's my duty. I'm not a policymaker. I'm not a researcher. And as the clinician and the medical educator, I think in my country, everything should start from the medical, the health professionals, the patient. The decision of the patient convert from the combustible cigarette into the HTB should starting from the advice of the doctor, not from the company, not from the Ministry of Health. It's my lesson on my daily practice.
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David MacKintosh: Thank you very much for that. And I think we'll be coming back to professional barriers and to explore that a little bit more. Dr. Karioki, I wonder if you'd like to provide a different clinical perspective.
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Michael Kariuki: Yes, thank you. As you heard, I'm a paediatrician, and back in the country I've been doing this harm reduction work for the last three years. And one of the biggest questions that I do get back at home is, what is a paediatrician doing in harm reduction? And my answer is quite straightforward. We want the parents to stop smoking. We want to assist the parents to stop smoking for the benefit of the born and the unborn child. We all know the effects of cigarette smoking on children, and especially the unborn children, in preterm births, very low birth weights. And that is essentially my drive, because if we have a community that has less smoking rates, if we're able to achieve a stop smoking, or rather no smoking society, then the future generation will be protected. Back at home, we did envision the whole aspect of harm reduction so that we bring it into perspective. And what I did is that I did form an organization called Harm Reduction Society of Kenya. And we have tried to bring on board not only harm reduction in tobacco, but harm reduction in alcohol, in drugs of abuse, in HIV, so that we bring into focus what harm reduction is all about, because we all know these other aspects of harm reduction are well understood. So we want to bring into focus the concept of tobacco harm reduction, so that policy makers, Kenyans in general, and most of those who consume these products, combustible cigarettes, to be aware. Our question has always been, despite all the very many efforts that we have had in the country, we all know that smoking rates in lower middle income countries is actually on the rise. And we have had quite a number of interventions which are not as effective. And we have seen other nations achieve very low smoking rates. How can we emulate? What can we borrow from these nations? And it has come to my realization that we have a lot of work on the ground, especially to educate and give more knowledge to our people back at home on the concepts of harm reduction, especially more so tobacco harm reduction, so that we can improve knowledge and the understanding of tobacco harm reduction. One of our key areas is research. We've done research on smokeless tobacco products, which are quite popular back at home. And we are trying to bring into focus that we not only should concentrate on the smoke products, we need to look at these smokeless tobacco products. And the statistics were quite revealing. because a large percentage of our rural population is using these smokeless tobacco products that are homemade with very high carcinogenic components, which are equally as harmful as smoking cigarettes. And we are bringing this on board and telling Kenyans that Hey look, you're using very high toxic products from tobacco despite the availability of smokeless, or rather despite the availability of safer alternatives that can assist you to quit smoking. We know we have faced some opposition, but the question has always been, the nicotine replacement therapies, how accessible are they? Let's begin the conversation from the pharmacotherapeutics that are out there recommended. How available are they in our setup in the lower socioeconomic status? And how can we increase the reach? How can we educate the people on these safer alternatives which are being proven to work elsewhere? And it's not an easy journey, but we keep on moving and we keep on educating our policymakers to try and understand the concept of tobacco harm reduction in the broader aspect of harm reduction. And we believe that the conversation is alive because there are many fears and misconceptions around safer nicotine products. And we have also realized that the makers of these products have very little concentration efforts in serving the lower socioeconomic status We don't have some of these makers or proponents of these products coming down to the lower socioeconomic status countries. where the burden of smoking is actually on the rise. And it's a call upon the international community. We have international collaborations so that we can have more research because we do emphasize that we need evidence-based policies, you know, not just policies out of the whims of politicians and all that. And our policy makers, our countrymen back at home and in Africa will tend to understand more this research as we try to bring in more health care workers into the fold. Because we need them as our allies. We need them to understand what are we talking about. We do have health care workers who smoke. And once they get to learn this, they are always asking, how can we gain or how can we be assisted to stop smoking? So it's a conversation that we have begun, and we do believe that we will make strides as we continuously try to localize the data. Because once we have local data, once we have local research, it resonates well with the population. And of course, the whole aspect of, oh, this research was not done here. Oh, why are you bringing research from Europe? Why are you bringing research from the U.S.? They will now tend to understand, oh, this research was done locally and definitely improve knowledge and understanding of THR.
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David MacKintosh: Thank you. Thank you very much. I certainly picked out the importance of knowing your local situation, having good data on the problems that you're facing in the area you're working. And something that I definitely think we need to come back to is the economic aspect, and there's a barrier and affordability to a lot of communities. Kasia, over to you again.
