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Clive Bates: OK, ladies and gentlemen, good afternoon. I am standing in for Michelle Minton, who has been unable to travel to this event. She sends her apologies. Her husband's had a pretty serious operation. She decided to stay in the United States, not unreasonably. So I'm afraid it's me instead as the host. I think this is going to be a fascinating session, and actually it's centred on the subject that I think is the most important subject of all, which is what is the changing nature of nicotine and the demand for nicotine? What is actually going on with the fundamental driver here? We've got a brilliant panel lined up to interrogate that question and try to get to the bottom of what's going on. Now, I think we can... There are really... polar opposite views on what's happening with nicotine and what even nicotine is. So on the one hand, you'll have people who'll say, nicotine provides, you know, relief from stress and anxiety, it modulates mood, it improves concentration, it helps with a regulatory function, with ADHD, and it may have therapeutic benefits with, you know, serious diseases like Parkinson's. and make a case that people like it for hedonistic, functional, and therapeutic reasons, and therefore it's an important drug and so on. There's another view, which you would hear at a conventional tobacco control conference, which is that it is largely a worthless drug of addiction. It's something that people experience only as in the form of relief from craving and withdrawal. Any benefits are something of an illusion. The only reason people use it is that ruthless predatory industry markets it to teenagers while they're young enough to know better, before they're old enough to know better, and that hooks them for life and they maintain a life of sort of possession by the demon drug nicotine. That's the sort of polar opposite argument about nicotine. And then I think there's an emerging view which is sort of kind of in between those, which is does it really matter If there isn't much harm associated with it, why don't we think of it a bit like how we think of caffeine? Does everybody lose their minds over caffeine or moderate alcohol consumption? It's a recreational drug. People like it. Just leave them. Let them get on with it. People do all kinds of things that they choose to do. They take all kinds of risks. Why are we having a conference or even talking about it? Why are there journal articles about it? There's no coffee control movement. There's no caffeine cessation clinics or anything. Just back off and just calm down, because it's not a big issue. So there's three perspectives there. I would like us to get to the heart of which of those is right, or is that even a misframing of the issue? Am I just talking rubbish when I say that's what the debate is? We're going to have opening kind of statements from the four experts we have on the panel, which will keep reasonably concise. And then I'll perhaps put a few questions, and then I want the audience to give us a mixture of insights from their own experience, but briefly. I don't want lengthy speeches. And then insightful questions. to the panel to help us navigate our way through what nicotine is, and if you like, what the demand function for nicotine is made up from. What exactly are we dealing with here? So, without that, without any further ado, I will start with opening remarks. Paul, would you like to go first?

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Paul Newhouse: Yes, so I'm Paul Newhouse. I'm a physician and neuroscientist at Vanderbilt University Medical Center in Nashville, Tennessee in the U.S. I've been studying nicotine and nicotinic mechanisms in the brain since the 1980s, and I'm still learning what nicotine does, what nicotinic receptors do in the brain. I come at this question from a rather different perspective, I suspect, from the majority of people at this meeting, which is that I am not an expert on tobacco control or substance abuse, but I am interested in the potential for nicotinic therapeutics in disease development, and I've spent many years trying to establish what nicotinic receptors do in the brain. I'm not a neurochemist or a cellular physiologist, so I don't work at that level, but I work at the level of brain systems and human cognition. And what we have spent decades, several decades doing is trying to explain what it is that nicotine receptors or nicotinic receptors, to be more specific, are responsible for in terms of human cognitive and emotional functioning. That has been in the service of trying to understand whether we could use nicotine or nicotinic-like substances as drug treatments for brain disorders. I'll have more to say about this tomorrow in my keynote address, but my interest is in how nicotine is potentially therapeutic and how we can utilize that. And I think the answer to that question, and I've talked to several people already at this meeting, is complex. And we cannot reduce it to a simple yes or no answer. It may be important, or it is important to understand that nicotine may be good for this, but not for that. It may be good at this time, but not at that time. It may be helpful for this patient, but not that patient. And we have to be comfortable with this complexity. So I'll stop there as an opening remark, and I'll hand it to Garrett.

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Clive Bates: Did you get the advert for his session tomorrow?

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Garrett McGovern: Yeah, thanks Clive. That's really interesting, Paul. I suppose I come from the background of being a harm reductionist for 25 years. I'm very lucky, I suppose, when I came into the harm reduction sphere because I came straight in. I didn't do any treatment with alcohol or any other drug. I was straight in treating heroin users. So straight away we were taught the benefits of opioid substitution treatment. needle exchange, et cetera, et cetera. I kind of realized the phenomenon of not being able to cure anything. So some people, the abstinence kind of fiends, as we call them, will say, oh, you've got a very low bar for people to survive. But if they worked in the area I worked in, they'd realize the social backdrop to drugs like heroin and crack cocaine. I'm a relative latecomer. I don't know when I came into the tobacco harm reduction kind of area. I have to say my interest was piqued by electronic cigarettes because I thought to myself, hold on a sec, here's something that looks immeasurably safer than burning inhaled tobacco. This looks like a great product. Now, where does nicotine come into all this? Well, I think nicotine reminds me of, you know, I think I made a joke the other night that it's the Jeremy Corbyn of tobacco harm reduction. I mean, you can say what you like about Jeremy Corbyn, but from the perspective of living in Ireland, he seemed to be blamed for absolutely everything, even when he wasn't there. And nicotine is a little bit like that. I have to say, I mean, I've done a good bit of media stuff back home, I've done articles, and I really am despairing when experts, and I won't mention any names, Clive will know what I'm talking about, Damien Sweeney, Tom Gleeson are here, so they've seen all my radio and television pieces on this, but you get into an arena with somebody, and they straight away go and talk about this phenomenon of nicotine addiction. And nicotine and the developing brain of young people, which really interests me. Because I'm pretty sure before electronic cigarettes arrived, we never heard of nicotine and the developing brain. I never heard of the phenomenon. As soon as electronic cigarettes come, it's nicotine and the developing brain. And in a way, it's kind of tacit. sort of approval of electronic cigarettes in many ways, if they have to pull out something which has really only been studied on rodents, and I don't think it was particularly brilliant evidence that nicotine affects the developing brain, then the real issue is, of course, about harm reduction. I've had many patients over the years where we've prescribed or facilitated nicotine replacement therapy. I haven't seen any problem with addiction. In my world of addiction, we use criteria like DSM-4, DSM-5, ICD-10 in relation to addictions. And addiction to me has to come with some notable consequences. And I have to say, I haven't seen any notable consequences. I did a radio or a television piece there recently, and I made the point that I have never in all my career as a doctor ever, not once, seen a nicotine-only, nicotine-absent of inhaled tobacco, a nicotine-causing illness. Not once. In fact, I joked. I said the only time I saw nicotine poisoning was in an episode of Columbo. Nicotine sulfate, yes. That's the only time I ever saw it. Outside of that I never saw any nicotine problem. I never seen a bed. When I was a junior doctor, as a GP, I never seen somebody come in to me, I'm addicted to nicotine. Nothing. And yet we have this scapegoat now, which has been used to attack electronic cigarettes. Didn't seem to see it with nicotine replacement therapy, but we're seeing it large with electronic cigarettes. I hadn't really thought about the benefits, and I've followed a lot of what Clive does, and Clive's talked about, he's got a bit of criticism about his views on nicotine and maybe the benefits. And it's really interesting, Paul, I had no idea what Paul was going to talk about. Paul was actually talking about the therapeutic. benefits of nicotine. And I talked about Jeremy Corbyn, maybe we might go for this analogy. I kind of look at nicotine a little bit like Nelson Mandela. We couldn't see the great that Nelson Mandela did because he was in jail. Well, let's get nicotine out of jail and let's see what are the benefits of nicotine because it is an absolutely extraordinary thing. And Clive is absolutely right. I mean, we don't demonize caffeine. But we demonize nicotine. And who remembers many, many years ago when I was a kid, I used to see those cartoons of nicotine. And I thought, in my naivety, I thought nicotine was what caused all the problems. Everything else didn't matter. So look, I do have a tendency to bang on these things. Clive, I'm sure, will ask some questions. I'm going to pass the mic. And this is a fascinating discussion because often, really, the whole idea of nicotine benefits are often not talked about. Thanks.

