Bloomberg scrutinised. Unusually, a journalist decided to take a sceptical look at Bloomberg Philanthropies and its many proxies and the impact of their war against vaping. The result is an excellent must-read piece by Mark Gunther (@MarcGunther) in the Chronicle of Philanthropy: Bloomberg’s Millions Funded an Effective Campaign Against Vaping. Could It Do More Harm Than Good? (web archive) (23 March 2021).
It is first-class public-interest journalism, with some hard messages for Bloomberg but plenty of balancing comment too.
The response. The interesting thing is that this drew a joint response from Kelly Henning of Bloomberg Philanthropies, Matthew Myers of the Campaign for Tobacco-Free Kids and Robin Koval of the Truth Initiative. See Vaping and Philanthropy: Debating Strategies That Work (web archive). There is a substrate of anger and panic in the letter that suggests that Gunther hit a raw nerve.
What is unusual about this letter is that Henning, Myers and Koval actually try to defend their positions. Normally, they don’t defend their positions, they just assert them with millions of dollars of amplification. It offers a rare opportunity to provide a critique of their stance. So I have taken their response letter, broken it down into 15 propositions, and provided a response to each. Each section starts with a quote from the letter pulled out in a quote box in bold dark-blue. The letter is analysed in its entirety.
- No sign of debate about strategies that work
- Dismissing credible and well-informed critics
- Misunderstanding adolescent vaping
- Misrepresenting the role of flavours in vaping
- Baseless claims about the vaping industry
- Alarmist but empty claims about nicotine
- Banning flavoured e-cigarettes – a campaign that is likely to do more harm than good
- Claiming credit for reductions in vaping achieved by misleading claims about lung injuries
- Tobacco control as inflexible dogma locked in the past
- Smears and innuendo
- Displaying basic misunderstandings about tobacco harm reduction
- Missing the point about vaping regulation
- In denial about evidence for smoking cessation but prohibitionist anyway
- Anti-industry war-cry to deflect attention from their own weaknesses
- The question of accountability
Vaping and Philanthropy: Debating Strategies That Work
MARCH 29, 2021
To the Editor:
Their work does not suggest interest in what works for public health. Let’s be clear, the authors of this letter, Henning, Myers and Koval, are not debating strategies that work. If they were interested in what works or debating it, their organisations, outputs and activism would look very different. Here are some ways in which their work would look different:
- They would be focused on intervention research. That means understanding how people, individually and collectively, as both consumers and suppliers, respond to policy measures like banning e-liquid flavours, imposing huge barriers to market access through FDA’s PMTA process, taxing vape products, banning the use of the US postal service for mail-order vapes etc.
- Their policy work would be highly focussed on the all-too-plausible unintended consequences of the measures they are so aggressively promoting – constantly asking “will this new anti-vaping rule actually increase smoking?” Will we just end up with bigger criminal networks? Will users adopt workarounds that are more dangerous than the risks we are trying to address?
- They would be endlessly struggling with trade-offs created by policy choices: trade-offs between smokers and non-smokers, between adolescents and adults, between adolescent smokers and non-smokers, between state intervention and personal autonomy, between harms arising from tobacco use and harms arising from anti-tobacco policies, and between focussing their efforts on smoking or on vaping.
- There would be much more curiosity and hunger to explore opportunities from new technology. What do they make of the experience of heated tobacco products in Japan? What can they learn from Europe’s policy framework? Does the Swedish experience teach us anything?
- Once they’d secured some new legislation, I would expect them to be investing in monitoring and evaluation to find out what actually happened and to correct course if something went wrong – for example, if there was an increase in smoking.
- They would be seized by identifying the real at-risk populations (generally poor or otherwise disadvantaged middle-aged adults) where interventions can have the largest and fastest returns to public health investment.
- As groups that profess to be focused on “kids”, I would expect far more detailed research on adolescents – particularly the ‘bad kids’, that is the kids who are not doing well, come from distressed homes, doing poorly or dropping out of school, gang-affiliated, substance-using, risk-taking kids – the ones who are more likely to be smoking, vaping or engaged in other youth risk behaviours.
You can search their websites, reports, grants, events, video gimmickry, media statements, and political letters and you will find none of this.
The primary interest is in securing restrictive tobacco control legislation and policy, regardless of the consequences. If they were interested in public health, the work of their organisations really would look very different. What they appear to be doing is pursuing maximally restrictive laws, policies, and policy implementation, particularly directed at the new non-combustible alternatives to smoking. The kids used in their activism are not the ‘bad kids’ from tough backgrounds. Instead, kids have been weaponised for the advocacy battle – to create anxiety in middle-class parents, legislators and public health groups. To me, they are acting like prohibitionists and abstinence-only evangelists. For them, it seems that every new restriction is one more turn of the ratchet, one more step towards an ultimate (and usually unstated) goal of a nicotine-free society. It’s not about health, they are the new battalions in an expanded war-on-drugs.
Regarding Bloomberg’s Millions Funded an Effective Campaign Against Vaping. Could It Do More Harm Than Good? [access](Chronicle, March 23), there is still much we don’t know about e-cigarettes. But here is what we do know.
