NOT PEER REVIEWED
Professor Malone’s call for a better understanding of the context of the tobacco epidemic is timely. For tobacco as for sugar and alcohol, the extent of population harm is linked to the historic growth of an oligopoly which has used economies of scale, aggressive sales tactics and ingredient modification to transform commodities into highly-processed, convenient and affordable artefacts1-3. At a time when the pandemic has brought the role of governments in protecting the public into greater focus, the implementation of market restrictions which we know to be effective in reducing demand (higher tax, minimum price, minimum pack size)4 should receive a new impetus.

Professor Malone’s call to unite opponents and proponents of ‘newer and novel nicotine and tobacco products’ (NNNTPs) around opposition to the tobacco industry should be heeded. Imperial Brands’s recent decision to turn back to ‘neglected’ cigarettes after being ‘overly focused’ on alternative nicotine products shows that profits, not smokers’ lives, will always be the tobacco companies’ priority5. The enormous influence exercised by the tobacco industry over governments worldwide is perhaps the most pressing tobacco control issue today, with countries including the US continuing to score highly on the Global Index of Tobacco Industry Interference6.

As to whether NNNTPs represent a ‘breakthrough’, it is not so much the products themselves that are disruptive, but rather the fact that the most popular product i.e. the electronic cigarette did not originate with the tobacco industry, and that independent, non-tobacco companies have carved out a significant, perhaps even the largest slice of the market 7. The independent sector is routinely underreported because it is made up of a multitude of small to medium-sized companies rather than a few big players8, and because of market analysts’ outdated reliance on sales data from tobacco retail outlets rather than specialist shops. As Professor Malone says, the world is changing; the need to implement the provisions of the Framework Convention on Tobacco Control is as pressing as ever, but to fight tobacco harm in the new nicotine landscape, we need to move on from a simplistic conflation of tobacco and NNNTP industries. More sophisticated research is required to discern and illuminate the various strategies being employed by both tobacco and non-tobacco industry players in promoting combusted, smokeless or new nicotine products in different national markets, and to tease out the implications for population health and regulatory regimes.

1. Mintz SW. Sweetness and power. New York: Viking; 1985.
2. Schudson M. The Emergence of New Consumer Patterns: the case of the cigarette. In: Miller D, ed. Consumption: critical concepts in the social sciences: Routledge; 2001: 475-501.
3. Benson P. Commentary: Biopolitical injustice and contemporary capitalism. American Ethnologist 2012; 39(3): 488-90.
4. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: WHO 2004.
5. Nilsson P. Imperial Brands turns focus back to tobacco. Financial Times. 2021 27 January 2021.
6. Assunta M. Global Tobacco Industry Interference Index 2020. Bangkok, Thailand: Global Center for Good Governance in Tobacco Control (GGTC), 2020.
7. Brown R. Scaring the Giants: Vaping Category Report 2020. The Grocer. 2020 14 February 2020.
8. Levy DT, Lindblom EN, Sweanor DT, et al. An Economic Analysis of the Pre-Deeming US Market for Nicotine Vaping Products. Tobacco Regulatory Science 2019; 5(2): 169-81.

NOT PEER REVIEWED
We thank Tobacco Control for the opportunity to respond to the comment above. Our study was obviously not looking into the harms of secondhand aerosol from e-cigarettes (SHA). Our paper departs from previous compelling research on the harms of SHA and assesses the prevalence and duration of such exposure among e-cigarette non-users, i.e., bystanders who are potentially exposed to the aerosols emitted by e-cigarette users.

Firstly, it is clear that we conducted the study on the basis of knowledge that bystanders were involuntarily exposed to potentially hazardous SHA in many places. We have clearly mentioned the growing evidence that supports our assertion about the potential harms of SHA in the Introduction and Discussion sections of the paper. SHA contains many toxicants, including nicotine, particulate matter and carcinogens (e.g., volatile organic compounds, polycyclic aromatic hydrocarbons, formaldehyde, acetaldehyde and tobacco specific nitrosamines-TSNAs). As mentioned, this evidence comes from previous scientific research (please, foresee the references 11 to 14 of our paper). Of special interest, fine particulate matter (PM2.5) concentration increased during e-cigarette use sessions with human volunteers in settings such as a room[1–3], during vapers’ conventions[4,5], and in vape shops and their neighbouring businesses[6]. Some TSNAs, such as N-nitrosonornicotine and nicotine-derived nitrosamine ketone, which are carcinogenic[7], have been identified in e-cigarette aerosol (reference 12 of our paper). Airborne nicotine concentration was found to increase after e-cigarette use in an experimental study in a room[1], in an observational study conducted in users’ and non-users’ homes (reference 13 of our paper), and in a study of vapers’ conventions[8]. Also, nicotine in SHA was found to be systematically absorbed by bystanders at levels comparable to secondhand tobacco smoke (references 10 and 42 of our paper), which is worrisome. Additionally, SHA may cause reduced lung function and asthma exacerbations among non-users exposed to it (references 15 and 16). Unfortunately, we are unable to review the study conducted by the California Department of Public Health that was mentioned in the comment, as the source is a blogsite without any specific reference to the scientific publication. Personal blogsites tend to be subjective and are dominantly used to express the bloggers’ personal views, even when these blogsites are maintained by academics. It is worth mentioning, our work was published in a peer-reviewed journal, developed by a team of researchers devoted to public health, and, importantly, who have no conflict of interests.

