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  • UKVIA Welcomes Vaping Evidence Review

    UKVIA Welcomes Vaping Evidence Review

    John Dunne (Photo: UKVIA)

    The U.K. Vaping Industry Association (UKVIA) welcomed the first vaping evidence review published by the Office for Health Improvement and Disparities (OHID).

    The latest vaping review builds on evidence collected by its predecessor, Public Health England (PHE), and further highlights the role that vaping can play in improving public health.

    “It’s good to see that the experts involved in this latest review stand by the estimates that vaping is ‘at least 95 percent less harmful’ than combustible tobacco and that it ‘poses only a small fraction of the risks of smoking,’” said UKVIA Director General John Dunne in a statement.

    “This figure was first revealed by the then PHE in 2015 in what was at the time described as a landmark review, and the statement that vaping is substantially less harmful than smoking on the back of this statistic continues to be cited by all the leading public health organizations in the U.K. today.

    “Particularly welcoming is the evidence that indicates significantly lower relative exposure from vaping compared to smoking in biomarkers that are associated with the risk of cancer, respiratory conditions, cardiovascular conditions and other health conditions’ which lead to tens of thousands of deaths every year, not to mention the high levels of those suffering from debilitating smoking-related illnesses.”

    Dunne also welcomed the review’s focus on youth vaping, which he said is currently at unacceptable levels.

    “Our own Youth Access Prevention taskforce is working tirelessly with Trading Standards, the retail sector and brand owners to prevent youth access to vaping. We have recently sent the Department for Health and Social Care a number of recommendations, which are designed to cut the sale of vapes to minors off at the source. These include the introduction of a retail licensing or approved retailer and distributor scheme; increased penalties of at least £10,000 per instance for traders who flout U.K. law; and the introduction of a national test purchasing scheme to ensure all retail operations are performing to high standards when it comes to preventing youth access to e-cigarettes.”

  • The PMTA Mystery

    The PMTA Mystery

    Credit: Gustavo Frazao

    How effective must a product be in helping adult smokers quit to overcome the theorized level of harm to youth?

    By Neil McKeganey

    If there is one thing that you can say about the U.S. Food and Drug Administration’s premarket tobacco product application (PMTA) process, it is that it is exceedingly data heavy. E-cigarette manufacturers’ submissions under the PMTA process can run to the thousands of pages, reporting the results of research costing millions of dollars. To receive a marketing authorization, e-cigarette manufacturers have to be able to show that their product is “appropriate for the protection of the public health” (APPH).

    The APPH standard has become something of a modern-day mantra in the world of tobacco regulation, but what exactly does it mean? While nobody would accuse the FDA of excessive clarity in its communications with industry, this much is clear—in the simplest of terms, manufacturers need to be able to show that their product is helping adult smokers to quit, or at least to substantially reduce their smoking, and that their products are not being used by nonsmokers. This, in a nutshell, is what the FDA means when it talks about the importance of assessing the net public health impact of new tobacco products—the capacity to assess the likely overall impact of a new tobacco product on the nation’s health.

    The kind of evidence that manufacturers are required to present under the PMTA process ranges from longitudinal customer studies collecting data from consumers of their products over weeks or months to assess how those products are impacting on the individual’s smoking behavior. Alongside such customer studies are the randomized control trials that monitor changes in smokers’ behavior when they are using the new tobacco product under control conditions. The randomized trials are probably the sort of things most manufacturers have heard of before even if they have not carried them out. These studies are often presented as the gold standard in research evaluating the impact of a new drug. The shortcoming with the control trial design, though, is that it tells you about the impact of your product under controlled conditions; it does not tell you how people will use your product in their real life.

    The results of these studies can be presented to the FDA along with studies showing which population groups are currently using the new tobacco product and which ones are likely to start using the new tobacco product if it were approved. This is where the PMTA process starts to get more mysterious. One of the key groups that the FDA wants to know about is young people. With recent studies showing that more than one in 10 young people in the U.S. are using e-cigarettes, the FDA has repeatedly stressed that in deciding whether a manufacturer’s product is going to be judged as APPH, it needs to balance the impact of the product on adult smokers and young people. When the former FDA commissioner stated in 2018 that the “offramp” to adult smoking must not be achieved at the cost of the on-ramp to youth vaping, he was making it clear that the FDA would be prepared to deny approval to a new tobacco product that might be helping adult smokers to quit if at the same time it was being used by youth or likely to be used by youth.

    In a scenario where youth use of a new tobacco product can become a deal breaker for a company seeking regulatory approval for their new tobacco product, it is clear that the FDA is placing greater weight on youth vaping prevention than on adult smoking cessation. For many people, the greater value placed on youth vaping prevention may seem entirely fair—but the question at the heart of all this is by how much is the FDA valuing youth vaping prevention over adult smoking cessation? The answer to that question, or more accurately, the failure of the FDA to answer that question, is the mystery at the heart of the PMTA process. An e-cigarette manufacturer may be able to present stellar data to the FDA showing the benefit of their product in helping adult smokers to quit and still receive a marketing denial order on the basis that in the view of the FDA, the product poses too great a risk to youth.