Despite the opening claim, the letter does not give a realistic account of what we do and do not know about e-cigarettes. Henning, Myer and Koval clearly did not like Marc Gunther’s reporting on their approach, but his account is basically accurate and mostly told through the testimony of credible independent experts. Gunther appears to have gone to great lengths, excessively generous in my view, to reflect the views of the anti-vaping activist-academics in his coverage. But the criticisms made in the article rest on statements from impeccable sources like:
- Ken Warner, Avedis Donabedian Distinguished University Professor Emeritus of Public Health, Dean Emeritus of Public Health, University of Michigan
- Cheryl Healton, Dean of School of Global Public Health, Professor of Public Health Policy and Management, New York University. Founding President and CEO of the Legacy Foundation / Truth Initiative.
- Steven Schroeder, Distinguished Professor of Health and Health Care, Department of Medicine, Director of the Smoking Cessation Leadership Center, University of California at San Franciso.
- Ethan Nadelmann, Founder, Drug Policy Alliance.
- David Abrams, Professor of Social and Behavioral Sciences, School of Global Public Health, New York University and founding Executive Director of the Schroeder National Institute of Tobacco Research and Policy Studies at Truth Initiative
- David Sweanor, Advisory Committee Chair, University of Ottawa Centre for Health Law, Policy and Ethics, Adjunct Professor, Faculty of Law, University of Ottawa, Canada
Without pausing for breath or reflection, or even considering if these serious critics may have a point, Henning, Myers and Koval go straight on the attack. Theirs is a vast financial and corporate advocacy undertaking in which there is no room for doubt, humility or debate – even if raised politely by acknowledged experts in the field.
We know that 3.6 million kids currently use e-cigarettes, a threshold that in 2018 led the U.S. surgeon general to declare youth e-cigarette use an epidemic. Of these kids, 1.3 million use e-cigarettes frequently or every day, a strong sign of nicotine addiction.
This statement is designed to generate alarm to support the case for anti-vaping activism. However, far more nuance is needed to understand these headlines. However, the underlying position is more subtle than they are willing to explain to readers.
- Firstly, the number of vaping adolescents sharply decreased between 2019 and 2020. In 2019, it was 5.38m high-school and middle-school students. In 2020, it was down to 3.57m. This reminds us that some use is transitory and that demand is prone to fads and fashion. In 2019, past-30-day e-cigarette prevalence among high school students was 27.5%, but by early 2020 its was down to 19.6%.
- Secondly, and most importantly, frequent vaping is highly concentrated in young people who have already used tobacco. Vaping is entering the mix of their tobacco/nicotine use and may well be beneficial by diverting them into a much less risky behaviour than smoking. In 2019, 27.5% of high school students had vaped at least once in the last 30 days. This is how that breaks down, when segmented by frequency of use and prior tobacco use (see data)
- Third, if these adolescents were really dependent they would be using daily and intensively. It is not necessary to make heroic leaps of faith about nicotine addiction. Researchers have examined the actual indicators of dependence in the NYTS dataset and found that signs of dependence are highly concentrated in those already using tobacco. See: Jarvis et al. Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey 2017-2019 reveal about high school e-cigarette use in the USA? Qeios, 2020.
Empty terminology designed to mislead. This claim is simply not true unless you define any flavour that appeals to anyone (other than tobacco flavour) as ‘kid-friendly’, which is the approach adopted by these groups. Flavoured vaping products are also chosen by the overwhelming majority of adults. This is partly because, for many, the point is to get away from tobacco and smoke flavours. Almost all vaping products are flavoured in some way, including tobacco flavoured products. What exactly would a ‘kid-unfriendly’ flavour be? Just something that tastes nasty? Unless they can define their terms, these assertions are meaningless. The fact is that adults find (non-tobacco) flavours attractive and many adults will choose them, even if Henning, Myers and Koval declare they are targetted at kids. Here is one study (annotated by me in red), showing adult flavour preferences, Russell et al (2018):
Sleight of hand. Back in 2017, these groups were defining ‘kid-friendly’ flavours very differently – raising concerns about flavour descriptors with a plausibly childish connotation like ‘Gummy Bear’ and ‘Cotton Candy’. Then came the rise of Juul (as an adult product and among young people). Juul did not have any flavours like this. But the internal logic had to hold together:
IF kid-appealing flavours cause teenage e-cigarette use AND the use of Juul among teenagers has increased THEN Juul flavours must be kid-appealing.
That meant Juul flavours like mango, creme, cucumber were by definition kid-appealing flavours. And with this started the gigantic scope-creep that has led to pretty well any flavour other than tobacco flavour being defined as kid-appealing. I describe this sleight of hand in more detail: Kiddie-flavours are now defined as all flavours except tobacco flavour – but it wasn’t always that way.
Bring the money and they will come. This has created the basis for what amounts to an e-cigarette prohibition drive at all levels in the US and increasingly internationally. Before long Bloomberg Philanthropies had piled in to fund a multimillion-dollar campaign.
Bloomberg Philanthropies Launches New $160 Million Program to End the Youth E-Cigarette Epidemic
Goals of the initiative, “Protect Kids: Fight Flavored E-Cigarettes,” include banning all flavored e-cigarettes—and stopping Juul and other e-cigarette companies from marketing their products to children. The three-year program will be led by the Campaign for Tobacco-Free Kids, which will partner with other leading organizations including parent and community groups concerned about the nation’s kids and health.
