Understanding the emergence of the tobacco industry's use of the term tobacco harm reduction in order to inform public health policy

Analysis of Philip Morris International's 'aspirational' target for its 2025 cigarette shipments

BACKGROUND

Philip Morris International (PMI) claims to be transforming and has committed to a 'smoke-free' future. In 2020, it announced an 'aspirational' target for reduced cigarette shipments by 2025.

METHODS

PMI cigarette shipment data are taken from PMI quarterly financial reports 2008-2023. Trends in these data before and after the 2020 announcement are analysed using linear regression, and auto regressive integrated moving average and error, trend, seasonal time-series models to assess if PMI's 2025 target would be met on pre-existing trends, and if the trend changed after the announcement. These trends are also compared with the global retail market for cigarettes, using sales data from Euromonitor.

RESULTS

Findings were consistent across all three models. PMI's shipment target of 550 billion cigarette sticks by 2025 would readily have been met given pre-existing shipment trends. Following the 2020 announcement, the decline in PMI cigarette shipments stalled markedly with a statistically significant change in trend (p<0.001). The current and projected trend to 2025 is consistent with no further decline in cigarette volumes, meaning PMI is unlikely to hit its target. This mirrors a global pattern in which declines in cigarette sales have stalled since 2020.

CONCLUSIONS

PMI's 2025 target was not 'aspirational' but highly conservative-it would have been met based on pre-existing trends in declining cigarette shipments. Yet PMI will nonetheless fail to meet that target providing evidence it is not transforming. Stalling of the decline of PMI and global cigarette sales raises significant concerns about progress in global tobacco control.

Document analysis of the Foundation for a Smoke-Free World's scientific outputs and activities: a case study in contemporary tobacco industry agnogenesis

BACKGROUND

Tobacco corporation Philip Morris International launched the Foundation for a Smoke-Free World (FSFW), a purportedly independent scientific organisation, in 2017. We aimed to systematically investigate FSFW's activities and outputs, comparing these with previous industry attempts to influence science, as identified in the recently developed typology of corporate influence on science, the Science for Profit Model (SPM).

DESIGN

We prospectively collected data on FSFW over a 4-year period, 2017-2021, and used document analysis to assess whether FSFW's activities mirror practices tobacco and other industries have historically used to shape science in their own interests. We used the SPM as an analytical framework, working deductively to search for use of the strategies it identifies, and inductively to search for any additional strategies.

RESULTS

Marked similarities between FSFW's practices and previous corporate attempts to influence science were observed, including: producing tobacco industry-friendly research and opinion; obscuring industry involvement in science; funding third parties which denigrate science and scientists that may threaten industry profitability; and promoting tobacco industry credibility.

CONCLUSIONS

Our paper identifies FSFW as a new vehicle for agnogenesis, indicating that, over 70 years since the tobacco industry began to manipulate science, efforts to protect science from its interference remain inadequate. This, combined with growing evidence that other industries are engaging in similar practices, illustrates the urgent need to develop more robust systems to protect scientific integrity.

Awareness of tobacco industry tactics among tobacco control communities in Thailand and its association with attitudes towards tobacco industry and perceptions of e-cigarettes

BACKGROUND

Tobacco industry denormalisation is a key strategy recommended by the WHO Framework Convention on Tobacco Control as it is associated with reducing smoking behaviours and positively influencing public and policymakers' opinion towards tobacco control. However, studies of awareness of tobacco industry tactics among public health players and policymakers in low-income and middle-income countries are limited.

METHODS

We conducted an online survey of individuals who had been involved in tobacco control in Thailand. Multivariate ordinal logistic regression analysis was used to determine the association between awareness of tobacco industry tactics and different attitudes towards tobacco industry and perceptions towards e-cigarettes, controlling for role in tobacco control and demographics among 441 respondents.

RESULTS

Of the respondents, 11.3% had never heard of any tobacco industry tactics, whereas 11.1% had heard of all tactics asked in the survey. Tobacco industry tactics which were less known by participants were intimidation (30.6%) and illicit trade (37.4%). Participants who were more aware of tobacco industry tactics were more likely to have negative attitudes towards the tobacco industry and e-cigarettes. Compared with active experts of the Provincial Tobacco Products Control Committee and provincial public health officials who work in tobacco control programmes, advocates who worked for civil society organisations in tobacco control were more aware of tobacco industry tactics and had less favourable perceptions of e-cigarettes.

CONCLUSION

This study emphasises the importance of educating public health professionals and policymakers about tobacco industry behaviour, especially in the era of e-cigarettes.

PMI-funded foundation for a smoke-free world: application of criteria to assess funding models that include financial support from the tobacco industry

Recent changes to the leadership and the terms of tobacco industry financing of the Foundation for a Smoke-Free World (FSFW) have called for a revisiting of a paper published in 2009 where we proposed criteria and other considerations to assess possible funding models for research that include financial support from the tobacco industry. This paper reviews and attempts to apply the elements laid out in 2009 to the current state of FSFW. After discussing each criterion and consideration we conclude that, at this point in time, conducting a thorough assessment using our 2009 paper is not possible because critical details related to FSFW governance, decision-making and process have not been announced. Nonetheless, we hope this paper will remind the tobacco control community that the 2009 criteria exist and highlight the information needed and questions that might be asked of FSFW to help form judgements about this new iteration of the foundation. We further hope this will put the FSFW on notice that they need to address each of these criteria and speak publicly about their plans regarding the specific issues raised in the 2009 paper.

Pharmaceuticalisation as the tobacco industry's endgame

CONTEXT

Declining smoking prevalence and denormalisation of tobacco in developed countries reduced transnational tobacco company (TTC) profit during 1990s and 2000s. As these companies faced increasingly restrictive policies and lawsuits, they planned to shift their business to socially acceptable reduced-harm products. We describe the internal motivations and strategies to achieve this goal.

METHODS

We analysed previously secret tobacco industry documents available through the Truth Tobacco Documents Library. These documents were triangulated with TTCs' investor and other professional reports, websites and public statements.

FINDINGS

Mimicking pharmaceutical business models, tobacco companies sought to refurbish their image and ensure long-term profitability by creating and selling pharmaceutical-like products as smoking declined. These products included snus, heated tobacco products, e-cigarettes, nicotine gums and inhalers. Tobacco companies created separate divisions to develop and roll out these products, and the majority developed medical research programmes to steer these products through regulatory agencies, seeking certification as reduced-harm or pharmaceutical products. These products were regarded as key to the survival of the tobacco industry in an unfriendly political and social climate.

CONCLUSIONS

Pharmaceuticalisation was pursued to perpetuate the profitability of tobacco and nicotine for tobacco companies, not as a sincere search to mitigate the harms of smoking in society. Promotion of new pharmaceuticalised products has split the tobacco control community, with some public health professionals and institutions advocating for the use of 'clean' reduced-harm nicotine and tobacco products, essentially carrying out tobacco industry objectives.

Philip Morris International's Formula 1 Sponsorship-Linked Marketing: Transformation From Marlboro to Mission Winnow

INTRODUCTION

Transformation describes a dramatic modification in appearance or character. Philip Morris International (PMI)'s sponsorship-linked marketing of Formula 1 auto racing is illustrative of transformation. The company's flagship cigarette brand, Marlboro has been replaced as the identified partner by their newly developed brand, Mission Winnow. This study examines the tobacco company's marketing objectives for transforming the brand identity of its Formula 1 Ferrari race team partnership.

AIMS AND METHODS

We provide a case study, and our method of qualitative enquiry is textual analysis. We review marketing planning documents from Philip Morris, which would normally be proprietary, but are publicly accessible because of litigation. Additionally, we review Mission Winnow's social media posts, over a 3-year span, from the brand's Facebook, Instagram, and Twitter accounts.

