Invisible smoke: third-party endorsement and the resurrection of heat-not-burn tobacco products

Pharmaceuticalisation as the tobacco industry's endgame

CONTEXT

Declining smoking prevalence and denormalisation of tobacco in developed countries reduced transnational tobacco company (TTC) profit during 1990s and 2000s. As these companies faced increasingly restrictive policies and lawsuits, they planned to shift their business to socially acceptable reduced-harm products. We describe the internal motivations and strategies to achieve this goal.

METHODS

We analysed previously secret tobacco industry documents available through the Truth Tobacco Documents Library. These documents were triangulated with TTCs' investor and other professional reports, websites and public statements.

FINDINGS

Mimicking pharmaceutical business models, tobacco companies sought to refurbish their image and ensure long-term profitability by creating and selling pharmaceutical-like products as smoking declined. These products included snus, heated tobacco products, e-cigarettes, nicotine gums and inhalers. Tobacco companies created separate divisions to develop and roll out these products, and the majority developed medical research programmes to steer these products through regulatory agencies, seeking certification as reduced-harm or pharmaceutical products. These products were regarded as key to the survival of the tobacco industry in an unfriendly political and social climate.

CONCLUSIONS

Pharmaceuticalisation was pursued to perpetuate the profitability of tobacco and nicotine for tobacco companies, not as a sincere search to mitigate the harms of smoking in society. Promotion of new pharmaceuticalised products has split the tobacco control community, with some public health professionals and institutions advocating for the use of 'clean' reduced-harm nicotine and tobacco products, essentially carrying out tobacco industry objectives.

Tobacco industry messaging around harm: Narrative framing in PMI and BAT press releases and annual reports 2011 to 2021

Influencing public perception is a key way in which all transnational corporations (TNCs) maintain market dominance and political power. Transnational tobacco companies (TTCs) have a long history of leveraging narratives to serve commercial ambitions. The global reach of these companies' narratives has been highlighted as a challenge in combatting public health problems caused by tobacco. The corporate power of TTCs is carefully curated, and their narratives play an important role in the setting of governance dynamics at local, national and transnational levels. This qualitative work explores and compares the language used by British American Tobacco (BAT) and Philip Morris International (PMI) around harm, harm reduction and terms used to refer to newer nicotine and tobacco products, including electronic cigarettes and heated tobacco products. We systematically examine framings used by these two TTCs through company reports published between 2011 and 2021. Qualitative coding was carried out by four coders, according to a protocol developed specifically for this work. We firstly identified the presence of pre-selected keywords and then assigned chunks of text containing those key words to one or more associated frames drawn from Boydstun's policy frames codebook (2013). Qualitative coding identified the most common frames from Boydstun's codebook and thematic analysis highlighted three overarching themes. The most common frames assigned were "capacity and resources", "health and safety" and "economic" frames. The overarching themes were individualization, normalization, and regulation. These themes capture how both BAT and PMI use particular framings to downplay the role of TTCs in the perpetuation of population- and individual-level harms related to tobacco use. They seek to normalize their role in public discussions of health policy, to cast themselves as instrumental in the redress of tobacco-related inequalities and shift responsibility for the continuation of tobacco-product use onto individual consumers. These tactics are problematic for the effective and impartial development and implementation of local, national and international tobacco control agendas.

Electronic Cigarette Use and the Risk of Cardiovascular Diseases

Electronic cigarettes or e-cigarettes are the most frequently used tobacco product among adolescents. Despite the widespread use of e-cigarettes and the known detrimental cardiac consequences of nicotine, the effects of e-cigarettes on the cardiovascular system are not well-known. Several in vitro and in vivo studies delineating the mechanisms of the impact of e-cigarettes on the cardiovascular system have been published. These include mechanisms associated with nicotine or other components of the aerosol or thermal degradation products of e-cigarettes. The increased hyperlipidemia, sympathetic dominance, endothelial dysfunction, DNA damage, and macrophage activation are prominent effects of e-cigarettes. Additionally, oxidative stress and inflammation are unifying mechanisms at many levels of the cardiovascular impairment induced by e-cigarette exposure. This review outlines the contribution of e-cigarettes in the development of cardiovascular diseases and their molecular underpinnings.

Characterizing heated tobacco product use among adult cigarette smokers and nicotine vaping product users in the 2018 ITC Four Country Smoking & Vaping Survey

INTRODUCTION

Heated tobacco products (HTP) have diversified global tobacco markets, and user characteristics remain understudied. This study evaluated sociodemographic characteristics, nicotine-related perceptions and behaviors of current HTP users within a sample of adult (18+ years) nicotine users across four countries.

