When Public Health and Big Tobacco Align
Nobody trusts the tobacco industry, and it's easy to understand why. For decades, industry executives knew that smoking caused cancer and heart disease yet publicly denied the dangers of cigarettes. It relentlessly attacked its critics. Documents that emerged in the 1990s showed that the industry targeted teenagers, knowing that the earlier someone became addicted to cigarettes, the more likely they would be lifelong smokers. And so on.
In the 1980s and 1990s, the public health community went to war with the tobacco industry. Though the war largely ended in 1998 with Big Tobacco agreeing to a multi-billion-dollar settlement with the states, it remains a powerful memory for public health.
To this day, most tobacco-control advocates view the cigarette companies as being every bit as duplicitous and evil as they were in the bad old days. Some years ago, I asked Stanton Glantz, perhaps the leading anti-tobacco scientist in the U.S., what his ultimate goal was. He didn't say it was to eliminate the scourge of smoking. He said: "To destroy the tobacco industry."
What brings this to mind is an excellent cover story in the upcoming issue of Bloomberg Businessweek about the efforts of the tobacco industry to devise and market so-called reduced risk products like electronic cigarettes -- products that give users their nicotine fix without most of the attendant carcinogens that come with combustible tobacco.
Although the tobacco companies have done decades of R&D on smokeless products, the business was dominated early on by startups like NJOY, which is today the largest independent e-cigarette company in America. From the start NJOY has said that a big part of its mission was "to end smoking-related death and disease." And from the start, messages like that have been scorned by the public health community.
Ingesting nicotine in some smokeless fashion is vastly safer than smoking a combustible cigarette. (In the words of the late South African tobacco scientist Michael Russell, "People smoke for the nicotine but die from the tar.") Last year, the Royal College of Medicine issued a report saying that e-cigarettes were some 95 percent safer than cigarettes.
Even so, the public health community in the U.S., led by the Centers for Disease Control and Prevention, has done everything it can to demonize smokeless products. Some of this has been with good reason: to try to keep kids from picking up an addictive habit. But this effort has also helped to create the impression that smokeless products are as dangerous as cigarettes. One result, sadly, is that many long time smokers have refused to try them, even though they could save their lives.
My sense in talking to tobacco-control officials over the years is that too many of them simply don't believe in a reduced-harm approach. We give heroin addicts methadone not because methadone is good but because it is better than heroin. With cigarettes, however, the public health mindset appears to be all or nothing -- that the only "right" thing for smokers to do is to go cold turkey.
But the lingering distrust of the tobacco industry has also had a lot to do with public health's unwillingness to acknowledge the potential benefits of alternative products. Matt Myers, the president of the Campaign for Tobacco Free Kids, has often complained, for instance, about the marketing of e-cigarettes, saying that companies are using the same tactics to hook teenagers that Big Tobacco once used.
With the e-cigarette market clearly established, the four big tobacco companies -- BAT, Reynolds American, Altria (formerly Philip Morris) and Philip Morris International (spun off from Altria) -- have proclaimed themselves all in.
Philip Morris International is an especially interesting case: Not only does it have an array of e-cigarettes and other smokeless products, but as the Bloomberg Businessweek story points out, it has publicly proclaimed that its goal is to lead the world into "a smoke-free future." The home page of its website asks, "How long will the world's leading cigarette company be in the cigarette business?"
As astonishing as it is that a company with $26 billion in tobacco revenue last year would be calling for the end of cigarettes, I believe Philip Morris is sincere. It has spent around $3 billion in research. Its new flagship product, called IQOS, heats tobacco but doesn't burn it -- which the company believes will be more satisfying to smokers than vaping. IQOS already has 7 percent of the tobacco market in Japan, and is being rolled out in other countries.
Philip Morris recently asked the British government that tobacco products "be taxed according to their risk profile." In other words, it wants the government to impose higher taxes on cigarettes to encourage smokers to move to reduced-risk products. What tobacco company has ever done that before?
In the U.S., Philip Morris has done something extraordinary: It has made a submission to the Food and Drug Administration to get the right to market IQOS as a reduced risk product. The expensive submission consumed 2.3 million pages and is backed by a great deal of research, including several clinical trials. So far, none of the U.S. e-cigarette companies have attempted to get such a designation, and it is a big problem. How do you sell a reduced risk product when you can't tell anybody it reduces risk?
The business case for diving into this market is that it's a product category that's growing, while the cigarette market is shrinking. Philip Morris doesn't want to be left behind. But there is no particular need for the company to set out such a transformative agenda, at least not yet. The small smokeless companies are not much of a threat. NJOY filed for bankruptcy last fall. And under a 2009 law, every company in the e-cigarette industry will have to file something called a premarket tobacco application with the FDA by August 2018. The submissions will cost, on average, over $450,000, and the companies will have to show that their products have some public health benefit. There is a legitimate chance that some small companies won't be able to clear the hurdle.
No, Philip Morris is pushing as hard as it is, I believe, because it wants to get on the right side of the issue, finally -- to be viewed as a good corporate citizen. When I spoke to Glantz the other day about the company's new anti-smoking agenda, he said, "I don't believe them." (He added, "If they were serious, they would stop marketing cigarettes right now.")
No doubt many others in the tobacco-control community feel the same way. They still loathe Big Tobacco, and view Philip Morris's new strategy as just another deception. But the truth is, if there is ever going to be a serious move from cigarettes to less dangerous products, it will have to come from Big Tobacco. They have the R&D resources, they have the marketing apparatus -- and, it appears, they have the will.
Public-health advocates don't have to trust Philip Morris, or any other tobacco company. They don't have to believe what I believe in order to arrive at the same conclusion: that the advocates should be rooting for the companies' innovations -- pushing them, double-checking their data, making sure regulations are in place to prevent their products from being marketed to kids. The advocates should also be spreading the word that there is an alternative to cigarettes. Who really cares whether it's Big Tobacco or some other entity that reduces smoking deaths? What matters is that it happens.
The tobacco wars are long over. Continuing to fight the cigarette companies may bring a certain satisfaction to the veterans on the public-health side. But joining forces is the way to save lives.
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