We sat down with Dr. Rohan Sequeira, a cardio-endocrinologist, at the recent World NIcotine Congress, to discuss his involvement in Tobacco Harm Reduction (THR) and its potential synergy with GLP-1 drugs like Ozempic for addressing public health challenges. The conversation covers the latest data on nicotine, pharmaceutical company reluctance regarding THR, and the pushback he faces from the medical community.
Rohan Sequeira: My name is Rohan Sequeira. I am a cardio-endocrinologist, so I handle cardiology and endocrinology problems. I’ve been practicing medicine for about 30 years and have been involved in Tobacco Harm Reduction (THR) for tobacco-based products for the last eight years. One of the reasons I got into THR was because most people who use tobacco-based products end up in our clinics with all sorts of problems; I thought it was better to attack the root cause rather than managing the secondary issues. I found that THR was the way to go ahead with the reduction of harm.
Peter Beckett: Okay, great. We now have about a decade of data, maybe more, of real-world use of e-cigarettes specifically, with nicotine pouches now coming up behind them. What’s the most important thing that the data tells us and what remaining uncertainties do you see?
Rohan Sequeira: The decade of data gives us first-hand information that breaks the perception that nicotine causes cancer and is responsible for most issues. That was the traditional approach, but this ten years of data has shown that it’s not nicotine that causes all the medical or psychological problems we see. It’s the combustion and the form of tobacco. The data has caused a significant paradigm shift in thinking; nicotine is not as bad as it was said to be, but it’s the tobacco that causes most of the harm. I think that’s a very strong point that this data brings into the picture.
Peter Beckett: We were talking earlier before you came on and you were saying that you’d been involved in some investigations on Ozempic and GLP-1 type drugs. I interviewed Derek Yach for this channel a little while ago, and he was saying there are really three major population-level health innovations that will drive the improvement in life expectancy and quality of life over the next 20 years: nicotine and tobacco harm reduction, GLP-1 type drugs, and the increase in vaccinations through technologies like that which has been developed by Moderna. How would you react to a statement like that, having been intimately involved in two of those three?
Rohan Sequeira: I think what Derek said was absolutely spot on. There is a huge paradigm shift in the management of long-term weight gain issues. We see that people who are overweight or obese have a seven times higher risk of getting cardiac, diabetic, and cholesterol issues, and even blockages in the arteries of the legs, heart, and brain. GLP-1 receptor analogues have shifted that balance and are bringing people into better health. One thing I see is a slight overlap between GLP-1 and tobacco harm reduction, though this is not common knowledge. One of the actions of GLP-1 is that it reduces cravings for food. If you understand there’s a common pathway for addiction, which is dopamine, there is an investigation going on right now where people are looking into how GLP-1 can also be used concurrently in people who are obese and using tobacco to reduce cravings for tobacco or nicotine.
Rohan Sequeira: So, there is some commonality between THR and GLP-1 in the future. When you take a GLP-1, you just don’t feel like eating because your cravings have come down. Of course, there are other effects, but nicotine works by increasing your craving. If a GLP-1 receptor analogue provides a slight benefit in the reduced need for nicotine, that creates a window of opportunity to decrease the dose of nicotine over time and bring people out. It’s called dose de-escalation. I have many patients who are on Ozempic and they’re also smokers. When we shifted them to THR products, I experimented with about ten of my patients. I started reducing the nicotine levels over a period of 1.5 years. We found that these patients who took reduced levels of nicotine were much more compliant with the dose de-escalation than those who weren’t on Ozempic. That’s open for discussion.
Peter Beckett: That’s interesting. Do you think that sort of investigation might be something that Novo Nordisk and Eli Lilly are interested in doing on a wider scale?
Rohan Sequeira: There’s a very big fear factor in any of the pharmaceutical companies to touch nicotine in any way, unless they’re into nicotine replacement therapies like lozenges or patches. I don’t see that research coming from the companies, but maybe that leaves a very big window for THR doctors to look into that aspect.
