A tobacco industry study of airline cabin air quality: dropping inconvenient findings

Analysis of mainstream emissions, secondhand emissions and the environmental impact of IQOS waste: a systematic review on IQOS that accounts for data source

OBJECTIVE

To highlight the general features of IQOS literature focusing on the chemical analysis of IQOS emissions.

DATA SOURCES

PubMed, Web of Science and Scopus databases were searched on 8 November 2021 using the terms 'heated tobacco product', 'heat-not-burn', 'IQOS' and 'tobacco heating system' with time restriction (2010-2021). The search yielded 5480 records.

STUDY SELECTION

Relevant publications on topics related to IQOS assessment were retrieved (n=341). Two reviewers worked separately and reached agreement by consensus.

DATA EXTRACTION

Data on author affiliation and funding, article type and date of publication were extracted. Publications were categorised depending on their focus and outcomes. Data on IQOS emissions from the chemical analysis category were extracted.

DATA SYNTHESIS

Of the included publications, 25% were published by Philip Morris International (PMI) affiliates or PMI-funded studies. PMI-sponsored publications on emissions, toxicology assessments and health effects were comparable in number to those reported by independent research, in contrast to publications on IQOS use, market trends and regulation. Data on nicotine yield, carbonyl emissions, other mainstream emissions, secondhand emissions and IQOS waste were compared between data sources to highlight agreement or disagreement between PMI-sponsored and independent research.

CONCLUSIONS

Our analysis showed agreement between the data sources on nicotine yield from IQOS under the same puffing conditions. Also, both sources agreed that IQOS emits significantly reduced levels of some emissions compared with combustible cigarettes. However, independent studies and examination of PMI's data showed significant increases in other emissions from and beyond the Food and Drug Administration's harmful and potentially harmful constituents list.

A conflict of interest is strongly associated with tobacco industry-favourable results, indicating no harm of e-cigarettes

Researchers reach contradictory results when trying to assess the potential harm of e-cigarettes. This study investigated whether the findings and conclusions in papers published on e-cigarettes and health differ depending on whether the authors had a financial conflict of interest (COI) or not. A total of 94 studies (identified in a previous systematic review) that investigated the content of fluid/vapor of e-cigarettes or in vitro experiments were included. The type, level and direction of the financial COI were coded. Abstracts were blinded and evaluated by two assessors. Fischer's Test and Logistic regression analyses were used to investigate the associations between findings of harm/conclusions and COI. All three dimensions of COI showed the same tendency: studies with industry-related COI found potential harm significantly less often than studies without a COI. 95.1% of papers without and 39.4% of papers with a COI found potential harmful effects/substances. Only 7.7% of tobacco industry-related studies found potential harm. The odds of finding of no harm were significantly higher in studies with an industry-related COI (OR 66.92 (95% CI 8.1-552.9)) than in studies without a COI. A strong/moderate COI was associated with very high odds (OR 91.50 (95% CI 10.9-771.4)) of finding of no harm compared with studies with no/weak COI. This blinded assessment showed that almost all papers without a COI found potentially harmful effects of e-cigarettes. There was a strong association between industry-related COI and tobacco- and e-cigarette industry-favourable results, indicating that e-cigarettes are harmless.

PMI's own in vivo clinical data on biomarkers of potential harm in Americans show that IQOS is not detectably different from conventional cigarettes

INTRODUCTION

New 'heated tobacco products' are being marketed in several countries with claims that they expose users to lower levels of toxins than conventional cigarettes which could be read as being less likely to cause health problems than conventional cigarettes. In the USA, Philip Morris International (PMI) has submitted an application to the Food and Drug Administration for permission to market its heated tobacco product, IQOS, with reduced exposure and reduced risk claims.

METHODS

Analysis of detailed results on 24 biomarkers of potential harm in PMI studies of humans using IQOS compared with humans using conventional cigarettes.

RESULTS

Among American adults, there is no statistically detectable difference between IQOS and conventional cigarette users for 23 of the 24 biomarkers of potential harm in PMI's studies. In Japan, there were no significant differences between people using IQOS and conventional cigarettes in 10 of 13 biomarkers of potential harm. It is likely that some of the significant differences are false positives.

CONCLUSION

Despite delivering lower levels of some toxins than conventional cigarettes, PMI's own data fail to show consistently lower risks of harm in humans using its heated tobacco product, IQOS, than conventional cigarettes.

Evidence Regarding the Impact of Conflicts of Interest on Environmental and Occupational Health Research

PURPOSE OF REVIEW

This review describes published literature providing evidence for financial conflicts of interest in environmental and occupational health research. Secondary goals were to describe evidence that (a) utilized quantitative methods to evaluate the association of conflicts with study outcomes, and (b) assessed undisclosed as well as disclosed conflicts of interest.

RECENT FINDINGS

Forty-three studies were identified which contained descriptions of the impact of financial conflicts of interest on research results; 11 of these conducted quantitative analyses to demonstrate these relationships. All 11 articles which quantified associations identified significant associations of the presence of financial conflicts of interest with study findings. In studies which measured undisclosed conflicts, these comprised a substantial proportion of all conflicts. Suggestions for improving understanding and interpretation of research results are presented.