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Kasia Kowalczyk: So I'm here representing the third sector with my organization. We are working in, let's call it, general harm reduction in public health and we support other organizations and institutions in their work with key and vulnerable populations. So, the issue of inequality of access to services, this is something that we encounter a lot in our work, whether we think about opioid substitute treatment, antiretroviral therapy, tuberculosis treatment or access to mental health services. And I think it's intriguing to note that while a tremendous effort invests into engaging people in services and ensuring adherence to treatment, so little is done to sort of keep them alive, because we know that key and vulnerable populations are disproportionately affected by smoking. And as I said, I think that one of my key messages would be that we are not utilizing the third sector as much as we should. And there are various reasons why the situation looks as follows. And one of them is the way the third sector is being financed, usually organization based on grants, which sort of restrict the activities to what you outline in your program. And also, in general, this area is quite scarce with regards to money, which makes it quite a challenge to carry out comprehensible work. Then, the other issue is the capacity of the organizations to focus on the issues that are beyond their primary objectives. Another issue is, and this was raised here a couple of times, is the education. People are lacking of knowledge, but that goes beyond, of course, the third sector. I think that could be applied to all the people that somehow are involved with healthcare. And it's not only about THR, it's about harm reduction in general. People who are working in health sector oftentimes do not understand the principles. And that is why I also, of course, agree that we should provide education and training. And one of the key group are doctors. And my God, it is so difficult sometimes to collaborate with doctors. So this is why I'm very pleased that I'm here together with two representatives of this group. Then we need to remember also that the third sector used to be sort of the driven force of many, many changes when we look back into 80s and HIV pandemic. And also is the third sector that usually have the access to difficult to reach out to population. And finally, what I think is that the way the services are being provided is also of high importance. So the services, especially when we think about key and vulnerable population, should be tailored to their unique needs. Of course, they should consider it and take into account the current political situation in the country, availability of product, culture, but they should be based on trust and empathy. And again, in the healthcare sector, this is something which, at least in Poland, we are definitely lacking. The other thing is that, I'm a psychologist, so I know that every change requires time. And so if you want people to shift, to change into using other products, that requires time, but so does building trust. So this is why I think it should also be sort of integrate part of the services. Thank you.
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David MacKintosh: Thank you very much and a powerful reminder of the potential role of NGOs and voluntary groups. Before I start seeking questions from the audience, there's just one I point out of the way. It is a question, really, and it links to two things that I've heard raised there. Professional resistance in a number of areas, and also the need for education and information. How much do we think that the professional resistance is based purely on a lack of understanding of these new products and as we've heard about nicotine? Cheryl, I'll start with you if I may.
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Cheryl Olson: I can't speak to clinicians directly, but I can speak about my public health colleagues. One thing I've noticed, I sometimes will, when I'm talking about these issues, talk about when I used to research on the effects of video game violence on youth, and I noticed that when I would talk to colleagues about that issue some years ago when there was a rash of shootings in the U.S., which they were attributing to video games, and colleagues would talk about them, and I'd realize that what they'd, you know, these researchers and informed people, I would think that they would be informed. I realized they were getting their information not from the research literature, but from what they'd heard colleagues say on coffee breaks, seen in the newspapers, or perhaps on an article abstract they glanced at. And they would say things like, don't these games cause, you know, cause school shootings or this or that? And I saw the same thing with attitudes towards things like vaping. I recall going to a, a Harvard Public Health alumni event in San Francisco before COVID. And I think I just started to do the pre-research on this product, and this project that I was going to be doing with people in custody. And I was very excited about the things I was learning. And people were saying things like, oh, you know, oh, vaping, doesn't that cause popcorn lung? Isn't that what, you know, addicts kids? Isn't that, you know, they had very superficial knowledge. And I realized that People who are ... I think this probably goes for health professionals as well as researchers. Those of us who think of ourselves as people who are data-based in our knowledge and understanding, we don't always realize that a lot of what we know doesn't come from data. It's anecdote. And we don't stop to say, wait, how do I know what I know? And if you can find ways to startle people out of that complacency and make them say, Wait a minute. I found that the issue of people in custody was a fascinating one when I talked to people at a later Harvard meeting that I went to. And I was talking to a few young people, you know, in their 20s, 30s, 40s professionals about the work of the data I had been collecting at that point. And they were fascinated. And they saw, oh my gosh, this is a really vulnerable population. These are people who were multi-substance users before they went in. They have so many disadvantages. They really need an alternative. They really need something. And it made them just turn around 180 degrees in their view of vaping as something they had to keep away from kids, as something that could be a harm reduction tool. So it's a matter of, I think, of trying to figure out how do you, what for a given group can you do to kind of nudge their mind open, give them some kind of example that makes them go, oh, and then at that point they're open to looking at the data and going, wait, oh, huh, maybe there is more to this than I thought.
