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Abstract
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.
- harm reduction
- public policy
- tobacco industry
- tobacco industry documents
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Introduction
Thirty years of research and analysis in Tobacco Control provide the opportunity to step back and critically appraise the advances made in understanding and addressing the tobacco industry as the primary vector of the global tobacco epidemic.1 2 This is particularly timely given that, responding to the success of tobacco control activities, transnational tobacco companies (TTCs) are redoubling their aggression and remain a crucial barrier to further progress (box 1).3–6 Perhaps as a result, declines in smoking prevalence appear to be stalling and most countries have not had sufficient decreases to offset population growth,7 resulting in all-time high of 1.1 billion smokers in 2019, over three-quarters of whom live in low-income and middle-income countries.5 7
Background: the existential threat driving TTCs strategies
TTCs’ business models involve manufacturing tobacco products at a very low cost and maintaining their sale at relatively high prices, resulting in massive profit margins. In 2020, PMI’s profit margin was 40.8%, BAT’s was 38.6%, JTI’s was 22.4% and Imperial Brands’ was 41.2%, with combined profits of just under US$33 bn.50 109 These margins enable both huge reinvestment, for example, in marketing or lobbying budgets, and the promise of ever increasing shareholder dividends. However, as a result of advances in tobacco control, cigarette sales have been falling since 2013.5 6 TTCs were initially able to maintain and even increase profits by exploiting their market power and overshifting taxes such that their price increases more than offset the decline in cigarette sales volumes.6 However, more recently, continued tax increases and implementation of tobacco control measures appear to have precipitated a tipping point where declining sales are no longer offset by overshifting, and profitability is falling.16 110 111
This fundamental, existential threat for TTCs has driven: aggressive responses to prevent rises in tobacco taxes around the world; involvement in tobacco smuggling as a means of tax avoidance (discussed in Case Study 2); undermining the impact of tax increases on consumption and prevalence111 112 and heavy investment in ‘product innovation’ in HTPs and e-cigarettes. This investment arguably provides the best opportunity to replicate the oligopoly control they benefit from in the cigarette market and, if they remain untaxed or taxed at low level, provides a new route to profits while also allowing them to attempt a hostile takeover of the harm reduction narrative (discussed in Case Study 1).16 17 113
BAT, British American Tobacco; HTP, heated tobacco product; JTI, Japan Tobacco International; PMI, Philip Morris International; TTC, transnational tobacco companies.
Great advances have been made in understanding the TTCs’ short-term reactive corporate political activity to prevent, delay or divert tobacco control policies,8 with the accumulation of thousands of case studies enabling a sophisticated understanding of these tactics.9–11 These insights have been operationalised to good effect in protecting and advancing diverse policies across multiple jurisdictional levels.9 10 12 13 There has, however, been comparatively little work on the proactive long-term policy influence strategies, despite leaked documents showing TTCs plan for the long term.14–16 There is, therefore, an urgent need address this gap.
This paper aims to explore the TTCs’ long-term influence strategies using two case studies: harm reduction and the illicit tobacco trade, two key policy areas in which TTCs have a long history of engagement and have in recent years redoubled their influence efforts. In this way, we aim to identify lessons for the tobacco control movement and the commercial determinants of health more broadly.
Methods
We selected harm reduction and illicit tobacco as our two case studies. We drew on multiple sources of evidence including previous research, recently leaked TTC documents and material obtained through established routine monitoring of TTC activities. The latter involves established Google alerts on all TTCs and on key areas of their activity and brands, regular searches of tobacco industry and retail journals and information provided from a wide network of informants.