    In interpreting the results of the empirical studies that manufacturers may have carried out, the FDA is trying to model the likely impact of the product on the total population—adults and youth. Modeling, though, is a mysterious process in which you try to anticipate what you think might happen in the future under various assumed conditions in the present. Some years ago, the National Academies of Science Engineering and Medicine carried out a modeling exercise to try to quantify the impact of e-cigarettes on population health in the U.S. This was a limited exercise carried out under precisely stated assumptions about how effective e-cigarettes might be in helping smokers to quit and how harmful they may be compared to combustible cigarettes. In contrast to such transparency, the FDA has never specified how it is weighing youth harm prevention against adult smoking cessation. As a result, e-cigarette manufacturers will never know how effective their product needs to be in helping adult smokers quit to overcome the theorized level of harm to youth to be judged APPH.

    Neil McKeganey is the director of the Center for Substance Use Research in Glasgow, Scotland.
  • ‘States Must Use Juul Payouts for Prevention’

    ‘States Must Use Juul Payouts for Prevention’

    Photo: gawriloff

    Medical groups are urging the U.S. states that recently won a case against Juul Labs to use the money for tobacco prevention and cessation programs, according to Pew. The court case ended in a $438.5 million settlement.

    The deal, which resolved an investigation by 33 states into Juul Labs’ marketing practices, requires Juul to pay states over six years to 10 years, prohibits Juul from further marketing to young people, limits where Juul products can be sold and advertised, bans flavors that haven’t been approved by the U.S. Food and Drug Administration and prohibits free samples and brand name merchandise marketing.

    Groups, including the Campaign for Tobacco-Free Kids (CTFK), the American Cancer Society Cancer Action Network, the American Heart Association, the American Lung Association, Americans for Nonsmokers’ Rights and the Truth Initiative, called on the states involved in the settlement “to both build on the successes of the historic 1998 Master Settlement Agreement with the tobacco industry and avoid some of the mistakes that were made.”

    The groups cited a CTFK report showing that of the $27 billion that states collected from tobacco settlements and taxes in fiscal 2022, only 2.7 percent was spent on programs to prevent kids from smoking and help smokers quit.

    Several attorneys general have expressed intent to use the Juul settlement money for smoking prevention and cessation programs. The health groups urged the officials to “translate that admirable intention into a firm commitment expressed in the text of the final agreement.”

  • Study: Smoking Costs U.S. Economy Billions

    Study: Smoking Costs U.S. Economy Billions

    Image: Elnur

    Smoking cost the U.S. economy $891 billion in 2020, almost 10 times the cigarette industry’s revenue of $92 billion, reports Medical Xpress, citing a new American Cancer Society study.

    “Economic losses from cigarette smoking far outweigh any economic benefit from the tobacco industry—wages, and salaries of those employed by the industry, tax revenue and industry profit combined,” said Nigar Nargis, senior scientific director of tobacco control research at the cancer society.

    “As a society, we can mitigate these economic losses through coordinated and comprehensive evidence-based tobacco control measures, which encourage people to quit smoking and prevent people from starting to smoke in the first place,” Nargis said.

    Researchers used economic modeling that measured economic loss from cigarette smoking by state. Kentucky, West Virginia and Arkansas showed the highest losses while Utah, Idaho and Arizona showed the lowest losses.

    “The damage this industry causes on individuals’ lives and our nation’s economy is horrifying,” said Lisa Lacasse, president of the American Cancer Society Cancer Action Network.

    “It’s particularly alarming, but not surprising, to see some of the states with the highest economic loss have the weakest tobacco control policies in place,” Lacasse said. “We know what works to reduce tobacco use and lessen this burden, and it’s past time we get it done.”

    The U.S. Department of Health and Human Services has a goal of reducing smoking to 5 percent of adults by 2030. “The Healthy People 2030 goal provides an important target that will help reduce smoking and correspondingly the negative economic impact of tobacco use,” Nargis said.

  • Prescription Vaping Has Failed: Mendelsohn

    Prescription Vaping Has Failed: Mendelsohn

    Photo: makistock

    Australia’s prescription-only model for nicotine vaping has failed, according to Colin Mendelsohn, founding chairman of the Australian Tobacco Harm Reduction Association. Writing in Filter, he urges the country to adopt a more realistic regulatory model for nicotine products.

    In October 2021, the Australian government introduced a policy that requires nicotine vapers get a doctor’s prescription and purchase supplies exclusively from pharmacies or international online vendors.

    The regulations were intended to prevent youth vaping and to allow access for adults as a smoking-cessation aid. One year on, the policy has achieved neither of those goals, according to a report prepared by Mendelsohn.

