Skepticism at Launch of the Foundation for a Smoke-Free World

Kristin Jenkins

October 16, 2017

The goal to end smoking worldwide — the number one preventable cause of death globally — appeared to take a big step in the right direction with the launch last month in New York City of the Foundation for a Smoke-Free World

Surely any move toward ending smoking is a good thing. In the period 2005 to 2009, cancer deaths attributable to smoking — primarily lung cancer — topped the list of smoking-related cancer mortality in the United States, surpassing deaths caused by smoking-related heart disease, stroke, and diabetes mortality combined, according to the Centers for Disease Control and Prevention (CDC).

However, many tobacco control experts remain skeptical about the new foundation, after the announcement that funding of $80 million annually over the next 12 years had been secured from Philip Morris International (PMI), one of the world's leading tobacco manufacturers and cigarette marketer.

The foundation will focus on funding critical research and finding ways to speed up science-based solutions to the current public health crisis involving 1 billion smokers worldwide, said its founder, Derek Yach, MD, an antismoking crusader and former member of the Secretariat of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), in a press release announcing its launch.

"The Foundation for a Smoke-Free World will bring new energy, needed resources and significant expertise to the fight," added John R. Seffrin, PhD, professor at Indiana University-Bloomington School of Public Health and former CEO of the American Cancer Society.

When asked to comment on the apparent conflict of interest, Dr Yach said the foundation is "legally, operationally and philosophically distinct and separate from the tobacco industry. Our nonprofit status and mission demand ironclad separation. As someone who has dedicated his entire career to ridding the world of death and disease caused by smoking, I wouldn't have it any other way," he told Medscape Medical News.

The foundation's bylaws — constructed by using the criteria for evaluating tobacco control research funding programs proposed by Cohen et al —include "an independent research agenda, independent governance, ownership of data, freedom to publish, and protection against conflict of interest," he explained, adding that the bylaws are available for public review on the foundation's website.

One of the foundation's strategies for ending smoking as quickly as possible will include investigation into the health risks of e-cigarettes and "heat not burn" (HNB) products, Dr Yach confirmed. "Harm reduction strategies, such as transitioning smokers to new technologies that separate the deadly smoke, tar, and chemicals from the addictive nicotine will certainly be part of what is studied," he said. "The foundation is currently developing its research agenda through an open, collaborative process with the tobacco control community, and as part of that we will try to answer the lingering questions about the safety of e-cigarettes."

He added: "In the meantime, it is worth considering that recent major studies have demonstrated that e-cigarettes have proven to be safe and effective in helping some smokers quit."

Health professionals, including physicians, need to support accelerated ways of ending smoking, Dr Yach emphasized, noting that with 1 billion smokers globally, "the preventive potential for health professionals to advise their patients about methods for quitting cigarettes is extremely high but rarely realized."

He also encouraged clinicians to partner with the foundation "to help us determine the most effective ways to end smoking, and then to help disseminate those learnings to other health professionals so they may provide their patients who smoke with science-based advice about which quit methods work best and which products will lower their risks substantially."

Until now, he pointed out, the investment in public sector tobacco control has been "miniscule" compared with funding for public sector research into HIV/AIDS and malaria. "My hope is that this foundation will re-energize the field with new ideas, new players, and innovative partners who don't come from the traditional tobacco control core, and together we will discover new and innovative ways to help smokers quit."

Negative Reactions

Reaction to the launch of the foundation and its funding partnership has been swift and largely negative.

"Derek Yach's journey to the Dark Side is now complete," declared a blog post on the University of California San Francisco Center for Tobacco Control Research and Education website, authored by Stanton Glantz, PhD, professor of medicine. He pointed out that the funding for the Foundation represents about 0.1% of its revenues and 1% of its profits.

"If PMI was serious about achieving a smoke free world, it could stop aggressively lobbying against proper implementation of the WHO Framework Convention on Tobacco Control or stop selling Marlboros and other cigarettes. That's what Derek [Yach] would have said in response to this ruse back when he was a public health leader at WHO," wrote Dr Glantz.