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David MacKintosh: Thank you. That's a very positive and practical example. Dr. Phuong?
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Le Dinh Phuong: In my country, I think the acceptance of the medical professionals can be divided into two groups. The first group is the old doctor, my old professor, for a long time they practice based on the personal habit and personal experience. They may lack the minimal knowledge about statistical evidence-based medicine. That's why it's very hard for me to convince them about the evidence base of the HTP. They just said it's tobacco, it's tobacco, nicotine is very toxic, and stop to tell me about this. But for the young doctor who familiar with the avian-based medicine, when I show them the data of the study on the medical newspaper or journal, with the OAT ratio, with the G-square, with the HAZA ratio, they are very easy to accept it, and they are very surprised. And I starting to the first lecture about the pharmacology of the nicotine. I tell them a very simple example about the not very harmless toxin of nicotine. You should know in the United States, the nicotine patch is OTC product. You can buy it free with the prescription at any supermarket. Why you think nicotine is a toxin? That's it. Yeah, it depends on the education and the background of the doctor. And especially, I think it's the age of the doctor. Generation matters.
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David MacKintosh: Generation matters. I mean I was very taken when we spoke before today when you made the point as you've just repeated that you know nicotine replacement therapy was also seen with a great deal of suspicion and that's not something we're going to do because it's the nicotine that's dangerous.
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Michael Kariuki: Yes, indeed. The level of knowledge amongst healthcare workers on harm reduction is very, very low. I mean, we did a short survey whereby we found out that of those patients who present to hospital, Let's say with other issues, during the history-taking, the patient says, I've been a smoker for the last 10 years. Most clinicians have no idea what do we do next. So they'll end up probably managing what has brought the patient there, be it hypertension or pneumonia. And as far as assisting this smoker to quit smoking ends there. And there is a huge knowledge gap. When we started telling clinicians that nicotine does not cause cancer, it was a big shock to them. I mean, they always knew that nicotine causes cancer. And these are some of the misinformations that we are trying to fight. and educate our healthcare workers because they form a very key role as allies in harm reduction. And the knowledge gap is huge, beginning with health professionals. And we are trying to do our level best. We have been to several scientific conferences back at home for professional bodies. And we are preaching the same message. It comes as a big shock that the level of misinformation and disinformation amongst healthcare workers is appalling. And we are trying to pass the message that this is the right direction. This is what science is telling us, even as we try to approach our policymakers so that we can have evidence-based policies. So it's a long journey, and we are up to the task. Karasha?
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Kasia Kowalczyk: Well, I believe I will just echo what already has been said, but whenever I have a sort of a contact with either doctors or other groups of people involved in health care services, there are like four key arguments that I hear. One is, of course, that the industry then there is vaping cataracts kids, then there is that you don't have data, and the fourth one is belief that THR exists not long enough to be able to have like conclusive results. And I just think it's the doctors are sort of the key group that we should focus on and also it should be sort of like peer-to-peer education, because I'm not sure what else could be done, but I think, yeah, there is a tremendous role to play by doctors.
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David MacKintosh: Okay, well one of my plans from today is it will produce a bit of a to-do list. So doctor's education is on the to-do list and then we can think about that. I'm going to come out to the audience now for questions, but there's an observation that was raised when you were talking about a lot of healthcare workers smoking. It's my experience that an awful lot of people working in NGOs or frontline services who work with populations that have very high smoking weights also tend to have higher rates of smoking themselves. Something there. Right. Right at the back, please. I'll do the translation if you call me any difficult. Yeah, thank you.
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Martin Cawley: Martin Cawley from Glasgow in Scotland. I hope that was very clear. Building on the theme that you've just touched on, Dave, and the point you made right at the outset, how does the panel feel that you could best build trust between key stakeholders who have got a different stake in the game? If you like, you know, they've got a different point of interest. So how best can you build trust in stronger collaborations?
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David MacKintosh: fundamental question, I guess. Have we got any ideas about how we can improve trust?
