You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Archive for May, 2013

Tobacco harm reduction and e-cigarettes: setting a unified research agenda

29 May, 13 | by Marita Hefler, News Editor


Marisa de Andrade & Gerard Hastings

Institute for Social Marketing, University of Stirling

Recent discussions about an endgame for tobacco have built on a sense that we in the tobacco control (TC) movement know where we are going. The consistent application of evidence based strategies, from adbans to tax increases, was, it seemed, driving an inevitable progression towards a smoke-free world; the only question was ‘when would the prevalence line cross the X axis?’

Tobacco harm reduction (THR) has been a carefully modulated dimension of this debate. Now this balance has been unsettled by the sudden arrival onto the market of a wide range of e-cigarettes and other Nicotine Containing Products (NCPs). The development suggests both opportunities (such as greatly reduced harm for the heavily addicted) and threats (like the potential rehabilitation of the tobacco industry), and in the process throws up multiple research questions. This THR Research Agenda commissioned by Cancer Research UK presents a first attempt to map these questions.  It was informed by a review of the academic and grey literature and consultations with twelve TC experts.

It quickly became apparent that research questions could be grouped into four broad (and sometimes overlapping) areas: impacts on the individual; the tobacco control movement; the political environment; and philosophical issues.

A taxonomy of harm reduction research









A taxonomy of harm reduction research


According to the National Institute of Health and Care Excellence (NICE) draft HR guidance, e-cigarettes offer a cleaner vehicle for the delivery of nicotine as ‘the harm associated with cigarette smoking is almost entirely caused by the toxins and carcinogens found in tobacco smoke’. Ongoing evaluations of safety (short and long-term) are recommended by the health body, a call which a recent German Cancer Research Center report and presentation to the European Parliament also makes very strongly.

This research needs to be balanced with an examination of efficacy: how effective are NCPs and e-cigarettes as smoking cessation aids and at helping smokers cut down, and what impact does this have on quitting? We also need to know how NCPs are being used – for dual use, temporary abstinence, long-term as a tobacco substitute or part of a quit attempt – and by whom, covering age, socio-economic status, gender and ethnicity. By extension, potential impact on individual and population level inequalities also needs to be assessed.

More broadly there is a need to examine how key stakeholders, including smokers, non-smokers, policymakers, primary healthcare staff, journalists, children and young people, are perceiving HR, NCPs and all related commercial and social marketing activity.

Tobacco control

Developments in THR and e-cigarettes also raise strategic questions for tobacco control.  What priority should the TC community give to HR relative to other tobacco control approaches? We need to know how, if at all, HR interacts with these other approaches and specifically with complete cessation (eg do NCPs and/or e-cigarettes help or hinder quit attempts?) and youth prevention (eg could they act as a gateway to smoking?). In each case the net needs to be thrown wide to capture the effects not just of the products themselves, but the way they are presented and promoted in digital and conventional media.

The regulatory response is varying around the world and the efficacy and wider impact of these alternate models needs to be examined. In the UK, for example, where NCPs could soon be regulated by the Medicines and Healthcare products Regulatory Agency (MRHA), questions arise about how marketing will be overseen. What would the official channels be for reporting potential breaches, and how would this fit within the regulator’s remit? How well does this regime operate compared with other jurisdictions where tighter controls (eg complete adbans) are in place? More broadly, how did these different approaches arise?

The impact, if any, of HR and the use of NCPs on the denormalisation of smoking is currently unknown. Does e-cigarette use, for example, model smoking?  More specifically, to what extent, if at all, do the new products undermine smoke-free legislation, or the packaging, point of sale (POS) display and advertising of them undermine tobacco marketing controls? Potential conflicts with current regulation could also raise concerns relating to the Framework Convention on Tobacco Control (FCTC).  Specifically, how should Article 5.3 be interpreted and deployed when the tobacco industry (TI) is investing so heavily in HR and associated products?