RESULTS

PMI initiated its Formula 1 sponsorship in 1972. Through Marlboro, the company's sponsorship-linked marketing was largely centered on building brand image and reinforcing Marlboro's brand identity of rugged masculinity, independence, heroism, and adventure. When Mission Winnow replaced Marlboro as the identified brand sponsor in 2018, the company's marketing communication shifted to highlighting transformation, progress, open dialogue, teamwork, innovation, technology, and science.

CONCLUSIONS

Despite Article 5.3 of the World Health Organization's Framework Convention on Tobacco Control (WHO FCTC) calling for Parties to protect public health policies from the commercial and vested interests of tobacco companies, PMI still seeks to be an important stakeholder in such consultations, including those pertaining to harm reduction. Mission Winnow's sponsorship-linked marketing points to a larger company narrative about trying to gain or reclaim legitimacy and credibility.

IMPLICATIONS

PMI's continued sponsorship of Formula 1 is a strategic means of drawing attention to the company's "next-generation products" and communicating their supposed "transformation." The company's sponsorship-linked marketing initiatives point to a need for Parties to enforce Article 13 of the WHO FCTC, which calls for a comprehensive ban on tobacco advertising, promotion, and sponsorship.

Perceived Truthfulness of Reduced Lung Cancer Risk Advertising Claims Influences Consumers' Intention to try and to Purchase Snus

The objective of the current study was to evaluate the impact of a reduced risk claim about lung cancer, presented in various formats, on smokers' and non-smokers' interest in trying Camel Snus and intention to purchase Camel Snus. We varied claim formats by varying advertising messages for Camel Snus in 4 ways (1) text only; (2) bar chart; (3) text/testimonial; and (4) bar chart/testimonial. 3001 participants were recruited from a web-based consumer specialty panel via an email invitation. In 2015, a second study was conducted, using similar methods, where 3001 additional participants were recruited. Overall, controlling for other factors, the presence of an MRTP claim was not significantly related to interest in trying snus [X2 (4) = 8.567, P = .073], or purchase intentions [X2 (4) = 1.148, P = .887]. Relative to a control ad where no explicit health risk claim was made, the Graphic + testimonial [OR = 1.29] or Text only [OR = 1.41] claims did significantly increase interest in trying Camel Snus. However, the adverting format did not impact interest in purchasing Camel Snus. While current smokeless tobacco users (95%) and smokers (59%) expressed interest in trying Camel Snus, non-tobacco users (7%) showed low interest in trying or purchasing Camel Snus (P < .001). Interest in trying Camel Snus was stronger in younger smokers compared to older smokers. Among current smokers, worry about lung cancer (the key focus of the reduced risk claim) was not associated with interest in trying Camel Snus or with purchase intention [OR = .91, 95% CI: .72, 1.14] or intention to purchase snus [OR = 1.07, 95% CI: .86, 1.32]. Future research should evaluate how claim and messaging formats influence perceived truthfulness and whether this effect differs among sub-groups of consumers, such as adolescents, those with tobacco-related disease, and former smokers. It will also be helpful to understand whether perceptions of ad truthfulness result in changes in product use patterns over time. In sum, giving people truthful, credible information about relative product risks, such as through authorized MRTP claims, is important, but such information is likely insufficient to get smokers to switch.

An Analysis of Arguments Advanced via Twitter in an Advocacy Campaign to Promote Electronic Nicotine Delivery Systems

INTRODUCTION

Advocates of electronic nicotine delivery systems (ENDS) increasingly use Twitter to promote liberal ENDS policies. "World Vape Day" (WVD) is an annual campaign organized by pro-ENDS advocacy groups, some of which have links to the nicotine industry (eg, via funding from the "Foundation for a Smoke-Free World"). In 2020, the campaign used dedicated social media accounts to disseminate WVD-branded images and campaign messages. We examined tweets posted as part of WVD 2020 to identify and analyze pro-ENDS policy arguments.

AIMS AND METHODS

We extracted tweets posted between 26 May and 3 June 2020 that included the hashtag #WorldVapeDay. We used qualitative thematic analysis to code a random sample (n = 2200) of approximately half the original English language tweets (n = 4387) and used descriptive analysis to identify the most frequently used co-hashtags.

RESULTS

Arguments related to four themes: harm reduction, smoking cessation, rights and justice, and opposition to ENDS restrictions. Tweets criticized individuals and groups perceived as opposing liberal ENDS regulation, and used personal testimonials to frame ENDS as a harm reduction tool and life-saving smoking cessation aid. Tweets also advanced rights-based arguments, such as privileging adults' rights over children's rights, and calling for greater recognition of consumers' voices. Tweets frequently used hashtags associated with the WHO and World No Tobacco Day (WNTD).

CONCLUSIONS

The WVD campaign presented a series of linked pro-ENDS arguments seemingly aimed at policy-makers, and strategically integrated with the WHO's WNTD campaign. Critically assessing pro-ENDS arguments and the campaigns used to promote these is vital to helping policy actors develop proportionate ENDS policy.

IMPLICATIONS

Social media platforms have considerable potential to influence policy actors. Tweets are easily generated and duplicated, creating an impression of sizeable and influential stakeholders. Evidence that the "World Vape Day" campaign was supported by groups with industry links, and targeted-at least in part-at WHO officials and those who follow the WHO World No Tobacco Day campaign, highlights the importance of critically reviewing such campaigns. Further research could examine how health advocates could engage in pro-ENDS campaigns to support balanced messaging and informed policy-making.

E-Cigarette Retailers' Use of Instagram in New Zealand: A Content Analysis

E-cigarette companies claim their products are key to improving health outcomes by providing smokers with lower-risk alternatives. However, the rapid uptake of e-cigarettes among young people has prompted concern about company marketing practices. In 2019, there was no legislation to govern e-cigarette marketing in New Zealand. This period provides an ideal context for examining how e-cigarette companies promoted their products before the introduction of marketing regulations. We conducted a content analysis of the Instagram accounts of five prominent e-cigarette retailers based in New Zealand during 2019-2020. We assessed health- and risk-related claims and marketing techniques. Less than 10% of Instagram posts refer to smoking alternatives or risk of nicotine addiction. E-cigarette devices were more likely to be promoted for stylistic features such as colours and ease of use (29.7%). Music festival sponsorship (19.1%), social media influencers (9.2%), and lifestyle marketing (41.5%) were identified as youth-oriented promotional strategies. E-cigarette retailers claim to promote harm-reduction tools to smokers, yet this study finds few references to smoking alternatives in any content. Instead, retailers utilised strategies to engage with a young audience, including festival sponsorship and stylish influencers. This youth-oriented marketing, in combination with weak and delayed government action, may have contributed to the high use of e-cigarettes among young New Zealanders.

Age, gender and socioeconomic patterns of awareness and usage of e-cigarettes across selected WHO region countries: evidence from the Global Adult Tobacco Survey

OBJECTIVES

The study explores the awareness and e-cigarette use by demographic and socio-economic characteristics of selected 14 Global Adult Tobacco Survey (GATS) countries.

DESIGN

Cross-sectional.

SETTING

14 countries.

PARTICIPANTS

Surveyed population ≥15 years selected through multi-stage cluster sampling.

PRIMARY AND SECONDARY OUTCOME MEASURES

We selected 14 countries from 6 different WHO regions where GATS was conducted in different years during 2011-2017.

