Article Text

PDF

Seeking out ‘easy targets’? Tobacco companies, health inequalities and public policy
  1. David Clifford1,
  2. Sarah Hill2,
  3. Jeff Collin2
  1. 1Department for Health, University of Bath, Bath, UK
  2. 2Global Public Health Unit, School of Social and Political Science, University of Edinburgh, Edinburgh, Midlothian, UK
  1. Correspondence to Dr Sarah Hill, Global Public Health Unit, School of Social and Political Science, University of Edinburgh, 15a George Square, Edinburgh EH8 9LD, UK; s.e.hill{at}ed.ac.uk

Abstract

Introduction The prominence of socioeconomic and ethnic disparities in tobacco use has led to increased policy attention on smoking inequalities in many countries. In 2008 the UK Department of Health held a consultation on the future of tobacco control, including a focus on reducing socioeconomic inequalities in smoking, to which tobacco companies made written submissions. These organisations have historically opposed regulation, favouring a depiction of smoking that emphasises individual choice and downplays broader influences such as industry activities.

Methods We undertook thematic analysis of submissions from tobacco manufacturers and allied organisations, with particular focus on industry engagement with health inequalities.

Results Alongside well-established arguments (including defence of individual liberty and challenges to scientific evidence), industry actors adopted and misrepresented the language of health inequalities and the social determinants of health in order to oppose specific tobacco control interventions including tobacco taxation, denormalisation of smoking and cessation support. While industry submissions generally opposed state regulation of the tobacco market, tobacco companies argued for increased government investment in harm reduction products and in countering illicit trade.

Conclusions Tobacco companies co-opted and misrepresented a social determinants model of health to argue against government regulation of the tobacco market. By drawing on this model, tobacco companies are misappropriating a powerful public health discourse in an attempt to create a false dichotomy between reducing inequalities and regulating of the tobacco market. Such tactics highlight the need for ongoing monitoring of industry attempts to undermine tobacco control policy, particularly with reference to harm reduction.

  • Tobacco industry
  • Disparities
  • Socioeconomic status
  • Public policy
  • Harm Reduction

Statistics from Altmetric.com

Introduction

The prominence of socioeconomic and ethnic disparities in tobacco use has led to increased policy attention on smoking inequalities in many countries.1–4 The importance of tobacco control to health equity has also been recognised in global health policy, with the preamble to the WHO Framework Convention on Tobacco Control (FCTC) noting the burden of tobacco use on the poor5 and the WHO Commission on the Social Determinants of Health highlighting tobacco control as an effective means of addressing health inequalities.6 A social determinants model of health inequalities draws attention to the unequal social and economic positions of different population groups as well as the unequal exposure of such groups to unhealthy behaviours such as smoking.7 In the context of tobacco control, a social determinants approach therefore entails long-term efforts to improve social equity8 alongside measures to reduce smoking prevalence among socially disadvantaged groups.9

In 2008, the UK Department of Health (DH) launched a ‘Consultation on the Future of Tobacco Control’, including specific objectives around reducing health inequalities caused by smoking.10 Initiatives under consideration included tackling smuggled/illicit tobacco, controlling the display of tobacco products, selling tobacco products in plain packaging, increasing utilisation of National Health Service (NHS) cessation services and introducing a harm reduction approach. Open to all stakeholders, the consultation offered the tobacco industry and its allies an opportunity to engage directly with policy-makers regarding these proposals.

The tobacco industry has a well-established track record of seeking to undermine effective tobacco control policy through such tactics as misrepresenting scientific evidence, exploiting disagreement in the policy community and arguing that regulation of tobacco markets breaches individual liberties.11 ,12 Industry organisations have historically favoured a libertarian depiction of smoking behaviour, portraying this as a purely individual choice and downplaying the role of industry marketing and social norms in tobacco use.13 This depiction contrasts with theories emphasising the broader social determinants of health and health inequalities.6

The tobacco industry has directly contributed to social inequalities in smoking by targeting its marketing activities at disadvantaged areas and social groups,14–16 thus increasing environmental cues to smoke and manipulating social norms in these communities.17 The industry has also contributed indirectly to smoking inequalities by opposing population-level measures with the greatest potential to reduce smoking among disadvantaged groups.18 The prominent social gradient that characterises tobacco use in many countries19–22 underlines the importance of disadvantaged social groups as a core market for the tobacco industry.

