Responsible for the development of the National Health Policy in his native Pakistan, Dr. Ehsan Latif, now based in Scotland, has a long career on the boards of various public health entities and international groups in the field of lung health and tobacco control established under the Framework Convention for Tobacco Control and the World Health Organization including The Framework Convention Alliance, the Non-Communicable Disease Alliance, and most recently (2009-2017) he was senior advisor for noncommunicable diseases and director of tobacco control at the International Union Against Tuberculosis and Lung Diseases.
Calmly and lucidly, Dr. Latif who is currently Vice President and responsible for grant management and stakeholder engagement at the Foundation for a Smoke-Free World (FSFW), spoke with the Editor of The Vaping Today about the current role of the WHO, the status quo of the Framework Convention, the upcoming COP9 and the challenges of harm reduction in the immediate future.
Vaping Today: The objective of the FCTC is to protect present and future generations from the harmful health, and social, environmental, and economic consequences of tobacco consumption and exposure to tobacco smoke. What effective progress has the Framework Convention achieved during its existence?
Dr. Ehsan Latif: I am a physician by training and have been involved in tobacco control for the past 20 years, i.e., since the start of the FCTC negotiations. My involvement as a tobacco control advocate started with attending and providing input to the negotiation meetings in Geneva organized by the WHO. I have a long relationship with policymaking, and implementation of cohesive strategies to achieve public health gains by linking global priorities related to tobacco use to needs on the ground.
For me, the most important thing that FCTC did was to bring tobacco use in all forms onto the political agenda and highlight the need to reduce the burden of tobacco attributable deaths and diseases globally, especially in LMICs where 80% of the world’s 1.1 billion smokers live. It also – both as an explicit goal and a major achievement – brought countries together and galvanized political will for its implementation. The existence of the treaty in itself, which was built on consensus, represents a major international achievement.
We must remember that this treaty was negotiated almost 20 years ago, and is based on the information and research available at that time. A lot has changed since then. The evidence base has continued to grow. Disruptive technologies are available to end combustion and substantially reduce the risks associated with smoking by decoupling nicotine from the lethal smoke. We know more about smokers’ behaviors and needs, as well as the potential for innovative solutions to reduce the harms of using tobacco and support users on the road to cessation.
Unfortunately, since then, WHO and the FCTC-Secretariat, including the major funders, have not kept up with the science and technological advances in this field. In addition, misconceptions around nicotine are emboldening some key decision-makers to ban reduced-risk products and are slowing down innovation.
After initial successes, the FCTC ultimately has not led to a substantial decline in the number of people smoking combustible cigarettes worldwide. WHO continues to report on the successes; yet it is clear that countries, especially LMICs, will not achieve their goals and targets under NCDs and the SDGs if the status quo is maintained.
The reality for me is that the vision of the FCTC has not really materialized mainly due to the lack of support for LMICs, lack of support for smokers to quit, and complete neglect of technological innovations in shape of availability of safer nicotine delivery systems that can assist smokers to quit or switch from more harmful forms of tobacco use based on their preferences.
Vaping Today: A relevant factor is that about 80% of the more than one billion smokers in the world live in low- and middle-income countries. What specific benefits and actions have the FCTC presented to these countries?
Dr. Ehsan Latif: WHO, with the support of its funders, developed a set of demand reduction measures referred to as MPOWER. Though progress has been made across some of these areas, in some countries, there is a global need to do far more to bring down death and disease rates linked to tobacco use – especially in LMICs.
Even with a narrow, trimmed down focus, the support for smokers to quit – the ‘O’ in MPOWER – has been largely neglected. We know that providing access to, and encouraging the use of, effective cessation interventions greatly increase the likelihood of quitting yet, as of 2018, only 6 middle- and one low-income countries offered comprehensive cessation support.
Lack of financial resources is largely cited as a key barrier to full implementation, yet there is no clear estimate of the amount needed to achieve this. At the same time, Governments continue to raise taxes on cigarettes, with very few allocating the additional revenue to support smokers – the very people paying these taxes – to quit or switch to safer nicotine products. This general lack of consideration for current users is further highlighted by the fact that, if and when they fall sick, it is oftentimes the user who must bear the majority of healthcare costs as out-of-pocket expenses. This again disproportionately affects LMICs.
