00:11 - 02:29
[Paddy Costall]
So turning to our first keynote speaker, it's my pleasure to introduce Dr. Mark Tyndall. Mark is an internationally renowned physician and a pioneer in harm reduction. A proud Canadian, he's worked for over 40 years in Canada and internationally as clinician, researcher, teacher, and advocate. principally with a focus on HIV, illegal drug use, and harm reduction. He's authored over 250 academic papers and presented a 2017 TED talk on harm reduction. He's been at the forefront of needle syringe programs, methadone maintenance therapy, supervised injection sites, and most recently, safe supply projects that greatly reduce the risk of illegal drug use. This work included being the driving force behind the establishment of Insight, the first supervised injecting site in Vancouver in 2003. And this has since become a model for similar initiatives in other countries. He's currently a professor at the University of British Columbia, and was previously the director of the British Columbia Center for Disease Control. In 2018, Mark hosted the first public event on vaping in Vancouver. At the time, KAC was a partner for this event, and it certainly attracted a mixed reaction, including a boycott from public health authorities in the locale. Happily, this didn't deter Mark in his determination to bring this experience with harm reduction into other fields to bear on advancing tobacco harm reduction. And he remains committed to seeing an end to combustible cigarettes through vaping and other low-risk nicotine products. His book, Vaping Behind the Smoke and Fears, will be launched here in this room tomorrow at lunchtime. But for now, I'm going to invite him up to tell us all about what's so scary about tobacco harm reduction. Mark.
02:35 - 38:30
[Mark Tyndall]
Okay, thank you very much, Paddy. And it's really my pleasure to be here in Warsaw to be part of the opening session for this conference. I've been to Warsaw on one other occasion in 2007, and the International Harm Reduction Conference was held here. And I checked back in Google, and Jerry Stimson opened that conference. So that was 18 years ago. And the other interesting thing is that the theme of that conference was harm reduction, coming of age. And it reminded me, if harm reduction came of age 18 years ago, nobody told people in tobacco control that. So here we're kind of starting from scratch almost again. I wasn't asked to do this session because of a long career in tobacco control or research. In fact, most people with long careers in tobacco control and research wouldn't be found at this conference, they'd be at the conference for a global forum on the elimination of nicotine if that was held somewhere else. So this is my opportunity to try to introduce my experience with harm reduction and how it would apply to tobacco control. Now, I got into harm reduction not because I took a doctoral degree in harm reduction, but because that became a big part of my work in HIV prevention. And I quickly learned that approaching behaviors and exposures that had inherent risk, the only approach would be to offer interventions that reduce that risk because we couldn't eliminate the risk. So that was really my motivation for a lot of the work that I did in harm reduction as far as HIV prevention. Now, I thought long and hard how I'm gonna try and present this kind of information, and about a week ago, I watched the new Bono film called Stories of Surrender. So for those of you who couldn't care less about U2 or Bono, He wrote a memoir about two years ago about his life experiences, and he turned that into a one-hour, one-and-a-half-hour movie, and he demonstrated some of the things from his book and acted it out in role play. And that gave me an idea, maybe I could do that here. Now, don't worry, I'm not going to sing or act things out, but I thought that I'd demonstrate some of the work that I've been involved in by... coming up with little conversations that I've had along the way. So it's just kind of an experiment, but bear with me. After I do these little role play things, I'll summarize some of the learnings from the experiences that I've had, look at some of the barriers to harm reduction, and finally address some of the way forward that we can use and leverage so that we can move vaping and safer nicotine products forward. Okay. So I want you to picture with me the years 1989. It's in Nairobi, Kenya. I'm doing my infectious disease fellowship, and I'm doing it with the University of Manitoba, who has had a long-standing program on sexually transmitted disease infections in Kenya. And all of a sudden, HIV hit, and it became sort of a major international center for this research and as part of my infectious disease training I went there to work on this project and I'd never been to Africa before I was married with two young children one two years old and one six months old and we arrived in in Nairobi and And I was assigned to work in a clinic called the Special Treatment Clinic on River Road in Nairobi. And it was a part of the city that no tourists would ever visit. And there was a large clinic there that saw people who had problems between their waist and their thighs or suspected sexually transmitted infections. And they'd be referred to this clinic. And there would be up to 1,000 people lined up there every day. So picture me transported in here. One other context is HIV at that time was rampant. There was really very little documentation of the infections. Estimates of HIV prevalence ran from 10% to 30%. Nobody really knew much about the transmission. Obviously there was no treatment at that time and even very little testing. So it was quite a historic time to arrive in Sub-Saharan Africa. So, here I was at this clinic, a little cinder block room with a wooden chair and a wooden desk and an interpreter, and a lineup of young men would come into my room. And so, picture a guy coming into the room, and I'd introduce myself, and, Dr. Tyndall, what can I do for you? And he'd kind of point down that he had a problem below. I'd examine him, and I won't get into the details of that, but I determined that he had gonorrhea. Actually, I became a pretty expert at sexually transmitted infections. There was really only five possibilities. Two caused drips, and three caused ulcers. You had either gonorrhea or chlamydia, or you had herpes, chancroid, or syphilis. By the end, I could pick people out even before they came in the room. Anyways, so the conversation would be that I'd examine him, say that, you know, I think you have gonorrhea, and we can treat that. I have antibiotics at the clinic, and I can treat your gonorrhea infection. But what I'm really concerned about is HIV. And as you know, there's a lot of HIV out there. We've done a test on you, and you're negative. But if you continue to expose yourself like this, I think you have a high chance of getting HIV. but fortunately for you I have something that will help and I gave him a condom or I gave him a whole stack of condoms and I said if you use a condom every time you have sex you won't get HIV and you won't get these other sexually transmitted diseases and in fact if you use it you have a 95% less chance of getting HIV if you use this condom so he thanked me and I give him condoms and tell him that you know when you run out come back and we'll give you more Fast-track to Vancouver, Canada, 10 years later. It's now 1999. I had worked in Kenya for... I lived there for about four years, but was doing projects back and forth for almost a decade, and decided with my family that we'd settle in Canada for a while and I wouldn't travel as much. And I took a job at the BC Centre for Excellence in HIV-AIDS. And then I was transported to another catastrophic HIV problem, only among people who were injecting drugs. And at that time, in that little community called the Downtown Eastside, it was estimated that between 20 and 30% of active drug users were already HIV positive. And we knew that the way people got HIV is because they shared needles. And it was very difficult to get new needles, so people were basically forced to share. So somebody would come into my office and I'd say, you know, how are you doing today? He said, well, you know, not so great, doctor. I have an abscess on my arm and I'm really heavy into the cocaine. I'm injecting a lot. I keep getting skin infections. I'm losing weight, not doing very well. And I say, well, look, I can treat your abscess. I have antibiotics for that. But I can also prevent you from getting HIV. And I have right here a needle. And if you use a clean needle every time you inject, I can guarantee you will not get HIV. And there's a new program down the street that they have a needle exchange program. And when you run out of these ones, I want you to take them and get new ones. And so if you can use a clean needle every time you inject, there's a 95% chance that you will not get HIV. And I think that's really important because even though we have some treatment now, it's really difficult and it's way better if you don't get HIV. Okay, fast forward to again in Vancouver, 2003. The situation by then is still... There's a lot of needles out there. I don't see a lot of new HIV infections. There's still a lot of people that I'm treating for HIV. But the situation on the street is quite chaotic. There's a lot of homelessness, a lot of crime, a lot of open drug use, and things are really... People are getting