Based on industry submissions to the 2008 UK consultation, we examined how tobacco companies and their allies are engaging with health inequalities and their prominence in contemporary public health policy. Our findings highlight the potential for tobacco companies to draw on widely accepted public health theories and manipulate these to undermine tobacco control interventions and downplay the role of industry influence on tobacco use, including among disadvantaged population groups. They also underline the risks of treating the industry as a ‘stakeholder’ in health policy development and the need for ongoing monitoring of industry attempts to undermine tobacco control, particularly with reference to emerging policy interest in harm reduction.

Methods

We searched for all submissions made by tobacco industry and allied organisations that discussed the issue of health inequalities and smoking. We used the FCTC industry definition of ‘tobacco manufacturers, wholesale distributors and importers of tobacco products’ with its allies comprising organisations that ‘benefit from the sale of tobacco or from tobacco sponsorship’ (including known front groups).5 Organisations meeting this definition that were listed as respondents in the DH consultation report included 12 tobacco manufacturers, four tobacco importers or distributors and seven industry allies.2 Submissions from these organisations were obtained via company websites or internet search engines (using combinations of the company name—including abbreviations—and the consultation title or ‘Department of Health consultation’), and a small number of submissions were obtained via a subsequent Freedom of Information request to the DH for all submissions responding to the section of the consultation titled ‘Reducing smoking rates and health inequalities caused by smoking’. The content of these submissions was then reviewed to examine whether and how they addressed smoking and inequalities.

A total of seven tobacco industry submissions were identified that discussed health inequalities and smoking. These included five submissions from tobacco companies, including four leading cigarette manufacturers that now also make smokeless tobacco products (British American Tobacco (BAT),23 Imperial Tobacco Group and Imperial Tobacco UK,24 Philip Morris Limited25 (the UK affiliate of Philip Morris International) and Japan Tobacco International (JTI)26), as well as the International Smokeless Tobacco Company (ISTC).27 A further two submissions came from tobacco industry allies Freedom To Choose28 and Freedom Organisation for the Right to Enjoy Smoking Tobacco (FOREST).29 Tobacco companies included in this study manufacture over 90% of cigarettes sold legally in the UK30; those tobacco manufacturers whose submissions were excluded as not addressing inequalities were principally cigar producers.

A thematic analysis of submissions was undertaken31 ,32; that is, submission texts were read and re-read to identify common ideas or arguments, with sections of text subsequently organised into these themes. How tobacco companies framed health inequalities was identified as an a priori theme, while other themes emerged inductively during data analysis. Submissions were initially coded by one author (DC) with validation undertaken (across all seven submissions) by the other two authors.

Results

While acknowledging the adverse impacts of smoking on the health of smokers, tobacco companies and their allies broadly opposed strengthened state regulation of the tobacco market. Alongside established industry tactics (such as critiquing the evidence cited to support tobacco control and recruiting ‘expert’ witnesses to support alternative positions11), all seven submissions used the concept of health inequalities within their advocacy for reduced tobacco control.23–29 Arguments included criticising smoking cessation services and increased tobacco taxation as failing to address the underlying causes of health inequalities. Industry submissions also called for greater state involvement in harm reduction approaches to tobacco use and in countering illicit trade.

Health inequalities and the role of smoking

Two industry submissions23 ,24 linked health inequalities to broader social inequality, using this specific association to argue against state intervention targeting tobacco use at the individual level. A further four submissions largely accepted the DH's position that smoking contributes to health inequalities.25–28 Only one submission (from FOREST) denied any link between health inequalities and smoking, stating that they ‘do not believe that inequalities, health or otherwise, are caused by tobacco use’.29

BAT and Imperial Tobacco depicted smoking as an intermediary factor between inequalities in social factors (such as education and income) and inequalities in health.23 ,24 BAT cited the work of Sir Michael Marmot,9 Johan Mackenbach20 and Martin Jarvis2 ,33 in justifying their conclusion that ‘for economically disadvantaged people, it is primarily social circumstances that influence smoking’.23 Imperial Tobacco also highlighted the underlying ‘social determinants’ of smoking in contrast to the influence of marketing: This evidence suggests that the root causes of youth smoking have little or nothing to do with tobacco advertising, displays or packaging. Instead, the principal causes include personal factors such as rebelliousness and risk-taking and other factors such as family structure and relationships, quality of schools and educational success and socioeconomic status.24

