The tobacco industry has long sought interactions with the health and medical communities that will enhance its legitimacy and augment profits. In the early 20thcentury, advertising involved the medical community emphasizing doctors who recommended cigarette smoking. From the mid 20thcentury, as scientific evidence developed, the tobacco industry contested restrictions vigorously as tobacco regulation intensified. The advent of ENDS products opened a new phase in marketing which stretched the limits of conventional tobacco control. The PMI Foundation, launched in 2017, targets the health and medical communities, promising research funding, the “Smoke-Free” aim and its interactions with high profile researchers. In the first few decades of the 20thcentury, tobacco companies involved physicians in advertising campaigns to promote health benefits and minimisation strategies for particular brands. Analysis of 1930s and 40s tobacco advertising in medical journals identified a number of strategies employed to involve doctors in promoting cigarettes including flattery, tobacco ‘science’, the advisory role to patients, less “irritating” brands and promotion of specific brands1. Analysis of tobacco advertising from the 1920s to the 1950s identified a focus on throat irritation, strategies to protect from harmful symptoms and portrayal of otorhinolaryngologists as promoters of cigarette-related benefits2. The “More Doctors smoke Camels” campaign3launched in the late 1940s by RJ Reynolds made a number of zealous health benefit claims, although landmark publications linking tobacco cigarettes to lung cancer led to scepticism from the health community and eventual banning of cigarette advertising and promotion in medical journals and at medical conventions3. From the mid-1960s, the paradigm for tobacco regulation shifted as evidence accumulated for the harmful effects. Additional key papers include a 1912 monograph, one of the first publications to link lung cancer with tobacco, early writings on lung cancer surgery and the 1964 US Surgeon General Report on Smoking and Health. Legislative efforts to control tobacco accelerated with, in the United States, the pivotal 1998 Master Settlement Agreement by which tobacco companies were obliged to pay compensation to 46 states to offset costs of smoking-induced illnesses4. In the early 21stcentury the WHO FCTC came in to force in 2005 with the launch of the MPOWER measures in 2008, setting up the tobacco framework that has characterised the last decade and a half and to which 181 countries are signatories. The emergence of e-cigarettes and other ENDS products has shifted tobacco control outside the current purview of the FCTC and opened up new areas of controversy as these products evade conventional regulation. E-cigarettes first appeared in the 20thcentury including designs from the 1960s from BAT and from the 1990s from PMI with the contemporary model attributed to an individual inventor5. The early designs were abandoned at least in part due to concerns about commercial viability6,7and it was not until the last decade or so that e-cigarettes have reached prominence. The emergence of highly appealing and commercially successful ENDS products such as the Juul device has stimulated concern at the level of the FDA and review of e-cigarette regulation. Companies such as Juul Labs (now owned by a tobacco corporation) and PMI advocate harm-minimization through their ENDS products while parent companies continue to sell conventional tobacco cigarettes in less tightly regulated markets. The Phillip Morris Foundation for a Smoke-Free World8was launched in 2017 and immediately prompted controversy. The stated aims of the Foundation include the funding of research, a focus on smoking cessation and harm reduction and the search for solutions to “unique challenges”8. Its launch prompted immediate debate and discussion, including a Lancet Viewpoint by the Foundation’s director, advocating the benefits of reduced-harm products and expressing concern that full implementation of the FCTC would take many years. An editorial in the same Lancet issue raised strong concerns about involving the tobacco industry in tobacco control while acknowledging that (at the time of writing) the Foundation had yet to begin work9. An accompanying commentary piece questions the credibility of the Foundation and points out that the funding of research is used by the tobacco industry as a deliberate strategy that in fact acts as a “public relations” exercise while PMI, in this instance, continues to sell cigarettes as its core product10. More recently, a review of the published tax returns from the Foundation suggest that it is having trouble both raising and spending funds, perhaps indicating some trouble engaging with the research community and multiple publications raise questions about its ethical robustness, the risks of long-term nicotine dependence and its commercial integrity. While the stated aims of the Foundation may appeal, concerns remain about engaging with the tobacco industry, about persistent global cigarette sales, about the use of the Foundation to divert attention from PMI’s efforts to build its market for ENDs products and about the prioritisation of harm-minimisation (with accompanying profits) over genuine efforts to make the world free from tobacco.
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Nov 8, 2019
Jonathan Grigg 
Open Access