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Abstract
Objectives To identify proponents and opponents of the commercialisation and marketing of e-cigarettes and heated tobacco products (HTPs), identify the arguments used on both sides and compare how the arguments have changed over time, we analysed three policy discussions occurring in 2009, 2018 and 2019.
Methods We conducted a content analysis of one document and six videos from these discussions, provided on the Brazilian Health Regulatory Agency website, or upon request.
Results The arguments most used by tobacco companies were related to claims that the use of e-cigarettes and HTPs is less harmful than conventional tobacco. Unions that support its commercialisation also argued that lifting the ban would prevent smuggling and guarantee their quality. On the other side, universities, medical and anti-tobacco institutions argued that such devices may have health risks, including the risk of inducing cigarette smoking. In 2009, most arguments belonged to the ‘health’ theme, while in 2018 and 2019 economic arguments and those related to morals and ethics were frequently used.
Conclusions Those that supported the commercialisation and marketing of e-cigarettes and HTPs first focused on arguments of harm reduction, while 10 years later the right to access and potential economic consequences also became common. Public health agents and academics must gather evidence to effectively respond to these arguments and discuss these policies, and must prepare themselves to use and respond to arguments related to moral and economic themes.
- harm reduction
- electronic nicotine delivery devices
- public policy
- tobacco industry
Data availability statement
We conducted a content analysis of the arguments used by stakeholders involved in three different events of public discussion about the regulation of e-cigarettes and heated tobacco products in Brazil. (1) Public consultation n. 41/2009—the report of the event (analysed document) was requested to the Brazilian government through a simple system of access to information and sent to the corresponding author by email. (2) Panel of 2018—the videos of the event (analysed documents) can be found on these websites: https://youtu.be/PjA3A-BgvC8; https://youtu.be/_UrM6YoF0b4; https://youtu.be/DRRS57m4Sgc. (3) Public hearings of 2019—the videos of the event (analysed documents) can be found on these websites: https://www.youtube.com/watch?v=JLjgDraDDxM; https://www.youtube.com/watch?v=UAuEV3atvdc; https://www.youtube.com/watch?v=MIy9JK3dmm0; https://www.youtube.com/watch?v=tiqA90lZIoc.
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Introduction
Brazil is one of the world’s leading tobacco producers and one of the main exporters of non-manufactured tobacco.1 Until the 20th century, tobacco production was dispersed throughout the country. After the establishment of American and British companies, the tobacco industry became controlled by those companies—British American Tobacco became the main shareholder of Sousa Cruz in 1914—and production became concentrated in the country’s southern regions. In 2008, taxes on tobacco products generated about US $2.2 billion.2 Despite the importance of the tobacco industry on its economy, Brazil was one of the first countries to implement strong tobacco control measures,3 which led to a consistent reduction of the prevalence of tobacco consumption since the 1980s.4
In 2009, after a public consultation by the Brazilian Health Regulatory Agency (Anvisa),5 the marketing and commercialisation of e-cigarettes and heated tobacco products (HTPs) were banned in Brazil. However, their registration for sale could be allowed if producers presented toxicological studies and scientific tests proving their effectiveness in smoking cessation6; this occurred only in 2021 but registration was denied.7 After pressure from the tobacco industry,8 9 discussion resumed in 2018 with a panel of several stakeholders, and in 2019 through public hearings, to review the existing regulation. The final decision has been postponed until the last months of 2021.
Discussions on the regulation of e-cigarettes have been held in several countries, namely in the UK.10 Government and non-government organisations, and researchers in the UK who have traditionally supported strong tobacco control were divided.10–12 Despite both sides claiming to be supported by the evidence, some have advocated that e-cigarettes should be regulated as tobacco products, while others wanted to regulate them as pharmaceutical products. During the revision of the Tobacco Products Directive in Europe in 2012, medical and public health organisations, the e-cigarette industry, e-cigarette users, and liberal politicians used several strategies and arguments, gathering and discussing evidence, asserting or contesting rights, and breaking or forming coalitions to influence the regulation.13 As in Europe, opponents of e-cigarette sales, taxation, public use, and marketing regulation from four US cities lobbied to define e-cigarettes as ‘alternative nicotine products,’ and not as ‘cigarettes’ or ‘tobacco products’. Their arguments were based on the lower risk for health, potential for tobacco cessation, choice, freedom and economic harm. Legislators and government agency movements to support e-cigarette regulation focused on protecting youth.