Imperial went on to claim that selective use of research leads to inappropriate policy recommendations: If the UK Government is serious about [reducing smoking prevalence] they should look more closely at all the evidence and propose solutions that address the evidence rather than seeking out ‘easy targets’ which can be introduced at little cost to the Government but will be entirely ineffective.24

BAT and Imperial Tobacco both argued that the DH made a biased assessment of the evidence base,23 ,24 and that health inequalities ‘should be addressed by an appropriate range of interventions designed to address poverty, poor educational performance, etc’24 rather than enhanced provision of cessation services. BAT argued that the same factors that drive people to smoke make them less likely to engage with such services, and cited Jarvis34 in claiming that ‘social, economic, personal and political influences all play an important part in determining successful cessation’.23

The social determinants model was also used to criticise the DH's stated intention to ‘denormalise’ smoking among lower socioeconomic groups.24 ,28 ,29 FOREST depicted the DH's position as ‘entirely misleading and only help[ing] to stigmatise people on low incomes’, claiming that ‘education, skills and employment opportunities are the keys to reducing inequality, not legislation designed to limit or control lifestyle choices’.29 They presented the consultation as part of a concerted campaign to ‘make ordinary people pariahs within their own communities’, incorporating an ‘extreme level’ of victimisation by which ‘the government intends to step up its aggression against a significant minority simply because the minority does not meet the government's definition of ‘normal’’.29 Freedom to Choose argued that an emphasis on denormalisation and smoking cessation places undue pressure on smokers who enjoy cigarettes,28 while Imperial Tobacco claimed that: …‘denormalisation’ is not in itself a conceptual objective that is compatible with the principles of good regulation of a legal product. […] Government either regulates or it does not regulate. In turn, a product is legal or it is not legal. To attempt to create a grey area as an objective of public policy represents a deliberate and illegitimate attempt to demonise and discriminate against a chosen, legal activity freely enjoyed by a significant proportion of the adult population.24

Health inequalities and regulation of tobacco sales

All four cigarette manufacturers used health inequalities to argue for stronger state action to address smuggled and illicit tobacco.23–26 Arguments combined the public health impact of this cheaper tobacco with the fiscal blow of lost tax revenue. Philip Morris claimed that ‘the widespread availability of cheap smuggled and counterfeit cigarettes, accessible to adults and minors alike, severely undermines the government's public health objectives’,25 while JTI warned of ‘regulatory measures that have the unintended consequences of increasing the availability of lower-priced, illicit tobacco products’.26

Alongside illicit tobacco, smoking inequalities were also used to argue against increased tobacco taxation. Philip Morris and JTI criticised tax increases as fuelling demand for illicit tobacco,25 ,26 particularly among lower socioeconomic groups for whom ‘tax-driven price differentials are an incentive and therefore an important factor in regard to illicit trade in tobacco products’.25 Imperial described the ‘[e]xcessive and regressive taxation of tobacco products’ as placing a ‘disproportionate tax burden on the lower income groups… who tend to turn to the illegal market once they are unable to afford legitimate tobacco products, rather than stop smoking’.24

All four cigarette manufacturers claimed that enforced plain packaging of cigarettes would be counter-productive.2326 Imperial Tobacco criticised plain packaging as failing to address the societal factors associated with smoking uptake among young people,24 while Philip Morris argued that ‘plain packaging will not only fail to achieve its stated objectives, but will actually work against them’ by increasing trade in illicit cigarettes.25 In a similar vein, BAT argued that consumers’ inability to distinguish between brands on appearance would ‘lead to price becoming the sole identifiable product feature, encouraging vigorous price competition and leading to consumers switching to cheaper products, of which they can afford more’.23 JTI suggested that plain packaging would inadvertently worsen social inequalities by simplifying production of counterfeit cigarettes and lowering their street price.26

The language of health inequalities and social determinants was also employed in opposition to the prohibition of tobacco displays, with Imperial Tobacco arguing that ‘it is difficult to understand … how banning tobacco displays will address the problem of educational failure and poor schools, which are widely acknowledged as strong predictors of smoking uptake’.24 JTI claimed that banning tobacco products from plain sight would blur the distinction between illicit and legal products, jeopardising the policing of tobacco retailing.26