The FCTC also raises political debates.  Is the TI using HR to engage in and influence health policy, perhaps via third parties (either commercial or public)? What, if any, conflict of interest does TI investment in reduced risk products present? Could it, for instance, undermine or remove public health gains from HR? And what is the TI’s business strategy with regard to NCPs and the implications for TC? Under what circumstances, if at all, could the TI come to be seen as a legitimate stakeholder? Is the tobacco TI using HR as a corporate social responsibility or stakeholder marketing strategy? If so, how is this happening and what are the potential dangers?

It is also necessary to know how research on HR and NCPs is being funded, and what impact will this have on TC. What, if any, similarities are there between TI interest in HR and its past activities around filtered, safe and low tar, cigarettes? What, if any, links will develop between the tobacco and pharmaceutical industry and what are the implications for TC?

International implications also need to be addressed.  What impact do decisions made in one country have on the rest of the world, and what can be learnt from countries where both smoking rates and HR activities are low?


More broadly still, HR and NCPs raise questions about the fundamental purpose of public health. Is it an acceptable and effective public health practice to promote an addictive product? How does this vary between cultures and classes? What, if any, impact does HR have on the individual’s sense of agency and his or her ability to address wider health behaviours?

Finally, does the resulting accumulation of corporate power present any threats to TC or public health more generally?


There is a new sense of uncertainty in tobacco control.  THR has been presenting alternate perspectives for some years in an appropriately cautious fashion, but the sudden arrival on the scene of heavily marketed e-cigarettes and other NCPs has greatly energised the debate.  It is vital that the tobacco control movement agrees a unified strategy to address these developments; amidst all the uncertainty there is one certainty: any divisions will be ruthlessly exploited by vested interest. This taxonomy of harm reduction research provides a first step towards this unified strategy.

Ireland joins tobacco plain packaging leaders

28 May, 13 | by Becky Freeman, Web Editor

According to New Europe:

“It is with great pleasure that I announce, ahead of World No Tobacco Day on Friday, that I have received Government approval to begin the process of introducing standardised/plain packaging of tobacco products in Ireland.  While many arguments will be made against such an introduction, I am confident that this legislation will be justified and supported purely by the fact that it will save lives,” said Ireland’s health minister,  James Reilly.

The tobacco industry will no doubt introduce the same arguments it has used in the UK, New Zealand and Australia to try and stop this essential public health measure. But with strong leadership as shown by Minister Reilly, it is only a matter of time before tobacco brands become a quaint and strange thing of the past.

plain pack

Timor-Leste: Asia’s newest country in Marlboro’s sights as company targets growth markets

21 May, 13 | by Marita Hefler, News Editor

Mary Assunta
Southeast Asia Tobacco Control Alliance

Marlboro Black Menthol billboard in Timor-Leste, 2013  Photo: George Darroch

Marlboro Black Menthol billboard in Timor-Leste, 2013
Photo: George Darroch

At its annual shareholder meeting in New York on 8 May, Philip Morris International (PMI) celebrated yet another successful year selling tobacco in more than 180 markets. In 2012 the company shipped 927 billion cigarettes, and earned revenue of more than $31 billion. It applauded the fact its sales, especially from emerging markets (euphemism for developing countries), had increased from 53% in 2007 to 61% in 2012. PMI claimed it had an estimated 16.3% share of the total international cigarette market outside of the USA (see the annual report here).

The American cowboy continues to make mega profits from the developing world, even from new, small countries like Timor-Leste in Southeast Asia. Timor-Leste ranks low on the Human Development Index at 134 out of 186 countries. Its GDP is $1.6b and 50% of its population live below the poverty line, with about 40% experiencing severe poverty. About 37% of its people earn US$1.25 a day.

To add to its challenges, it has a growing smoking problem. One third of adult men smoke, while an alarming 50% of teenage boys (13-15 years) and 17% of teenage girls smoke. A pack of cigarettes cost $1.00, and a Global Youth Tobacco Survey study showed 35% of all teenagers have an object with a tobacco logo on it.

