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We thank Mr. Clive Bates (1) and Dr. Moira Gilchrist (2) for their reconsideration of our work (3) and previous response where we corrected some errors (4). We also reiterate that all data informing our Industry Watch are publicly available at Tobacco Watcher (https://tobaccowatcher.globaltobaccocontrol.org/) for anyone to analyze. As with any analyses of observational data, there are limitations and we do not disagree with some of the limitations that Gilchrist and Bates point out in our analyses (as we addressed nearly all of these in our previous response (4)). However, we remain unchanged in our conclusion that, as the title of our initial article stated, “Philip Morris International used the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak to market IQOS heated tobacco” (3).
While statistical analysis indicated a correlation between (a) PMI’s public statements regarding EVALI and their IQOS brand of heated tobacco posted to their corporate “media center” (5) and (b) trends in news coverage of EVALI and IQOS, our primary assertion is that PMI used EVALI to market IQOS. The necessary and sufficient analysis to substantiate this assertion is reporting what PMI publicly claimed, which we did by analyzing the statement made by PMI which promoted IQOS through mentioning, contrasting or describing it along with EVALI and/or vaping.
NOT PEER REVIEWED
We thank Mr. Clive Bates (1) and Dr. Moira Gilchrist (2) for their reconsideration of our work (3) and previous response where we corrected some errors (4). We also reiterate that all data informing our Industry Watch are publicly available at Tobacco Watcher (https://tobaccowatcher.globaltobaccocontrol.org/) for anyone to analyze. As with any analyses of observational data, there are limitations and we do not disagree with some of the limitations that Gilchrist and Bates point out in our analyses (as we addressed nearly all of these in our previous response (4)). However, we remain unchanged in our conclusion that, as the title of our initial article stated, “Philip Morris International used the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak to market IQOS heated tobacco” (3).
While statistical analysis indicated a correlation between (a) PMI’s public statements regarding EVALI and their IQOS brand of heated tobacco posted to their corporate “media center” (5) and (b) trends in news coverage of EVALI and IQOS, our primary assertion is that PMI used EVALI to market IQOS. The necessary and sufficient analysis to substantiate this assertion is reporting what PMI publicly claimed, which we did by analyzing the statement made by PMI which promoted IQOS through mentioning, contrasting or describing it along with EVALI and/or vaping.
The full text of the PMI’s public statement is available in the appendix of our original piece (the version available presently on the PMI website has been changed) and we analyze excerpts to make our case below.
PMI’s statement recounted the EVALI outbreak beginning: “Skepticism and fear around vaping has emerged following the cases of respiratory illness and deaths in the US associated with the use of e-cigarettes.” PMI then contrasted this against their IQOS heated tobacco product, writing “on April 30 2019, the FDA authorized IQOS for sale in the US, finding that marketing of the product would be ‘appropriate for the protection of public health’ [quotes used in the original release].” As we previously argued, some readers (especially novice consumers) can interpret this as implying the FDA endorses IQOS and such statements are not allowed. The Food, Drug and Cosmetic Act prohibits ‘any expressed or implied statement...that either conveys, or misleads or would mislead consumers into believing that [a tobacco] product is approved by the Food and Drug Administration’ (ACT 21 U.S.C. § 331(tt)). The same “appropriate for the protection of public health” statement also implies that IQOS is safer than vaping, a claim disallowed by the FDA.
While Bates and Gilchrist may still object to our assertions that PMI’s intent in publishing their statement was to promote IQOS using EVALI, this objection contrasts with public statements PMI executives have made that are perhaps even clearer in their intent. For example, a Wall Street Journal article began “tobacco giant Philip Morris International Inc. says vaping fears in the U.S. should give a boost to the recent launch of its IQOS smoking alternative” and cited PMI executives discussing how EVALI could be a boon for IQOS promotion just days after PMI published the materials we studied (6).
Bates and Gilchrist may similarly still object that other events (such as the failed merger talks between Altria and PMI (7)) may be responsible for news coverage of IQOS and EVALI. However, generating earned media about an issue is not a one-shot game. Any public relations expert could attest that a multi-modal strategy is required to get an issue in the news media agenda including a media statement, follow-up interviews, case studies, activations, integrations, etc.
Our assertion is that the EVALI outbreak was used by PMI as part of an overall strategy to promote IQOS - a fact we discovered in our Industry Watch piece. For example, the Irish Times reported that PM had called off merger talks with Altria, “…after it became apparent the US government crackdown on vaping could have a negative impact given Altria’s stake in Juul.” André Calantzopoulos, PMI’s chief executive, said that they had decided to focus on its launch of IQOS, which was not a vaping product (8) --thereby again leveraging EVALI to promote its new product.
We echo our previous call for the FDA to investigate the statement PMI published and subsequent news coverage for compliance and if a violation has occurred appropriate regulatory actions be taken. We call on the tobacco control community to invest in surveillance of industry speech and research on the potential impacts of industry speech that can inform additional regulations governing marketing channels such as websites, online news sources and other digital media.
There’s a published paper by Hammond and colleagues in 2019[1] using the same survey results, but there are some discrepancies.
1. The Table 2 of the 2019 paper, prevalence of vaping in 2018 for ever, past 30 days are 37.0% (1425), 14.6% (562) in Canada, 32.7% (1276), 8.9% (346) in England and 33.6% (1360), 16.2% (655) in the US, respectively. However, in this article’s Table 1, for vaping in the same year 2018 for ever, past 30 days are 33.2% (1275), 12.1% (463) in Canada, 33.1% (1283), 9.0% (351) in England and 33.1%(1336), 15.7% (635) in the US. More discrepancies can be found on cigarette smoking section as well. These numbers warrant further explanation particularly why numbers in Canada and the US decreased while numbers in England increased? Considering previous correction of numbers to the 2019 paper has raised serious concern among some readers[1], such timely clarification in this article will be very necessary.