Hiding in the Shadows: Philip Morris and the Use of Third Parties to Oppose Ingredient Disclosure Regulations

Background

In 1996 Massachusetts proposed regulations that would require tobacco companies to disclose information about the ingredients in their products on a by-brand basis. This paper examines the strategies employed by Philip Morris to stop these regulations from being implemented.

Methods and Finding

We used previously secret tobacco industry documents and published literature to examine the activities of the tobacco companies after the regulations were proposed. Philip Morris hired a public relations firm to establish a coalition that was instructed to oppose the regulations by linking them to other industrial sectors (the slippery slope) and stating they would damage the state's economy. Philip Morris also retained a polling firm to test the popularity of specific arguments against ingredient disclosure and developed a strategic plan for opposing similar regulations in Vermont.

Conclusion

Tobacco companies have historically used third parties to form coalitions to oppose ingredient disclosure regulations. These coalitions have had success preventing regulations from being implemented after they are initially proposed by creating the appearance of local opposition. With countries around the world currently implementing ingredient disclosure regulations in the WHO Framework Convention on Tobacco, governments and regulatory agencies should be aware of the political strategies that the tobacco companies have used to create the impression of popular opposition to these measures.

Tobacco companies' efforts to undermine ingredient disclosure: the Massachusetts benchmark study

OBJECTIVES

To assess the 'Massachusetts Benchmark Study' (MBS) that the tobacco companies presented to the Massachusetts Department of Public Health (MDPH) in 1999 in response to ingredient disclosure regulations in the state. This case study can inform future ingredient disclosure regulations, including implementation of Articles 9 and 10 of the WHO Framework Convention on Tobacco Control (FCTC).

METHODS

We analysed documents available at http://legacy.library.ucsf.edu to identify internal communications regarding the design and execution of the MBS and internal studies on the relationship between tar, nicotine and carbon monoxide and smoke constituents and reviewed publications that further evaluated data published as part of the MBS.

RESULTS

The companies conducted extensive studies of cigarette design factors and ingredients that significantly impacted the levels of constituents. While this study asserted that by-brand emissions could be estimated reliably from published tar, nicotine, and carbon monoxide levels, the tobacco companies were well aware that factors beyond tar, nicotine and carbon monoxide influenced levels of constituents included in the study. This severely limited the potential usefulness of the MBS predictor equations.

CONCLUSIONS

Despite promises to provide data that would allow regulators to predict constituent data for all brands on the market, the final MBS results offered no useful predictive information to inform regulators, the scientific community or consumers. When implementing FCTC Articles 9 and 10, regulatory agencies should demand detailed by-brand information on tobacco product constituents and toxin deliveries to users.

A critical evaluation of the volume, relevance and quality of evidence submitted by the tobacco industry to oppose standardised packaging of tobacco products

OBJECTIVES

To examine the volume, relevance and quality of transnational tobacco corporations' (TTCs) evidence that standardised packaging of tobacco products 'won't work', following the UK government's decision to 'wait and see' until further evidence is available.

DESIGN

Content analysis.

SETTING

We analysed the evidence cited in submissions by the UK's four largest TTCs to the UK Department of Health consultation on standardised packaging in 2012.

OUTCOME MEASURES

The volume, relevance (subject matter) and quality (as measured by independence from industry and peer-review) of evidence cited by TTCs was compared with evidence from a systematic review of standardised packaging . Fisher's exact test was used to assess differences in the quality of TTC and systematic review evidence. 100% of the data were second-coded to validate the findings: 94.7% intercoder reliability; all differences were resolved.

RESULTS

77/143 pieces of TTC-cited evidence were used to promote their claim that standardised packaging 'won't work'. Of these, just 17/77 addressed standardised packaging: 14 were industry connected and none were published in peer-reviewed journals. Comparison of TTC and systematic review evidence on standardised packaging showed that the industry evidence was of significantly lower quality in terms of tobacco industry connections and peer-review (p<0.0001). The most relevant TTC evidence (on standardised packaging or packaging generally, n=26) was of significantly lower quality (p<0.0001) than the least relevant (on other topics, n=51). Across the dataset, TTC-connected evidence was significantly less likely to be published in a peer-reviewed journal (p=0.0045).

CONCLUSIONS

With few exceptions, evidence cited by TTCs to promote their claim that standardised packaging 'won't work' lacks either policy relevance or key indicators of quality. Policymakers could use these three criteria-subject matter, independence and peer-review status-to critically assess evidence submitted to them by corporate interests via Better Regulation processes.

Protecting the world from secondhand tobacco smoke exposure: where do we stand and where do we go from here?

INTRODUCTION

Article 8 of the Framework Convention on Tobacco Control mandates all signatory countries to "protect citizens from exposure to tobacco smoke in workplaces, public transport and indoor public places." Even though there has been great progress in the implementation of Article 8, still most of the world population remains exposed to secondhand smoke (SHS). In this article, we sought to summarize the research that supports Article 8, where do we stand, and current research gaps and future directions.