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Kasia Kowalczyk: I don't know. Well, trust, as I said, requires time, but it also requires sort of everyday work. This is how we build trust. Yeah. So
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Michael Kariuki: Yes, sir. For the low socioeconomic status, we have identified five key barriers on the concept of harm reduction. And one of them is the ability to perceive. The consumers have very low ability to perceive. or the lack of perception of the need for support, and the need for motivation to quit, and the health risks of smoking. So to build the trust, we need to educate the smokers that you need to improve your perception, you need to know that you can be assisted, because the need will be derived from the smoker, that I need these services. And the other biggest barrier we are having is the ability to seek the lack of knowledge and distrust and misperceptions about cessation support. And that cuts across both with the users, the healthcare workers, the policy makers. There's a lot of distrust and misperceptions which can only be removed by enhancing knowledge on harm reduction, cessation programs that can assist these smokers to quit. And of course, a very unique challenge also as a barrier is ability to reach. You know, we have a huge population living in areas with very few resources, you know, poor social support and mobility. And it's a big challenge to get to this. And of course, very, very important is the ability to pay as a barrier. The issue of cost, the issue of prioritizing it in the to-do list or to-buy list was the other competing priorities because of the high cost of these products. And the last one is the ability to engage. You know, we need to engage our political establishment, policy makers, to improve trust and fight the misconceptions and the myths around harm reduction.
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Le Dinh Phuong: To my knowledge, the clear message from the doctor, please, Turkey, quit. Quit completely. It's very easy. But it just increase the rate of quit smoking 1.3. Yeah, it's not very high. But in my own experience, when I spend enough time to explain for my patient, for the consumer about the harm reduction of the HTP, And I should emphasize the HTP is not clear on the risk of the heart disease, but at least it can reduce the risk. The quitting completely is the best. If you cannot quit, you can transfer into the HTP. And my willing is not make my patient any confusion and making the fake advertisement for the industry for their help, for their good health, for their willing to reduce the risk in the future. I think in my experience, it's totally convincing for my patients.
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David MacKintosh: Thank you. I know there's another question here and then we've got a couple along the front, but we start with our friend from Sweden.
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Bengt Wiberg: I'm Bengt Wiberg - EU4snus from Sweden. In 2022, I'm going to ask a question first, and then I'll just explain why. Is the gender inequality between the use, when it comes to user of smokeless tobacco and tobacco-free nicotine pouches. There was a population study done in the UK in 2022, which was a mirror of the UK population. It concluded that only one out of five users of nicotine pouches in the UK were women. One year later, I'm very happy, Sheryl takes the initiative to do a survey among U.S. women asking them what are Why don't they, in a higher degree, use smokeless oil products? You came to the conclusion there were four main deterrents. Could you share the light with the rest of the world? Thank you.
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Cheryl Olson: That might be a little beyond the scope of what we're covering here right now. I could use that to segue to a larger point, though, which is the importance of having data for things, the thing that Bengt is referring to. I write most months for the Public History and Tobacco Reporter, and the reason I do that is because I felt that I don't want to just be preaching to the choir, as they say. I don't want to be just talking to public. I want to build bridges between public health and And so I try to address, sometimes I'm addressing industry, sometimes I'm addressing public health colleagues when I write. But one of the things I did in sort of a quick and dirty informal survey through email of a U.S. consumer group, CASA, because I did want to understand why is this not more widely used. And it's, I think, I mean, the lack of good data is a real problem that we face because When I looked at the data on people in custody, for example, I kept seeing different estimates that were old estimates of, oh, it's this many people are tobacco users, this many people. I thought, why don't we have better data on that? How hard is it to go into some facilities and collect some data? And I think that's something that we need to be thinking about is, are there You know, and when we do collect those data, we have to be transparent about who funded it, but I think sometimes it is possible to do low-cost things and then use that as a, what my journalist friends would call a news peg, something to hang the story on and get people's attention about an idea. And if you could look at my tobacco reporter piece on the women in spoke, let's see if you want to know more about what Bengt is talking about.
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David MacKintosh: Thank you, and it's a valuable reminder about not to forget issues around gender, because one of the things, I can't remember which session it was yesterday, is about hidden smoking populations in some countries amongst women who were not admitting, but when the data was collected well, they actually had much higher rates of lipid. Charlie, do you, sorry, the microphone's coming.