2. The 2019 paper use the criteria of ≥15 days in past 30 days but the current paper adopts different criteria of ≥20 days in past 30 days, for both vaping and cigarette smoking. Further explanation is needed for such change.
Additionally, a few considerations on possible limitations of the paper’s findings:
1. Since the invitations were sent to nearly twice more parents than youth themselves according to the technical report[2], responds to survey questions might be biased because study has shown many...
There’s a published paper by Hammond and colleagues in 2019[1] using the same survey results, but there are some discrepancies.
1. The Table 2 of the 2019 paper, prevalence of vaping in 2018 for ever, past 30 days are 37.0% (1425), 14.6% (562) in Canada, 32.7% (1276), 8.9% (346) in England and 33.6% (1360), 16.2% (655) in the US, respectively. However, in this article’s Table 1, for vaping in the same year 2018 for ever, past 30 days are 33.2% (1275), 12.1% (463) in Canada, 33.1% (1283), 9.0% (351) in England and 33.1%(1336), 15.7% (635) in the US. More discrepancies can be found on cigarette smoking section as well. These numbers warrant further explanation particularly why numbers in Canada and the US decreased while numbers in England increased? Considering previous correction of numbers to the 2019 paper has raised serious concern among some readers[1], such timely clarification in this article will be very necessary.
2. The 2019 paper use the criteria of ≥15 days in past 30 days but the current paper adopts different criteria of ≥20 days in past 30 days, for both vaping and cigarette smoking. Further explanation is needed for such change.
Additionally, a few considerations on possible limitations of the paper’s findings:
1. Since the invitations were sent to nearly twice more parents than youth themselves according to the technical report[2], responds to survey questions might be biased because study has shown many parents are unaware of their children’s e-cigarette use[3]. Young participants who receive the questionnaire from their parents, in suspicion of their parents might know, may be unwilling to fill out honestly.
2. A clearer definition of stop smoking/quitting. In Table 3, when asking participants quitting plans, it is better to clarify the quitting of traditional tobacco products or quitting nicotine products. As some youth may treat vaping itself as quitting and some may not, the survey result might therefore, be ambiguous.
3. Seasonality. Previous studies have indicated seasonal variations in the initiation of smoking among adolescents[4], Unsupervised time out of school during the first months of summer vacation is a period of increased smoking behavior. However, significantly lower rates during September were observed which seem to be related to the beginning of school. Survey for this study were conducted July/August in 2017, August/September in 2018 and 2019. As cross-sectional study only offers a snapshot of the situation, to conduct surveys at different months with fluctuating trends would inevitably lower the liability of the result.
[1] Hammond, D., Reid, J. L., Rynard, V. L., Fong, G. T., Cummings, K. M., McNeill, A., Hitchman, S., et al. (2019). Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys. BMJ (Clinical Research Ed.), 365, l2219.
[2] Hammond D, Reid JL, White CM. ITC Youth Tobacco and E-Cigarette Survey:
Technical Report – Wave 3 (2019. Waterloo, ON: University of Waterloo, 2020. http://
davidhammond.ca/wp-content/uploads/2020/05/2019_P01P3_W3_TechnicalReport_updated202005.pdf
[3] Wu T and Chaffee BW. Parental Awareness of Youth Tobacco Use and the Role of Household Tobacco Rules in Use Prevention. Pediatrics. 2020;146(5): e20194034
[4] Colwell, B., Ramirez, N., Koehly, L., Stevens, S., Smith, D. W., & Creekmur, S. (2006). Seasonal variations in the initiation of smoking among adolescents. Nicotine & Tobacco Research, 8(2), 239–243.
We would like to thank Mr. Wang for his feedback on our paper, Indicators of dependence and efforts to quit vaping and smoking among youth in Canada, England and the USA.
With regards to the ‘discrepancies’ in vaping and smoking prevalence between those reported in Table 1 and an earlier publication [1], we have previously published these same estimates [2], along with a description of the survey weighting procedures—which were modified since the first estimates were published (as outlined in a published erratum to the cited publication [3]). Briefly, since 2019, we have been able to incorporate the smoking trends from national ‘gold standard’ surveys in Canada and the US into the post-stratification sampling weights. A full description is provided in the study’s Technical Report [4], which is publicly available (see http://davidhammond.ca/projects/e-cigarettes/itc-youth-tobacco-ecig/).
Mr. Wang has also noted a change in the threshold used for a measure of frequent vaping/smoking: ≥20 days in past 30 days rather than ≥15 days, as previously reported [1]. We have adopted the convention of reporting using ≥20 days in past 30 days to align with the threshold commonly used by the US Centers for Disease Control for reporting data from the National Youth Tobacco Survey (NYTS), as well as the Population Assessment of Tobacco and Health (PATH) Study and the Mo...
We would like to thank Mr. Wang for his feedback on our paper, Indicators of dependence and efforts to quit vaping and smoking among youth in Canada, England and the USA.
With regards to the ‘discrepancies’ in vaping and smoking prevalence between those reported in Table 1 and an earlier publication [1], we have previously published these same estimates [2], along with a description of the survey weighting procedures—which were modified since the first estimates were published (as outlined in a published erratum to the cited publication [3]). Briefly, since 2019, we have been able to incorporate the smoking trends from national ‘gold standard’ surveys in Canada and the US into the post-stratification sampling weights. A full description is provided in the study’s Technical Report [4], which is publicly available (see http://davidhammond.ca/projects/e-cigarettes/itc-youth-tobacco-ecig/).