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Clive Bates: That's great, Gary. We're going to come back to what is addiction as well. I think that's going to be an interesting part of this because that is a very loaded term. Carolyn Beaumont.

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Carolyn Beaumont: Thank you. So Dr. Carolyn Beaumont from Australia. Apologies. That's all I can say. So because I am new to GFN I had the misconception that I could put some slides up and talk to some slides and I have some beautiful slides for you. Unfortunately they're here because I couldn't do that. I'm also under threat by Clive of expulsion never to ever darken the hallways of GFN again unless I stick to under 10 minutes. So what I had prepared, and I will do in an under 10 minute form, is something titled Real Life Stories of Smokers Who Changed to Vaping, an Australian Doctor's Perspective. And I wrote it speaking to the theme of this talk, which is who uses nicotine and why, and what health benefits do they report on switching from smoking to vaping. So I prescribe nicotine in Australia for smokers who want to switch to vaping and through that business I've had the pleasure and amazing opportunity to talk to thousands of Australian smokers and I've learned such a lot about them. So what I've done for this, I've collated the responses from 400 of my customers or patients, depending if you subscribe to a recreational or therapeutic model of nicotine. So over the past six months. And I've just pulled out some various themes about why they use or why they smoke, why they vape and what benefits. But firstly, what I want to do is just dedicate this talk to the many ex-smokers who have been very open and honest with me about their struggles to quit smoking. And they simply want to be listened to and they just want their stories heard. So who do I prescribe for? What I've noticed with my demographics, and I find it very exciting and I'll explain why, is that over 50% of my Australian smoking customers are men in their 30s to 50s. And the reason why I find this exciting is that they're already established smokers, but they're switching before the long-term damage from smoking should set in. So this is fabulous. So we're really getting in there for an important demographic. I then wonder, well, why are more than half of my customers men in their 30s to 50s? And they give some common themes. One are that in their 30s, they're starting a family. Some say the wife or girlfriend is putting the pressure on. They say things like, so I can run around with my kids. In their 40s to 60s, they tend to be saying that the health effects of smoking are accumulating and they realise it's time to switch. And some say that they're divorced and they're entering a new relationship and they're on a health kick and going to the gym. Other information I collect is about their medical conditions. And I've detected two key themes, one of which is they say they have no other medical conditions, which I find a bit hard to believe. So I presume that they're just choosing not to disclose that to me, which is understandable. I'm a fairly, you know, unknown quantity to them. But of those who do disclose medical conditions, over half of them say that they have pre-existing mental health conditions, not just depression and anxiety. Also autism and ADHD and schizophrenia appear quite commonly as well. Other significant existing conditions are things like cardiovascular and respiratory as you'd expect, but also things like insomnia and even chronic pain conditions like fibromyalgia, which I find fascinating. and they do report that the vaping improves that compared to smoking. And drug use is also a not uncommon other, let's call it a medical condition. So I then asked them, well, why did you start smoking in the first place? And what I found with that is four key reasons. So one of them is teenage peer pressure, socializing, it's a normalized behavior. The second one is their environment. They grew up in a smoking household. The third one is stress relief. And the fourth one is just they were initially curious, but they couldn't stop. And because I present to schools about the issues with vaping, especially black market vaping, I have teenagers myself and I used to be a teacher, so I love getting out there and talking to kids. I've been reflecting more about why starting as a teenager is such a crucial, vulnerable time for them. If we consider adolescence, it's defined as a period of exploring your self-identity. There's a crucial need for social acceptance by your peers and from separating yourself from parents, essentially. Neurologically, there's an absolute explosion in dopamine receptors and dopamine sensitivity as well. So they are absolutely primed for the positive effects of nicotine. And it creates this perfect storm as to why teenagers will start smoking, or these days, vaping. Am I okay for time? Yeah. Good, okay. So then I asked them, well why do you think you continued smoking? And a lot of them report stressful life events as why they continued smoking. And I need some audience participation. So just roughly as a percentage, how many do you think would report stressful life events as to why they continued smoking? Just to call out here. Oh, you can see my slides.

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Garrett McGovern: How many do you think? Percentage-wise? Yeah, just roughly.

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Carolyn Beaumont: Ballpark. How many keep smoking because of... 60%. I'd say 70%. Oh, damn, you're both right. Okay, yes. Essentially two-thirds. Reports just fall off a bit. So I was hoping it would be the big reveal, but no, unfortunately not. But also, half also report, because I can give multiple answers, half report that just being around other smokers is a trigger to keep smoking. And this is very relevant for those people who work in high-risk smoking industries like construction, hospitality, casino workers. They can't just leave their job. So they're going to stay in their smoking environment. So, you know, we have to be realistic about that. They can't just up and leave from their social environments, from their families either. Then I ask, since changing to vaping, what has improved for you? And I love this question because I'm just blown away by the number of answers. They will usually give at least four, up to probably 10 different improvements. Most, I guess most commonly, not surprisingly, two-thirds will report financial improvements and also breathing. But over half will also report their energy is better, their mood is better, and their sense of smell is better. One improvement that I had never anticipated, and almost half of them will say this, I feel less self-conscious about smoking in public. Another third will also co-report just general self-confidence, better personal relationships, and fewer lung infections. And a small but significant number even report a better sex life. I don't ask them any further about that one, I just note the answer. So then I ask them, well, why do you continue to vape now? And here again, I need a bit of audience participation. So a very important answer is, well, I'll return smoking otherwise. How many do you think continue to vape because otherwise they'll return smoking? So 80% of my patients, and this is based on 400 which is only representative of over 3,000 Australian patients, 80% say that they would return smoking otherwise if they couldn't access a vape. But also over half say that their physical or mental health is much better when they vape. and financial improvements as well. But another one is one third roughly say that I like how it feels like a cigarette. And finally, I believe, yes, finally, I asked them, if you couldn't access nicotine via a script, what would you do? It's actually very similar to the previous one, which is why you continue to vape. But I also say that I'd probably return to smoking. So 80% roughly say that they would probably return to smoking if they couldn't get the nicotine via a script. About 20% say that they would access the black market. Some say that they would return to other drugs as well. I think that's it.

