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e-cigarettes

Is Philip Morris’ claim it wants to phase out conventional cigarettes credible?

1 Dec, 16 | by Marita Hefler, News Editor

In recent months, Philip Morris International has been claiming it wants to lead the push to a smoke free world and  wants to work with governments towards the phase out of conventional cigarettes. The claims have been met with scepticism, but do they stand up to scrutiny?

At an investor day held in late September 2016, PMI chief executive officer Andre Calantzopolous outlined the company’s strategic priorities, which include “to continue leading the combustible product category and deliver against our current growth algorithm” and for “Reduced risk products (RRPs) to ultimately replace cigarettes to the benefit of all stakeholders”. Calantzopoulos described the ‘excellent combustible fundamentals’ which include: improving cigarette industry volume/trend mix, and broad and balanced geographic footprint with expansion opportunities. While these are not exactly the words of a leader who wants to get out of the cigarette business, he also states that the company is committed to achieving widespread conversion to RRPs, and that PMI “welcome all alternatives to achieve a combustion-free world as quickly as possible.” Together these contradictory priorities sound very much like a bet each way.

At first glance, the latter rhetoric sounds like the company has finally – after more than 50 years of denial and deceit about the harms of tobacco – realised that not only is the tobacco business ethically and morally bankrupt, but it is also the wrong profit-making horse to back. However, a closer look suggests that reduced risk products may be yet another cynical tactic for the company to position itself as a socially responsible entity that deserves to be treated as part of the solution, rather than the problem.

The glaring omission in the rhetoric is the most obvious alternative for PMI to meaningfully contribute to achieving a combustion-free world: announce a date by which the company will phase out combustible products entirely. Calantzopoulos is on record as stating the iQOS (I Quit Ordinary Smoking) technology which appears to be the platform it is pinning most hope on, put the industry “on the cusp of a revolution”. At the September meeting, he told investors that almost one million smokers have already converted to RRPs and it had captured nearly 3% of the Japanese cigarette market. Wells Fargo Securities tobacco analyst Bonnie Herzog estimates that iQOS could displace 30% of the global combustible market by 2025.

At the September 2016 investor day, Calantzopoulos was not shy about framing RRPs as a public health solution with enormous potential, claiming “…if we can encourage a meaningful portion of adult smokers to rapidly switch to RRPs that meet this standard, it is likely to create a significant additional population health benefit relative to current regulatory efforts.” He called on the public health community to embrace this approach, and noted “we are very much encouraged by the growing number of pre-eminent public health advocates that already support the principle of tobacco harm reduction through products and science.”

The public health community has seen similar promises before: the promise of reduced risk products is nothing new, and the safety of iQOS is largely untested. If these products fail, as their predecessors have done, PMI will have benefited from iQOS and other reduced risk products being branded consistently with its combustible tobacco products.

Presumably anticipating such objections, Calantzopoulos noted, “I fully recognise there is scepticism and a deficit of trust in our determination to lead the effort to achieve a combustion-free world as soon as possible. Although we cannot change the past, we can certainly change the future and transform our company.”

Indeed, PMI can certainly change the future and transform the company. Nothing will accelerate the transition to a smoke free world more effectively than PMI withdrawing completely from the combustibles market, supported by the intensive consumer engagement strategies it is already using to promote uptake of iQOS.

Public health advocates who are willing to work with the tobacco industry on joint harm reduction approaches would do well to remember the fable of the scorpion and the frog, in which the frog agrees to carry the scorpion across a stream. Halfway across, the scorpion stings the frog. As they both start to drown, the frog asks ‘why?’, to which the scorpion replies ‘it’s my nature’.

This is an edited version of an article which was published in the Worldwide News & Comment section of the November edition of Tobacco Control. 

Additional links:

E-cigarettes and children: advocates walking on both sides of the street?