METHODS

Data were from current smokers or nicotine vaping product (NVP; known as "e-cigarettes") users from Canada, England, the United States and Australia (n=11,421) who participated in the 2018 ITC Four Country Smoking and Vaping Survey. Current (at-least-monthly) HTP users were characterized (n=441), and weighted multivariable logistic regressions examined correlates of HTP use.

RESULTS

Compared to non-users, current HTP users were younger (mean age: 44.4 vs 31.0 years; p<0.001) and had higher socioeconomic status (p<0.001). A majority of current HTP users used HTPs non-daily (daily: 40.3% vs non-daily: 59.7%). Most HTP users concurrently used both cigarettes and NVPs (90.5%). Among concurrent cigarette-HTP-NVP users, 36.2% used all three products daily. Use of other combusted tobacco products (cigars, cigarillos, pipe, waterpipe/hookah), cannabis, and binge drinking were each associated with current HTP use. HTP use was more common among smokers intending to quit within 6 months or reporting a quit attempt in the past 18 months, and vapers who had experienced negative side effects.

CONCLUSION

HTP users in this sample tended to be younger and more affluent. Most reported concurrent use of multiple nicotine products and other substances. Those cigarette smokers who used HTPs appeared more interested in smoking cessation, while some characteristics of concurrent HTP-NVP users were suggestive of dissatisfaction with NVPs.

IMPLICATIONS

Few studies have scrutinized characteristics of HTP early-adopters in emerging markets. Our results indicate that in 2018, characteristics of established nicotine users who adopted HTP use in four high-income Western countries mirror those of HTP users in East Asian markets (South Korea and Japan) where HTPs are popular. HTP users reported high levels of concurrent use of non-cigarette combusted tobacco products (e.g., cigars, pipe tobacco). These findings point to the need for future longitudinal studies of HTP use given the implications of those use patterns on the harm reduction potential of HTPs. HTP user characteristics may yield important information to consider in regulation of these products.

Review of data on chemical content in an aerosol resulting from heating a tobacco or a solution used in e-cigarettes and in the smoke generated from the reference cigarettes

BACKGROUND

The article presents a review of the literature on the chemical composition of smoke generated from a standard cigarette and the aerosol generated after heating tobacco and chemical compounds formed in the aerosol of electronic cigarettes.

METHODS

The literature review was carried out on the PubMed online bibliographic database, Google search engine, Google Scholar based on science articles published in recent 20 years.

RESULTS

The bibliographic analysis shows that: replacing smoking in the traditional way by heating tobacco modifies significantly the content of chemical substances found in aerosol, the substances found in aerosols generated by e-cigarettes have proven toxic effects, e.g. pro-inflammatory effect on lung epithelial cells (e.g. crotonaldehyde) or a mutagenic effect (e.g. NNK), using e-cigarette aerosol does not rule out a health risk for people, which is not fully recognized at present.

CONCLUSIONS

Replacing smoking in the traditional way by heating tobacco modifies significantly the content of chemical substances found in aerosol. Using e-cigarette aerosol does not rule out a health risk for people, because the substances found in aerosols generated by e-cigarettes have proven toxic effects.

Association between Intention to Quit Cigarette Smoking and Use of Heated Tobacco Products: Application of Smoking Intensity Perspective on Heated Tobacco Product Users

Tobacco companies have designed sophisticated marketing strategies for heated tobacco products (HTPs), and many smokers are exposed to advertisements purporting that HTPs can replace combustible cigarettes. The present study evaluates the relationship between poly-use of tobacco products and intention to quit cigarette smoking in association with smoking intensity, a meaningful indication of one's interest in quitting cigarette smoking. A total of 36,397 current cigarette smokers who participated in the 2019 Korea Community Health Survey were evaluated. A multivariable logistic regression model was designed. Additionally, smoking-intensity-stratified analyses were conducted. A total of 4.7% of the participants reported planning to quit cigarette smoking within one month. Current dual users of combustible cigarettes and HTPs presented no significantly increased likelihood of intention to quit cigarette smoking regardless of cigarette-smoking intensity. By contrast, light and heavy daily smokers who accompanied e-cigarette use presented significant adjusted odds ratios (aORs) of 1.81 (95% confidence interval (CI): 1.04-3.14) and 1.97 (95% CI: 1.14-3.42), respectively. Occasional and daily smokers who reported using both HTPs and e-cigarettes presented no significance. The results of the present study suggested that a complete replacement of combustible cigarettes with HTPs was unlikely.

