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Martin Cawley: My name is Martin Cawley. I am from Glasgow in Scotland. I'll explain a wee bit more about what I do in a moment. Often when I do sessions like this to an international audience, I'm very conscious of my accent. But as it turns out, it's like when you're waiting on a bus, you've actually got three Scots on the panel today, so this is a major test for you. And if you're struggling to understand anything we say, just tune in to the translation service and turn it to English. And you'll be fine. My name is Martin Cawley. I am the chief executive of a cancer charity, the Beetson Cancer Charity, which is based in Glasgow. I'm a nurse by profession, but I had a career predominantly in the third sector, working and managing organisations who deliver services for people with drug and alcohol issues, people involved in the criminal justice system, people who experience homelessness, and of course very much driven by harm reduction principles, so I can resonate with this subject matter. The subject matter for this session is actually who has skin in the game, who's got a stake in the game here, and perhaps maybe exploring in a wee bit more detail what that means for each stakeholder, what are the responsibilities and accountabilities that go along with that, right through from a consumer's perspective, right through to a manufacturer's perspective, and indeed a regulator's perspective, albeit we don't have a regulator on the panel, but it's a very important aspect to think about. We'll do this in the way that generally the conference has been following. I'll ask each of my colleagues around the table here, our virtual table, to say a few words by way of introduction, share a few reflections and observations and hopefully what that'll do is it'll stimulate some thoughts in your own minds about asking questions and then we'll just take it as it comes. And we'll try and moderate that in a way that covers all sorts of angles that we've talked about at the beginning, so please bear with us. I'm conscious, again, of the lighting in this room, so it's really quite difficult to see up in that far corner if you do raise your hands. So if you want to move into the main body of the hall, please do so, that might make it a wee bit easier. But as we get to the question and answer time, just please put your hands up, say your name, maybe if you've got a question directed to any particular panel member, just let us know and we'll take it from there. Sound okay? So let me introduce my panel then. To my far left we've got Chris Russell, psychologist and director of the Russell Burnett Research Consultancy, and a fellow, Scott. And as we were chatting last night, I discovered that he actually lives right on the bonnie bonnie banks of beautiful Loch Lomond. It is one of the most stunning places. Next to Chris is Moira Gilchrist, Moira also from Scotland, from the east of the country actually, Moira from PMI. And we've actually just been talking before we kicked off about how strange it feels back home because the weather has been so good for the last three weeks. And you don't often get sunny weather back in Scotland, so it's been most enjoyable. To my right, we've got Fiona Patten, who's... Half Scottish. Half Scottish? Oh, well, there we go. I'm sorry. I'm sorry. Fiona, who's an ex-member of Parliament for Victoria and Australia. And to my far right, we've got Sam Ratchoudhury, a journalist and consumer advocate, who'll give us very much a consumer perspective on the state of play as we stand. So, the subject matter, who's got a stake in the game? What's that stake about? What are the relevant factors to consider? And what does that mean in relationship with other stakeholders who are part of this scheme? Chris, can I start with you?

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Christopher Russell: Just checking it's on, yeah, okay. So I'm gonna hopefully make, over the next maybe two or three minutes, just make the case for why my field, behavioral science, behavioral research, is a key stakeholder for the future of tobacco harm reduction globally. I'd start by arguing that 10 years ago, the primary concern about e-cigarettes and other non-combustible tobacco and nicotine products The primary concern among regulators and health authorities was what's in these products? What are the toxicological risks to individuals from using these products? And the world is very precautionary. We just don't know. They have not been around long enough, used by enough people, are tested sufficiently. So that was the regulator's concern. I would argue that for the past several years, and I would say for the next 10 years, regulators' primary concern about non-combustible tobacco and nicotine products will be about the risks to the wider population, the whole population. Who uses these products and what impact does the use of these products have on the use of other potentially more harmful tobacco products? So I would argue First of all, the target of concern has shifted somewhat from the toxicological risks to individuals to the risks to the health of the whole population. And this then presents a new challenge for manufacturers of the products and for people working in universities and other research groups in terms of what they study. I think obviously there are differences between regulators globally, but regulators fundamentally looking for two sources of evidence in relation to these products. What is their effect on smoking cessation among existing adults who smoke? And what is their effect on initiation among youth and ultimately the progression towards more harmful tobacco products? And I would argue, unfortunately, and I'll use the example of flavors because that is perhaps the hottest topic of debate in tobacco harm reduction, flavors in different form factors. I would argue, unfortunately, I don't think... Behavioral research has been of the necessary quality in the past several years to adequately demonstrate the actual or potential benefits that flavored ends, flavored e-cigarettes, flavored other THR products can provide to adults who smoke. And as just a single example of Of this, there was a systematic review published in March of this year by Alex Lieber and colleagues, Ken Warner and David Levy, authors on the paper, and they reviewed 29 studies that had assessed cigarette cessation outcomes among adult users of e-cigarettes and had reported differences in cessation outcomes between users of tobacco, menthol, and then non-tobacco, non-menthol flavors, mostly fruit flavors. And they concluded from the review of these 29 studies that the role of flavored e-cigarettes in smoking cessation is at present inconclusive. Now, I'd take a guess that there's probably 10, 20, 30 people in this room who would personally testify to the effectiveness of a flavored e-cigarette in their own journey in switching from combustible cigarettes to an ENDS product. I imagine there's a lot of consumers who have primarily used and benefited from those flavored products. But my point is that the, and as was the conclusion of the systematic review, is that the studies that have sought to assess or test the hypothesis that flavored ends produce higher cessation rates than tobacco flavored ends have largely been not of the highest quality. There are substantial methodological limitations with those studies, substantial heterogeneity in how these studies measure outcomes, which outcomes to measure, and ultimately what we're left with is a mess of studies that are all speaking different languages, and no clear message emerges. So whereas there will be people who have personal lived experience of the benefits of flavors and multiplied by a million people not here today, unfortunately the scientific research that has taken place in the past five years as argued by this systematic review, have not been of the sufficient quality to adequately test the hypothesis that flavors do, in fact, reliably increase smoking cessation rates relative to tobacco flavors. The problem then is, in the real world, what we see is that regulators look at papers like this, and they cite it in support of prohibition or restrictive policies. And as a consequence, flavors in the United States have largely gone away. There's an EU directive coming into effect in a couple of months that will ban characterizing flavors in heated tobacco products in the EU. And all of this, maybe we agree, reduces, the consequence of reducing these options for adult smokers will in all probability be fewer adult smokers contemplating switching to a less harmful product, fewer adult smokers attempting to switch, and ultimately fewer adult smokers succeeding in their attempt to switch. So just to conclude, why I'm arguing that behavioral science is a key stakeholder here is behavioral scientists like myself and research groups that we work with and the behavioral science in-house at manufacturers, I argue need to be better in designing the studies that will be a fair test of the benefits or absence of benefits of flavored products versus tobacco and menthol flavored products. We need to take a more uniform approach so that when we all conduct our studies and submit evidence to a regulator, We're not speaking 27 different languages to the regulator. We're agreed on standards and standardization of design and assessment so that when the regulator receives our evidence that there are commonalities of design and measurement across the evidence being presented. So, sorry if I've went on just a few minutes longer there. Thank you very much, Chris. Yep, so just to say, behavioural science in conjunction with the other stakeholders who are on the stage.

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Martin Cawley: Thank you very much. A few themes that I'm sure delegates in the audience will want to explore a bit further, but let's move on. Moira, sorry, nearly called you Fiona there. Sorry, Moira.