13 Nov, 15 | by Becky Freeman, Web Editor

Post written by Prof Simon Chapman AO

Follow Simon on Twitter: @simonchapman6

—-

In a 2014 open letter to the WHO’s director general Margaret Chan signed by 53 researchers, it was argued “Controls on [ecigarette] advertising to nonsmokers, and particularly to young people are certainly justified, but a total ban would have many negative effects, including protection of the cigarette market and implicit support for tobacco companies. It is possible to target advertising at existing smokers where the benefits are potentially huge and the risks minimal.”

Clive Bates who “had a hand” in organising the letter but curiously did not sign it, is a former director of England’s Action on Smoking and Health. In that role, Bates directed and wrote one of the most excoriating critiques ever published of the tobacco industry’s long standing (and still running) denials of its designs on children.

In the October 2000 Danger in the Playground, Bates documented many of the most telling examples of candid industry talk about the vital role of children to the future of tobacco industry profitability. This accompanying powerpoint presentation (also authored by Bates) rubs it in even harder. These revelations were all made in internal tobacco industry documents released through the US Master Settlement Agreement between US state governments the tobacco industry, millions of which are now freely available here.

The tobacco industry’s business model about the importance of youth smoking was never put more succinctly than in this 1984 document from an RJ Reynolds tobacco official: “If younger adults turn away from smoking, the industry will decline, just as a population which does not give birth will eventually dwindle.” (“younger adults” was industry code from the mid 1970s for children and young adults, to be used in all written communications)

In a 2000 press statement at the time of the launch of the publication, Bates said “When you look at what they say privately, and compare it to their public posturing, the whole idea that tobacco companies might be working against teenage smoking is revealed as sinister self-serving public relations.  The more they try to define smoking as only for adults, the more they are saying ‘hey kids, smoking’s for grown-ups’ with a sly nod and a cynical wink.”

Today, Bates runs his own consultancy business and is a leading advocate of ecigarettes. Of 220 tweets he posted between Oct 1 and Nov 1, 80% were about ecigarettes. On a recent blog he wrote that when it comes to ecigarettes “There is little evidence of marketing to children, only assertions that certain ads or brands are designed to appeal to children but with no empirical evidence, and apparently minimal understanding of modern advertising.”

On reading this, I was struck by how far Bates appears to have moved in the 15 years since he wrote Danger in the Playground and so tweeted a juxtaposition of the two quotes above, asking “which Clive Bates to believe?”

Bates replied challenging this apparent inconsistency, arguing that his 2000 statement referred to tobacco companies while his 2015 statement referred to ecigarette companies. He argued that currently, the vaping market is worth 100 times less than the cigarette market and that “nearly all vape customers come from the ranks of existing smokers”, which he said explains why adult smokers are the target market for ecigs.

The same analysis can of course be applied to the current contribution of young smokers to the total cigarette market. For example, an early Australian analysis showed that while in one year the value of the underage market to manufacturers was $AUD18.7million, if 50% of young smokers continued to smoke, they would contribute $AUD112 billion at current prices to the industry across their lifetime.

Bates knows perfectly that tobacco companies understand the importance of smoking uptake by children to their future, but seems to believe that such a thought has never crossed the minds of ecig manufacturers.

In an extraordinary statement, he wrote that “there are good reasons why the e-cigarette companies, even tobacco owned ones, would not target adolescents … demand, reputational, legal and regulatory risk etc … it would be bad business.”

flavour

E-cigarettes contain many child-friendly flavors. Flickr/keoni101

This language only needs to be contrasted with the many counterfactual examples he supplied in his own 2000 publication. Yes, there are many good reasons why designs on kids need to be publicly denied. As one 1973 tobacco document describing a supposed anti-youth smoking initiative put it “This is one of the proposals that we shall initiate to show that we as an industry are doing something about discouraging young people to smoke. This of course is a phony way of showing sincerity as we all well know.”