RESULTS

Awareness and usage of e-cigarette were highest in Greece and lowest in India. Females were less aware of e-cigarette across ages. The gender gap in awareness is wide in Greece post 50 years of age, while the gap is distinct in early ages in Kazakhstan and Qatar. The gender difference in use of e-cigarette was negligible in most of the countries except among the younger cohorts of Russia, Philippines Malaysia and Indonesia. Relatively higher prevalence of e-cigarette smoking among females in the older adult age was observed in some of the Asian countries like India. Multivariate analysis indicates that those who were younger, male, residing in urban areas, current tobacco smokers were more likely to use e-cigarette than their counterparts. Though prevalence of e-cigarette use increased with wealth and education, such pattern is not strong and consistent. Promotional advertisement plays important role in higher use of e-cigaratte. The predicted national prevalence of e-ciragette use was highest in Malaysia .

CONCLUSIONS

E-cigarette use is more among urban adults, current smokers, males and in countries with promotional advertisement of e-cigarette. Area specific interventions are needed to understand the nature of e-cigarette use. Russia, Ukraine, Costa Rica and Mexico need better understanding to explore whether e-cigaratte use is an indulgence to new mode of addiction, as youth being highly likely to adopt this practice.

JUUL preference among Korean adult tobacco users and its effect on attempts to quit tobacco: A follow-up survey four months post JUUL launch

INTRODUCTION

This study examined the various factors in the selection of JUUL (and/or), a pod-mod type electronic cigarette (EC), and the changes in EC patterns before and after the JUUL debut on 24 May 2019, using follow-up survey data of adult tobacco users in South Korea.

METHODS

This study examined transition outcomes among tobacco users and factors associated with future JUUL use. Convenience sample data were collected from adult tobacco users in South Korea, from March-April 2019 (baseline, n=2173) to September 2019 (follow-up, n=779). Results were obtained from the 779 respondents in the follow-up survey, and user data of one or more tobacco products were analyzed. The changes in the proportion of EC and JUUL use during this period were calculated, and multivariate logistic regression analysis was conducted to investigate the selection factors of JUUL.

RESULTS

Four months after the JUUL launch, the proportion of current EC and JUUL users among the whole sample increased by 10.3% (42.6-52.9%, p<0.001) and 17.7 % (4.0-21.7%, p<0.001), respectively, while the proportion of triple users doubled (18.7% vs 37.5%, p<0.001). Among current EC users, the percentage of quitting EC within one month decreased from 18.7% to 8.7%; this change was more pronounced among concurrent JUUL users than non-JUUL users (p<0.001). In the multivariate logistic analysis with adjustment for possible confounders, JUUL use was significantly associated with male sex, young and middle age, and metropolitan residency status at the baseline survey.

CONCLUSIONS

After the launch of JUUL in South Korea, EC users, including JUUL and triple users, increased significantly, but the intention to stop EC decreased significantly. Given the serious interests of the tobacco industry in these products, additional regulation is warranted.

Impact of Visual Elements of Tobacco Packaging on Health Risk Perceptions of Youth Groups

Tobacco products are hazardous to public health and are one of the greater public health threats facing the world to date. Although international research on tobacco packaging has been thorough and comprehensive, the risk perception of visual elements in tobacco packaging varies by country, race, and smoking status. Therefore, the study aimed to investigate the risk perceptions of visual elements in tobacco packaging among young and middle-aged people in selected cities in China. This study used a questionnaire to construct an index system for visual elements of tobacco packaging and used it to design a related questionnaire. Our group conducted an online questionnaire survey among 296 young people (18-44 years old) in selected cities in China between 16 June and 26 June 2022. The results of the influence of visual elements of tobacco packaging on the perception of tobacco health risks in the youth group were analyzed by SPSS 26.0. A chi-square test analysis yielded differences in the perception of tobacco package color among youths with different smoking status. A linear regression analysis revealed that age group and visual elements were significant, and five groups of visual element comparisons had an effect on the youth group. First, there were differences in the perceptions of tobacco products among participants with different smoking status. Secondly, the more youthful the respondents were, the greater the probability that they were able to identify that the picture fitness warnings had a greater probability of making them conscious of the fitness dangers of smoking (p < 0.05). The older the participants, the greater the probability that the textual content fitness warnings made them conscious of the fitness risks of smoking (p < 0.05). Third, the percentage of health warnings did not make a good-sized impact for the youth groups (p > 0.05). Fourth, the more youthful the participant, the greater the probability that cigarette products with whole brand images would appeal to buyer(p < 0.01).

Does a human rights-based approach to harm reduction support commercialized harm reduction? Brief research

In recent years, the tobacco industry has been pushing a narrative that their newer lines of products-including electronic nicotine delivery devices-are offered in part to meet a social responsibility of providing potentially reduced-harm choices to their consumers. While some of the newer tobacco products might potentially be less harmful than combustible tobacco products, there is also significant deviation from the very concept of harm reduction when it is used for such a conspicuously commercialized purpose. The framing of commercialized tobacco harm reduction as a mere consumer preference by the industry is not clearly consistent with the core principles of harm reduction, let alone the human right to health and the highest attainable level of health. A human rights-based approach (HRBA) to harm reduction is a set of principles that frame an effort to respect and promote human rights, including the right to health. Whether the HRBA supports commercialized harm reduction requires study. We review industry materials from 2017 to 2022 to identify themes in the harm reduction narrative of the tobacco industry and analyse those themes using an HRBA to the tobacco harm reduction framework. Using this analysis, the industry's continued marketing of combustible products alongside their "potentially less harmful" products, and preference that their non-combustible products be regulated less strictly than cigarettes and cigars, adulterates the public health principles of harm reduction and undermines the right to health. We conclude that the tobacco industry's commercialized tobacco harm reduction is incompatible with a human rights-based approach to tobacco harm reduction.

Tobacco industry messaging around harm: Narrative framing in PMI and BAT press releases and annual reports 2011 to 2021

Influencing public perception is a key way in which all transnational corporations (TNCs) maintain market dominance and political power. Transnational tobacco companies (TTCs) have a long history of leveraging narratives to serve commercial ambitions. The global reach of these companies' narratives has been highlighted as a challenge in combatting public health problems caused by tobacco. The corporate power of TTCs is carefully curated, and their narratives play an important role in the setting of governance dynamics at local, national and transnational levels. This qualitative work explores and compares the language used by British American Tobacco (BAT) and Philip Morris International (PMI) around harm, harm reduction and terms used to refer to newer nicotine and tobacco products, including electronic cigarettes and heated tobacco products. We systematically examine framings used by these two TTCs through company reports published between 2011 and 2021. Qualitative coding was carried out by four coders, according to a protocol developed specifically for this work. We firstly identified the presence of pre-selected keywords and then assigned chunks of text containing those key words to one or more associated frames drawn from Boydstun's policy frames codebook (2013). Qualitative coding identified the most common frames from Boydstun's codebook and thematic analysis highlighted three overarching themes. The most common frames assigned were "capacity and resources", "health and safety" and "economic" frames. The overarching themes were individualization, normalization, and regulation. These themes capture how both BAT and PMI use particular framings to downplay the role of TTCs in the perpetuation of population- and individual-level harms related to tobacco use. They seek to normalize their role in public discussions of health policy, to cast themselves as instrumental in the redress of tobacco-related inequalities and shift responsibility for the continuation of tobacco-product use onto individual consumers. These tactics are problematic for the effective and impartial development and implementation of local, national and international tobacco control agendas.