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Clive Bates: Under 10? Massive overachievement there, yes. Thank you. Under 10. I thought that was absolutely fascinating. The data was really compelling. I think there's a big story in that, which is that the demand for nicotine is much more persistent and deeply entrenched than the demand for any particular way of delivering it. You know, and that if people can't get vapes, they'll smoke. If people can't smoke, they'll get vapes, whatever. But they will get their nicotine somehow. And I think that's a really big learning about this is that the demand function there for nicotine is much more resilient than the demand function for any particular device like smoking or anything. Mark.

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Mark Oates: Okay. I just want to, I'm a consumer, an advocate, harm reduction advocate across the board, whether it's drugs, sex, or tobacco. And my background, I worked in the British Parliament. And so I was what we pejoratively call a bag carrier. But when I wasn't carrying the bags, I was given free reign to take an interest in political issues that were interesting to me. And one of those was, of course, nicotine, because I'm a consumer. But I just want to look, and as a campaigner, the sort of cultural understanding and the media understanding of a subject is very important to me. It means how effective is campaigning going to be, how easy is it going to persuade people. And to give a sort of contrasting example of a subject that's similar but has a much better success in terms of understanding, I'd say the campaign I was involved in to legalize medical cannabis. And that was extremely successful. Six weeks from beginning the campaign to the government signaling they were going to legalize it. And the two main reasons I give for that, the first one is that the campaign was led by a mother and a child. and the child had seizures and medical cannabis was there to prevent the seizures and she came back from a country where medical cannabis was legal, arrived and had her medical cannabis prescription for the child taken off her. And if there's any advice I can give to any politicians, if a mother is trying to protect the health of her child, just raise your hands, submit and give her whatever she wants. The other reason which I think was so successful was the public were primed They knew that medical cannabis had potential for therapeutic assistance. And for years and years, the media have been pushing articles, even the Daily Mail, saying, you know, medical cannabis could do this. It could cure this disease. It could stop that pain. Some of them are a bit dubious, I'd say, but there's an area there. But that helped the campaign so much. And in nicotine, we're on the opposite end. You know, the public think that nicotine is what causes illness. The media are incredibly scared to discuss this issue, which is a huge shame. And science also lacks the ability to research it because funding is hard to come by. And an example of where this is so clear is when COVID happened and we started to see data. that maybe that smokers weren't dying at the same rate as non-smokers. And there was an intransigence to look into that. No one wants to suggest that people should take up smoking to stop themselves getting COVID. But rather than actually say, yeah, this is something we need to look into, it was immediately dismissed. And that's not good science. And we're going to fail if we continue with that attitude. And just quickly, I enjoy nicotine and I don't have any plans to stop. And I have actually stopped. I do some work whereby I can't actually consume nicotine very easily. So I go two weeks sometimes. I came back from my stag do and I was so exhausted I decided I'd give it a go and stop using nicotine for six weeks. But I went back, not because of a dependency, I personally didn't find it too difficult to stop when I wanted to do it because I enjoyed it and my life was better for it and I didn't see a health reason not to use it.

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Clive Bates: That's excellent, Mark. Thanks very much. I just want to pull out from you, just get some opinions first of all on this question that sort of vexes me. Why is there a demand for nicotine? Is it just because it's addictive? Is there something on it? How should we think? about the demand for nicotine. If it's only there because people smoked, when smoking eventually dies out, will nicotine use die out? Or should we expect new people to take it up because it does something for them or they like it or what? How should we think about the demand for nicotine going forward in the future? Especially nicotine that's delivered without the harmful effects of Tobacco smoke and therefore is relatively safe. How should we think about that? Do you want to do you want to go first on that Paul?

00:25:40 --> 00:27:17

Paul Newhouse: Yeah, I I actually am not sure of the answer to that question I think that We understand that nicotine stimulates receptor systems in the brain that are important for regulation of mood, cognition, a variety of neural functions. It changes the nature of neural circuitry in the brain. It turns out that the effects are very state-dependent. They're age-dependent. They may even be sex-dependent. It hasn't been looked at carefully. So I suspect that for many people, they will never want or need to use nicotine. But for some people, it may be useful, and it may turn out to be important for their cognitive performance, for regulating their mood, or managing anxiety. So I suspect that for a certain percent of population, nicotine will be helpful. I mean, we know now that after the Second World War, the majority of American men smoked, right? That was standard. And when you and I grew up, probably most of the men that our fathers knew were smokers. But that's not the case anymore. So for the vast majority of them, they gave up nicotine or they will never use nicotine. And so for those folks, there's no need and there's no benefit. But I think we have to acknowledge that for some folks and for some brains, nicotine has beneficial effects.

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Clive Bates: Gareth, any views on this?

00:27:21 --> 00:28:47

Garrett McGovern: Yeah. I mean, I think it's very, very interesting question because nicotine seems to be inextricably linked to, you know, inhaled combustible tobacco for, I don't know, centuries probably. We've never really had an opportunity to study its beneficial effects. What I do know is this, is that it doesn't seem to be very harmful, and certainly not in the concentrations that it is in any of its formulations. But I don't have any... I think we need more. probably more research into what the benefits are. I mean, if you look at, say, one of them is improving cognition and concentration. I mean, you hear an awful lot about students using amphetamines to concentrate, and here's something that I'm sure has far less side effects than stimulants. So, as a doctor, the old adage is do no harm. I don't see a huge amount of harm with nicotine. I think it certainly seems to have benefits in people. I mean, I was talking to Clive earlier on, and I was talking, you know, we probably have a population out there who've been on N or T, whether it's gum or patches, which we haven't studied. We don't seem to study this population other than the efficacy of staying away from cigarette smoking. So I think we do need to change the narrative a bit and start doing research to see what the benefits are. I mean, Paul's work is fascinating in many ways, and this needs to get highlighted, because you're not going to read about this in the media, that's for sure.

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Carolyn Beaumont: It may be the jet lag or it may be hanging out at Skybar a bit too much in the wee hours, but I've slightly forgotten all the details of your question, Clive.

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Clive Bates: All right. Just pass the mic down here and pick up one of the other mics. I'm just trying to get... I'm just trying to answer... address a really basic question. Why do people use nicotine? Is it because it provides benefits and rewards that are valuable to them? Or is it, as some would say, an illusion that it feels like it's rewarding and beneficial, but actually all you're doing is addressing craving and withdrawal, and that makes you feel better compared to how you would have felt if you didn't use it. So what's going on with nicotine use? I might get a couple of views from the audience in a minute, if that's all right.