Being aware of the arguments presented during discussions of e-cigarette and HTP regulation in middle-income tobacco-producing countries, and how arguments have changed over the past decade due to new evidence produced, may contribute to a more agile and effective response from public health institutions devoted to reduce the impact of smoking on people’s health.
The current study aimed to, first, identify the participants who supported or opposed the regulation of e-cigarettes and HTPs; second, analyse the arguments presented by the different participants in the policy discussions (public consultation, and in panel and public hearings); and third, compare the arguments used in 2009 with those presented 10 years later.
Methods
We conducted a content analysis14 of the arguments of stakeholders involved in three separate discussions concerning the regulation of e-cigarettes and HTPs in Brazil: (1) the public consultation number 41, held in 2009, which preceded the preparation of the Collegiate Board Resolution number 46, 2009, that prohibited the sale and marketing of e-cigarettes and HTPs in Brazil; (2) the panel for discussion in 2018; and (3) the public hearings held under the Regulatory Impact Analysis in 2019. These discussions were held by Anvisa and were open to all stakeholders interested in discussing the ban on the commercialisation and marketing of e-cigarettes and HTPs and aimed to gather and explore the existing evidence about their health risks and potential contribution for harm reduction.
We reviewed the document proceedings (one document) of the 2009 public consultation as well as the videos of the 2018 panel and 2019 public hearings (two from 2018 and four from 2019). Other available documents (32 in total), including memorandums, reports, presentations and plans, were also screened but were not included in the analysis because they were either administrative documents or summaries from the discussions and did not provide any new arguments. The videos were available on the Anvisa website and the 2009 document was shared by Anvisa, following the transparency guidelines for Brazilian public institutions.
The analysis involved both deductive and inductive approaches. Drawing from the literature about the positions taken by the scientific society and tobacco industry,15–19 we defined the following themes: ‘health arguments’, ‘economic and social arguments’, and ‘legal, moral and ethical arguments’. Themes and codes were then updated during data analysis; three new codes were added (table 1).
Themes and codes
We analysed and compared arguments used in 2009 with those used in 2018 and 2019. We looked for shifts in the arguments as proponents of the commercialisation and marketing of e-cigarettes and HTPs could have been exploring new framing or lobbying strategies and opponents could have been changing their initial positions after a decade of research and experience from other countries.
To avoid over-representation of arguments repeated by the same participant, we coded only one mention of each argument per participant in each hearing. Responses to others’ arguments, justifications or comments that did not constitute an argument to support their position were not coded as arguments.
Data analysis was conducted by the first author of the article. Coding was verified by the last author and discrepancies were discussed by both and resolved after agreement. Data analysis was performed with MAXQDA Analytics Pro 2020.
Results
The analysis of the arguments used during these discussions allowed us to identify the proponents and opponents of the commercialisation and marketing of e-cigarettes and HTPs in Brazil. Proponents of the commercialisation and marketing of e-cigarettes and HTPs included tobacco companies (Philip Morris; Souza Cruz, a subsidiary of British and American Tobacco; Japan Tobacco International; and Imperial Brands), consumers, non-tobacco enterprises (eg, kiosks and tobacconists, unidentified commercial spaces and consultants), politicians (congresspeople, mayors, city councillors and former senators and secretaries from tobacco-producing municipalities/states), and unions or associations (related to tobacco production, restaurants or working in kiosks). Opponents of the commercialisation and marketing of e-cigarettes and HTPs were Anvisa (the Brazilian Health Regulatory Agency), a consumer protection organisation, representatives of universities (from Brazil and the USA), and medical and anti-tobacco institutions (namely, related to cancer prevention, health promotion, tobacco control, paediatrics, pneumology, oncology and other medical associations). Details on these actors can be found in online supplemental table.
Supplemental material
Arguments used and themes
Arguments used in 2009, 2018 and 2019 are presented in figure 1 and online supplemental table.
Arguments used by participants by hearing moment. Thicker lines correspond to higher frequency of arguments mentioned.
The impact of e-cigarettes and HTPs on health was the most frequently mentioned theme (147 mentions). Under this theme, several arguments emerged: the argument of no sufficient evidence being available to support/oppose their commercialisation or marketing (23 mentions), risks for health (31 mentions), the risk of smoking induction (26 mentions), and, among proponents, the arguments of being less harmful than cigarettes (24 mentions), their potential role to substitute cigarette smoking in a harm reduction strategy (19 mentions), the non-induction of smoking (11 mentions), and the benefits of lifting the ban to guarantee product quality (13 mentions). The argument ‘e-cigarettes and HTPs present risks’ was mentioned by Anvisa and representatives of universities, medical and anti-tobacco institutions. The argument that e-cigarettes and HTPs ‘induce smoking’ was used by all those who oppose the commercialisation and marketing of these products. While both sides cited that there was ‘insufficient evidence, proponents of the commercialisation and marketing of e-cigarettes and HTPs argued that they are ‘less harmful’ and provide ‘harm reduction’.