DISCUSSION

Secondhand smoke is an established cause of heart disease and several types of cancer. Additional research is needed to reach final conclusions for diseases where evidence is only suggestive of causality. The only solution to SHS exposure in public places is banning smoking indoors. Research on the gaming industry and nightclubs, particularly in developing countries, needs to be disseminated to support their inclusion in smoke-free laws. Aside from indoor bans, additional research is needed for outdoor and multiunit housing bans and in support of measures that protect children and other vulnerable populations. The impact of smoke-free laws on other health outcomes, besides heart disease and respiratory outcomes, is another area where further research is needed. Thirdhand smoke assessment and health effects are also likely to be a topic of further research. As new tobacco products emerge, evaluating SHS exposure and effects will be vital.

CONCLUSIONS

Furthering research in support of Article 8 can contribute to reach the final goal of protecting everyone from SHS exposure.

Reduced exercise tolerance and pulmonary capillary recruitment with remote secondhand smoke exposure

Rationale

Flight attendants who worked on commercial aircraft before the smoking ban in flights (pre-ban FAs) were exposed to high levels of secondhand smoke (SHS). We previously showed never-smoking pre-ban FAs to have reduced diffusing capacity (Dco) at rest.

Methods

To determine whether pre-ban FAs increase their Dco and pulmonary blood flow () during exercise, we administered a symptom-limited supine-posture progressively increasing cycle exercise test to determine the maximum work (watts) and oxygen uptake () achieved by FAs. After 30 min rest, we then measured Dco and at 20, 40, 60, and 80 percent of maximum observed work.

Results

The FAs with abnormal resting Dco achieved a lower level of maximum predicted work and compared to those with normal resting Dco (mean±SEM; 88.7±2.9 vs. 102.5±3.1%predicted ; p = 0.001). Exercise limitation was associated with the FAs' FEV₁ (r = 0.33; p = 0.003). The Dco increased less with exercise in those with abnormal resting Dco (mean±SEM: 1.36±0.16 vs. 1.90±0.16 ml/min/mmHg per 20% increase in predicted watts; p = 0.020), and amongst all FAs, the increase with exercise seemed to be incrementally lower in those with lower resting Dco. Exercise-induced increase in was not different in the two groups. However, the FAs with abnormal resting Dco had less augmentation of their Dco with increase in during exercise (mean±SEM: 0.93±0.06 vs. 1.47±0.09 ml/min/mmHg per L/min; p<0.0001). The Dco during exercise was inversely associated with years of exposure to SHS in those FAs with ≥10 years of pre-ban experience (r = −0.32; p = 0.032).

Conclusions

This cohort of never-smoking FAs with SHS exposure showed exercise limitation based on their resting Dco. Those with lower resting Dco had reduced pulmonary capillary recruitment. Exposure to SHS in the aircraft cabin seemed to be a predictor for lower Dco during exercise.

Tobacco industry success in Costa Rica: the importance of FCTC article 5.3

OBJECTIVE

To analyze how the tobacco industry influenced tobacco control policymaking in Costa Rica.

MATERIALS AND METHODS

Review of tobacco industry documents, tobacco control legislation, newspaper articles, and interviewing of key informants.

RESULTS

During the mid-to-late 1980s, Health Ministry issued several advanced (for their time) smoking restriction decrees causing British American Tobacco (BAT) and Philip Morris International (PMI) to strengthen their political presence there, resulting in passage of a weak 1995 law, which, as of August 2011, remained in effect. Since 1995 the industry has used Costa Rica as a pilot site for Latin American programs and has dominated policymaking by influencing the Health Ministry, including direct private negotiations with the tobacco industry which violate Article 5.3's implementing guidelines of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC).

CONCLUSIONS

The Costa Rica experience demonstrates the importance of vigorous implementation of FCTC Article 5.3 which insulates public health policymaking from industry interference.

Local Nordic tobacco interests collaborated with multinational companies to maintain a united front and undermine tobacco control policies

OBJECTIVE

To analyse how local tobacco companies in the Nordic countries, individually and through National Manufacturers' Associations, cooperated with British American Tobacco and Philip Morris in denying the health hazards of smoking and undermining tobacco control.

METHODS

Analysis of tobacco control policies in the Nordic countries and tobacco industry documents.

RESULTS

Nordic countries were early adopters of tobacco control policies. The multinational tobacco companies recognised this fact and mobilised to oppose these policies, in part because of fear that they would set unfavourable precedents. Since at least 1972, the Nordic tobacco companies were well informed about and willing to participate in the multinational companies activities to obscure the health dangers of smoking and secondhand smoke and to oppose tobacco control policies. Cooperation between multinational companies, Nordic national manufacturer associations and local companies ensured a united front on smoking and health issues in the Nordic area that was consistent with the positions that the multinational companies were taking. This cooperation delayed smoke-free laws and undermined other tobacco control measures.

CONCLUSIONS

Local tobacco companies worked with multinational companies to undermine tobacco control in distant and small Nordic markets because of concern that pioneering policies initiated in Nordic countries would spread to bigger market areas. Claims by the local Nordic companies that they were not actively involved with the multinationals are not supported by the facts. These results also demonstrate that the industry appreciates the global importance of both positive and negative public health precedents in tobacco control.