Misleading descriptors on cigarette packs have been prohibited in the US since 2006, when tobacco companies lost a case brought against them under the Racketeer Influenced and Corrupt Organizations Act (RICO). However, outside the US, PMI continues to sell cigarettes with misleading claims such as ‘fresh’ and ‘gold touch’. PMI launched Marlboro Black Menthol in Asia in 2008, including in Indonesia, Malaysia, Philippines and Japan, promoting it as a “fresh taste sensation”. In 2009 Marlboro Black Menthol brand sold four billion units in Asia. PMI claimed each new introduction has a positive impact on the vibrancy of the brand across a wide range of markets through “a very positive ‘halo’ effect on the whole brand family.”

With high male smoking prevalence, Asia is a key PMI target region; between 2007 and 2012, its market share grew from 25% to 35%. It has identified several countries as exciting growth opportunities especially Indonesia, Philippines, Vietnam, Thailand, Korea and Bangladesh. Marlboro cigarettes are positioned as a key driver of growth, together with local brands such as A-Mild in Indonesia and Fortune in the Philippines.

PMI’s strategy to introduce several brand extensions of Marlboro such as Flavour Filter Plus, Gold Touch and Fresh capsule has enabled the company to sell 179 billion extra sticks, equivalent to 6% of its sales. The WHO Framework Convention on Tobacco Control (FCTC) Article 9 calls upon countries to regulate tobacco products specifically to address these types of extensions.

With an eye on the 750 billion sticks currently sold by state-owned monopolies, PMI has slated partnerships with these as the way forward to tap into markets. In Vietnam, through a partnership with Vinataba to produce Marlboro cigarettes, PMI is already seeing increases in Marlboro sales from 0.5% in 2009 to 2.8% of total sales in 2012. Vietnam has just passed comprehensive tobacco control legislation that bans tobacco advertising and promotions and requires 50% pictorial health warnings on cigarette packs, however strict implementation is needed and all loopholes plugged to arrest increasing cigarette sales.

The tobacco industry has shown it will aggressively pursue market expansion, frequently profiting even where poverty rates are high. Its sales are increasing. However as long as the tobacco industry is viewed “like any other business” by departments of trade, it will continue to milk its status as an investor and enjoy a thriving business. The industry is using the trade platform and bilateral investment agreements to challenge governments such as Uruguay and Australia who take stringent measures like prominent health warnings and plain packaging to protect public health.

Developing countries do not have the necessary resources to defend their public health measures in expensive, prolonged arbitrations. Tobacco cannot have the privileges (Article 5.3 Guidelines) accorded to other businesses and it cannot be treated like a normal product on the trade platform.

#keeptheban: Welsh Government drops contested proposal to amend smokefree premises legislation

18 May, 13 | by Marita Hefler, News Editor

Rosanne Palmer

Ash Wales/Ash Cymru

Editors note: this is an update to a blog post published on 3 May about a proposed amendment to Wales’ smoke free legislation to allow cast members to smoke on film and television sets.

The Welsh Government announced on 15 May that the proposals were being dropped. This move followed a review of the evidence submitted to the National Assembly for Wales’ inquiry into the amendment by the two principal ministers concerned – Mark Drakeford, Minister for Health and Social Services and Edwina Hart, Minister for Economy, Science and Transport.

Whilst the timing of the move was unexpected, it was clear from his time as Chair of the Health and Social Services Committee that Professor Drakeford was resolutely opposed to the amendment, a stance that he maintained when appointed as Health Minister in March this year. It has been suggested that, in addition to opposition from health organisations, including the British Medical Association and the Royal College of Physicians, there was weak support for the amendment amongst Assembly Members (AMs). Given that the two ministers themselves were due to give evidence on 12 June, perhaps the timing is not so surprising after all.

Throughout the campaign, social media channels were used as a medium for maintaining pressure in opposition to the proposal, in particular the use of an on-line petition and the use of Twitter to both spread the message and communicate with important actors involved in the debate. Of particular note were the activities of the Chartered Society of Physiotherapists in Wales in writing to AMs as well as other members of the Wales Tobacco Control Alliance in opposing the proposed amendment.

The same announcement also confirmed that the Welsh Minister for Health and Social Services had written to the UK Secretary of State for Health, Jeremy Hunt, supporting the introduction of legislation on standardised packaging.