In all discussions, tobacco companies recognised that e-cigarettes and HTPs could present health risks, as did the unions and associations in the 2019 hearings. However, these mentions were preceded or followed by claims that e-cigarettes and HTPs were less harmful compared with cigarettes and could be used as part of a harm reduction strategy.
Under the theme of economic and social impact, the argument that the sale of e-cigarettes and HTPs is ‘important to the economy’ was mentioned by proponents of the commercialisation and marketing of such products (12 mentions), with the exception of tobacco companies. One opponent observed that while tobacco was important to the economy, there should be incentives for them to be gradually replaced by other agricultural crops, to reconcile the interests of producers with the demands of public health. The argument that the regulation of the sales of e-cigarettes and HTPs would prevent smuggling was used by tobacco companies, consumers, politicians, and unions or associations (14 mentions).
Arguments related to the law, morality and ethics were also used by both sides. Anvisa and universities, medical institutions and anti-tobacco institutions’ representatives highlighted the aggressive marketing practices of the industry, frequently targeting youth (18 mentions). On the other side, tobacco companies, consumers, unions and associations used the argument that consumers have the ‘right to have e-cigarettes and HTPs’ (five mentions).
Evolution of arguments used from 2009 to 2018 and 2019
It is important to note that some arguments used from 2009 to 2019 differed. In 2009, the arguments used by the tobacco industry and other proponents of the commercialisation and marketing of e-cigarettes and HTPs were mostly focused on harm reduction. On the other hand, in 2018 and 2019, proponents frequently used arguments as ‘right to have e-cigarettes and HTPs’, ‘important for the economy’ and ‘prevent/fight smuggling’. Online supplemental table presents these arguments by date and type of participant. University representatives also shifted in the arguments used, from ‘insufficient evidence’ in 2009 to arguments of alerting that e-cigarettes and HTPs may induce smoking and present risks, as well as aggressive marketing. In 2018 and 2019, opponents and proponents included HTPs in the discussion, presenting arguments of insufficient evidence of safety, risks for health and smoking induction, as well as of lower risk for health, harm reduction and do not induce smoking.
Discussion
As expected, opponents of the commercialisation and marketing of e-cigarettes and HTPs—a consumer protection organisation and representatives of universities, medical and anti-tobacco institutions—primarily presented health arguments, but also used arguments related to law, morals and ethics in terms of the aggressive marketing by the tobacco industry. On the other hand, proponents of the commercialisation and marketing of e-cigarettes and HTPs—tobacco companies, non-tobacco enterprises, consumers, politicians, unions and associations—argued that these products could be useful in harm reduction because they are less harmful than cigarettes, and they mentioned the importance of lifting the ban for quality control. They also used many economic, social, legal, moral and ethical arguments, such as the right to use e-cigarettes and HTPs and the economic consequences of the ban, including in terms of smuggling.
A study carried out in four US cities20 showed that retailers, users, and the industry opposed local and state legislation, while legislators, government agencies, and, in a later stage, voluntary health organisations supported policies to minimise youth initiation and treat e-cigarettes as conventional tobacco products. During the discussion of the Tobacco Products Directive in the European Union and in the UK,13 public health and tobacco control experts disagreed about the potential of e-cigarettes for harm reduction and the risk of their consumption leading to hindering the efforts for harm reduction and smoking denormalisation.21 The differences in the actors found opposing or supporting the bans on the commercialisation and marketing of e-cigarettes and HTPs in this study can be due to the fact that the above-mentioned studies listed actors who expressed their positions in hearings, scientific journals, media and social media, while in our study we considered only those who participated in government-sponsored policy discussions. Also, the identical perspectives of the different health agencies in the discussions studied herein may be due to the perceived effectiveness of the tobacco endgame strategies in Brazil, with strong tobacco control policies that led to important reductions in smoking prevalence and to smoking denormalisation.22
In our study as in the literature, actors who were against the bans on e-cigarettes centred their arguments on the lower health risk associated with the use of e-cigarettes and HTPs, compared with cigarettes, and their potential use in smoking cessation.17–20 As expected, this argument contrasts with the classic discourse by tobacco companies when selling cigarettes, which favoured claims of individual right to use and of economic importance of their products since there was extensive evidence of the dangers of their use.23 These arguments of lower health risk and harm reduction were coupled with those of the supposed insufficient evidence of the harmful effects of e-cigarettes and HTPs. Meanwhile, opponents of the commercialisation and marketing of e-cigarettes and HTPs also argued there was insufficient evidence that e-cigarettes and HTPs do not cause harm, instead noting that e-cigarette and HTP consumption may pose health risks and induce smoking. The need to protect youth was the most common claim among opponents of the regulation of e-cigarettes in the USA, and this was also present in the arguments used by the stakeholders who opposed sales and marketing in our study.20 The differences in framing the existing evidence, obtaining different conclusions and supporting different political choices, have been previously discussed,11 13 24 showing that this largely depends on the actors’ belief of the most effective strategy to reduce smoking consequences in the population: harm reduction or abstinence.