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Carolyn Beaumont: Yeah, well, I guess just based on my not personal experience, because I don't smoke, I don't vape, so I can only base it on people that I speak to. But yeah, I would say it definitely seems to have earned more in the camp of being it's a positive. thing rather than some awful thing that unless they have it their whole life shrivels up. But I guess I then tend to reflect on maybe an overuse of the word addiction where I was talking about nicotine addiction. And I mean addiction is a very strong term and even though it can be defined in a few different ways, the most, you know, the common thread of how addiction is defined is that it's causing some sort of harm, whether it's, you know, breaking the law to get the product or it's tearing families apart or it's, you know, you're stopping being able to put food on the table because you're having to spend all your money on nicotine. perfectly reasonable to say smoking is an addiction because smoking obviously reduces people's budget and we all know the death and disease etc etc about smoking but then if you just take the nicotine part of it, what's addictive? What is the harm here? And sometimes people say I'm addicted to coffee and we know their meaning in a light-hearted way because we know in relation to something like coffee it's not real addiction in a harmful thing. It's just that they love it so much. And so, yeah, I would just like to reconsider how often we pair the word nicotine with addiction.

00:31:06 --> 00:31:23

Clive Bates: Caroline's given a brilliant answer to my next question, which is very helpful. Thank you for that. Mark, on the, which is good, we are going to come back to that, because I think it's a really important thing about language, meaning, and loaded terms. Mark, you are a nicotine user. Why?

00:31:23 --> 00:33:17

Mark Oates: Well, for me, the why is pleasure. It's a pleasurable thing to do, and humans chase pleasure across the board. Whether it's sex, whether it's playing sports, you know, when you play sports, you get a release of endorphins and also painkillers in a mild sense, and that's pleasurable. And that's why people chase long-distance running. And I do some long-distance running that is, at the time, in any way enjoyable. It's the most painful thing, but afterwards, we call it type 2 pleasure. So afterwards, you feel amazing. And that is the rush of the natural drugs going into your body. So I think sometimes in this subject, there's more people that I speak to would never try illicit drugs or nicotine, may not even use caffeine. But when you talk to them, they have something that they do which they find pleasurable, and they're chasing it. So that's widely important. One interesting aspect is societal position and war zones. So the smoking rate in Ukraine has gone up dramatically. And we know that people in tougher environments socioeconomically are more likely to smoke. And so I think that there's a level whereby perhaps people are looking for a boost and that provides that boost. I think Ukraine and war maybe added an emphasis where people care less about their own survival because they're worried about surviving the next day. And you see that with soldiers smoking when they're on mobilized tours but coming back and not smoking to the same degree. And I know for me in my 20s I went out into the world into an economy which was The financial crisis had just happened, and I was a social smoker before, but I thought, who cares? And I didn't care about survival. What would I care about three more years at the end of my life? And that's sometimes, I think, people in public health struggle with, that someone actually doesn't think maybe rationally.

00:33:18 --> 00:33:58

Clive Bates: There's a whole science of psychological discounting going on there, isn't it? The way people have different views of their interests over different time periods. And if you're very poor and your life is very difficult, maybe your worldview is condensed into a much more immediate perspective on your welfare than someone who looks out over, say, 20 to 30 years and tries to optimize their welfare over that period. And maybe that's why we see nicotine use concentrated in people experiencing stress, deprivation, and so on over time. Maybe that's something to do with the way they perceive their welfare.

00:33:58 --> 00:34:32

Carolyn Beaumont: Can I just add something? Yes, please. I mean, I guess we're talking about Maslow's hierarchy of needs, which is, at its most basic level, we need to have our essential needs met, which are food, and shelter. And often, if that's a struggle, nothing else can be matched. And then after that, we have, I think, something like family relationships. But then right up to the top, once those things are all met, then you have the concept of self-actualisation and being your best self and in best optimal health. So, yeah, that top of the pyramid is not reachable for many people.

00:34:32 --> 00:34:39

Clive Bates: So I want to comment from Paul. Do you want to just pass that microphone down? Paul and Garrett, you share that one, and then you share the one at the end. I can have my own.

00:34:40 --> 00:36:40

Paul Newhouse: So I want to come back to the question you asked a few moments ago, which is that, you know, what are the beneficial effects and what can we say about them? And the answer, sadly, is it's probably unknowable at its core, because we can't Assign people you you this group starts vaping and this group doesn't or this group vapes You know the real thing and this group learns to vape something else or placebo you know the gold standard when we try to establish whether a treatment is Valuable is to do a randomized controlled trial and we can't do that with vaping and with cigarette smoking and with tobacco use unless we identify a particular condition for which we're trying to treat. So to ask the question of whether nicotine is helpful to human health, you have to specify, well, what part of human health, and can you actually prove that in a reproducible and valid way? And unfortunately, that's not really possible with consumer-based products because Eventually, people are going to use them regardless of whether we think they're valuable or not. Now, people may perceive that they get benefit from using a product. That benefit is actually hard to prove in the laboratory. It's not impossible, but it's difficult to prove. And by its very nature, proving it in the laboratory doesn't really translate well into real life. And so we're sort of caught in this conundrum, which is we can establish that people take it for reasons of their own, but it's very hard to say, well, nicotine is beneficial for this or that without trying to study it. And I'm sure Garrett has seen this.

00:36:41 --> 00:37:01

Clive Bates: Is that one of those things where there are potential natural experiments? So where there's a population like, say, in China, where, you know, the majority of men smoke and hardly any women smoke, can you get comparisons between them in terms of, you know, do they suffer different levels of stress and everything, all living in the same household? Has that sort of thing ever been done?

00:37:02 --> 00:37:38

Paul Newhouse: I mean, I'm not an epidemiologist, but I believe it has been, yeah. So I think societal effects, and there was one, somebody told me that they were interested in the genetics of smoking. And they said, well, you know, there's this interesting thing that men's, the genetics in Sweden, if you looked at the men, there was a genetic link to smoking, but not for women. Well, it turned out almost no women smoked in Sweden at the time. And so, of course, the genetics can't be expressed if you have a population that has a zero smoking rate. And I think that's the answer.

00:37:38 --> 00:37:58

Clive Bates: All right, let me just turn to the audience now. Has anybody got a view, particularly people who do use nicotine, anyone got a view on why, what the experience is, their own insights into how they feel about it? Andrew, is somebody got mics? OK, pass the mic.

