Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
    • WoS Reviewer Recognition Service
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
    • WoS Reviewer Recognition Service
  • Alerts
  • Subscriptions

Tobacco control and the ERS: new problems and old foes

Jonathan Grigg
European Respiratory Journal 2021 57: 2003499; DOI: 10.1183/13993003.03499-2020
Jonathan Grigg
Centre for Child Health, Blizard Institute, Queen Mary University of London, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Jonathan Grigg
  • For correspondence: j.grigg@qmul.ac.uk
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

A review of future tasks of the ERS Tobacco Control Committee from the incoming chair: e-cigarettes and novel heated tobacco products, preventing the uptake of cigarettes, advocating basic smoking cessation measures, and learning from the COVID-19 pandemic https://bit.ly/3nvC6eT

Introduction

The European Respiratory Society (ERS) Tobacco Control Committee (TCC) has a key role in coordinating ERS activities related to tobacco control. In addition to working across ERS Assemblies, it monitors the implementation of the Framework Convention on Tobacco Control by European Union (EU) member states, and works with international organisations such as the Framework Convention Alliance. As the incoming chair of the ERS TCC, this article highlights my personal view on the areas to be addressed by the TCC over the next 3 years.

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?

FIGURE 1
  • Download figure
  • Open in new tab
  • Download powerpoint
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).

View this table:
  • View inline
  • View popup
TABLE 1

Examples of interventions to encourage smoking cessation

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].

Shareable PDF

Supplementary Material

This one-page PDF can be shared freely online.

Shareable PDF ERJ-03499-2020.Shareable

Footnotes

  • Conflict of interest: J. Grigg reports personal fees for advisory board work from AstraZeneca, GSK and Vifor Pharma, and personal fees for lectures from Novartis, outside the submitted work.

  • Received September 14, 2020.
  • Accepted November 11, 2020.
  • Copyright ©ERS 2021
https://www.ersjournals.com/user-licence