Not found in previous studies on e-cigarette and HTP regulation was the argument that allowing the sales of e-cigarettes and HTPs could help better control their quality and prevent smuggling. Concerns about the quality of these products were reported in the UK, with some stakeholders supporting their regulation as medical devices to ensure that high-quality products would be available.25 In Australia, where e-cigarettes are strictly regulated, illegal import and sales of e-cigarettes have been reported.26 In Brazil, this argument was previously used during discussions on a ban on additives to enhance the flavour and taste of tobacco products, on a display ban and new health warning labels.27 28
The potential impact of a ban on e-cigarettes and HTPs on the economy due to the ban of e-cigarettes and HTPs has been brought up during discussions on e-cigarette regulation in the USA.20 In Brazil, this argument was used in the discussions of the additive ban and the regulation of the display and health warning labels,27 28 probably as those who have used this argument—unions of workers in companies related to tobacco production or sales, tobacconists, kiosks owners and politicians—may fear the consequences of these bans on their own or their populations’ income.29 Brazil has been one of the world leaders in tobacco leaf exports and holds 25% of global sales,30 with about 520 000 people working in tobacco farming.31 Still, tobacco cultivation uses only 0.15% of the agricultural land in Brazil32 and is linked to occupational risks29 and to health and social costs of tobacco consumption,33 which is in line with the arguments used by an opponent of the commercialisation and marketing of e-cigarettes and HTPs.
Regarding the use of the argument ‘aggressive marketing’, a research group at Stanford University compared the images used today and in the past and found that the pattern was very similar: e-cigarettes are associated with sophistication and cheerful lifestyle and even use the images of health professionals endorsing the use of such products.34 35 In contrast, in the UK tobacco and e-cigarette industries opposed to the restriction of marketing of e-cigarettes claimed that these practices were already controlled by self-regulation and social responsibility practices.12
Consumers’ right to use e-cigarettes and HTPs, here advocated by unions/associations, tobacco companies and consumers, was frequently conveyed by consumers in the discussions held in the USA and Europe.13 20 26 This finding may be related to the fact that consumers who manifest in these discussions are those interested in having access to e-cigarettes and HTPs, as they may value the right to use them and their supposed importance for smoking cessation, while undervaluing their potential risks.13 26 Another hypothesis is that consumers are often, directly or indirectly, incited to participate in the events to express useful testimonials and reinforce the position of tobacco companies.13 36
It is important to highlight the change in arguments used, with tobacco companies coupling health arguments with the right of consumers to use e-cigarettes and HTPs and the importance of regulation to prevent smuggling in 2018–2019. The tobacco industry has been condemned in the USA for, among other actions, misleading public opinion, the government, the health community and consumers regarding the dangers of smoking.37 The arguments used in the e-cigarette and HTP discussions in 2018 and 2019 became, thus, closer to those used in the discussions of the additives ban and regulations of display and health warning messages.27 28
The change in the arguments used by university representatives, from ‘insufficient evidence’ to arguments linked to the risks of e-cigarettes and HTPs and of the marketing strategies used, may be related to the evidence produced in this decade, supporting caution regarding the safety of e-cigarettes and HTPs and the risk of inducing smoking among adolescents.
Decision-makers and technical advisors from regulatory agencies must carefully consider the expressed (and vested) interests of each participant in government-led discussions, as well as the WHO recommendations in the article 5.3 of the Framework Convention on Tobacco Control (FCTC). They must be prepared to verify the validity of the arguments here used—those related to health (harms, safety, induction/non-induction of smoking in youth and quality control), to morals and ethics (as the effects of marketing in the youths’ uptake of these products), or to economic reasons (as smuggling or the impact in the local economy)—as they will probably continue to emerge in future discussions. Researchers from public health agencies and academies must continue to investigate and gather the existing evidence to be able to reject or support the health arguments here discussed. Also, they must be able to frame and respond to arguments under economic and moral themes, which became more frequently used in recent discussions especially by proponents of the commercialisation and marketing of e-cigarettes and HTPs.
