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In the months following the position paper published by The Union, titled Why Bans Are Best, VIDA News has been dedicating both time and resources to panel discussions with leading experts around the world on the tobacco industry and its relation to harm-reduction products. 

This roundtable discussion centers its focus on Africa, one of the LMICs targeted by the bans against safer nicotine products, with Senior Correspondent Dom Garrett, Joel Sawa, and Dr. Kgosi Letlape.

Sawa is a Tobacco Harm-Reduction Uganda Activist, as well as a Knowledge Action Change Scholar Recipient, who not unlike others in the field, has encountered many challenges in attempting to reframe how LMIC consumers view harm-reduction products – especially in Africa.

“It’s perceived to be more of a danger than of any good,” he says. “So, the challenge is to demystify the understanding of what tobacco harm-reduction is.”

One of his goals is to help people understand that they have choices instead of what Sawa calls the “quit or die option.”

Sawa is joined in this discussion by Dr. Kgosi Letlape, MD, Cofounder of Africa Harm Reduction Alliance (AHRA), former President of the World Medical Association, and a private practice ophthalmologist. 

Dr. Kgosi describes his tobacco harm-reduction industry journey as beginning at the World Medical Association with the patient alliance when his perspective started to shift. He began viewing his work through his patients’ perspective, removing any personal opinions from the situation.

“Whatever our (doctor) views are, there’s a user on the other side who would be looking for information and for things that could improve their health,” says Dr. Kgosi. “It’s how I’ve come to harm-reduction.”

He stresses that his work in harm-reduction is not tobacco-specific, that he has been involved with the food industry, HIV and Aids, and hygiene. 

“It’s the reduction of harm, and improvement of health, and moving away from the do or die concept,” he states. “People need to be provided with alternatives so that they can make informed choices.”

Senior Correspondent Dom Garrett steps in to echo in Dr. Kgosi’s sentiment, adding, “Its part of the mission that we want people to understand is that tobacco harm-reduction is part of the overall family of harm-reduction.” Emphasis is placed on the ability of those most affected by these issues to be given the option to choose.

“I’m a medical doctor, and in our training, we sometimes kind of get a God complex, where we want to tell people what to use,” says Dr. Kgosi. “We know what’s right for people.”

As someone who has been in private practice for more than three decades, he’s come to understand his role as a health advisor above anything else.

“I’m an advocate for the patient,” he states. “I’ll provide them with information that will enable them to make informed decisions about their lives.”

His approach to his role as a health advisor began as he worked with and advised patients with HIV. 

“And what I’ve learned was instead of coming to them with the notion of wanting to do something for them, it became important to ask, “How can I help you?”

This was how he grew into being labeled as an advocate and an activist above all else. He began to understand the importance of his patients speaking for themselves instead of telling them what to do.

“You listen to them; you hear what their problems are, what their challenges are, you then advocate on their behalf, become an activist for their own benefit.” 

Sawa agrees with the notion of giving people the right to choose what alternative is best for each individual. In his work with the Africa Tobacco-Free Alliance (ATFA), he noticed an urge to push people off tobacco by force. He tried to approach each situation from the view of the individual and their experience, rather than focusing on the policies. 

The ban on safer nicotine alternatives has been a cause of contention in LMICs. Sawa stresses the importance of these products being viewed positively by the government, producing less harm while simultaneously giving people access to options.

“It’s really hard to tell where the mind of people pushing such policies are,” Sawa says. “They need to come down to the individuals who are actually using this because that would help, that would put more perspective on the matter.”

Dr. Kgosi agrees and goes on to explain the challenges behind people who want products banned. 

“The biggest drivers are two things: fear and ignorance,” he states. “People are fearful, but they are also not informed.”

In addition to fear and ignorance, Dr. Kgosi believes these issues are compounded by the fact that people have made careers from being anti-smoking. 

“And when you have something that is a technological revolution that comes up, it’s a threat to their world view.”

He recalls an address he gave seven years ago regarding addiction and spoke of three different addicts. “The first addict being the industry that are addicted to the products, the government that are addicted to the taxes, and the smokers that are addicted to the nicotine.” 

Dr. Kgosi continues by stressing the importance of being open and honest in all discussions of these issues. “That is why people tend to go to prohibition because it was part of the empowering concept of dealing with tobacco,” he says.

“What people have not taken into account is that today we are not in the position we were in twenty years ago when you spoke about nicotine and tobacco. Beyond nicotine replacement therapies, there were no other alternatives on the table. We are now in a totally different position where there are other alternatives.”

The impact these alternatives could have, particularly in LMICs, is tremendous.

“The research shows that right now, there are over six million people dying annually because of cigarette smoking and tobacco use-related effects,” according to Sawa. “However, it’s projected that by the year 2032, it will be over eight million…that over 80% of this will be coming from low and middle-income countries.”

He recommends that these countries need to reach a point of acceptance with tobacco harm-reduction products and make it accessible to the user.

“Don’t make it an evil,” Sawa says, “but rather accommodate it, encourage it.”

The conversation shifts to the Framework Convention on Tobacco Control (FCTC) and the outdated recommendations within it.

“The FCTC is a good framework,” states Dr. Kgosi. “It’s an essential framework, but it has to be amended to be appropriate for the times.” An opinion similar to that of Dr. Desai during the panel discussion aired on India just weeks ago.

Both panelists agreed that while the framework is necessary, at the time, it was written, the availability of harm-reduction products was minimal and technology wasn’t nearly as advanced as it is now. 

This is also why Sawa views The Union paper’s stance, “Why Bans Are Best,” ridiculous. 

“Things are changing rapidly; we need to go with the times,” he says. 

One of the commonalities expressed by both panel participants is involving more people and engaging in an open dialogue regarding these policies and bans on safer nicotine alternatives.

Much of the frustration lies in the fact that there is no distinction between combustible cigarettes and harm-reduction products regarding these bans. 

“They want everything that gives us nicotine treated the same way as tobacco is treated,” states Dr. Kgosi. “And we hope we will engage and educate about the fact that there’s a different product, they have different degrees of harm, and you need to look at them with different lenses.”

The proof is in the evidence, according to Dr. Kgosi. And that there needs to be an acceptance of the “overwhelming evidence that the greatest problems associated with tobacco is if you get your nicotine through combustion.”

Garrett chimes in and adds that media coverage focuses too much on potential harm rather than relative harm concerning combustible cigarettes.

COVID-19 has presented even more significant problems for these already detrimental issues. Sawa speaks of the heightened border security during the pandemic, with the few products that enter Uganda’s borders being subjected to increased scrutiny. These locked borders make it even harder to access safer alternatives.

“As far as I know, in my research and the people I’ve engaged, as well as information that I have,” says Sawa, “you would find that there was more cigarette use in this period and people kind of went back to cigarette use in order to be able to access nicotine.”

The result of having to use more harmful substances, as opposed to safer alternatives, illustrates the ludicrous effects of these bans amid a pandemic.

Dr. Kgosi refers to the medical community’s approach to dealing with former heroin addicts, with the treatment of methadone, something less harmful than heroin. He doesn’t understand why the same principles cannot be applied to the tobacco and harm-reduction industry.

“We have an ethical obligation to inform ourselves and to be able to inform our patients so they can make informed choices,” he says.

About his comment at the beginning of this panel discussion on many medical doctors’ having a God complex, Dr. Kgosi concludes by saying:

“It’s not our duty to act like pastors, I’m not your divine leader, I’m just a healthcare professional to assist you, and I have an ethical obligation to give you all the information that is available so that you can make an informed choice.”

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