Tobacco control in Asia-Pacific: wins, challenges and targets

For many decades, the international tobacco industry has set its sights on Asia, due to the large population numbers, the high prevalence of male smokers who might shift to its brands, and the extremely low number of female smokers who could possibly be induced into starting smoking. Because of US trade threats against several Asian countries in the 1980s, Asia became quickly aware that tobacco control involved politics, legislation, economics and trade. Several Asian jurisdictions pioneered tobacco control measures, and the Western Pacific is still the only WHO region where all countries have ratified the WHO Framework Convention on Tobacco Control (FCTC). Progress needs to be accelerated to reduce the still high male smoking prevalence and maintain the low female prevalence by fully implementing the WHO FCTC as part of achieving sustainable development, even while grappling with the looming epidemic of new products, holding the companies accountable, and protecting tobacco control policies against constant industry interference.

Moving targets: how the rapidly changing tobacco and nicotine landscape creates advertising and promotion policy challenges

Tobacco, nicotine and related products have and continue to change rapidly, creating new challenges for policies regulating their advertising, promotion, sponsorship and sales. This paper reviews recent commercial product offerings and the regulatory challenges associated with them. This includes electronic nicotine delivery systems, electronic non-nicotine delivery systems, personal vaporisers, heated tobacco products, nicotine salts, tobacco-free nicotine products, other nicotine products resembling nicotine replacement therapies, and various vitamin and cannabis products that share delivery devices or marketing channels with tobacco products. There is substantial variation in the availability of these tobacco, nicotine, vaporised, and related products globally, and policies regulating these products also vary substantially between countries. Many of these products avoid regulation by exploiting loopholes in the definition of tobacco or nicotine products, or by occupying a regulatory grey area where authority is unclear. These challenges will increase as the tobacco industry continues to diversify its product portfolio, and weaponises 'tobacco harm reduction' rhetoric to undermine policies limiting marketing, promotion and taxation of tobacco, nicotine and related products. Tobacco control policy often lags behind the evolution of the industry, which may continue to sell these products for years while regulations are established, refined or enforced. Policies that anticipate commercial tobacco, nicotine and related product and marketing changes and that are broad enough to cover these product developments are needed.

Understanding the long-term policy influence strategies of the tobacco industry: two contemporary case studies

OBJECTIVE

This paper explores transnational tobacco companies' (TTCs) long-term policy influence strategies using two case studies, harm reduction and illicit tobacco, to identify lessons for the tobacco control movement and wider efforts to address the commercial determinants of health.

METHODS

Evidence from a broad combination of sources including leaked documents and findings from over two decades of TTC monitoring were reviewed for each case study and categorised using the Policy Dystopia Model, focusing on the primary discursive strategy and key instrumental (action-based) strategies used.

RESULTS

In both case studies, TTCs seek to advance their interests by engaging primarily in reputation management, coalition management and information management strategies over the long-term to propagate their over-riding discursive strategy-'we've changed, we are part of the solution'-despite clear evidence from both case studies that this is not the case. These strategies are globally coordinated and attempt primarily to reshape norms towards TTC involvement in tobacco control policy and delivery. Findings also suggest that industry denormalisation and the advent of Article 5.3 have led to the TTCs growing use of increasingly complex and opaque 'webs of influence'.

CONCLUSIONS

The tobacco control community must develop its own proactive long-term strategies which should include industry denormalisation, new ways to fund research that reduce industry control, and improved transparency measures for research and policy. These findings, including TTC adaptations to Article 5.3, also indicate the need for more structural solutions, addressing corporate power and the underlying political and economic system. These lessons can be applied to other unhealthy commodity industries.

Identifying misleading corporate narratives: The application of linguistic and qualitative methods to commercial determinants of health research

Narratives are key to the way corporations represent themselves to the outside world, are important to the development of shared understandings and ultimately determine whether and how corporations are able to influence societal norms and participate in policy debates. A leaked corporate affairs strategy document, from the world's largest transnational tobacco company, Philip Morris International (PMI), suggests a company concerned about credibility; it highlights "normalization" as a key strategic priority until at least 2024. This suggests that the PMI are seeking to rehabilitate their image and alter perceptions of their business. We designed a mixed-methods analysis of corporately authored content, combining quantitative querying of large bodies of text (Corpus Linguistics) with inductive coding of key themes to critically examine PMI's corporate language and how these themes might impact public health debates. We systematically analysed a sample of PMI's corporate communications (n = 170), comparing investor-facing (investor reports, slides and presentations as well as annual reports) and public-facing (YouTube content and Webpage content) communications covering a period of eight years (2012-2019). Our analysis identifies how PMI's misleading external communication contradicts its core business focus and may threaten public health. In public-facing communications, PMI stress their commitment to transformation and change, while in investor-facing communications, they focus on cigarettes and reiterate the strength of their existing cigarette brand portfolios. This suggests that webpage and YouTube content provide a means through which PMI attempt to neutralise negative public perception of tobacco-product related harms and to present themselves as advocates of "better" consumer choice and even public health. The recurrence of transformation, sustainability, and science, as well as the co-option of united-nations terminology in their external-facing communications may serve to legitimise their involvement in policy arenas from which they currently excluded. We present a novel method through which corporate narratives can be monitored and critically assessed.

Developing more detailed taxonomies of tobacco industry political activity in low-income and middle-income countries: qualitative evidence from eight countries

INTRODUCTION

Historical evidence, predominantly from high-income countries (HICs), shows that the tobacco industry uses a recurring set of arguments and techniques when opposing tobacco control policies. This data formed the basis of a model of tobacco industry political activity known as the policy dystopia model (PDM). The PDM has been widely used in tobacco control research and advocacy and has subsequently been shown relevant to other unhealthy commodities industries in both HICs and low-income and middle-income countries (LMICs). Before it can be validated as a generic tool for researching corporate influence on policy, one needs to determine whether the PDM successfully captures contemporary corporate political activities in LMICs.

METHOD

We conducted semistructured interviews with 22 LMIC-based advocates and used the transcripts as the primary data source. The discursive and instrumental taxonomies constituting the PDM served as the starting point for the coding framework. Using thematic analysis, we combined deductive and inductive coding to ensure we captured all strategies from the PDM and the interviews.

RESULTS

This study found that the tobacco industry uses a set of discursive and instrumental strategies that is largely consistent across LMICs and with the PDM. We identified several minor contextual nuances absent from the PDM. Some of these nuances were characteristic to individual countries, while others to LMICs more broadly. They included the argument that tobacco control policies unfairly punish reputable tobacco industry actors, and an emphasis on instrumental strategies centred around maintaining a good image, rather than rehabilitating a tarnished image as emphasised in the PDM.

CONCLUSIONS

Allowing for the nuances identified in this study, the PDM has been found to be fit for purpose. The revised model should now be tested through in-depth LMIC case studies and could be used to facilitate comparative studies of unhealthy commodity industries' political activities.

A review of tobacco abuse and its epidemiological consequences

Aim

The economic burden caused by death and disease in the world is credited mainly to tobacco use—currently linked to approximately 8,000,000 deaths per year with approximately 80% of these faralities reported in low and middle income economies. The World Health Organization (WHO) estimates that nearly 7,000,000 deaths are attributed to direct tobacco use, while approximately 1,200,000 non-smokers exposed to second hand cigarette smoke die every year. Accordingly, tobacco use is a major threat to the public health infrastructure; therefore, proper cessation interventions must be put in place to curb tobacco abuse and ease economic and social burdens caused by the tobacco epidemic.

Methods

A systematic review was conducted to investigate how scientific efforts have been advanced towards harm reduction among smokers and non-smokers. Relevant articles published during the period 2010–2020 in PubMed, Crossref, Google scholar, and Web of Science were used in this study. The articles were selected based on health impacts of cigarette smoking, tobacco cessation and emerging diseases, including Covid−19. Various cessation strategies have been identified although their efficiency is yet to match the desired results.