To no-one’s surprise, activist organisations quickly came to see the merit of banning flavours. To paraphrase Mrs. Merton, “what was it about the multi-million dollar campaign to ban e-cigarette flavours that convinced you of the central importance of banning e-cigarette flavours?”
We know that tobacco companies have spent billions of dollars to create, distribute, and advertise e-cigarette products in a “patently youth-oriented” manner.
This claim is obviously wrong. We certainly do not know this. By far the most lucrative market for e-cigarette companies is the population of adult smokers – people who make regular use of vaping products as alternatives to smoking. They consume more and more regularly and are potential longer-term customers. Even among the e-cigarette businesses of traditional tobacco companies, the marketing effort is targeted at winning market share from the cigarette and e-cigarette consumers of rival companies and defending their own market share. Selling to under-18s is simply not worth it – both in terms of the return on promotional expenditure and in terms of the massive political and regulatory grief it would cause the companies. That does not mean all companies are beyond reproach. Nor does it mean none are simply clueless and don’t even realise what they are doing. But to claim that all e-cigarette products, marketing and innovation are “patently youth-orientated” is obviously nonsense – it’s the adult market that brings in the money and reliable customers.
The evidence presented does not support their claim. The link provided by Henning, Myers and Koval to justify their claim is to a very poor quality 2019 white paper by Jackler and colleagues. The analysis is risibly simplistic and cannot support the claim that “tobacco companies have spent billions of dollars…” on anything, let alone on marketing products to youth. The paper does not even analyse tobacco companies marketing spend or themes. Nor does it look at how much spend went behind which themes. All the paper does is selectively show pictures of marketing from one company, Juul, and invites the reader to be scandalised. Juul is not even a tobacco company. On 19 December 2018, a real tobacco company, Altria, took a 35% stake in Juul, but that is after the period studied in the paper (June 2015 – November 2018) and coincided with a decline in Juul’s fortunes. It does not assess the advertising weight (how much the ad was shown and seen) or attempt to correlate the evolving themes of Juul advertising to the timing of the rise in Juul product sales among youth or adults. Much of the advertising Jackler et al. refer to is in Juul’s earliest campaigns in 2015-16. (the Vaporize campaign – 2015 to early 2016 uses young adult models – see below),
The timing is all wrong. But the Vaporize campaign runs in 2015 and early 2016, well before Juul started its dramatic ascendancy – see data on convenience store sales below.
US teen vaping fell after the Juul Vaporize campaign. Juul’s youth-orientated (actually, young adults) 2015-16 campaign was so successful that adolescent vaping actually, um, DECREASED sharply in the United States after the Vaporize campaign. It was substantially higher in 2015 than in 2016 and 2017. So that is hardly a conclusive indictment of Juul, the vaping industry or the tobacco industry.
By 2018 when the Juul product was taking the vaping world by storm and driving down smoking, Jackler’s paper shows that Juul marketing had become relatively sedate and adult-orientated.
Wholly unconvincing. So Henning, Myers and Koval are trying to spin the entirety of the e-cigarette industry as tobacco industry youth predators on the back of the marketing of one company, which briefly produced youth-orientated ads (using young adults) before its product was successful with adults and while youth vaping plunged. So no, I am not convinced. It is a ridiculous assertion with no basis in fact and the authors present no evidence to support it.
A vacuous comparison. The first part about an e-cigarette delivering as much nicotine as a cigarette packet an empty scare line, albeit one that is widely used in tobacco control propaganda. No one smokes one pack of cigarettes in one go. No one vapes a pod in one go either. A larger pod would contain more nicotine and last longer, a smaller one less and would run out sooner. So what? This has no public health relevance at all. In fact, the inclusion of this line in the letter tells us that its authors have grown used to uncritical groupthink and no substantive challenge.
Competing with cigarettes. It is unclear what Henning, Myers and Koval actually think is good here. Do they want cigarettes to be the best way of delivering nicotine? Do they think that e-cigarettes should be regulated to make them less satisfactory as alternatives to smoking and to make it less probable that smokers will switch? Do they want to gift cigarettes a monopoly of effective nicotine delivery? This is what we mean by protecting the cigarette trade, promoting smoking and adding to the burden of disease and death. So what is it?
Show us the brain-damaged teenage smokers. American campaigners (including agencies like CDC and FDA) have gone all-in on the activist talking point that nicotine damages the young brain. The first problem with this argument is that it rests primarily on rodent studies with large nicotine exposures. But the fatal problem is that if there was any real effect here, it would be visible in the multiple generations of adults that grew up as adolescent smokers – but no one can find it. It is simply implausible that we would not have detected some sort of lasting cognitive detriment in adults who started as adolescent smokers. The proponents of this theory have never addressed this objection.
All of this led our organizations to mount major campaigns to reverse the youth e-cigarette epidemic, including Bloomberg Philanthropies’ Protect Kids: Fight Flavored E-Cigarettes initiative launched in 2019 and Truth Initiative’s National Youth-Vaping-Prevention Truth® campaign, which includes This Is Quitting, a free text-message program currently helping hundreds of thousands of young vapers quit.