a lot of pressure to clean this up, and the politicians are really clamping down, and law enforcement's becoming more and more aggressive in trying to... get people off the streets. So somebody comes into the office. I'm, again, sitting in a small office, and I ask them, you know, how are you doing today? And they say, well, doctor, I'm doing really terrible. I don't have a place to live. I'm sleeping under the bridge right now. I don't have any money. I'm still injecting. I'm having to steal to get the drugs I want. And, you know, life is really terrible. In fact, last week, somebody stole all my shit. I have nothing. And I'm really quite scared. And so I'd say, well, look, This sounds like a really dangerous situation for you. What we've opened on Hastings is a supervised injection site. So instead of injecting by yourself under a bridge that's dangerous, I think if you come to the supervised injection site to use your drugs, it's a clean environment. There's clean rigs there. There's people that can help you if you have medical questions. They can help you. There's social workers there. And it will help you not to have to inject off the street and... being chased by police all the time. And if you go to the supervised injection site, there's a 95% chance that things will be better. You won't overdose. People will be there if you did make a mistake and took too much drugs to save you. And I really think that this would be an excellent thing for you to get involved with. So he looks at me and says, yeah, doctor, that sounds like a really good idea. And they're off to the supervised injection site. Fast forward to 2019. So at this time, I'm the director of the BC Center for Disease Control. I'm responsible for a wide range of public health programs, but I'm still most interested in injection drug users and what was going on in the community. And we noticed that overdoses were skyrocketing in the province of British Columbia. And it started about 2015, 2016, 2017. Every year, it seemed to double the number of people that were dying. And we knew from the toxicology that it was because of fentanyl. So there was no heroin left. We were a city that had a lot of really high-quality Afghanistan white heroin for decades, and all of a sudden the cartels must have decided it's too risky and expensive to do this. Why don't we give people fentanyl, which we can mix up in a bathroom somewhere, and it's super cheap, and people can get quite high on fentanyl. The problem with fentanyl is it's about 20 to 100 times more powerful per gram. So people were buying these flaps, what they thought was regular powder, and they were not waking up. And this problem is still continuing. The numbers are going down slightly, but at the peak, there was 2,500 deaths a year in the province of British Columbia and about 12,000 across Canada, about 100,000 in the United States, all due to fentanyl. And clearly, people were not going to stop using drugs, even in light of the imminent risk of death. And so the only ethical way forward, I thought, was to give people a safe supply of pharmaceutical drugs and to avoid buying street drugs. And I got money to develop a program where I had these very secure vending machines that were biometric. People were enrolled in the program and they could go and show their palm and they'd qualify and a bunch of hydromorphone pills would dump out of the machine and they could go every day and get their medication and wouldn't have to buy street drugs. And so somebody comes into the office, and I say, you know, how's it going? And they tell me, really terrible out there. A lot of my friends are dying. I've overdosed three times in the last month. If I wasn't helped by somebody with naloxone, I'd be dead. And I say, well, this is not, you know, going to end well for you, and I'd like you to You can come to the machine. It's open 24-7. You can go once a day. I can give you medications to use. And if you get in this program, I can guarantee you, there are 95% less chance you'll overdose. I mean, it's not impossible to overdose with these hydromorphone pills, but it's highly unlikely that you will. And I really think you'd be best not buying these street drugs anymore because you really don't know what's happening. And so, you know, I think it's important the person enrolled in the program and didn't overdose anymore. That's harm reduction. So let's fast forward to 2020. I'm sitting in the clinic still. Things are calmed down a little bit. I mean, there's still a lot of overdoses going on. Not everybody's getting safe supply. Not everybody's going to supervised injection sites. Most people are using clean needles. Somebody comes into my office and I ask them how they're doing, and they say, well, I'm doing okay. I'm off. I'm not buying street drugs right now. I'm on a methadone program. I have a place to live, but I have this really bad cough. I'm not feeling so great. My exercise tolerance is really low. I used to walk all the time. I can't do it anymore. And I can't get rid of this cough. And I said, well, how long have you been smoking cigarettes? And, well, I started when I was 15. And now I'm 40, so 25 years. And I'd say, well, I think most of the problem you're having with your breathing is because of your smoking. And you really need to get off these cigarettes. And what I'd like to offer you is I have vapes. And I think when you try them, you'll almost immediately feel better. Within a couple weeks, I think your cough will get better, and you can wean yourself off cigarettes. And I'm going to give you a starter kit, and then you still have to pay for it eventually, but there... Excuse me. actually cheaper than cigarettes once you get on it, and I think this will really help you out. And they're 95% safer. So I really think this would really be important that you start vaping. Thanks, doc, and he's off. Now, that conversation happened because he saw the crazy doctor who gives out drugs and needles to people, and now he's giving out vapes to people. If he had have seen the doctor down the street, the conversation might have been a bit different. So this is a conversation with the other doctor. somebody comes in, how are you doing today? Or the doctor would say, how's the steroid inhalers that I gave you last time? Are they helping with your breathing? And they'd say, well, doc, no, they didn't really make much difference, but my friend gave me some vape, and I've been starting to vape, and I feel quite a bit better already when I've started vaping, and I've really cut back on my cigarettes, and I think, like my friend, I can start vaping. And the doctor would pause, and he'd go, you're what? Have you not read about vaping? Do you not know anything about vaping in the news? And he'd said, well, no, I heard that it might be a little safer or something. It might be safer, but do you know who's using vape? Well, my friends are using vape. Kids are using vape. Haven't you seen the high school kids? Everybody's using vape. It's an epidemic, and they'll see you vaping and think it's okay. I don't think it's okay. And we can't be allowing you to get vapes because it's gonna end up in the hands of kids. And don't you know who makes vapes? And the person would go, I don't know, vaping companies? No, big tobacco companies. Those tobacco companies are now addicting a whole new generation of people to nicotine. They don't care about you. They just want you to buy new products from them. And this is... A huge scandal. I don't think you should be vaping. These tobacco companies are out to get you. They want to hook you on something else. And haven't you heard of popcorn lung? This is something that could kill you, and we don't even know in the long term what's going to happen with these things. You might feel fine after a week or two weeks or a month or a year, but what about 10 years, 20 years, 30 years from now? We don't know what these things are going to do. And the guy will go, well, probably I'll be dead in 30 years. But yeah, we don't know. So if you continue this path of vaping, I don't really want to see you as a patient anymore. And I've been trying so hard to help you with your breathing. I've given you steroids. And we're doing a chest X-ray every year just to find out if you get a lung, so we can detect lung cancer early. patient who can't well I kind of hoping to avoid lung cancer, but Anyways, I could go on but that's a much more common scenario for most of the physicians in in Canada who would actually discourage people from From vaping and and basically tell them they should continue with smoking so So those are my five scenarios, and they're all about harm reduction. They're all like almost real life examples. And there's some common themes to all of this thing. So you'll notice that I use the 95% effectiveness taken from Public Health England, but it's really true. All these harm reduction things are really effective. Like extremely effective. And I can tell people that if you use a condom, you won't get HIV. If you use a clean needle, you won't get HIV. If you use these drugs, you will not die of an overdose. I mean, these are highly effective interventions. They're also extremely simple. So these are, you know, most of them are little pieces of plastic that we're doing. It's not a big deal. We don't need big infrastructure or big investments to do it. They're all based on strong scientific evidence. And not only strong scientific evidence, but just