The toxic effects of cigarette additives. Philip Morris' project mix reconsidered: an analysis of documents released through litigation

BACKGROUND

In 2009, the promulgation of US Food and Drug Administration (FDA) tobacco regulation focused attention on cigarette flavor additives. The tobacco industry had prepared for this eventuality by initiating a research program focusing on additive toxicity. The objective of this study was to analyze Philip Morris' Project MIX as a case study of tobacco industry scientific research being positioned strategically to prevent anticipated tobacco control regulations.

METHODS AND FINDINGS

We analyzed previously secret tobacco industry documents to identify internal strategies for research on cigarette additives and reanalyzed tobacco industry peer-reviewed published results of this research. We focused on the key group of studies conducted by Phillip Morris in a coordinated effort known as "Project MIX." Documents showed that Project MIX subsumed the study of various combinations of 333 cigarette additives. In addition to multiple internal reports, this work also led to four peer-reviewed publications (published in 2001). These papers concluded that there was no evidence of substantial toxicity attributable to the cigarette additives studied. Internal documents revealed post hoc changes in analytical protocols after initial statistical findings indicated an additive-associated increase in cigarette toxicity as well as increased total particulate matter (TPM) concentrations in additive-modified cigarette smoke. By expressing the data adjusted by TPM concentration, the published papers obscured this underlying toxicity and particulate increase. The animal toxicology results were based on a small number of rats in each experiment, raising the possibility that the failure to detect statistically significant changes in the end points was due to underpowering the experiments rather than lack of a real effect.

CONCLUSION

The case study of Project MIX shows tobacco industry scientific research on the use of cigarette additives cannot be taken at face value. The results demonstrate that toxins in cigarette smoke increase substantially when additives are put in cigarettes, including the level of TPM. In particular, regulatory authorities, including the FDA and similar agencies elsewhere, could use the Project MIX data to eliminate the use of these 333 additives (including menthol) from cigarettes.

Associations between respiratory illnesses and secondhand smoke exposure in flight attendants: A cross-sectional analysis of the Flight Attendant Medical Research Institute Survey

ABSTRACT: BACKGROUND: Secondhand tobacco smoke (SHS) is associated with increased risk of respiratory illness, cancer, and cardiovascular disease. Prior to smoking bans on airlines in the late 1980s, flight attendants were exposed to a significant amount of SHS. In the present study, we examine associations between flight attendant SHS exposure and development of respiratory illnesses and cardiovascular disease. METHODS: Between December 2006 and October 2010, three hundred sixty-two flight attendants completed an online questionnaire with information regarding experience as a flight attendant, medical history, smoking history, and SHS exposure. Rates of illnesses in flight attendants were compared with an age and smoking history matched population sample from NHANES 2005-2006. Logistic regression analysis was used to examine the association of reported medical conditions and pre-ban years of exposure. RESULTS: Compared with the sample from NHANES 2005-2006, flight attendants had increased prevalence of chronic bronchitis (11.7% vs. 7.2%, p < 0.05), emphysema/COPD (3.2% vs. 0.9%, p < 0.03), and sinus problems (31.5% vs. 20.9%, p < 0.002), despite a lower prevalence of medical illnesses including high blood pressure, diabetes, high cholesterol, heart failure, cancer, and thyroid disease. Amongst flight attendants who reported never smoking over their lifetimes, there was not a significant association between years of service as a flight attendant in the pre-smoking ban era and illnesses. However, in this same group, there was a significantly increased risk of daily symptoms (vs. no symptoms) of nasal congestion, throat, or eye irritation per 10-year increase of years of service as a flight attendant prior to the smoking ban (OR 2.14, 95% CI 1.41 - 3.24). CONCLUSIONS: Flight attendants experience increased rates of respiratory illnesses compared to a population sample. The frequency of symptoms of nasal congestion, throat or eye irritation is associated with occupational SHS exposure in the pre-smoking ban era.

Pulmonary function abnormalities in never-smoking flight attendants exposed to secondhand tobacco smoke in the aircraft cabin

OBJECTIVE

To determine whether the flight attendants who were exposed to secondhand tobacco smoke in the aircraft cabin have abnormal pulmonary function.

METHODS

We administered questionnaires and performed pulmonary function testing in 61 never-smoking female flight attendants who worked in active air crews before the smoking ban on commercial aircraft (preban).

RESULTS

Although the preban flight attendants had normal FVC, FEV1, and FEV1/FVC ratio, they had significantly decreased flow at mid- and low-lung volumes, curvilinear flow-volume curves, and evidence of air trapping. Furthermore, the flight attendants had significantly decreased diffusing capacity (77.5% +/- 11.2% predicted normal) with 51% having a diffusing capacity below their 95% normal prediction limit.

CONCLUSIONS

This cohort of healthy never-smoking flight attendants who were exposed to secondhand tobacco smoke in the aircraft cabin showed pulmonary function abnormalities suggestive of airway obstruction and impaired diffusion.