This campaign is likely to do more harm than good. These are the reasons…
The wrong way to address youth risk behaviours. Firstly, they are targeting a relatively trivial youth risk behaviour compared to other things that harm young people, including smoking, opioids and other illicit drugs, teenage pregnancy and STDs, binge drinking, drunk driving or riding, fighting and carrying weapons, mental health problems, bullying, and discrimination. Often in combination with poverty and poor prospects, these make some young lives miserable. A truly humane approach to young people would not start from the lens of a relatively innocuous substance use behaviour and make that the big issue. It would start with the young person and their troubles.
Ignoring a likely diversion from smoking. Secondly, if they engaged with adolescents as ‘young people’ rather than ‘teen vapers’, they might even find that their vaping is a positive thing – a diversion from smoking or other risk behaviours. Because smoking is far more harmful than vaping only a small diversion effect would make the overall impact of teenage vaping net positive protective for youth. If there is a substantial net diversion effect, the impact of a “successful” anti-vaping campaign would be to reduce diversion from smoking and cause harm. However, there is convincing evidence that this is exactly what is happening.
Seyla & Foxon, 2021 show evidence for a diversion effect:
“a substantial diversion effect is needed to explain observed nicotine use trends among US adolescents, and it must be larger than any possible opposing catalyst effect, if present.”
Levy, Warner and Cummings 2019, showed that as youth vaping increased, the rate of decline in smoking accelerated:
“There was a substantial increase in youth vaping prevalence beginning in about 2014. Time trend analyses showed that the decline in past 30-day smoking prevalence accelerated by two to four times after 2014”
So what have Henning, Myers and Koval done to check they are not, if successful, breaking a diversion from smoking for adolescents? The answer appears to nothing. If they had, they wouldn’t be doing what they are doing.
Indifference to the welfare of adults. Thirdly, what about adults? Henning, Myers and Koval do not consider the impact of their campaign on the approximately 10 million adult vapers in the United States, other than just saying they can use NRT and prescription meds (see 11 below). The fact that these people are choosing to vape instead of using NRT or Varenecline would tell anyone interested in their welfare that they are making that choice for a reason. They cannot just assume that smoking cessation medications are a viable substitute for vaping. (more on this in sections 11 and 12 below).
Fourthly, they clearly have no idea what the effect of interventions to ban flavours or stigmatise vaping would do in practice. Let’s try to imagine what they hope will happen and what might happen.
Desired outcome: young people stop vaping and smoking, become abstinent from nicotine and do not adopt any other risk behaviour, but do something virtuous instead.
Range of reality-based possible outcomes:
- Relapsing back from vaping to smoking – both teenagers and adults
- Not switching from smoking to vaping and continuing to smoke
- Initiating smoking instead of initiating vaping
- Continuing to smoke or to start smoking as an adolescent because parents or adult role models smoke instead of vaping
- Using other tobacco or nicotine products – hand-rolling tobacco, smokeless tobacco, heated tobacco, or new nicotine pouches
- Using tobacco-flavoured vape products instead of other flavoured products
- Accessing flavoured vapes via an illicit supply chain (a black market)
- Buying from foreign or out-of-state suppliers in person or via the internet and importing for personal use
- Buying from foreign or out-of-state suppliers to resell to others through informal networks
- Making and mixing their own flavours at home or buying or selling home-mixed flavours
- Adding flavour agents for food, drink or aromatherapy to unflavoured nicotine liquids
- Using flavours made for vaping but ostensibly marketed for another purpose
- Switching to cannabinoid (THC or CBD) vapes
- Adopting another risk behaviour that may be worse
- Buying flavoured vapes from criminals who introduce young people to other illicit substances – a gateway effect from flavour prohibition to fentanyl! Prove me wrong.
Some or all of these may happen in response to a vaping flavour ban and the mix might change over time as an illicit supply chain develops. How have Henning, Myers and Koval assessed the risks of doing more harm than good? Bear in mind that because of the respective risks, it only needs a small uptick in smoking to swamp any possible benefit from reduced vaping. Let’s see the working.
Thanks to these and other efforts, youth e-cigarette use has started to decline, although it remains at epidemic levels, with nearly one in five high-school students vaping.
The lung injury outbreak is a more likely cause. Without any evaluation or any obvious sign that their interventions make any difference and without checking their effect on smoking, they are claiming a win for their methods. A much more likely explanation is a fake scare story about E-cigarette or Vaping product Associated Lung Injury (EVALI). This was an outbreak of severe lung injuries that led to over 2,800 hospitalisation and 68 deaths between mid-2019 and early 2020. The outbreak was caused by illicit cannabinoid vapes that had been adulterated by a cutting agent, Vitamin E Acetate, used to dilute the THC oil to make more money. Vitamin E Acetate cannot be added to nicotine vaping products and would serve no purpose if it could. Nevertheless, many anti-vaping campaigners allowed and encouraged the cause to remain ambiguous and associated with nicotine vaping long after the real cause was clear. In doing so, they allowed many in the public to believe that e-cigarettes were much more dangerous than they are. Dave et al 2020 examined the deterioration in risk perceptions about vaping following the EVALI scare:
The EVALI outbreak created an information shock, which was followed by additional new information in a later CDC recommendation. We use data on consumer risk perceptions from two sets of surveys conducted before (HINTS survey data) and during the EVALI outbreak (Google Survey data). The empirical model examines changes in risk perceptions during the early crisis period when the CDC was warning consumers that they should avoid all vaping products and during a later period when the message was refined and focused on a narrower set of illegal vaping products that contain THC (the main psychoactive compound in marijuana). Econometric results suggest that the immediate impact of the first information shock was to significantly increase the fraction of respondents who perceived e-cigarettes as more harmful than smoking. As the outbreak subsided and the CDC recommendation changed to emphasize the role of THC e-cigarette products, e-cigarette risk perceptions were only partially revised downwards.
