Tobacco control and the ERS: new problems and old foes

E-cigarettes and heated tobacco products

The tobacco industry's strategy to sell novel electronic nicotine delivery devices (E-cigarettes and E-nicotine delivery systems (ENDS)) is a commercial secret. But their plans can, in part, be discerned from Philip Morris's publication “Unsmoke your mind, pragmatic answers to tough questions for a smoke-free future” [1]. First, their corporate position of “if you don't quit, change” and that “there are solid commercial reasons for unsmoking the world” suggests that they see ENDS profits replacing the decline in global sales and profits from their primary cigarette product. Second, the report's statement that “regulations should reflect these products’ relative levels of risk”, suggests that industry will lobby governments to introduce much lower taxes for ENDS compared with conventional cigarettes. Remarkably, Philip Morris claims in the report that the “tobacco industry is uniquely positioned to help address the global public health problem of smoking”.

Set against the plans from an industry well versed in the dark arts of obfuscation and deceit, the divergence in views about ENDS within the public health community weakens this community's ability to protect health. The ERS's view, in line with other organisations, such as the World Health Organization and the American Academy of Paediatrics, is that there is no evidence to recommend the use of E-cigarettes and heated tobacco products for smoking cessation [2, 3]. The other end of the spectrum of opinions, exemplified by a letter to the European Respiratory Journal by UK-based anti-smoking advocates, is that the ERS should “reconsider its position” so that “we can focus on our shared goal to make smoking history” [4]. In response to this letter, Pisinger and Vestbo [5] gave seven reasons why the ERS TCC considered the harm reduction argument advocated by the letter's authors to be flawed. The decision of the US Food and Drug Administration (FDA) in July 2020 to authorise Philip Morris S.A.'s IQOS (I Quit Ordinary Smoking) heated tobacco product as a “modified risk tobacco product” (MRTP) is an unwelcome contribution to this debate. The confusingly titled MRTP criteria actually consist of two separate FDA standards: risk modification and exposure modification. The FDA did not approve risk modification status for IQOS, stating that Phillip Morris did not demonstrate that IQOS significantly reduces harm and risk of tobacco-related disease, and granted only the lower exposure modification status [6, 7]. Although the FDA did not conclude that IQOS was safe and reduced the risk of disease [7], this ambiguous decision risks being both exploited by the tobacco industry and misinterpreted by the public [6]. Indeed, health benefits of IQOS are claimed by Phillip Morris. For example, the chat function of the UK IQOS website when asked whether IQOS is “much better for my heath than cigarettes?” replied “that is correct :-)” (sic). Furthermore, a heated tobacco product has been marketed in Germany as “better” (figure 1), which begs the question: better for whom?

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FIGURE 1

Advertisement for a heated tobacco product in Berlin.

Despite the apparent lack of common ground between advocates of using novel ENDS for harm reduction, and the numerous medical societies that do not recommend ENDS, both sides of the academic spectrum should agree on the need for more independent research and will hopefully find some common ground when interpreting new studies. For example, the UK National Institute for Health Research recently funded a large trial into the effectiveness of E-cigarettes as an aid to smoking cessation in comparison with varenicline, and the effect of vaping on lung health in patients with COPD [8]. Since the toxicity of the complex mix of chemicals and metals [9] in E-cigarette vapour is unknown, and a wide range of adverse effects of E-cigarette vapour are reported in airway cells in vitro [10, 11], it must be assumed, until proved otherwise, that prolonged exposure is associated with significant pulmonary toxicity. New data on ENDS will therefore need to achieve a very high bar. Specifically, by demonstrating that prolonged ENDS use does not occur, and that youth uptake is not increased.

Preventing uptake of cigarettes

A continuing aim of the TCC will be to stop young people taking up smoking. Progress has been made across Europe in controlling access to the advertising of tobacco products for young people, and it is welcome news that new legislation was recently passed by the German Federal Government that finally banned outdoor advertising of tobacco products. However, even this welcome news is tempered by delay in implementation. While the ban on advertising on outdoor areas such as billboards or bus stops for conventional tobacco products will be from 2021, the outdoor advertising ban for heated tobacco products will only be from 2023, and it will take one further year for outdoor advertising of E-cigarettes to be banned. There remains a need to advocate for stricter laws on cigarette packaging and protecting children and young people from seeing cigarette displays cigarettes in shops. Increasing the cost of cigarettes also discourages their uptake and encourages quitting. The TCC will therefore have to counteract tobacco industry lobbying in order to bring the EU Commission's tobacco tax proposals to fruition. In February 2020, the Commission published an evaluation of the current directive which concluded that there is a need to have a more comprehensive and holistic approach, taking on board all aspects of tobacco control, including public health, taxation, the fight against illicit trade and environmental concerns. The need of tobacco taxation to map to the EU agenda to fight against cancer was also emphasised. In response, the European Council has asked the European Commission to present new legislative proposals, and the Commission confirmed that they will launch a proposal. However, since any Council Directive on tax requires agreement from all member states, a single country influenced by tobacco industry lobbying can disrupt this process. As described above, one lobbying strategy signposted by the Phillip Morris report is to conflate reduction of emissions with improved health benefits, and thus argue that IQOS and other devices should be exempt.