In much the same way as the tobacco industry has long done, many of those promoting vaping are today trying to walk on both sides of the street on youth vaping. They know the reputational risk of openly saying that they are unconcerned about youth uptake. Whenever data show negligible uptake by youth, this is rapidly megaphoned as self-evidently a good thing. But when data show significant use, they try to spin this as being an entirely positive development where it happens: all children who are now vaping would have been smoking instead, these clairvoyants assure us.

In the USA today data from the US National Youth Tobacco Survey show that while cigarette smoking continues to fall in US teenagers, e-cigarette use has been dramatically increasing since 2011 and is now way ahead of cigarette smoking: there are now some 50% more middle and high school kids vaping than are smoking, with an estimated 340,000 vaping on more than 20 days each month. Advertising like this, and 3 year old birthday party favourite flavours like these which Bates thinks should be allowed, are plainly intended to beguile teenagers.

A recent systematic review in the Lancet of nicotine and psychosis concluded that “Daily tobacco use is associated with increased risk of psychosis and an earlier age at onset of psychotic illness. The possibility of a causal link between tobacco use and psychosis merits further examination.” It set out important arguments about why the “self-medication” hypothesis about nicotine (promoted by the tobacco industry) deserves reassessment against one where nicotine might be causative in psychosis. Such serious considerations demand that trite dismissals of nicotine as being as benign as “like drinking coffee or something” be condemned.

Clive Bates and others who signed his letter might like to comment on how “it is possible to target [ecigarette] advertising at existing smokers”; how many of these allegedly “adult targeted” ads would never attract the interest of non-smoking teens; and where parents can buy one of the miraculous magic filters that let such advertising through to smokers but somehow render it invisible or uninteresting to young non-smokers.

WHO report on regulation of e-cigarettes and similar products

27 Aug, 14 | by Becky Freeman, Web Editor

The following content is courtesy of the WHO.

The report on “Electronic nicotine delivery systems” (ENDS), of which electronic cigarettes are the most common prototype, is on the agenda of the 6th Conference of the Parties (COP) to the WHO Framework Convention on Tobacco Control (WHO FCTC), being held 13-18 October 2014, in Moscow.

E-cigarettes and similar devices are frequently marketed by manufacturers as aids to quit smoking, or as healthier alternatives to tobacco, and require global regulation in the interest of public health, this new World Health Organization (WHO) report states.

The report states that while e-cigarettes represent an “evolving frontier filled with promise and threat for tobacco control,” regulations are needed to:

  • Impede e-cigarette promotion to non-smokers and young people;
  • Minimize potential health risks to e-cigarette users and nonusers;
  • Prohibit unproven health claims about e-cigarettes; and
  • Protect existing tobacco control efforts from commercial and other vested interests of the tobacco industry.

It explains that while additional research is needed on multiple areas of e-cigarette use, regulations are required now to address health concerns, in particular for:

  • Advertising: An appropriate government body must restrict e-cigarette advertising, promotion and sponsorship, to ensure that it does not target youth and non-smokers or people who do not currently use nicotine.
  • Indoor use: legal steps should be taken to end use of e-cigarettes indoors in public and work places. Evidence suggests that exhaled e-cigarette aerosol increases the background air level of some toxicants, nicotine and particles.

Since 2005, the e-cigarette industry has grown from one manufacturer in China to an estimated US$3 billion global business with 466 brands, a market in which the tobacco industry is taking a greater stake. The report highlights WHO’s concern about the role of the tobacco industry in this market.

The regulations outlined in the report include a ban on e-cigarettes with fruit, candy-like and alcohol-drink flavours until it can be proved they are not attractive to children and adolescents. E-cigarettes have been marketed in almost 8 000 different flavours, and there is concern they will serve as a gateway to nicotine addiction and, ultimately, smoking, particularly for young people. Experimentation with e-cigarettes is increasing rapidly among adolescents, with e-cigarette use in this group doubling from 2008 to 2012, the report says.

Among other conclusions, the document found there was currently insufficient evidence to conclude that e-cigarettes help users quit smoking or not. Therefore, WHO currently recommends that smokers should first be encouraged to quit smoking and nicotine addiction by using a combination of already-approved treatments.