common sense. So if we know how HIV is transmitted and we can block it, then it won't be transmitted. If we know the chemicals that cause lung cancer and we can give you something that doesn't have those chemicals, then I don't think you're gonna get lung cancer. So there's a lot of common sense as well as strong academic evidence to support these interventions. They're extremely cost effective. So because of the simplicity of them, compared to what the outcome is, treating a case of HIV in Canada over a lifetime probably costs over a million dollars. I mean, and a needle or a condom are just pennies. And so the cost effectiveness argument of these interventions is very clear. They're easily scalable. We don't need an infrastructure. We can just, by our policies and just supplying these things, we could scale them up big time. And probably most importantly, they're enthusiastically supported by people who will benefit from them. So this is not a nanny state type thing we're trying to foist on people. This is like what people want and what people need. And so there's people knowing that they could get HIV are quite happy to use a condom. people injecting drugs are quite happy to use a clean needle, and people using nicotine are generally quite happy to find alternative sources. So these are driven largely by the people that will benefit it from the most. So, sorry here. So with that in mind, it's kind of a bizarre twist that these interventions are controversial. So I've talked about all these things as though it should be a slam dunk, but it's not. And it's not because they don't work, it's because of ideology. And this prevailing thought that anything that we do will make things worse. So this is not anything that doing right now, but if you give people drugs, it'll be worse. If you give people needles, things will get worse. If you start giving people vape, things will get worse. And there's three main obstacles then to harm reduction. One is this focus on primary prevention, which I'll talk about, stigma and discrimination, and finally apathy. So this idea that public health is really about primary prevention really doesn't make any sense. I mean, I'm not going to sugarcoat addiction. I've personally seen the worst that can happen when people get addicted to heroin and crystal meth, when they get addicted to alcohol and even nicotine. Things end up very badly. I know people have trouble stopping when they start, and I know that primary prevention on the surface makes total sense. But I also know that substance use and addiction are extremely common, that I know it's naive and unhelpful and even unethical to tell people just quit. I know that people are using drugs for a reason. I know that everyone has their own story of why they're using these drugs, and I'm not really in a position to judge that. I know that addiction is not forever, so most people get over it. I know that prohibition doesn't stop people from using drugs, so any ideas we had to ban things will not end up well. And I know that if we put people in difficult situations where it's difficult for them to access the drugs or what they need, they'll find ways to get them in in a much more dangerous way. And this idea of a catastrophic... scenarios when things happen, again, doesn't make any sense. With condoms, when I was in Kenya, there was a huge backlash for giving out condoms because what would it tell kids? Wouldn't it encourage them to have more sex? Wouldn't giving clean needles out to people injecting drugs encourage kids to start injecting drugs? Wouldn't supervised injection sites encourage kids to go and start joining the community? I mean, I... I've taken my own children down there and I can tell you that it's not a place that they want to start going to. And vaping, the whole idea that we really need to control this because it's gonna affect the kids. These are really made up catastrophic stories that will never happen and have never happened. The second thing is really just basic stigma and discrimination against people. So the history of harm reduction is controversial mainly because of the people it's designed to help. So generally people choosing risky or socially unacceptable behaviors are frowned upon in society. And this idea of moral panic comes up where we create all these scenarios and really discriminate against people that are most vulnerable and most in need of our help. So you just imagine a scenario where 15% of the richest Canadians, Americans, Europeans were smokers. And they knew that it cut 10 years off their lives and resulted in a number of chronic illnesses. Then along came something like vaping that could reverse that. Do we really think we'd be holding this conference? I don't think so. They demand that they get a safer product. So there's a lot of discrimination and stigma that's attached to our responses. Also, imagine like from an international perspective, what if 50% of American men smoked and 15% of Vietnamese men smoked? Do you really think that Michael Bloomberg would go in there and ban vaping in North America? It would not be possible. He wouldn't do that. So he can do it in Vietnam because they're poor and reliant on Americans to give them aid and listen to Americans. Basically, he's depriving a whole nation of getting access to a safer product. The third thing is just apathy and how we've become so comfortable with the status quo. And that applies to the medical profession. So we've developed a whole medical system in some countries around smoking. So we have excellent cardiac care wards. We have excellent lung cancer centers. We have excellent respiratory clinics. And people... need people to keep coming, and there's really not a lot of impetus to make any changes with that. And the other irony of people who work in these type of clinics only see the patients once something bad has happened. So if you have a heart attack, you see a cardiologist. If you have a lung cancer, you'll see an oncologist. If you have bad COPD, you'll see a respirologist. they don't really think for one minute about prevention. They're really focused on helping people at their current situation and don't really look at the big picture of prevention. But the point is we've really created a whole medical infrastructure around treating these chronic illnesses due to smoking, and nobody's in a big hurry to change it. Also, tobacco control organizations aren't in a big hurry to change things, so they've really had decades of working on abstinence-based programs. I think at the very beginning, when safer products became available, they were constantly cautious, but now instead of starting to discuss the possibilities of how these could help people and help people's health, they just continue to double down. And now, 10 or 15 years into it, it's really hard for these tobacco control organizations to to take a big breath and say maybe we were wrong all along, and that's probably not likely to happen because then people would ask, well, what else have you been wrong about for the last 10 or 15 years? So there's a lot of credibility at store there, and it's very hard, I think, for people to change course when they've doubled down and dug in so deep against these safer products. And finally, tobacco companies are also not pushing hard for change. So certainly, there's a lot of industry here, and there's a lot of new products, and the websites of PMI and BAT are very forward-looking and want to go smokeless. But they seem to be in no hurry. And they're quite happy to kind of let this transition happen slowly, don't really want to take leadership in it and kind of let the consumers drive things. And that's so much different than how vehemently they've pushed back on any tobacco control regulations in the past, where they've had whole teams of lawyers trying to change policies in canada and i think in many countries tobacco companies aren't allowed to say that vaping is safer and so that's a a huge uh a huge problem as far as getting the a message out there and you would think that these companies would have a whole team of lawyers trying to push back on things like that but it really hasn't happened and the slow transition that the these companies will support but are not aggressively trying to make this change quickly. So I think the future of safer tobacco is promising, but it's taking far too long, and we really need to find ways to speed up this transition that I think will inevitably occur, but there's things that we can do right now, and I've come up with three things. So one, and I get this information from my experience with community in other harm reduction, is that community activism is extremely important, and we need to encourage and and get people who have started to vape and people in the community who can really advocate for themselves and have a voice. And I think we can all gather around and really help these groups to have a voice. You'll hear from Maria in a couple of days, and she's kind of a Canadian hero to try to mobilize the community and push back on policies that are discriminatory and damaging. We also can use people who can speak truth to power. So there's people in the world who are coming out for vaping and I think we need to do a better job and really get to policy makers and really put pressure on it. We have so many enemies out there, people that are fighting back, and it's very difficult to keep up with it. I get a lot of requests, you know, did you