    Instead, the rules have created a thriving illicit market for unregulated vaping products that do not comply with Australian standards. Meanwhile, vaping by adolescents has reportedly increased in Australia. With no age controls in an unregulated market, vaping products are easily accessible by teens from stores and through social media.

    Nicotine liquid should be an adult consumer product, sold from licensed retail outlets such as vape shops, convenience stores, tobacconists and general stores as it is in other countries.

    Colin Mendelsohn, founding chairman of the Australian Tobacco Harm Reduction Association

    While the prescription model has made it harder for adults legally access nicotine vapes, combustible cigarettes remain widely available.

    According to two recent surveys, between 88 to 97 percent of vapers do not have a prescription and only 2 percent of purchases are made from a pharmacy. Exposed to frequent negative messaging by Australia’s medicines regulator, the Therapeutic Goods Administration, general practitioners have been reluctant to prescribe nicotine.

    The only way forward, according to Mendelsohn, is to replace the prescription-only model with a legal and regulated retail market. “Nicotine liquid should be an adult consumer product, sold from licensed retail outlets such as vape shops, convenience stores, tobacconists and general stores as it is in other countries,” he writes. “There should be strict age verification and penalties up to loss of license for underage sales.”

  • Report: Vaping Less Harmful Than Smoking

    Report: Vaping Less Harmful Than Smoking

    Photo: Prostock-studio

    Using vaping products rather than cigarettes leads to a substantial reduction in exposure to toxicants that promote cancer, lung disease and cardiovascular disease, according to new research from the Institute of Psychiatry, Psychology and Neuroscience at King’s College London.

    Commissioned by the Department of Health and Social Care’s Office for Health Improvement and Disparities, the independent report represents the most comprehensive review of the risks of vaping to date. It found that, while vaping is not risk free—particularly for people who have never smoked—it poses a small fraction of the health risks of smoking in the short to medium term.

    The report reviewed many aspects of vaping, including who is vaping and what products, the effects on health (both absolute and compared with smoking) and public perceptions of harm. The authors examined studies of biomarkers of exposure (measures of potentially harmful substance levels in the body) as well as biomarkers of potential harm (measures of biological changes in the body) due to vaping or smoking.

    The strongest evidence came from biomarkers of exposure. An exploration of the available studies found that levels of tobacco specific nitrosamines, volatile organic compounds and other toxicants implicated in the main diseases caused by smoking were found at significantly lower levels in vapers. Among vapers, overall levels of nicotine were lower or similar to smokers.

    When comparing biomarkers between people who vape and people who don’t smoke or vape, they were often similar, but in some cases there was higher exposure when vaping. The investigators therefore concluded that whilst less harmful than smoking, vaping is likely to sustain some risks particularly for people who have never smoked.

    While the investigators are clear on the benefits of vaping vs smoking, they found that public perceptions are lagging behind. In 2021, only 34 percent of adults who smoked accurately perceived that vaping was less harmful than smoking, while only 11 percent of adult smokers knew that nicotine wasn’t the primary cause of the health risks connected to smoking tobacco.

    Vaping has gained popularity among British adults. According to the latest data from the Action on Smoking and Health (ASH) Smokefree GB Adult survey, current vaping prevalence is 8.3 percent in 2022, compared with 7.1 percent in 2021 and 6.3 percent in 2020.

    Vaping has also increased among young people. Data from the ASH Smokefree GB Youth survey of 11-to 18-year-olds in England show that current vaping prevalence (including occasional and regular) is 8.6 percent in 2022, compared with 4.0 percent in 2021 and 4.8 percent in 2020. Use of disposable vaping products has increased substantially over the last year. Vaping among young people who have never smoked remains very low at 1.7 percent.

    “This important study is the latest in a series which carefully pulls together the science on vaping to help reduce the damage from smoking,” said Jeanelle DeGruchy, deputy chief medical officer for England, in a King’s College press note.

    “Vaping is substantially less harmful than smoking so the message is clear, if the choice is between smoking and vaping, choose vaping. If the choice is between vaping and fresh air, choose fresh air.”

  • Transformation Index Finds ‘Differentiated’ THR Progress

    Transformation Index Finds ‘Differentiated’ THR Progress

    Photo: ehabeljean

    The world’s 15 largest tobacco companies have made limited progress since 2020 to reduce the harm of their products, with high-risk combustible products still accounting for around 95 percent of retail sales volume, according to the second edition of the Tobacco Transformation Index, an initiative of the Foundation for a Smoke-Free World.

    The Index was created to accelerate the reduction of harm caused by tobacco use by ranking the world’s 15 largest tobacco companies on their relative progress or the lack thereof. The first Index  was published in 2020.

    Presented during the recent GTNF 2022 conference in Washington DC, The 2022 Index evaluates tobacco companies’ behavior across six categories and 35 underlying indicators that cover measures indicative of harm reduction, from product sales to capital allocation and marketing policies.

    Swedish Match ranked first in the 2022 Index, with Philip Morris International, Altria and British American Tobacco in second, third and fourth places, respectively; Djarum of Indonesia ranked last.