Mr. Wang has also noted a change in the threshold used for a measure of frequent vaping/smoking: ≥20 days in past 30 days rather than ≥15 days, as previously reported [1]. We have adopted the convention of reporting using ≥20 days in past 30 days to align with the threshold commonly used by the US Centers for Disease Control for reporting data from the National Youth Tobacco Survey (NYTS), as well as the Population Assessment of Tobacco and Health (PATH) Study and the Monitoring the Future (MTF) survey—three of the most widely cited sources of data for youth vaping.[5,6,7]
Mr. Wang questioned whether the process for ascertaining parental consent may bias the survey responses. Ascertaining parental consent among minors is a common and required practice in most jurisdictions. To the extent that young respondents may not have provided honest responses due to concerns about confidentiality, the likely impact would be to under-report smoking and vaping status. However, the recruitment process has not changed over the course of the study; thus, this is unlikely to account for the trends over time reported in our paper. In addition, the trends in the ITC Youth Tobacco and Vaping Surveys are very similar to the trends in vaping reported by national surveillance surveys in the US,[5] Canada, [8,9,10] and England.[11]
Regarding Mr. Wang’s assertion that “when asking participants quitting plans, it is better to clarify the quitting of traditional tobacco products or quitting nicotine products”, we can confirm that questions about intentions to quit and cessation were indeed asked separately for smoking and vaping. Thus, if a youth reported smoking cigarettes and vaping e-cigarettes, they would have been asked cessation-related questions in different sections of the survey for each of cigarettes and e-cigarettes/vaping.
Finally, Mr. Wang has noted seasonal variation in smoking and vaping rates. Despite some variations in the exact survey timing, the ITC Youth Tobacco and Vaping Surveys have been conducted over a similar time period in each year. For example, across the first three waves of the survey, 64%, 79% and 74% of surveys, respectively, were conducted in the month of August. As noted above, trends in vaping prevalence over time from the ITC surveys align very closely with other national surveys over the same period. With respect to specific findings reported in our Tobacco Control manuscript, we would not expect any material differences in levels of dependence, cessation-related outcomes or vaping brands due to the minor variation in data collection periods.
We hope this additional information will provide context for interpreting the study results and feedback on the manuscript.
References
1. Hammond D, Reid JL, Rynard VL, Fong GT, Cummings KM, McNeill A, Hitchman S, et al. Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys. BMJ. 2019; 365: l2219. doi: 10.1136/bmj.l2219.
2. Hammond D, Rynard V, Reid JL. Changes in prevalence of vaping among youth in the United States, Canada, and England, 2017 to 2019. JAMA Pediatr. 2020;174(8):797-800. doi: 10.1001/jamapediatrics.2020.0901.
3. Published Erratum: Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys. BMJ. 2020 Jul 10;370:m2579. doi: 10.1136/bmj.m2579.
4. Hammond D, Reid JL, Rynard VL, Burkhalter R. ITC Youth Tobacco and E-Cigarette Survey:
Technical Report – Wave 3 (2019). Waterloo, ON: University of Waterloo, 2020. http://davidhammond.ca/wp-content/uploads/2020/05/2019_P01P3_W3_Technica...
5. Park-Lee E, Ren C, Sawdey MD, et al. Notes from the Field: E-Cigarette Use Among Middle and High School Students — National Youth Tobacco Survey, United States, 2021. MMWR Morb Mortal Wkly Rep 2021;70:1387–1389. DOI: http://dx.doi.org/10.15585/mmwr.mm7039a4.
6. Hyland A, Kimmel HL, Borek N, on behalf of the PATH Study team. Youth and young adult acquisition and use of cigarettes and ENDS: The latest findings from the PATH Study (2013-2019). Society for Research on Nicotine & Tobacco Annual Conference, March 2020
7. Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME. Trends in adolescent vaping, 2017-2019. N Engl J Med. 2019;381(15):1490-1491. doi:10.1056/NEJMc1910739.
8. Government of Canada. Detailed tables for the Canadian Student Tobacco, Alcohol and Drugs Survey 2016-17. Available from https://www.Canada.ca/en/health-Canada/services/canadian-student-tobacco...
9. Government of Canada. Canadian Tobacco, Alcohol and Drugs Survey (CTADS): Summary of Results for 2017. 2017. Available from https://www.Canada.ca/en/health-Canada/services/canadian-tobacco-alcohol....
10. Statistics Canada. Canadian Tobacco and Nicotine Survey, 2019. Available from https://www150.statcan.gc.ca/n1/daily-quotidien/200305/dq200305a-eng.htm.
11. Action on Smoking and Health UK. Use of e-cigarettes among young people in Great Britain, 2021. June 2021. Available from https://ash.org.uk/wp-content/uploads/2021/07/Use-of-e-cigarettes-among-...
¶ I enjoyed reading this paper. I appreciate the author's use of difference-in-difference (DD) methodology. There were some things I found unclear that I would like to ask the authors to comment on.
¶ First, could the authors provide greater clarity on the model for column 1 of Table 1? Is the dependent variable here a yes/no for current cigarette use? The authors write, "Adolescents reported lifetime and prior month use of cigarettes, which we combined into a count variable of days smoked in the past month (0–30)." How does lifetime cigarette use help the authors to code the current number of cigarette days? The authors later state that they show that "increasing implementation of flavoured tobacco product restrictions was associated not with a reduction in the likelihood of cigarette use, but with a decrease in the level of cigarette use among users." Do the authors mean lifetime cigarette use here, or current cigarette use? The authors estimate this equation with an "inflation model," which I am not aware of. Could the authors provide more information on this modelling technique? This is not discussed in the "Analysis" section.