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Moira Gilchrist: My sister's called Fiona, that's fine.

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Martin Cawley: Oh, you look very like her.

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Moira Gilchrist: Here's the third Scottish accent. I have the Edinburgh version of the Scottish accent, which some would say is a harm reduction version of the Scottish accent. Softer. I hope I'm understandable. So I'm here, I guess, to argue the case of why the industry should have a stake in harm reduction. I just want to preface what I'm going to say. I don't speak for the industry as a whole. I speak for my company, Philip Morris International. But I'll just give some broad thoughts of why I think we have an important role to play in tobacco harm reduction. And it really comes down to two main things. First of all, the will. So the will comes from ensuring that we have a sustainable business for the long term. And for my company, this vision about having a sustainable business started more than 20 years ago, before I even joined the company. And the vision was driven by the acknowledgement that smoking is harmful, it causes serious disease and premature death, and probably we should do something about that. It took us a long time to do something about that. It took us a long time to develop the products and the science that have ended up with us in the state we are today, which is having a bright future, I believe, in tobacco harm reduction. But nevertheless, it's a path that we set ourselves on 20 years ago, and in 2016 we announced that this is the future of our company. It's in fact the purpose of our company, is to replace cigarettes with non-combustible alternatives that are a better choice than continuing to smoke. The second point of why we should have and do have a stake in tobacco harm reduction is kind of a dirty word for some people, and that's money. So the money, the investment that we have been able to make, which is $10.5 billion since 2008, have unlocked innovation number one. So we've been able to design products, a range of different products, that meet the needs of adult consumers, that deliver the aerosol that we would like to see, that has a much different toxicological profile. than cigarette smoke. The second thing that money unlocks is science, and we've invested extremely heavily on the highest quality science, I think, that exists in this field today. That's going from laboratory science, the very basic in terms of chemistry, through to toxicology, clinical studies, behavioural research, and longer-term post-market surveillance studies. So with that investment in science, I believe has come an ability to build trust with consumers, build trust with the public health community and build trust with regulators and policy makers. We don't assume trust, we make all this data available and ask people to make up their own minds. The third thing that we bring to the table under the money bucket is an ability to understand consumers. So we knew our smokers before, but we've invested in understanding how to switch them, and switch them as quickly as we possibly can, away from combustible cigarettes to better alternatives. That has required diligence, it has required one-on-one conversations all across the globe, which we have carried out even before the products were on the market. And then the final thing that this investment brings is also scale. So I'm not knocking startup companies. I believe they have a really important role to play. I'm not knocking small individual mom-and-pop vape shops. They have a really important role to play. But what the industry can bring to the table is scale. Scale of distribution, scale of manufacturing. and simply getting these products out there as quickly as we possibly can to the biggest possible audience that we can in as short a time frame as possible. So that's why I believe my company has a stake at the table. We didn't kind of wait to be asked. We kind of went and did it, and I think we've gone as fast as we can. We would like to go faster, and we call on all of you to help us do that. That's my case for industry.

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Martin Cawley: Thank you very much. I'm sure the issue of trust again will be explored in a bit more depth a bit later. Why don't we just keep going, Fiona?

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Fiona Patten: Thank you. In thinking about where my position might be in this, and as a former Member of Parliament, I have a role to continue to influence politics and I have a role to continue to influence in these areas of harm reduction, and particularly as a harm reduction activist. So I've spent decades in this area, in establishing a supervised injecting room, in decriminalising sex work, in pushing for reforms around the decriminalisation of the use and possession of all drugs. With those campaigns, I've had allies. I've had the medical associations, the College of GPs, the harm reduction associations. But when we start to speak about tobacco harm reduction, those allies disappear and we're standing there alone. And that's why I think I continue to have a stake here and to continue to work And from what we've learned over the conference, particularly today, it is the justice issue as well here, and it's an equity issue. Because in Australia, we are a relatively wealthy country, and most Australians who are relatively well-off don't smoke. Unfortunately, if you are one of our First Nations people, if you're Indigenous in our country, we've probably got rates of around 40% smoking. If you are experiencing poverty, if you're from disadvantaged or vulnerable communities in my country, you are much more likely to smoke. And that is going to have a significant effect on everything. And I've been involved in inquiries into homelessness, inquiries into the criminal justice system, inquiries into drug use. Every time, disadvantage is one of the components and one of the issues that we need to address. So we need to address that equity issue in tobacco harm reduction as well. I get very frustrated. As an example, I was speaking to the medical director of the supervised injecting room. Now, here is a room where people who use heroin come into the space with their heroin, inject under supervision so they don't overdose and die. they then go outside and have a cigarette. 99% of them go outside and have a cigarette. Now, when I broached the topic of tobacco harm reduction with the medical director there, he just looked at me aghast and askance, like, what? You think we should be supporting big tobacco in here? And I'm afraid that in tobacco harm reduction spheres, that that trust is not there yet. And I feel I need to start working on that. Also, I suppose, being an Australian, where we are leading the way in what not to do. And I apologize to all of you. Sometimes we are infectious in these areas, and I really hope that we do not infect your communities and your countries in the way that some of you are moving forward far more progressively. We now have an enormous illicit black market. Now, I come from the adult industry. I come from The first screeches of protect the children came when we wanted to ban pornography, not just in my country, but around the world. It was, protect the children, ban pornography. Now, of course, it didn't happen, and we were able to argue for far more sensible restrictions on adult access to this product, the same as we need to be arguing for similar restrictions on adult access for this product, but I come from that background of fighting for the rights of adults to access a product that they should legally be allowed to access, but also fighting for the rights of small businesses to provide these products. Now, in Australia, when 92% of people who vape buy them on the illicit market, when it is illegal for a tobacconist to sell an ENDS with tobacco. They can sell a unit without tobacco—I'm yet to find one—but they can't sell them with tobacco. Obviously, they can sell tobacco. They can't sell them with nicotine. They can only sell cigarettes. So from a small business perspective, we're going to see businesses go out of business. Legal shops that have been providing vape supplies, whether that's coils, whether that's juices, or without nicotine, mind you, but providing those devices to adults, they will actually be criminalised in the forthcoming year if we do not fight hard in Australia. And I fear that when Australia does do things like this, it will infect other parts of the world. And I think finally, and probably most importantly, New Zealand. Australia hates to lose to New Zealand. We absolutely hate it. You know, sometimes it's our reason for getting up in the morning is to beat New Zealand. And seeing that our smoking rates used to be, you know, we used to be doing better than New Zealand. We're not now. We're falling behind. We're seeing New Zealand really beat us at this game. I mean, we beat them at netball. Actually, I'm not sure we did beat them at netball. But, you know, we beat them a lot in sport. We win a lot. But right now, in tobacco harm reduction, they are leading the way. And I think that gets me out of bed in the morning. Thank you.

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Martin Cawley: I'm not sure if I understand that conflict between Australia and New Zealand. You know, as a Scot living next door to England, it doesn't really resonate with me. Samrat.