00:38:00 --> 00:41:02

Andrew Manson: Hi, I'm Andrew Manson. I've been a nicotine scientist for 30 years, over 30 years, and also taken part in a lot of consumer research sessions, talking directly with smokers in order to develop novel products. So I got a lot of insights from real consumers and real smokers. A lot of what Caroline said is absolutely reflected And also what Mark said as well, there are smokers that just smoke for hedonistic pleasure. Those pleasure seekers, many of them have now quit because, you know, the overall demonization of smoking basically has taken the pleasure away for most of them. So getting that cohort to quit has been achieved pretty much with, you know, traditional sort of methods. But stress management, weight management, mood management, and the ability to focus on tasks, either very boring repetitive tasks or tasks that require detailed concentration, nicotine is a clear conscious and subconscious benefit for those people. And nicotine is the only drug I'm aware of that has, it definitely has that biphasic method. Small amounts of nicotine stimulate, large amounts of nicotine, the nicotine basically sticks to the receptor and stops it firing and so can kind of calm down anxiety and panic attacks. And you get, both of those effects from the same product, a cigarette, depending on how you smoke it. Smokers titrate, they smoke heavily when they're stressed, they smoke lightly when they need stimulation. And the challenge, I think, in developing alternative products is first of all to accept that fact and talk to smokers about it and accept that fact, but to develop products that you can have that same effect with that you get with a cigarette because although there's some very good vaping products around you can't titrate as effectively with the same product and manage your moods in a way that a cigarette can or you can manage weight with nicotine products to some extent and focus but it's that mood management which is why, as has been said before, low socioeconomic groups and people in certain professions like the armed forces and nurses and these sort of things in stressful professions, they tend to smoke more than people in less stressful professions.

00:41:02 --> 00:41:18

Clive Bates: That's great, Andrew. Thanks. Now, anyone wanting to make comments along similar lines or anyone who's a nicotine user wants to Explain it to us. You know I mean, I I've never used nicotine, but I would like to know more about it genie Let's keep the comments nice and brief.

00:41:18 --> 00:41:53

Jeannie Cameron: I'll just be brief. I think some people might remember last year I said that I've been never a smoker, never a vaper, but had just started using nicotine in pouch form. Now a year on, I found it's also incredibly useful for weight control for women my age, and I've also found that early onset arthritis that I've had in my hands has has gone without any other drug. Now, I don't know if that's related to it or not, but I think there are benefits, and I intend to continue using nicotine, but never was before.

00:41:53 --> 00:43:11

Clive Bates: So would you advise everyone in the audience to take it up? I'll need your help. All right. Andrew raised quite an interesting point for me, and I'll maybe just go back to the panel. Do signal if you want to speak, by the way. But there's an interesting question. The people have been... moved away from smoking with the justification associated around the public health impact of smoking, cancer, cardiovascular disease and so on. And some pretty heavy methods have been used, punitive methods like taxation, restrictions, brutal warnings, plain packaging, stigmatizing campaigns and so on. If all of that, the harms of smoking themselves as a deterrent, the campaigns and policy imposed on smoking because of the harms, what does that mean for the demand for nicotine if it's, relatively speaking, much, much less harmful? Should we anticipate a significant increase, for example, significant increase in the demand because maybe there was a suppressed demand on account of the harms associated with smoking, but not with using nicotine without smoke?

00:43:11 --> 00:44:31

Paul Newhouse: Right. So I want to come back to something that Gene sort of hinted at and Mark also hinted at, which is that there are really two separate reasons to use nicotine, right? So one is the hedonistic, and another might be because of therapeutic effects. And those aren't necessarily the same. So for example, I might like to have a cocktail or martini tonight, but I don't delude myself that I'm treating myself for a disease, right? So I'm doing it because I enjoy it, right? I might enjoy a cup of coffee in the morning because I enjoy it, not because I need it to be aroused. But there are people who find that nicotine could be therapeutic for mood regulation or anxiety management or stress. And so there's really two faces of this product, of this molecule, which I think we have to just acknowledge. We have to say that it has pleasurable effects for some people or it has useful therapeutic benefit for some people, but we can acknowledge that for others it may just be used for pleasure. I think we have to acknowledge that and convince folks and regulatory authorities that there really are two aspects.

00:44:33 --> 00:45:34

Clive Bates: I agree with that. I mean, in my mind, which is nothing like as sophisticated as Paul's on this, I think of hedonistic, functional, and therapeutic. And functional being maybe to do with the stress and anxiety, and therapeutic being addressing sort of clinical conditions like Parkinson's or whatever. So another form of distinction. But they are definitely different. They may all be present in any given individual. or present in different individuals at different times and so on, which might explain some of that mixed pattern, where it's some of the people, some of the time. Any thoughts on what will happen to the demand for nicotine if the main deterrent for use of it, which is the harms of smoking, is withdrawn or removed, and that becomes well understood by the public, which it isn't at present. And maybe we can learn something from that about the demand for snus or other things that are not particularly harmful. Any views?

00:45:34 --> 00:47:21

Garrett McGovern: Yeah, I just think that one of the problems we have with all of this is there's such a campaign against nicotine by certain factions. So it's a campaign against nicotine a campaign against vaping, even a campaign against nicotine replacement therapy. So I find an awful lot of the time, you know, when you're trying to talk about this subject, it's hard to get away from that aspect of it in order to talk about the benefits of it. I mean, it's interesting, Mark talked about medical cannabis, I've been involved in that campaign back in Ireland. There's a huge lobby of anti-cannabis people who will just absolutely reject that there is any therapeutic benefit to cannabis. And I have to say, there's a drug that springs to mind that has both very, very beneficial properties and in the wrong circumstances. It's not completely analogous with nicotine, and that's morphine. So we, you know, you break your leg, you go to hospital, you're given morphine. It's, you know, given in a controlled way. We now have even heroin given in a controlled way in some jurisdictions. But in heroin, it's completely and utterly demonized. I mean, it's essentially the same drug. And nicotine, people can't move away from nicotine and its image. It's an image issue in many ways to any therapeutic benefits. And also it brings me to another aspect Mark was talking about, the pleasure. Every drug strategy that in my own country, I'm sure it's no different in any other country, is you'll notice in any drug strategy and you could say in any tobacco harm, that you're not allowed to talk about pleasure. You're not allowed to talk about benefits. We nearly, ostensibly, nearly always talk about the harms. And we're rooted in talking about the harms. So if you try and talk about the benefits, it's sort of poo-pooed. No, stick to the harms. We understand the harms. Benefits, no.

00:47:21 --> 00:47:37

Clive Bates: I just want to go to Alex here, and then we'll go to the next comments. Or do you want to start straight away? Let's hear from Alex, and anyone else in the audience? Come on, I want views from the audience. Yeah, let's go to Alex and then Mark.

