The panel discussion, chaired by Professor Konstantinos Farsalinos, focused on perceptions of nicotine and harm reduction, highlighting significant misconceptions among healthcare professionals, regulators and public health community regarding nicotine’s association with smoking-related diseases, which are not compatible with current knowledge and science.
Professors Farsalinos, Giovanni Li Volti, Rohan Andrade Sequeira and the Chair of the consumer advocacy association New Nicotine Alliance Ireland, Damian Sweeney, also discussed the regulatory challenges THR faces, the role of consumers’ organizations in reversing the situation, science communication issues and the media influence on public perceptions.
Nicotine perceptions and Harm Reduction
Professor Giovanni Li Volti presented evidence suggesting that many healthcare professionals mistakenly associate nicotine with smoking-related diseases, stressing the need for better education on the topic, and argued that scientific literature often presents a skewed view of nicotine’s effects, which contributes to these misperceptions.
Journalists write their articles based on scientific literature they find on the internet, where there are many controversial publications, he explained. Many publications describe indirect effects of nicotine on possible risk of cardiovascular disease, for instance, such as increase in heart rate, and an increase in blood pressure. But according to two important papers published on top journals of the American Heart Association, Circulation and Stroke, nicotine is perfectly safe for cardiovascular disease, is not associated to recurrent stroke and is associated with cardiovascular safety. Unfortunately, according to a European survey, 80% of health professionals believe that nicotine is associated with smoking-related disease. This is the result of the failure of scientists to communicate and teach medical students what exactly the effect of nicotine is and which the toxic effect of combustible products is, Professor Li Volti said, and stressed the necessity of including nicotine in research protocols to accurately evaluate its safety compared to combustion products.
Within the literature you can find studies discussing harms of nicotine, Professor Farsalinos agreed, but these publications are mainly based on preclinical data, while clinical data fully reject such claims. There is a discrepancy between animal laboratory studies and human studies, but there’s no doubt that human evidence is much more valuable than any kind of laboratory evidence. There are studies showing that nicotine is toxic, and studies showing the opposite. But the truth is that when you look at the highest level of quality evidence, which is human epidemiological evidence, you will not find studies reporting an increase in the risk of cardiovascular disease or cancer for nicotine, and that’s why nicotine is not even a carcinogen.
Tobacco-related health issues and regulatory challenges in India
Professor Rohan Andrade Sequeira highlighted the alarming statistics regarding tobacco use in India, noting that 80% of users rely on smokeless tobacco, contributing to a high incidence of oral cancers. He pointed out the difficulties clinicians face in helping these patients, especially since the law does not allow them to prescribe alternatives. Globally, the success rate for nicotine replacement therapies is only 7%. That means out of 100 people who go on nicotine replacement therapies, only seven are successful. The other 93% go back to their old patterns of using tobacco, the speaker said.
The prevalent misconceptions among healthcare providers about nicotine complicates treatment efforts, Professor Sequeira said, and emphasized the need for evidence-based education for both practitioners and patients to promote safer alternatives.
THR is very important to break misconceptions, he said. Its scientific and evidence-based messages have to be put out to medical fraternities, and doctors, nurses, and caregivers should be made aware. But there are very few organizations which target medical doctors to help them understand THR. Because misconception sometimes is not a misconception, but propaganda. To fight this propaganda, we need THR and its scientific evidence-based evidence, Professor Sequeira concluded.
Unfortunately, government policy in India seems rather irrational, Professor Farsalinos commented. They have banned the importation and sales of snus, which is known from long-term human evidence that it does not cause any oropharyngeal cancer and it doesn’t increase the risk compared to not using any nicotine product; they have banned electronic cigarettes, although you couldn’t see vaping in the country, and at the same time they criminalized research on electronic cigarettes. All these actions resulted in an explosion of cigarette use and availability of illicit products which didn’t exist before. So, the government wanted to save the population from a non-existent problem, and they created the problem themselves, and now they pretend that they have banned it so that it doesn’t exist. And for all these actions, they received an award from the WHO, because it seems that the WHO awards those who follow their advice without looking at the outcome of such advice. “This is not public health,” Professor Farsalinos said, and gave the floor to Damian Sweeney.
