This year could shape up to be a historic one for tobacco control — or one in which Big Tobacco accelerates its steady transformation into Big Nicotine. We are hoping for the former, but aren’t betting against the latter.
For the last few years, the tobacco industry has publicly endorsed harm reduction. This public health strategy includes efforts designed to reduce, though not eliminate, risks for people who engage in harmful behaviors. Harm reduction supports methadone treatment for opioid addiction, for example, which is closely regulated in clinic settings.
The tobacco industry’s take on harm reduction includes mass marketing nicotine-laden vaping products that flood retail outlets while furiously lobbying against the regulation of traditional cigarettes. This strategy could change. But for now, the companies’ embrace of e-cigarettes looks like a self-serving attempt at reinvention, not public health.
Let’s start with why this year has so much promise. The Food and Drug Administration can accelerate momentum on two major 2022 commitments designed to prevent children and adolescents from tobacco addiction and devalue deadly combustible tobacco. First, the FDA announced plans to ban menthol as a flavoring agent in cigarettes and prohibit all flavors (other than tobacco) in cigars. Doing so will make tobacco less appealing to youths, as well as to Black adult cigarette smokers who have higher rates of using menthol cigarettes.
The FDA also announced plans to establish a near-zero maximum nicotine level for cigarettes and certain other combusted tobacco products, which would essentially render them nonaddictive and prevent, over the course of the century, 33 million from becoming dependent on tobacco products and 8 million from dying from their use.
Americans are ready for bold steps: A recent poll found 57% would support a blanket ban on all tobacco products.
Official statements from tobacco companies make it look like they on board too. Altria, which makes Marlboro, the leading cigarette brand in the U.S., announces on its website it is “Moving Beyond Smoking” to transform “From tobacco company to tobacco harm reduction company.” British American Tobacco says “we know combustible products pose serious health risks… That’s why we are changing: creating new products, backed by science, that provide adult smokers with less risky alternatives.”
Other companies have taken what appear to be even more stunning marketing actions in the name of public health. Philip Morris International, for example, sponsored a series of “advertorial” articles in The Boston Globe that promote health equity, inclusive design for people with disabilities, and sustainable business practices, while also trumpeting through a “Message from the Sponsor” that it has invested billions of dollars toward becoming a smoke-free company.
But actions speak louder than words. Altria flatly opposes the proposed ban on menthol and cigar flavorings and the near-zero maximum nicotine standard. And it isn’t alone in its obstructionism. When California recently enacted a statewide ban on flavored tobacco products, R.J. Reynolds sued to block it. When that failed, the company began marketing new “fresh” and “crisp” cigarettes clearly meant to appeal to smokers who missed menthol flavoring.
This familiar playbook, which has also long included opposing taxes on tobacco, graphic warning labels, and other policies proven to reduce cigarette consumption, reflects an industry that has regularly lied and obfuscated the science.
Meanwhile, the tobacco industry has fully embraced vaping. The two leading e-cigarette brands in the U.S. (according to 2022 Nielsen data, which represent the best data currently available but may underestimate sales from online and specialty tobacco/vape shops) are now fully or partially owned by tobacco companies. British American Tobacco (which owns R.J. Reynolds) makes Vuse, the market leader with nearly 40% share of the U.S. e-cigarette market and the second most common brand for youth e-cigarette users. Altria holds a 35% stake in Juul, which is second in the U.S. e-cigarette market share and the third most common brand for youth e-cigarette users.
The companies say their harm-reduction goal is to help adult smokers unable or unwilling to quit combustible tobacco products to transition to e-cigarettes. What they don’t say is that since global cigarette sales have fallen each year over the past decade, the industry needs new customers. Hooking a new generation of youths to nicotine through vaping could do the trick. Thus, “harm reduction” offers a unique opportunity for both reinvention and profit.
To be sure, it is important to continue research and the policy debate on the potential value of e-cigarettes as agents of tobacco harm reduction; their current status as a health intervention remains uncertain. Some data suggest that e-cigarettes can help adult smokers quit, but their uptake among youths and adolescents has sparked great concern. As we wrote in a recent JAMA Viewpoint, the FDA should move toward creating a marketplace where all stakeholders abide by three major principles:
- protect children and adolescents from tobacco addiction and exposure
- devalue cigarettes and other combustible tobacco products
- and support efforts for a tightly regulated system with wide availability of medications to aid smoking cessation and FDA-authorized reduced-harm products.
Until that happens, the tobacco industry hopes the public will ignore its profound and fundamental hypocrisy: promoting harm reduction while continuing to market and sell deadly combustible cigarettes that cause harm in the first place. If they truly want to reduce harm, they have the unique power and savvy to do so. They can stop opposing proven tobacco control measures, set a date to stop marketing deadly combustible cigarettes, and support the pending FDA regulations.
No more smokescreens and obfuscation. This should be the year where Big Tobacco learns it can’t have it both ways.
Howard K. Koh is a physician and professor of the practice of public health leadership at the Harvard T.H. Chan School of Public Health, the former U.S. assistant secretary for health, and the former Massachusetts commissioner of public health. Michael Fiore is a physician, professor of medicine at the University of Wisconsin School of Medicine and Public Health, and the founding director of the University of Wisconsin Center for Tobacco Research and Intervention.
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