Results

A series of carcinogenic chemicals are generated during cigarette smoking resulting in serious health complications such as cancer and mutagenesis. The precursors for tobacco induced diseases are toxic and carcinogenic chemicals of the nitrosamine type, aldehydes, polonium-210 and benzo[a]pyrene, which bio-accumulate in the body system during cigarette smoking to cause disease. Rehabilitation facilities, use of drugs to diminish the desire to smoke, heavy taxation of tobacco products and warning labels on cigarettes are some of the cessation strategies employed towards curbing tobacco abuse.

Conclusion

The need for further research to develop better methods and research based policies for safe cigarette smoking and workable cessation strategies must be a priority in order to deal with the tobacco epidemic. Campaigns to promote tobacco cessation and abstinence are recommended in this review as a sure measure to mitigate against the deleterious impacts caused by cigarette smoking and tobacco abuse.

Exposure to the advertisement of toombak at the point-of-sale among adolescents in Khartoum State, Sudan: A cross-sectional study

INTRODUCTION

This study aimed to assess the association between toombak (smokeless tobacco) advertisement at point-of-sale (PoS) and its use among adolescents in Sudan.

METHODS

A cross-sectional school-based and self-administered questionnaire study was conducted. Schools were randomly selected using a one-stage stratified sampling procedure, during 2013–2014, as part of a larger research project focusing on the use of toombak among secondary school students in Khartoum State, Sudan. The sample size was 1526 students. Data were collected on exposure to toombak advertisement, social acceptability, perceived accessibility to toombak, susceptibility, and toombak use.

RESULTS

A total of 41.8% of the adolescents were exposed to an advertisement at PoS, while 12.5% perceived direct access to toombak, 5.3% reported that they were susceptible to use toombak, and 10.9% were ever toombak users. Exposure to the advertisement of toombak at PoS was found to be associated with the older age group (44.3%) (p≤0.05). Males were more than females (45.2% vs 38.8%; p≤0.05). Those exposed to toombak advertisements at PoS reported more social acceptability towards toombak (48.9% vs 37.6%; p≤0.001) and direct accessibility to toombak (68.8% vs 47.2%; p≤0.05). Ever toombak users reported higher exposure to advertisements than non-users (54.5% vs 40.3%; p≤0.001).

CONCLUSIONS

Exposure to toombak advertisements at PoS was found to be high and associated with increased toombak use in Khartoum State, Sudan, in addition to increasing social acceptability to its use and perceived easy accessibility. The current law, which bans toombak advertisement and promotion at PoS, needs to be enforced.

Cigarette Packs With URLs Leading to Tobacco Company Websites: Content Analysis

BACKGROUND

Tobacco companies include on the packaging of their products URLs directing consumers to websites that contain protobacco messages. Online media tend to be underregulated and provide the industry with an opportunity to present users with protobacco communication.

OBJECTIVE

The objective of our study was to document the content of websites that were advertised on tobacco packs in 14 low- and middle-income countries.

METHODS

We purchased tobacco packs from 14 low- and middle-income countries in 2013 and examined them for the presence of URLs. We visited unique URLs on multiple occasions between October 1, 2016 and August 9, 2017. We developed a coding checklist and used it to conduct a content analysis of active corporate websites to identify types of protobacco communication. The coding checklist included the presence of regulatory controls and warnings, engagement strategies, marketing appeals (eg, description of product popularity, luxury/quality, taste), corporate social responsibility programs, and image management. We coded brand websites separately and also described social media and other website types.

RESULTS

We identified 89 unique URLs, of which 54 were active during the search period. We assessed 26 corporate websites, 21 brand websites, 2 nontobacco websites, and 5 social media pages. We excluded 2 corporate websites and 14 brand websites due to limited accessible content or incomplete content. Corporate social responsibility was discussed on all corporate websites, and marketing appeals were also common. Corporate websites were also more likely to include more nonspecific (12/24, 50%) than specific (7/24, 29%) health warnings. Promotions (6/7, 86%) and sociability appeals (3/7, 43%) were common on brand websites. The small number of social media webpages in our sample used gendered marketing.

CONCLUSIONS

URLs appearing on tobacco packs direct consumers to websites where users are exposed to marketing that highlights the "positive" contributions of tobacco companies on corporate websites, and extensive promotions and marketing appeals on brand websites and social media pages. It is essential that marketing regulations become more comprehensive and ban all protobacco communication, a policy that is in line with articles 5.3 and 13 of the World Health Organization Framework Convention on Tobacco Control. For countries that already ban internet tobacco advertising, enforcement efforts should be strengthened. Tobacco companies' use of URLs on packs may also be compelling for plain packaging advocacy, where all branding is removed from the pack and large graphic health warning labels are the only communication on the tobacco packaging. Future research should consider including tobacco websites in marketing surveillance.

Financial Conflicts of Interest and Stance on Tobacco Harm Reduction: A Systematic Review

Background. Tobacco companies have actively promoted the substitution of cigarettes with purportedly safer tobacco products (e.g., smokeless tobacco, e-cigarettes) as tobacco harm reduction (THR). Given the tobacco, e-cigarette, and pharmaceutical industries' substantial financial interests, we quantified industry influence on support for THR. Objectives. To analyze a comprehensive set of articles published in peer-reviewed journals assessing funding sources and support for or opposition to substitution of tobacco or nicotine products as harm reduction. Search Methods. We searched PubMed, Embase, Web of Science, and PsycINFO with a comprehensive search string including all articles, comments, and editorials published between January 1, 1992, and July 26, 2016. Selection Criteria. We included English-language publications published in peer-reviewed journals addressing THR in humans and excluded studies on modified cigarettes, on South Asian smokeless tobacco variants, on pregnant women, on animals, not mentioning a tobacco or nicotine product, on US Food and Drug Administration-approved nicotine replacement therapies, and on nicotine vaccines. Data Collection and Analysis. We double-coded all articles for article type; primary product type (e.g., snus, e-cigarettes); themes for and against THR; stance on THR; THR concepts; funding or affiliation with tobacco, e-cigarette, pharmaceutical industry, or multiple industries; and each author's country. We fit exact logistic regression models with stance on THR as the outcome (pro- vs anti-THR) and source of funding or industry affiliation as the predictor taking into account sparse data. Additional models included article type as the outcome (nonempirical or empirical) and industry funding or affiliation as predictor, and stratified analyses for empirical and nonempirical studies with stance on THR as outcome and funding source as predictor. Main Results. Searches retrieved 826 articles, including nonempirical articles (21%), letters or commentaries (34%), editorials (5%), cross-sectional studies (15%), systematic reviews and meta-analyses (3%), and randomized controlled trials (2%). Overall, 23.9% disclosed support by industry; 49% of articles endorsed THR, 42% opposed it, and 9% took neutral or mixed positions. Support from the e-cigarette industry (odds ratio [OR] = 20.9; 95% confidence interval [CI] = 5.3, 180.7), tobacco industry (OR = 59.4; 95% CI = 10.1, +infinity), or pharmaceutical industry (OR = 2.18; 95% CI = 1.3, 3.7) was significantly associated with supportive stance on THR in analyses accounting for sparse data. Authors' Conclusions. Non-industry-funded articles were evenly divided in stance, while industry-funded articles favored THR. Because of their quantity, letters and comments may influence perceptions of THR when empirical studies lack consensus. Public Health Implications. Public health practitioners and researchers need to account for industry funding when interpreting the evidence in THR debates.

