Original article by Howard K. Koh, MD, MPH; Alan C. Geller, MPH, RN
In September 2017, Philip Morris International (PMI), the world’s largest publicly traded tobacco company and manufacturer of the world’s leading cigarette brand (Marlboro), announced establishment of the Foundation for a Smoke-Free World, with nearly $1 billion in funding over the next 12 years.1 The foundation states that it will promote a vision of “ending smoking in this generation by eliminating the use of cigarettes and other forms of combustible tobacco.”1 In its agreement with PMI, the foundation also states that “…a paradigm shift is needed to accelerate the pace of research and support of projects regarding alternatives to cigarettes and other combusted tobacco products and advance the field of harm reduction.”2 The president of the foundation, Dr Derek Yach, a well-known member of the World Health Organization (WHO) Secretariat when the 2005 Framework Convention on Tobacco Control (FCTC) was developed, noted that the foundation not only “supports and endorses implementation of all elements of the FCTC” but also reflects PMI’s commitment “to making cigarettes obsolete.”1
The announcement, which has stirred intense worldwide reaction, comes amid heightened global attempts to advance tobacco control. The UN Sustainability Development Goals propose a 30% reduction in smoking prevalence (2025 vs 2010) through the FCTC, which has been ratified by 180 countries representing 90% of the world’s population.3 The FCTC commits nations to proven, evidence-based strategies through its MPOWER framework: Monitor use and prevention policies, Protect people (eg, smoke-free public places), Offer help to quit, Warn (eg, through graphic labels and media counter-advertising), Enforce bans on tobacco advertising, promotion and sponsorship, and Raise tobacco taxes. Nearly two-thirds of countries now have at least one MPOWER measure in place.3 But tobacco, which claimed an estimated 100 million lives last century, is projected to cause a billion more deaths in this century. Globally, it is estimated that 1.1 billion smokers consume 5.7 trillion cigarettes each year.
Bloomberg Philanthropies and the Gates Foundation, among others, have provided critical funding to advance FCTC implementation. Nevertheless, in light of the global tobacco challenge, any additional research funding, regardless of source, could be considered by some as welcome news. In efforts to demonstrate transparency, the foundation promises to prohibit tobacco industry representation on its board, make research data available for reanalysis, and publish study findings from all grant recipients, regardless of success or failure.1
Of note, the foundation’s stated goal of a “smoke-free,” but not “tobacco-free,” world underscores its goal to focus on a future that potentially features harm reduction—offering smokers less harmful nicotine products to decrease risk of death and disease. This strategy, gaining recent global attention, is nevertheless currently under intense debate. The 2017 US Food and Drug Administration announcement to establish a comprehensive nicotine regulatory framework4 has now proceeded to the critical next step of requesting public comment on a Tobacco Product Standard for Nicotine Level of Combusted Cigarettes. PMI fully understands that should harm reduction ever become well established, noncombustible products, such as electronic cigarettes and other novel agents, could substantially expand the future marketplace.2 Yach argues that pursuing a “bolder scientific agenda” offers an opportunity to transform the tobacco industry of the future.1
Opponents, however, question whether PMI can truly lead meaningful change, given its long history5 of manufacturing and promoting products that cause death for half of its long-term users.3 Deploying substantial resources, the tobacco industry has leveraged design changes and additives to enhance cigarettes as effective nicotine delivery devices while seeking to expand global reach through youth marketing of flavored cigarettes (banned in the United States), in Latin America,6 for example. According to its 2017 Consolidated Statement of Earnings, PMI reports annual net revenues of $78 billion and annual net earnings attributable to PMI of $6 billion,7 figures that are far greater than the proposed foundation funding.
PMI and other transnational tobacco companies also have systematically opposed tobacco control strategies represented by MPOWER.5 In recent years, tobacco companies have leveraged international trade agreements to bring legal challenges against cigarette-pack plain packaging in Australia, graphic warning labels in Uruguay and Thailand, and bans on retail store displays of tobacco products in Norway.8 Even though the industry has lost these cases, lengthy and complex litigation has drained resources in these countries while producing a chilling effect on adoption of stronger policy measures in others. Regarding tax increases, the tobacco industry’s longstanding global opposition5 at the national, provincial, state, and local level has involved, for example, funding $70 million in an attempt to defeat a 2016 California ballot initiative that successfully raised the cigarette pack price by $2.
Yach indicates that the foundation will be independent from PMI, citing adherence to FCTC Article 5.3, which obligates parties to protect public health policies from the tobacco industry’s vested interests.1 He also contends that the foundation meets the 8 evaluation criteria9 (which include transparency and independence, competitive funding process, independent research agenda) previously published by public health experts to assess acceptability of models that propose tobacco industry funding for credible research.1 In response, however, the authors of those criteria refute (on their institutional website) his contention, finding the foundation model unacceptable because of lack of independence, potential for conflicts of interest, and clear public relations gains. Previous tobacco-funded groups, such as the Center for Indoor Air Research and the Council for Tobacco Research in the United States, had also promised to promote independent research but were ordered disbanded pursuant to the 1998 Master Settlement Agreement.10
The foundation’s stated goals are also reminiscent of past unfulfilled industry vows to promote public health. For example, in 1997, Philip Morris CEO Geoffrey Bible stated in a deposition that the company, if presented with evidence that smoking caused cancer, would “shut it down instantly.” Previous alternative products marketed by the industry, such as “light” and “low-tar” cigarettes, were ultimately shown not to be less harmful than conventional cigarettes. In addition, a 2006 federal court decision United States v Philip Morris found that tobacco companies “…suppressed, concealed and terminated scientific research…and destroyed documents including scientific reports and studies”9 in efforts to defraud the public about health harms. The tobacco industry has recently issued court-ordered corrective statements (extending into 2019 through the mass media and other means) regarding adverse health effects of smoking and secondhand smoke exposure, intentional design of cigarettes to make them more addictive, addictiveness of nicotine, and lack of health benefits of “light” and “low tar” cigarettes.
For these reasons and more, the global community has been virtually unanimous in denouncing the foundation, involving, by one estimate, nearly 120 organizations. WHO has urged a complete boycott, citing the UN General Assembly’s recognition of a fundamental conflict of interest between the tobacco industry and public health. The Framework Convention Alliance recommends that no government, organization, or researcher accept money from, endorse, or enter into partnership with the foundation. Other international organizations, such as the World Heart Foundation, the Union for International Cancer Control, and the International Union against Tuberculosis and Lung Disease, have announced they will not accept foundation funds. In the United States, groups including the Campaign for Tobacco-Free Kids, the Truth Initiative, and the American Cancer Society have forcefully opposed acceptance of research funds from the Foundation for a Smoke-Free World. Deans of 17 leading North American schools of public health announced that they would not be accepting funding from, or pursuing work with, the foundation. Tobacco Control has announced it will not publish foundation-funded research manuscripts.
PMI has unique power to fulfill the foundation’s vision. It can set a target date to cease production of cigarettes and other combustible tobacco products; terminate marketing and advertising, particularly efforts that target youth and other vulnerable populations; stop litigating against tobacco control measures; support tobacco tax increases; and promote full implementation of all FCTC policies. Short of that, the new foundation only diverts attention from evidence-based global tobacco control efforts that are needed now more than ever.