The Philip Morris Nordic journalist program: strategies, implementation and outcomes

OBJECTIVES

To describe media strategies for the Nordic countries outlined in internal Philip Morris documents and to evaluate their implementation and outcomes.

METHODS

Systematic search of internal tobacco industry documents from the databases available on the Internet and retrieval of newspaper and magazine articles from Sweden and Finland.

RESULTS

The Philip Morris Nordic journalist program contained a broad range of strategies to communicate company views and to counteract negative publicity, including trips for journalists, media briefings and special events. While several of these strategies were implemented, the efforts were largely unsuccessful in that the media in Sweden and Finland carried few tobacco industry friendly articles. Articles defending the tobacco industry appeared mainly in business papers. However, support of smokers' rights' groups and sponsoring of cultural events generated positive publicity for Philip Morris.

CONCLUSIONS

Despite minor transient victories The Philip Morris Nordic journalist program was largely unsuccessful in providing the anticipated media coverage to question the health hazards of environmental tobacco smoke (ETS) and in preventing ETS regulation in the Nordic countries. The study further supports the notion that the internal corporate documents may expose the intents of the industry, but do not include enough information to evaluate implementation of industry's strategies or their outcomes.

Tobacco interests or the public interest: 20 years of industry strategies to undermine airline smoking restrictions

OBJECTIVES

To understand the evolution of 20 years of tobacco industry strategies to undermine federal restrictions of smoking on aircraft in the United States.

DESIGN

We searched and analysed internal tobacco industry records, public documents, and other related research.

RESULTS

The industry viewed these restrictions as a serious threat to the social acceptability of smoking. Its initial efforts included covert letter-writing campaigns and lobbying of the airline industry, but with the emergence of proposals to ban smoking, the tobacco companies engaged in ever increasing efforts to forestall further restrictions. Tactics to dominate the public record became especially rigorous. The industry launched an aggressive public relations campaign that began with the promotion of industry sponsored petition drives and public opinion surveys. Results from polling research that produced findings contrary to the industry's position were suppressed. In order to demonstrate smoker outrage against a ban, later efforts included the sponsorship of smokers' rights and other front groups. Congressional allies and industry consultants sought to discredit the science underlying proposals to ban smoking and individual tobacco companies conducted their own cabin air quality research. Faced with the potential of a ban on all domestic flights, the industry sought to intimidate an air carrier and a prominent policymaker. Despite the intensification of tactics over time, including mobilisation of an army of lobbyists and Congressional allies, the tobacco industry was ultimately defeated.

CONCLUSIONS

Our longitudinal analysis provides insights into how and when the industry changed its plans and provides public health advocates with potential counterstrategies.

Tobacco industry documents from outside sources: new perspectives on industry strategies on local levels

The internal tobacco industry documents have also been used to study tobacco industry operations outside the United States. The scope of the documents on a country outside the US is decided mainly by the extent to which documents and reports were transmitted from the abroad offices of the US tobacco companies to headquarters. We explored whether the material from a private archive of a Finnish public relation consultant to Philip Morris will augment or revise the earlier reports on tobacco industry manipulation in Finland. The private records add more details to previously published reports. The new information mainly concerned implementation of the tobacco industry strategies. A general conclusion is that tobacco industry documents may not give a detailed picture of tobacco industry activities in distant markets, which would be of interest locally, even if they provide sufficient information to convey a general view of tobacco industry strategies.

The tobacco industry's role in the 16 Cities Study of secondhand tobacco smoke: do the data support the stated conclusions?

BACKGROUND

Since 1996, the tobacco industry has used the 16 Cities Study conclusions that workplace secondhand tobacco smoke (SHS) exposures are lower than home exposures to argue that workplace and other smoking restrictions are unnecessary.

OBJECTIVES

Our goal was to determine the origins and objectives of the 16 Cities Study through analysis of internal tobacco industry documents and regulatory agency and court records, and to evaluate the validity of the study's conclusions.

RESULTS

The tobacco industry's purpose in conducting the 16 Cities Study was to develop data showing that workplace SHS exposures were negligible, using these data to stop smoking restrictions by the U.S. Occupational Safety and Health Administration. The extensive involvement of R.J. Reynolds Tobacco Company and the tobacco industry's Center for Indoor Air Research in controlling the study was not fully disclosed. The study's definition of "smoking workplace" included workplaces where smoking was restricted to designated areas or where no smoking was observed. This definition substantially reduced the study's reported average SHS concentrations in "smoking workplaces" because SHS levels in unrestricted smoking workplaces are much greater than in workplaces with designated smoking areas or where no smoking occurred. Stratifying the data by home smoking status and comparing exposures by workplace smoking status, however, indicates that smoke-free workplaces would halve the total SHS exposure of those living with smokers and virtually eliminate SHS exposure for most others.

CONCLUSIONS

Data in the 16 Cities Study reveal that smoke-free workplaces would dramatically reduce total SHS exposure, providing significant worker and public health benefits.

Tobacco industry consumer research on socially acceptable cigarettes

OBJECTIVE

To describe tobacco industry consumer research to inform the development of more "socially acceptable" cigarette products since the 1970s.

METHODS

Analysis of previously secret tobacco industry documents.