Rise of misinformation in Ireland
Misinformation in Ireland and in the EU has ramped up massively from approximately 2019 onwards and unfortunately is spread through what we would call trusted sources, i.e., public health people, Damian Sweeney said. In Ireland, the Health Service Executive just recently posted a tweet to say that e-cigarettes and smoked tobacco are equally harmful. According to the results of the Healthy Ireland Survey, from about 2016 until 2019, Ireland saw a record decline in smoking prevalence, that was unprecedented. Smoking dropped from 23% to 17%, but from 2019, when misinformation ramped up, smoking prevalence is still 17%; so, it remains unchanged since.
Sweden is the proof of concept for THR, he continued. Sweden has overall nicotine use that is about the EU average; but because the majority of that nicotine use is through snus, they have half the levels of lung cancer among males compared to the EU, and the lowest rates of tobacco-related morbidity and mortality in the EU. Giving people who smoke an option to use a product that is much less harmful has quite a dramatic effect on public health, Mr Sweeny said.
The misconceptions and misperceptions about nicotine and low-risk alternatives need to be corrected through organized campaigns to inform consumers that there are alternative products which don’t cause cancer, don’t increase their risk of cardiovascular disease, and can vastly improve their health. “Frankly —the speaker concluded— misinformation about nicotine and low-risk alternatives to smoking is as deadly as smoking itself.”
Who is to blame for misperceptions about nicotine and THR?
Misconceptions about nicotine and THR are not a mistake of the journalists, since journalists are exposed to very diverse information and obviously, they’re not experts to understand what they should write and how they should approach this issue, Professor Farsalinos said.
The scientific community is more responsible than journalists: people who do experiments without been familiar with the scientific methods, and also reviewers that review articles without having the necessary knowledge, Professor Li Volti agreed.
The problem is not only the false methodology that some studies use, but also the fact that the misconceptions they include are disseminated fast through media, Professor Farsalinos said, and asked Professor Andrade Sequeira what the obligations are or the politicians’ accountability in creating and shaping such misperceptions in society.
“When you visit countries like India, where the bans are very strictly enforced and there is no alternative for people, Professor Sequeira said, you have to be very careful.” What works over there is scientific evidence and a very consistent effort of providing evidence-based scientific data to the point where they start realizing that maybe there is some sense in the information that you are trying to convey. Regulators and politicians create misconceptions in society, since in many cases journalists are not allowed to publish data that oppose the official line in the media. So, there are restrictions, but the underground work of supplying this information continues, Professor Sequeira replied.
That’s not only in India, globally there is no balance between supporters and opponents of harm reduction, Professor Farsalinos commented, and the weighting scale is very heavily leaning towards the opponents. They are stronger, they have more resources, more funding, and more access to the media. But it’s also a matter of human psychology. The human brain is programmed as an instinct to first and foremost avoid harm and pays a lot of attention to any negative message coming from the media, which gets very well stored in memory. So, a negative story, including negative stories about harm reduction, will be remembered for a longer period and will have a higher impact compared to, for example, discussing THR products being better than smoking. That means that the supporters of harm reduction need to be much more vocal to just have their message delivered.
The important role of consumers
The biggest problem is that when a smoker doesn’t know that the “reduced harm product” is less harmful, he or she will not even try it, will not even make an effort, Professor Farsalinos said and asked Mr. Sweeney his opinion about what could be done to reverse this situation and what could be the consumer organizations’ responsibilities or opportunities to address this problem among consumers, particularly among smokers.
The best thing consumers can do, Mr. Sweeney said, is to contact their elected representatives to tell them that these products help them and can improve their health. The problem is that, when it comes to public health in Ireland and tobacco control, they consider enforcing policies as one, and they don’t look at their results. It is very difficult to get the information out to consumers from what we call trusted sources, because the bottom line is that there’s no accountability of policymakers for their decisions. The lack of accountability in public policies is a huge problem that needs to be addressed.
As it concerns the dissemination of misconceptions, Mr. Sweeney said, New Nicotine Alliance Ireland receive calls if something extremely negative comes out in the media; so, our organization can put its arguments against whatever the “anti-everything brigade” has to say.
It’s very important to have access to the media because media are very influential, so many other countries should follow the example of Ireland and create a consumer organization that will be able to have a voice there, Professor Farsalinos commented.
Science communication and media influence on public perceptions
Another issue that needs to be addressed, which is related to science, Professor Farsalinos said, is the problem of science communication. Some studies may not have methodological issues or problems in reporting the data, but the interpretation and communication of data may be based on generalizations and provide incorrect or misleading information, the speaker explained.
Scientists have the responsibility to not create misconceptions to society in their effort to communicate their science, Professor Li Volti commented. There is a strong connection between scientists and media, and sometimes they both pursue attention.