The EVALI scare may have exerted a downward effect on vaping risk perception and vaping behaviours, but this was in my view an unforgivable and deliberate operation to mislead the public. We can be pretty confident that it was deliberate because those who implied it might be attributable to nicotine vaping have made little effort to reset risk perceptions or to clarify that nicotine vaping was not involved.
Bloomberg Philanthropies’ e-cigarette initiative is a complement to and not a substitute for Bloomberg’s ongoing $1 billion commitment to reduce traditional tobacco use, the Bloomberg Initiative to Reduce Tobacco Use, which has saved more than 35 million lives around the world over the past decade by investing in and advocating for proven policies to prevent tobacco use.
Mr Bloomberg has a preferred policy package for tobacco control called MPOWER. This includes six measures that form the tortuous acronym.
- Monitor tobacco use and prevention policies
- Protect people from tobacco smoke
- Offer help to quit tobacco use
- Warn about the dangers of tobacco
- Enforce bans on tobacco advertising, promotion and sponsorship
- Raise taxes on tobacco
MPOWER is a Bloomberg initiative. MPOWER was launched by WHO in February 2008 in conjunction with Michael Bloomberg and it has remained the central pillar of Bloomberg funded tobacco control activism (along with anti-industry campaigns). The tobacco control grants awarded by Bloomberg Philanthropies (by far the biggest funder of anti-tobacco and anti-vaping activism worldwide) come with a contractual commitment to promote MPOWER. I am not going to discuss the merits or otherwise of MPOWER here other than to say that I don’t think the evidence is strong as Mr Bloomberg thinks it is or that MPOWER measures are without harmful unintended consequences that limit its applicability.
MPOWER has not, will not, and cannot solve the problem. Whatever the merits of MPOWER, we still have 1.1 billion people smoking worldwide (WHO 2016 data). The World Bank puts global tobacco-use prevalence at 24% (World Bank 2018 data). In countries with advanced economies, smoking prevalence ranges from 1-in-7 to 1-in-3 adults, despite extensive and long-standing warnings of the risks and decades of anti-smoking campaigns. In the United States, 14% of adults smoke, that’s 34 million Americans – 2019 CDC data). In richer countries, smoking is usually concentrated in disadvantaged groups in society (by socio-economic, race/ethnicity, education, employment, mental health status etc- see CDC summary on smoking inequalities in the United States and on smoking disparities). WHO claims that “Tobacco kills more than 8 million people each year. More than 7 million of those deaths are the result of direct tobacco use while around 1.2 million are the result of non-smokers being exposed to second-hand smoke“. At the time of writing (March 2021), the SARS-CoV-2 virus pandemic has killed about 2.8 million worldwide in its first full year (data).
Being clear about the endgame. The basic ‘problem’ is that nicotine is a popular drug and would be more popular if it was not so closely related to cancer etc through smoking. There is a big difference between smoke-free, tobacco-free and nicotine-free goals. Of these, the only public health goal that matters is smoke-free – trying to achieve the others will fail and will hold back progress on the first. The smoke-free goal cannot be attained by the brute force of regulation – that will just nourish black markets. The only way to do it is with the consent of consumers – and that means having appealing nicotine products available that will substitute for smoking but with risks consistent with more normal risk-appetite in society. For more on this, see my piece: The endgame revisited.
The case for additional harm reduction measures is strong. So, given the number of people dying in agony and living in misery as a result of smoking-related disease, I would expect advocates in this field to be looking for new ideas and opportunities to reduce the toll of cancer, cardiovascular and lung disease. I would expect them to be open to innovation and new ideas. I would expect them to approach new technology by asking “how do we make this work for health?” not by reflexively trying to bock it. I would expect activists in this field to be open to harm reduction strategies – i.e. approaches to reducing the health and other impacts of tobacco use (including the harmful effects of anti-tobacco policies such as regressive taxation and stigma) for people who wish to use tobacco and nicotine or find it difficult to stop. Harm reduction is widely practised in other branches of public health – illicit drugs, HIV, sexual health etc. Why not in tobacco control? In fact, it should be an ethical obligation – if policymakers want to ratchet up the pressure to quit with coercive, punitive, restrictive and stigmatising measures, then there is an ethical obligation to offer every possible option out of smoking and to make it as easy as possible to quit.
But Bloomberg-funded entities oppose harm-reduction and campaign for prohibition. What we see instead is a Bloomberg-funded worldwide movement of prohibitionists, dedicated to banning reduced-risk products, even in counties where there are high levels of smoking and cigarettes are ubiquitously available. For example, see the position paper of The International Union Against Tuberculosis and Lung Disease (“The Union”) urging bans on low- and middle-income countries (LMICs) – where 80% of the world’s smokers live: Where bans are best: Why LMICs must prohibit e-cigarettes and heated tobacco product sales to truly tackle tobacco’ (press release – May 2020). See also the excellent response to this dreadful position statement by the consumer organisation INNCO: Why Bans of Low-Risk Nicotine Alternatives to Smoking in Low- and Middle-Income Countries (LMICs) Will Do More Harm Than Good (March 2021).