Japan Society for Tobacco Control warns against appointing ex tobacco executive to national broadcaster

17 May, 13 | by Marita Hefler, News Editor

Manabu Sakuta

President of the Japan Society for Tobacco Control

According to an article published on 13 May in Nihon Keizai Shinbun (Japan’s equivalent of the Wall Street Journal ) the former president of Japan Tobacco Company Mr Katsuhiko Honda is being considered for appointment as the next Chief Executive Officer of Japan Broadcasting Company (popularly known as NHK). Mr Honda continues to be affiliated with JT as a consultant advisor.

The Japan Society for Tobacco Control unequivocally protests the possible appointment.

Japanese Broadcasting Law has a mandate to “broadcast in accordance with public welfare”. This includes the urgent public health priority of reducing consumption of tobacco to protect the health and life of Japanese people, in line with Health Japan 21, and the Basic Policy against Cancer. Appointing the former president of Japan Tobacco creates an environment for broadcasting which is favourably biased to maintain cigarette consumption, particularly given Mr Honda’s ongoing association with the company. Tobacco kills more than 120 thousand people in Japan every year; an unacceptably high toll.

The Japanese Government ratified the World Health Organization Framework Convention on Tobacco Control (FCTC) in 2004, and has an obligation to observe the treaty under Japanese Constitution article 98.2. Article 5.3 of the FCTC states: “Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law “. The government should avoid the influence of tobacco industry to pursue its policy.

Appointment by the Japanese parliament of a former president and now consultant of JT as the CEO of NHK would be a fundamental breach of Japan’s obligations under the FCTC.

We stand together with our colleagues from around the world who have also expressed concern about the possible appointment. NHK is broadcast in more than ten languages globally; its reach and influence is international.

New study: partial smoking bans in hotels fail to protect guests from tobacco smoke

14 May, 13 | by Marita Hefler, News Editor

Non-smokers should shun hotels operating partial smoking bans, advise authors

Non-smoking rooms in hotels operating a partial smoking ban don’t protect their occupants from tobacco smoke, reveals new research published online in Tobacco Control. [Thirdhand smoke and exposure in California hotels: non-smoking rooms fail to protect non-smoking hotel guests from tobacco smoke exposure Online First doi 10.1136/tobaccocontrol-2012-050824]

Non-smokers should give hotels that allow smoking in certain rooms a wide berth, say the authors, and instead choose completely smoke free hotels.

The researchers analysed the surfaces and air quality of rooms for evidence of tobacco smoke pollution (nicotine and 3EP), known as third hand smoke, in a random sample of budget to mid-range hotels in San Diego, California.

Ten hotels in the sample operated complete bans and 30 operated partial smoking bans, providing designated non-smoking rooms.

Non-smokers who spent the night at any of the hotels, provided urine and finger wipe samples to assess their exposure to nicotine and a cancer causing agent found specifically in tobacco smoke—known as NNK—as measured by their metabolites cotinine and NNAL.

The findings showed that smoking in hotels left a legacy of tobacco pollution in both smoking and non-smoking rooms. A partial smoking ban did not protect the occupants of non-smoking rooms from exposure to tobacco pollution.

Compared with hotels operating total smoking bans, surface nicotine and air 3EP levels were higher in both non-smoking and smoking rooms of hotels operating partial bans.

Surface nicotine levels were more than twice as high in non-smoking rooms of hotels operating partial bans as those of hotels operating total smoking bans (3.7 µg/m2 compared with 1.4 µg/m2), while air levels of 3EP were more than 7 times as high.

Surface and air nicotine levels in rooms where previous guests had smoked were 35 and 22 times higher than those of rooms in hotels operating a total smoking ban.

Air nicotine levels in smoking rooms were significantly higher than in non-smoking rooms; and they were also higher 40% higher in non-smoking rooms of hotels operating partial smoking bans than in those operating total bans.

Similarly, hallway surfaces outside smoking rooms also showed higher nicotine levels than those outside non-smoking rooms.

Non-smokers who stayed in hotels with partial smoking bans also had higher levels of finger nicotine and urinary cotinine than those staying in hotels operating total bans. Urinary NNAL was also significantly higher in those staying in the 10 rooms containing the highest levels of tobacco pollutants.