We analysed these sources to identify industry strategies which we categorised using the Policy Dystopia Model (PDM) as our conceptual framework. The PDM is an evidence-based taxonomy of tobacco industry political activity derived from systematic reviews of industry influence on policy.10 The PDM has been shown to capture key elements of TTC influence strategies in a range of settings, dividing these into discursive (argument-based) and instrumental (action-based) strategies (see online supplemental tables 1 and 2). While the PDM defines illicit trade as an instrumental strategy, here we focus on the TTC’s narrative around illicit trade.17–19 We sought to identify the primary discursive and key instrumental strategies that best captured the long-term influence strategies in both case studies. Triangulation, prolonged engagement, persistent observation and discussion among authors were used to test the validity of our findings.20 21
Supplemental material
Case study 1: TTCs use of harm reduction as a long-term ‘pathway to profit’ strategy (1950s–2021)
Since the 1950s when the links between smoking and lung cancer became known,22 TTCs have attempted to ward off the denormalisation of the industry and threats to their cigarette sales by professing a commitment to harm reduction, and actions such as introducing cigarette filters (1950s), ‘light’ cigarettes (1970s) and investing in smokeless tobacco options such as snus and nicotine pouches (2000s). These actions were supported by broader communication strategies and activities (table 1).23–27 Now, TTCs have once again returned to harm reduction. Seen with the context of previous actions, this is most likely the latest manifestation of the long-term strategy of seeking to rebuild credibility to secure policy influence and boost declining sales and profits.28
Timeline of key political activity in harm reduction involving the company currently known as Philip Morris International (including when working alongside other TTCs)
While recognising that other TTCs have developed similar ‘transformational’ narratives,29–32 in this case study we focus on Philip Morris International (PMI).28 PMI has led the latest iteration of this historic tactic and recently leaked documents give a unique insight into its long term strategies around harm reduction.16 28 Our analysis identified PMI’s utilisation of three main and inter-linked instrumental strategies—reputation management, information management and coalition management—to convince the world of its commitment to harm reduction both historically (table 1) and currently. Below, we consider each in turn.
Reputation management
In 2018, PMI announced it was ‘giving up cigarettes’ as part of a slew of transformation rhetoric around its supposed reincarnation into a disruptive technology company.33 PMI pledged to ‘unsmoke’ the world by promoting a ‘switch’ to its heated tobacco product, iqos,34 35 despite simultaneously claiming that heated tobacco products (HTPs) are not intended to help quitting,36 and a lack of independent evidence that they reduce health harms compared with cigarettes.37 Furthermore, the true motivation appears to be maximise sales and profits rather than to improve population health. Evidence for this includes the high price (and even greater profitability relative to cigarettes) of iqosand PMI’s targeting of iqosmostly at high-income countries with relatively strong tobacco control policies (ie, where smoking was already declining) while continuing to invest in and market cigarettes elsewhere.16 38
Leaked documents from 2014 reveal PMI’s long-term strategy to appropriate harm reduction to renormalise its image as a ‘trusted and indispensable partner, leading its sector and bringing solutions to the table’.28 39 Using the guise of transformation, PMI has harnessed the media and piggybacked on global platforms such as the World Economic Forum, G20 summit and UN General Assembly, to give the impression that it is a trusted partner of the global political and public health communities.16 40–43 At a national level, PMI is attempting to operationalise its newly constructed reputation as a public health partner and vast resource to leverage political influence. For example, it offered the NHS (National Health Service) one billion pounds to help smokers switch to alternatives if the UK relaxed European Union (EU) regulations on e-cigarettes and heated tobacco products post-Brexit, a proposal known as the Tobacco Transition Fund (which the UK government rejected).44
Most recently, PMI capitalised on the COVID-19 pandemic to propagate its transformation narrative.45 Efforts ranged from a global rollout of corporate social responsibility activities, focused on donations to hospitals and crisis centres, to investing in COVID-19 vaccine development through PMI’s part-ownership of biopharmaceutical company Medicago.46 47 PMI’s chairman described the investment as ‘part of our new course, based on science, technology and innovation’.48 Medicago went on to secure a partnership with the Government of Canada,47 contravening Article 5.3 of the Framework Convention on Tobacco Control (FCTC). PMI also used messaging around the pandemic to boost sales, through offers of free HTPs, free contactless home delivery with waived ID validation and matched COVID-19 donations based on points accumulated iqos purchases.49
Information management
As part of its 2014 10-year corporate affairs plan,28 PMI set out to ‘establish the concept of harm reduction as legitimate public policy in tobacco regulation’ and ‘establish the legitimacy of tobacco companies to be a part of the regulatory debate [‘part of the solution’]’ (figure 1).