read this article or what this person said? You need to respond to them. And it's important that we do that and to try to push back, but we need a whole team of people and organized to make sure that we keep on top of all the false claims and narrative that are out there. And finally, to use the legal justice system better. So I know with other harm reduction things that I've been involved in, taking cases to the courts has been very successful. So the supervised injection site, needle exchanges have all gone to Canadian courts and they've ruled in favor of access to these things. And I think it's pretty hard from a justice perspective to say that people who want a safer product can be denied and I think the legal system would be in our favor to open up access to these things and I think we need to bring more cases and I know in Canada I've been involved in one case around flavors and and that I think it's going to go up the court system but I think it will be come out in favor that you cannot tell people that what kind of nicotine flavors that they can access so I think I'm going to end there, but I just want to tell one last story. So just bear with me for one more minute. One of my experiences with HIV was around HIV treatment. And I started medical school in 1982, and the first cases were in 1981. So really, my whole career has been around HIV. And at that time, I saw mostly young gay men dying of HIV, and there was really no treatment. And there was a turning point about 1996 when combination antiretroviral therapy was tested, and to everybody's great surprise, it was highly effective. So all of a sudden, these people that have been told that, you know, you have a few months, all of a sudden got a new life. And quickly, in rich countries, antiretrovirals became widely available, and many lives were saved from that. I was still working on and off in Kenya during that time, and I'd go back after working in a clinic and seeing these people come back to life in Canada, and then go back to Africa and have to explain to people, sorry, there's no treatment for you, it's too expensive, the companies don't want to release their patents, they're not willing to rev up manufacturing of these things. And this went on until 2003 or 2004 when PEPFAR, the American under George W. Bush, put in some billions of dollars and set up these generic manufacturing plants, mostly in India, and really made a big effort to get medications out there. And that's always thought of as a success story, but from my perspective, that was eight years of people dying unnecessarily. We had treatment, and literally millions of people, mainly in Africa, died because somehow we weren't able to get them the medication they need. Now, you could ask me, well, what are you talking about this at a nicotine conference for? I think there's a lot of similarities between smoking and HIV. And they're both behaviors or both ailments that are very slowly progressing. So HIV, they're stealth. You don't even know you got infected. And it's probably between 10 and 15 years before you get your first opportunistic infection. And much like smoking, you don't really realize anything's happening until 20, 25 years later you start developing symptoms and some of them are quite severe. And if you look at it in that way, that these are similar things, denying people safer products is basically like denying people antiretroviral treatment. Because we'd be saying that, you know, you're going to die from this. We have things that can help you here, but we're not going to be able to get them to you right now. And then in tobacco harm reduction, it's even more bizarre because we're not only saying that we're not going to supply them to you, but we're going out of our way to ban them. And we're going out of our way to make things harder to get. This conference will be talking about flavor bans and banning disposable vapes. I mean, these should be really small print things. We should be doing everything we can to increase access and increase the acceptance of these products, make them as easy to get as possible so we can get as many people off cigarettes. But that is not what's happening. I really believe there's some urgency to this. So the HIV analogy might be a little out there, but from my perspective, I don't think it's far-fetched. And I think the policies that make vaping and safer nicotine products harder to get for people who smoke is much equivalent to denying them the HIV treatment, and they're going to die. So thank you.
38:44 - 41:00
[Paddy Costall]
Thanks, Mark. I think you made a very compelling case there for a job with the Global Forum. It's yours. Before I open up the discussion for questions from the floor, I'd just like to introduce Dr. Carolyn Beaumont, who's going to make a short response to what Mark had to say. Carolyn is an Australian general practitioner. She founded the Australian Smoker Health National Telehealth Clinic. which was started in response to Australia's policy of having vape prescriptions. It's an odd country, to say the least, but she no doubt will tell you all about that. She also combines this with work as a locum general practitioner in remote Australian communities, so understands firsthand the complex healthcare barriers the smokers from these regions face. With the Australian government's hostile stance towards vaping, Carolyn plays an important role in keeping tobacco harm reduction to the fore. She's well known for her media engagement, presentations, publications, and conference involvement. Engagement with the media has also brought its trials with some negative coverage related to her efforts, particularly in trying to engage with younger smokers. But she remains committed to the principles of harm reduction. She's currently writing a book which will be entitled Unfiltered, a collection of interviews with doctors from the fields of cardiology, vascular surgery, anesthesia, neurosurgery, and oncology. It aims to provide a compelling narrative across medical specialities. which focuses squarely on the harms caused by smoking and not by nicotine itself. So Carolyn, can you please come up and let's hear your response to Mark. Thank you.
41:00 - 54:14
[Carolyn Beaumont]
It's a tough gig, isn't it? It shouldn't be this hard, right? helping smokers become smoke-free and healthier via a range of alternative nicotine pathways. We shouldn't need to put our reputation on the line, risk media censure and medical board discipline amid false accusations of being beholden to the tobacco industry. But as a doctor, that's exactly what I've experienced. No wonder tobacco harm reduction isn't attracting more health professionals. So what on earth are two doctors doing on stage for the opening of GFN25? It's incredibly exciting, and I hope the voice of health professionals continues to play a leading role in promoting THR. Not only doctors, pharmacists, nurses, dentists, social workers, psychologists, to name a few. I'd like to see a show of hands in the room. Who is a health professional? Quite a number. So maybe not quite 20, but more than 10. And let's aim for double that next year. And even though that number in the room is small, the impact a single health professional can have on helping many smokers is remarkable. So traditionally, the role of keynote respondent is to critically analyze the issues raised, maybe bring some alternative points of view. However, my job has been made very easy. Everything Mark says, I can only nod in strong agreement. We are very aligned in what we see as the key issues in THR, health inequity in heavy smokers. public education about tobacco harm reduction, and concern about the stigma of choosing to smoke, which leads to apathy, apathy by the general public, and apathy, or worse yet, punishment by policy. Mark highlighted the importance of education and health equity issues for smokers. I'll expand on this by sharing my clinical experience. I choose to practice medicine in lower socioeconomic towns, which inevitably have much higher smoking rates than nationwide statistics suggests. It's an incredibly rewarding area of medicine to practice in and I can really get to that very early level of primary care prevention of reducing the cardiovascular risk and screening early for the lung cancer risk and yes, getting them onto vaping instead of smoking and it's very rewarding because we're stopping it right at the start. This year, though, I did some locum placements in a remote Australian mining community. It's a typical remote community, hundreds of miles from major towns. In fact, this particular town is 1,500 kilometres from its capital city, Perth. For all of you northerners, London to Rome. Smoking rates are higher than average, cardiovascular risk is high, mental health is poor, substance abuse is rife. The scale of geographical isolation in Australia is astonishing and it impacts their healthcare in so many ways. For example, these towns can't retain regular doctors. Issues such as lack of childcare and poorer outcomes in schools are reasons why doctors won't relocate with their families. So towns like these have a series of locum doctors staying instead maybe two weeks like I did or two months. There is no continuity of care and even medical record keeping is affected. I did not truly appreciate the degree and causes of health inequity in high smoking populations until I worked in clinics like this. During one two-week placement this year, I was able