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Samrat Chowdhery: Hi. I'll be making the case for consumers, which I think should be self-evident. But the reality is that the space for a tobacco user, you know, their space is shrinking. I mean, it started, I guess, you know, when the secondary risk, and then from there on, the autonomy and the respect. At this current state, even basically a humane treatment of consumers is also sort of something, you know, that you have to fight for. The problem is the people who are charged to protect us and our health, tobacco control, don't see us as human beings. I mean, they're not thinking about us. If that were the case, we wouldn't have being pushed and punished to make decisions that they want us to make. There would be a more collaborative approach. Despite being a billion people, we don't have representation, a true genuine representation. In fact, the groups claiming to represent past smokers are actually AstroTurf. The genuine consumer is not allowed in. When we try to engage, Article 5.3 is thrown at us. But the tobacco company which is run by the state, is somehow not a problem, you know, and that country is not a problem, despite being stakeholder in a tobacco company. So, you know, the system is designed against us. You know, we don't have a voice. We, in fact, cannot even directly engage with the industry, the people who make products for us, to tell them what we would like. because that also disqualifies us. And so we are in a very, and we are also a vulnerable group, because most of us are poor. 80% of us live in a developing world where there isn't public health care to talk of. So health prevention should have been considered really vital as a strategy. But what we have is limiting our choices, with bans. spreading, I mean, each country is making a decision, but every day you do hear someone has banned, Taiwan banned. So in countries where this reduction would have really helped, we have bans. And it's surprising that in Western nations where they do have public health care, there aren't bans, but where it could have really helped. So we are also frustrated. No one is listening to us. People who are supposed to be on our side are not on our side. Numbers like 8 million and 1 billion are just thrown about. But there's no humanity involved in those numbers. We people, we don't exist. We don't have rights. And also, one really well-known doctor from my country, India, was making the case that, anyway, very few of them quit. So let them go. They are lost. And that's about 1 billion people you are trying to disenfranchise. And it is published in a mainstream newspaper, and no one challenges it. So that is really a problem. Until we start looking at these people as human beings who are making choices, who need to be worked with, and not given directions, and not punished and pushed into corners, this problem will continue. Also, if you're using something which is among the deadliest things that you can use over time, and if there was something safer, then it is alright. to protect our health, and it is therefore also a human rights issue, which, for example, a drug user has more respect, and as part of the UNDP program, they are part of deliberations. But in tobacco, despite there being that many more people and so many more deaths, you don't have that.

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Martin Cawley: Okay, thank you very much, colleagues. I think we've heard an array of different perspectives there, one very driven by a consumer rights, human rights movement, if you like, and the interest of both a political perspective but a social justice underpinning to that, the motivations of tobacco industry and maximizing the benefit of different markets, and obviously a behavioral science perspective and what the influence on individual human behaviour and their motivations for decisions that they might make in life. Are there any questions? Let's open this up a bit. Are there any questions? I've got a few things in my own head that I want to ask, but any questions from the floor, first of all, that you'd like to explore in relation to what my colleagues have said so far? One down the front. I'll get a microphone. Is there a microphone? Just a question down... Oh, we'll go there first, then, OK. I'll come to you next.

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John Oyston: Hi, John Oyston, I'm a doctor from Toronto, Canada, particularly for Moira. Given the amount of distrust in the medical community and in the wider harm reduction community of vaping, why hasn't the tobacco companies spent some of their enormous resources on developing a licensed medical product for vaping? Because the Canadian government, the New Zealand government, the UK government have all expressed an interest in such a product, and yet it doesn't seem to be in the works.

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Moira Gilchrist: So I think Tobacco Company did. I believe BAT certainly had a medicinal licensed product in the UK. We as a company have not pursued that path. I'm not gonna say that we've completely cast it aside. But if you think about it from a smoker's view, and I was a smoker myself, smokers very rarely even admit to their doctors that they smoke. So you're already putting in place a barrier for somebody going and getting a product that could help them. The second thing that we've thought about is also a little bit the stifling of innovation. When you go through the medicinal products route, you're kind of locked into almost yesterday's product. We see this also with the US route, the FDA. Center for Tobacco Products, the timeline to develop the evidence and go through the review process is extremely long. And in the meantime, innovation is going at light speed, and in countries outside of the US, you have products that are two, three, four generations ahead of the ones that are authorized for sale there. So that's a little bit the concern that we would have, is that you lock a product in order to get through the regulatory approvals, but you then can't innovate on it because it's not necessarily what a consumer wants. So those are two things that really have made us pause. I'm not saying that we would never do it, But it certainly made us pause and think, OK, what would be the right product to go through that process?

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Martin Cawley: You OK, John? I think it would be a cheap product that's no longer available.

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John Oyston: I don't see why you couldn't have both a medical product, maybe a little dated, and a commercial product that may be more up to date.

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Martin Cawley: Just on the commercial front, I mean, a question that's floating around my head listening to your introduction, Moira, those motivations, where do they lie? If there was a market opportunity or a moral obligation to try and change behaviours, where does that balance swing in PMI?

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Moira Gilchrist: So I can't speak to the original motivation, I can speak to the story that I sort of came across in 2005 before I joined the company and it really came down to a sort of a desire of one or two or three individuals within the organization and seriously maybe even one individual in the organization who basically made a decision that the further he got up in the company, the more he would advocate for investment in science and research that could solve the problem of smoking. And he eventually became our CEO. He's now chairman of our board. He doesn't like this story being told, but it came from the vision of one man, one individual, who had the courage to say, we can do better than this. And he also had the courage to stick with us in R&D, because I was in R&D at the time, whenever we had problems. So any product development, anybody who's worked in a pharma industry or anywhere else, you know, you come across problems as you're developing a product. And sometimes you require more time or more investment. He put his money on the table every time we came and asked because he was so convinced that this was the right thing for the business and ultimately would be the right thing for adult smokers and the right thing for society.

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Martin Cawley: And does that culture permeate throughout the organisation today?

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Moira Gilchrist: It does now, and I'm not going to say it was a dream scenario from day one. You have an organization where people's careers were built on knowledge of the combustible business. So in the beginning, I do recall some resistance from some areas in the organization. We are well past that now and I think the leaders of our combustible business have actually done a really good job of showing people who work in that part of the business how they play a role in our transformation to smoke-free alternatives. It's about being the conduit to communication to smokers who ultimately can be encouraged to switch to smoke-free alternatives.

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Martin Cawley: I don't want to hog the mic, but there's some really important messages in there about how you would relate that message to regulators and others, I would have thought. There was a gentleman at the front who wanted to ask a question. There's a mic just on its way.

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Colin Mendelsohn: Thank you. Yeah, Colin Mendelsohn from Australia. I just had a comment to Chris about that Lieber study. The results were inclusive. Of course, it still may well be that flavours are effective but there's so much more about flavours than what that study was looking at. So flavours we know are an important incentive for smokers to switch to vaping. They do seem to play a role in preventing relapse. Studies have shown that when you ban flavours people do relapse to smoking and they find Flavours on the illicit market as well. There's growing evidence that it's not such a high priority for kids as we used to think it was, and surveys in the UK and the US have found that it's down the list below peer pressure and curiosities. Flavours aren't the driving force. And this research that shows people who use flavours are more likely to make a quit attempt. So I agree and why I'm bringing this up is because we've got a flavour ban proposed for Australia and it's coming up in other countries as well. And I think it will be a mistake and I think that paper shows something that we need to be aware of but there's a lot more to it than that of course. And I just wanted to make those points.