“Our findings demonstrate that some non-smoking guest rooms in smoking hotels are as polluted with [third hand smoke] as are some smoking rooms,” write the authors.

They go on to say: “Moreover, non-smoking guests staying in smoking rooms may be exposed to tobacco smoke pollutants at levels found among non-smokers exposed to second hand smoke.”

Few countries have adopted a smoking ban that includes hotels, say the authors, but their findings “suggest that it is time to abandon smoke-free exemptions for hotels,” they write.

New hotels should operate total smoking bans to protect not only their guests, but also their employees, say the authors. In the meantime, they advise: “Guests who wish to protect themselves from exposure to tobacco smoke should avoid hotels that permit smoking and instead stay in completely smoke-free hotels.”

The contact author for the study is Dr Georg Matt, Department of Psychology, San  Diego State University, San Diego, California, USA. Email:

Philip Morris & IBM IMPROVER project: downplaying links between smoking & disease

13 May, 13 | by Marita Hefler, News Editor

Chris Bostic

Action on Smoking and Health (US)

I wonder if Philip Morris International (PMI) researchers have studied the ‘length of public memory.’ If so, the resulting answer seems to be ‘about 15 years.’ That’s how long it has been since the Tobacco Institute closed its doors, after 40 years of obfuscating the science on tobacco addiction, disease and death. A key aspect of industry strategy to forestall meaningful regulation has always been to question the causal link between tobacco and disease.

PMI has just launched phase two of its sbv IMPROVER project (the title is short for “systems biology verification of industrial methodology for process verification in research”). The theme is “species translation challenge,” and PMI, in collaboration with technoogy giant IBM, will award three US$20,000 grants to scientists who can best poke holes in translating disease lab results in rodents to humans. In one online article very sympathetic to Philip Morris, the reporter states “not every smoker suffers all or any of those health effects, suggesting that a combination of environmental and genetic factors lead to disease.” This years project follows on the “diagnostic signature challenge,” in 2012 which gave a US$50,000 award for showing genetic markers for diseases linked to tobacco.

The main purpose of IMPROVER seems clear – remuddy the waters on the causal link between tobacco and disease. But they actually get much more. By enticing young researchers to compete, PMI pushes back against the trend among major universities to not do business with big tobacco. These researchers are also a natural recruitment pool for the next generation of scientists who are untroubled by the ethics of working with big tobacco. By linking with IBM, working with universities, and comparing the effort to legitimate scientific endeavors such as DREAM, PMI gains legitimacy among the scientific community.

Finally, IMPROVER is a rather brilliant example of corporate social responsibility marketing. Turning the purpose of the scheme on its head, PMI says its “number one objective is to do something about our dangerous products.” How can anyone argue with that? That’s not rhetorical – I invite responses on all the ways we can argue with that.

On a side note, is the name IMPROVER a subtle nod and affront to MPOWER?

UK: Government condemned for bowing to tobacco industry over plain packs

7 May, 13 | by Marita Hefler, News Editor

Author credit: Marita Hefler and Stan Shatenstein

On 2 May, the Sun newspaper reported that the UK government had decided to abandon cigarette plain packaging legislation. An announcement about the legislation had been widely tipped to be included in the Queen’s speech at the start of the next parliamentary session on 8 May.

No other media outlets initially reported the decision to drop the policy, leading to confusion about whether the report was correct. However, in the face of a surge of support for the tobacco-friendly UK Independence Party (UKIP) and tobacco industry pressure, it appears that the government has decided to put the tobacco lobby ahead of public health.

Jamie Doward in The Guardian reports that the move comes after tobacco industry representatives met with health department officials and threatened that the plan would result in thousands of jobs going abroad. Details reported in the article of the industry’s campaign against the proposal show it took lessons from the failed Australian campaign, and was in part masterminded by Australian lobbyist Lynton Crosby, who has close ties with Australia’s conservative opposition Liberal Party. While the measure will still be implemented in Scotland, dropping it elsewhere in the UK is likely to be divisive with the government, as the Liberal Democrats are strong supporters of plain packaging.