Creeping prohibition. Bans of much safer vaping products where cigarettes are easily accessible have steadily become normalised instead of being widely seen as obviously insane. In 2018, WHO proudly reported that 30 countries had banned e-cigarettes [FCTC/COP/8/10] and John Hopkins Bloomberg School of Public Health also shows 30 countries with bans, including India (89m smokers); Egypt (13.7m smokers, male smoking prevalence = 44%) and Turkey (16.7m smokers, male smoking prevalence 41%). Bloomberg Philanthropies targets its grants programme at 10 LMICs (see table below) and these account for around one-half of the world’s smokers and many with very high males smoking prevalence (data from the Tobacco Atlas) and, of course, the ubiquitous availability of cigarettes.
Risk of more harm than good. The way I see this table, half a billion people, almost half the world’s smokers, are at considerable risk of Bloomberg-induced policies that will deny them access to the safer products that they can use at their own expense and on their own initiative to reduce their own personal risks. This will potentially harm and possibly kill some of them. It is quite possible that Bloomberg will do more harm than good.
Bloomberg money reaches deep inside important institutions like WHO and the World Bank. Bloomberg money funds the 2-yearly WHO Report on the Global Tobacco Epidemic (2019 version) which takes a highly positive view of MPOWER (and is based on it) and, unsurprisingly, a very hostile approach to tobacco harm reduction and reduced-risk products. The Global State of Tobacco Harm Reduction looks into the well-funded attack on tobacco harm reduction and the complex structure of grant-giving and influencing that sits behind it: see Chapter 5: Project Fear: the war against nicotine.
In my view, this constantly evolving infrastructure has become a vector for harm through its opposition to much safer alternatives to smoking. Despite all its hostility to the tobacco industry, this Bloomberg Anti-vaping Propaganda Complex is doing a great deal to protect the cigarette trade from technology disruption that would ultimately render cigarettes obsolete.
Tobacco companies have fought us tooth and nail every step of the way, and we are disappointed to see so many similarly baseless assertions receive safe haven in Mr. Gunther’s article.
Dismissing criticism rather than engaging with critics. This is a cheap smear and an attempt to delegitimise the arguments made by Mr Gunter’s sources (see 2 above) by attributing them to the tobacco industry. This is another reason why it is clear they are not sincere: they choose not to engage their critics but to dismiss them. The fact is that there is a deep base of support for tobacco harm reduction among academics and practitioners, including those quoted in Mr. Gunther’s article. For example, see the 72 signature to this letter to the WHO – they can hardly be called tobacco industry stooges, yet they disagree with Henning, Myers and Koval.
The tobacco and nicotine industry transition. This may be a surprise, but the tobacco companies are, to varying degrees, actually following their consumers, who have no interest in dying from cancer if there is an alternative. It is a good thing if the companies are trying to get out of the Merchants of Death business. The rate of transition from combustibles to non-combustibles will depend on what people think about switching and the regulatory and fiscal environment. This rate is currently much slower than it might otherwise be because campaigners like Henning, Myers and Koval are working tirelessly to impose restrictive regulation and the creating of a hostile information environment, which makes it less likely that smokers will switch from cigarettes to e-cigarettes. It is worth thinking about how tobacco companies see changing market. I have tried to put myself in the seat of a tobacco CEO and imagine what it looks like: Pariahs, Predators or Players: the tobacco industry and the end of smoking. Public health advocates should be working out what system of incentives would expedite this transition, but the tobacco companies are just too useful as the bad-guys in the story to do that.
The threat of safer products. At first sight, it seems difficult to understand why these organisations would oppose products that are, beyond any reasonable doubt, much safer than the dominant market incumbent, cigarettes. In my view, the reason is that ‘harm’ is their campaigning currency. Were it not for harms in some form, then the whole edifice of tobacco control organisations, grants and campaigns would have little reason to be. Safer products create a lifeline for smokers, they create disruption for the industries involved in the transition, but they create an existential threat to tobacco control interests. I’ll leave it to readers to consider the interests and incentives of the various actors involved when confronted with the prospect of much safer nicotine products.
For instance, the article strongly implies that removing flavored e-cigarettes from the marketplace will prevent adult cigarette smokers from quitting. That is simply not true. The FDA has approved a variety of smoking-cessation products — some with nicotine, others without — including patches, gums, nasal sprays, inhalers, lozenges, and pills.
Tobacco harm reduction is not the same as smoking-cessation treatment. This comment betrays a misunderstanding about how vaping works to reduce risks, and it shows that Henning, Myers and Koval have not done adequate due diligence on their policy proposals. They are missing an important distinction:
- Smoking-cessation medication: used to mitigate the effects of withdrawal and craving while the user attempts to transition from smoking to abstinence.
- Tobacco harm reduction: different ways of using the mildly stimulating and calming drug nicotine with much less harm and more pleasure.