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Christopher Russell: Yeah, and the authors of that paper, while they're concluding that the state of the totality of evidence at present is not sufficient for concluding that non-tobacco, non-methyl flavors produce better cessation outcomes than tobacco flavors, much of the discussion section of that article was saying, well, it's because of the quality of the studies. It's not necessarily a true effect or the absence of evidence. It's more saying that the standard of the studies that were included in the review were not sufficiently of high quality and were not designed actually to test the hypothesis. For example, it's really important when, if you want to, really ask or test the hypothesis that flavored products produce higher cessation outcomes than tobacco flavored products, you need to enroll a sample of people who actually have an intention to quit smoking. It's unfair to assess cessation in a population of people for whom cessation was not the intention. So many of these studies would include people both with and without an intention to quit smoking. And usually when you do the subgroup analysis cessation outcomes. among the people intending to quit versus not intending to quit, there you see the effect. The problem is that most of these studies will just lump everyone in together, and maybe you've got 75% of the sample with no intention to quit, and then lo and behold, six months later, you find out that barely anyone quit. Well, yes, because that was the intention of most people at the start. So that's just one of the methodological limitations that are pointed to by the authors and by me and others in the field. But the higher quality studies, as you say, do show that flavors, non-tobacco, non-menthol flavors are more strongly associated with intentions to quit, attempts to quit, and succeeding in those attempts to quit. And that's been shown in the UK, in the US, and several European countries. My broader point is that There's so much heterogeneity in how these studies are being done that when they're all put together in a pool, no clear message is emerging. because you have high quality mixed in with medium quality mixed in with low quality. And my argument is that we, people who design these studies, need to be speaking to each other to decide on a uniformity of approach, agreement on best standards and so on to create the conditions that will allow any positive or negative effects to emerge.

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Colin Mendelsohn: people will say to the regulators, well, this shows, research shows that baking flavours is no more effective than non-flavours, that's what I'm worried about.

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Christopher Russell: That's precisely, yeah, the conclusion of the abstract of the paper, which is unfortunately all many politicians will ever be pointed to, says there is, at present, evidence is inconclusive, evidence of the role of flavours in cessation is inconclusive. Unfortunately, many people will not read down to the caveats and limitations of the paper. So, yes, my broad point being that that paper will be used as a weapon against flavors where it shouldn't. What the paper is advising is that higher quality studies are likely to, the higher qualities that were included in that review did reveal a superior effect of flavors, but there's not enough of them.

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Martin Cawley: Samrat, do you have a view at all, or do you want to make any observations just from a consumer perspective on flavored buns?

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Samrat Chowdhery: About flavors? Yes. See, I mean, we do go to restaurants, we enjoy flavors. I mean, flavors are part of adult life, you know. And there has been this notion, and I don't know why it exists, that quitting should be a not pleasurable activity. You know, it should not give you any pleasure. So I think they're just against the fact that, you know, we were smoking and when we got away with something less harmful and that's like, cheating the system, you know, somehow we should have died to prove them right. So flavors are important, so quitting if it's not pleasurable. The reason I think why vaping took off and has, you know, had so many people doing it in such short span of time despite so much misinformation and laws and regulations, so it's because it works for a lot of people. you know, I started, when I started out, for example, I wanted first the tobacco flavors, because, you know, I didn't know, like, vaping, anything, you know, I didn't, I just wanted to do that. But then I realized, why would I want to, you know, when I'm trying to get away from tobacco, I'm trying to get away from the smell and the taste, why would that be the only way that you're asking me to quit? You know, I mean, you're just setting us up for failure, then. Which is not to say that, you know, kids may not find them attractive. I'm not, I'm not coming into that, and that could well be true. Point is, there are a lot of things, you know, which kids could have access to. I mean, alcohol comes in so many flavors nowadays, but no one talks about that. So it should not be an either-or situation, you know, because you have to find solutions for all the constituents and not pit one against the other. We have nothing against good, effective measures to prevent teens from taking it up, and the best of which would be to tell them honestly what is the risk relation between these products. Because kids today are smart. They are making calls. And a lot of them, if you did a survey, would accurately tell you that vaping is much less harmful, which, again, somehow doesn't sit well, and it feels like, you know, something, someone did something wrong, you know, which is accurate information that they have and it's remarkable how even in India, you know, when very few people know about vaping, when they did surveys with the teens or the youth, they seem to have the correct ideas. So flavors are important, you know, if you took flavors out of the equation, it just makes it less attractive and I don't know why that would help anyone.

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Martin Cawley: OK, let's move on. John, I know you have a question here. I'll come to you shortly, Bengt. And Charlie, you had a question? So we'll do John, Charlie, and then we'll get to you again, Judy. We'll go to Bengt.

00:41:06 --> 00:41:59

Jonathan Fell: Yeah, sorry, Martin. I'm not sure if this is going to be moving on, but I just wanted to ask an additional question in relation to this. point about flavors. And I apologize, Chris, this might sound like an attack on you or behavioral science, which is not intended as at all. But it strikes me that the problem is that you're having difficulty proving in these studies what most consumers in this room would tell you. And I wonder, isn't there a bigger problem here of regulators and academia not giving proper weight to what consumers will tell you? And why is that? Do you think that's true and why is it? And is there perhaps more of a role for a sociological or anthropological approach and just giving more weight to what people say?

00:41:59 --> 00:45:09

Christopher Russell: Perfectly valid point. I'm a big believer in giving the regulator what they ask for. We can argue about how clear or ambiguous different regulators are in telling the research community and manufacturers what types of data and information they need. But how I interpret, say, the situation in the United States, the regulator saying, we need longitudinal, prospective, data, either from a randomized control trial or a longitudinal observational cohort study, which, I won't go into the details, but it demonstrates reliably that a change in smoking behavior is attributable to use of the product under assessment. Now, people can disagree on whether that level of research is necessary. FDA is saying it is, I interpret. The problem then is that those types of study designs cost money, they take a long time to do, there's no fast answer. When people say we want to know what's the six month rate of switching or cigarette reduction, you need to wait at least six months for something to find something out. It takes money and people and resource and perhaps there's only a small number of companies that can afford to wait that long to invest that amount of money. So I completely appreciate that while the regulator is setting a standard or specifying the types of information they need as clearly as they can, not every applicant will be able to meet that level of investment in time. The problem with more qualitative assessments, cross-sectional assessments is FDA and other regulators will say, well, it doesn't demonstrate change or allow us to attribute the change to any intervention or any product. So we can certainly, there's a great deal we can learn and I certainly have learned in 12 plus years of sitting down one-on-one listening to smokers and vapors, people who use other products, especially from people who have smoked all their life, tried using e-cigarettes or something else and ultimately went back to smoking to understand what was it about the product experience which didn't stick and they felt they needed to go back to smoking. There's a great deal that can be learned about how to innovate products to be more satisfying and appealing and affordable. But in terms of convincing a regulator or demonstrating to a regulator that a certain flavor is the product feature, product characteristic that's driving change, there's certain types of study designs that are big, expensive, long, and not easy to do. And that's a hurdle we're all facing. But certainly there's much that can be learned about adult smokers' decision-making about using or not using products from the one-on-one format you're describing there. I hope I've answered.

00:45:09 --> 00:45:21

Martin Cawley: Thanks. There are a few people who wanted to ask a question. Are your questions around this particular theme? Are you looking to move it on a wee bit more? Alex, was yours around this theme? OK, let's take Alex, and then I'll sort of shift it on a wee bit. I'll come to you shortly, Janet.