¶ Second, I felt like this statement is too strong. "Our findings suggest that[...] municipalities should enact stricter tobacco-control policies when not pre-empted by state law." Municipalities need to weigh many factors in making these decisions, including the effects of popu...
¶ I enjoyed reading this paper. I appreciate the author's use of difference-in-difference (DD) methodology. There were some things I found unclear that I would like to ask the authors to comment on.
¶ First, could the authors provide greater clarity on the model for column 1 of Table 1? Is the dependent variable here a yes/no for current cigarette use? The authors write, "Adolescents reported lifetime and prior month use of cigarettes, which we combined into a count variable of days smoked in the past month (0–30)." How does lifetime cigarette use help the authors to code the current number of cigarette days? The authors later state that they show that "increasing implementation of flavoured tobacco product restrictions was associated not with a reduction in the likelihood of cigarette use, but with a decrease in the level of cigarette use among users." Do the authors mean lifetime cigarette use here, or current cigarette use? The authors estimate this equation with an "inflation model," which I am not aware of. Could the authors provide more information on this modelling technique? This is not discussed in the "Analysis" section.
¶ Second, I felt like this statement is too strong. "Our findings suggest that[...] municipalities should enact stricter tobacco-control policies when not pre-empted by state law." Municipalities need to weigh many factors in making these decisions, including the effects of population health (not just to youth tobacco use). This study provides evidence from a single state that may not be generalizable to other states without preemption policies. Other studies have found unintended negative effects of flavor policies, and these studies should be referenced to balance the discussion section.
¶ I applaud the authors for providing an early data point on the effect of these policies, but certainly more work in this space is needed before policy recommendations can be made. The authors may also wish to consider for future difference-in-difference papers whether there is evidence in support of the parallel trends assumption , which is a crucial assumption underpinning the reliability of the model.
¶ References:
¶ Friedman, Abigail S. "A difference-in-differences analysis of youth smoking and a ban on sales of flavored tobacco products in San Francisco, California." JAMA pediatrics 175, no. 8 (2021): 863-865.
¶ Xu, Yingying, Lanxin Jiang, Shivaani Prakash, and Tengjiao Chen. "The Impact of Banning Electronic Nicotine Delivery Systems on Combustible Cigarette Sales: Evidence From US State-Level Policies." Value in Health (2022).
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This article does not distinguish between characterizing flavour (menthol) bans that were implemented in Canadian provinces between 2015 and 2017 and the implementation of a national ban on menthol additives in Canada in October 2017. Although unreported, the analysis was performed exclusively on provincial characterizing flavour bans. This significant distinction should be reported to ensure that researchers and policy makers are aware of the potential impact of a characterizing flavour ban and to ensure that this policy measure is not dismissed or discounted.
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In his comment, Les Hagen brings up an important distinction between two types of restrictions on menthol: a menthol additive ban, and a menthol characterizing flavour ban. Canada's menthol ban across the provinces did indeed involve both types. Between May 2015 and July 2017, Nova Scotia, Alberta, Quebec, Ontario, Prince Edward Island, and Newfoundland & Labrador implemented characterizing flavour bans, whereas New Brunswick implemented a menthol additive ban [1]. When the Federal Government implemented a menthol additive ban in October 2017 [2] , it applied only to the remaining provinces—British Columbia, Saskatchewan, Manitoba—as well as Nunavut, Yukon, and the Northwest Territories. Thus, the "menthol cigarette ban" in Canada is a mixture of the two types.
Our article [3] evaluated the impact of menthol bans implemented between the 2016 and 2018 waves of the Canadian arm of the ITC Four Country Smoking and Vaping Surveys. Hagen incorrectly stated that "the analysis was performed exclusively on provincial characterizing flavour bans." In fact, the provinces evaluated in our study included both those that implemented characterizing flavour bans (Quebec, Ontario, Prince Edward Island, Newfoundland & Labrador) and those that implemented the Federal menthol additive ban (British Columbia, Saskatchewan, Manitoba).
In our original study, we did not test for differences between the two kinds of bans, beca...
NOT PEER REVIEWED
In his comment, Les Hagen brings up an important distinction between two types of restrictions on menthol: a menthol additive ban, and a menthol characterizing flavour ban. Canada's menthol ban across the provinces did indeed involve both types. Between May 2015 and July 2017, Nova Scotia, Alberta, Quebec, Ontario, Prince Edward Island, and Newfoundland & Labrador implemented characterizing flavour bans, whereas New Brunswick implemented a menthol additive ban [1]. When the Federal Government implemented a menthol additive ban in October 2017 [2] , it applied only to the remaining provinces—British Columbia, Saskatchewan, Manitoba—as well as Nunavut, Yukon, and the Northwest Territories. Thus, the "menthol cigarette ban" in Canada is a mixture of the two types.
Our article [3] evaluated the impact of menthol bans implemented between the 2016 and 2018 waves of the Canadian arm of the ITC Four Country Smoking and Vaping Surveys. Hagen incorrectly stated that "the analysis was performed exclusively on provincial characterizing flavour bans." In fact, the provinces evaluated in our study included both those that implemented characterizing flavour bans (Quebec, Ontario, Prince Edward Island, Newfoundland & Labrador) and those that implemented the Federal menthol additive ban (British Columbia, Saskatchewan, Manitoba).
In our original study, we did not test for differences between the two kinds of bans, because the number of menthol smokers across the seven provinces in our evaluation study was low (N=138). However, we did report that there were no statistically significant differences in smoking cessation outcomes between menthol and non-menthol smokers across the seven provinces, consistent with the possibility that there were no differences between a characterizing flavour ban and an additive ban. Hagen's comment did prompt us to do the explicit analysis, comparing the four provinces with characterizing flavour bans to the three provinces with menthol additive bans.