In addition, the report says existing evidence shows that e-cigarette aerosol is not merely “water vapour” as is often claimed in the marketing of these products. While they are likely to be less toxic than conventional cigarettes, e-cigarette use poses threats to adolescents and foetuses of pregnant mothers using these devices.

E-cigarettes also increase the exposure of non-smokers and bystanders to nicotine and a number of toxicants, the report says.

The COP is the central organ and governing body of the Convention and comprises 179 Parties as of today.

The WHO FCTC was adopted by the World Health Assembly on 21 May 2003 and entered into force on 27 February 2005. It has since become one of the most rapidly and widely embraced treaties in United Nations history.

Report on e-cigarettes to WHO Framework Convention on Tobacco Control

e-cigarettes hot topic in global tobacco control

3 Apr, 14 | by Becky Freeman, Web Editor

At the 6th European Conference on Tobacco Control in Turkey last month, the panel discussion on e-cigarettes was one of the most popular and controversial sessions on offer. While much of the data presented was from the UK, there is near universal agreement that e-cigarette use has risen in the past few years, that some (if not most) of the marketing and promotions are clearly attractive to the youth market, and that there is lack of transparency from the industry about it aims and sales targets. Agreement on issues surrounding how best to regulate products and the utility of e-cigarettes within a comprehensive tobacco control framework remains elusive.

Simon Chapman has blogged a series for the BMJ on e-cigarettes and we recommend these posts and ensuing comment discussions to our TC Blog readers:

1. e-cigarettes: the best and the worst case scenarios for public health

2. Will vapers really “quit and (not) die?”

3. Why is Big Tobacco investing in e-cigarettes?

The Bluetooth e-cigarette

23 Feb, 14 | by Becky Freeman, Web Editor

By Stan Shatenstein

There are so many spoof sites on the Internet, you have to think carefully before sharing news of an airline that provides in-flight shisha lounges. But a Bluetooth e-cigarette that lets you receive calls and listen to music? Oh, that one’s for real.

On the Dutch-based Supersmoker’s UK site, the Bluetooth e-cigarette is depicted in all its orchestral complexity, with its speaker, microphone, volume control and Bluetooth buttons – and a few musical notes for illustrative purposes.

For just 79 Euros (US$108), you will be able to stream music from Spotify or YouTube through the built-in speaker. The e-cigarette will buzz and vibrate on incoming calls, and it’s recommended you keep the microphone close when speaking, so you can look as suave as a latter-day Maxwell Smart speaking into his shoe phone.

No word if the song ‘Smoke Gets in Your Eyes’ will play if you’re stuck on hold.

http://supersmokerclub.nl/

Bluetooth E-cigarette

E-cigarettes and the marketing push that surprised everyone

2 Oct, 13 | by Becky Freeman, Web Editor

The e-cigarette debate rages on over at the BMJ…

E-Cigarette-Ad

E-cig ads like these potentially undermine effective quitting messages. Photo source: http://www.trinketsandtrash.org/

Martin McKee writes  how ” the more attention policy makers give to the aggressive marketing of e-cigarettes in their own countries, the more they conclude that the downsides far exceed any benefits.”

Naturally, for such a hot topic, opposing views are quick to materialise. Clive Bates argues that the:

“advertising of e-cigarettes is not something to worry about or ban, rather it should be embraced. It is how smokers will find their way to these new products and it is how new brands will push the cigarette brands aside. The normal controls on truth and fairness in advertising, supplemented by restrictions of the type applied to alcohol, should be sufficient to balance public health opportunities and fears that something might go wrong.”