References

  1. ↵
    Philip Morris International (PMI). Unsmoke Your Mind: Pragmatic Answers to Tough Questions for a Smoke-free Future. www.pmi.com/our-initiatives/unsmoke-your-mind/white-paper-Pragmatic-Answers-to-Tough-Questions-for-Smoke-Free-Future Date last updated: 21 Jan 2020. Date last accessed: 14 Sep 2020.
  2. ↵
    1. Pisinger C,
    2. Dagli E,
    3. Filippidis FT, et al.
    ERS and tobacco harm reduction. Eur Respir J 2019; 54: 1902009. doi:10.1183/13993003.02009-2019
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Ferkol TW,
    2. Farber HJ,
    3. La Grutta S, et al.
    Electronic cigarette use in youths: a position statement of the Forum of International Respiratory Societies. Eur Respir J 2018; 51: 1800278. doi:10.1183/13993003.00278-2018
    OpenUrlAbstract/FREE Full Text
  4. ↵
    1. Britton J,
    2. George J,
    3. Bauld L, et al.
    A rational approach to e-cigarettes: challenging ERS policy on tobacco harm reduction. Eur Respir J 2020; 55: 2000166. doi:10.1183/13993003.00166-2020
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Pisinger C,
    2. Vestbo JA
    . A rational approach to e-cigarettes: challenging ERS policy on tobacco harm reduction. Eur Respir J 2020; 55: 2000355. doi:10.1183/13993003.00355-2020
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Gilmore AB,
    2. Braznell S
    . US regulator adds to confusion around heated tobacco products. BMJ 2020; 370: m3528. doi:10.1136/bmj.m3528
    OpenUrlFREE Full Text
  7. ↵
    US Food and Drug Administration. FDA Authorizes Marketing of IQOS Tobacco Heating System with ‘Reduced Exposure’ Information. www.fda.gov/news-events/press-announcements/fda-authorizes-marketing-iqos-tobacco-heating-system-reduced-exposure-information Date last updated: 07 Jul 2020.
  8. ↵
    University of Birmingham. https://research.birmingham.ac.uk/portal/en/projects/effectiveness-of-electronic-cigarettes-compared-with-varenicline-for-smoking-cessation-in-patients-with-chronic-obstructive-pulmonary-disease-and-effect-on-lung-health-ecal-study Date last accessed: 23 Nov 2020.
  9. ↵
    1. Zhao D,
    2. Aravindakshan A,
    3. Hilpert M, et al.
    Metal/metalloid levels in electronic cigarette liquids, aerosols, and human biosamples: a systematic review. Environ Health Perspect 2020; 128: 36001. doi:10.1289/EHP5686
    OpenUrl
  10. ↵
    1. Grigg J,
    2. Walters H,
    3. Sohal SS, et al.
    Cigarette smoke and platelet-activating factor receptor dependent adhesion of Streptococcus pneumoniae to lower airway cells. Thorax 2012; 67: 908–913. doi:10.1136/thoraxjnl-2011-200835
    OpenUrlAbstract/FREE Full Text
  11. ↵
    1. Scott A,
    2. Lugg ST,
    3. Aldridge K, et al.
    Pro-inflammatory effects of e-cigarette vapour condensate on human alveolar macrophages. Thorax 2018; 73: 1161–1169. doi:10.1136/thoraxjnl-2018-211663
    OpenUrlAbstract/FREE Full Text
  12. ↵
    1. Astuti PAS,
    2. Assunta M,
    3. Freeman B
    . Why is tobacco control progress in Indonesia stalled? A qualitative analysis of interviews with tobacco control experts. BMC Public Health 2020; 20: 527. doi:10.1186/s12889-020-08640-6
    OpenUrl
  13. ↵
    Southeast Asia Tobacco Control Alliance. Indonesia: Disneyland for Big Tobacco: how Indonesia's lax smoking laws are helping next generation to get hooked. https://seatca.org/indonesia-disneyland-for-big-tobacco-how-indonesias-lax-smoking-laws-are-helping-next-generation-to-get-hooked/ Date last updated: 01 Jun 2018. Date last accessed: 06 Nov 2020.
  14. ↵
    British American Tobacco. Potential COVID-19 vaccine – BAT in the news. www.bat.com/group/sites/UK__9D9KCY.nsf/vwPagesWebLive/DOBNHBWR Date last accessed: 06 Nov 2020.
  15. ↵
    Southern African Legal Information Institute. British American Tobacco South Africa (Pty) Ltd v Minister of Health (463/2011) [2012] ZASCA 107; [2012] 3 All SA 593 (SCA) (20 June 2012). www.saflii.org/za/cases/ZASCA/2012/107.html Date last updated: 20 Jun 2012. Date last accessed: 20 Sep 2020.
  16. ↵
    World Health Organization. Smoking and COVID-19. www.who.int/news-room/commentaries/detail/smoking-and-covid-19 Date last updated: 30 Jun 2020. Date last accessed: 06 Nov 2020.
  17. ↵
    1. Gaiha SM,
    2. Cheng J,
    3. Halpern-Felsher B
    . Association between youth smoking, electronic cigarette use, and COVID-19. J Adolesc Heal 2020; 67: 519–523. 10.1016/j.jadohealth.2020.07.002.
    OpenUrl
  18. ↵
    1. Ioannidis JPA,
    2. Jha P
    . Does the COVID-19 pandemic provide an opportunity to eliminate the tobacco industry? Lancet Glob Health 2020; in press [https://doi.org/10.1016/S2214-109X(20)30466-6].
  19. ↵
    1. Redfield RR,
    2. Hahn SM,
    3. Sharpless NE
    . Redoubling efforts to help americans quit smoking — federal initiatives to tackle the country's longest-running epidemic. N Engl J Med 2020; 387: 1606–1609. doi:10.1056/NEJMp2003255
    OpenUrl
  20. ↵
    Science Media Centre. Expert Reaction to the VESUVIUS Study Comparing the Cardiovascular Effects of Smoking and Vaping. www.sciencemediacentre.org/expert-reaction-to-the-vesuvius-study-comparing-the-cardiovascular-effects-of-smoking-and-vaping/ Date last updated: 15 Nov 2019. Date last accessed: 06 Nov 2020.
PreviousNext
Back to top
View this article with LENS
Vol 57 Issue 1 Table of Contents
European Respiratory Journal: 57 (1)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Tobacco control and the ERS: new problems and old foes
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Tobacco control and the ERS: new problems and old foes
Jonathan Grigg
European Respiratory Journal Jan 2021, 57 (1) 2003499; DOI: 10.1183/13993003.03499-2020

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Tobacco control and the ERS: new problems and old foes
Jonathan Grigg
European Respiratory Journal Jan 2021, 57 (1) 2003499; DOI: 10.1183/13993003.03499-2020
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Introduction
    • E-cigarettes and heated tobacco products
    • Preventing uptake of cigarettes
    • Learning from the pandemic
    • Conclusion
    • Shareable PDF
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

  • Long-term outcome of co-infection of COVID-19 and TB
  • Leukocyte telomere length: personalised medicine for fibrotic ILD?
  • An attack of asthma is not an attack of the heart
Show more Editorials

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2023 by the European Respiratory Society