Secondly, the evidence available at the time of the writing of our paper shows that e-cigarette use and seeing e-cigarette use may renormalise tobacco smoking, induce relapse to smoking among former smokers and trigger initiation of e-cigarette use among non-smokers, particularly young people, by decreasing the harm perception of e-cigarettes (references 17 to 21, and 57). This means the concern around SHA is not only about the air quality but also the social norm it might shape.

In conclusion, based on the evidence mentioned, we wanted to know to what extent e-cigarette exposure was perceived among the general population in European countries; consequently, our study estimates the prevalence of passive exposure to SHA from e-cigarettes. Perhaps the “fear” (we prefer to say “concern”) should exist for selling or using products that may harm the health of people who use them and bystanders who are involuntarily exposed to their aerosols. Based on our results, current evidence, and arguments previously discussed[9], we continue to believe that governments should include e-cigarettes use in smoke-free laws.

References mentioned in this response:

1 Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health 2014;217:628–37. doi:10.1016/j.ijheh.2013.11.003
2 van Drooge BL, Marco E, Perez N, et al. Influence of electronic cigarette vaping on the composition of indoor organic pollutants, particles, and exhaled breath of bystanders. Environ Sci Pollut Res 2019;26:4654–66. doi:10.1007/s11356-018-3975-x
3 Volesky KD, Maki A, Scherf C, et al. The influence of three e-cigarette models on indoor fine and ultrafine particulate matter concentrations under real-world conditions. Environ Pollut 2018;243:882–9. doi:10.1016/j.envpol.2018.08.069
4 Chen R, Aherrera A, Isichei C, et al. Assessment of indoor air quality at an electronic cigarette (Vaping) convention. J Expo Sci Environ Epidemiol 2018;28:522–9. doi:10.1038/s41370-017-0005-x
5 Soule EK, Maloney SF, Spindle TR, et al. Electronic cigarette use and indoor air quality in a natural setting. Tob Control 2017;26:109–12. doi:10.1136/tobaccocontrol-2015-052772
6 Li L, Nguyen C, Lin Y, et al. Impacts of electronic cigarettes usage on air quality of vape shops and their nearby areas. Sci Total Environ 2021;760:143423. doi:10.1016/j.scitotenv.2020.143423
7 Hecht SS. Biochemistry, Biology, and Carcinogenicity of Tobacco-Specific N -Nitrosamines. Chem Res Toxicol 1998;11:559–603. doi:10.1021/tx980005y
8 Johnson JM, Naeher LP, Yu X, et al. A biomonitoring assessment of secondhand exposures to electronic cigarette emissions. Int J Hyg Environ Health 2019;222:816–23. doi:10.1016/j.ijheh.2019.04.013
9 Wilson N, Hoek J, Thomson G, et al. Should e-cigarette use be included in indoor smoking bans? Bull World Health Organ 2017;95:540–1. doi:10.2471/BLT.16.186536

NOT PEER REVIEWED
Thank you for the opportunity to clarify and correct some of the recent statements about our research article, ‘Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control’.