In another blog post, Dr Glantz declared: "I hope former American Cancer Society CEO John Seffrin reverses his endorsement of PMI's foundation."

The American Cancer Society commented in its own press release that the PMI support was just "a continuation of a decades-long effort to paint over tobacco's role in spreading death and misery around the globe." It adds that the company has the power to make a difference. "Stop selling cigarettes. Stop spending billions to market cigarettes. Stop suing governments around the world. And stop fighting every meaningful, evidence-based tobacco control effort."

The WHO Secretariat called the launch of the Foundation "a deeply alarming development" and immediately distanced itself from Dr Yach, a former member of the Secretariat during the negotiation of the WHO FCTC. "The Foundation's president is in no way linked to the Convention Secretariat, nor does he represent the Convention Secretariat's views," it said in an online statement.

In addition, the WHO statement made it clear that the foundation's mission is seen as a direct threat to WHO FCTC's sovereignty as "the world's only tobacco control evidence based treaty" and that the Secretariat would be alerting countries to "its potentially harmful impact, particularly through contentious research program[me]s."

In an online statement, the Truth Initiative — a nonprofit tobacco control organization —called the announcement "an affront," pointing to the absence of any evidence that the PMI was going to stop marketing combustible products or quit fighting tobacco control efforts globally. "History has proven, time and time again, that the tobacco industry only looks out for its best interest. The profit motives of the tobacco industry and public health are simply incompatible, and this is a Pandora's Box that should remain closed."

Michael Siegel, PhD, professor at Boston University School of Public Health in Massachusetts and a 32-year veteran of the tobacco control wars, wrote in his blog that he was declining the foundation's invitation to consult. "Since Philip Morris International (PMI) continues to aggressively market cigarettes internationally and to aggressively fight public health efforts to reduce tobacco use, this is just not a project that I can participate in as a public health practitioner."

Matt Myers, president of the Campaign for Tobacco-Free Kids, called the move a "get-out-of-jail-free card" for PMI to continue its opposition to high taxes on cigarettes and to continue marketing new products aimed at children and young women, according to a report in the Cancer Letter. "Philip Morris International has a long history of funding what it calls independent research by previously credible researchers. In the past, they've always funneled that research to try and set an agenda, to divert attention away from what they're doing. They're doing the same thing here."

For many tobacco control experts, the announcement sounded like a thinly veiled attempt on the part of PMI to gather more legitimized support for its e-cigarettes and other smokeless HNB smoking alternatives. PMI's top-of-the-line product, IQOS, heats tobacco-leaf refills known as Heets or HeatSticks and is sold under the Marlboro brand for about the same price as regular cigarettes.

When approached for comment, Iro Antoniadou, a spokesperson for PMI, referred Medscape Medical News to its online vision statement about its "commitment to a smoke-free future." Profits from cigarettes sales will be used to replace regular cigarettes with a "portfolio" of smokeless nicotine-delivery products. "Over three million people have already given up smoking and switched to our new products, and this is just the beginning," the statement said. "We're investing to make these products the Philip Morris icons of the future."

Combustible tobacco burns at temperatures of 600°C and higher, generating smoke that contains at least 70 known carcinogens. IQOS heats tobacco to much lower temperatures, up to 350°C, without combustion, fire, ash, or smoke. "Because the tobacco is heated and not burned, the levels of harmful chemicals are significantly reduced compared to cigarette smoke," the PMI statement said.

Other HNB products developed by PMI include TEEPS, which uses a carbon heat source to heat tobacco and is also sold under the Marlboro brand. There's also the next generation of e-cigarettes, called MESH. Each prefilled and presealed cartridge contains its own heater, made of metallic mesh with tiny holes. When a button is pressed, the nicotine and flavor contained in each cartridge is vaporized.

In 2014, PMI acquired a leading UK e-cigarette company called Nicocig, which also produces a variety of disposables, rechargeables, and tank systems under the brand names Nicocig and Vivid. PMI also markets e-cigarette products in Israel and Spain under the brand name Solaris.