Other coverage of the decision has been justifiably scathing:

“The tobacco industry argues that there is no evidence that plain packs discourage young people from starting to smoke. But inspection of tobacco industry documents released as a result of lawsuits reveals that the industry has been preparing for the battle for at least a quarter of a century. It will deny it, but the tobacco industry understands how brands lure in young smokers. It needs this new generation to replace the older one that it is killing. The UK government has a mandate to improve the health of its citizens. Last week, it failed them.” [Editorial. Smoking: the government’s cowardly surrender to the tobacco lobby, The Observer]

“I don’t blame the tobacco firms. Death is their business. When BAT says, after exhausting its arguments, that “We will take every action possible to protect our brands, the rights of our companies to compete as legitimate commercial businesses selling a legal product, and the interests of our shareholders”, I almost admire its dedication to cash. Yet the British government, theoretically dedicated to the health of its citizens, has a duty not to sink to lobbyists… It attacks the habits of the poor, but does nothing helpful. As ever with this government, hollow rhetoric will do.” [Tanya Gold, Death is tobacco companies’ business, The Guardian]

“The statement, attributed to a Whitehall source, describing plain packaging as “nothing to do with the Government’s key purpose” is extraordinary. The health of the people is surely the highest purpose of government, so it is chilling to hear that the Coalition does not consider the prevention of ill health and premature mortality to be part of its role.” [Letter signed by 155 health professionals. Plain cigarette packets, The Telegraph]

#keeptheban campaign: Saying no to amending Wales’ smokefree premises legislation

3 May, 13 | by Marita Hefler, News Editor

Rosanne Palmer, ASH Wales

In July 2012, on the same day that the National Assembly for Wales approved point of sale display bans for tobacco products in Welsh stores, the Welsh Government laid an amendment to Wales’ smokefree premises legislation to allow cast members to smoke on set for film and television productions. This move came despite 75% of respondents to the 6-week consultation in spring 2012 opposing such an amendment, a strength of feeling that has become increasingly evident as attempts to introduce the legislation have become more drawn out.

The creative industry claims it needs to compete with England, which has an exemption built in to its existing smoking legislation for the film and television industry to protect the “artistic integrity” of a performance. Yet these production companies are able to simulate a wide range of actions like drug taking, car crashes and shootings – so why should smoking, which kills 5450 people every in Wales, be any different?

A vote on the amendment was scheduled for the Assembly plenary in mid-October but a campaign to #keeptheban generated enough interest and concern to see the amendment referred to not one, but two, committees – Health and Social Care and Enterprise and Business – leading to a first for the Assembly, the creation of two sub-committees, sitting jointly and composed of equal numbers of members from both parent committees, to take evidence around the ban.

Committee hearings began in January 2013 with evidence from, amongst others, Cancer Research UK, the British Heart Foundation, ASH Wales and the BBC. The opposition of public health practitioners and supporters to the proposed amendment is clear, and the scientific research on the impact of second hand smoke was frequently referenced. Counter assertions about the loss of production investment to England have yet to be substantiated, with the BBC being forced to retract a claim that a story-line for prime-time UK hospital drama Casualty had to be dropped because it required filming a smoking scene.

Following three evidence sessions in January and February, with the report expected in mid-March, the announcement was made that there would be a further evidence session in June with both the Health and Enterprise Ministers, as well as the Chief Medical Officer for Wales and members of the Welsh Government’s executive creative industries units invited to give evidence. Despite the degree of opposition, the amendment has thus far refused to go away.

During a recent Welsh Government reshuffle, the most outspoken opponent of the amendment as chair of the Health Committee in the Assembly, Professor Mark Drakeford, was elevated to the role of Health Minister. Whilst this represents a potentially promising development for opponents of the amendment, it currently remains on the table.

If you are interested in finding out more about the #keeptheban campaign, please visit the ASH Wales website and sign the #keeptheban e-petition to register your opposition to the dilution of smokefree legislation in a country that was the first UK nation to call for a smoking ban and help  prevent Wales taking a step back in time.

Keep the ban pic

TC blog homepage

TC Blog

Analysis and debate of the latest tobacco control research findings and policy developments. Visit site

Creative Comms logo

Latest from Tobacco Control

Latest from Tobacco Control