Or, is it actually the case that e-cigarettes are, as Mike Daube states:

” a weapon of mass distraction – distracting advocates, researchers, and decisions makers from time and resources that could otherwise be devoted to measures we know to be effective, and the community from messages about quitting. “

But it remains the case, as Simon Chapman points out, that e-cigarettes have yet to deliver on lofty promises of:

“rapid and spectacular migration from incontestably far more dangerous cigarettes, driven by an unprecedented consumer acceptable nicotine delivery system; negligible harm to others from the exhaled vapour; children who would have taken up cigarettes, taking up ecigs instead; few children “currently” adopting ecigs who would have never started smoking; no ex-smokers nostalgically returning to nicotine via ecigs; and horrible tobacco caused diseases eventually declining far more than now.”

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

marisa.deandrade1@stir.ac.uk

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

Individual

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?

Political

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?

Philosophical

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?

Conclusion

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.

The marketing of e-cigarettes: a UK snapshot

6 Apr, 13 | by Marita Hefler, News Editor

Marisa de Andrade & Gerard Hastings

Institute for Social Marketing; University of Stirling

marisa.deandrade1@stir.ac.uk

Editor’s note: The United Kingdom’s health regulator, the Medicines and Healthcare products Regulatory Agency (MHRA), is currently considering how to regulate ecigarettes. Given that marketing of these e-cigarettes is of particular concern, Marisa de Andrade and Gerard Hastings were commissioned by Cancer Research UK to conduct a rapid review of current practices and emerging trends. Here they provide highlights from the review.

————–

Multiple brands of e-cigarettes are being widely marketed, both online and in conventional media, as safer, ‘healthier’ and cheaper alternatives to smoking that can be used either to quit, or for dual use in places where smoking is not allowed – thereby enabling smokers to ‘take back their freedom’.

The products come in various flavours, colours and innovative packaging and have been endorsed by celebrity doctors and actors as well as fictional cartoon characters; presented as ‘must-have’ accessories; linked to charities; featured in various television programmes and films and been pictured in the hands of celebrities.  The ads frequently use images of young, attractive men and women and, in one case, sponsor a 19 year old British Touring Car professional racing driver.  Much imaginative use is made of online marketing – including social networking platforms; online consumer forums and internet-affiliate schemes which turn users into sellers.

The advertising regulator – the Advertising Standards Authority – is struggling to tackle this plethora of marketing communication. It has taken steps to remove claims on e-cigarette websites suggesting that the products are harmless (this remains unproven), and is monitoring television advertising – which cannot, for instance, make reference to the act of smoking.  However, the regulatory challenges are significant.

Early efforts to regulate tobacco advertising showed how difficult it is to control the content of imagery-rich appeals; thus the fact that smoking cannot be directly mentioned does not mean that it is not being indirectly invoked using pictures or associations.  Even with the best intentions, transgressions slip through the net; for example many e-cigarettes are being promoted as smoking cessation aids although they are not currently licensed for this in the UK.  Furthermore, online publicity presents particular difficulties – websites can be set up outside UK jurisdiction, for instance, and website age protection remains rudimentary.  The potential appeal of ecigarettes to the young is a particular concern, with at least one baseline study suggesting that younger, non-minority smokers with higher incomes have a high awareness of these products.

These developments have recently taken a more sinister turn because the tobacco industry has acquired large stakes in the e-cigarettes business.  As a corporation, a tobacco company’s overriding objective is to maximise profits. It is possible that this could be benefit public health by enabling them to diversify away from burned tobacco products, and so hasten the move to smokefree.  However, given the market size and dominance of burned tobacco, it seems more likely that these acquisitions will be used to bolster the status quo by normalising nicotine use, providing control of the recreational (and possibly pharmaceutical) gateways to it and turning a potential competitor into a product range (or even brand) extension.

The rapid review pinpoints two key areas of e-cigarettes which urgently need more research. Firstly, we have to know much more about public, and especially young people’s (including smokers and non-smokers), response to ecigarettes and the related marketing. To what extent are these developments modelling, reinforcing, or in any way promoting smoking? Secondly, it is vital that we learn much more about the tobacco industry’s intent. The current swathe of ecigarette marketing in the UK is chillingly reminiscent of the early days of tobacco advertising; this past experience suggests there is good reason to be deeply concerned.

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