Whether smokeless tobacco products, including electronic or e-cigarettes, are a viable solution to reducing or eliminating the health consequences of smoking combustible tobacco remains highly controversial. As previously reported by Medscape Medical News, current understanding about the potential health risks and long-term harms of e-cigarettes is incomplete, and the unregulated marketplace — which consists of up to 300 products bearing different constituents — is continually growing.

The CDC remains opposed to e-cigarettes and other forms of HNB products, saying that smokeless tobacco is also a known cause of cancer. However, the US Food and Drug Administration's strategy to reduce nicotine levels in all combustible tobacco products is actively encouraging the development of nicotine-delivery alternatives, including e-cigarettes. It is expected that the high costs associated with the tobacco product review applications of these products — which require original research and testing—will be prohibitively expensive to all but the major tobacco companies.

"It is critical to understand the relative differences in exposures from e-cigarette vapor and cigarettes," Dr Yach told Medscape. "Current evidence [shows] that the difference is substantial, favoring e-cigarettes."

He added that the use of flavors will be examined carefully, as will the impact of e-cigarettes on juvenile smoking. "The largest studies of e-cigarettes and kids' uptake of cigarettes suggest fears about e-cigarettes being a gateway to cigarettes and that young people are using them instead of cigarettes are unfounded. That said, it will be important to further study e-cigarette use and youth to make sure that tools with the potential to help adults quit smoking aren't used by nonsmokers and youth."

In a viewpoint article published online October 14 in The Lancet, Dr Yach says that harm reduction is gaining acceptance as part of tobacco control worldwide, noting the FDA's shift toward consideration of smokeless nicotine-delivery systems along with its nicotine reduction strategy.

Shortly after leaving WHO, he suggested in 2014 that "harm reduction could one day represent a new frontier for accelerated progress. That day has come."

Industry That Sells Death and Disability

In a related comment in the same issue of The Lancet, Martin McKee, CBE, MD, DSc, from the Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, United Kingdom, and colleagues, write that the foundation's arrival on the tobacco control scene "changes nothing." In fact, they point out, its research priorities dovetail with the smoke-and-mirrors strategies deployed by PMI to divert attention away from evidence-based smoking reduction methods.

"PMI, like other tobacco companies, may well want to sell a range of products, but anybody who believes that they really do want to see a smoke-free world is, we argue, living in a fantasy world," Dr McKee and colleagues suggest. In the meantime, they add, governments, health organizations, and scientists should continue in their efforts to reduce smoking. "And the public should be aware that Big Tobacco remains as it was, the main cause of premature death and disability from the world's most preventable pandemic."

In an accompanying editorial, editors at The Lancet note that critics of the foundation have suggested its focus on harm reduction is the wrong way to get people to quit smoking. Not only does this approach undermine efforts to prevent people from starting smoking, particularly young people, but the efficacy of e-cigarettes to help people quit smoking remains to be seen.

On the other hand, following the WHO directive to boycott the foundation could be a mistake, they say, pointing to the fact that Dr Yach is a "respected public health leader. If anyone can achieve the objectives of the Foundation, it is him."

Keeping the lines of communication open with all parties — "as unpalatable as it may seem to engage with the tobacco industry" — is essential if the foundation is to be held to account, they add, noting that Dr Yach is no stranger to controversy. He crossed over into commercial interest territory once before when he joined PepsiCo to help fight obesity-related diseases. He also encouraged reductions in salt, sugar, and fat in the food and drink manufacturer's products.

Still, the editors at The Lancet don't hold out much hope that the foundation will be successful in its mission to end smoking worldwide — even with Dr Yach at the helm. The costs of failure will damage more than his reputation, they predict. "They will represent another victory for an industry that sells death and disability."

Dr McKee and colleagues have disclosed no relevant financial relationships.

Lancet.  Published online October 14, 2017. Viewpoint, Comment, Editorial

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