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- advertising and promotion
- electronic nicotine delivery devices
- harm reduction
- tobacco industry
Harm reduction is a respected public health strategy for managing addictive behaviours that pose severe health risks. Such an approach recognises that for people unable to abstain from a certain risky behaviour, public health interventions can be used to mitigate the potential dangers and health risks. For drugs such as heroin, harm reduction applications include needle exchange and supervised injection sites where the provision of sterile injection equipment can minimise the risk of HIV and other infections, naloxone can be administered to manage overdoses and medical staff can arrange treatment referrals. In such instances, harm reduction applications can serve as a gateway to accessing vulnerable and marginalised groups.1 Harm reduction, which is typically overseen by clinicians, nurse practitioners and outreach workers, represents a movement that tends to be community-based, activism-driven and concerned with human rights. An important question pertains to the multitude of stakeholders involved and who is overseeing the harm reduction intervention. For tobacco harm reduction, the curious involvement and role of the industry prove to be contentious.2 3
Multinational tobacco companies, such as British American Tobacco (BAT) and Philip Morris International (PMI), have adopted harm reduction in their public relations initiatives and marketing communication, which provides them an opportunity to showcase their engagement in new product development of self-styled ‘next-generation products’.4 BAT, for example, publishes an annual report on sustainability that includes a section on harm reduction where their e-cigarette brand, Vype, is offered as a harm reduction product.5 During a 2017 annual shareholder meeting, Altria—the parent owner of Philip Morris USA—identified ‘tobacco harm reduction’ as a responsibility priority for the company with their branded ‘innovative products’ and heated tobacco products presented as examples.6 Also in 2017, PMI established a Foundation for a Smoke-Free World with committed funding of roughly US$1 billion and a stated mandate of ‘ending smoking in this generation’. Nevertheless, the independence of the foundation has been questioned.7 For PMI, a ‘smoke-free world’ is largely presented as getting existing users of cigarettes and combustible tobacco to switch to innovative non-combustible products that are positioned as harm reduced.
The underlying goal, however, for the tobacco industry is the maximisation of sales, profit and return to shareholders, which places them at odds with serving a mandate of harm reduction. When considering a marketing management perspective, it is apparent that tobacco companies pursue multiple sales growth strategies that have an underlying objective of profitable growth by expanding the size of the market. Market expansion strategies include market development, product development and diversification. Market development involves seeking new users and market segments to increase the consumption of the company’s existing products (eg, targeting ‘starters’, entering new geographic markets). Product development involves offering new products to current customers (eg, offering vaping products and encouraging dual use). Additionally, the acquisitions of vaping companies by major tobacco companies are a strategic demonstration of diversification, which involves the growth of sales by establishing both new markets and new products through acquisitions.8
Proponents of a tobacco harm reduction approach are likely to argue that vaping promotion, for example, should be allowable that normalises switching from conventional cigarettes and shifts nicotine consumption to lower risk alternatives. However, such a viewpoint overlooks that marketing communication for next-generation products is not limited to a target group specific to a harm reduction mandate (ie, existing adult cigarette smokers who fully convert to vaping, yet would not otherwise quit smoking). In the USA, where vaping by youth has been declared an ‘epidemic’,9 the promotion of sweet flavours makes the products more palatable and appealing to youth.10–13 Vaping products resembling USB flash drives are readily available with discreetness being another key product feature with youth appeal (figure 1).14 Youth have been a key target group for marketing purposes, and vaping brands are successfully marketed to youth.15–18 Put simply, the goals of harm reduction will not be realised if new users are brought into the market and introduced to nicotine addiction.
Promoting dual use also contradicts the goals of harm reduction. An important impact of implementing smoke-free policies that do not allow cigarette smoking indoors has been a reduction in consumption, including stimulating more quit attempts among smokers, enhancing the number of quit attempts that are successful, and diminishing the number of cigarettes that are smoked among continuing smokers.19–22 Nevertheless, marketing communication for next-generation products commonly encourages use in settings where cigarette smoking is not allowable (figure 2). Retail websites for e-cigarettes commonly include claims that their products can be used virtually anywhere and thereby used to circumvent smoke-free policies.23 E-cigarette promotions often show indoor settings to imply that vaping is still possible when cigarette smoking is not. Dual use is not harm reducing in such instances as consumers remain cigarette smokers, yet they are likely to vape when they might otherwise be inhibited from smoking (figure 3). There is indication that continued smoking, even if reduced, is unlikely to result in notable health benefits.24 Several studies have also found that dual users, who are trying to quit or reduce smoking, are less successful in their cessation attempts.25–27 Given the profit maximisation aims of the tobacco industry, it is not in their strategic interests to have consumers successfully quit and exit the market altogether (figure 4).
Lempert and Glantz make a valuable contribution by giving careful consideration towards a submission of a premarket application made by Philip Morris, to the Food and Drug Administration (FDA), to market IQOS in the USA.28 The authors present strong arguments that question the FDA’s decision to approve the IQOS premarket application, which gives the tobacco company authorisation for marketing the product with modified risk claims that are ultimately deemed ‘appropriate for the protection of the public health’. Yet, it is important to recognise that marketing and promotion initiatives by tobacco companies aim to influence overall consumption levels. A major conclusion of the 2012 US Surgeon General’s report is ‘advertising and promotional activities by tobacco companies have been shown to cause the onset and continuation of smoking among adolescents and young adults’.29 The US National Cancer Institute similarly concluded that the total weight of evidence ‘demonstrates a causal relationship between tobacco advertising and promotion and increased tobacco use’.30 Moreover, according to the 2016 US Surgeon General’s report, ‘the marketing of e-cigarettes drives consumer demand for these products’.31
Ultimately, scholars have attempted to quantify the harms and health benefits of e-cigarettes at the population level. The conclusion reached, in the USA context, is that ‘e-cigarette use currently represents more population-level harm than benefit’.32 In summary, the goal of harm reduction is not achieved if the commercial marketing communication of next-generation products serves to attract new users such as youth that are never smokers, encourages dual use (in combination with combustible cigarettes in accordance with the use setting) or discourages cessation or altogether quit attempts. Indeed, a BAT investors presentation from 2017 reveals both combustible tobacco and vapour products being forecasted as growth opportunities.33 34 Moreover, a 2020 BAT investors presentation outlines their evolving strategy regarding ‘A Better Tomorrow’, which specifies increasing the occasions in which nicotine is used, maintaining tobacco while expanding through new products that include ‘beyond nicotine’, and maintaining growing profits (described as ‘superior returns’).35 The maximisation of private profit is the underlying goal of the tobacco industry, with objectives of their marketing activities including sales and profit growth.
Patient consent for publication
Contributors TD is the sole contributor to this editorial.
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 TD is an Associate Editor of Tobacco Control with respect to Product Marketing and Promotion. He has served as an expert witness in tobacco and vaping litigation on behalf of governments whose policies have undergone constitutional challenges, and he was a delegate at the 2019 Harm Reduction International Conference.
Provenance and peer review Commissioned; internally peer reviewed.