to engage about 20 smokers in tobacco harm reduction. They were current smokers who had tried to quit at various times with existing nicotine replacement therapies but without success. Although they might have seen me for an unrelated reason, and yes, the appointments were brief, it was still possible to briefly mention the risks of smoking and to offer some alternatives. I would tell them that alternatives include patches and gums, but also pharmacy vapes. Note that in Australia, as Patti mentioned, vapes can only legally be purchased from a pharmacy. I'll leave my thoughts about that to one side. Maybe you need a stiff drink to go further with that one. It was always interesting to see their reaction when I said pharmacy vapes. It would range from, isn't vaping as bad as smoking? Or even the memorable Aussie chap who bluntly stated, I wouldn't vape if you shoved it up my... But he did finish the sentence in that case. But more commonly, patients were interested and open to learning more about vaping. They liked that the quality of vape from a pharmacy was regulated and that access wasn't too difficult once I pointed them in the right direction. Ultimately gaining their trust and letting them know we could chat further in a non-judgmental way was a crucial first step. A few came back to discuss further and some followed up with me separately via my own telehealth business. I was able to supply them with some information and a script and they could order their pharmacy vape products through some online pharmacies in Australia. I even managed to convince a few to have a lung CT scan due to their high risk of lung cancer. They would have to travel 400 kilometres, or London to Amsterdam, for a CT, but they did take my advice seriously, and I can only hope they follow up. Unfortunately, I was only there for two weeks each time. But if other locum doctors in this remote community could continue these discussions, the impact on smoking rates in this mining town would start to become significant. So although we won't easily get media or politicians on side any time soon, we must focus on educating health professionals about tobacco harm reduction. It's simply about offering smokers more solutions, about acknowledging that many don't want to give up nicotine and that they're sick of being lectured to and judged by doctors. I'm not telling doctors to ignore existing replacement therapies. I'm simply telling them there's another extremely effective tool in the toolbox. I want to briefly talk about the future of nicotine products, in particular nicotine pouches. And all I can say about this is three things. Innovate, regulate, educate. Whatever helps a smoker quit has to be considered seriously, and not just dismissed as yet another tobacco industry ploy to addict the next generation. Surely we could remain open to new nicotine technologies and at the same time ensure they remain regulated and as safe as possible. Of course, the trick is how do we prevent teenagers from accessing pouches? I do wonder, though, if the general media and political concerns about underage nicotine pouch use is premature. Nicotine pouches on initial use are quite irritating and burning to the gums. It takes persistence. I'm only basing this on my hunch, but maybe teenagers won't be as excited about nicotine pouches as they have been with vaping. If their initial experience of a pouch is burning and an extreme and unpleasant head rush, maybe they won't bother experimenting further with it. This leads me to teenage vaping, which I'll address briefly. Such a loaded topic and the darling of media and politicians. It ticks every box. Who doesn't want our kids to be safe and drug free? Who doesn't want to stick it to the tobacco industry? A politician would be crazy not to jump on the teen vaping bandwagon. I would like to consider teen vaping from a more holistic perspective. In my clinical experience, the numbers of undiagnosed and untreated mental health conditions, such as ADHD, must be considered in their use of vapes or other nicotine products. Also, is school demanding too much? Is there too much homework, too many late nights, poor sleep quality? Excessive phone use worsens these issues. Quite simply, I see that many teenagers are exhausted and overwhelmed. Is it then surprising teens resort to whatever stimulant they can easily find? Many schools these days have fancy cafeterias and coffee is not banned for kids. Maybe we shouldn't be too surprised that teenagers seek out whatever substances help get them through. Sounds like I need something to help get me through that. Developmentally, adolescence is the time of establishing our own identity and becoming independent from our parents. It's a time of excess and curiosity. Adolescence can be an overwhelming period full of extremes, seeking peer approval and craving new experiences as usual. Maybe it's unrealistic to expect teenagers to not be interested in nicotine. But let me be clear. Teenagers should not be vaping or becoming reliant on nicotine. And if they are relying on nicotine to self-manage an undiagnosed condition such as ADHD, social anxiety, or a mood disorder, then what is needed is good medical care. Of course, accessing good medical care is easier said than done in many countries. What tends to happen instead for a teenager who vapes is that they're caught, maybe even suspended from school, which simply teaches them to be more careful about where they vape. Or they never found out, they continue to vape on the sly and no one is ever the wiser. Either way, in my clinical experience, it is very rare that the vaping teenager will have the chance to see a compassionate doctor who looks at the whole person and doesn't just judge them for being a teenage vaper. Last year, I attempted to promote my services to help teenagers stop their problematic vaping. It was an expansion of my existing smoker health clinic which helped adult smokers get a pharmacy script. The concept was that teenagers, just like adults, need a holistic approach which considers their reasons for vaping, their physical and mental health, their sleep quality, their triggers for vaping. But fundamentally, the approach was to simply engage the teenager in non-judgmental conversation and start the process of them re-examining their vaping use. Unfortunately, last year, certain media forces took too much of my time and attention, and I reluctantly had to shelve this concept for the time being. I was reported, instead of attempting to start a clinic for teenage vaping, which subtly but successfully managed to imply that I actually want teenagers to vape. Nothing could be further from the truth. So my take on teen vaping is that it's complex. There are many reasons why a teen will try vaping and continue it, but at least it's diverting them away from smoking. There's much data to support this. This is a generational win in my books. What does sadden me though is that the vapes they are using are generally illicit, unregulated, disposable vapes. Apart from smoking, this is the worst possible type of nicotine product. And sadly, with so many barriers and restrictions in many countries about accessing better quality products, It seems likely that today's teenagers will grow up only knowing of illicit disposable vapes. What is really needed, apart from effective regulation of vapes and the removal of the illicit market, not so easy, is a massive investment and commitment to accessing good medical care. These are huge requirements. I wish I had easier solutions. I don't. Mark also raised some excellent points about the importance of public education and community involvement to help remove the apathy and stigma about tobacco harm reduction. And my contribution to this is that clear, simple messaging is crucial to cut through the noise. Think about the signs we universally recognize. Stop signs. Green man means we can safely cross the road. No smoking signs. Let's consider airports. Many have a smoking room, a weird fishbowl packed with smokers and advertising. Unfortunately, vapers in airports have nowhere to go except these smoking rooms. Vaping and smoking is sadly packaged into the one evil, and the general public continues to believe that. Signs and symbols are powerful. I would love to see separate vape-only spaces in airports with clear signs showing vaping only, no smoking. an instantly recognisable sign easily seen by the millions of people passing through global airports. Whether or not someone vapes or smokes, seeing this sign may spark some recognition that vaping is different to smoking, that vapers need to have a separate space to smoke as if they choose. I would love to see that extend to any public area that has a designated smoking space. Apart from the powerful public health messaging this could convey, imagine the benefit to vapers who are overwhelmingly ex-smokers. I can't think of any other product where the less harmful option needs to be used in the same space as the harmful version. Imagine if a recovering alcoholic could only have their soft drink at a bar. Or someone who fought their food addiction could only have their salad in a lolly shop. It's ludicrous and damaging. Forcing vapors to use smoking areas exposes vapors to smoking triggers and the risk of relapse. So if I had the power to make one change right now, it would be to create vape-only spaces in public places such as airports. And that's me, over and out, hopefully within 10 minutes.