Electronic cigarette

Despite significant efforts during the last decades, cigarette smoking still remains prevalent. Discouraging the use of all tobacco products, it is certainly the most effective mean to enhance public health, but complete prohibition is unlikely to succeed. The greatest challenge is the approach to chronic smokers, particularly those affected with cardiovascular conditions. To better support these patients during the difficult process leading to complete smoke cessation, it is important to characterize each patient from a clinical and psychological perspective, introducing the most reliable approaches to incentivize and support abstinence, such as varenicline and nicotine replacement therapy, thus providing a personalized recommendation. The recent introduction of electronic systems for nicotine release or tobacco heating (electronic cigarettes), offers an important challenge. These devices are reasonably considered as lower risk tools, thus providing a useful alternative which unable the patient a smoother transition toward smoking cessation, also presenting an array of choices among which a personalized selection could be made. This technology, though, should not be overemphasized, considering also its potential harmful effects, and certainly its use should be strongly discouraged in non-smokers, particularly at young age. This approach, cautious and pragmatic, aside from demonization or over-enthusiastic appraisal, could provide favourable results in the constant struggle against cigarette smoking.

Free-Base Nicotine Is Nearly Absent in Aerosol from IQOS Heat-Not-Burn Devices, As Determined by 1H NMR Spectroscopy

Heat-not-burn products, eg, I quit ordinary smoking (IQOS), are becoming popular alternative tobacco products. The nicotine aerosol protonation state has addiction implications due to differences in absorption kinetics and harshness. Nicotine free-base fraction (α_fb) ranges from 0 to 1. Herein, we report α_fb for IQOS aerosols by exchange-averaged ¹H NMR chemical shifts of the nicotine methyl protons in bulk aerosol and verified by headspace-solid phase microextraction-gas chromatography-mass spectrometry. The α_fb ≈ 0 for products tested; likely a result of proton transfer from acetic acid and/or other additives in the largely aqueous aerosol. Others reported higher α_fb for these products, however, their methods were subject to error due to solvent perturbation.

The E-Cigarette Debate: What Counts as Evidence?

Two major public health evaluations of e-cigarettes-one from the National Academies of Science, Engineering, and Medicine (NASEM), the other from Public Health England (PHE)-were issued back to back in the winter of 2018. While some have read these analyses as broadly consistent, providing support for the view that e-cigarettes could play a role in smoking harm reduction, in every major respect, they come to very different conclusions about what the evidence suggests in terms of public health policy. How is that possible? The explanation rests in what the 2 reports see as the central challenge posed by e-cigarettes, which helped to determine what counted as evidence. For NASEM, the core question was how to protect nonsmokers from the potential risks of exposure to nicotine and other contaminants or from the risk of smoking combustible cigarettes through renormalization. A precautionary standard was imperative, making evidence that could speak most conclusively to the question of causality paramount. For PHE, the priority was how to reduce the burdens now borne by current smokers, burdens reflected in measurable patterns of morbidity and mortality. With a focus on immediate harms, PHE turned to evidence that was "relevant and meaningful." Thus, competing priorities determined what counted as evidence when it came to the impact of e-cigarettes on current smokers, nonsmoking bystanders, and children and adolescents. A new clinical trial demonstrating the efficacy of e-cigarettes as a cessation tool makes understanding how values and framing shape core questions and conclusive evidence imperative.

Imitating waterpipe: Another tobacco industry attempt to create a cigarette that seems safer

INTRODUCTION

The use of waterpipe (also known as hookah) increased between 2011 and 2016 in the US and globally, especially among youth and young adults. The aim of this study is to examine the tobacco industry's interest, involvement and role in proliferating waterpipe-like products and its technology.

METHODS

We searched the University of California San Francisco Truth Tobacco Industry Documents beginning with the search terms "hookah', 'waterpipe', 'narghile', 'shisha', 'hooka', 'e-hookah', 'electronic hookah', 'water filtration', and 'hubble-bubble' and then expanded the search using snowball sampling. Over 1500 documents were reviewed, and 39 were included in this analysis.