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Charles Hamshaw-Thomas: Charles Hamshaw-Thomas from the UK. The opponents of harm reduction cite regularly, and the WHO cite this regularly, that there's no need for this because our tobacco and smoking control policies have been working very well. I've heard Stanton Glantz say that. I've heard it from leading opponents in the UK over 10 years ago. We hear from David and from Gerald that it's manifestly not working in the hard-to-reach communities. Ergo, don't we need to prioritize the hard-to-reach communities if the whole THR movement is to move forward? And if you agree with that, how do we go about it, i.e. putting it front and center of the harm reduction movement?
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David MacKintosh: Thank you for that. A very complex but important question. I can see you're biting at the bit there, Kasia.
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Kasia Kowalczyk: Of course, I agree with you. Because this is the primary objective of my organisation. Of course, definitely we should focus on knowing the death data among key populations and vulnerable populations. They should be prioritised, but the question is Who exactly cares about vulnerable populations? Well, a few people from organizations and I just think it's What we could do is just to try to sort of popularize THR among third sector, but as I said, it's a daily work, which is mainly based on individual contacts. So this is what we do. We talk to our friends, we try to educate them. Sometimes it works, sometimes it doesn't, but all I've learned so far is that it just takes time
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Michael Kariuki: Yes, indeed. A key observation in the lower middle income countries are the developers and producers of these nicotine replacement therapies, safer nicotine alternatives. They have very minimal focus on the vulnerable groups. And this needs to change so that we can have more focus on these vulnerable groups and increase success. They have products that are geared towards assisting these groups. And more importantly, on the ground level, we need local research people will tend to listen to research that has been localized because it affects them directly and they are likely to act on it for purposes of evidence-based policies rather than having research done elsewhere because they will always say, oh, this is not our data. I mean, we don't own it up. And those are two key areas that need to change for the vulnerable groups in the lower middle income countries.
00:46:55 --> 00:47:59
David MacKintosh: I'm being a bad host, but I can't quite avoid chipping in a little bit myself here. But you know, there are some examples. I think sometimes it's highlighting the broad examples than just to the individual, but if you think in the UK, one of the sectors did adopt tobacco harm reduction quite early and it helped them deliver their services so much better was in mental health services. which has been quite a success. But like a lot of THR successes, no one shouts about them very much. And then there's another issue about the direct economic benefits to individuals in countries where THR products are much cheaper than smoking. And Cancer Research UK quite clearly, you know, they're not the loudest cheerleaders for some aspects of THR. but they do highlight the financial benefits to individuals in their piece highlighting THR. So I think there's a lot more we could do around case studies and I will try to be more restrained about my own inputs.
00:47:59 --> 00:48:31
Kasia Kowalczyk: Can I only quick comment on something you said because I'm a researcher so I appreciate and I value and treasure the data. But when you work with key publications, well, the data are important, but this is not something you work with. I don't think people that we work with are looking forward to read the data. It's quite complex, it's even difficult for the researchers. So what I think is helpful are, is this individual personal contact, personal stories, personal examples, this is what works.
00:48:31 --> 00:48:36
Cheryl Olson: I think stories are what change people's minds.
00:48:39 --> 00:49:35
Will Godfrey: Touching on a few themes already mentioned, panelists may be aware of a model known as contingency management, whereby people are offered small financial incentives to reduce risky drug use. Evidence, I believe, has supported it with groups of people who use methamphetamine in the United States. And more recently, we've seen it rolled out at a council level pilot in the UK. And if you quit smoking during pregnancy, very much including if you switch to safer products, then you receive vouchers as a reward. Obviously, there are upfront costs to such programs, but potential huge healthcare savings as well as many other larger benefits. So my question to anyone who wants it is, do you think that this model has the potential to be scaled up and then targeted towards marginalised vulnerable communities?
00:49:35 --> 00:49:40
David MacKintosh: Okay, so that's about incentivising people switching. Gerald?
00:49:41 --> 00:51:04
Cheryl Olson: Yeah, I'd like to make a bit of a related point, because I think that's more of a Katja question, since you're more on the ground with these things. But I know talking to, I think this is a great point for doing cross across profession collaborations. We talk about trust building. The economists often have some great data and I think sometimes they're more logically driven than some of the advocates. And I interviewed for an article I wrote, a gentleman named Michael Pesco, who has all of the right credentials, an academic who came through the National Institutes of Health or CDC training and very respectable publishers and respectable journals, but he is publishing things that will show it is better to give rural teenage girls who are pregnant access to vaping because otherwise they'll smoke. That's just a little study of his that has not been, but he has study after study that is where the data are very logical, very pro-harm reduction, flying in the face of things. And I think sometimes you can, if you find yourself blocked with your own profession, sometimes you can go to another one, make an end run, and then bring their data back and say, hey, did you know about this? Because I'm absolutely 100% agree with Katya that it is stories, anecdotes, that get people to listen to the data. That if you start with data, they almost never listen to you.