Mr Sarangapani, Director of the Association of Vapers India (AVI), is incorrect in claiming that our article makes “false allegations” and “unsubstantiated claims”, and that it frames AVI as a tobacco industry (TI) front group. We categorise his organisation as a ‘next generation product (NGP) advocate’ and we state that AVI is a member of the International Network of Nicotine Consumer Organisations (INNCO). We also report that INNCO has received funding from the Foundation for a Smoke-Free World (FSFW),[1] which is an organisation that continues to be funded solely by Philip Morris International.[2] Thus, AVI is a member of an organisation that receives indirect funds from Philip Morris International, via the FSFW. Those statements are factual and substantiated; readers can locate further details and references to the FSFW’s grantees and tax returns via our Tobacco Tactics pages, as referenced in our article. In his letter, Mr Sarangapani points out that the Founder-Director of AVI is the current President of INNCO’s Governing Board; however, our research article makes no mention of that fact. We clearly state that: “We found no evidence that the individuals affiliated with INNCO or its member organisations were themselves funded by FSFW or by the TI directly” (p4). I acknowledge that on page 5 of the article, we have referred to AVI by their Twitter handle (vapeindia), as opposed to the organisation’s full name.

Mr Cullip’s interpretation of our article as a “smear” against vaping consumer advocates is an inaccurate representation of our research. As set out in our research objectives (p2), we examined the main themes and sentiment of tweets about WHO FCTC COP8, identified and classified the most active tweeters, explored how people who tweeted about COP8 engaged with one another and, lastly, explored the presence of TI links among the most active tweeters. Our article makes no statements that denigrate vapers’ opinions. Rather, we conclude there was an extensive online presence by Philip Morris International (PMI) executives, and by organisations and individuals funded directly and indirectly by PMI (e.g. Consumer Choice Center, Foundation for a Smoke-Free World, INNCO, Knowledge-Action-Change). We conclude that our findings are consistent with PMI’s 2014 corporate affairs strategy, which was leaked as part of an exposé by Reuters.[3] Far from being a “mythical tobacco industry plot” as Mr Cullip claims, PMI’s corporate affairs strategy described engaging tobacco harm reduction advocates to “amplify and leverage the debate on harm reduction” around events such as the WHO FCTC COP.[3]

Dr Gilchrist’s letter contains several inaccurate assertions. Our research does not “malign” either the individuals or the organisations that participated in the Twitter debate during COP8. We do not use the term “front group” in relation to any of the organisations supporting tobacco harm reduction referred to in our article. Nor do we imply that “any person or organisation who publicly supports tobacco harm reduction are paid to do so by the industry”. Our research article presents a factual account of the most common topics and sentiment of tweets that used #COP8FCTC, the categories of individuals and organisations tweeting, and their networks and patterns of engagement with one another. Around one-fifth of the most active tweeters were either tobacco companies, third-party organisations that have received direct tobacco industry funding, or employees of those organisations. We refer (accurately) to those tweeters as ‘tobacco industry actors’; we provide a detailed definition of our inclusion criteria and provide references to evidence tobacco industry funding. The only specific criticism Dr Gilchrist makes about our study is that we did not explore links between the most active tweeters and non-tobacco industry sources of funding. Given the irreconcilable conflict between the tobacco industry’s interests and tobacco control policy interests, and given tobacco companies’ repeated attempts to influence policy via third parties and intermediaries,[4] our focus on documenting tobacco industry involvement in FCTC debates is justified. Unlike tobacco companies, public health advocacy groups do not stand to generate or lose billions of dollars in profit as a result of decisions made at WHO FCTC COP. Neither do they have a history of obfuscating their funding sources.

Professor Stimson’s letter incorrectly states that we claim tobacco industry money is behind all the activity on Twitter by harm reduction advocates; in fact, on page 4 we state: “…for 23 of the 50 NGP [next generation product] advocates, we found no publicly available evidence of any link with the TI”. Professor Stimson is correct that we state: “…vaping consumer advocacy groups that receive TI funding are emerging and attempting to influence the WHO.” He insinuates this claim is unsubstantiated, yet we provide clear evidence that factasia.org and INNCO, each of whom describe themselves as a vaping consumer advocacy organisation, receive funding from PMI (directly and indirectly, respectively).[1,5] We do not claim TI links with national vaping advocacy groups and, as already noted, we state: “We found no evidence that the individuals affiliated with INNCO or its members organisations were themselves funded by FSFW or by the TI directly” (p4). As Professor Stimson points out, our article includes a paragraph where we report that a member of INNCO, ProVapeo Mexico, encouraged vapers to tweet during COP8. Professor Stimson interprets our research as “picking on” that organisation, yet we make no criticism of ProVapeo Mexico’s activities. Our article documents only the facts about the number of tweets using #COP8FCTC that appear to have been posted as a result of ProVapeo Mexico’s appeal.