Furthermore, the range of tobacco cessation intervention types recommended by WHO and the FCTC – including both behavioral and pharmacological – vary in terms of cost, intensity, and effectiveness. In LMICs, the availability of pharmacotherapy cessation interventions, including Nicotine Replacement Therapy (NRT), is especially limited. Even where it is available, the success rates for NRT are low. While the evidence grows about the substantial benefits of tobacco harm reduction, all governments, including in low- and middle-income countries, need to start looking at how they can help smokers with new and innovative technologies and methods.
To give you an example of my own limited focus at the start of my work for tobacco control, journalists would ask me where smokers would go once indoor spaces were declared smoke-free given the sub-zero temperatures in some countries. They should go outside to smoke’ was my standard answer, which I now realize was very inadequate. In all smoke-free work, I now recognize that any measures implemented should be delivered in unison with reliable information on quitting, where to seek help, and the options available to support users on their journey.
We should always remember that the reality that some smokers do not want to give up nicotine at all. We know that nicotine does not cause cancer; it does not kill, rather it is the tar that kills. For the defense of that autonomy, we also have to support them with the provision of devices and opportunities where they can have access to clean nicotine i.e., without tar. Coming from tobacco control and with my history as a doctor, I didn’t realize how important it was to give those smokers all the support possible and available.
Vaping Today: The COP is funded by the Parties, right? That is, with public money. So, despite the collective interest in the subject and the fact that its decisions impact millions of lives around the world, the meetings are held in secret, without the participation of many social actors related to the subject, such as industry, science, and technology, and the consumers themselves are excluded from observation and dialogue: Why? Why the rejection of the participation of contradictory views and social participation?
Dr. Ehsan Latif: During the negotiation phase, observers were allowed to attend the meetings. They would come to observe the proceedings, what their country representatives were saying, and hear what was really going on in the negotiations or COP meetings at large. Journalists would report the proceedings in an unbiased manner and others would note the tone of the negotiations. This type of observation is necessary to keep the governments and representatives of the countries true to their promises.
But from being very open and inclusive, where even the tobacco industry representatives attended as observers, WHO and the FCTC secretariat have unfortunately become very, very closed. The meetings today are exclusive to hand-picked observers and NGOs.
Indeed, the minutes of the meetings are made available; however, these do not tend to reflect the environment and tone. The entire process would certainly benefit from media presence, i.e., to do accurate and holistic reporting of proceedings, and to clearly communicate these outcomes to the public. While the need for some closed sessions is clear and understandable, to completely exclude the media and stakeholders from COP entirely, except for a few hand-picked delegates, is something I fail to understand.
It could be argued that the industry has an inherent conflict of interest due to Article 5.3. But what about e-cigarette manufacturers? They are not cigarette manufacturers. They do not produce combustible tobacco products.
Another aspect or the question is, will Article 5.3 still apply to the industry now that their THR products are deemed fit for public health as in the recent announcements by US FDA? What about state monopolies who form part of country delegations to FCTC meetings – COPs. Do they come under Article 5.3?
Vaping Today: So, Dr. Ehsan, why did the FCTC/COP, which deals with a public health and sociocultural issue so relevant, and which affects the lives of so many people, become this monolithic and exclusive entity?
Dr. Ehsan Latif: This is a good question. We would hope that an international treaty and its related processes would be more open and receptive to inclusive participation, new science and evidence, and innovative technologies that clearly have the potential to support it in reaching its objectives.
For example, the Conference of the Parties 26 on Climate Change will bring together journalists, activists, NGOs, and other stakeholders to accelerate action towards the goals of the Paris Agreements and the UNFCCC. Can you imagine this COP without the participation of stakeholders including industry to get environmental policies to accepted scientific standards? No, it would not be possible.
Similarly, a decrease in the consumption of combustible tobacco cannot be imagined without the participation of stakeholders – including industry. So why can’t FCTC be as inclusive and bring together all stakeholders to jointly consider the collaborative need to end smoking in this generation?
We face the same old questions time and again: where should smokers go to seek help to quit or switch if their country under the recommendation of WHO and major philanthropies has already banned alternatives? Who is going to support them? What alternatives do you have so that their needs are considered?