Consistent with our previously reported findings of no differences across the seven provinces, the explicit comparison found no significant differences in smoking cessation outcomes among daily and among all smokers between menthol smokers and non-menthol smokers in provinces with menthol additive bans vs provinces with menthol characterizing flavour bans. Thus, the findings do indeed, as Hagen aimed to highlight, point to the positive impact of the characterizing flavour ban, being not different from that of the national menthol additive ban ─ with the caution that the small sample sizes afforded low statistical power to test for differences.
Our follow-up analysis also showed that a significantly higher percentage of pre-ban menthol smokers reported that they still smoked menthols at follow-up in provinces with menthol characterizing flavour bans, compared with provinces with menthol additive bans (25.3% vs 8.4%, p=0.02). We will describe these results more fully in a forthcoming paper.
There are complexities in the distinctions between a characterizing flavour ban and an additive ban. Each would call upon different kinds of regulatory oversight. For example, the European Union's characterizing flavour ban under the 2016 Tobacco Products Directive [4] required the establishment of an Independent Advisory Panel to determine whether a particular tobacco product has a characterizing flavour, with input from a technical group of sensory and chemical assessors, whose methodology is "based on a comparison of the smelling properties of the test product with those of reference products." [5] In contrast, regulating an additive ban requires product testing to determine the presence of a banned additive.
As jurisdictions consider measures to eliminate the well-documented impact of menthol in increasing attractiveness and reducing harshness of combustible tobacco products [6], these differences in regulatory capacity need to be considered.
3. Chung-Hall J, Fong GT, Meng G, et al. Evaluating the impact of menthol cigarette bans on cessation and smoking behaviours in Canada: longitudinal findings from the Canadian arm of the 2016–2018 ITC Four Country Smoking and Vaping Surveys. Tobacco Control Published Online First: 05 April 2021. doi: 10.1136/tobaccocontrol-2020-056259
6. Tobacco Products Scientific Advisory Committee. Menthol cigarettes and public health: review of the scientific evidence and recommendations. Rockville, MD: Food and Drug Administration, 2011.
Thank you for the corrections and for acknowledging the omission. The additional analysis performed by ITC is greatly appreciated and provides further insight into the impact of both interventions. Although unstated, Canada’s regional characterizing flavour bans contributed significantly to the development of a national menthol additive ban as chronicled by the U.S. Tobacco Control Legal Consortium[1] . I look forward to reading the full analysis when published.
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We object to the framing of Association of Vapers India (AVI), erroneously referred to as ‘Vape India’ in the paper, as a tobacco industry front group, without providing any basis for the claim except our membership of International Network of Nicotine Consumer Organisations (INNCO).
AVI was organised in August 2016, when consumers of low-risk alternatives came together to arrest the tide of state bans in India, which were being lobbied for by the Bloomberg Philanthropies network the authors belong to.[1] Though one of our directors is the current president of INNCO’s governing board, elected through a member vote in the 2020 General Assembly, he is serving in unpaid, honorary capacity.
AVI has not received funding from INNCO, nor from the Foundation for Smoke-free World (FSFW), and neither from the tobacco industry. Our work is financed through voluntary contributions, and like INNCO, the affairs are conducted by a governing board comprising unpaid consumer volunteers.
It is scurrilous to cast AVI as a tobacco industry group or anything other than a consumer-led movement that is seeking access to harm reduction avenues for India’s nearly 270 million tobacco users, among whom cancers are rising[2] even as most have meagre means to deal with the health consequences, which makes harm prevention a vital mitigation strategy. We are product agnostic and advocate access to lower-risk alternatives for both smokers and smokeless tobacco...
NOT PEER REVIEWED
We object to the framing of Association of Vapers India (AVI), erroneously referred to as ‘Vape India’ in the paper, as a tobacco industry front group, without providing any basis for the claim except our membership of International Network of Nicotine Consumer Organisations (INNCO).
AVI was organised in August 2016, when consumers of low-risk alternatives came together to arrest the tide of state bans in India, which were being lobbied for by the Bloomberg Philanthropies network the authors belong to.[1] Though one of our directors is the current president of INNCO’s governing board, elected through a member vote in the 2020 General Assembly, he is serving in unpaid, honorary capacity.
AVI has not received funding from INNCO, nor from the Foundation for Smoke-free World (FSFW), and neither from the tobacco industry. Our work is financed through voluntary contributions, and like INNCO, the affairs are conducted by a governing board comprising unpaid consumer volunteers.
It is scurrilous to cast AVI as a tobacco industry group or anything other than a consumer-led movement that is seeking access to harm reduction avenues for India’s nearly 270 million tobacco users, among whom cancers are rising[2] even as most have meagre means to deal with the health consequences, which makes harm prevention a vital mitigation strategy. We are product agnostic and advocate access to lower-risk alternatives for both smokers and smokeless tobacco users, adhering to harm reduction and human rights principles laid out in UN drug policies and in Article 1(d) of the FCTC charter.
We find these accusations especially mischievous in light of our Indian government owning a major 28% stake in the country’s cigarette monopoly and gaining directly from the e-cigarette ban,[3] despite which it was invited to chair COP8 proceedings, whereas consumer advocates, including from AVI, who were there to seek deliberations on their right to access lower-risk alternatives, and whom the FCTC policies affect most severely, were ousted after the plenary session on the pretext of preventing industry influence, left to protest outside the venue and use social media to make ourselves heard.
We strongly oppose this unfair application of Article 5.3 of FCTC which covets tobacco-trading governments but forcefully excludes consumers and attempts to delegitimize them under the garb of the same provision.