In response to Julie Woessner’s letter, at no point does our article state that INNCO is a tobacco front group. As I note above, our article documents substantial activity on Twitter during COP8 both by PMI, and by organisations (and people affiliated with those organisations) that have received money from PMI either directly, or indirectly via the FSFW. We believe this activity is consistent with proposed actions laid out in PMI’s leaked 2014 corporate affairs strategy, which included plans to: “Establish the concept of harm reduction as legitimate public policy in tobacco regulation”, “Identify and engage non-traditional 3rd party stakeholders/allies (e-cigarette manufacturers and retailers, adult consumers of RRP products, tobacco harm reduction advocates…” and “Amplify and leverage the debate on harm reduction around global events (eg, COP6)”.[3] We believe our findings raise important questions about PMI’s claims of transformation, as the activity we have documented appears part of a long-standing corporate affairs plan. Our article presents the facts that some harm reduction-related organisations receive PMI (or FSFW) funds. We do not cast those funded organisations as “nefarious”.

Our research aims to increase transparency in tobacco control policy-making. Making known any links between tobacco companies and individuals and organisations that participate in tobacco control policy debates, even if those links are indirect and occur through intermediaries, is in the public interest and consistent with the principles of WHO FCTC Article 5.3.[6] Vapers who belong to INNCO-affiliated organisations are also entitled to know the network (or “umbrella organization”) to which their organisation belongs receives tobacco industry funding via the FSFW. It is encouraging therefore to observe that following our publication, INNCO appears to have added a statement declaring its FSFW funding onto its homepage (that development appears to have occurred between 1 and 16 November 2020).[7,8]

We are transparent about our research funders. The researchers working on this paper were funded by Bloomberg Philanthropies through the STOP initiative, and by Cancer Research UK; neither funder, nor any of the STOP partners, had any role in the research conceptualisation, study design, data collection, analysis, decision to publish, or preparation of the manuscript.

Lindsay Robertson, MPH, PhD
Conflict of Interest: None declared

References

[1] Tobacco Control Research Group (TCRG). International Network of Nicotine Consumer Organisations (INNCO). https://tobaccotactics.org/wiki/international-network-of-nicotine-consum... (accessed 23 November 2020).
[2] Tobacco Control Research Group (TCRG). Foundation for a Smoke-Free World. https://tobaccotactics.org/wiki/foundation-for-a-smoke-free-world/ (accessed 23 November 2020).
[3] Philip Morris International (author unknown). 10 Year Corporate Affairs Objectives and Strategies (p.5). 2014. https://assets.documentcloud.org/documents/4333395/10-Year-Corporate-Aff... (accessed 23 November 2020).
[4] Ulucanlar S, Fooks GJ, Gilmore AB. The policy dystopia model: an interpretive analysis of tobacco industry political activity. PLoS Medicine 2016; 13(9): doi.org/10.1371/journal.pmed.1002125.
[5] Factasia.org. Our Supporters. 2020. https://web.archive.org/web/20200302113900/https://www.factasia.org/our-... (accessed 2 March 2020).
[6] World Health Organization (WHO). Guidelines for implementation of Article 5.3 of the WHO Framework Convention on Tobacco Control. Available at: https://www.who.int/fctc/guidelines/article_5_3.pdf?ua=1 (accessed 20 August 2020).
[7] International Network of Nicotine Consumer Organisations. Home page. https://web.archive.org/web/20201101140032/https://innco.org/ (accessed 1 November 2020).
[8] International Network of Nicotine Consumer Organisations (INNCO). Home page. https://web.archive.org/web/20201116161303/https://innco.org/ (accessed 16 November 2020).

NOT PEER REVIEWED

When doing scientific research, following the scientific method, you have a hypothesis (question) that you are going to investigate - in this case: Does xxx consumer organisation have any direct ties to tobacco companies that influence their advocacy?

After you have chosen your method, you then gather your evidence, make an objective analysis and state your findings and make a conclusion.

Your method SHOULD be thorough and your research should be objective in order to maintain the integrity of your research (and yourself). The evidence will either prove/disprove your original hypothesis.

Instead, the authors have chosen to not only demonise the participation of consumers in the narrative of their own health, one has lobbied false claims about tobacco industry connections that do not exist.

It is very concerning that the authors find it necessary to disenfranchise the very people who are fighting for their right to make informed choices about their health. It defies logic, and the principles of fairness and decency.

It perhaps would have been more helpful to all concerned if the authors had done due diligence beyond looking at a website that does not have verified information, to cast aspersions on consumer advocacy organisations.

It definitely would be more productive to welcome the voices of the people for whom felt impassioned enough to get involved in consumer advocacy to help smokers not only have the choices they need switch to less harmful alternative, but to be informed consumers of safer nicotine products.