00:51:05 --> 00:51:09
David MacKintosh: Thank you. Anyone else on the panel views on incentivizing people?
00:51:09 --> 00:51:12
Cheryl Olson: Might know one.
00:51:25 --> 00:53:23
Marewa Glover: So I did a few studies, pilot studies using incentives with Māori, indigenous pregnant women in New Zealand. So we tried vouchers. Another thing that we tried was sort of, I don't know if you have like, you join up to a program and there's like a gift catalogue. You know, you have a card, the more points you get and you can pick your gift from the catalog. We did that instead of vouchers. You know, some women are in relationships where they have a partner that controls the money or if you give vouchers. safer groceries that will be taken off them. So it was interesting they liked the booklet that had, you know, a care package or a camera or, you know, we just had a range of things. They actually really liked that because there were things that their male partner weren't going to take. So there's things to think about like that, but definitely the vouchers worked. The program ended up being rolled out by the government and Māori Health and other health cessation services got to offer incentives. So it definitely got picked up in New Zealand. I was working with Linda Bald at that time on one of those studies and they were doing it in the UK as well. And there were some similar pilot trials among Aboriginal women in Australia. One of their voucher systems were for whiteware. What the women wanted was to be able to buy a new fridge or a new washing machine. So you can, you know, maybe even put together a program like that where you have stores sponsor and provide, you know, product.
00:53:23 --> 00:53:35
Kasia Kowalczyk: Can I ask you about the sort of sustainability of such, because I would be very eager to use them, but I'm just curious what happens while the project is over, finished, whether it still works.
00:53:37 --> 00:54:59
Marewa Glover: So, do you mean in the follow-up if they stay stopped? Well, obviously these pilot projects are just a limited run, you know, so 12 weeks or something like that. I did get to evaluate one of the hospitals that use the system. When you're working with hospitals, but you're supposed to be doing kind of evaluation or research, the data collection is not necessarily always good. You have kind of a bias selection bias and they don't keep track of the ones that don't join the program. So there's those that are referred and then they don't get counted in. So it is good to have robust science done rather than just sort of an evaluation. I'm pretty sure the evidence overall, and the Cochrane Review shows this, that overall incentives do work. Interestingly, among Aboriginal people looking at incentives for pregnant women at a committee, a kind of a consensus summit on it, they decided no, it wasn't appropriate culturally. There was something offensive about it, they felt, paying women to stop smoking while pregnant. So there's also cultural factors to take into account.
00:55:00 --> 00:55:30
David MacKintosh: Thank you, Maroua. Good points to know the communities you're working with and targeting and also good practical examples of things that have worked. I'm very keen that we don't forget to start thinking about the allies and we've touched on it. Is there anyone in the audience who's got any ideas about the groups that we should be seeking to engage to promote THR? Wave your arms vigorously because I am slowly going blind in front of this light here. Fair enough.
00:55:36 --> 00:56:40
Fiona Patten: Thank you. Oh, it's just in case you couldn't hear me. I really enjoyed the work that Dr. Olson's been talking about, but certainly thinking about, just thinking about that question, it's looking at some of those organizations, long running organizations that help vulnerable communities and people from low socioeconomic organizations. And I'm thinking the St. Vincent's, the St. John DePaul, the different charity organisations that are out there, even with their food, you know, the sort of food centres and things like this, because we know from Marawa's work that if we can convince, particularly some women who are smoking, that this can put more food on the table, and I certainly think that those organisations providing that type of basic essentials to to people experiencing poverty in our communities. They would be a group that I haven't actually considered, and I'm certainly going to go home and think about them.
00:56:40 --> 00:56:48
David MacKintosh: Thank you very much. Oh, Charlie at the front. Sorry, the front.
00:56:48 --> 00:56:53
Charles Hamshaw-Thomas: Well, let's repeat business leaders.
00:56:57 --> 00:57:04
David MacKintosh: I'll be after your diary in here, but it's a good point because funding for this is complicated.
00:57:04 --> 00:57:09
Charles Hamshaw-Thomas: Yes funding, and why can't we work?
