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Tobacco Control as a journal has long been focused not only on addressing the negative disease-promoting impacts of tobacco products but on the industry that produced them. From its inception, the journal has had a normative aim. Tobacco Control is focused primarily on research and analysis that advance understanding of how best to develop, defend and extend public policy measures to protect the public from an industry that promotes products that harm and kill people. Tobacco Control’s very first issue in 1992 featured an analysis by now-Editor Emeritus Simon Chapman on the Australian tobacco industry’s massive media campaign to derail an advertising ban. Many of the arguments in use then have a strangely familiar smell to them.1
This special e-issue features a wide range of papers about the tobacco industry. Taken together, they provide an updated, partial snapshot of multiple aspects of this industry and the ways in which it continues to aggressively promote use of both old and new harmful, addictive products, thwart and undermine public health policy measures, engage in neocolonialist exploitation and disseminate deceptive messages about itself, its products and about policies it regards as threats to its profits. Unfortunately, some within (or formerly within) the tobacco control movement have convinced themselves that the tobacco industry is now creating the solution to the tobacco disease pandemic. Yet the shiny veneer of faux sincerity cannot effectively cover over the many industry activities that increase harm to so many around the world.
However, the tobacco industry has indeed changed since 1992. In addition to considerable consolidation among the major multinational cigarette companies, the development of e-cigarettes and multiple other nicotine and tobacco products has created acquisition opportunities, as Levy and colleagues discuss in their analysis of why Altria bought JUUL.2 Public health work at all levels increasingly involves surveilling for the plethora of new, unregulated products which continually appear on the market, sometimes even in violation of existing policies, and tracking the expenditures for promoting new products, which can serve as an early warning of increased uptake.3 It may also involve, as McKelvey and colleagues illustrate in a study with youth,4 trying to navigate how the blunt instrument of policy can address public perceptions of ‘reduced exposure’ and ‘reduced risk’ claims such as those now being made by tobacco companies about a broad range of newer tobacco and nicotine products being marketed with minimal independent evidence to support such claims.
Tsourounis et al 5 examined all warning letters sent by the US Food and Drug Administration’s (FDA) Center for Tobacco Products to online retailers of e-liquids regarding violations. The majority were violating provisions on sales to minors or featured advertising appealing to children. While most corrected their websites after receiving warnings from FDA, almost 17% of retailers did not fully do so. The FDA and other regulators are faced with playing a continuing game of hide and seek as companies develop products intended to thwart public health policies, as Cwalina and colleagues show in their discussion of PUFF Krush, a product created to circumvent flavour bans,6 and Delnevo and colleagues report regarding other illegal ‘pod mod’ products.7 In an accompanying commentary, Hemmerich8 calls attention to the FDA’s failure to enforce its own premarket review policies. Since these papers went to press, the agency has sent additional warning letters, but other work in this issue9 10 suggests new products are likely to continue to pop up in response to regulatory measures.
Despite assurances by several multinationals that they really, really want everyone to quit smoking, they seem intent on continuing the longstanding practice of fighting against the most effective tobacco control policies, including taxes. Apollonio and Glantz11 describe how the industry developed an extensive lobbying campaign to protect manufacturer discounts, keeping tobacco cheap even when states set minimum price policies. In Mauritius, as Berthet Valdois and colleagues show,12 they manipulated prices to keep discount brands cheap, undercutting the potential public health benefit of tobacco taxes on encouraging more price sensitive consumers to quit.
Because of the industry’s interference with public health policies, the WHO Framework Convention on Tobacco Control includes Article 5.3, which urges governments to take measures to exclude the tobacco industry from such policy-making. It is needed now as much as ever. As Willemsen and Fooks show in a study of tobacco control governance in the Netherlands,13 the tobacco industry worked to try to shift governance of tobacco control in the Netherlands from the Ministry of Health to the Ministry of Economics, regarded as more favourable to industry positions. The e-cigarette industry seems determined to follow the same path. Ollila14 describes how government attempts in Finland to regulate e-cigarettes have been thwarted by multiple legal challenges.
Deceptiveness has been a hallmark of the tobacco industry since the days when it denied that cigarettes caused lung cancer and nicotine was addictive. Have they changed? Maybe not so much. Risi and Proctor used computational linguistics to examine language patterns used by tobacco company lawyers in the courtroom to show how they try to put plaintiffs harmed by tobacco products on trial, deceptively diverting attention from industry practices by suggesting the plaintiffs simply made bad ‘decisions’ and ‘assumed risks’.15 The decisions made by tobacco companies are thus effectively obscured. Deception can also mean obscuring the industry face by creating front groups. Lewis et al 16 conducted a content analysis of industry-sponsored political websites made to appear as though they were grassroots groups fighting against policy measures; with names like Citizens for Tobacco Rights and sponsorship from Philip Morris International (PMI), they promoted pro-tobacco industry activism.