00:45:25 --> 00:46:54

Alex Wodak: Thank you. Alex Wodak, Australia, and I'm happy for anyone who would like to, on the panel, respond to this question. The traded tobacco companies in the world are said to be worth around about $800 billion collectively, and of course we don't know what the non-traded tobacco companies, government-owned, are worth, but presumably it's at least as great, if not as great again, We know that the share price of the traded tobacco companies as a category rose faster for over a century. And then until 2017, when they fell by 50% over the next four years, and the presumed interpretation of that is that investors started getting nervous about the lack of tobacco harm reduction. on the part of the tobacco companies. So my question is, my first question is, do investors have a stake at the table? And if not, why not? And my second question is, if the workforce of tobacco companies around the world is said to be around 100 million people, and maybe that's not accurate, I'm not an economist, but if it's around that figure, it's a lot of people, do they have a stake at the table?

00:46:56 --> 00:47:01

Martin Cawley: Moira, you anticipated that I was going to come to you by lifting that mic right away there, so why don't you address that first?

00:47:01 --> 00:48:30

Moira Gilchrist: Okay, thanks for the points and the questions, Alex. On the first point, I think it's difficult to talk about the industry as a whole when talking about share prices, so I can only again talk about my company. When we split from Alchea back in 2008, I think our listed share price was in the region of $35 or $40 a share. Today, yesterday, I think it was $95, $96 a share. And I personally think that's a reflection of the promise of harm reduction for us as an organization. And I think the reason that the share price has risen, I'm not an analyst, I'm not a finance expert, but we spent a lot of time and effort in bringing analysts and investors along on the journey, even before we launched our products, our first products in 2014-15. We explained the innovation, we explained the science, we explained what we felt the market opportunity was, and I think that was done absolutely deliberately, because of course they have a say. If they don't believe in what you're doing, if they believe it's too risky, then they're not going to invest, they're going to withdraw their support, and without their support, obviously, you're going to get pressure to reverse course. So it was a deliberate strategy of ours to ensure that we kept them informed and onside from the get-go.

00:48:32 --> 00:48:46

Martin Cawley: I think I have a follow-up question there, I'm not sure if it's a fair one. You're suggesting there that investors are making the decision to invest in PMI for the reasons of the strategic intent as opposed to the profitability of the organisation?

00:48:47 --> 00:50:03

Moira Gilchrist: Look, I'm definitely not a finance expert, but I think there are multiple types of investors. There are ones that are there just for the dividend. There are ones who are there for the long-term future and value increment. Maybe John Fell is the best person to answer this. But maybe I forgot to answer your point, Alex, about employees. Absolutely, employees really have a big stake in the game. And I remember I was one of the first people to understand the full program because I was working deeply in it and it was kind of like this secret skunk works operation in our R&D facility in Neuchâtel. And as soon as we started to communicate to the broader employee base, the thirst for knowledge, the thirst for, you know, getting to know the inside story about the products was just unbelievable. People were highly motivated by this as a long-term strategy for the company. And everybody, literally everybody, sees the role that they can play, whether it's physically on the ground talking with smokers, or whether it's cleaning laboratory equipment, or whether it's just simply telling their friends and family about the transformation story that we're going through. So everybody has a stake in the game.

00:50:04 --> 00:50:11

Martin Cawley: Thank you, Alistair. We'll do Charlie, then Bengt, then we'll come to you, Judy, up the back, OK?

00:50:11 --> 00:50:24

Charles Hamshaw-Thomas: Are you satisfied with the rate of progress? And if I can extend the game analogy, where are we in the game? Have you got any plans for... Do you think there are any tactical changes needed in the game?

00:50:24 --> 00:50:31

Martin Cawley: Is that question directed to Moira or...? All four, really. All four. Hmm. Why don't I come to you first, Fiona?

00:50:33 --> 00:52:20

Fiona Patten: Thank you. Well, from an Australian perspective, we are well behind the game. But what we're also seeing and what I think should worry us in Australia the most is the movement to the illegal market. So, you know, we now have an illicit tobacco industry like we've never seen before. We are seeing huge crops of illicit tobacco. We are seeing organised crime now very heavily involved in illicit tobacco. And And it's a much easier drug for them, it's a much easier product for them to distribute. So they're distributing it through the local convenience stores, they're distributing it through the local supermarkets, through the local tobacconists. So, I think for us, the game to stop the criminals from taking over is we're losing, and we're addressing this in other drugs. So, we're seeing the decriminalisation and legalisation of other substances, but we're going backwards in the game in Australia, I'm afraid. I suspect we, you know, I'm always, when Dr. Alex Wodak is optimistic, then I'm optimistic that we will prevail and that the consumer will actually, in the end, prevail and we will change direction. But right now, most consumers have to go to the black market to buy a nicotine-style vape, but also now a growing number of them are having to go to their black market to buy tobacco. because they can't afford the legal product.

00:52:20 --> 00:52:27

Martin Cawley: Shamra, are consumers doing enough to step up to the plate and fight their corner?

00:52:27 --> 00:54:05

Samrat Chowdhery: It's a fight we cannot afford not to fight, you know, because our lives are at stake and these are, you know, living is important to everyone. But the problem is we never thought of this as a fight. It didn't even appear to be one because it looked quite simple. There's cigarettes which are really deadly. There's something which is less harmful. We know it is less harmful because our health improved. So there can't be research on one end. walk 40, or like cycle 40 miles, then I know that's true, and I can climb. So there are a lot of benefits which we have experienced, so therefore we are sold on the idea. But we don't come from public health. This is not something which any one of us thought we would do, but now we have to organize, and research papers are written against us, and we have to figure out how to respond to it, and Jerry was quite helpful last time we could get a response in. So we are just put in a fight which we were not equipped. And so it takes time for a consumer movement, because there have been smoker rights groups, but they didn't have traction. They didn't have a wide buy-in. But now it is genuinely about saving lives, because people should have access, which is not to say that everyone will switch, but we should increase the number of options they have at price points they can afford, and in places where they can find them easier. It should not be that you can buy tobacco at every nook and cranny, but to get something less harmful, you have to pay more or go to a medical store.

00:54:10 --> 00:56:10

Moira Gilchrist: I'm a scientist and I'm also an optimist. I think ultimately the science becomes impossible to ignore. I think the question is how much collateral damage is going to happen while we wait for people to get on board with the science. And we did an interesting exercise recently where our statistical modeling team did a model to look at what's the opportunity of tobacco harm reduction, the best case, if you like. Because today, the debate is so focused on the potential unintended consequences and challenges of harm reduction, we thought, okay, let's look at what's the opportunity. And the results were absolutely stunning. So they took WHO's data on smoking prevalence, et cetera, and WHO's modeling method, and looked at 54 countries, which I think was something like three quarters of the world population, or something like that, and had a look to see what we could predict if all of the smokers in that country switched to smoke-free alternatives overnight, a smoke-free alternative that was 80% less risky than continuing to smoke hypothetical product. They showed that over the course of those smokers' lifetime, if they switched to smoke-free alternatives and stayed with them and didn't go back to cigarettes, there could be a tenfold reduction in the number of smoking attributable deaths compared to historical tobacco control measures on their own. So that tells me, okay, this is not a binary thing we're talking about. It's not the empire measures or harm reduction. It's both together and can we get on with it and move because we're losing a massive opportunity and there will be now collateral damage and people are going to suffer because this debate is taking too long.

00:56:10 --> 00:56:21

Martin Cawley: So the strength of a collaborative approach seems to add value, if you like, a way to convince the message or to convey the message. Bengt, I apologize that it's taken so long to get here.