Health inequalities and harm reduction

Several tobacco industry submissions used health inequalities to argue for harm reduction strategies centred on ‘reduced-risk’ products.23–25 ,27 ,28 Citing the Royal College of Physicians,35 ISTC argued that such strategies could help in ‘denormalis[ing] smoking [and] significantly reducing social inequalities in health’.27 BAT also emphasised agreement between their own position and that of some health professionals: We and a proportion of the public health community believe that regulators, including in the UK, could achieve further public health gains through regulatory approaches that include potentially reduced-risk products.23

Imperial went beyond this, positioning harm reduction as not only necessary but an option that the government is duty-bound to pursue in order to protect those who continue to smoke: If the Government is serious in exercising its obligations to adults who choose to smoke they should thoroughly examine potential modifications to existing product types […] the best way forward is to pursue a policy of constructive dialogue with the industry.24

Such an ‘ethical duty’ was also highlighted by Freedom to Choose. Citing a US Institute of Medicine report,36 they concluded that ‘it is impossible to achieve a zero smoking rate and therefore immoral to disallow research and marketing of safer products’.28

Discussion

Tobacco industry submissions to the UK's 2008 ‘Consultation on the future of tobacco control’ highlight tactics and themes consistent with established industry strategies, including a depiction of tobacco use that diverts attention away from industry conduct.11 ,12 But this study also demonstrates a significant development within the industry's persistent misrepresentation of scientific evidence in order to undermine regulation.11 By drawing on the social determinants of health literature, tobacco companies are not only aiming to divert attention from industry influences on tobacco use but are co-opting and misrepresenting a powerful model of public health and health inequalities. Under the guise of recognising the broader drivers of such inequalities (including ‘the inequitable distribution of power, money, and resources’6), tobacco companies are appropriating the language of social determinants to divert responsibility for smoking inequalities onto the state.

This purported concern with the ‘upstream’ social determinants of smoking behaviour sits ill with the industry's longstanding use of libertarian arguments to oppose tobacco control.12 Tobacco companies and their allies have historically emphasised an individual's ‘right to choose’, with statutory regulation of tobacco markets depicted as unwanted government interference.13 Imperial's suggestion that the government should undertake ‘an appropriate range of interventions designed to address poverty [and] poor educational performance’ represents a profound disjuncture with these established industry arguments, underlining the extent to which its newfound engagement with the social determinants of health constitutes a politically opportunistic strategy to undermine effective regulation.

The submissions analysed here incorporate innovative and complex manipulation of the health inequalities discourse to depict current tobacco control policies as misusing resources, failing to tackle the social determinants of smoking behaviour, and potentially exacerbating health inequalities. The industry's opposition to increased tobacco control regulation and expanded smoking cessation assistance and their support for harm reduction strategies are consistent with the core commercial need to protect marketing opportunities and tobacco consumption. Industry submissions draw on inequalities arguments to oppose prohibition of tobacco displays and the introduction of compulsory plain packaging—measures that have the potential to significantly compromise their business interests, since a distinctive image and the effects of product displays on brand recognition and social acceptance are key tools in the protection of manufacturers’ product markets.37 Similarly, arguments regarding the contribution of illicit tobacco products to inequalities in smoking constitute a politically expedient adjunct to the industry's longstanding opposition to increased taxation,38 an opposition attributable to taxation's unparalleled impact as a tobacco control intervention.39 By presenting these arguments in the language of health inequalities, tobacco corporations are seeking to portray themselves as socially responsible organisations aligned with the values of health professionals and policy-makers. This disingenuous use of public health arguments to promote industry goals is in direct contrast with industry marketing strategies that explicitly target disadvantaged social groups.14 ,16 ,40

Tobacco manufacturers are seeking to create a false dichotomy between the goals of reducing inequalities in individual smoking behaviours and reducing social inequality. BAT cite Sir Michael Marmot's work9 to support their claim that the DH should be acting on the structural determinants of health rather than developing specific tobacco control interventions,23 yet Marmot himself states (in the same piece) that, given the substantial contribution of smoking-related mortality to health inequalities, ‘the conclusion might be to forget [social inequality] and focus on getting smoking rates down in people of low status’.9 Thus, the tobacco industry has clearly ignored the possibility that smoking and social inequalities might be tackled concomitantly, instead making selective use of Marmot's work and prominent policy roles6 ,8 ,41 as a tactic to lend credibility to their own arguments.