    The key takeaways from the 2022 Index findings are as follows:

    • Only Swedish Match sells a greater volume of reduced-risk products (RRPs) than substantially more harmful combustibles, due in most part to the popularity of its snus in Sweden and non-tobacco nicotine pouches in the U.S. A key feature underpinning the Index is its adoption of the Relative Risk Assessment, based on a systematic review of scientific studies of the health risks associated with 15 nicotine products.  
    • Four Index companies directed the majority of capital and R&D investments toward RRPs. In addition, five Index companies, including three state-owned entities, made incremental investments or early indications of movement toward future production of RRPs during the review period.
    • However, tobacco companies are also failing to invest in harm reduction in low- and middle-income countries, with the vast majority of sales for their RRPs concentrated in markets with the highest disposable income. One obstacle is that several countries ban RRPs.

    Transformation of the tobacco industry toward harm reduction remains inconsistent and in its early stages.

    David Janazzo, FSFW

    “Transformation of the tobacco industry toward harm reduction remains inconsistent and in its early stages,” said David Janazzo, Index program officer and interim co-president, executive vice president of operations and finance, and chief financial officer at the Foundation for a Smoke-Free World, in a statement.

    “That said, the 2022 Index demonstrates that differentiation is forming across the largest tobacco companies, related to measures of commitment, performance and transparency. While some companies are making progress, others regressed. On the whole, they are all failing to deliver outcomes toward a world in which combustible, other forms of toxic tobacco, and smoking related death and disease are eliminated, in order to accomplish the Foundation’s mission of ending smoking in a generation.

    “Based on the current trajectory of smoking rates, it is estimated that by the end of the current century up to 1 billion people will die of smoking. The majority of those will live in developing countries, which is why transformation of the tobacco industry is both essential and urgent.

    “It is my hope that industry leaders will take heed of the findings in the 2022 Index to push forward and intensify efforts to strengthen harm reduction strategies and tactics.”

    The 2022 Index is a reminder of how far tobacco companies have to go. The differing and at times hostile regulatory standards around the world have made implementation of harm reduction more challenging, but many opportunities are not yet fully maximized.

    Erik Bloomquist, chair of the Index Technical Committee

    “Institutional investors such as banks and pension funds are increasingly looking at harm and harm reduction. The Index is an important tool for those investors to constructively engage and encourage change in the market,” said Erik Bloomquist, chair of the Index Technical Committee.

    “The 2022 Index is a reminder of how far tobacco companies have to go. The differing and at times hostile regulatory standards around the world have made implementation of harm reduction more challenging, but many opportunities are not yet fully maximized.”

    The 2022 Tobacco Transformation Index can be accessed at www.tobaccotransformationindex.org

  • EU Menthol Ban Helped Smokers Quit: Study

    EU Menthol Ban Helped Smokers Quit: Study

    Photo: Valeriy Monseev

    The 2020 European ban on menthol cigarettes made it more likely that menthol smokers would quit smoking, according to a new study published in Tobacco Control.

    “This Dutch study is our second major national study to provide evidence of the powerful impact of banning menthol cigarettes on quitting, which supports proposed menthol bans in the U.S. and other countries,” said Geoffrey T. Fong, professor of psychology and public health sciences at Waterloo, and the principal investigator of the ITC Project in a statement.

    Previous Canadian research also found a positive public health impact of banning menthol cigarettes.

    In the most recent study, the research team surveyed a national sample of adult smokers of menthol and non-menthol cigarettes in the Netherlands before and after the EU menthol ban. Of the menthol smokers surveyed before and after the ban, 26.1 percent had quit smoking. This quit rate was higher than the control group of non-menthol smokers, of whom only 14.1 percent had quit.

    In fact, the increased quit rate of 12 percent of menthol smokers after the European ban is greater than the increased quit rate of 7.3 percent found in an ITC study of the menthol ban that was in effect across Canada in 2018.

    The World Health Organization’s Framework Convention on Tobacco Control calls upon countries to prohibit or restrict menthol and other additives that make smoking easier.

    To date, 35 countries have banned menthol cigarettes. On April 28, 2022, the U.S. Food and Drug Administration announced a proposed rule to ban menthol in cigarettes and cigars. An ITC study published that day on the impact of the Canadian ban projected that a ban on menthol cigarettes in the U.S. would lead more than 1.3 million smokers to quit.

    The Dutch study also found that one-third of menthol smokers reported continuing to smoke menthol cigarettes even after the ban. The tobacco industry markets a wide range of accessories to enable people to add menthol flavoring to tobacco products themselves.

    “These tobacco industry actions undermine the effectiveness of the menthol ban,” said Marc Willemsen, co-author of the Dutch study and professor in tobacco control research at Maastricht University and scientific director of tobacco control at the Trimbos Institute. “By tightening the regulations to include these menthol add-ons, the impact of the menthol ban on quitting could be even greater.”