Knowledge about E-Cigarettes and Tobacco Harm Reduction among Public Health Residents in Europe

Introduction: Although electronic cigarettes (e-cigarettes) and other tobacco-related products are becoming widely popular as alternatives to tobacco, little has been published on the knowledge of healthcare workers about their use. Thus, the aim of this study was to elicit the current knowledge and perceptions about e-cigarettes and tobacco harm reduction (THR) among medical residents in public health (MRPH). Material and Methods: A Europe-wide cross-sectional study was carried out amongst MRPH from the countries associated with the European Network of MRPH from April to October 2018 using an online questionnaire. Results: 256 MRPHs agreed to participate in the survey. Approximately half the participants were women (57.4%), with a median age of 30 years, and were mainly Italian (26.7%), Spanish (16.9%) and Portuguese (16.5%). Smoking prevalence was 12.9%. Overall, risk scores significantly differed for each investigated smoking product when compared with e-cigarettes; with tobacco cigarettes and snus perceived as more risky, and nicotine replacement therapy (NRT) and non-NRT oral medications seen as less risky (p < 0.01 for all). Regarding the effects of nicotine on health, the vast majority of MRPHs associated nicotine with all smoking-related diseases. Knowledge of THR was low throughout the whole sample. Conclusions: European MRPH showed a suboptimal level of knowledge about e-cigarettes and THR. Training programs for public health and preventive medicine trainees should address this gap.

E-Cigarette Chemistry and Analytical Detection

The study of e-cigarette aerosol properties can inform public health while longer-term epidemiological investigations are ongoing. The determination of aerosol levels of known toxins, as well as of molecules with unknown inhalation toxicity profiles, affords specific information for estimating the risks of e-cigarettes and for uncovering areas that should be prioritized for further investigation.

Tobacco and electronic nicotine delivery systems regulation

The smoking of tobacco cigarettes by millions of people over the past 100 or more years has had devastating public health consequences around the world. In some countries, this has been mitigated by the introduction of multiple regulatory strategies that have taken decades to implement. But even in the countries with most success at tobacco cigarette regulation, some smokers find it very hard to quit and need better treatment. Electronic cigarettes and other electronic nicotine delivery systems (ENDS) have emerged in the last decade or so. Initially designed to help smokers quit and produced by small independent entities, ENDS have become big business, with major transnational tobacco companies competing hard for market share where, for example, in the United States, a single device came to dominate the market within a couple of years and where soaring uptake by adolescents reached levels high enough to alarm the FDA. No doubts remain about the damaging health consequences of tobacco cigarettes. Controversies persist about e-cigarettes-their efficacy, health impacts, development of addiction and whether or not they provide a "gateway" to tobacco cigarette smoking. The regulation of tobacco cigarettes falls under a global WHO treaty, the Framework Convention on Tobacco Control (FCTC); over 180 countries are party to the FCTC. The regulation of ENDS has no such treaty, varies considerably around the world and in many countries remains completely untrammelled by specific directives. This paper will not discuss the evidence for or against the of e-cigarettes in smoking cessation (effectively discussed in this issue by Dr. Wallace) but aims to review the current state of tobacco regulation around the world, identify key differences in ENDS regulation, examine the impact of industry influence on public health policy and determine how the lessons of tobacco control should apply to ENDS.

European Respiratory Society International Congress 2018: four shades of epidemiology and tobacco control

In this article, early career members and experienced members of the Epidemiology and Environment Assembly of the European Respiratory Society highlight and summarise a selection of six sessions from the Society's annual congress, which in 2018 was held in Paris, France. The topics covered in these sessions span from cutting-edge molecular epidemiology of lung function to clinical, occupational and environmental epidemiology of respiratory disease, and from emergent tobacco products to tobacco control.

Hostage to fortune: an empirical study of the tobacco industry's business strategies since the advent of e-cigarettes

The tobacco market has been transformed by the arrival of e-cigarettes and array of alternative nicotine delivery systems (ANDS). Public health has struggled to cope with these changes and clear divisions are apparent, but less is known about the tobacco industry (TI) response. This first empirical study to examine TI and independent ANDS companies' business strategies fills this gap. Primary data were collected through 28 elite interviews with senior/influential TI and independent stakeholders, triangulated with a documentary analysis of company reports, investor analyses, market research, and consultation responses (1022 documents). A deliberately emic analysis shows that tobacco multinationals were initially disconcerted by ANDS, but logic provided by the fiduciary imperative is enabling them to turn a potential threat into profitable opportunities. Interviewees argue market changes played to their strengths: customer links, expertise in nicotine, and enormous financial resources. This enabled portfolio diversification in which combustible and ANDS coexist; providing potential to develop robust scientific and regulatory positions and hope of retrieving corporate reputations. The principal threat for major tobacco players comes from the independent sector, which is prepared and able to satisfy bespoke consumer needs. Multinationals by contrast need to turn ANDS into a genuinely mass-market product appealing to its global customers. They are making progress. Given the continued buoyancy of the combustibles market, they have extensive resources to continue their efforts. Disruptive innovations are not unique to tobacco control. Equivalent technological solutions - with concomitant business opportunities - are emerging in obesity and alcohol fields with implications for public health.

Heated tobacco products: another tobacco industry global strategy to slow progress in tobacco control

There has been a global decline in tobacco consumption that, if continued, will negatively impact the tobacco industry's profits. This decline led the industry to invent and market new products, including heated tobacco products (HTP). HTP are an extension of the industry's strategies to undermine government's tobacco regulatory efforts as they are being promoted as part of the solution for the tobacco epidemic. Under the moniker of 'harm reduction', the tobacco companies are attempting to rehabilitate their reputation so they can more effectively influence governments to roll back existing tobacco control policies or create exemptions for their HTP. Rolling back tobacco control policies will make it easier for the companies to renormalise tobacco use to increase social acceptability for all their products. When regulations are absent or when loopholes exist in classifying HTP as a tobacco product (thus subject to all tobacco control regulations), the industry's marketing of HTP is making these products more visible to the public and more accessible. Governments need to ensure that HTP are regulated as tobacco products or drugs and reject partnerships with the tobacco companies to promote 'harm reduction'. The tobacco companies remain the vector of the tobacco-caused epidemic and cannot be part of the global tobacco control solution.

Applying Corporate Political Activity (CPA) analysis to Australian gambling industry submissions against regulation of television sports betting advertising

Aims

This research aimed to assess the application to the gambling industry, of Corporate Political Activity (CPA) analysis previously developed from public health research on tobacco industry interactions with political institutions and previously applied to the alcohol industry, but not the gambling industry.

Background

A growing body of literature has confirmed how public interest outcomes are frequently opposed by vested interests. This research focused on gambling industry submissions to a 2013 Australian Parliamentary inquiry into sports betting advertising. Gambling advertising became highly controversial following deregulation of sports betting advertising in Australia subsequent to the 2008 Australian High Court Betfair challenge. The dramatic increase in gambling advertising during sporting event broadcasts at children’s viewing times and on new interactive technology, sparked public concerns. A series of national regulatory reviews followed and the gambling industry was actively involved in opposing further regulation.

Method

The research used a corporate political activity (CPA) framework of analysis developed by UK tobacco public health researchers, which identified strategies and tactics used internationally by the tobacco industry, to broker pro-tobacco public policy outcomes. Testing the application of this CPA framework to gambling pro-industry strategies/tactics, this research focused on gambling industry submissions to the 2013 Australian Parliamentary Committee Inquiry.

Results

Like the tobacco industry, the research found the gambling industry used identified strategies and tactics, some new tactics and a new strategy of ‘Corporate Social Responsibility’, promoting ‘responsible’ industry practices and pre-emptive establishment of internal ‘responsibility’ units/practices. Despite public concerns regarding sports betting advertising, the gambling industry reinforced individual choice/blame for harms and claimed it acted responsibly. It did this using strategies identified in the tobacco industry CPA framework: information strategy (and shaping the evidence base); financial incentive strategy; constituency building strategy; policy substitution strategy; legal strategy; and constituency fragmentation and destabilization strategy.