Frankly, and unfortunately, the answer is that most countries are not doing enough to move forward and have taken the easier route of continuing with last century methods showing an inability to change with time. While we see more evidence emerge on the potential public health benefits of tobacco harm reduction, this is yet to be moved into action.
Vaping Today: Can we say that are exceptional circumstances that require private and secret meetings?
Dr. Ehsan Latif: Countries have legal autonomies, they have their own constitutional limitations and scope, they need to operate under these. They can discuss their laws and their approach in closed meetings. So yes, it can be understood that this is done behind closed doors. But making all meetings and negotiations and development of plans for the future closed is not the right way to go.
But when you talk to the very people who use nicotine, they need to be present in some way. They need to see what is being said, how are they being represented in these meetings. And if you don’t include them, or make efforts to exclude them, that is where the trust is broken. Most of the advances in science are coming from the private sector including the tobacco industry. WHO needs to consider these developments and not shun these under the extended interpretation of FCTC Article 5.3
Vaping Today: Within the same umbrella of the UN paradigm, the COP on Climate Change goes in the opposite direction. What are the reasons for this disparity and dissimilarity between equivalent bodies? (in its 21st edition, which took place in 2015, in Paris, thousands of journalists, NGOs, the public, and even industry and agents from the business world were accredited and were able to participate and debate. Even in a space called “Climate Generations Area”, civil society was able to demonstrate, express their opinions, engage in conversations, debate, protest, and even aspire to influence the delegations of the Parties that officially participated in the Conference).
Dr. Ehsan Latif: I believe it is WHOs duty to act as an unbiased, evidence-based, independent organization representing the interests of all 192 Member States. To deliver on its Mission, it must be a plural body that considers all science and opinion, regardless of its source, to reach an impartial decision that truly reaffirms the right of all people to the highest standard of health. WHO should not be seen to represent only international donors or philanthropic organizations it works with.
Yes, it is true that I would expect an international UN agency to serve all member states in a democratic way. They now have another chance to see what some of the countries are doing and what they like or work for. So why are they still disregarding the efforts happening in the UK or the developments is US given the recent FDA announcements?
Everything we do in public health is related to human rights. Every constitution in the country notes health as a basic human right. We cannot go against that. And it’s up to WHO to safeguard it. And if not, it goes against the basic principles of the United Nations system. And this safeguard must be intensified.
Everyone has the right to choose. And each smoker or user of tobacco needs to choose what is best for them. Smokers should not be directed by a single path which currently is either quit or die, when there are other possibilities available, they need to know all the options available to them and to make a well-informed decision about their health and use of nicotine-containing products.
Vaping Today: Should we be suspicious of the aims of the WHO/FCTC with regard to the problem of smoking?
Dr. Ehsan Latif: Suspicion is a strong word. What I would say is that we must be careful. We need to look at where WHO is going and at each step point out what it is doing right and what it is doing wrong. We need to see and comment on reports and positions taken up by WHO and its experts and make sure these are unbiased and reflect the best science available at any given point in time. This also includes drawing on examples of successful THR and cessation approaches, including where relevant the development of best-practice recommendations.
Needless to say, these reports and positions cannot and should not be influenced by major donors. We need to see more evidence of WHO and its expert committees acting both transparently and independently.
To these ends, WHO and FCTC Secretariat is not doing enough. It must do more. With growing evidence, there is also growing potential. For example, there is a lot of space in the FCTC documents that can be interpreted as support for smokers and support for tobacco harm reduction approaches. Yet, there is little movement into bold recommendations and action.
You and I, and all of us who work on harm reduction and cessation, and support safer options for smokers, must continue to say that.
Vaping Today: And how do you see the near future of the subject? What could the post-COP9 world look like?
Dr. Ehsan Latif: You cannot stop the advances in technology in the shape of safer nicotine delivery systems that have already helped millions of people around the world. You also cannot ignore the growing evidence base regarding their potential to reduce tobacco-related harms and/or help adults to quit smoking.
I would consider these safer nicotine delivery systems as game changers that will break the status quo of tobacco control efforts. WHO and some funders of tobacco control may hide from this reality for a while, but there is hope that the Member States are going to wake up to this need, and see the examples of other countries that are succeeding in reducing tobacco harms with new technologies.