Philip Morris International (2014) corporate affairs objectives and strategies: reduced risk products (p4)28
This plan has been operationalised in a multifaceted information management campaign, part of over $50 million spent over the past 6 years in marketing and research costs.50 Three key strategies have emerged in which PMI attempts to control everything from the science on HTPs, to the media discourse about harm reduction.
First, building on the industry’s earlier tactical co-option of harm reduction terminology,27 PMI is now attempting to redefine the concepts ‘smokefree’ (away from the complete absence of tobacco products) and ‘quitting’ (away from ending the use of tobacco and nicotine products). Its presentation of iqosas ‘smokefree’ may not be entirely accurate, due to the pyrolysis that occurs when the tobacco is heated.51 52 Similarly, PMI publishes estimates of ‘quitting’ based on the number of people who have ‘switched’ to iqos, even for a brief period, including dual users alongside cigarettes.16 PMI’s ‘harm reduction equation’ suggests a broader attempt to redefine harm reduction (figure 2). Although there is no single definition of harm reduction, definitions generally acknowledge the need to reduce harm not only for the individual user but within the community and society in which they live.53–57 PMI’s equation instead focuses just on individual smokers using new products to ‘switch’ (notably not ‘quit’), positioned as equivalent to proven population-based tobacco control measures. While moving smokers from a higher to a lower risk product will achieve significant health benefit, this equation overlooks concerns and evidence that, in some jurisdictions, wide availability and promotion of new products will lead to uptake among never smokers.58–60
Philip Morris International harm reduction equation.124
Second, PMI is increasingly controlling the science through its internally conducted and directly funded science (promoted through the ‘PMI Science’ website) and that funded by the Foundation for a Smokefree World (FSFW), created by PMI with a billion-dollar pledge in 2017.61 62 Reminiscent of the disbanded TIRC (Tobacco Industry Research Committee) and CIAR (Center for Indoor Air Research), FSFW has been accused of operating as little more than a PR arm of the tobacco company.63 PMI and FSFW, operating together, are propagating rhetoric that lies in stark contrast to reality (table 2).
Transformation claims made by PMI on harm reduction (the rhetoric vs the reality)
Third, the company is attempting to further control discourse on harm reduction and ensure favourable representation of its transformation and products by influencing the media. It has invited journalists on all-expenses paid trips to attend science tours at its labs, placed large advertorials in broadsheets64 and is funding PR and media companies to promote both the company and switching to alternative products.16 While it promotes this sympathetic media coverage, it opposes research findings and media coverage that critiques or contradicts its messages.61
Coalition management
In addition to FSFW and other established industry allies,61 PMI, with other controversial industries (oil/gas/unhealthy food), has recently formed the Industry Transformation Coalition, a corporate public relations organisation positioning industry as a ‘catalyst for good’ and lobbying for technological solutions for the world’s problems.65 FSFW has also funded International Network of Nicotine Consumer Organisations (INNCO), an umbrella organisation with 40 listed members and affiliates (industry-linked and independent) which publicise many of the same harm reduction messages promoted by TTCs.66 67 Such networks represent a mobilisation of the company’s corporate affairs plan, leveraging ‘third party coalition building’ to create an ‘alliance of credible messengers’.28
PMI has attempted to exploit divisions in the public health community over harm reduction and, along with front groups and allies, is attempting to tarnish the reputation of the global tobacco control community.14 16 68 69 PMI’s targeting of individuals and organisations within tobacco control has roots in project sunrise, initiated in 1995 (table 1), where PMI questioned the credibility and integrity of some in tobacco control, while working with others to promote favourable policy options.70 This strategy was re-emphasised in their 2014 corporate affairs plan which described their aim to ‘amplify and leverage the debate on harm reduction’.28 PMI have since claimed that tobacco control research and advocacy is biased by charitable or philanthropic funding,43 71 that they are the victim of misinformation and ‘sham science’,72 73 and used social media to criticise people and organisations perceived as opposing its products and harm reduction claims.69 These challenges to the tobacco control community aim to fragment the usually unified voice of the tobacco control movement, muddying the waters in policy debates and distracting attention from effective tobacco control measures.27 74 75
Case study 2: TTCs long-term ‘victim and solution’ strategy to define the narrative on illicit tobacco trade (1990s–2021)
In the late 1990s, internal industry documents demonstrated that facilitating the smuggling of their own products had been a core part of TTCs’ global business strategies for decades.76–80 This led to a series of investigations and legal action and within a relatively short-time TTCs had been exposed as suppliers of illicit tobacco.15 81–84 In response, the Protocol to Eliminate Illicit Trade in Tobacco Products was developed, coming into force in September 2018, aiming to eliminate illicit tobacco trade through a package of measures taken by countries acting cooperatively.