  • The Dilemma of Diversification

    The Dilemma of Diversification

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    While lambasted by anti-smoking activists, the tobacco industry’s move into pharmaceuticals may well turn out to be a positive for public health.

    By Cheryl K. Olson

    “The pharmaceuticalization of the tobacco industry.” This awkward phrase comes from a 2017 Annuals of Internal Medicine article referring to industry moves into noncombustible nicotine products. But recently, it’s gaining some literal truth. Legacy tobacco companies are stepping up diversification into pharmaceutical ventures.

    Given that their current business direction is stalling, new adjacent opportunities that let tobacco companies use their specialized knowledge (say, of the tobacco plant genome or lung physiology or means of delivering substances) make sense. It may seem counterintuitive, or ethically iffy, for these companies to start offering solutions to problems they helped create. But they may frankly be well placed to do so because of their deep expertise. The criticisms of current industry moves into medical research and pharmaceuticals, such as Philip Morris International’s acquisition of Vectura and Fertin Pharma, seem more rooted in emotion than in practical concerns about effects on public health.

    A Tour of Recent Criticisms of Diversification

    Let’s review some recent criticisms and attempt to separate the moral from the practical. Take this September STAT+ article by Olivia Goldhill, titled “Tobacco Giant Philip Morris is Investing Billions in Health Care. Critics Say It’s Peddling Cures for Its Own Poison.”

    The tone of the article makes ordinary business behavior sound sinister. Vectura Fertin Pharma, a firm combining two companies previously acquired by PMI, was “quietly incorporated.” PMI has been “racking up patents and taking over healthcare companies, an unlikely pivot that has accelerated dramatically in the past year.” PMI has also been “poaching considerable regulatory and pharma expertise.” All this in the article’s first two paragraphs.

    The recent move by Matt Holman, who was director of the Office of Science at the Food and Drug Administration’s Center for Tobacco Products (Goldhill mislabels him as head of the CTP), to a position at PMI is described as a “move that shocked public health and tobacco researchers.” Why the surprise? Employees cycling from the FDA to the pharmaceutical companies they reviewed is commonplace; back in 2016, Time magazine called it “a revolving door.”

    When PMI purchased Vectura, best known for making asthma medicine inhalers, the Reuters headline read, “Philip Morris seals deal for U.K.’s Vectura despite health group concerns.” The chief executive of Asthma U.K. and the British Lung Foundation stated, “There’s now a very real risk that Vectura’s deal with big tobacco will lead to the cigarette industry wielding undue influence on U.K. health policy.”

    The U.S. reaction was similar. A joint statement by the presidents of the American Lung Association and American Thoracic Society called the acquisition a “reprehensible choice” by PMI. They were concerned that PMI might use Vectura’s inhalation technologies “to make their tobacco products more addictive.” They raised the prospect that PMI “could further profit from the disease their products have caused by now selling therapies to the same people who were sickened by smoking.”

    The idea of cigarette companies profiting from conditions such as asthma and lung disease was reportedly also raised by British government officials, with the U.K. business minister asking for information on PMI’s plans for Vectura.

    A deliberate company strategy to invest simultaneously in selling addictive poison and in peddling cures for that addiction would indeed be reprehensible. Is that what’s happening here? Or are tobacco companies making effortful attempts to find paths to replace the profits from cigarettes with profits from products that don’t harm and might improve public health?

    Time will tell. PMI’s website states, “We are focused on our mission to one day stop selling cigarettes.” The Guardian newspaper’s coverage noted that while the Vectura acquisition was part of PMI’s smoke-free vision, “the company still makes about three-quarters of its $28 billion in annual revenue from ‘combustible’ products that involve the burning of tobacco.” 

    Critics of the tobacco industry didn’t always take such a dim view of moves away from cigarettes. A quick search in Google Scholar for “tobacco industry diversification” brought up this 1985 piece by Alan Blum in the New York State Journal of Medicine. He stated, “Some health professionals believe that criticism of tobacco companies for promoting cigarette smoking should be tempered because they have become conglomerates that are diversifying into nontobacco products and services. By encouraging such diversification, it is reasoned, health professionals can help expedite the phasing out of smoking while tobacco companies can have an opportunity to replace the resultant lost revenue.”

    Blum’s concern was that this belief among “individuals working to eliminate smoking may be misguided.” This was not because those individuals saw industry diversification as a potentially positive step. Rather, he thought diversification wasn’t happening fast enough. Blum noted that tobacco companies were not decreasing investment in cigarette manufacturing and that “the percentage of total profit accounted for by tobacco sales is still the highest of all sources of revenue for tobacco companies.”

    “Those It Employs [or] Funds Are Therefore Banned”

    PMI’s announced acquisition of Vectura triggered efforts to exclude its employees and their research. The Drug Delivery to the Lungs conference terminated Vectura’s sponsorship. A Thorax editorial titled “Vectura and Philip Morris: The leopard has not changed its spots” stated that “The tobacco industry, those it employs and those it funds are therefore banned from membership of professional societies, including the British Thoracic Society (BTS).” The BTS would “exclude the tobacco industry as a legitimate partner in science and education,” including “publishing in respectable journals” and collaborations with universities. The editorial warns that “Vectura employees will need to consider their future.”