RESULTS

28 projects to develop more socially acceptable cigarettes were identified from Philip Morris, RJ Reynolds, British American Tobacco, and Lorillard tobacco companies. Consumer research and concept testing consistently demonstrated that many smokers feel strong social pressure not to smoke, and this pressure increased with exposure to smoking restrictions. Tobacco companies attempted to develop more socially acceptable cigarettes with less visible sidestream smoke or less odour. When presented in theory, these product concepts were very attractive to important segments of the smoking population. However, almost every product developed was unacceptable in actual product tests or test markets. Smokers reported the complete elimination of secondhand smoke was necessary to satisfy non-smokers. Smokers have also been generally unwilling to sacrifice their own smoking satisfaction for the benefit of others. Many smokers prefer smoke-free environments to cigarettes that produce less secondhand smoke.

CONCLUSIONS

Concerns about secondhand smoke and clean indoor air policies have a powerful effect on the social acceptability of smoking. Historically, the tobacco industry has been unable to counter these effects by developing more socially acceptable cigarettes. These data suggest that educating smokers about the health dangers of secondhand smoke and promoting clean indoor air policies has been difficult for the tobacco industry to counter with new products, and that every effort should be made to pursue these strategies.

From strange bedfellows to natural allies: the shifting allegiance of fire service organisations in the push for federal fire-safe cigarette legislation

BACKGROUND

Cigarettes are the leading cause of fatal fires in the USA and are associated with one in four fire deaths. Although the technology needed to make fire-safe cigarettes has been available for many years, progress has been slow on legislative and regulatory fronts to require the tobacco industry to manufacture fire-safe cigarettes.

METHOD AND RESULTS

We conducted a case study, drawing on data from tobacco industry documents, archives, and key informant interviews to investigate tobacco industry strategies for thwarting fire-safe cigarette legislation in the US Congress. We apply a theoretical framework that posits that policymaking is the product of three sets of forces: interests, institutions, and ideas, to examine tobacco industry behaviour, with a special focus on their and others' attempts to court fire service organisations, including firefighters' unions as allies. We discuss the implications of our findings for future policy efforts related to fire-safe cigarettes and other tobacco control issues.

CONCLUSIONS

Tobacco control advocates ought to: continue efforts to align key interest groups, including the firefighters unions; contest tobacco industry "diversionary" science tactics; and pursue a state based legislative strategy for fire-safe cigarettes, building towards national legislation.

Philip Morris toxicological experiments with fresh sidestream smoke: more toxic than mainstream smoke

BACKGROUND

Exposure to secondhand smoke causes lung cancer; however, there are little data in the open literature on the in vivo toxicology of fresh sidestream cigarette smoke to guide the debate about smoke-free workplaces and public places.

OBJECTIVE

To investigate the unpublished in vivo research on sidestream cigarette smoke done by Philip Morris Tobacco Company during the 1980s at its Institut für Biologische Forschung (INBIFO).

METHODS

Analysis of internal tobacco industry documents now available at the University of California San Francisco Legacy Tobacco Documents Library and other websites.

RESULTS

Inhaled fresh sidestream cigarette smoke is approximately four times more toxic per gram total particulate matter (TPM) than mainstream cigarette smoke. Sidestream condensate is approximately three times more toxic per gram and two to six times more tumourigenic per gram than mainstream condensate by dermal application. The gas/vapour phase of sidestream smoke is responsible for most of the sensory irritation and respiratory tract epithelium damage. Fresh sidestream smoke inhibits normal weight gain in developing animals. In a 21 day exposure, fresh sidestream smoke can cause damage to the respiratory epithelium at concentrations of 2 microg/l TPM. Damage to the respiratory epithelium increases with longer exposures. The toxicity of whole sidestream smoke is higher than the sum of the toxicities of its major constituents.

CONCLUSION

Fresh sidestream smoke at concentrations commonly encountered indoors is well above a 2 microg/m3 reference concentration (the level at which acute effects are unlikely to occur), calculated from the results of the INBIFO studies, that defines acute toxicity to humans. Smoke-free public places and workplaces are the only practical way to protect the public health from the toxins in sidestream smoke.

Aircraft Cabin Air Quality Trends Relative to Ground Level Standards

Aircraft cabin air quality has attracted much attention, summarized recently by a detailed examination and commentary by a U.S. National Academy of Sciences Committee. Ventilation of aircraft has several significant variables that require control measures that are seldom of concern for occupied space at ground level. The principal of these special requirements are the need to compensate for the substantial difference between cabin and outside pressures, the much lower available space per occupant in aircraft cabins, and the need for coping with more extreme external temperatures than are common at ground level. The breadth of these concerns is of interest in the policies and regulatory aspects of a number of agencies which are briefly described, and their roles and areas of potential interest outlined. Types of possible contaminants are listed, and the limits which have been set by several of these agencies for many of these potential contaminants are tabulated. In addition recent measured aircraft cabin concentrations of several key contaminants are listed. This chapter provides an overview of the general air quality variables affecting enclosed space to enable these to be related to the special needs of some of the less common enclosed spaces described in the following chapters.