00:47:37 --> 00:49:47

Alex Wodak: Thank you. Alex Wodak, Australia. We all know 8 million people thereabouts die from smoking-related diseases around the world every year. That's equivalent to the population of Switzerland every year. Reducing that number as fast as possible should be the paramount objective of everyone at this conference, and I guess it pretty well is. To paraphrase Michael Russell, people smoke from the nicotine but they die from the hostility to harm reduction. And our challenge is to come up with strategies that not just work but work better than other strategies because we'll never solve this problem of the hostility to tobacco harm reduction, nicotine harm reduction, simply with one strategy or inevitably use a number of strategies. But the criterion should be how much is each strategy likely to contribute to the achievement of the objective. If we look at psychological research in economics, what drives economic behavioral decisions is much more the possibility of loss or cost rather than the possibility of benefit. And that's very, very clear, very, very consistent finding. And I think it also applies in drug law reform, that costs have been a huge driver of preserving prohibition against all the evidence and the possibility of benefits has been a very small driver. And I think that's likely to be the case here. So I wouldn't put a lot of resources into campaigns or strategies built around showing benefits, especially if that benefit is pleasure. That'll be a big driver in the United States, but not much of a driver outside the United States. I think we have to keep on hammering away on the cost side rather than the benefit side.

00:49:47 --> 00:51:24

Clive Bates: All right. So there's an interesting thing emerging from that, which is What are the public health objectives here? And maybe there's a fundamental difference there between what I would call a public health or a harm reduction view, which is about reducing the burdens associated with smoking, and then there's those that are maybe pursuing a nicotine-free society, essentially looking at this as ridding the world of an unwanted and unnecessary drug, and sometimes I think questioning what the underlying motivations are is quite an interesting approach to this. If I just continue this theme just very briefly, then we'll go to Mark. I think the danger with that approach is what happens when you've got to the point where smoking has reached a very low level, especially in young people, as it's starting to do in parts of Europe and the United States now. Do you then say, well, we've lost the rationale for this, and therefore, You know, we now need to move from encouraging people to switch to vaping to really clamping down on vaping because too many young people are using it. Or do we go back and say, look, there's a fundamental driver of demand here. The challenge is to provide this drug in a way that is acceptably safe within the normal risk appetites in society. So I think we've got to be careful about solely relying on a harm reduction justification. Not yet, Andrew. Down here, please. Thanks. Mark.

00:51:24 --> 00:54:27

Mark Dickinson: Thank you. Mark Dickinson from Claritize. I'd just like to... And forgive me, this might take the conversation back a bit prior to Alex's comment. But I just want to share, anecdotally, my story of my teenage children, just to maybe illustrate one or two broader points, I think, that are relevant. So I have three teenage kids. 18, just turned 16, and 12. My boy who's 16 suffered from really quite serious mental health issues around lockdown and COVID. My 12-year-old daughter is adopted from Ethiopia, so transracially adopted and has quite severe dyslexia and all of those issues. My 18-year-old doesn't suffer from those things. Two out of my three kids are on ADHD medication, which is extremely helpful. Two out of my three kids, I've got a real issue. Well, not a real issue. Two out of my three kids feel the need to vape nicotine. So I'm left with this thing of, what do I do with it? and I'm facing all sorts of other risk-taking behaviour that cause me, that keep me up at night and do all sorts of stuff. So, two things, I think, two points out of all of that. One, I think kids try nicotine because of social pressure and peer pressure and because it's available and all the rest of it. A small proportion of those convert into more regular use. I think a lot of those who convert into more regular use are actually getting some sort of therapeutic benefit out of it I think it's interesting, both have got ADHD, smoking rates in ADHD are about twice those of non-ADHD people. I think they'd really struggle to articulate what benefits they're getting from it. I've tried to do that, and it's very difficult for them to articulate, but they both do it. And then there's other issues with cannabis use and all the rest of it that I'm struggling with, but I think the issues are similar. But then I go, right, as a parent, and I think the other point is, if you start with the behavior, it's easy to end up in a anti-vaping position. If you start with the child, and then you go like, this is a child who is just displaying all sorts of risk-taking behavior. And then I go, well, what's on the menu for them of risk-taking behaviors? And then I look at where vaping is. I really don't care about vaping, right? Because in the context of everything else that they could be doing, I do find it uncomfortable. I feel quite, as you know, I feel quite passionately about this area. And even for me, when I've got a 12-year-old who's going out buying vaping, I do find that quite uncomfortable. But the other part of my brain goes, well, 20 years ago, she'd be smoking now. So I think it's really important to start with the child and not with the behavior. And I just think you end up in a really different place in terms of what's acceptable and not for young people.

00:54:27 --> 00:54:50

Clive Bates: Mark, do you mind if I ask you a slightly personal question and refuse to answer if you wish or avoid the question? But do you think differently about your children using ADHD medication and possibly self-medicating for ADHD with nicotine vaping? How do you process that differently in your mind?

00:54:50 --> 00:55:25

Mark Dickinson: I think that they're probably using Both to a degree, probably. I think the effects of the ADHD medication are much more obvious and profound than they are from nicotine. So I can tell a real, real difference when they're on it and when they're not. And they can tell a real difference when they're on it and they're not. But I don't think it's really a coincidence. I think my anecdote probably reflects broader population stuff that shows that twice as many people with ADHD use nicotine as those who don't have it.

00:55:26 --> 00:55:32

Clive Bates: All right, any thoughts from the far end of the panel on the discussion so far? And I've got some more questions to bring up in a minute.

00:55:34 --> 00:57:56

Carolyn Beaumont: Yes, oh gosh, I have so much to say. I resonate so much with what you're saying, Mark. Thank you so much for sharing that. And I do remember the question this time, Clive, but essentially I see that nicotine use will continue. I loved what I think you were saying, Paul, that once nicotine is out of the jail of cigarettes, it's kind of free the bird to continue the metaphor. I reflect on the fact that teenagers are not stupid and so yes they might be trying it initially out of curiosity and the flavour's good and it helps them socially but I think at some point they're also continuing to use it because it works for them. Being a teenager is incredibly stressful for so many reasons and it helps them, yes they might be overusing, I have a feeling that maybe once they enter their early adulthood they're going to start naturally self titrating down and just use it in a therapeutic manner. I also, I don't know if I should admit this or not, in my other life as a general practitioner, I see a lot of adults who come to me with undiagnosed ADHD, and it is such a common thing for adults to struggle for years and years until they realise that actually they probably do have ADHD-type symptoms. So then the question is, okay, well, let's get you to see a psychiatrist so that we can trial, or similar, because as a GP I'm not able to initiate that. And then it's a matter of, OK, there's a six-month-plus wait to see a psychiatrist. So I have sometimes suggested to them and have trialled them on... Fentamine or Duramine, which is an appetite suppressant, similar mode of action, to say, look, this is just, it's a band-aid, it's to see if a stimulant-type medication will help you. And they often report, yeah, it did. And it carried them over until they got to see the psychiatrist and trialled their stimulant. And I've started sometimes suggesting, look, don't know if I should say this, but maybe just try vaping. to carry you over until you get that trial of Ritalin as well. I think nicotine's a great molecule. Honestly. There, I've said it.

00:57:56 --> 00:57:59

Clive Bates: You don't have lawyers, do you? I can see that.

00:57:59 --> 00:58:03

Carolyn Beaumont: Not yet. Australia, I hope you're not listening.