00:56:26 --> 00:57:32

Bengt Wiberg: I'm Bengt Wiberg, I'm not from Australia. I'm from Sweden. Bringing up flavours is very important. Why? Because it affects snus, nicotine pouches, heat, e-cigarettes and you name it. So flavours are very important in order to succeed bringing down smoking. But has anybody, and this is a question to the panel, has anybody investigated those politicians or regulators who want to ban flavors? Is it banning a flavor or is it reacting to provocative packaging? I have seen Russian-made nicotine pouches with 150 milligram per gram nicotine content with bumby bears or cartoons or Kalashnikovs or, you know, skeleton skulls. Thank you.

00:57:32 --> 00:57:34

Martin Cawley: Yeah, go on, Fiona.

00:57:34 --> 00:58:48

Fiona Patten: I think it's a very good point and certainly the regulators in Australia are responding to, you know, the unicorn hair flavoured product, the teddy bear chocolate or those things. So there's absolutely, it's provoked by those flavours out there that seem to be addressing children, going towards children. But then But then when you start looking at things like the cheesecake flavour or the cookies and cream or those ones, no, those are not necessarily directed at children, and you'll find that many adults – and we've seen these debates going back and forth on social media with some of our regulators and some of our health officials about The fact that just because a flavour is sweet does not mean that it's directed at children. But certainly those products that are using teddy bears, that are using unicorns, that are using cartoon characters, then they are provocative and they certainly are engaging and making it a lot easier for the regulator to say, yeah, obviously these are for children, so we will ban them all.

00:58:49 --> 00:58:51

Martin Cawley: Chris, do you want to add anything?

00:58:51 --> 01:00:22

Christopher Russell: Sorry, if I could just go back to what I was going to give an answer to Charlie and the game analogy. Well, before the end of this year, Sweden will be world champions. They will be the first country with a smoking prevalence below 5%. So we should all want to be like Sweden in that respect. And I just want to expand something Moira said in relation to the modelling. One of the best arguments I've ever heard for tobacco harm reduction as a complement to existing tobacco control was a paper in 2013 by David Mendez and Ken Warner who estimated that if all of the Empower policy measures and interventions were implemented fully and immediately and funded without interruption through to 2030, then the best case scenario is that there would still be 523 million smokers in the world. And the question then is, well, what else can be done for those 523 million smokers who are not responsive to everything we're already doing? And that's a great argument for doing something in addition to existing tobacco control policies and measures. And, sorry, to Ben's question about, is it the flavor itself or is it the packaging? I've always found it unclear as to what it is people are trying to regulate, if it's the appeal of the product or the experience.

01:00:22 --> 01:00:32

Bengt Wiberg: You cannot view how a flavour tastes, you have to taste it.

01:00:32 --> 01:00:38

Martin Cawley: Agreed, yeah. Judy, I have kept you waiting for far too long.

01:00:38 --> 01:02:20

Judy Gibson: It's a story of my life. They don't call me the late Judy Gibson for nothing. The title of this is Who Has a Stake in the Game? And I was thinking that actually the WHO, Bloomberg, Big Pharma, All these people will be represented at the forthcoming in November at COP10, and yet what stake do they have in the game? Because we who have a stake won't be there. And I was just going to ask you, probably to Moira, I'm aware of Bloomberg's cabal and the various malign influences, and they are malign, and there's been an awful lot more. I think most people will agree that, I mean, for instance, in the UK, it's not now a drip against, you know, epidemic, children, vaping. It's become a river. I mean, we're almost drowning in it. I wonder if, it's a mad question, but the pharmaceutical industry, who do have a stake, they have a stake because they don't necessarily want tobacco harm reduction to go forward. Do you feel that they have got a malign influence behind the scenes, which we are not aware of, but you might be, Maureen, because you're more in the scientific pharmaceutical sphere, because it seems to me that people are pulling an awful lot of strings,

01:02:23 --> 01:03:55

Moira Gilchrist: Yeah. Look, I don't have a clear answer to that. I think you can trace money flows from all sorts of different foundations into all sorts of different organisations. but it's extremely difficult to put your finger on, okay, what's the motive and what's the outcome? I think whether we all like it or not, these people have claimed a stake in the debate about harm reduction, so we do have to listen to them, we do have to understand what their point of view is, and we do have to have a response, and a response that's a rational response rather than perhaps the emotional one that we all feel in our guts. So I think that's the unfortunate situation we're in. There is not a magic answer that I can think of to turn these people and organizations around other than science and a focus on the consumer. That's the two magic bullets because ultimately they become really impossible to ignore and we've seen it in regulatory debates in many countries, when the voice of the consumer is elevated, it's really hard for the Bloomberg-funded organisations to drown them out, because policy makers have to listen to their citizens. So I think that's why this forum is really important, to encourage consumer groups and consumer advocates to make sure their voices are heard, because they're so, so important.

01:03:58 --> 01:04:38

Fiona Patten: I just think it's an interesting one, Judy, because this is one of the only health issues that our health regulators are speaking about without the consumer. you know, in every other conversation, it's, you know, nothing about us without us. And, you know, whether it's sex work, law reform, it's always expected that sex workers will be at the table. If it's other forms of drug use, it's expected that the consumer, the drug user, will be at the table. And this is really quite unique, that this is the only debate where the consumer is absolutely excluded.

01:04:38 --> 01:04:39

Martin Cawley: Why do you think that may be the case, Simon?

01:04:41 --> 01:06:16

Samrat Chowdhery: I think there seems to be a view that the moment you pick up a cigarette, you sign away all your rights and you shouldn't expect to be treated humanely. And of course, since you're an addict, you cannot have your bias because of your addiction, so therefore you also should not comment on And of course, the moment you say anything about tobacco harm reduction, no matter where you come from, you are already in the tobacco camp. Apparently, the concept of tobacco harm reduction is not something which a consumer benefits from. It's just a construct. But that's how arguments have been made, and we have been excluded. We went to the last COP, and they wouldn't even talk to us. They would stay away from us. But we are the people who are dying from these products, and we really have a stake. So to say this to Judy about pharma, I'm not equipped to comment on that, but what I do see a lot of times is people who are not experts in understanding, they're not addiction experts, they're not behavioral scientists, they're not people who have been trained. to deal with addiction are the ones who actually control the narrative. So usually when you would have something which would require expert opinion, you would have it from the right kind of experts. But I don't think those are involved, at least not in my country and many countries that I see, even at the WHO level.

01:06:17 --> 01:06:57

Martin Cawley: There's a, I'm reminded of a psychologist, I don't know if you'll know her, Chris, from Harvard, I think, Donna Hicks. She does a lot of work in conflict resolution, and she talks about you won't overcome conflict unless you understand dignity, and that dignity is an intrinsic human value, but it's also an intrinsic human need. and the more dignity you afford one, the more you reinforce yours and the more you reinforce that person's dignity at the same time. So is there a loss of dignity or a lack of dignity or respect among the stakeholders that is denying the opportunity for progression. I don't know if you want to take that, Chris.