    The treatment Vectura’s employees received is far from unique. Ian Fearon, director of whatIF? Consulting, has conducted research in a variety of settings and helps manufacturers write up their scientific data for publication. “The barriers to publication for tobacco companies and independent ENDS [electronic nicotine-delivery system] manufacturers are high, with many journals flatly refusing to even accept a paper to undergo peer review,” he said. “One major irony is the ‘we need the industry to be transparent’ phrase, yet the reality is that the number of journals willing to publish manufacturers’ data, despite its potential importance in assessing public health impacts, is small and diminishing.”

    Fearon noted the criticism Juul received for “buying out” a 2021 special issue of the American Journal of Health Behavior to fully present their findings, which were a comprehensive examination of the potential impact of Juul on public health. Such publishing fees are common in academia; Juul even paid extra to make the articles free to all readers.

    Derek Yach, formerly with the World Health Organization and the Foundation for a Smoke-Free World, equates the opposition based on the tobacco industry’s past bad practices to the 1980s U.S. boycott of Nestle. “That pushed NGOs [nongovernmental organizations] and WHO to vilify them for decades despite changes in their marketing way back,” he said. “To this day, in many public health leadership settings, Nestle is a real villain, regardless of all they have done to change. I suspect that playbook will apply here too.”

    Yach sees the downside of diversification as less about ethics and public health and more about the practical difficulties. “It’s all about company focus and the inevitable clash of cultures—a pharma culture versus a tobacco company one, for example—and as a result, the ability to manage the transition.”

    David Sweanor

    Thinking About Diversification: A Conversation with David Sweanor

    David Sweanor of the Centre for Health Law, Policy and Ethics at the University of Ottawa has long monitored tobacco company behavior.

    Tobacco Reporter: Why are you interested in the issue of tobacco companies diversifying into things like pharmaceuticals?

    Sweanor: My main interest is public health policy: How do you end up with a healthier population? Is this doing anything that’s going to create poorer health—in which case, there’d be a need to oppose it or try to regulate it in some way? Is it going to be neutral in terms of public health? Then, who cares who owns these companies?

    If it’s something that could actually be good for public health, then we should be supporting it. And there’s reason to believe this could be the case. When companies have loads of resources to throw at something, and if this signals more of a move to transformation within the industry, it would be incredible for public health.

    If they are working on [inhalation] technologies for lower risk alternatives to cigarettes, we have the potential for enormous breakthroughs. If we can get any of the major companies to really switch to being all-in on risk reduction, it would completely change the environment. The impact globally would be remarkable and happen very quickly.

    If you want to get tobacco companies to switch to being in favor of transformation, the last thing you want to do is prevent them from doing things that would aid transformation. If you’re trying to get automobile companies to switch to electric cars, don’t prevent them from buying companies with battery technologies. You’re forcing them to continue to focus on internal combustion engines.

    What do you see as valid and invalid criticisms of this diversification?

    No valid ones immediately come to mind. If they were buying up technology that gave a far better alternative to cigarettes and then trying to kill that, then yeah.

    It’s easy to talk about the invalid criticisms. A really good example of that is in Canada, where Medicago, based in Quebec City, developed a vaccine for Covid-19. In developing countries, this vaccine would work well because it doesn’t need to be stored at cold temperatures. Philip Morris has an indirect holding of about 30 percent in Medicago. Anti-tobacco groups attacked the government for approving the vaccine, and WHO refused to approve it.

    What’s the thinking behind that? It’s saying: We don’t like this company because we think it’s done bad things in the past. To deal with this, we’ll prevent them from doing good things now. They created an epidemic of disease from smoking that became larger and lasted longer than it should have. So we’re going to prevent them from doing things that could reduce this epidemic of disease from Covid to make it last longer than it should.

    Are people following the principles of the Enlightenment or the Inquisition? So much now with mainstream anti-tobacco groups is the latter. We don’t care about the quality of your work; we won’t give you a platform to discuss or debate it. That some affiliation you have is more important than the knowledge you bring is pretty reprehensible. It’s like saying Roman Catholics are not allowed to express their views.

    What do you see as potential benefits to public health from this diversification? For example, Matt Holman’s new position as vice president of U.S. scientific engagement and regulatory strategy at PMI.

    Look at the counterfactual. If they don’t do that, the only people working in cigarette companies working on transformation spent their careers working on and understanding and benefiting from cigarettes. If General Motors says, “we’re hiring engineers who understand electric mobility rather than hydrocarbons,” isn’t that a good thing? How can you transform if all the people in senior positions have their expertise in internal combustion engines?