54:25 - 55:00
[Paddy Costall]
Thanks, Carolyn. We're now gonna take some questions, comments from the floor, and also potentially if anybody is actually wanting to ask a question who's watching online, we'll take a few questions from those as well. So there are people in the audience, volunteers with microphones, so if anyone would like to ask a question or make a comment, don't be shy. So, cameras.
55:08 - 57:08
[Garrett McGovern]
Hello. Yeah, that's good. Listen, thanks to both speakers for excellent presentations. I'd just like to ask Mark, one of the things I work... My name is Garrett McGovern. I work as a GP addiction specialist in Dublin. And a lot of the... sort of barriers that we're sort of seeing in relation to vaping. You know, you go back, I think you said you were in medical school in 1982. I'm a little bit younger than you, but we had a lot of these barriers to try and, like in Ireland, for instance, opiate substitution treatment probably didn't arrive until 19 early 90s it wasn't formalized until 1998 with a raging injecting uh drug use problem for probably about 15 years how many people died of hiv hepatitis it was actually public health who sadly are probably our enemy today in relation to this that changed that they said listen there could be a hiv epidemic there could be a hepatitis c epidemic We need to get these interventions, needle exchange. We now have the first injecting room in Dublin. What's very interesting is if you look at the data, I think there's about 100,000 people a year who die from drug overdoses. There's 8 million a year who die from cigarette smoking directly. You would think that this would be a public health emergency. You would think that something like vaping, which is a game changer as far as I see it, not just vaping, but safer nicotine products, would be something for people in tobacco harm reduction policy positions to prick up and say, hold on, we can make a real dent into these 8 million deaths a year. Rather than do that, they're actually running counter to that. They're running against that. Can you... Explain to me why it is a terribly hard questions I can't really discover the answer with this why they are doing that why they would not embrace this new technology that has a really great potential in Reversing the the damaging effects and the mortality related to cigarette smoking listen.
57:08 - 59:59
[Mark Tyndall]
Thanks for listening to my question Yeah, I mean I've spent over two years writing this book and I the more I got into it, the more ridiculous it really seemed to me. It's just so obvious to me as a public health person that we should be embracing it. I've had, I don't know, a hundred more thousand conversations with people in public health The one thing that's striking to me is they don't know much about it. I'm pretty convinced that most haven't even thought through it. They had an opinion right from the beginning that, They're called e-cigarettes, and they must be the same as smoking. They stick to this idea that there's all kinds of chemicals in vape, even though some of these studies are 10 years old. It's just not true, and they really have not... made any effort, and I think socially, from their medical perspective, they're so ingrained into that people can stop smoking, like, quit smoking, is, uh, continues to be, and this is, you know, it's quite amazing to me that, um, People would have somebody in their practice who smoked cigarettes, and for 20 years they'd tell them to quit smoking, and they didn't, and they couldn't. And that didn't change their... You know, if you asked somebody to do something, and after 20 years they didn't do it, you'd probably think, maybe there's something else I should be trying. But it's just so programmed that... Why should you use an alternative nicotine product when it's just easy to quit? And, you know, from other... Why would you, you know... Why are you worried about HIV to stop using drugs, you know? Why don't, you know... It's... Yeah, so I think we've been socialised in our medical training that cigarettes, people can quit, and that that should be our go-to thing. And... And then my second point, I'm just always amazed how little people know about it. They're so entrenched in it, and when I try and tell them, no, these chemicals don't even exist in vape. It's implausible that you'll get lung cancer. There's no mechanism for that. And they don't seem to know that. So I don't know. I can take some, but if I get 10 minutes with most people, I can at least get them to admit that it's safer. But doing it person by person is a really arduous task.
60:03 - 61:49
[Carolyn Beaumont]
Do you want to comment? Sure. It's on? Good. Okay. Yes, I think all I would add to that is, you know, absolutely, Gareth, the scale of the problem is just staggering. And I compare it to the figures of the COVID deaths. For example, in Australia, there were more smoking-related deaths every year in Australia than there were for the entire COVID pandemic over three years. And, you know, we rightly addressed the COVID pandemic as being of huge urgency and we needed to do something right now and even if that solution wasn't perfect. And so, you know, COVID vaccines were produced and they were tested and we know that they weren't perfect and we didn't. We knew we couldn't wait 10 years to get all the data on the vaccine, but we knew, look, it's safe enough for now and the threat of COVID is so bad that we just need to get this vaccine out there and so that's what happened and we're still learning about the vaccine but I think it's a fair call to say look yes we had to do something and then as time as we can now relax and the threat of covert has fortunately receded and we can now exhale and spend time on the vaccines and really fine-tune them That's good. I think that's a reasonable way to go. And so why can't we be doing that with vaping, just saying, look, we don't have the 50 years of evidence that we need, but we've got a pretty damn good product right now, and we've got something that's killing more people than COVID did and is going to continue to do forever. Let's just do something. Let's just get these vapes out there, and we'll start to refine it as we go, but at least we're going to stop that lung cancer and heart attack and stroke in its tracks.
61:51 - 61:58
[Paddy Costall]
Anybody else? Gentleman at the back. Next.
61:58 - 65:14
[Baharudin Abdullah]
Hello, good morning. I'm Baharudin from Malaysia. And I actually am very captivated by the life journey as shared by Professor Atamak Tindal just now. And I think what you have done probably saved a lot of lives. And I think basically what we are, as doctors, that is what is our main contributions about saving life. And I think about this topical harm reduction is about saving life. But the problem is whatever measures that we do may not be seen as something that is palatable for some segment of the society. I would like to share with you, in Malaysia, we are basically a very conservative society, and whatever things that we mentioned just now is rightly so, is probably considered as unacceptable to them. And coming to the smoking campaign and whatnot, they always adopt this all or nothing. Either you stop smoking or you continue smoking, but there's no other way in between. And for me, I'm basically an otolaryngology, ear, nose and throat surgeon. And I see a lot of patients, they have allergic rhinitis, they have... chronic rhinitis, venous polyp, bronchial asthma as well. And I think for them not to be exposed to smoke, probably will actually solve a lot of their issues and problems. But the thing is, when we talk about whey pain, we talk about that it's not being supported by government. And I think for my patient at least, it will benefit them. And I think probably what we need to do and from my own perspective is that still convey the message in the right way, work together in a concerted effort to enlighten everybody as to the benefit of having these sort of options. at least there is an option for these people to at least continue in this sort of habit without causing more damage to them as well as the other people that are surrounding them. And I think it's not going to be easy because when those who are in power are not supportive of this sort of efforts, it's not going to be something that is going to be smooth sailing. And what I've seen over the years is Whenever anyone spoke about this, it would be something that would be like, you know, their efforts would be going to discredit them. And as always, the messenger gets shot first. So when they want to hear what they don't want to hear, then they will not be supportive of this sort of, you know, efforts or measures. And I think I give you the credit for sharing that very interesting journey. But then again, I think probably what we need to do is probably keep on giving the right message and being consistent in what we can do to save life and make life better for everybody. Thank you very much.