In their dismissal of vaping, Henning, Myers and Koval make the rookie error of offering the former as an alternative to the latter.
Smoking cessation options remain available. There is no doubt that some people wish to give up smoking and nicotine completely – for them, the smoking cessation medications are available and are not in any way diminished by the tobacco harm reduction options. It is also the case that vaping products can function as smoking cessation aids and there good data from randomised controlled trials to suggest that they work well and probably better than the alternatives. The reason they work well is that that they replace more of the smoking experience than smoking cessation medications, for example, nicotine exposure, throat sensation, flavour, hand-to-mouth movement, behavioural ritual – and all at much lower risk. There is therefore less to lose by switching.
Swapping one pleasure for another. But a significant proportion of vapers have little interest in complete abstinence or, if they do, it may be driven by baseless safety fears, given what we know of risk perceptions. The point is that the appeal of the product (including its flavours, branding, nicotine effect, and cost-saving) is what makes vaping an attractive rival ‘value proposition’ to smoking, but at much lower risk. This is why it is an important option for the population at risk, adult smokers. The population at greatest risk is the people who like using nicotine, may like smoking and don’t want to quit or find it difficult to quit smoking. These are not the people who volunteer for smoking cessation trials on which the approvals of smoking cessation medications are based. The diagram shows elements of the rival proposition using the ‘7 Ps’ of the marketing mix. In tobacco control, activists try to degrade the smoking value proposition. But what is the effect if they degrade the vaping value proposition – through taxes, bans, packaging mandates, nicotine limits etc? That would make the transition from smoking to vaping harder – and that’s exactly what Henning, Myers and Koval are doing – protecting the cigarette trade, probably without realising.
A feature of the second mechanism, tobacco harm reduction, is that it works in a way that Henning, Myers and Koval are unlikely ever to embrace – the interplay of pleasure-seeking consumers with profit-seeking innovators in a lightly-regulated market, where regulation is focussed on competition and consumer protection. If that sounds scandalous, remember that is how the markets for alcohol and caffeine work, and I can think of many tobacco control activists who enjoy the mild intoxication of a glass of wine with their dinner or a beer after work.
It takes Mr. Gunther more than 2,500 words to mention that the FDA has not approved a single e-cigarette as a smoking-cessation device, and he ignores completely the fact that no e-cigarette company has even tried to prove to the FDA that its products are effective at helping smokers quit.
If vaping is too difficult to understand, consider the case of snus. Henning, Myers and Koval resort to a non-sequitur in this lame attempt at mockery. Vaping products are not ‘smoking cessation devices’ (as explained in 11 above) above, but that does not mean people are not quitting smoking using them. Consuming diet cola may help reduce sugar consumption, but that does not make it a medication for type 2 diabetes. If that explanation still seems puzzling, then these leaders in tobacco control can try to think of the role played by snus, a form of smokeless tobacco, in Sweden. Sweden is an outlier in smoking prevalence in the EU and globally, with current smoking at 7% and daily smoking at 5%, compared to the EU average of 23%. The reason for the low rate of smoking is the widespread use of snus, primarily by men. See latest data from Eurobarometer 506.
A tobacco product that reduces smoking and tobacco-related harm without being a medicine? No one, not even Henning, Myers and Koval, would think of the smokeless tobacco product snus as a “smoking-cessation product” that should be taken to a regulator and approved as a smoking-cessation medication. Yet, here we are with a tobacco product responsible for an anomalously low rate of smoking. Thanks to the peerless work of Lars Ramström, we also know this translates directly to health gains in the Swedish population – see: Tobacco-related mortality Sweden & EU charts – the difference between men and women arises because snus use among women is lower.
Henning, Myers and Koval are leaders in this field and they control the funds and policy positions of hundreds of activists in the United States and worldwide. Frankly, I find it disturbing that they do not understand this public health model. It’s troubling to me that they cannot see that this basic idea also applies to vaping. Through vaping, heated tobacco products, smokeless tobacco and nicotine pouches we might be able to generalise the spectacular harm reduction proof-of-concept from Sweden to most countries. Though they may look like (and can perform like) a kind of pimped-up NRT, e-cigarettes fit into a similar psychological enclave as snus, not as NRT. I hope that is now clear.
Vaping companies are properly following FDA’s regulatory pathway. Henning, Myers and Koval imply that the vaping companies are somehow rogue operators. However, they know, or should know, that the vaping companies are following the FDA’s process for approving vaping products under the Tobacco Control Act – the ultra-burdensome Pe-Market Tobacco Application (PMTA) process under Section 910 of the Act. After a federal court determined that vaping products were not smoking cessation medications in 2010, FDA deemed vaping products to be ‘tobacco products’ for the purposes of the Act in 2016. It did not finalise its guidance on the requirements for this process until early 2020. Companies were required to submit their applications by 9 September 2020 and now FDA is considering thousands of application. To gain approval, applicants have to show their products are “appropriate for the protection of public health”. The companies are doing what the law and their regulator requires.