Recognising the threat to profitability from loss of this avenue for sales and profits, tobacco companies began to publicly position themselves as both victims of, and solutions to, the illicit tobacco trade. This despite evidence that tobacco companies continue to facilitate the illicit trade of their own products.15 85 TTC promotion of the inadequate and inefficient industry-developed tracking and tracing system Codentify further serves to ensure that illicit trade continues.15 86 87 TTCs have come to dominate the debate around illicit tobacco trade effectively setting the agenda on the topic.15 This poses a substantial risk to accurate understandings of the illicit tobacco trade and, more broadly, of tobacco industry regulatory capture and neutralisation of effective measures to address tobacco smuggling. Our analysis shows how TTCs have used their vast resources to reach key stakeholders at global level with subsequent policy impacts at regional and national levels, using three main and inter-linked instrumental strategies over two decades (table 3). Below, we consider each in turn.
Timeline of key tobacco industry activities relating to the illicit tobacco trade
Reputation management
TTCs have engaged in a global PR campaign to promote their primary discursive strategy—that the industry has changed and is a necessary part of the solution for illicit trade (table 4). Despite data indicating that approximately two thirds of the global illicit tobacco market between 2007 and 2016 consisted of product smuggled from the supply chains of tobacco companies, tobacco companies now emphasise the presence of other products (counterfeits and illicit white cigarettes) on the illicit market to portray the illicit tobacco trade as detrimental to their profits.15 88 Tobacco companies appear to have been successful in presenting themselves as victims, largely through extensive efforts to ingratiate themselves with authorities tasked with addressing illicit trade, including through large donations and providing anti-illicit trade training events for law enforcement officials in various countries (table 4).15 89
Claims made by TTCs on illicit trade (the rhetoric vs the reality)
Information management
Such efforts are supported by a well-funded information management strategy where TTCs have positioned themselves as a major provider of data on illicit trade. Over the past two decades, TTC-commissioned reports have become the primary source of data on illicit tobacco throughout most of the world.90–92 These reports have often criticised been for lacking transparency and inadequate methodologies, producing inflated estimates of illicit tobacco trade and downplaying or concealing the presence of tobacco companies’ product on the illicit market.91 These reports—often regional and well-publicised—allow TTCs to define the problem of illicit tobacco trade (eg, its nature, scale and drivers) and to garner media interest, ensuring the industry’s ‘victim and solution’ messaging dominates media coverage of illicit from global to local levels (table 4). Similarly, by funding international conferences and reports on track and trace technology, TTCs have promoted their own track and trace system, Codentify, seeking to have this implemented over other systems without industry links.15 93 94 These efforts ultimately increase TTCs access to regulators and policy makers.
Coalition management
Tobacco companies use of front groups to perpetuate arguments that tobacco control policies drive illicit trade is well documented.95 However, over the past decade, we have seen increasingly covert and deceptive strategies to try and undermine measures to address illicit trade.15 96 This includes TTCs collaborative, long-term strategy to promote their industry-controlled and ineffective Codentify system to governments15 (table 3). While coordinated efforts to influence tracking and tracing implementation at national level used global TTC messaging around illicit trade, often through a complex system of third parties, front groups and media spokespeople (including ex-law enforcement).15 96–98 Such groups also present TTCs positions in policy consultations and elsewhere, often without disclosing their links to these companies.15 98
Discussion
This paper set out to examine TTCs’ long-term policy influence strategies which the literature hitherto has rarely examined in detail. It shows that in addition to their reactive efforts to oppose almost every effective tobacco control policy country by country, TTCs engage in long-term, proactive strategies to promote their corporate interests and goals. Using two case studies, we show that three mutually reinforcing instrumental strategies dominate in the longer-term—reputation management, coalition management and information management. These instrumental strategies work synergistically to propagate one over-riding discursive strategy—‘we’ve changed, we are part of the solution’—despite clear evidence in both case studies that this is not the case. In this way, tobacco companies attempt to redefine the dominant narrative away from a ‘pariah’ industry which should be systematically excluded from decision making (as per FCTC Article 5.3) towards one central to solving the tobacco epidemic.