00:57:09 --> 00:57:18
David MacKintosh: And that's a very good point, and if anyone in here does know any billionaire philanthropists who would be interested in this area, feel free to approach me at the end of the session.
00:57:27 --> 00:58:50
Marewa Glover: Thank you. An interesting development in New Zealand, there's a group forming to end prohibition of all substances. And they've seen me tweeting about my concern about the vaping regulation, the smoke tobacco product regulation, which is really going towards prohibition of all nicotine and tobacco use in New Zealand. And so I got invited to a meeting they were having. So we shouldn't forget the drug harm reduction sector. And Nick talked about it previously. It can be difficult. There is some resistance. I think there is some potential fear of bringing the hate of public health down on them for you know, for adding tobacco into it. But there are groups that are against prohibition, and that is what many of our, for the harm-reduced products are facing prohibition. And they would see this as the, you know, this is part of the slippery slope. New substances keep being added to the list of substances to be prohibited. And so we have something in common with them.
00:58:51 --> 00:59:48
David MacKintosh: Thanks, that's an interesting point on sort of policy and political alliances. Anyone else out there? I would also like to do a little bit more on perhaps the economic barriers to people adopting THR. And I don't know if anyone on the panel would like to point us on that, but I, you know, mentioned in the UK, Once you've found the kit that works for you, vaping is cheaper, there's an initial barrier there, but obviously in some countries, particularly where smoking is relatively much cheaper, there's a huge disincentive, if you like, or a huge barrier to get over. You know, you've been asked to invest in a THR product that no one's using around you, and I wonder if there's any thoughts about how that can be addressed
00:59:52 --> 01:01:02
Cheryl Olson: Well, while you're thinking, that's something that I've really seen in research I was just doing with older smokers. I guess I did a qualitative study on smokers in their 60s and 70s primarily, and they're using these older cigarette-like products. Because they like something that looks and feels like a cigarette, and they are incredibly price sensitive. Sometimes shipping costs will be enough to deter them from going for something. And that's a side point with that is that I think we need to look for who are sympathetic And so if people aren't sympathetic to the needs of drug users, others who they think brought it on themselves, if you're looking at people who are now, for example, in their 60s and 70s, who started smoking at a time when everyone around them smoked, even on TV, as they were saying. And they were once the vulnerable youth who were hooked, and they're still smoking. And don't we care about them? We're immediately at risk of disease and death from the smoking they're doing today. And that's a way you can look at, okay, these people are out there and they need an affordable alternative. And if you find that for them, they will switch.
01:01:02 --> 01:02:10
David MacKintosh: I say it's a really helpful reminder of the older smokers and it also reminds me of quite an early ally in the UK around switching to vaping was the fire brigade because although we currently have lots of stories about disposable cigarettes setting fire to bins and things, they don't cause as many house fires and fire fatalities as smoking did, particularly amongst the older population. We are getting towards the end. I am, in a moment, going to pass over to the panel for their last thoughts on particularly the things we can do to overcome the barriers and, as I say, the identifying allies. We've got a few on the list. If there's any other allies you think we're missing, now's a good time to put your hand up and share. I don't think I'm seeing any hands up in the audience at the moment. So, oh, we should have given you a microphone. That's a good thing.
01:02:10 --> 01:03:12
Marewa Glover: Just on the cost. So interesting, you know, obviously there's different arguments for the banning of disposables, but they, disposables are like, well, they're cheap, they're cheaper. And so I think in New Zealand it is increasing, it is improving access for groups who previously found the other devices inaccessible or they were worried about investing in something because if it doesn't work for them then they've lost the money that would have bought that packet of cigarettes or two packets of cigarettes for that week. And it's interesting that disposables are now coming under heavy attack because they are lower priced, it's a lower entry point for people and it's giving access to lower income groups, older people and they're quite efficient devices.
01:03:12 --> 01:03:39
David MacKintosh: Yeah, I think the simplicity of use is a huge, huge advantage. Okay, I'm going to go across We'll end with you Cheryl, so we'll go across from my right. Your number one, and if you've got two, two things you think we should do to help overcome the barriers and improve understanding or allies that we should be targeting.