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We appreciate the authors’ concern about industry “astroturfing.” We believe astroturf activities undermine the genuine consumer movement that INNCO and its members represent. But the conclusions that the authors draw from their research are attenuated and inaccurate. In particular, we object strenuously to the authors’ conclusion that because INNCO has received funding from the Foundation for a Smoke-Free World (the Foundation), we are a tobacco front group.
INNCO was formed in 2016, a year before the Foundation was established. All of INNCO’s members are autonomous, independent consumer organisations, and with rare exception are run by volunteers on a shoe-string budget. These organisations joined forces to create INNCO, and they nominate and elect INNCO’s Governing Board members, who serve without compensation.
INNCO only accepts funding from sources where our independence as an organisation run by and for consumers is assured. INNCO operated for more than two years with only volunteer efforts and no funding. (Funding from the Foundation was received in December of 2018, which is after the period this paper covers.)
As the authors note, INNCO was formed in large part to ensure the consumer voice is heard on international platforms. However, we question the authors’ intent in casting our desire to engage as legitimate stakeholders as nefarious.
While the authors have cited numerous references on the motivations of t...
NOT PEER REVIEWED
We appreciate the authors’ concern about industry “astroturfing.” We believe astroturf activities undermine the genuine consumer movement that INNCO and its members represent. But the conclusions that the authors draw from their research are attenuated and inaccurate. In particular, we object strenuously to the authors’ conclusion that because INNCO has received funding from the Foundation for a Smoke-Free World (the Foundation), we are a tobacco front group.
INNCO was formed in 2016, a year before the Foundation was established. All of INNCO’s members are autonomous, independent consumer organisations, and with rare exception are run by volunteers on a shoe-string budget. These organisations joined forces to create INNCO, and they nominate and elect INNCO’s Governing Board members, who serve without compensation.
INNCO only accepts funding from sources where our independence as an organisation run by and for consumers is assured. INNCO operated for more than two years with only volunteer efforts and no funding. (Funding from the Foundation was received in December of 2018, which is after the period this paper covers.)
As the authors note, INNCO was formed in large part to ensure the consumer voice is heard on international platforms. However, we question the authors’ intent in casting our desire to engage as legitimate stakeholders as nefarious.
While the authors have cited numerous references on the motivations of the tobacco industry, they appear to not understand the tobacco harm reduction consumer space, relying solely on the previous work of their own organisation to draw inferences. Consumer advocates are passionate about alternatives that have helped them wean off smoking, and are committed to ensuring continued access for these potentially life-saving products.
Consumers are aligned with FCTC’s goals of mitigating tobacco-related death and disease, although our approach differs in that we reject prohibitionism and stigmatisation in favour of pragmatic, humane and ultimately more effective policies that recognise human rights and the agency of users to become proactive participants in improving their health. INNCO thus brings a unique, ear-to-the-ground perspective to tobacco control efforts, and should be welcomed as FCTC observers.
By encouraging governments, policymakers and others to view consumers and consumer groups as fronts for the tobacco industry, the authors deplatform and disenfranchise an already unfairly marginalised group. We urge the authors to consider the ethical implications of nudging decisionmakers to dismiss the consumer voice. This disregard of the most profoundly affected stakeholders occurs in no other health or policy arena.
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It’s surprising finding oneself involuntarily part of a research study. Given no chance to contribute, perhaps I can offer privileged insight into the processes the authors seek to describe.
Analysis of tweets around the COP8 meeting show that nicotine consumer advocates were the most active, followed by public health advocates and the tobacco industry. My company – Knowledge Action Change – also tweeted, at the Geneva launch of our tobacco harm reduction report. [1] Tweeting by tobacco harm reduction advocates out-shadowed “official” FCTC messaging (and if the authors had searched #FCTCCOP8 and #COP8 as well as #COP8FCTC, they would have uncovered more).
The article asserts that tobacco industry money is behind this activity. But it is beyond this study’s narrow methodological reach to illuminate why nicotine consumer advocates tweet. My discussions with nicotine consumer advocates – the majority of whom are volunteers - demonstrate passionate interest in the policymaking that influences their lives. Having found safer alternatives to smoking, they fear that inappropriate regulation including bans will see their options disappear. They are frustrated that they are ignored by tobacco control policymakers, regulators and researchers. Barred from COP8 along with the public and press, consumer organisations are also barred from the NGO coalition Framework Convention Alliance. No other field of health policy excludes the affected. Consu...
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It’s surprising finding oneself involuntarily part of a research study. Given no chance to contribute, perhaps I can offer privileged insight into the processes the authors seek to describe.
Analysis of tweets around the COP8 meeting show that nicotine consumer advocates were the most active, followed by public health advocates and the tobacco industry. My company – Knowledge Action Change – also tweeted, at the Geneva launch of our tobacco harm reduction report. [1] Tweeting by tobacco harm reduction advocates out-shadowed “official” FCTC messaging (and if the authors had searched #FCTCCOP8 and #COP8 as well as #COP8FCTC, they would have uncovered more).
The article asserts that tobacco industry money is behind this activity. But it is beyond this study’s narrow methodological reach to illuminate why nicotine consumer advocates tweet. My discussions with nicotine consumer advocates – the majority of whom are volunteers - demonstrate passionate interest in the policymaking that influences their lives. Having found safer alternatives to smoking, they fear that inappropriate regulation including bans will see their options disappear. They are frustrated that they are ignored by tobacco control policymakers, regulators and researchers. Barred from COP8 along with the public and press, consumer organisations are also barred from the NGO coalition Framework Convention Alliance. No other field of health policy excludes the affected. Consumers use social media to speak out, asking others to do likewise. Picking on a tiny unfunded Mexican organisation for encouraging peers to tweet misunderstands how social media works: the FCA itself recently exhorted members to tweet in the week of the postponed COP9.