00:58:05 --> 00:58:59

Mark Oates: Just quickly on that question of consumption figures and, you know, if we've got this sort of 20% seems to be a figure of nicotine users and then maybe the risk takers and then you might see an increase because people, it's not as dangerous. I think there's a little bit of a frame issue and it's such a hard thing to talk about and get across. People talk about, you know, vaping is just there if you're a smoker. But I see reduced risk nicotine products a bit like the electric car. It's a revolution in which there are going to be people that start driving electric cars that never damage the environment with a combustion engine vehicle. And we shouldn't be saying to them, whoa, you weren't damaging the environment. You know, you should just not drive. And so there are going to be people, and that is a difficult frame. I already hear lots of people talk about it, but they never smoked, but they wanted to use nicotine. So it's much better if you use it in a safer version.

00:59:00 --> 00:59:56

Clive Bates: I think this is a really important point here, because there are maybe people in the audience, companies who say, these nicotine products are only for people who smoke and for only reducing the harm associated with smoking. That, in my view, is a losing argument in the long run, because in the end, the smoking will go through the processes that you're talking about. Essentially, diffusion of innovation will drive the cigarette products out. The question is whether there is demand for nicotine that is outwith the demand for smoking, and I think there clearly is. That's what we're hearing, is that there is demand for the drug. Okay, now, and if you just hinge everything on a harm reduction proposition, the danger is you'll start setting impossible hurdles, like we can't have any teenagers using this, or we can't have any non-users ever taking it up, which will work briefly, but not for very long. Any, Mark, sorry.

00:59:58 --> 01:00:41

Mark Oates: Someone tell me if I'm wrong, but I found no evidence of any society that started using nicotine and then just stopped and got to that nicotine-free society. We've only seen countries like Sweden transition to safer versions. And so if people in public health and policymaking recognize and understand that, then they can understand that the only way is to safer products. On the consumption level, Sweden's kind of interesting. I heard yesterday someone suggest Sweden was 27% nicotine use. So it's a little bit more than the UK. but it's not vastly, and we haven't seen in the UK a big increase. We were at 20% of smoking rate 10 or so years ago, and now we're about, I think 7% is vaping, 13% smoking, so it's been a like for like crossover.

01:00:41 --> 01:00:42

Clive Bates: Any, Gareth?

01:00:42 --> 01:00:53

Garrett McGovern: Just been a bit irreverent here, but we need to be careful to highlight and trump up the therapeutic benefits of nicotine, because it might go to the prescription model.

01:00:53 --> 01:00:54

Clive Bates: Okay.

01:00:54 --> 01:02:47

Paul Newhouse: So coming back to the ADHD question, which I think is a very interesting one. So my laboratory showed in the late 1990s that nicotine could relieve or improve the best laboratory correlate of impulsive decision making. We showed that. We published that. We published it in adolescents. We published it in adults. And we got companies interested in novel nicotine agonists. These were companies that were developing, companies like Abbott, companies like AstraZeneca, that were interested in developing novel nicotinic agonists. And came to us and said, help us design studies to see if nicotine-like molecules or subtype-specific nicotine agonists could relieve symptoms of ADHD. And what we were able to show was that, yes, that the relief of this particular cognitive impairment, it's a measure of impulsivity, does correlate with the improvement, clinically, with a nicotinic agonist. Unfortunately, all of these drugs failed in clinical trials. Now, why did they fail? I'm not entirely aware of that, but one by one they've been discarded, probably because the overall effect size is smaller than that for amphetamines or stimulants, right? So just as this gentleman said, the effects of stimulants are dramatic, they're immediate, and they are obvious. But the effects of nicotine are much more subtle. They can be shown in a laboratory and they can be shown in a clinical trial, but in real world use, it's much more difficult.

01:02:49 --> 01:03:09

Clive Bates: Paul, can I ask you a question that's sort of intriguing me? If there were substantial therapeutic benefits from nicotine and people could make medications out of them, is there a barrier to doing that associated with the stigma that goes with nicotine? Do people just not look or not want to invest in it?

01:03:09 --> 01:04:22

Paul Newhouse: No, I actually don't think so. So I was explaining this to a couple of people I was talking to this morning. Our work and other people's work got companies very interested in designing subtype-specific nicotinic agonists because, of course, they would have IP. They would have intellectual property, right? So if you design a molecule that only activates a subtype of nicotinic receptors, and there are multiple types of receptors in the brain, of nicotinic receptors in the brain, you could then patent that and sell that. And so a lot of companies got in the business of designing these molecules, and only one of them ever came to market, and that was varenicline, Chantix, right? And that was for smoking cessation. None of the others ever made it. All of them had unreproducible phase two studies. All of them had either side effects or problems, or the effect size was just too small. And so, no, I don't think the stigma really was the issue. I think it was just maybe you need a dirty molecule like nicotine, which hits all of the receptors.

01:04:22 --> 01:05:02

Clive Bates: I was thinking a little bit of the point that Mark made about the way there was a really visceral reaction to the idea that nicotine may be implicated in reducing COVID risk. And there was a plausible hypothesis for that around the control of inflammation reactions and so on. But the willingness to engage with that and the grudging way it was The grudging way it was sort of conceded through gritted teeth just made me wonder whether there's a sort of barrier to thinking about therapeutic, even amongst the professional community.

01:05:02 --> 01:05:09

Paul Newhouse: Oh, I definitely think there's a barrier, but I think, you know, the best answer to that is data.

01:05:10 --> 01:05:18

Clive Bates: I have a question from Peter.

01:05:18 --> 01:07:01

Pieter Vorster: I just wanted to get back to your point on harm reduction and the whole thing about it's only for smokers. I think there's a clear risk, as you point out, in that strategy, and I think it is partly because in the harm reduction community there is also a split between what people believe. I think there are some people who honestly believe that it really should only be. And there's sort of an alliance now between I think those who think of it in a sort of broader sense are accepting that because they think or we think that they would appease the sort of regulators and authorities and it would be easier to get these things done. But I really think there is a big risk in that as you point out, and perhaps we should start thinking more of the phrase smoke or would have smoked otherwise, because you have the sort of core of people who likely would have used it so that, you know, probably, you know, as you were pointing out, the sort of general usage doesn't go up. There may be a little bit of an increase, people who would not have done it. But as you pointed out, risk-taking behavior is, those are the people who would take on the risk anyway. And the people who are likely to smoke, smoke anyway, they might be fewer, but generally those are, they've taken that risk anyway, so that sort of sits in that group of stats.

01:07:03 --> 01:07:43

Clive Bates: All right, Peter, what if it's a bit more complicated than that? I mean, I like that formulation, you know, smokes or would otherwise have smoked. But what if there's a category of people who would have used nicotine had it not been for the harms of smoking? or the policies designed to suppress smoking, but use nicotine when those harms are eliminated and those policies are withdrawn. So they are people who wouldn't have smoked previously because of the delivery system, but would use nicotine in a situation where the delivery system was not as harmful. That's the sort of intriguing middle category here. What do you think about that framing?