65:15 - 65:36
[Paddy Costall]
Thank you. Gentlemen, gentlemen further down the aisle. I'll just take this comment or question and then I'll ask the panelists to respond.
65:37 - 66:14
[Kai-Jen Chuang]
Thank you. I'm KJ from Taipei Medical University in Taiwan. I have a question for Dr. Caroling. I fully agree with you about we have the smoking room for smoker and we should have the vaping room for vapor, but in Taiwan now we ban e-cigarette, but we permit heated tobacco products. So how do you think about the people who use heated tobacco products? The toxicity, I think, for the heated tobacco products is between the vaping and the smoking. So should we have a room for them, or maybe we should put them into the smoking room? That's my question.
66:14 - 67:27
[Carolyn Beaumont]
Thank you. Thank you. What a great question. Yes, so if anyone didn't catch the question, basically, yes, it would be good to have smoking rooms and a separate vaping room in places like airports, but what about people who use heated tobacco products, HTPs? Much safer than smoking, but maybe is... The exhaled aspect of things like that, worse for vapours. Actually, I have to admit, I don't know in terms of the exhaled aspect of HTPs. As far as I know, I don't think there's much of an issue, to be quite honest. Obviously, it just makes sense to have them in with vapours. But again, it's one of those things, as the fellow from Malaysia, I think, was saying over there. We need to have unity and consistency of our messaging. So again, it would be something like, smokers here. everyone else over there. And let's just get that initial thing of smoking versus everything else. And then we could sort of fine tune it to, you know, depending on the market and the country. Yes, there might be an HGP area and a vaping area, whatever. So yeah, I think very much big picture, smoking here, everything else there, consistency, unity of messaging symbols.
67:35 - 68:16
[Rashidi Mohamed Pakri Mohamed]
The gentleman at the front. Hi, Carolyn. I'm Rashidi. I'm a consultant for a physician. Here, here, I'm here. I'm in front of you. I'm sitting behind you. I'm a consultant primary care physician and an addiction specialist from Malaysia. As a fellow primary care physician running a quit smoking clinic in Malaysia, I'm curious, in Australia, who primarily funds the use of e-cigarettes for smoking cessation and what's the strategy or evidence which has been used, which is most effective, in engaging policymakers to support their use as part of the National Harm Reduction Program?
68:16 - 68:28
[Carolyn Beaumont]
Sorry, I'll just make sure I've got the question correct. So you asked who funds the... You mentioned that you use e-cigarettes as part of your smoking cessation program?
68:29 - 68:36
[Rashidi Mohamed Pakri Mohamed]
Yes. And who funds it? And how do we actually convince policymakers to actually use it?
68:37 - 72:42
[Carolyn Beaumont]
Yes, so you're asking who funds the clinic that I run? Well, I've set that up myself. It's the great thing, I guess, about telehealth and learning how to set up a website through YouTube. You can actually establish a medical practice quite easily. So I've set that practice up. myself, and the patients pay private out of pocket. The type of consult it is by telehealth doesn't qualify for a Medicare rebate. So yeah, it's a privately funded clinic. Very minimal overheads. So it's very easy to set up, actually, which is great. I love how telehealth is really opening up all sorts of options. The second part of your question, sorry, can you please repeat what that was? What is the most effective strategy to convince policymakers to use e-cigarettes? Oh, goodness, yeah. So what is the most effective strategy, maybe, as a doctor, to be able to convince politicians, other people about it? it's really hard I'm probably learning more what's ineffective actually and what's damaging rather than through a process of exclusion then working out what's effective so what I found is that I can't do which I'd love to be able to do though is to engage via webinars or through information on my website I'd love to be able to engage more health professionals and just the general public about vaping, just basically telling it how it is. But I'm not allowed to do that because that is then seen by a therapeutic goods administration, the government that oversee medical advertising, et cetera. That is seen as me promoting vaping. And it's, you know, I've got to be so careful what I say. So anything that's something like that it is or it could be reasonably seen by the general public to be promoting in any form whatsoever the use of vaping. So they just keep the language so broad. So essentially I can't say anything. It's very limiting, very, very limiting indeed. And, you know, that's why I've had issues with vaping. Yeah, the medical board in the last year, yeah. Very minor things that I thought I was still playing within the rules, things were still caught out. Because it's like, this person may think that may think that may think that person thinks that you said vaping is okay. It's like I've committed vaping advertising fraud. So what to do? Well, I guess, I mean, that's why I've decided, well, look, I'd like to read, I like to communicate. You can probably tell that I've been long interested in writing a book. well let's write a book about about smoking harms again i can't put in it things that are pro-vaping because again that can be breaking laws but it can be all about smoking and i think there's still a lot of interest and appetite for people to learn about the issues of smoking itself and i can certainly separate in the book the smoking harms from nicotine i just can't talk about vaping per se but i can definitely you know get that dialogue because If people could just understand, health professionals, general public, can understand smoking and nicotine, different things, different issues, then it's not difficult to then say, OK, nicotine, all these other things, vapes and patches and whatnot. So yeah, so I guess to sum it up, my approach is to learn from bitter experience what isn't working and keep to the rules. stay on side with policy makers in Australia, try to continue to be seen as a reasonable, honest voice in this. Just do the best I can, keep engaging with patients one on one.
72:44 - 75:09
[Mark Tyndall]
Just to add to that, it brings up the idea of having to follow what the policies are. When I was head of a provincial agency and I was a deputy provincial health officer for the province, there was quite a heavy-handed... view of what I said and the communications people, there was probably more communications people than public health people in the ministry. But now I'm unshackled by that. And I do think that we need some brave voices just saying, screw you, I'm not going to do that because it's stupid. And, you know, just be disobedient. And I think we're on, we're so much on the right side of history and so much on the right side of advocating for people's health that I really think it's, you know, the media can kind of find ways to, you know, decimate what you're trying to say, but I do feel that we can't be shackled with these ridiculous ideas and policies, and we need to show some civil disobedience. And all my experience, when I think about, you know, Patty introduced me as being a part of harm reduction, but I was supportive of it, but none of them were my ideas. They were people that... went against uh policies and uh and went you know went outside and and did things that uh took some um some bravery and uh i think that's you know the position we're at so if we're given you know if the government gives us what are clearly kind of ridiculous guidelines of what we can say, I think we're in a good position to go outside of those guidelines and say what's right and let them try and come after you. But, I mean, people are in different positions. If I still wanted to get paid by the province of British Columbia, I probably wouldn't be quite as bold in saying that, but I'm not doing that. I'm not getting paid by them anymore, so I don't really care. And I think that this particular topic, we're so on the right side of history that I think that we need to not follow the rules.
75:11 - 75:14
[Carolyn Beaumont]
And maybe, oh, sorry.
75:14 - 75:19
[Paddy Costall]
Lady there, and I'm going to take one more. Thank you. And then ask the panel to wrap it up.
75:20 - 75:51
[Attendee]
Thank you for very interesting keynote speakers. And my question goes to Mark. And to save you time, I will just read from what I was thinking about. How can we reframe tobacco harm reduction into the human rights issues as me as well as you are working with the marginalized and addicted population in general who may not benefit from absent solely messaging? Thank you.
75:54 - 75:57
[Paddy Costall]
Just take one more and then I'll... Axel.