The tobacco industry's worldwide ETS consultants project: European and Asian components

BACKGROUND

The tobacco industry has formed regional environmental tobacco smoke (ETS) consultants programs in order to generate controversy on the issue of secondhand smoke (SHS) in Europe, Asia and Latin America. Only those countries in which the industry foresaw SHS restrictions were included. This paper describes the European and Asian components of the tobacco industry's worldwide ETS consultants program.

METHODS

A systematic search was carried out of tobacco industry documents available on the Internet between October 2002 and February 2004.

RESULTS

Beginning in 1987, Philip Morris assembled an international ETS consultants program in collaboration with other tobacco companies based on their market shares in different regions of the world. The law firm Covington & Burling contacted and hired consultants with a wide range of expertise, usually affiliated with an academic institution, in order to avoid direct contact with the industry. The objective of the program was to influence policy makers, media and the public by providing, through their consultants, 'accurate' (pro-industry) information concerning smoking regulations in public places and workplaces, indoor air quality and ventilation standards, and scientific claims regarding SHS. Consultants also conducted research related to SHS and organized and attended regional and international symposiums related to SHS without acknowledging industry funding.

CONCLUSIONS

Despite evidence that the issue of smoke-free environments was close to emerging within the general public throughout the world in the late 1980s, the tobacco industry used its well-organized network of consultants to avoid SHS regulations in most of the world.

Changing conclusions on secondhand smoke in a sudden infant death syndrome review funded by the tobacco industry

BACKGROUND

Prenatal and postnatal exposure to tobacco smoke adversely affects maternal and child health. Secondhand smoke (SHS) has been linked causally with sudden infant death syndrome (SIDS) in major health reports. In 1992, the US Environmental Protection Agency (EPA) first noted an association between SHS and SIDS, and both prenatal exposure and postnatal SHS exposure were listed as independent risk factors for SIDS in a 1997 California EPA report (republished in 1999 by the National Cancer Institute) and a 2004 US Surgeon General report. The tobacco industry has used scientific consultants to attack the evidence that SHS causes disease, most often lung cancer. Little is known about the industry's strategies to contest the evidence on maternal and child health. In 2001, a review was published on SIDS that acknowledged funding from the Philip Morris (PM) tobacco company. Tobacco industry documents related to this review were examined to identify the company's influence on the content and conclusions of this review.

METHODS

Tobacco industry documents include 40 million pages of internal memos and reports made available to the public as a result of litigation settlements against the tobacco industry in the United States. Between November 2003 and January 2004, we searched tobacco industry document Internet sites from the University of California Legacy Tobacco Documents Library and the Tobacco Documents Online website. Key terms included "SIDS" and names of key persons. Two authors conducted independent searches with similar key terms, reviewed the documents, and agreed on relevancy through consensus. Thirty documents were identified as relevant. Two drafts (an early version and a final version) of an industry-funded review article on SIDS were identified, and 2 authors independently compared these drafts with the final publication. Formal comments by PM executives made in response to the first draft were also reviewed. We used Science Citation Index in July 2004 to determine citation patterns for the referenced SIDS reviews.

RESULTS

PM executives feared that SHS and maternal and child health issues would create a powerful and emotional impetus for smoke-free areas in the home, public areas, and the workplace. In response to the 1992 US EPA report on SHS, the Science and Technology Department of PM's Switzerland subsidiary, Fabriques de Tabac Reunies, searched for "independent" consultants to publish articles addressing SHS. The first industry-funded article was a literature review focusing on smoking and SIDS, conducted by consultant Peter Lee and co-author Allison Thornton, which stated that the association between parental smoking and SIDS could have been attributable to the failure to control fully for confounders. That first review has only been cited once, in the subsequent industry-funded review. In 1997, PM commissioned a consultant, Frank Sullivan, to write a review, with coauthor Susan Barlow, of all possible risk factors for SIDS. The first draft concluded that prenatal and postnatal smoking exposures are both independent risk factors for SIDS. After receiving comments and meeting with PM scientific executives, Sullivan changed his original conclusions on smoking and SIDS. The final draft was changed to emphasize the effects of prenatal maternal smoking and to conclude that postnatal SHS effects were "less well established." Changes in the draft to support this new conclusion included descriptions of Peter Lee's industry-funded review, a 1999 negative but underpowered study of SIDS risk and urinary cotinine levels, and criticisms of the conclusions of the National Cancer Institute report that SHS was causally associated with SIDS. In April 2001, the Sullivan review was published in the United Kingdom journal Paediatric and Perinatal Epidemiology, with a disclosure statement that acknowledged financial support from PM but did not acknowledge contributions from PM executives in the preparation of the review. By 2004, the Sullivan SIDS review had been cited at least 19 times in the medical literature.

