Latin American experts share their experience on THR & relevant ethics & people’s rights issues

October 6, 2021

Experts from Brazil, Mexico, Ecuador and Colombia presented the current situation regarding tobacco harm reduction, ethics and people rights in Latin America, in a panel discussion held in collaboration with DIRETA & ATS and chaired by the specialized in addiction clinical psychologist Dr Monica Gorgulho, who also is a founding member of SCOHRE.

In Latin America, number of smokers is higher than in any other region of the world, Dr Gorgulho said, and one of the reasons for that could be the high number of young people that smoke in the region, which is estimated to be around 106 million tobacco users. In general, there has been an important decrease in the number of smokers, especially among men, but smoking-related morbidity and mortality continues to be a very important issue for health authorities. Around 70 million people are at risk for tobacco-related diseases and death. Looking at the high number of smokers and the consistently growing but still small number of electronic smoking devices’ users, we can understand there is a disagreement within the scientific community and a lack of clear government policies, Dr Gorgulho underlined.

Ms Zara Snapp started her speech, by introducing Instituto RIA of Mexico which focuses on harm reduction in the traditional sense, i.e. how possible risks of people using illegal or legal substances can be reduced; the Institute also examines how harms from some applied governmental policies can be reduced: for example, in Mexico only conventional cigarettes are allowed, consequently, many people are harmed by the prohibition of alternative choices and the lack of regulation. It is really contradictory, the panellist continued, that, although government is exploring the use of harm reduction for illegal drugs, its policy about legal drugs is just “quit or die”, despite the proven reduced risks of products such as heat-not-burn devices. It is worth mentioning, Ms Snapp pointed out, that there is total lack of participation of nicotine/tobacco users regarding the policies that affect them, while government exclusively focuses on possible underage use without considering the human rights of people who use nicotine. Health Secretary denies that there are fewer risks from non-combustion, the panellist said. In Mexico, current initiatives are to increase taxes, prohibit online sales and prohibit any flavours, since the government’s policy is only abstinence and does not include harm reduction. But if we want better results, Ms Snapp suggested, policy reforms must include providing high quality alternative products, heat-no-burn devices, cigarettes and vaporizers or even snuff. We need to commercialize products in specialized stores where harm reduction information can be provided to users, and of course educate doctors regarding alternatives, including patches, gum and therapy, the speaker concluded.

Mr Alexandro Lucian, president of DIRETA, a non-profit, non-governmental organization aimed to act as a centre of information for Tobacco Harm Reduction in Brazil, spoke about his personal experience as a heavy smoker and his numerous unsuccessful attempts to quit using all available help, including gum, patches and medicine, until he learned about e-cigarette and by using it he finally managed to stop smoking. Of course, since sale of these products was banned in Brazil, Mr Lucian confessed that he had to buy an illegal product, but it was a decision that saved his life. Surprised that he managed to quit smoking so easily, he started to study and created a website group to share his story and gather more information about tobacco harm reduction. Due to the huge interest for the project, the group turned over the years to a large network of knowledge and the speaker became a symbol of the fight to regulate vaping in Brazil. It is clear that Brazil is in the middle of a ‘war of agendas’, the speaker pointed out, and the interests of the consumers are the least of their priorities. Government, agencies and health organizations officers, he explained, don’t recognize that there are consumers who had their lives saved by vaping and so many other who could benefit from it. Of course, e-cigarettes are not safe and they are harmful for health, he added, however compared to the conventional cigarettes are far less harmful, and the recommendation for switching to the less harmful choice to people who are not able to quit is good for public health. Prohibition is ineffective and results to the sale of many of these products in illegal markets without any quality control and, even worse, without information about their risks, Mr Lucien concluded.

Next speaker, Professor Enrique Teran from Ecuador, spoke about the ethical aspects that should be taken into consideration by the medical community regarding harm reduction, pointing out that yearly more than 7 million deaths are directly related to tobacco consumption. Countries of Latin America present big differences in the prevalence of tobacco consumption, Prof. Teran said, and one of the reasons is that unfortunately, although there is a worldwide decrease in cigarette consumption, the regulation and actions related to tobacco control have been losing ground concerning the commercialization and consumption of illegal tobacco. That is an issue of high concern, he underlined, not only because tobacco is harmful, but also because illegal tobacco market promotes child labour, unformal work, and drug trafficking, exposing particularly children and minors to tobacco consumption and illegal drugs. Another important point, Prof. Teran added, is the refusal from several organisations including WHO, to openly discuss the use of alternatives to cigarettes that, although they are not free of risk, they significantly reduce it, and are now widely used, based on the concept of harm reduction. Of course, it is crucial to put all kind of efforts to smoking cessation and preventing new smokers, especially young people―he said―but we have also to do something for those who are already smokers. Just the suggestion to stop smoking is not the solution, he pointed out; smokers need to be supported, since we know that nicotine is addictive and stopping its use is not easy. Reduced harm products, Prof. Teran concluded, offer to smokers the opportunity to gradually reduce nicotine consumption and to finally quit smoking.

The fourth panellist, Ms Maria Alejandra Medina from Colombia, focused on the importance of the participation of nicotine users in national and international decision-making that affects them, as one of their fundamental rights. A human rights approach responds to our comprehensive and differential attention to the specific needs of each population group, Ms Medina emphasized. Therefore, smokers and nicotine users’ rights include the right to enjoy the highest attainable standard of health, the right to freedom of thought, expression and access to information, the right to benefit from scientific progress and its applications and, finally, the right for free development of personality, she explained. In addition, children and adolescents have the right to prevention and protection; to receive accurate and objective information about drugs such as nicotine and its related harms and to be protected from harmful misinformation. Governments should facilitate the participation of nicotine users to the planning, implementing and evaluating nicotine use regulation, as it leads to better and more optimal regulatory and public policy outcomes, Ms Medina pointed out. Harm reduction encourages dialogue, consultation and open debate, she said, and people should be at the core of decisions about their health. The goal of “Nicotine and Harm Reduction” Platform, which was created as a project of ATS in 2020, is to introduce the approach of risk and harm reduction in nicotine consumption and make visible and enforceable the adult nicotine users rights; the Platform also demands the differentiated regulation of reduced risk alternatives, such as heated tobacco products e-cigarettes and others. Concluding, Ms Medina said that, although in Colombia electronic nicotine delivering devices are not regulated and so far nicotine users’ participation in decision-making is very restricted and not very effective, it is promising that today there are two bills being discussed concerning the regulation of alternative nicotine delivering products in the framework of tobacco control policy.

The situation in Latin America regarding tobacco legislation is more complicated compared to other parts of the world because we have an informal way of dealing with the existed legal policies, Dr Gorgulho said, asking the panellists to summarise the situation and the difficulties in their countries.

In Mexico, we are trying to create pressure from people who use these products and are requesting their regulation, Ms Snapp said. So, on one hand, we are trying to organize consumers and provide them with evidence-based arguments, she explained, and on the other hand, we are trying to reach out to government officials and seek for chances to open the discussion and make them understand that current policy is not promoting public health.

E-cigarettes and other nicotine delivering products are been used mainly by adult smokers, Mr Lucian said, and the people who are defending these products are the users, because they know how they have helped them improving their health and lives. Unfortunately, consumers are never listened to when related decisions and policies are discussed, the panellist added, and DIRETA is trying to change that and give voice to those consumers.