Rendez-vous #17 with Roberto Sussman.
Roberto is President of ProVapeo Mexico, a consumer association defending in Mexico the right to access "products that provide nicotine without combustion".
Thank you Roberto for accepting our rendez-vous.
Can you please introduce yourself by telling us a bit about yourself and when/how/why you got involved in Pro Vapeo Mexico?
Roberto Sussman: Three years ago I started vaping regularly.
I was a pipe/cigar smoker (I puffed without lung inhalation) so I didn't do it for health reasons but for practical convenience (no matches, no ash, no secondhand smoke, many flavors, no irritation in my throat, etc).
In a few months, I was vaping regularly every day and enjoying it a lot, smoking only a pipe or a cigar every 2-3 days. I started to become interested in the science of vaping. I am a professional physicist, so I have the training to critically assess the literature, more so because the evaluation of e-cigarettes involves a lot of knowledge that is not medical (analytic chemistry, physics, and chemistry of aerosols, statistics).
While I was aware that medical and public health institutions like the RCP and PHE were endorsing vaping within a Tobacco Harm Reduction strategy, I also noticed the existence of vast amounts of politically and ideologically motivated junk science in the anti-vaping and anti-THR literature. I was outraged to see this junk filtering into Mexico, where I live.
Some Bloomberg/CTFK funded NGO’s and health authorities in Mexico started to mount an insidious and organized misinformation campaign, so I decided to act. Vaping associations in Mexico dealt only with consumers exchanging info on mods, liquids, resistance, on sales and bargains, all discussed in social networks. Nobody was providing info systematically or responding to the misinformation campaign. Thus, myself (physicist) and three vapers (two lawyers and an architect) decided in January 2018 to create an ‘only consumer’ non-profit association with the specific aim to advocate for vaping and to spread scientific information. This was the birth of Pro-Vapeo Mexico, which was admitted as an active member of INNCO.
Q1. My first digital encounter with you was in August 2018, on the Nicotine Policy Group created by Clive Bates (thank you so much Clive for this great tool), when you protested about an anti-vaping video clip broadcasted by the Mexican Health Ministry. Can you tell us about this video and the position of the health community in Mexico about e-cigs and other non-combustibles?
Roberto Sussman: In spite of the misinformation campaign, vaping is booming in Mexico, even if sales, marketing, and advertising are illegal (usage is legal). Anti-smoking groups are paying much more attention to vaping than to smoking. They have tried over the years to pass several anti-vaping law initiatives, all of which failed to pass (more on this further ahead).
A very important election took place in 2018 in which an anti-establishment presidential candidate won a landslide victory. Anti-vaping Bloomberg/CTFK groups had crafted over the years a full alliance with the outgoing health authorities (strongly influenced by the WHO) that are still in office until December.
This broad anti-vaping alignment has become desperate. They are now raising the pitch and trying a last minute institutional attack on vaping, turning the ongoing misinformation campaign into an ugly fear mongering propaganda war. The aim is no longer to exaggerate harms and risks, but simply to use official government mass media (radio and TV) to broadcast lies, fear and disgust towards vaping and vapers: the message is that “vapor produces cancer and heart disease in bystanders, it is merely a Big Tobacco plot to make our children nicotine addicts and it is worse than smoking”.
This obnoxious video clip is the main example, as it is directly sponsored by the Health Ministry. Opposition to THR is part and parcel of the dirt and corruption of the outgoing administration (plus the abject failure of health authorities to curb smoking: prevalence passed from 17.0% in 2011 to 17.6% in 2016).
The lady narrating the video is a psychologist in charge of a smoking cessation clinic in a major public hospital, yet she is also (or was at least two months ago) employed by a private clinic to provide smoking cessation therapies to the cost of 1500 US dollars for a 7 day treatment, a huge amount for most Mexicans (a nasty conflict of interest). We cannot stop this video broadcasting (and other media fear-mongering pieces). We have seen that the more educated and urban sectors regard this video as a piece of disgusting propaganda spread by a corrupt government to protect vested interests, however, unfortunately, for millions of lower-income, less educated folks this propaganda is the only thing they have heard about vaping.
Hopefully, one day these anti-vaping groups and their allied corrupt health bureaucracy will be held accountable for this Goebells level propaganda having denied or blocked access to lower risk products to millions of low-income smokers in Mexico.
Q2. In the presentation (10 minutes) you gave to the 2018 Global Forum on Nicotine, you explain the legal situation in Mexico that is a bit complicated because the existing law regulating tobacco products should not apply (as it is written) to alternative nicotine delivery products but the present administration is still trying to prohibit or very much restrict their commercialization. How do you assess the situation now and do you hope for positive changes with the next government? Any hints where they stand on the issues?
Roberto Sussman: The political forces in the outgoing parliament were very fragmented. Thus, many law initiatives (on many issues) were torpedoed because of the inter-party rivalry. This situation partly explains why anti-vaping and pro-vaping initiatives failed. Part of the problem was the obstination of the regulatory agency (COFEPRIS) to refuse to consider any approach except strict regulation of all non-combustible products (including e-cigarettes) as combustible products. They simply follow the doctrine of the WHO. Since they cannot prohibit usage, they want to stigmatize it by conflating vaping with smoking.
The new authorities are a mystery. We are trying to approach them, but we are just a small NGO, whereas anti-vaping forces have professional lobbyists and most of the leaders of official bureaucratic medicine behind. The new legislators and a lot of MD’s (the ones that see patients) and common citizens are completely ignorant about THR, so it is very likely that this vacuum of knowledge and experience could be filled by this lobbying effort, together with the false warning that Mexico must strictly follow the WHO agenda (because it signed the FCTC).