    We see this in high tech all the time; one company will buy another to get the expertise of their employees. You need them at the table when you make decisions on where to go with the next generation.–C.K.O

    Addendum

    In the main article above, I stated that the boycott of Nestle from the 1980s has had a lingering negative effect on WHO and many public health leaders’ views of the company many decades later. This despite Nestle being a global leader in addressing food insecurity, sustainable agriculture and the use of 21st nutrition science (see the company’s 2021 annual report).

    In the second half of October, Nestle’s past came back to haunt the company. The WHO Foundation, set up to build innovative private public partnerships, banned future Nestle contributions despite having originally accepted  a grant for their work on addressing Covid-19.

    The WHO Foundation already bans contributions from tobacco and arms manufacturers though it is unclear how “tobacco” is defined. Does it include governments with state monopolies? Does it include standalone e-cigarette, or nicotine pouch companies? Does it distinguish between companies where revenue from reduced risk products is increasing while combustible revenues are decreasing? Probably not.

    Labelling companies as good or bad is the far easier option. But that option that ignores serious transformation and the opportunity to nudge and support the good emerging faster.

    Derek Yach

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.
  • The Eye of the Beholder

    The Eye of the Beholder

    Photo: Nopphon

    Not all smokers will be put off by the ‘dissuasively’ colored cigarette papers promoted by health activists.

    By George Gay

    Writing in this magazine two years ago about the pressures being placed on paper suppliers to the tobacco manufacturing industry, I claimed, uncontroversially I think, that the market for combustible cigarettes was declining. Later in the piece, and more controversially, I speculated that the part of the decline in demand for combustible cigarettes being caused by their substitution by vaping devices might slow because of policies being followed by some authorities.

    Although that speculation still has validity today in many parts of the world, significantly in countries with big populations, such as China, India and the U.S., in the U.K., there has been a development that is aimed at putting a different hue on things.

    In June, Javed Khan published his U.K. government-commissioned review into government policies aimed at reducing the incidence of tobacco smoking in England to 5 percent by 2030, Making Smoking Obsolete. As part of that review, Khan suggested the government should rethink how cigarettes look—that it “should use every part of the cigarette, and what’s in the pack, to communicate the harms of smoking and offer opportunities to quit.” He gave three examples of what he was getting at:

    • mandating anti-smoking messages on cigarette sticks, such as the number of “minutes of life lost” per cigarette;
    • using dissuasive colors (like green or brown) on individual cigarette sticks or hand-rolling papers; and
    • [including] cigarette pack inserts that provide information on the health benefits of quitting, supported by web links that direct smokers to support for stopping smoking.

    I am little interested here in the third idea, though my concern would be that the information provided would be grossly misleading as is much of the “information” currently churned out on tobacco smoking. And I would say just two things in relation to the first. One is that you must always be careful what you wish for. Before mandating the printing onto cigarette paper of the estimated number of minutes of life lost to smoking those cigarettes, I would suggest checking whether this might prove to be a promotion among some young people, especially in the short term. Youngsters, at least those who might be drawn to smoking, tend to be perverse in some ways as was proved fairly conclusively when, in the 1990s, students in the U.K. took the Death brand cigarettes to their hearts. The second thing I would say is that, as far as I am aware, we possibly all lose more minutes of life to pollution than smokers lose to smoking, but of course it is difficult to disseminate the pollution figure because you cannot write on air no matter how polluted it is.

    Perception Matters

    But it is the second idea that interests me most. To my way of thinking, you have to try to be objective when describing and talking about colors, not least because not everybody perceives or experiences the same color in the same way. For instance, when the idea of standardized cigarette packaging was first raised in Australia, it was suggested that the background color should be an unattractive olive green. This idea went down like a lead balloon with Australian olive producers, and references to olive green were quickly shelved.

    In perhaps trying to sidestep such issues, Khan makes what to me is the mistake of claiming that all greens and browns are “dissuasive,” though I should point out that in saying this I am assuming he is using the word “like” in the bracketed phrase “like green and brown” to mean “such as” green and brown, not colors that are similar to green and brown, a concept that only an artist might be able to understand. In support of this claim, he references a web survey carried out among 281 adolescents (16–20 years of age) in Norway, though that survey references at least one other previous survey, which was carried out in the U.K. The Norway survey, which seemed to have investigated the reactions to yellow-colored and green-colored cigarette papers (as well as reactions to products with printed warnings) rather than green and brown, was summed up in an abstract that concluded: “This study supports earlier findings and suggest[s] that the use of unpleasant colors and warnings printed directly on cigarette sticks could increase perceived harmfulness, reduce notions of good taste and possibly reduce desires to experiment with cigarettes in adolescence.”