In the immediate future, we may see WHO continuing to resist change, but it has to change. WHO and FCTC Secretariat cannot sustain their current position on SNPs. I am sure that WHO does not want to be in that position and keeps ignoring the latest science and facts. WHO should consider both sides of the argument and then make a decision based on what the Member States need and not direct them to consider only one direction of banning SNPs or to prohibit these from being available to the people who need them the most.
Vaping Today: Could the UK contribute to that perspective?
Dr. Ehsan Latif: The UK – a country now no longer bound by the EU’s tobacco product Directive – with its policies conducive to tobacco harm reduction has the greatest opportunity at COP9 to set a strong and concrete example and lead the efforts. The UK through its international development programs also has a huge potential for providing resources for LMICs to adapt similar policies to reduce the tobacco use burden in their countries.
We must work collaboratively and have a more pragmatic perspective to advance science, technology, and public health. Together, we can do much more.
Vaping Today: You are in Scotland… and in addressing the issue of smoking, we see the United Kingdom and the United States at opposite poles. While the United Kingdom distributes electronic cigarettes in public hospitals, the United States seeks to ban flavors and curb consumption, almost creating panic or aversion to this alternative to smoking encouraged in the United Kingdom. If it is the same problem, in your view, what are the reasons for such different approaches and positions?
Dr. Ehsan Latif: FCTC treaty text defines ‘tobacco products’ as ‘products entirely or partly made of the leaf tobacco as raw material which is manufactured to be used for smoking, sucking, chewing or snuffing. Especially as nicotine can be manufactured without using a tobacco plant, a key challenge – and opportunity – is the lack of standard definition for nicotine and products such as electronic cigarettes using nicotine.
The way different countries classify nicotine leads to how they approach its regulation. This would be one key reason. For example, some countries classify it as a ‘poison’ and regulate it under their pharmaceutical regulations, and others as a tobacco product and want to place it under their current tobacco control acts. Indeed, an added complexity comes from each country’s tobacco control laws and their constitutional requirements.
Harm reduction is mentioned in the FCTC text but is not defined and elaborated upon. This is what the WHO should do. They need to look at the FCTC text and see where amendments or elaborations are needed to make it clear and relevant to current knowledge and technological innovations.
To avoid taking on this challenge, it is easier to recommend banning all safer nicotine products. This approach is simply not acceptable. WHO should bring all stakeholders including the private sector and industry – and not only its preferred partners’ – on one platform to discuss nicotine and its usage, and formulate next steps to be presented to COP10 for countries to debate upon and approve if found suitable. The time between COP9 in November 2021 and COP10 in 2023 provides ample opportunity to do this.
Vaping Today: In some circumstances, narratives are superior to didactic arguments; and that occurs in the universe of tobacco, and even more specifically in the scientific field, with the process of demonizing nicotine. In your opinion, why is nicotine so demonized?
Dr. Ehsan Latif: The main reason in my opinion is because people don’t understand it. Doctors even in this day and age of information and knowledge believe that nicotine causes cancer. Without correct understanding, acceptance will be difficult. And if the major world agencies do nothing to dispel that misinformation or misconception about the product or the molecule, then they become a party to these failings.
Doctors are the most trusted community in our daily lives and their influence is far-reaching. Imagine what happens if you go to a doctor and ask them what nicotine is, and the Dr comes back and says it is a cancer-causing agent? The choice again becomes quit or die.
Vaping Today: I’m already thanking you for the time you’ve dedicated to us. To close, could you talk a little about the short and medium-term goals or next steps of the Foundation?
Dr. Ehsan Latif: Our initial three-year Strategy 2019-21 is coming to an end. This phase saw the creation of partnerships, the mapping and addressing of critical gaps in knowledge and science, and outreach to vulnerable populations and communities.
Today, Foundation has a diverse range of active partners and collaborators working with us around the world. In the next three years, we will be building on these partnerships and working together to strengthen capacity on the ground. We will continue to assess and provide resources to fill the gaps in our knowledge and understanding of THR and cessation, and focus on dissemination through publishing in major scientific journals. An important aspect will be doing focussed work and outreach and work in low- and middle-income countries.
A clear and comprehensive plan and strategy can be expected by the beginning of next year.Please do visit our website, https://www.smokefreeworld.org, where you will be able to access our reports, resources available for LMICs to conduct research and a whole lot of information on THR and Cessation.
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