In engaging with health inequalities frameworks, industry submissions do highlight some uncomfortable issues that have arguably received insufficient attention within tobacco control. The risk of stigma associated with the denormalisation of smoking merits greater attention17 ,42; the impact of tobacco taxation on health inequalities may not be clearly regressive, but is far from unproblematic43; the medicalisation of tobacco control and strong emphasis on pharmaceutical cessation in the UK44 arguably reflects an excessive focus on individual-centred approaches; and it would be unrealistic to suggest that tobacco control interventions have been developed within a comprehensive multi-sectoral approach to tackling the social determinants of health. Interventions targeting individual smoking behaviour are an important component of any serious strategy to reduce health inequalities, but need to occur alongside efforts to address more upstream determinants in order to achieve sustainable improvements in health equity. And while we have plentiful evidence for the effectiveness of tobacco control measures in reducing total population smoking, evidence for interventions that reduce inequalities in smoking is scarce.18 ,45

Interestingly, harm reduction is the one area in which tobacco industry submissions examined in this study used the concept of health inequalities to advocate for innovations in tobacco control policy. This is unsurprising, given that a harm reduction strategy has long been identified by tobacco companies as a potential future revenue stream46; indeed, all of the cigarette manufacturers represented in this study now also have interests in smokeless tobacco products. Smokeless tobacco potentially offers the industry both a new market and a means of maintaining addiction, maximising the continued use of tobacco products amid increasing restrictions on smoking.46 While smokeless tobacco products such as snus (widely available in Sweden but prohibited elsewhere in the EU) may carry lower health risks than smoked tobacco,35 the effects of their introduction into new markets remain highly contentious,47 and tobacco companies have sought to exploit the potential of reduced harm products to divide the public health community.48 More broadly, the tobacco industry's active pursuit of policy engagement raises serious concerns given the intrinsic conflict between its commercial interests and public health goals. Current policy interest in alternative nicotine delivery systems49 ,50 has led to increasing concerns about the strategic value of harm reduction to tobacco interests.51

Findings from this study highlight the risks inherent in treating the tobacco industry as a legitimate ‘stakeholder’ in tobacco control policy. These submissions demonstrate the industry's capacity to engage strategically and disingenuously in policy discussions, manipulating public health evidence and theory to argue in favour of some interventions and against others. While the government's tobacco control plan for England formally recognises its commitments under Article 5.3 of the WHO FCTC5 ‘to protect the development of public health policy from the vested interests of the tobacco industry’,49 the extent to which it fulfils these obligations is open to question.52

Manipulation of a health inequalities discourse and use of public health concepts to advance commercial objectives highlights the ongoing need for monitoring the tactics used by the tobacco industry to undermine effective health policy. It is also a reminder that policymakers should look beyond the superficial credibility of specific arguments used by tobacco companies and recognise the industry's objective interests: that is, to pursue profit and maximise the market for tobacco products. The fundamental incompatibility of such objectives with public health goals illustrates the importance of effectively and consistently excluding the tobacco industry from policy-making, in line with the UK's international legal obligations.5

What this paper adds

  • The tobacco industry has repeatedly sought to undermine tobacco control policy through such tactics as misrepresenting scientific evidence, exploiting disagreement in the policy community and arguing that regulation of tobacco markets breaches individual liberties.

  • This study shows the tobacco industry is manipulating public health concepts as part of new strategies to undermine health policy.

  • Tobacco companies are seeking to exploit public health's contemporary focus on health inequalities to distort health policy debates, promote industry involvement in policy development and create opportunities for ‘reduced risk’ tobacco products.

  • Policy-makers need to implement WHO Framework Convention on Tobacco Control commitments to protect health policy from tobacco industry interference, including with respect to emerging harm reduction strategies.

Acknowledgments

The authors would like to thank the University of Edinburgh's Tobacco Control Research Group for a grant in support of the writing of this paper.

References

View Abstract

Footnotes

  • Contributors JC and SH developed the initial concept for the paper; DC developed and undertook the data analysis, with support from JC and SH; DC and SH wrote the first draft. DC, SH and JC contributed to the writing of the manuscript and agree with its results and conclusions.

  • Funding DC received a postgraduate studentship for the writing of this paper from the University of Edinburgh's Mackay Tobacco Control Research Fund. JC and SH receive research support from the National Cancer Institute of the US National Institutes of Health (grant number: RO1 CA160695).

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.