    The first thing that has to be said about this conclusion is that it seems rather uncertain of itself. It is less than 40 words in length, but it manages to cram in at least three doubting words: “suggest[s],” “could” and “possibly.” This is unsurprising in a way. I doubt that it would be possible to find a color that was widely dissuasive, though a certain hue of a certain color might prove to be more so. What is an unpleasant color is in the eye of the beholder and might even be the subject of fashion movements. And, of course, people, especially young people, tend to get used to things changing. Pasta that was rendered blue, a color not usually associated with food, especially savory food, would probably meet some resistance from consumers, but they, especially the young, would surely get used to it.

    In any case, if there were such a thing as colors that were unpleasant in the eyes of everyone, as the conclusion appears to suggest, it seems to me that the research carried out in Norway would be rendered pointless. It stands to reason that an unpleasant color applied to a consumer product that was previously another color would make that product less attractive, though, once again, it is likely that, over time, consumers would get used to it. Not that I think such considerations would dissuade many of the people who carry out such research. Rather, these considerations would probably be seen as a reason why scientists should, in the usual way, call for further study into this issue—further study grants to be used to make life a little more unpleasant for smokers.

    There is also the issue of what green signifies. I would imagine that if a cigarette manufacturer launched on its own initiative a green cigarette, it would be pilloried by the anti-tobacco lobby, the media and possibly other manufacturers for trying to imply that the product was environmentally friendly and, by extension, healthier. Something similar has happened before in Europe, and the U.S. Food and Drug Administration makes such a link.

    Hypocrisy

    But the real issue is whether it is fair or, indeed, whether it makes sense to foist onto, say, a 40-year-old committed cigarette smoker in the U.K., a product variation that a web survey found made the product less attractive to a small number of adolescents in Norway. Not to mention that doing so amounts to rank hypocrisy. As above, the purpose of mandating that cigarette papers are available only in green or brown would be to make the cigarettes unattractive to smokers—that is, to ruin their enjoyment of them. Now the health evangelists might wring their hands and say they seek this only for the good of the smokers and their physical health, but they have to realize that once a smoker has made a decision to smoke, it is no business of those evangelists. Smokers are adults who are entitled, legally, to enjoy a tasteful, fragrant, satisfying and otherwise appealing product presented in attractive packaging. Goodness knows, they pay enough for this product.

    Now, let me explain what I mean by hypocrisy. Outdoor air pollution causes more deaths worldwide than tobacco smoking. It speeds up climate change and is a major cause of the biodiversity crisis, and yet we allow automobiles, which comprise one of the major causes of such pollution, to be sold in the most attractive forms imaginable. If it weren’t for hypocrisy, car design, like cigarette design, would have been heavily restricted so as to make people spurn these vehicles. Automobiles would come in a single “unattractive” background color adorned with health warnings covering everything from what happens when a pedestrian, especially a child, is hit by one to what happens to the lungs, especially young lungs, when they are hit by carbon dioxide and nitrogen oxide emissions. There would be no heaters or no air conditioning in automobiles, and the seats would be made from unadorned, used tires so as to make traveling uncomfortable. There would be no tops and no windscreens so that drivers and their passengers would have to wear goggles to keep (the quickly diminishing number of) insects out of their eyes. And, right now, somewhere, a person publishing a government-commissioned review would be recommending that all automobiles be fitted with square, solid-rubber wheels—brown ones with unevenly distributed knobs on them.

    Priorities

    Quite what will be the fate of the Khan review and his call for colored cigarette papers must be in doubt. For one thing, you have to wonder if any research has been done into whether adding pigments to cigarette paper would increase the toxicity of cigarettes, whether it would impede the technologies put in place to ensure that carelessly discarded cigarettes extinguish quickly, whether it would improve the taste of cigarettes and make them more attractive, or whether it would cause any other unintended—read: ill-thought-out—consequences. My bet is that the answer to those questions is no and that the only people who would gain in the short term from such a proposal would be the scientists who would be called on to carry out such research—and the follow-up research they would recommend.

    Secondly, the review was commissioned by a government that was falling apart and that, as I write, is de facto leaderless and wallowing in internecine battles as two woefully inadequate figures fight over who should take on the mantle of further undermining the U.K.’s tottering democracy and dragging further into impoverishment the long-suffering people of these increasingly septic isles. I write increasingly septic with conviction because, while the government is concerning itself about whether cigarette paper should be green, brown, puce, tomato red (my bete noire) or whatever color the most recent health minister might find unattractive, it is allowing water companies to discharge increasing and illegal amounts of raw sewage into our rivers and coastal waters.

    Why worry about the dangers of smoking when the air around you is putrid, the water around you is a lavatory and food crops are failing in a drought because, presumably, farmers are unable to irrigate given the low level and toxic nature of the rivers? Not to mention that, largely because of the Brexit dividend, “even if the crops were to survive, there would be nobody to harvest them.”

    George Gay is Tobacco Reporter’s European editor, but his territory spans the globe. Based in London, George has covered the tobacco industry since 1982, initially for a U.K.-based publication and since 2004 for Tobacco Reporter. George’s understanding of industry issues, combined with his keen sense of observation and dry wit, have earned him a loyal following among Tobacco Reporter’s readers.