Prior assumptions about tobacco industry interference dominate this article (as with much of the Bath group’s work). The authors assert that ‘vaping consumer advocacy groups’ receive industry funding, but provide no evidence for this for any national or local group cited. Net result – the article both smears and further disempowers a disenfranchised population.
Do the authors apply their ‘theory of external influence’ to their own work? The Bath group shares over $20m from the anti-nicotine and anti-tobacco harm reduction Bloomberg Philanthropies. [2] Philanthro-capitalism comes with its own strings attached. [3]
Perhaps more productive would be social science insights into the views of consumer advocates and the narratives that both drive and divide a field in which all parties ostensibly share a common outcome - an end to smoking.
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We thank Mr. Clive Bates (1) and Dr. Moira Gilchrist (2) for their reconsideration of our work (3) and previous response where we corrected some errors (4). We also reiterate that all data informing our Industry Watch are publicly available at Tobacco Watcher (https://tobaccowatcher.globaltobaccocontrol.org/) for anyone to analyze. As with any analyses of observational data, there are limitations and we do not disagree with some of the limitations that Gilchrist and Bates point out in our analyses (as we addressed nearly all of these in our previous response (4)). However, we remain unchanged in our conclusion that, as the title of our initial article stated, “Philip Morris International used the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak to market IQOS heated tobacco” (3).
While statistical analysis indicated a correlation between (a) PMI’s public statements regarding EVALI and their IQOS brand of heated tobacco posted to their corporate “media center” (5) and (b) trends in news coverage of EVALI and IQOS, our primary assertion is that PMI used EVALI to market IQOS. The necessary and sufficient analysis to substantiate this assertion is reporting what PMI publicly claimed, which we did by analyzing the statement made by PMI which promoted IQOS through mentioning, contrasting or describing it along with EVALI and/or vaping.
The full text...
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There’s a published paper by Hammond and colleagues in 2019[1] using the same survey results, but there are some discrepancies.
1. The Table 2 of the 2019 paper, prevalence of vaping in 2018 for ever, past 30 days are 37.0% (1425), 14.6% (562) in Canada, 32.7% (1276), 8.9% (346) in England and 33.6% (1360), 16.2% (655) in the US, respectively. However, in this article’s Table 1, for vaping in the same year 2018 for ever, past 30 days are 33.2% (1275), 12.1% (463) in Canada, 33.1% (1283), 9.0% (351) in England and 33.1%(1336), 15.7% (635) in the US. More discrepancies can be found on cigarette smoking section as well. These numbers warrant further explanation particularly why numbers in Canada and the US decreased while numbers in England increased? Considering previous correction of numbers to the 2019 paper has raised serious concern among some readers[1], such timely clarification in this article will be very necessary.
2. The 2019 paper use the criteria of ≥15 days in past 30 days but the current paper adopts different criteria of ≥20 days in past 30 days, for both vaping and cigarette smoking. Further explanation is needed for such change.
Additionally, a few considerations on possible limitations of the paper’s findings:
1. Since the invitations were sent to nearly twice more parents than youth themselves according to the technical report[2], responds to survey questions might be biased because study has shown many...
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We would like to thank Mr. Wang for his feedback on our paper, Indicators of dependence and efforts to quit vaping and smoking among youth in Canada, England and the USA.
With regards to the ‘discrepancies’ in vaping and smoking prevalence between those reported in Table 1 and an earlier publication [1], we have previously published these same estimates [2], along with a description of the survey weighting procedures—which were modified since the first estimates were published (as outlined in a published erratum to the cited publication [3]). Briefly, since 2019, we have been able to incorporate the smoking trends from national ‘gold standard’ surveys in Canada and the US into the post-stratification sampling weights. A full description is provided in the study’s Technical Report [4], which is publicly available (see http://davidhammond.ca/projects/e-cigarettes/itc-youth-tobacco-ecig/).
Mr. Wang has also noted a change in the threshold used for a measure of frequent vaping/smoking: ≥20 days in past 30 days rather than ≥15 days, as previously reported [1]. We have adopted the convention of reporting using ≥20 days in past 30 days to align with the threshold commonly used by the US Centers for Disease Control for reporting data from the National Youth Tobacco Survey (NYTS), as well as the Population Assessment of Tobacco and Health (PATH) Study and the Mo...
Show More¶ I enjoyed reading this paper. I appreciate the author's use of difference-in-difference (DD) methodology. There were some things I found unclear that I would like to ask the authors to comment on.
¶ First, could the authors provide greater clarity on the model for column 1 of Table 1? Is the dependent variable here a yes/no for current cigarette use? The authors write, "Adolescents reported lifetime and prior month use of cigarettes, which we combined into a count variable of days smoked in the past month (0–30)." How does lifetime cigarette use help the authors to code the current number of cigarette days? The authors later state that they show that "increasing implementation of flavoured tobacco product restrictions was associated not with a reduction in the likelihood of cigarette use, but with a decrease in the level of cigarette use among users." Do the authors mean lifetime cigarette use here, or current cigarette use? The authors estimate this equation with an "inflation model," which I am not aware of. Could the authors provide more information on this modelling technique? This is not discussed in the "Analysis" section.
¶ Second, I felt like this statement is too strong. "Our findings suggest that[...] municipalities should enact stricter tobacco-control policies when not pre-empted by state law." Municipalities need to weigh many factors in making these decisions, including the effects of popu...