As the ERS is a global society, the TCC must also call the tobacco industry to account by its global actions. In Indonesia for example, the lead producer of cigarettes HM Sampoerna, is 92% owned by Philip Morris International. The tobacco industry exploits lax rules in Indonesia, by substantially influencing policy decisions and public perceptions [12]. The Southeast Asia Tobacco Control Alliance in 2018 described the Indonesian market as a “Disneyland for the tobacco industry.” Since Indonsesia has not signed and ratified the World Health Organization's Framework Convention of Tobacco Control, individual cigarettes are sold as cheaply as 7 US cents each, and there are no penalties imposed for retailers breaking the law and selling these to young people [13]. Furthermore, HM Sampoerna advertises its name to children via the “Sampoerna School System”, which distributes scholarships, supports schools and trains teachers and principals. To develop this global view on tobacco industry, the TCC will need to develop links with a wide range of organisations, including those in low- and middle-income countries.

Learning from the pandemic

After months of the coronavirus disease 2019 (COVID-19) pandemic it is time to review its effect on smokers and tobacco control. Questions to be answered include: what was the effect of the South African ban on the sale of cigarettes during the lockdown? And, did being away from office co-workers along with increased awareness of respiratory disease encourage smokers, especially social smokers, to quit? Certainly, the tobacco industry demonstrated a self-serving response to COVID-19. For example, British American Tobacco (BAT) linked its name with improved public health when its Chief Marketing Officer announced that its US subsidiary was developing a SARS-CoV-2 vaccine, and its Director of Scientific Research linked this vaccine to “tobacco technology” [14], while at the same time tried to protect cigarette sales by contesting the cigarette sale ban in South Africa: a ban specifically aimed at protecting the public from more severe disease [15]. High-quality evidence on smoking and susceptibility to COVID-19 disease is therefore highly relevant to policy makers charged with making decisions to protect public health. Although there was initial speculation from non-peer reviewed preprints that smoking and/or nicotine “protected” against COVID-19, this has not been supported by the peer reviewed literature. Indeed, a review of studies by the World Health Organization in April 2020 found that the available evidence suggests that smoking is associated with increased severity of disease and death in hospitalised COVID-19 patients [16]. There may also be effects of E-cigarettes on COVID-19, since Gaiha et al. [17] reported results of an online survey of 4351 adolescents and young adults that found diagnosis of COVID-19 was five times more likely among ever-users of E-cigarettes only, seven times more likely among ever-dual-users, and symptoms were four times more likely among past 30-day dual-users. The importance of rapidly learning smoking cessation lessons from the COVID-19 pandemic was recently emphasised by an editorial in The Lancet Global Health entitled “Does the COVID-19 pandemic provide an opportunity to eliminate the tobacco industry?”, which concluded; “it will be devastating if the tobacco industry emerges as a winner from this global event, ameliorating its reputation and increasing sales. Conversely, now that major decisions and actions for health are acceptable under exigency, an unique opportunity exists to eliminate the tobacco industry” [18]. Since COVID-19 will remain with us for some time, it is important not lose sight of the need for simple basic strategies to encourage smoking cessation that should be implemented by all clinicians and health systems serving young people and adults, as summarised by a recent review by Redfield et al. [19] (table 1).

Conclusion

In summary, the TCC not only has to focus on its old foe, the tobacco industry, but also on the emerging threats to health from novel ENDS. By holding the ERS's institutional memory on the tactics the tobacco industry uses to lobby in order to protect its own commercial interests, the TCC has an essential role that includes: ensuring that EU tobacco legislation maximises public health benefits; developing an independent research agenda for novel inhaled nicotine technologies; and putting forward cogent arguments against concepts such as the acute stimulant effects of vaping are “similar to effects from drinking coffee as a health risk” [20].

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