In recent years, the industry has gone to great lengths to try to scare governments out of instituting various policies, always claiming they will lead to massive illicit trade, and to assure governments that anti-illicit trade measures the tobacco companies had a hand in developing are just fine, thank you, no need to worry about that any more. Evans-Reeves et al 17 draw on media accounts to demonstrate that tobacco companies used third parties to conduct tobacco purchases in prespecified areas, aimed at promoting to authorities the idea that standardised packaging of cigarettes would increase illicit trade. Gallagher and colleagues demonstrate how the tobacco industry has worked to exert influence over the European Union’s track and trace system for illicit tobacco products. They first created an entity called Codentify, which was then sold to a supposedly independent organisation, INEXTO; leaked documents show INEXTO continued to have financial and organisational relationships with tobacco companies.18
Tobacco companies pioneered many innovations in product marketing, and the pieces in this issue illustrate both aspects of that history as well as recent developments. Parascandola19 uses industry documents to look back at the history of tobacco company involvement with the Olympics, which shamefully still lacks a comprehensive policy against tobacco advertising and sponsorship that applies across the many levels of organisations affiliated with the Games. The industry has likewise used marketing channels that are challenging to regulate, including social media. O’Brien et al 20 explored social media use by tobacco and vape products companies, finding that although cigarettes were rarely seen, e-cigarette, hookah and cigar brands commonly had pages on at least two platforms, rarely used age gating, did not display health warnings, and many featured youthful imagery or mentioned flavours. The industry often claims that it will self-regulate, but Forsyth and McDaniel,21 exploring tobacco content in video games, demonstrate that racing video games popular with young people continue to feature Marlboro brand imagery despite voluntary measures taken by Philip Morris and video game makers to address the issue. Marketing is also about building relationships with potential consumers. Just as the cigarette companies did in an earlier era, the first exploration of e-cigarette industry scholarships for high-school students found 21 e-cigarette entities offering 40 scholarships for youth, the applications calling for essays on topics like ‘what are the different types of e-cigarettes and which would you recommend?’.22
In a series of Ad Watch pieces, authors demonstrate the multiple ways in which tobacco companies continue to link their products to popular social causes,23 target disadvantaged groups,24 deploy Native American and indigenous imagery25 26 to suggest ‘natural’ tobacco products are better,25 and convey misleading messages suggesting FDA’s approval of new products.27 As in the past, military personnel have been targeted, this time by the e-cigarette product JUUL.28
While we often think of the tobacco industry in terms of big companies, researchers are turning more attention to retailers as supply side policy measures are passed or contemplated.
Kephart and colleagues29 explored retailer compliance after Boston, Massachusetts, instituted a ban on sales of flavoured tobacco products. Availability of flavoured products in youth-accessible venues decreased and few customer issues were reported. In two papers by Watts and colleagues, Australian retailers’ views on selling tobacco and their relationships with tobacco companies were explored. Retailers who had stopped selling tobacco indicated that reduced sales or profits were the primary reason.30 A telephone survey of retailers31 found one-third were offered some benefit by tobacco companies in the form of price discounts, rebates and gifts in exchange for prominence on the stock list or influence over product range and stock levels. As New Zealand moves to legalise e-cigarettes, Hoek et al 32 found that tobacco retailers were ill prepared to offer guidance to customers about their use, health effects or use in cessation.
The Industry Watch has long been a closely followed feature of the journal, identifying usual and unusual, curious, and sometimes illegal and unethical industry activities. This issue features pieces illuminating how the industry has used trade and investment treaties to undermine national tobacco control efforts,33 how JUUL is entering Indonesia34 and how a wholly owned insurance company subsidiary of Philip Morris International offers discounts for users of PMI’s IQOS heated tobacco products that are greater than those offered for people who quit smoking, with no discount for use of nicotine replacement therapy products.35 Churchill et al. document IQOS’ introduction into the US market.36 Yadav and colleagues37 show how a tobacco company is brand stretching in India in apparent violation of existing law by applying its brand to non-tobacco products. The industry’s deceptive and colonialist exploitation of indigenous people is highlighted in a report from Thompson et al 38 and an accompanying commentary. 39
As public health increasingly turns its attention to corporate vectors of disease and commercial determinants of health, the tobacco industry remains first among several that serve up suffering, addiction and premature death to millions. But advocates can effectively fight back when they take on industry claims directly and forthrightly. Ackert and colleagues, in an Advocacy in Action piece, show how they used an evidence-based infographic for policy-makers to debunk industry claims.40 Tobacco control advocates everywhere must redouble their efforts to pull back the curtain on industry practices and name the basic problems: continued political interference with sound public health policies and deceptive promotion of products that hurt people.
Contributors I am the sole author of this work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests See statement: https://tobaccocontrol.bmj.com/pages/wp-content/uploads/sites/49/2019/10/DOI-Statement-Ruth-Malone.pdf
Patient consent for publication Not required.
Provenance and peer review Not commissioned; not peer reviewed.