Peter Beckett: So why are the pharmaceutical companies so scared of addressing one of the biggest public health challenges that exists in the world today?
Rohan Sequeira: It’s all about walking on thin ice. All of a sudden, they might get in the spotlight for being pro-tobacco or pro-nicotine, which they don’t want to do, whereas it is a very big opportunity. You have billions of people all over the world using tobacco in some form and suffering the harms of it. It makes a lot of sense for companies involved with GLP-1 to look at this as a possible approval for products that can reduce nicotine or other dependence issues.
Peter Beckett: Okay. But it’s certainly not the case that they’ve not developed drug-based therapies outside of nicotine replacement therapy to reduce addiction levels. Why in this particular instance?
Rohan Sequeira: The drugs you’re talking about, such as varenicline or bupropion, specifically targeted only smokers or tobacco users. It wasn’t a dual-action drug. For example, GLP-1 is primarily meant for people with diabetes, obesity, and cardiac problems. New research is showing it has great effects on the liver, such as the reversal of fatty liver disease. That entire segment is a cardio-metabolic medical segment. Using the same drug and bringing it into nicotine is something they’ll have to decide internally, but it makes a lot of sense if you are able to reduce cravings in a person who is a long-term smoker.
Peter Beckett: So you work with a lot of individual patients on a more holistic level. Tell me how you first discovered reduced-risk nicotine products and how you integrated them into clinical practice.
Rohan Sequeira: To be honest, I was a smoker; I used to smoke about one packet of cigarettes a day. One day I was examining a patient, and as I was over him with my stethoscope on his chest, he asked if I smoked because he could smell the tobacco. The next day he came to my clinic with a vape device and said it was for me. This was about eight years ago, and I had never seen one before. Being curious, I went through all the data and looked at it from a neutral, non-biased point of view. As I started getting into the science of THR, it made a lot of sense. Millions of people are dying every year, and I thought this should be mainstream. I shifted completely to THR products and haven’t touched a single tobacco-based product for eight years. I saw my lipid profiles improve and my breathing quality improve. I did my pulmonary function test and it came out clear. That convinced me at both a personal and a scientific level, so I started using it with my patients and seeing the same results. That’s why I’ve been in THR for the last eight years.
Peter Beckett: Okay. And have you received much pushback from the medical community who I guess know what you’re doing?
Rohan Sequeira: I’ve received a lot of pushback from the medical community, mostly because of propaganda. Various organizations fund narratives that THR is bad, and doctors don’t always have an open mind when looking at something traditionally linked to cancer or cardiac disease. It’s difficult to give them a perspective that nicotine itself doesn’t cause the harm and that we should take away the harm from tobacco. It’s a difficult process to convince people.
Peter Beckett: What forms does the pushback take? Are other doctors contacting you personally, or is there a level of professional isolation? How does it manifest itself?
Rohan Sequeira: I see it in our medical community groups, but they won’t usually talk to me personally because of my seniority. In group discussions, you can sense an animosity. They refuse to believe the facts in front of them. One opportunity might be for an organization working with THR to create a medical literacy program for doctors that demystifies nicotine in an easy-to-understand way.
Peter Beckett: The pushback you might get from that is that tobacco companies have tried that, and it often blows back on them and harm reduction in general. Is there any way around the fact that the primary vendors of these products are legitimately discredited businesses that have behaved appallingly in the past?
Rohan Sequeira: You’ve hit the nail on the head. It’s better if third parties or people not associated with tobacco companies start doing that. For example, Carolyn works with medical literacy programs for doctors. At this point, it’s not conducive for tobacco companies to go out with this because it looks like they’re just selling their product. But there is legitimate science behind it; hardcore data supports that nicotine does not cause cancer, but tobacco does. A literacy program for medical professionals would at least make people aware that there is a valid concept.