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This article does not distinguish between characterizing flavour (menthol) bans that were implemented in Canadian provinces between 2015 and 2017 and the implementation of a national ban on menthol additives in Canada in October 2017. Although unreported, the analysis was performed exclusively on provincial characterizing flavour bans. This significant distinction should be reported to ensure that researchers and policy makers are aware of the potential impact of a characterizing flavour ban and to ensure that this policy measure is not dismissed or discounted.
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In his comment, Les Hagen brings up an important distinction between two types of restrictions on menthol: a menthol additive ban, and a menthol characterizing flavour ban. Canada's menthol ban across the provinces did indeed involve both types. Between May 2015 and July 2017, Nova Scotia, Alberta, Quebec, Ontario, Prince Edward Island, and Newfoundland & Labrador implemented characterizing flavour bans, whereas New Brunswick implemented a menthol additive ban [1]. When the Federal Government implemented a menthol additive ban in October 2017 [2] , it applied only to the remaining provinces—British Columbia, Saskatchewan, Manitoba—as well as Nunavut, Yukon, and the Northwest Territories. Thus, the "menthol cigarette ban" in Canada is a mixture of the two types.
Our article [3] evaluated the impact of menthol bans implemented between the 2016 and 2018 waves of the Canadian arm of the ITC Four Country Smoking and Vaping Surveys. Hagen incorrectly stated that "the analysis was performed exclusively on provincial characterizing flavour bans." In fact, the provinces evaluated in our study included both those that implemented characterizing flavour bans (Quebec, Ontario, Prince Edward Island, Newfoundland & Labrador) and those that implemented the Federal menthol additive ban (British Columbia, Saskatchewan, Manitoba).
In our original study, we did not test for differences between the two kinds of bans, beca...
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Thank you for the corrections and for acknowledging the omission. The additional analysis performed by ITC is greatly appreciated and provides further insight into the impact of both interventions. Although unstated, Canada’s regional characterizing flavour bans contributed significantly to the development of a national menthol additive ban as chronicled by the U.S. Tobacco Control Legal Consortium[1] . I look forward to reading the full analysis when published.
1. Kerry Cork, Tobacco Control Legal Consortium, Leading from Up North: How Canada Is Solving the Menthol Tobacco Problem (2017). https://www.publichealthlawcenter.org/sites/default/files/resources/tclc...
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We object to the framing of Association of Vapers India (AVI), erroneously referred to as ‘Vape India’ in the paper, as a tobacco industry front group, without providing any basis for the claim except our membership of International Network of Nicotine Consumer Organisations (INNCO).
AVI was organised in August 2016, when consumers of low-risk alternatives came together to arrest the tide of state bans in India, which were being lobbied for by the Bloomberg Philanthropies network the authors belong to.[1] Though one of our directors is the current president of INNCO’s governing board, elected through a member vote in the 2020 General Assembly, he is serving in unpaid, honorary capacity.
AVI has not received funding from INNCO, nor from the Foundation for Smoke-free World (FSFW), and neither from the tobacco industry. Our work is financed through voluntary contributions, and like INNCO, the affairs are conducted by a governing board comprising unpaid consumer volunteers.
It is scurrilous to cast AVI as a tobacco industry group or anything other than a consumer-led movement that is seeking access to harm reduction avenues for India’s nearly 270 million tobacco users, among whom cancers are rising[2] even as most have meagre means to deal with the health consequences, which makes harm prevention a vital mitigation strategy. We are product agnostic and advocate access to lower-risk alternatives for both smokers and smokeless tobacco...
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We appreciate the authors’ concern about industry “astroturfing.” We believe astroturf activities undermine the genuine consumer movement that INNCO and its members represent. But the conclusions that the authors draw from their research are attenuated and inaccurate. In particular, we object strenuously to the authors’ conclusion that because INNCO has received funding from the Foundation for a Smoke-Free World (the Foundation), we are a tobacco front group.
INNCO was formed in 2016, a year before the Foundation was established. All of INNCO’s members are autonomous, independent consumer organisations, and with rare exception are run by volunteers on a shoe-string budget. These organisations joined forces to create INNCO, and they nominate and elect INNCO’s Governing Board members, who serve without compensation.
INNCO only accepts funding from sources where our independence as an organisation run by and for consumers is assured. INNCO operated for more than two years with only volunteer efforts and no funding. (Funding from the Foundation was received in December of 2018, which is after the period this paper covers.)
As the authors note, INNCO was formed in large part to ensure the consumer voice is heard on international platforms. However, we question the authors’ intent in casting our desire to engage as legitimate stakeholders as nefarious.
While the authors have cited numerous references on the motivations of t...
Show MoreNOT PEER REVIEWED
It’s surprising finding oneself involuntarily part of a research study. Given no chance to contribute, perhaps I can offer privileged insight into the processes the authors seek to describe.
Analysis of tweets around the COP8 meeting show that nicotine consumer advocates were the most active, followed by public health advocates and the tobacco industry. My company – Knowledge Action Change – also tweeted, at the Geneva launch of our tobacco harm reduction report. [1] Tweeting by tobacco harm reduction advocates out-shadowed “official” FCTC messaging (and if the authors had searched #FCTCCOP8 and #COP8 as well as #COP8FCTC, they would have uncovered more).
The article asserts that tobacco industry money is behind this activity. But it is beyond this study’s narrow methodological reach to illuminate why nicotine consumer advocates tweet. My discussions with nicotine consumer advocates – the majority of whom are volunteers - demonstrate passionate interest in the policymaking that influences their lives. Having found safer alternatives to smoking, they fear that inappropriate regulation including bans will see their options disappear. They are frustrated that they are ignored by tobacco control policymakers, regulators and researchers. Barred from COP8 along with the public and press, consumer organisations are also barred from the NGO coalition Framework Convention Alliance. No other field of health policy excludes the affected. Consu...
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