RESULTS

This review focuses on several companies' addition of water to the filter of one cigarette holder and to two cigarettes in an attempt to make these products seem safer. In 1954, the Aquafilter Corporation created and patented a filtered cigarette holder named Aquafilter, which the documents reveal was closely monitored by multiple tobacco companies. In 1965, the American Tobacco Company developed the Waterford cigarette. In 1987, Japan Tobacco patented the Rivage cigarette. Waterford and Rivage were very similar products that contained crushable water capsules designed to "wet" the cigarettes' filter.

CONCLUSION

Companies have been attempting to incorporate the water filtrating aspect of waterpipe into cigarette products. Ultimately, several tobacco companies adapted the technology from these devices to create cigarettes with crushable flavor capsules. Given the tobacco industry's history of resurrecting products, the industry may attempt to incorporate water filtration and other aspects of waterpipe into future products to attempt to make them appear safer.

Heated tobacco products: another tobacco industry global strategy to slow progress in tobacco control

There has been a global decline in tobacco consumption that, if continued, will negatively impact the tobacco industry's profits. This decline led the industry to invent and market new products, including heated tobacco products (HTP). HTP are an extension of the industry's strategies to undermine government's tobacco regulatory efforts as they are being promoted as part of the solution for the tobacco epidemic. Under the moniker of 'harm reduction', the tobacco companies are attempting to rehabilitate their reputation so they can more effectively influence governments to roll back existing tobacco control policies or create exemptions for their HTP. Rolling back tobacco control policies will make it easier for the companies to renormalise tobacco use to increase social acceptability for all their products. When regulations are absent or when loopholes exist in classifying HTP as a tobacco product (thus subject to all tobacco control regulations), the industry's marketing of HTP is making these products more visible to the public and more accessible. Governments need to ensure that HTP are regulated as tobacco products or drugs and reject partnerships with the tobacco companies to promote 'harm reduction'. The tobacco companies remain the vector of the tobacco-caused epidemic and cannot be part of the global tobacco control solution.

Revolution or redux? Assessing IQOS through a precursor product

Background

Philip Morris International (PMI) currently claims that its heated tobacco product, IQOS, reduces health risk by reducing users’ exposure to harmful and potentially harmful constituents present in tobacco smoke. Given the tobacco industry’s long history of misrepresenting and obfuscating research, independent assessment of PMI’s claims is important. Analysis of Accord, a failed but strikingly similar precursor to IQOS, may help contextualise PMI’s claims in its Modified Risk Tobacco Product (MRTP) application.

Methods

We analysed previously secret internal Philip Morris (PM) and PMI documents, public communications and MRTP application.

Results

PM marketed Accord as a ‘cleaner’ tobacco product in an attempt to address smokers’ growing health concerns without making explicit health claims. While PM communications asserted that Accord reduced users’ exposure to harmful constituents, company scientists and executives consistently stressed to both regulators and the public that such reductions did not render Accord safer. IQOS’s design and marketing are similar to Accord’s. On the basis of aerosol chemistry data, IQOS reduces user exposure to some compounds compared with Accord but raises them for others.

Discussion

IQOS appears to be a variant of Accord without consistent improvements in exposure to aerosol toxic compounds. In contrast to PM’s past claims for Accord, PMI now claims in its MRTP application that IQOS reduces health risk. This shift in stance is likely not the result of any toxicological difference between Accord and IQOS, but rather a change in the social and regulatory landscape permitting these claims.

Electronic cigarettes: the solution or yet another phase of the tobacco epidemic?

Tobacco use is the single largest preventable cause of death globally. For years, the tobacco industry sought to create a tobacco product that is less controversial than conventional cigarettes. Electronic cigarettes were created out of the supposed need to supply consumers of tobacco products with a less harmful tobacco product. The question remains, is it really less harmful for consumers of traditional cigarettes and other tobacco products to switch to electronic cigarettes? This article takes a closer look at the overall harm in relation to benefits of using electronic cigarettes for the individual and public health and the unintended negative consequences the introduction of electronic cigarette has had on overall public health. Given the evidence that the use of electronic cigarettes is a gateway to the use of other tobacco products especially among adolescents, we view electronic cigarettes as having the potential to cause a rebound of the tobacco use glut which the global public health community has been succeeding in reversing. We therefore support the World Health Organization’s suggestion that electronic cigarettes should be regulated as other tobacco products since there is, as yet, no harmless tobacco product. In the same vein, we view the new Tobacco Products and Electronic Delivery Systems Bill seeking to regulate electronic cigarettes in South Africa as other tobacco products as a step in the right direction.