01:06:57 --> 01:09:36

Christopher Russell: Yeah, and as some of the questions were asked, so Alex mentioned two groups of people who have very legitimate stakes in this, the employees and investors, and Judy mentioned WHO and other public health organizations not here. To me, One of the most under-discussed legitimate stakeholders in all this, and for obvious reasons not here, is children. And what I mean by that is, I view tobacco harm reduction as a child welfare issue. We're all agreed that tobacco smoking is the leading preventable cause of premature death and disease, and nothing kills like a cigarette. And we can also, I'm sure, agree that there's nothing more traumatic in a child's life than watching a parent or two parents suffer and die prematurely from a smoking-related disease, maybe in their 40s or their 50s, and that child has to go through life with that trauma, that pain, that lack of... parental presence for the rest of their life, and it affects all of their relationships for the rest of their lives. So the way, when the subject of youth comes up, it's always obviously in the negative of how do we prevent youth, but the way I think about youth as stakeholders here is their parents are smoking, their parents are going to die earlier than nature would otherwise allow them to live. There is something we can do. There's many things we can now do, many alternatives we can offer them as a route out of smoking and that path towards premature death. So we're not only immediately helping parents who smoke to live longer, healthier, happier lives, we're helping their children. and the family unit to exist together for longer. And so there are different people of different political leanings across the globe. When we think of perhaps in America, Democrats who are more opposed to tobacco harm reduction. I find that a way of speaking about tobacco harm reduction as a child welfare issue or as a social justice issue, it's something that they can more get on board with. And so just because Alex mentioned a couple of unrepresented stakeholder groups and so did Judy, I thought useful to mention children as being the population group who stand most to benefit from their parents being around for 20, 30 extra years.

01:09:36 --> 01:09:46

Martin Cawley: Okay, any other questions from the floor? Oh yes, sorry, couldn't see your hand there. You're in the Bermuda Triangle, as Clive described it.

01:09:46 --> 01:13:08

Helen Zhou: Thank you. I'm Helena from China. I'm quite interested about this tobacco harmless reduction. There's some interest in my mind. I'm not specialist in either area. I think about two words. One is addiction. Another one is about nicotine. As I talked with some people during the concept, I found many people misunderstanding nicotine and the word of addiction. Because when we talk about nicotine, many people immediately think about toxic, there's some problem. And then addiction is a dangerous word, I'm addictive. But indeed, personally I found Addiction and also nicotine, both of them are neutral words, neither positive or pejorative. I was thinking about the psychology side for children. They can think about parents, they get a disease or death or something, but they don't care. They still go to the grocery shop to buy the cigarette. They don't care about health because they rebel. As soon as something is forbidden, they buy it. So, the things I'm thinking about, why we don't have the right education to the current smokers and for the future generation, the right education means that, okay, nicotine is something like any chemical element, like sugar, coffee or something. It's not forbidden if you really control the rate, the risk. We can still, like we are taking the coffee, we are surviving, we are living in the right state. So why we cannot really access any nicotine? Like we eat eggplants, we eat tomato, there's some nicotines. Give them right education. We're not rebel. Nicotine is not bad. I will think about that. Why we don't have the right media, let's say channel to access the right information. Second thing is addiction. Anyone here is not addicted to anything, we are addicted to sell, to sugar, to anything. So the word addiction won't become rebel. Some people are suffering about addiction. I want to stop smoking, but I cannot. I feel guilty. Second time again, I feel guilty. I'm addictive. It's something bad. Psychologists feel very vulnerable. If I tell them addiction is not a problem, Okay, we can smoke, but like today, the wiping, whatever, any e-cigarette or heating system, we should minimize the risk for the health. We can smoke. Why do we have to control ourselves to, let's say, to avoid addiction, whatever? So what I mean at the end is give them the right education, give them the right assessment of media communication. What is really the health of, let's say, tobacco harmless? We're all here talking about tobacco harmless reduction, but any consumer understanding what it means, tobacco reduction. So something less in this chain is our consumer and also right media access. That's what I want to say. I'm not special in any field. It's my feeling about the consumer.

01:13:09 --> 01:13:16

Martin Cawley: Yeah, I think that was more of a statement than a question, but what resonated in my mind was the issue of stigma.

01:13:16 --> 01:13:56

Fiona Patten: Can I just make an observation on this? I mean, yes, there's the stigma, but in Australia, if you look at the other pharmaceutical nicotines, which are the gums and the patches, they're available to 12-year-olds. and there's never ever been a question and in fact I've looked at a packet of nicotine gum the other week and it says not recommended for under 12 but as far as I'm aware there's actually no restrictions on the sale of the product in Australia so we've never had this fear and loathing around nicotine when it was in gum form it's now only when it's now in the

01:13:58 --> 01:14:41

Martin Cawley: Someone asked a question online, has nicotine gum or lozenges, do they come in tobacco flavour? And if so, where are they? And if not, why not? I mean, so clearly the nicotine intake, if you like, is the key thing. Can we get back to the issue of stigma? I think if I wasn't interpret what you were saying properly, you know, addiction and toxicity and, you know, these are emotive words and convey a degree of stigma. Samrat, is that an issue that you think has inhibited progress, the stigma around vaping because of its perceived association with smoking? People feeling as though they're stigmatized because they vape because of the association with smoking.

01:14:42 --> 01:16:10

Samrat Chowdhery: Sure, I mean, smoking has been enough stigmatized. There was a Philippine law which came out which actually demarcated the rights of vapors, delineated from those of smokers. So vapors would not be forced into smoking rooms and they would have their own space. As people who have transitioned out of smoking, we would like to keep it that way, which is not to say that once you quit something, develop like a visceral hatred for everyone else who does it. I mean, there are people who do that, but generally, you know, we are supportive of the right of smokers to try something which is less harmful with the correct information. So I think it's important to also communicate accurately, even if, and I don't see the reason for miscommunicating and with the justification, no, but we're trying to achieve a noble thing and if it's a small lie in that direction or we, you know, inflate the risks of vaping intentionally, knowing that it's not true, because you want a certain end result. I don't think that's ever a good strategy, because then what happens is you're losing the trust of the people, and then they're not going to listen to you, or they'll know that you're okay. Because it's also the internet age, you can find facts. You can't really hide the fact that vaping is less harmful, though WHO would still double down and keep, I mean, they use language tricks. It's not, I mean, they wouldn't say it, but we know what they're trying to do.

01:16:15 --> 01:16:51

Fiona Patten: In Australia I'm starting to sense that it's almost more deviant to vape than it is to smoke. And certainly I've noticed that around Parliament, that members of Parliament that vape do it much more surreptitiously. They'll all go outside for a cigarette and that's actually seen as social, it's seen as Poor you, you're addicted to smoking. But if you move to a vape, then there is something seen as subversive and deviant still around vaping in Australia. And it's new. It wasn't like this probably 12, 18 months ago.

01:16:53 --> 01:17:57

Moira Gilchrist: That blows my mind. I've been thinking about this idea of stigmatization a lot recently since we joined forces with Swedish Match. I think stigmatization of vaping or heated tobacco users is quite an easy thing to do because they act mimics the act of smoking and, ooh, smoking is bad and smokers have made a bad choice and therefore you must have. And I've been thinking, okay, what about snus users and nicotine pouch users? Because that affects nobody. There's no signal that somebody is using the product if they're using it in a discreet way. So what's going to be the tactic that's going to be used against nicotine pouch or snus users as it starts to get more prevalent around the world? And that kind of worries me. What sort of tricks and devices are going to be thought up by those in tobacco control who are simply focused, I think, in my mind, on the wrong goal?

01:17:59 --> 01:18:02

Martin Cawley: We have, yeah, go on Chris.