75:58 - 75:59
[Axel Klein]
Yes.
75:59 - 76:00
[Mark Tyndall]
Should I respond to that?
76:00 - 76:04
[Paddy Costall]
No. Take one more question and then I'll give you both a chance to wrap up.
76:04 - 77:02
[Axel Klein]
Okay. This is to Mark. Well, thank you very much for both presentations. And I really like the journey you took us on arriving from taking us to Nairobi. I just wanted to invite you to modify your argument because I think you're right in your analysis that there are systemic obstacles to achieving harm reduction. And when you mentioned this, we've been inviting people to say that If we allow condoms, if we distribute them, then we encourage sexual behavior. And I think that's quite false. I agree. Ditto for when it comes to injection sites. These are not incentives to young people to start using and injecting drugs. However, when it comes to vaping, I do think that there is perhaps something attractive about vapes. And I just wanted to invite your response on how we can modify that argument, because we need to really bring it further, and the rest of the parallels are really apt and apposite. Thank you.
77:04 - 80:12
[Mark Tyndall]
Okay, I'll answer that first. But I think that's a... When I planned my talk, I did think about that because it isn't quite as clear-cut with the other examples that I used. And clearly, vaping is attractive to kids, and they try things. And smoking's not attractive to kids anymore. So it's quite fascinating that the idea that if you see an adult smoker, the kids will turn the other way and go, well, that looks disgusting to me. But if they see somebody vaping, well, that looks kind of interesting and fun. I think that the approach should be how we deal with other things that we don't want kids getting a hold of. We're not that successful at alcohol and cannabis and these other things, but I think we You know, it's reasonable to have age restrictions and to talk to kids openly about it. I think we don't want to... The current way that these NGOs try to discourage kids from vaping with these kind of scare tactics and things I don't think work very well. But I think we need to have open conversations with kids about nicotine. And... I think they're gonna definitely try, you know, they're gonna try things and, you know, I think that it's just trying to differentiate the conversation between access for people who will benefit from this from a smoking point of view to trying to protect kids from it is really two separate discussions for me and we cannot, certainly can't, we focus 90% on the primary prevention in kids and I think we need to switch that around and focus 90% on people who can benefit from this technology and if they spend 10% talking about how we can help kids not get a hold of it. Could you perhaps answer the... Yeah, I mean, one of the things I learned quite a bit about when I did work with Jonathan Mann in my HIV work is human rights and health and human rights. And I think that's a very strong argument for safer nicotine products. It's people's right to... to have access to those things. It's a human right to do that. It's a human right to use substances. And even though we don't like them or think people should use them, people do use them. Nicotine itself is a legal substance. And if people want to use a flavoured nicotine or they want to smoke cigarettes or they want to use it vaping, I think that that's their right to do that. And as health professionals who are worried about people's health, then we should direct them to the safer and incentivize the safer selection of that. But I do think from a legal standpoint, definitely, we cannot have prohibition laws that tell people that want these substances, that they're banned, you cannot have them. That is against, that's a human rights violation to me, especially when people are trying to seek out something that could save their lives.
80:14 - 80:32
[Paddy Costall]
Just before we wrap up, we have actually had a question come in online. Unfortunately, it's on a screen a bit far away from me, and I can't see it. But it's a question about India. Could you read it out, Mark? And then perhaps both of you could address that as a final.
80:32 - 82:51
[Mark Tyndall]
You said consumers are seeking vapes, and therefore, THR is going strong. In a country like India, wherein diverse products are used, cigarettes, VDs, various smokeless tobacco products, how do you foresee THR to be a success if consumers don't prefer it? I think that's actually quite a good question. Well, I think India does present... You know, one thing when I've been writing the book, especially I tried to have kind of an international perspective. I think a lot of my perspective is in Canada. But I lived the last two years in Bali, Indonesia, actually, and so knew quite a bit about what's happening in Southeast Asia. And I looked at India. India obviously really stands out because... That's probably the biggest prohibition policy in the world and for such a massive population. And the WHO gave them an award for banning alternative nicotine products. But I still think they're... even though it's complicated because there's different forms of tobacco use there, I think that vaping, still there's a lot of cigarette use and it's a really, it should be an option for people. So I think, and maybe some of these other, other tobacco delivery systems that people have, that they could also be, vaping could also replace those. So I think, you know, that the other thing, somebody mentioned the all or nothing thing. There's so many people that could benefit from this. I don't think we should approach safer nicotine as we have to change the whole world. I mean, that's ultimately maybe what we'd aim for, but we can do such an amazing difference to people's lives if we even take a segment of people and get them to switch to safer products. There's so many people in India who use tobacco products that obviously that's millions of lives at stake if we can switch people from what they're doing to a safer product. So I think it is international, but each country does have its idiosyncrasies and how you'd have to introduce and approach these things.
82:52 - 83:04
[Paddy Costall]
We're coming to the end of our time because the tech team need to split this room for the next session. But I'll give each of you one minute, 60 seconds, to make any final comments that you'd like to make. Carolyn.
83:06 - 84:43
[Carolyn Beaumont]
Oh, 60 seconds, gosh. OK, so no easy solutions. It's so hard to know where to start. I think health professionals, as I've said, we need to get health professionals as engaged as possible and just to bypass media and politics in some ways because they're going to remain negative for so long. But health professionals are really interested. We really do want to save lives. We want to know. And just like Mark was saying, one-on-one, yeah, I can have a really productive conversation with anyone, health professional or otherwise. Give me five minutes with them. And yeah, they can really open up and be very interested in it. So that is just so key and I guess in the last 60 seconds, I suppose the issue though is the type of education that health professionals will respond to immediately will tend to be suspicious if we see education event about vaping products put on by the tobacco industry. But then unfortunately the reality is that no one else is really funding these things. The GP college doesn't want to fund some sort of education like this. The Pharmacy Guild don't want to. Who's going to really except for those with the bigger pockets? It's tricky, but gosh, we've got to really keep focusing on educating health professionals about THR. They get amazing reach to so many thousands of people every day. And then one day when the media and politicians come on board, that's great, but we could quietly have been doing our thing for a long time before that.
84:43 - 85:52
[Mark Tyndall]
Mark? Yeah, I mean, I think I'd like to leave the idea that there is some urgency to this. This is not something that... We've got so used to people smoking and dying that we're really kind of not in the urgent kind of space that we need to be, and this should really be approached as vaping and safer nicotine is a revolution, and we can really change... change the world if we let this happen, or got this to happen, that I think we need to get, and this is sort of what this conference is about, a kind of counter-revolutionary group of people to fight against this. I think banging our heads against a wall, trying to change people's minds who are entrenched in their tobacco control is pretty much a waste of our time, and we really need kind of a counter-group that can push back on this. We have history on our side, we have all millions of people who could benefit from this on our side, and I think that we really can make some very important changes.
85:53 - 86:21
[Paddy Costall]
Thank you. I think the aim now is to actually win over medical professionals one at a time and I think we've got two empirical evidence that we've already got two here. I'd like to thank Mark and Carolyn for their contributions and for all of you who asked questions and generally for all of you who have actually bothered to turn up here today. I think it's a really important session and we will now end it and I'd like you to show your appreciation for both the speakers. Thank you.