CONCLUSIONS

PM executives responded to corporate concerns about the possible adverse effects of SHS on maternal and child health by commissioning consultants to write review articles for publication in the medical literature. PM executives successfully encouraged one author to change his original conclusion that SHS is an independent risk factor for SIDS to state that the role of SHS is "less well established." These statements are consistent with PM's corporate position that active smoking causes disease but only public health officials conclude the same for SHS. The author's disclosure of industry funding did not reveal the full extent of PM's involvement in shaping the content of the article. This analysis suggests that accepting tobacco industry funds can disrupt the integrity of the scientific process. The background of this SIDS review is relevant for institutions engaged in the debate about accepting or eschewing funding from the tobacco industry. Those who support acceptance of tobacco industry funds argue that academic authors retain the right to publish their work and maintain final approval of the written product, but this argument fails to recognize that the tobacco industry funds work to ensure that messages favorable to the industry are published and disseminated. Clinicians, parents, and public health officials are most vulnerable to the changed conclusions of the SIDS review. The national SIDS "Back to Sleep" campaign has been very successful in reducing SIDS rates. However, estimates of SIDS risk from SHS (odds ratios range from 1.4 to 5.1) have considerable overlap with estimates of risk from prone sleep positioning (odds ratios range from 1.7 to 12.9). With the Back to Sleep campaign well underway, efforts to address parental smoking behavior in both the prenatal and postnatal periods should be intensified. The tobacco industry's disinformation campaign on SHS and maternal and child health can be counteracted within clinicians' offices.

Smoke-free airlines and the role of organized labor: a case study

Labor unions play an important role in debates about smoke-free worksites. We investigated the role of flight attendants and their unions in creating smoke-free air travel. We used case study methodology to search tobacco industry documents and labor union periodicals and to interview key informants (i.e., people identified as having first-hand information and experience in the campaign to make airlines smoke free). We then compared findings across these data sources. Tobacco industry strategies against the establishment of smoke-free worksites failed in the case of airlines, largely because of the efforts of flight attendants and their unions. Other factors contributed to the failure but likely would have been insufficient to derail industry efforts without strong stands by the flight attendants. This case illustrates the potential for successful partnerships between unions and tobacco control policy advocates when developing smoke-free worksite policies.

Clearing the airways: advocacy and regulation for smoke-free airlines

OBJECTIVE

To examine the advocacy and regulatory history surrounding bans on smoking in commercial airliners.

METHODS

Review of historical documents, popular press articles, and other sources to trace the timeline of events leading up to the US ban on smoking in airliners and subsequent efforts by airlines and other nations.

RESULTS

In early years, efforts by flight attendants and health advocates to make commercial airliners smoke-free were not productive. Advocacy efforts between 1969 and 1984 resulted in maintenance of the status quo, with modest exceptions (creation of smoking and non-smoking sections of aircraft, and a ban on cigar and pipe smoking). Several breakthrough events in the mid 1980s, however, led to an abrupt turnaround in regulatory efforts. The first watershed event was the publication in 1986 of the National Academy of Science's report on the airliner cabin environment, which recommended banning smoking on all commercial flights. Subsequently, following concerted lobbying efforts by health advocates, Congress passed legislation banning smoking on US domestic flights of less than two hours, which became effective in 1988. The law was made permanent and extended to flights of less than six hours in 1990. This landmark legislation propelled the adoption of similar rules internationally, both by airlines and their industry's governing bodies. Though the tobacco industry succeeded in stalling efforts to create smoke-free airways, it was ultimately unable to muster sufficient grassroots support or scientific evidence to convince the general public or policymakers that smoking should continue to be allowed on airlines.

CONCLUSIONS

The movement to ban smoking in aircraft represents a case study in effective advocacy for smoke-free workplaces. Health advocates, with crucial assistance from flight attendants, used an incremental advocacy process to push for smoking and non-smoking sections on US commercial flights, then for smoking bans on short domestic flights, and finally for completely smoke-free domestic and international flights. Through the course of the battle, advocates from all quarters of tobacco control presented a unified message, exhibited remarkable focus on an attainable goal, and effectively leveraged their relationships with champions in both government and the private sector.

Tobacco industry efforts to present ventilation as an alternative to smoke-free environments in North America

OBJECTIVE

To describe how the tobacco industry developed a network of consultants to promote ventilation as a "solution" to secondhand smoke (SHS) in the USA.

METHODS

Analysis of previously secret tobacco industry documents.

RESULTS

As with its other strategies to undermine the passage of clean indoor legislation and regulations, the tobacco industry used consultants who represented themselves as independent but who were promoting the industry's ventilation "solution" strategies under close, but generally undisclosed, industry supervision. The nature of the industry's use of ventilation consultants evolved over time. In the 1980s, the industry used them in an effort to steer the concerns about indoor air quality away from secondhand smoke, saying SHS was an insignificant component of a much larger problem of indoor air quality and inadequate ventilation. By the 1990s, the industry and its consultants were maintaining that adequate ventilation could easily accommodate "moderate smoking". The consultants carried the ventilation message to businesses, particularly the hospitality business, and to local and national and international regulatory and legislative bodies.

CONCLUSION

While the tobacco industry and its consultants have gone to considerable lengths to promote the tobacco industry's ventilation "solution", this strategy has had limited success in the USA, probably because, in the end, it is simpler, cheaper, and healthier to end smoking. Tobacco control advocates need to continue to educate policymakers about this fact, particularly in regions where this strategy has been more effective.