We also note that in redefining the dominant narrative, TTCs are also attempting to redefine key concepts and shape the language of the debate and responsibilities for action. This includes redefining harm reduction, ‘smokefree’ and ‘quitting’. Similarly, the illicit case study suggests that TTCs have attempted to redefine illicit tobacco as largely a problem created by other actors—counterfeit or illicit whites produced by criminal enterprises, rather than the TTCs own product.15 In both cases, the TTCs’ resource advantage enables themto do this—to monopolise data, to publish extensive advertorials and ‘white papers’ and host events—all of which secure extensive media coverage, enabling TTCs to dominate debates and reach key audiences. In short, these longer-term strategies exert covert power by framing the parameters of debate, reshaping norms and beliefs around the tobacco industry and tobacco control, legitimising TTC positions and ultimately seeking to make TTCs’ agendas appear desirable to policymakers and the tobacco control community seem misguided.
It is notable that the dominant long-term instrumental strategies identified are indirect (and covert) rather than direct (and overt). This likely reflects the success of tobacco control and of Article 5.3 in ‘demonising’ the industry and explains TTCs’ significant focus on reputation management and coalition management in both case studies. Coalition management strategies have always been a means to exert hidden power, but these webs of influence have become increasingly complex and opaque. For example, through the umbrella organisation INNCO, TTC-funded third parties and independents are enmeshed, serving both to camouflage TTC influence where it occurs and increase exposure to their messaging. Similarly, Codentify, initially being promoted through one front group, has now been sold to another company (with multiple ex-PMI employees) which licenses software to other companies, which in turn apply for national track-and-trace tenders, making it hard to trace industry links.96 99 Our findings also suggest that these long-term strategies primarily operate at global level and are then leveraged at the national level, with the TTCs’ global efforts setting the stage on which national policies are negotiated. This may prove particularly problematic in countries where the tobacco industry is not yet delegitimised, and civil society is less well-resourced and hence less able to counter the TTCs and their narrative. Overall, our findings demonstrate the need to critically review TTCs’ current actions and claims in the context of evidence for extensive engagement in strategies aimed to build credibility, secure policy influence and reboost declining sales and profits, generally at the expense of population health.
Limitations
This paper has several limitations. First, TTCs activities are multiple and are often hidden. Extensive searches were conducted, but we were restricted to publicly available data and, while this includes detailed leaked industry documents, it likely provides a limited view of activities in each case study, particularly at national level, in countries without English as an official language, and across all TTCs. Further case studies are needed to see if the strategies identified in harm reduction and illicit trade are generalisable across the spectrum of industry activity.