01:03:41 --> 01:05:06
Le Dinh Phuong: In my experience and the journey to harm reduction concept, I got a lot of obstacles. And the first thing is the cost. The cost of the HTP product. You know, in Vietnam, the price of cigarette is incredible cheap, just one U.S. dollar for one package of cigarette. And it was very easy to buy at every corner of the street and even the supermarket. And the cost of the HTP, a pack of the Iqos, the Hiss, is maybe 10 times or 20 times of the package of combustible cigarette. That's why I got some difficulty to convince the patient to switch into the HTP because they complain with me, oh, hi, doctor, the price is too high, I cannot afford it, but my best way to handle it is high. I agree with you, but at least it's cheaper than the cost of stenting, coronary angiography. Yeah, and I think in the future the tax of the combustible cigarette should be higher in our country to make a little smaller gap between the HTP product and the cigarette.
01:05:06 --> 01:05:12
David MacKintosh: That's a really good point. The safer products should always be cheaper than the most dangerous product. Thank you.
01:05:17 --> 01:07:51
Michael Kariuki: Yes, indeed. The policies back at home and generally in Africa, East, Central, Sub-Saharan Africa, we're in the process of developing some of these nicotine policies. For example, it's only last month that the Kenyan parliament, that is the Senate, introduced a motion, a notice of motion, to have nicotine policy regulations. And that is a very good opportunity because it will involve public participation where we will present our views and bring in the concept of harm reduction simply because even back in Kenya, the Tobacco Control Act does not define what tobacco control is. It's an argument that we have tried to reach out And when you talk to the policymakers, they say, yes, we have drafted our Tobacco Control Act from WHO's FCTC. But when you show them that the FCTC has clearly defined what tobacco control is, and we are missing that definition in our own local Tobacco Control Act, then they start saying, oh, yes, there is a point here because FCTC defines tobacco control as a range of supply, demand, and harm reduction strategies. And it was like a deliberate attempt to omit that particular statement from the local Kenyan Tobacco Control Act. So it's an opportunity to begin with the legal and regulatory frameworks that bring in the concept of harm reduction, even as we continue the debate of harm reduction. And at the policy level, that's exactly what we are trying to do so that we can have some nicotine regulations and look forward to probably even have a nicotine act by itself. As part of the solutions to overcome these barriers, we need products that are approachable, acceptable, available, affordable and appropriate for the low socioeconomic status groups.
01:07:51 --> 01:07:58
David MacKintosh: Thank you very much. Yeah, that's key points and also the importance of appropriate legislation.
01:07:59 --> 01:08:53
Kasia Kowalczyk: Well, I would say utilize the potential of the third sector. There is a power there. And one more thought on our potential allies. I would say anyone who has a direct contact, any health care service and health care group who has a direct contact with key and vulnerable populations. And one that comes to my mind is, for example, social workers. I'm taking part in a project, and we are working in Central Asia, in three out of five Central Asian countries, when we are helping to build curriculum for social workers. And social work is a very specific area, and of course we know that it differs around the world, but there is a potential there. And if THR would be included into curriculum, that would be just fantastic.
01:08:54 --> 01:08:58
David MacKintosh: Excellent. And Cheryl, over to you.
01:08:58 --> 01:10:07
Cheryl Olson: I think there's so many good points here. I think that my colleagues here on the panel have made things like make sure that there are shared common assumptions that people understand it's not the nicotine giving you cancer. Make sure that you understand, you know, if you can find an authority or an individual who people listen to and agree on, that is a framework or a group or a person that we should listen to as a way to open minds. Looking for under-overlooked groups. I noticed in the U.S. that nurses are a group that I would love to target with reduced harm information. The reason I'm not with you in Warsaw is my spouse has been extremely ill and spent months in hospital. And when I speak to the nurses who come in to work with him, sometimes I show them, you know, little tobacco-free nicotine pouches or other things that I picked up at previous conferences. They've never seen these before. They didn't know that they existed. And I think we need to find people who can infiltrate and get around some of the barriers so that then perhaps, you know, the more senior people who are more resistant are forced to address, hey, the patients, the staff are asking about these things. What is this? We need to educate ourselves about it.
01:10:08 --> 01:10:52
David MacKintosh: Thank you very much. So I think we've got some clear things that we can all do there. We should all go out and try to engage with different organisations or individuals that we don't normally work with and start from that. And there's, I think, you know, focusing on the communities which have very high sloking rates. I think there's an awful lot of opportunity that we should be taking advantage of there because the potential gains are enormous. I am aware that your lunch will be outside, so I'm not going to keep you any longer, but I would please ask you to join me in thanking the panel, especially people who were getting up at something like two o'clock in the morning to join us.