Sabotaging the Tobacco Control Act – and I don’t mean Big Tobacco. It appears that groups like Campaign for Tobacco-Free Kids are now nervous that FDA might actually authorise some of these products and find that they are “appropriate for the protection of public health”. That was never the idea: the point was to use massive paperwork burdens to throttle these companies access to market. But now it has fired up its supporters in Congress to urge the FDA to dump all this careful analysis and weighing of benefits and detriments to public health, and get straight to the point and implement bans. Alex Norcia in Filter has the story: Why Are Congress Members Demanding That the FDA Halt Its Evaluation of Flavored Vapes? The groups behind this letter are the ones going rogue, not the tobacco and vape companies.
In fact, every major U.S. public-health authority that has comprehensively reviewed the scientific evidence has reached the same conclusion: To date, there is limited and inadequate evidence to conclude that e-cigarettes are effective for smoking cessation.
This is so feeble. Firstly, many in the US public health establishment are also caught up in the absurd anti-vaping moral panic created and amplified by Bloomberg-funded entities – so there is group-think at work.
Secondly, the absence of evidence is not evidence of no effect – it arises because the companies do not do expensive trials for no reason. They are following a different track – the PMTA as described above and the data in those applications remain confidential.
Third, they are not making therapeutic claims and therefore are not doing trials to support therapeutics claims.
Fourth, the evidence that supports the conventional smoking cessation treatments is only narrowly applicable and much weaker than Henning, Myers and Koval seem to realise.
Fifth, there is actually good evidence that vaping is effective for smoking cessation. The UK smoking cessation expert, Professor Robert West summarises the evidence in his presentation: Should health professionals recommend health professionals to switch to e-cigarettes? which includes the following slide:
There is good evidence on smoking cessation if you are open to it. What is disturbing is that Henning, Myers and Koval are prepared to treat a statement about ‘limited and inadequate’ evidence as if it means there is sufficient reliable evidence that the products are ineffective. On that basis, they try to justify punitive measures such as flavour bans. The evidence is already compelling if you are open to it. For example, the authoritative Cochrane Review concluded in its report on e-cigarettes of October 2020:
The results showed that more people quit smoking if they used electronic cigarettes containing nicotine than if they used another form of nicotine replacement.
Evidence from four studies (2312 people) showed that more people who used nicotine-containing electronic cigarettes quit smoking than those who received only behavioural support or no support.
These are conservative statements because e-cigarettes do not function as smoking cessation products in the same way as NRT as discussed above. But the problem with Henning, Myers and Koval is not only that they are ignoring the actual evidence that does exist from trials and the other sources mentioned by Professor West, but that they are acting as if they have strong evidence of no helpful effect. That is irresponsible, in my view.
For decades, tobacco companies were permitted to run rampant, ruthlessly addicting millions, before governments finally asserted their authority to prioritize the health of children and families over tobacco companies’ profits. E-cigarette companies are counting on the “wait and see” approach repeating itself. Not on our watch.
This is Henning, Myers and Koval retreating to their safe space – a kind of reflex outrage about tobacco companies, addiction, children and profits. A place where we all know who the bad guys are, where they can count on indulgent media and grandstanding politicians to rally to their defence without considering the consequences. The problem is that their traditional anti-industry war-cry functions as a distraction from examining the consequences of their actions and their policy positions, and the proper account of the harmful effect these have on people who are much less vocal and do not have billionaire backing. It is a distraction from considering the transformation underway in the industry from combustible to non-combustible products. It is there to shut down critics by implicitly identifying them as fellow travellers with the tobacco industry. It is a barrier to understanding what works and a barricade behind which they hide from scrutiny.
The letter signs off.
Public Health Program Lead, Bloomberg Philanthropies
Matthew L. Myers
President, Campaign for Tobacco-Free Kids
CEO, Truth Initiative
Professional responsibility. These people are leaders in their field. They should have a strong professional and ethical ethos, given that what they do may plausibly cause mortal harm to others who have little say and no money. But do they? Are they really thinking through the consequences – intended and unintended – of their actions? Are they appropriately open-minded and curious about developments in their field? Or are they incumbents vested in the tobacco control status quo and the large flows of money now involved? Are they prohibitionists doing more harm than good?
Oversight and accountability. And who puts tough questions to them about what they are doing and what effect it is having on public health and on smokers and vapers? Who takes care to test the possible perverse consequences arising from their advocacy? Who gets them to see how the world is changing and how they may need to change too? They are governed by boards of directors comprised of the great and good (see boards of Bloomberg Philanthropies, Campaign for Tobacco-Free Kids and Truth Initiative). But seriously what kind of oversight do these boards impose? What level of constructive challenge? Are they bringing fresh thinking and different perspective to the board? Or are they just compliant cheerleaders, hand-picked for their facility with a rubber stamp?
Accountability is at the heart of the problem here: these groups can spend millions of dollars harming ordinary citizens and there are no consequences for anyone involved – so far. The board members of these organisations should read Mr Gunther’s article carefully and start asking some questions. Mr Bloomberg likes to say “In God we trust. Everyone else, bring data“. Well, I’ll happily bring data if he brings an open mind.
Marc Gunther’s Twitter response
Marc Gunther’s interviews with Michael E. Hartmann – The Giving Review
Regulator Watch – Bloomberg’s War on Vaping
- No shame: Bloomberg’s war on vaping Part 1 with Samrat Chowdhery
- Call it colonialism: Bloomberg’s war on vaping Part 2 with Michelle Minton
- Scrutinised: Bloomberg’s war on vaping Part 3 with Roberto Sussman.