01:18:02 --> 01:21:24

Christopher Russell: I heard in your question about education around nicotine. Yeah, education around nicotine. So nicotine has a historical problem in that it's always been conflated with smoke for a hundred years. Smoke and nicotine in the eyes or the minds of smokers, even physicians, are one and the same thing and as a consequence we have very high rates of misperceptions among both physicians, smokers and the general population about nicotine as a constituent of smoke that causes cancer. Unacceptably high rates of misperceptions and that has been a misperception that has deterred a lot of adult smokers from even contemplating switching from smoking to vaping. Two, so to the question of education, I have to commend organisations like the National Centre for Smoking Cessation Training in the UK, whose part of their job is to communicate to smokers who come to National Health Services about what is vaping, how is it different from smoking. Because one of the key concerns or questions that smokers have is, am I not just trading one dependence for another or one addiction for another? The National Center for Smoking Cessation Training is clear and consistent in communicating to smokers that it's the inhalation of smoke that's the problem. That's what we need to change first. If there's a subsequent dependence on vaping, that is a problem that can be addressed in the future, but it is nowhere near as serious or urgent a concern as stopping the inhalation of smoke. So their FAQ section explains the difference a lot better than than I just did but my point is that organisation and to be honest all of the communications from Public Health England and Cancer Research UK and the British Lung Foundation consistently for the past five years now at least has been to try to dispel this notion that nicotine is what causes harm, what causes disease, and that nicotine, when decoupled from the toxic constituents of smoke, is actually, the risk profile is a lot, far, far lower. And so they should have confidence about using nicotine, a nicotine product that is decoupled from combustion. And I'm sure that these types of education efforts are taking place in many countries in the world. To me, the UK, from what I've seen, is leading the way on communicating to smokers through national health services, hospitals and clinics, explaining in basic English what is the difference between a cigarette and a vape, and what are the implications for health in the future attributable to those differences. So it can be done. Why Australia has such a different, I wouldn't say opinion, because we all have access to the same information, so why things are so different in Australia and India, other parts of the world, is the real question.

01:21:24 --> 01:22:20

Martin Cawley: I'm very conscious of our time, ladies and gentlemen, we're fast approaching the end of our allocated slot. I'm going to ask our panellists just to put their mind to any final concluding remarks that you might want to make. But we had a great session that Clive led on Wednesday night and it was the chronology, if you like, of alternative products from, I think he started off in about 2010, 2011 period and right through to 2023. And the thought that crossed my mind during that session was that life is best understood backwards, but it's just a pity you've got to live it forwards, you know, that was sort of prevalent in my mind. So if we were learning the lessons today and thinking about the future, sticking with our theme about staking the game, what may be your concluding remarks from your perspective? Does that make sense? Chris?

01:22:20 --> 01:25:05

Christopher Russell: So are you essentially asking, what do we think the next five, 10 years may look like? Yes. OK. It's not a bold or brave prediction to say that jurisdictions that implement more prohibitive or restrictive policies on smoke-free products in general, and then certain characteristics of those products like flavors, nicotine strengths, the more prohibitive, the more restrictive the portfolio of alternative options that are available to adult smokers, I'm worried that progress that has been made in reducing smoking prevalence over the past five, 10 years with the availability of those options is going to start to stall and perhaps even worse, start to uptick again. And it would be, no one here would take any pleasure in saying told you so because we're talking about people and quality of life and duration of life and the real people are going to suffer as a consequence of those prohibitions and restrictions is my prediction. And I would, at the other side of the coin, predict that jurisdictions that maintain and even expand adult smokers' options to a range of satisfying and appealing smoke-free alternatives will continue to see their adult smoking rates plummet. Speaking from a biased perspective, I hope, The UK continues to be a bright training example of resisting precautionary knee-jerk policy and continues to be driven by the excellent science that's coming out of UCL, King's College, multiple, multiple universities and organizations across the UK, the Cochrane Group. So I predict that the more permissive governments will continue to see smoking rates decline. Unfortunately, I shudder to think what Australia is going to look like in the next year or two, what the US might look like as more options are cleared from shelves. And I hope Well, as Maura said, science and data will ultimately come to be of such a weight that hopefully no government can deny it. And I just hope that things don't have to get too bad or go too much in the wrong direction for governments to acknowledge the huge contribution that THR products can make to driving down smoking that may not otherwise be achieved.

01:25:07 --> 01:25:09

Martin Cawley: You have a mighty samurai, so I might as well come to you next.

01:25:11 --> 01:26:25

Samrat Chowdhery: So I remain hopeful that we will see negligible, smoking will cease being a problem in our lifetimes. I remain hopeful because everyone does know that smoking is the deadliest way you can consume nicotine. And irrespective of how the policies come, because in India they banned vaping in 2019, and now you can find it in small villages. So the ban did nothing, right? And that's true also in other countries which have stricter, I think Hong Kong was discussing you know, that how the ban was not working. Taiwan, they had, you know, the people there said that it's not implementable. You know, it's not, you cannot have nicotine in only one form banned, but available in all the other forms. So I do believe, and as the science also becomes more robust, As consumers become more aware that these products exist, I think we will reach, you know, it took us this much time to reach 100 million. I think it will take much less to get to the next 200 million, and then there will be a, and then when people have voted with their, you know, choices, I think we'll have a huge impact on how it's also viewed in political or public health circles.

01:26:25 --> 01:26:25

Martin Cawley: Thank you.

01:26:29 --> 01:27:58

Moira Gilchrist: So, mostly what Chris said. I would just echo what you said, Chris. We start to see data that clearly shows that restrictions on smoke-free alternatives are directly correlated with the persistence of smoking. And I hope that people begin to really focus on that evidence and think, okay, well, what should we do next? And I just have two sort of additional thoughts. The first is, I think as a stakeholder group, and we mentioned most of the stakeholders, I think, that have a voice. We need to decide what's the goal we're fighting for. What are we actually trying to achieve? Is it the end of the tobacco industry? Is it the end of nicotine addiction, or is it the end of smoking-related disease and premature death? I firmly believe it's the latter. And then I'm minded of a panel discussion I took part in a few weeks ago in London, not about our subject, but about regulation and policymaking. And a former MP said, and this stuck with me, the best stakeholder, in her view, is a stakeholder who realises they're not the only stakeholder. So we all need to understand each other's point of view, whether we like it or not, get to know it, get to understand it, and get very, very good at arguing our point to achieve the right goal.

01:27:58 --> 01:28:00

Martin Cawley: Great concluding remark.

01:28:00 --> 01:28:57

Fiona Patten: Yeah, absolutely, Moira, and I think in Australia, The voter will convince the politician. It will be the voter that convinces an MP that if they want to be re-elected, then they need to change their policies and be more sympathetic to people who have chosen safer alternatives to nicotine use. And that is growing, but we are going to need to coordinate that in Australia especially. Now, I'm a Republican. I really want to see us become independent of the UK as fast as possible. I think Australia could have its own head of state. However, I do hope that we actually learn, we maintain some connections with the UK and that we do adopt some of the excellent work that the UK has been doing in tobacco harm reduction.

01:28:58 --> 01:29:35

Martin Cawley: Thank you very much, thank you. One of the roles of a chair of these sessions is to keep to time, so I have failed miserably in that respect. I can actually talk for Scotland, and I remember I was speaking at a conference once, and I had an allocation of 10 minutes to speak, and I was going on for about 15, 17 minutes, and I could see the chairperson getting really frustrated and upset, and I said, look, I'm really sorry, but I don't have a watch on, and there's no clock on the wall. And someone said, yeah, but there's a calendar on the wall behind you, mate. So listen, folks, I hope you found that an interesting and engaging session. So please show your appreciation for our distinguished panel here. Thank you very much indeed.