Conclusion

Similar to the CPA analysis applied to tobacco and alcohol industries, the research demonstrated the usefulness of the CPA taxonomy for analyzing and documenting pre-emptive industry policy strategies and tactics, exposing gambling industry efforts to maintain industry self-regulation via voluntary codes and avoid more government regulation. Cross-sectoral application of the framework signals great potential for use of CPA by policymakers and public health advocates as a tool in the analysis of corporate industry arguments/discourses.

Philip Morris International-funded 'Foundation for a Smoke-Free World': analysing its claims of independence

The Foundation for a Smoke-Free World was launched in September 2017 with an announced 12-year funding commitment of $1 billion from Philip Morris International (PMI). The Foundation claims that its governing documents (certificate of incorporation, bylaws and a pledge agreement) ensure that it has an independent research agenda and stringent protections from conflicts of interest. We analysed the text of these governing documents. Their provisions have multiple loopholes, particularly regarding conflicts of interest. Further, these documents cannot substitute for other important documentation such as information about PMI's internal business case for investing $1 billion in the Foundation, an unwaivable conflict of interest policy, annual disclosure statements, copies of pre-Foundation establishment correspondence between key individuals, all signed contracts or salary information, none of which, as of July 2018, the Foundation has made publicly available. Even if these were released, however, it is problematic that the Foundation's fundamental purpose was decided on and its leader selected following a tobacco company-paid, privately negotiated arrangement with the Foundation's president. It cannot be regarded as independent.

Origins of tobacco harm reduction in the UK: the 'Product Modification Programme' (1972-1991)

OBJECTIVE

To better understand the current embrace of long-term nicotine maintenance by British governmental agencies and tobacco harm reduction by several leading British public health organisations, describe the context and deliberations of the UK's first formal tobacco risk reduction programme: 'Product Modification'.

METHODS

Analysis of previously secret tobacco industry documents, news archives and Parliamentary debate records.

RESULTS

From 1972 to 1991, the British government sought to investigate safer smoking through the 'product modification programme'. The Independent Scientific Committee on Smoking and Health (ISCSH) advised the British government on these efforts and collaborated with the tobacco industry, with which government then negotiated to determine policy. The ISCSH operated from four industry-backed premises, which contributed to the ISCSH's support of safer smoking: (1) reduced toxicity indicates reduced risk; (2) collaboration with the tobacco industry will not undermine tobacco control; (3) nicotine addiction is unavoidable; (4) to curtail cigarette use, solutions must be consumer-approved (ie, profitable). These premises often undermined tobacco control efforts and placed the ISCSH at odds with broader currents in public health. The product modification programme was abandoned in 1991 as the European Community began requiring members to adopt upper tar limits, rendering the ISCSH redundant.

POLICY IMPLICATIONS

Endorsements of reduced harm tobacco products share the same four premises that supported the product modification programme. Current tobacco harm reduction premises and policies supported by the British government and leading British public health organisations may reflect the historical influence of the tobacco industry.

Can't see the woods for the trees: exploring the range and connection of tobacco industry argumentation in the 2012 UK standardised packaging consultation

INTRODUCTION

Transnational tobacco company (TTC) submissions to the 2012 UK standardised packaging consultation are studied to examine TTC argumentation in the context of Better Regulation practices.

METHODS

A content analysis was conducted of Philip Morris International and British American Tobacco submissions to the 2012 UK consultation. Industry arguments concerning expected costs and (contested) benefits of the policy were categorised into themes and frames. The inter-relationship between frames through linked arguments was mapped to analyse central arguments using an argumentation network.

RESULTS

173 arguments were identified. Arguments fell into one of five frames: ineffectiveness, negative economic consequences, harm to public health, increased crime or legal ramifications. Arguments highlighted high costs to a wide range of groups, including government, general public and other businesses. Arguments also questioned the public health benefits of standardised packaging and highlighted the potential benefits to undeserving groups. An increase in illicit trade was the most central argument and linked to the greatest variety of arguments.

CONCLUSIONS

In policy-making systems characterised by mandatory impact assessments and public consultations, the wide range of cost (and contested benefits) based arguments highlights the risk of TTCs overloading policy actors and causing delays in policy adoption. Illicit trade related arguments are central to providing a rationale for these arguments, which include the claim that standardised packaging will increase health risks. The strategic importance of illicit trade arguments to industry argumentation in public consultations underlines the risks of relying on industry data relating to the scale of the illicit trade.

Invisible smoke: third-party endorsement and the resurrection of heat-not-burn tobacco products

Background

Tobacco companies are introducing new ‘heat-not-burn’ cigarettes in dozens of countries. Historically, these products failed commercially, and independent researchers contested their health claims. The most prominent early heat-not-burn cigarette was RJ Reynolds’s (RJR’s) Premier, introduced in the USA in 1988. Curiously, The Lancet endorsed Premier as a ‘near-perfect low tar cigarette’ in a 1991 editorial, 2 years after Premier had been removed from the market. We examined the context of this endorsement.

Methods

To ascertain what RJR knew about this endorsement, we systematically searched and analysed previously secret RJR documents in public archives and triangulated the industry document data with other published work.

Results

RJR had a long-standing interest in collaborating with outside scientists to endorse potentially reduced harm cigarettes. The author of The Lancet editorial had previously corresponded with RJR regarding Premier’s health effects and market potential. Internally, RJR regarded The Lancet’s editorial, its stance on novel tobacco products, and its endorsement of Premier as major successes. While the editorial came too late to save Premier, RJR saw future business opportunities for novel products if endorsed by health authorities.

Conclusions

Endorsement by high-impact medical journals and health authorities may be critical in helping heat-not-burn’ products succeed where previous attempts have failed. Conflicts of interest influenced these endorsements in the past. Health leaders and academic journals should consider both conflicts of interest and the ethics of endorsing tobacco product substitution, as tobacco companies simultaneously work to promote cigarette smoking and undermine tobacco control globally.

Public versus internal conceptions of addiction: An analysis of internal Philip Morris documents

BACKGROUND

Tobacco addiction is a complex, multicomponent phenomenon stemming from nicotine's pharmacology and the user's biology, psychology, sociology, and environment. After decades of public denial, the tobacco industry now agrees with public health authorities that nicotine is addictive. In 2000, Philip Morris became the first major tobacco company to admit nicotine's addictiveness. Evolving definitions of addiction have historically affected subsequent policymaking. This article examines how Philip Morris internally conceptualized addiction immediately before and after this announcement.

METHODS AND FINDINGS

We analyzed previously secret, internal Philip Morris documents made available as a result of litigation against the tobacco industry. We compared these documents to public company statements and found that Philip Morris's move from public denial to public affirmation of nicotine's addictiveness coincided with pressure on the industry from poor public approval ratings, the Master Settlement Agreement (MSA), the United States government's filing of the Racketeer Influenced and Corrupt Organizations (RICO) suit, and the Institute of Medicine's (IoM's) endorsement of potentially reduced risk products. Philip Morris continued to research the causes of addiction through the 2000s in order to create successful potentially reduced exposure products (PREPs). While Philip Morris's public statements reinforce the idea that nicotine's pharmacology principally drives smoking addiction, company scientists framed addiction as the result of interconnected biological, social, psychological, and environmental determinants, with nicotine as but one component. Due to the fragmentary nature of the industry document database, we may have missed relevant information that could have affected our analysis.

CONCLUSIONS

Philip Morris's research suggests that tobacco industry activity influences addiction treatment outcomes. Beyond nicotine's pharmacology, the industry's continued aggressive advertising, lobbying, and litigation against effective tobacco control policies promotes various nonpharmacological determinants of addiction. To help tobacco users quit, policy makers should increase attention on the social and environmental dimensions of addiction alongside traditional cessation efforts.