01:07:43 --> 01:08:59

Pieter Vorster: I mean, personally, I agree with you. I think that's a very difficult I remember a few years ago at one of the BAT investor presentations, they put up slides showing that the overall nicotine market is growing and showed it as a good thing, and everybody jumped on them. Investors, analysts said, please don't say that. We don't want to invite that kind of But, I mean, the point I was making is that I think a lot of the, it probably is a smaller proportion than you think, because those who use nicotine currently as, well, either cigarettes or vaping, naturally, potentially are more risk-taking people anyway. So they would have chosen to smoke regardless of knowing. And I think the other point is when you're 15, 16 years old, you do it because you're not allowed to do it. And the sort of health effects are very long term.

01:08:59 --> 01:09:20

Paul Newhouse: Can I ask a question of you and about the other harm reduction people? What would be your estimate of the base rate of nicotine use in a society where Only alternative nicotine products are available and no combustible cigarettes. What would be the base rate of use?

01:09:20 --> 01:09:34

Clive Bates: It's an immensely cool and difficult question, Paul. I'll guess. I'll have a guess at sort of 30%, something like that, one third. I don't know.

01:09:35 --> 01:09:44

Garrett McGovern: Are you talking like, are they residuals now from smoking cessation who continue to use nicotine? Or are they new nicotine users?

01:09:44 --> 01:09:47

Clive Bates: In a libertarian paradise.

01:09:47 --> 01:10:21

Paul Newhouse: We banned combustible cigarettes. 20 years from now, what would be the base rate of alternative use nicotine products? And assuming everybody accurately knows the risk, because one of the things that's suppressing... Yeah, but let's assume that we have the ability to say, look, you know, nicotine packets are okay, vaping doesn't seem to have any long-term terrible benefits as long as we don't put glycerol in the vapor, you know, but what would be the base rate of use?

01:10:22 --> 01:10:30

Garrett McGovern: I have absolutely no idea, but I know this, that we'd be in a better position to maybe study the benefits when we remove the harms.

01:10:30 --> 01:10:41

Paul Newhouse: That's right. Could we just say, look, a society would be better off without combustible tobacco and let people have free use of novel nicotine products?

01:10:41 --> 01:11:38

Mark Oates: Mark, you might have a perspective on that. I think I'm right in saying the smoking rate was around 50% way back in the day. And so that might be the peak you could ever get to, before people sort of realise it was going to kill you. But I don't think we get back to those levels. And it is going to be a tough framing, a really tough framing, but ultimately, even if you had an increase and there's calculations to do when you understand the risk you can calculate obviously um at what stage would a percentage get to where you actually have more harm if if if the reduced risk is say you know if the risk of a alternative is one percent you might have to go you might even get to a hundred percent of use and you still wouldn't be at the same risk if you had twenty percent of people smoking and i would say that you you cannot i don't think you can get to a level of use whereby you'd have the same harm as people smoking at the rates they currently do?

01:11:38 --> 01:12:10

Clive Bates: And you may not be trying to optimize that anyway. You may be just simply saying, we'll let people do whatever they want. Free choice, can you believe it? I would answer about 30%. And I think when I asked you the equivalent question last year or the year before, you said about 30%. So I think, yeah, it's hard to know. There may be less dependence. There may be more pleasure. There may be lots of different factors We're going to have to draw to a close now. There was a comment from the back. These need to be, like, super quick, OK? Or we're going to go over time.

01:12:10 --> 01:13:03

Claude Bamberger: Well, Claude from France. And I understand it's a bit strange to see that from the frame of a country where a lot of people are still smoking. The idea of nobody smoking, even at 15, it's very strange for us. The point is, what we observe in France especially, it's teens and adults that quit smoking with vaping, they relapse, or they relapse to smoking, I mean, less. Even teens that take up vaping, there is a huge effect of they don't smoke then. So for your question about the maximum, there seems to be something in cigarettes. in tobacco cigarettes that makes it stick more. And whereas there is a difference there to study.

01:13:03 --> 01:13:09

Clive Bates: So a more complex range of reinforcers. Final, Andrew, do you want to say something very briefly? Did I see that?

01:13:09 --> 01:13:22

Andrew Manson: I was just going to say, just in answer to that previous question, just look at Sweden. It's around, I'd say, 23%, 25% when you add together snus users and cigarette users.

01:13:25 --> 01:13:42

Clive Bates: All right, I'm going to take the liberty of just getting a few like very quick closing remarks and thoughts and reflections on the discussion from each of the panel, then we'll wind it up.

01:13:42 --> 01:14:19

Paul Newhouse: Paul. So I think nicotine is a highly complex substance which has a panoply effects on the brain. And I think the long term or the short term and long term effects of nicotine on brain function are very state and condition dependent. And we have to understand that we have to acknowledge that acknowledge that and agree that no simple yes or no black or white up or down good or bad characterization is going to help us.

01:14:20 --> 01:14:27

Clive Bates: But perhaps people themselves are the best arbiters of whether it works for them. Perhaps. Yeah.

01:14:27 --> 01:14:49

Garrett McGovern: Garrett? I think, in simple terms, we need to push for nicotine to get its parole hearing and get out of jail and look at it a lot more favorably than we do. We have a big battle, unfortunately, as we all know here, with anti-nicotine, anti-vaping, anti-lots of things. And that's going to be the sticking point for me.

01:14:49 --> 01:14:49

Clive Bates: Carolyn?

01:14:52 --> 01:15:19

Carolyn Beaumont: I think we're probably many, maybe 10 years away from being able to have proper discussions about the benefits of nicotine, but I loved what you were saying about how the benefits of medicinal cannabis are now very easily and freely talked about and advertised, which contributes hugely to its legitimacy. So I'm really looking forward to maybe GFN 33,

01:15:21 --> 01:15:23

Clive Bates: My God.

01:15:23 --> 01:15:43

Mark Oates: Yeah, just quickly on that point regarding rates of consumption with reduced-risk products. It's a very interesting intellectual argument, but we should never let the other side attack us on that because there's still, we must remember, there's still 1.1 billion smokers in the world and that is the prize to try and reduce that and eliminate that harm and the 7 million people a year that die.

01:15:44 --> 01:16:36

Clive Bates: Okay, final very good point there is like stay focused on the big prize, you know, 8 million a year dying from smoking, hundreds of thousands of people sick, and we can really do something about that. But I think we also, you know, on the sort of Alice in Wonderland, if you don't know where you're going, any road will take you there. You have to have an eye on the future and where this debate is heading and what the future place of nicotine in society is. Or we'll take some missteps, like saying no non-users should ever use nicotine, it's only for harm reduction, it's only for smoking cessation. Dead end in my view, and would cause a lot of problems if you only did that. Okay, I'm gonna wrap it up there. If you would, please extend your thanks to the panel, which I think has been great, good discussion. And thanks to the audience contributions.