Challenges and recommendations
Our findings have implications for tobacco control. First, they demonstrate the importance of identifying and addressing the TTCs’ long-term influence strategies which are carefully coordinated at the global level yet which, by reshaping norms and beliefs, can have wider reaching impacts. The FCTC amply demonstrates the global ambition and reach of tobacco control. Yet, the FCTC, and tobacco control more generally, are largely operationalised at the national level where, in part due to resource constraints, advocacy efforts to address tobacco industry interference often focus on short-term policy opportunities. While national and regional work remain an essential entry point to understand and counter TTC strategies, a global focus could allow tracking and identification of new patterns of TTC activity or ‘norms’ that need countering and provide a means of bringing public health messages to, and countering TTC messages in, specific global settings. Such efforts would be closely coordinated with and support regional and national work, enabling efficiencies to be realised. Second, and closely linked to this, TTCs’ overwhelming focus on renormalisation through reputation management shows that tobacco industry denormalisation, for which there is substantial evidence, should be considered an essential tobacco control measure.100 The implementation of a global denormalisation campaign could be one such effort, which could then be leveraged at regional and national levels. Third, the dominant use of coalition management strategies and the increasing use of third parties and what can be described as ‘dark influence webs’ suggests we must become more adept at exposing TTC third parties. This requires new research methods, including novel digital methods to identify likely front groups. This is, however, complex and time consuming and we therefore need to shift the onus to others: participation in policy events and consultations should require full disclosure of funding for participants and submitted evidence—simply declaring ‘no COI’ or no funding is insufficient. The importance of Article 5.3 cannot be overstated, and effective transparency and lobbying registers remain essential. Finally, growing TTC control of data and evidence, which enables it to shape norms, will hinder progress in all areas unless addressed. For example, the potential for novel products to contribute to tobacco control is hindered by the fact that research on such products is dominated by TTCs with an appalling history of research misconduct which emerging evidence suggests may be being repeated, and a vested interest in showing its products are safe.101–103 Ways to address this include through a database of authors’ and editors’ conflicts of interest which can help overcome the documented failure to declare interests within specific papers and alternative means of raising research funds from corporations while protecting that research from vested interests, issues explored elsewhere.101 104 Open discussion and trust among the public health community will enable information on TTC conduct to be considered alongside emerging science on new products and their potential benefits and harms—only with this combination of evidence can the most effective policy decisions be made.
More broadly, there are lessons for efforts to address the commercial determinants of health, given the clear commonalities in underlying drivers and strategies already demonstrated across unhealthy commodity industries.105–107 Those working in alcohol and food policy should seek from the outset to address these global long-term influence strategies and not just focus on the immediate national level challenges. More broadly, we need to recognise that until we address underlying system drivers, progress will remain limited.107 108 The TTCs’ growing use of increasingly opaque ‘webs of influence’ indicates this problem—TTCs have used their resource advantage to adapt to and counter attempts to increase transparency in policymaking. The public health community must therefore work collectively to push for more radical structural and systems change to address the commercial determinants of health. This might include accountability mechanisms such as ensuring corporations pay for the costs of the harm caused by the sale of harmful products, amending corporate regulation to reduce the dominant focus on profit and/or change the rules on limited liability, and wider changes to the global political and economic system that have increased corporate power and influence.
What this paper adds
To date most literature on tobacco industry policy influence focuses on the TTC’s reactive efforts to oppose tobacco control policy, but TTCs also engage in long-term, proactive policy influence strategies to promote their corporate interests and goals. This paper sought to examine TTCs long-term influence strategies using two case studies.
In both case studies we found the industry draws on its immense material and ideational power to commission and publish misleading evidence, reports, advertorials and other outputs that serve its interests (information management), to establish and fund organisations that promote the industry’s messaging while often purporting to be independent or are meant to hold industry to account (coalition management), and to host events and secure media coverage that promote its messaging to key audiences (reputation management).
These long-term strategies serve to redefine key concepts and dominant narratives, reframe the parameters of debate and reshape norms to the TI. Collectively they serve to position the tobacco industry as part of the solution to tobacco control and tobacco smuggling, to create confusion and division, and to undermine Article 5.3.
These actions are globally coordinated and set the stage on which national policies are negotiated, thereby widely stymying progress.
The tobacco control community needs to pay greater attention to these efforts. Countering them will require a global focus which must include awareness raising and tobacco industry denormalisation, new ways to fund research, better requirements for transparency in research and policy, and innovative research to identify industry third parties. Above all, these ongoing problems despite decades of progress in tobacco control should serve as a lesson for efforts to address the commercial determinants of health and indicate the need for structural solutions to address corporate power.
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This study does not involve human participants.
References
Footnotes
Twitter @ThomasRHird, @AllenGallagher_, @pdiethelm, @BathTR
Contributors ABG and TRH conceived the idea for the paper. RE provided critical feedback on the idea. TRH, AWAG, KE-R, MZ, SD and PAD collected data for, analysed and drafted the case studies. TRH and AG drafted the overall paper. All authors contributed to editing of the paper.
Funding TRH, AWAG, KE-R, MZ, SD and ABG acknowledge the support of Bloomberg Philanthropies’ Stopping Tobacco Organizations and Products funding (http://www.bloomberg.org/).
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.
Author note This paper is dedicated to the memory of Dr Mateusz Zatoński.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.