US Media Coverage of Tobacco Industry Corporate Social Responsibility Initiatives

Media coverage of tobacco industry corporate social responsibility (CSR) initiatives represents a competitive field where tobacco control advocates and the tobacco industry vie to shape public and policymaker understandings about tobacco control and the industry. Through a content analysis of 649 US news items, we examined US media coverage of tobacco industry CSR and identified characteristics of media items associated with positive coverage. Most coverage appeared in local newspapers, and CSR initiatives unrelated to tobacco, with non-controversial beneficiaries, were most commonly mentioned. Coverage was largely positive. Tobacco control advocates were infrequently cited as sources and rarely authored opinion pieces; however, when their voices were included, coverage was less likely to have a positive slant. Media items published in the South, home to several tobacco company headquarters, were more likely than those published in the West to have a positive slant. The absence of tobacco control advocates from media coverage represents a missed opportunity to influence opinion regarding the negative public health implications of tobacco industry CSR. Countering the media narrative of virtuous companies doing good deeds could be particularly beneficial in the South, where the burdens of tobacco-caused disease are greatest, and coverage of tobacco companies more positive.

Corporate social responsibility and conflicts of interest in the alcohol and gambling industries: a post-political discourse?

The corporate pursuit of social goals - known as Corporate Social Responsibility or 'CSR' - has been subject to critique on a number of grounds. However, a hitherto underexplored potential consequence of CSR has been suggested in a recent paper by C. Garsten and K. Jacobsson ('Post-Political Regulation: Soft Power and Post-political Visions in Global Governance' (2013), Critical Sociology 39: 421-37). They suggest that CSR is part of an international trend towards 'post-political' governance discourses, where an emphasis on different actors' common goals obscures conflicts of interest, subverting the open political conflict necessary for a well-functioning democracy. This paper examines whether such post-political discourses - including an outright denial of conflict of interest - can be found within the alcohol and gambling industries, where conflicts of interest are likely to be particularly acute given the addictive nature of the goods/services in question. Based on interviews with CSR professionals in these industries in Italy, the UK, and at EU-level, we do indeed find evidence of a post-political discourse. In these discourses, alcohol/gambling industry staff deny potential conflicts of interest on the basis that any small benefits from sales to a small number of addicts are seen to be outweighed by the reputational damage that addicts cause. Crucially, however, this coexists with another, less post-political discourse, where addictions CSR professionals emphasize 'common ground' as a basis for CSR, while accepting some instances of possible conflict of interest. Here interviewees make considerable efforts to differentiate good (sustainable) from bad (short-term) self-interest in order to stress the genuineness of their own actions. We conclude the paper by considering whether CSR embedded within a 'common ground' discourse still hides conflicts of interests and subverts democratic debate, or overcomes the problems identified by Garsten and Jacobsson.

African media coverage of tobacco industry corporate social responsibility initiatives

Guidelines for implementing the World Health Organization's Framework Convention on Tobacco Control (FCTC) recommend prohibiting tobacco industry corporate social responsibility (CSR) initiatives, but few African countries have done so. We examined African media coverage of tobacco industry CSR initiatives to understand whether and how such initiatives were presented to the public and policymakers. We searched two online media databases (Lexis Nexis and Access World News) for all news items published from 1998 to 2013, coding retrieved items through a collaborative, iterative process. We analysed the volume, type, provenance, slant and content of coverage, including the presence of tobacco control or tobacco interest themes. We found 288 news items; most were news stories published in print newspapers. The majority of news stories relied solely on tobacco industry representatives as news sources, and portrayed tobacco industry CSR positively. When public health voices and tobacco control themes were included, news items were less likely to have a positive slant. This suggests that there is a foundation on which to build media advocacy efforts. Drawing links between implementing the FCTC and prohibiting or curtailing tobacco industry CSR programmes may result in more public dialogue in the media about the negative impacts of tobacco company CSR initiatives.

Unpacking commercial sector opposition to European smoke-free policy: lack of unity, 'fear of association' and harm reduction debates

OBJECTIVE

Tobacco companies have made extensive efforts to build alliances against comprehensive smoke-free legislation. This article analyses the interaction between actors who opposed the development of the European Council Recommendation on smoke-free environments.

METHODS

Drawing on data from 200 policy documents and 32 semistructured interviews and using qualitative textual analysis and organisational network analysis, opponents' positions on, and responses to, the policy initiative, strategies to oppose the policy, and efforts to build alliances were investigated.

RESULTS

The non-binding nature of the policy, scientific evidence and clear political will to adopt EU-wide measures combined to limit the intensity of commercial sector opposition to the comprehensive EU smoke-free policy. Most tobacco companies, led by the Confederation of European Community Cigarette Manufacturers (CECCM), voiced reservations against the proposal, criticised the policy process and fought flanking measures on product regulation. However, some companies focused on instigating harm reduction debates. These divergent approaches and the reluctance of other commercial actors to demonstrate solidarity with the tobacco sector prevented the establishment of a cohesive commercial sector alliance.

CONCLUSIONS

The comparatively limited opposition to EU smoke-free policy contrasts with previous accounts of tobacco industry resistance to tobacco control. While context-specific factors can partially explain these differences, the paper indicates that the sector's diminished credibility and lack of unity hampered political engagement and alliance building. Industry efforts to emphasise the benefits of smokeless tobacco during smoke-free policy debates highlight the potential of harm reduction as a gateway for tobacco companies to re-enter the political arena.

Exposing and addressing tobacco industry conduct in low-income and middle-income countries

The tobacco industry's future depends on increasing tobacco use in low-income and middle-income countries (LMICs), which face a growing burden of tobacco-related disease, yet have potential to prevent full-scale escalation of this epidemic. To drive up sales the industry markets its products heavily, deliberately targeting non-smokers and keeps prices low until smoking and local economies are sufficiently established to drive prices and profits up. The industry systematically flaunts existing tobacco control legislation and works aggressively to prevent future policies using its resource advantage to present highly misleading economic arguments, rebrand political activities as corporate social responsibility, and establish and use third parties to make its arguments more palatable. Increasingly it is using domestic litigation and international arbitration to bully LMICs from implementing effective policies and hijacking the problem of tobacco smuggling for policy gain, attempting to put itself in control of an illegal trade in which there is overwhelming historical evidence of its complicity. Progress will not be realised until tobacco industry interference is actively addressed as outlined in Article 5.3 of the Framework Convention on Tobacco Control. Exemplar LMICs show this action can be achieved and indicate that exposing tobacco industry misconduct is an essential first step.

Old wine in new bottles: tobacco industry's submission to European Commission tobacco product directive public consultation

Between September and December 2010 the European Commission Health & Consumer Protection Directorate-General (DGSANCO) held a public consultation on a possible revision of the European Union Tobacco Products Directive (2001/37/EC). We used content analysis of the tobacco industry's and related parties' 300 submissions to the public consultation to determine if tobacco industry and its allies in Europe are prepared to reduce harm of the tobacco products as their public statements assert. The industry submission resorted to traditional tobacco industry arguments where illicit trade and freedom of choice were emphasized and misrepresented the conclusions of a DGSANCO-commissioned scientific report on smokeless tobacco products. Retailers and wholesalers referred to employment and economic growth more often than respondents from other categories. The pattern of responses in the submission differed dramatically from independent public opinion polls of EU citizens' support for tobacco control policies. None of the major tobacco manufacturers or their lobbying organizations supported any of the DGSANCO's proposed evidence based interventions (pictorial health warnings, plain packaging or point-of-sale display bans) to reduce harms caused by cigarette smoking.