The odds are very much against our effort to regulate non-combustibles as a separate category from combustibles. It is very likely that the anti-vaping lobby will triumph and all non-combustibles will be regulated in 2019 under a modified version of the current Federal Tobacco Control Law, which was drafted in 2008 along the dictates of the FCTC.
This law is completely inadequate to regulate e-cigarettes, so it might have lots of loopholes and regulatory uncertainties and vacuums, all of which will justify winnable habeas corpus trials. The effort Pro-Vapeo Mexico has invested in advocating for THR will then pay off, since it is not outlandish to conceive that some judges may concede in the future that (i) non-combustible products can contribute to public health improvement (by virtue of being much safer than smoking) and (ii) the convincing of the political class was achieved not by superior science, but by an aggressive lobbying campaign protecting vested interests and a conservative reaction to a disruptive technology.
Q3. Can you estimate how many people presently use e-cigarettes in Mexico and who they are? Are there official data? Is there a significant number of young consumers? under 18?
Roberto Sussman: The government conducted in 2016 a large nation-wide poll: the ENCODAT 2016-2017 (results are summarized on our website and INNCO website).
Extrapolation of the sample of more than 57 thousand subjects aged 12-65 yields about 5 million Mexicans having tried e-cigarettes, 975 thousand “current users”.
Of these figures 938 thousand were underaged (12-17 years old) triers and 160 thousand “current users”. However, the “current user” category in the final report does not distinguish between daily and “some days” usage, but the raw data does distinguish.
We looked at these data and found that out of 12 thousand polled teenagers, only 147 were current users and of the latter, only three (yes three) vaped daily.
Extrapolation suggests that no more than 3 thousand teenagers vaped daily in all of Mexico. It is very likely that these vapers were almost all 16-17 years old, since vaping in the 12-17 age group is heavily concentrated in the 16-17 subgroup.
We believe that currently there are about 400 thousand regular vapers (vaping more than 20 days a month) in Mexico, of which probably no more than 20 thousand are underage.
Q4. How do you assess the prevalence of smoking in Mexico? The number of premature deaths linked seems high but the WHO profile for Mexico does not mention (see page 7) any mass media campaign against smoking? Are there significant efforts to incite and help smokers to quit?
Roberto Sussman: Mexico has never been an intensely smoking country.
In the 1970’s about 40% of men and about 5% of women smoked (38% both sexes). Prevalence steadily decreased to less than 20% in the early 2000’s, just by spreading information and without aggressive bans or denormalization. Taxes were significantly raised only relatively recently.
Smoking prevalence reached a low point of 17% in 2011 but bounced to 17.6% in 2016. According to WHO data, only about 52% of Mexican smokers declared smoking daily an average of 8 cigarettes per day, quite a low figure in comparison with the European Union.
The estimation is about 65 thousand yearly premature deaths due to smoking-related diseases. Historically smoking has been a male habit, but smoking among women (especially middle-class women) has increased recently. Among males, it is slowly becoming a predominantly lower class habit. Diabetes and obesity are much more pressing health problems in Mexico, and thus authorities have (justifiably) placed more attention and resources to tackle these ailments than on smoking. Curiously, health authorities have never campaigned against smoking with the full intensity in which they are currently attacking vaping
Q5. In Mexico, the market for cigarettes is dominated by big multinationals and seems to include a significant level of smuggling. Do you see any of the multinationals pushing for the possibility to sell their non-combustible products as they are doing in other countries?
Roberto Sussman: Illegal cigarette trade is booming, but the preferred illegal trade is the sale of individual legitimate cigarettes. A pack of 20 legitimate cigarettes costs about 50 pesos (2.50 US dollars). This may look inexpensive to European or North American standards, but is a lot of money to spend daily for low-income heavy smokers making less than 3-400 US dollars a month.
Individual legitimate cigarettes cost about 4 pesos each (25 US cents), which is an affordable daily rent for many smokers. Counterfeit 20 cigarette packs cost about 12-15 pesos, and thus they are a viable consumption alternative for low-income heavy smokers. Cigarette distribution is very wide and unrestricted.
Every teenager can easily get individual or counterfeit cigarettes. On the other hand, since vaping marketing and sale is illegal, the vapor market and distribution are still very fragmented. All this makes it laughable when anti-vaping campaigners claim that vaping vendors have induced multitudes of teenagers to vape and then blame vaping for increased underage smoking.
In reality, any teenager has much more chances to smoke than to vape. A longitudinal study based on 4695 junior high school teenagers examined the association between vaping trial in 2015 and “last month cigarette smoking” in 2017. The association turned to be not statistically significative.
Once you break percentages and risks into demographics: vaping could be blamed for smoking initiation in only 24 of these students. In other words, 98% of underage smokers started smoking without having ever tried an e-cigarette.
Q6. Is there anything else you would like to add?
Roberto Sussman: Latin America is the new frontier in advocating THR. Societies are much more open and liberal than in Asia or Africa and the strong ideological anti-smoking drive prevalent in English speaking countries never took root in our countries.
Some of my colleagues are visceral anti-smokers, but they do not care if someone smokes 20 or 50 yards away in an outdoor space in our campus. In the USA, Canada, Australia these anti-smokers would call the police because smoking would be forbidden in the whole campus. More social tolerance (less "denormalization") of smoking also means more tolerance and much less stigma to those trying to quit smoking through vaping.
Tobacco Harm Reduction is not only about product substitution, but it also means treating smokers with respect and dignity and throwing"denormalization" to the dustbin of history together with early XX century racialist eugenics and homophobia. Tobacco Harm Reduction without humanism is an empty shell that will always lose to anti-vaping lobbies and vested interests.
Thank you Roberto for having taken the time to answer our questions.
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