Study limitations
We followed a qualitative approach, which might be more influenced by personal experiences of the first author (MNR). However, TIdCL verified coding and interpretation of the results. The type of support for the data analysed varied between 2009 (written contribution report) and 2018/2019 (videos of the events). Moreover, some participants varied in between these two moments in time (eg, Anvisa, which came about in 2009, and the unions and associations that support the new regulation of the e-cigarettes and HTPs only attended the discussions in 2019). Despite this, representatives of supporting and opposing the commercialisation and marketing of e-cigarettes and HTPs were present in all occasions. The arguments presented by the participants may be biased, that is, they may present what is demanded by their employer and not their own beliefs. Nevertheless, we tried to gather the arguments presented in these discussions, which were made available to decision-makers. Finally, the results of our research focus on Brazil. However, among the participants in the discussions on both sides, there were representatives of multinationals and foreign universities, which makes us consider that most of the arguments raised in these discussions would be (or are) used in other countries and continents.
Conclusions
Tobacco companies focused mostly on the use of e-cigarettes and HTPs for harm reduction and smoking cessation but were more cautious with minimising the risks of e-cigarette and HTP consumption, which contrasts with what was argued by other proponents of the commercialisation and marketing of e-cigarettes and HTPs, who seemed unaware of many of their potential perils. Economic and social arguments for changing the regulation on e-cigarettes and HTPs were often mentioned by companies that supported the commercialisation and marketing of e-cigarettes and HTPs and by the unions or associations related to tobacco production and manufacture. The latter were also the ones that often used the argument of individuals’ right to have and use e-cigarettes and HTPs. Health arguments were the most frequently used but, while opponents to lifting the ban focused on the risks of e-cigarette and HTP use, those supporting lifting the ban used the argument of harm reduction.
These observations should be noted by those responsible for public policies. The insistence of tobacco companies on the potential use of e-cigarettes and HTPs to reduce the use of cigarettes must be handled with care because it may not only frustrate the achievements of the National Tobacco Control Program, but also further increase health-related costs. Additionally, once marketing and sales of these products are authorised in countries with universal health coverage, companies may pressure the state to fund their acquisition and supply to citizens who intend to quit smoking.
The identification and analysis of the arguments used by these institutions, especially the ones used by tobacco companies in the context of discussion for the definition of policies, allow public health groups, in Brazil and from the international community, to more adequately respond to them.
What this paper adds
There is variation in how countries regulate e-cigarettes and heated tobacco products (HTPs).
Evidence about the arguments used during policy discussions, especially regarding the regulation of e-cigarettes and HTPs, is lacking, especially from middle-income tobacco-producing countries and referring to more recent years, after the introduction of HTPs in the global market.
Tobacco companies, kiosks and tobacconists, workers in these sectors, consumers and politicians from tobacco-producing areas used arguments related to harm reduction of these products, risk of smuggling and lack of quality control due to the bans on sales, and consumers’ right to use these products, and economic and moral arguments were frequent in 2018–2019 discussions. Public health agencies and academies must continue to gather evidence to be able to reject or support the health, moral and economic arguments and policies discussed here.
Data availability statement
We conducted a content analysis of the arguments used by stakeholders involved in three different events of public discussion about the regulation of e-cigarettes and heated tobacco products in Brazil. (1) Public consultation n. 41/2009—the report of the event (analysed document) was requested to the Brazilian government through a simple system of access to information and sent to the corresponding author by email. (2) Panel of 2018—the videos of the event (analysed documents) can be found on these websites: https://youtu.be/PjA3A-BgvC8; https://youtu.be/_UrM6YoF0b4; https://youtu.be/DRRS57m4Sgc. (3) Public hearings of 2019—the videos of the event (analysed documents) can be found on these websites: https://www.youtube.com/watch?v=JLjgDraDDxM; https://www.youtube.com/watch?v=UAuEV3atvdc; https://www.youtube.com/watch?v=MIy9JK3dmm0; https://www.youtube.com/watch?v=tiqA90lZIoc.
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References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors Both authors contributed to study design, interpretation of results, writing and revision. TIdCL conceptualised the study. MNR performed data analysis and wrote the first draft of the manuscript. Both authors approved the final manuscript.
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 None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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.