Author: Franklin Apfel [including interview transcript from Derek Yach] January 31 2018 – This blog, one of four, is part of series in which Apfel analyses and McKee comments on Yach’s interview responses on the tobacco industry and his involvement in the Foundation for a Smoke-Free World. The series is intended to identify new ways in which the industry is attempting to (re)frame conversations on tobacco and health and tobacco industry behaviours as demonstrated by their adherence to or circumvention of article 5.3 of the WHO Framework Convention on Tobacco Control (FCTC). Article 5.3 of the WHO Framework Convention on Tobacco Control states: "In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law." 

A four part interview and commentary series 

Interviewer: Franklin Apfel, World Health Communication Associates (WHCA)

Interviewee:  Derek Yach, Founder and Director Phillip Morris International (PMI) Foundation for a Smoke- Free World

Commentary: Professor Martin McKee, London School of Hygiene and Tropical Medicine (LSHTM)

The Harm Reduction frame

Apfel: In this frame, the case is made for the development and marketing of non-combustible (e.g., heated not burned) tobacco and nicotine vaporised products to replace tobacco and save lives. Critics say that product safety and effectiveness is unproven; they question the need to addict people to nicotine; and they worry about shifting attention from the current end game plan that focuses on all countries implementing FCTC strategies related to taxes, advertising, cessation, etc.

Q. Some are calling PMI interest in non-combustibles a cynical market expansion geared towards expanding use of a new product and not necessarily eliminating use of more harmful products. What’s your thought on that?

DY. Well I don’t have just thoughts, I can look at the data in Japan which is showing that expansion of the Heat not Burn product is dramatically taking down Marlboro in that market. The same is happening in Korea and I suspect around the world. So you certainly see a displacement of their one brand which is known to have a certain level of toxicity ( all the consequences of cigarettes)  with another product with a risk reduction on the order of 90% of maybe even higher in time. In my view that's a good thing!. It wouldn't be perfect but it would be a dramatic reduction in death and disease for 150 million users of Philip Morris products and would probably accelerate what we also see in Japan: other companies starting to compete no longer on simple taste or flavor but on lowering risk to the consumer because that's where the smokers are increasingly want to go.  a large number of people currently on Japan tobacco, BAT and Chinese cigarettes and has them use iQOS or any other reduced risk product-make a profit over the next decade or so-public health would be the winner. In fact the consequences for public health are likely to be huge. The latest study by David Levy when he modeled the impact of e-cigarette use across the US over the next decade and shows that millions and millions of lives would be saved. Well, multiplied into these Marlboro figures, we are talking about tens of millions of lives. I don't see why that is not seen as a good thing.   

Q.Many of the noncombustible products are already patented by Philip Morris or other tobacco companies. Some believe that your  “independent” foundation is a just a vehicle to make those patents more valuable.

DY. [I c]annot see how that would be the case. We will evaluate the full range of products on the market as they evolve. If product A shows lowered risk and higher cessation potential-I would hope it wins in the market! We are agnostic to the manufacturer.

Q. Don’t you think people will go to other places where they could get tobacco if Philip Morris makes this shift? 

DY. We need a sector wide change and my hope and vision, is that what Philip Morris is doing now, what BAT is doing joining with Japan tobacco and what others are starting to do with e-cigarette businesses, and what the FDA is calling for, is the long wanted big shift in separating nicotine control from tobacco control. Basically if we had every single one of the billion smokers in the world today on one of these products we will be lowering risk. This has to be done incrementally. If PMI was to listen to the NGOs call and withdraw all cigarettes from the market, of course they would be bankrupt tomorrow and that would be the end of the company and of a deep transformation underway. Of course the Chinese would love to jump in! Such market naiveté would set back progress.

I wonder how many serious tobacco control folk ever, look at the data on who are the largest manufacturers of cigarettes in the world. They would see that while the discussion around Philip Morris,  BAT and Japan tobacco is important, the really big issue is going to be how we deal with the fact that 41% of all cigarettes produced in the world are produced by the Chinese state monopoly. That equals the sum total of all Philip Morris, BAT, Japan, Reynolds products plus another few percent added on the top! 

Q. Many would say that this represents an “ends justifies the means” approach and find it unacceptable to ignore moral concerns related to continued promotion of the deadly tobacco product. 

DY. I think that the issue of morals and ethics are quite interesting...[especially when it comes to harm reduction approaches]… Many people starting with Dan Wikler whom I regard as one of our finest bioethicists and epidemiologists from Harvard, many years ago wrote that it's unethical not to support harm reduction, …With HIV-AIDS needle exchange issues, methadone programs, many public health approaches are being (re)built on the realization that, for complex behaviors, people cannot go from black to white, they have to go through the gray zone and that gray zone is the area of harm reduction where you incrementally lower risk by either changing the product or the behavior… This is still an anathema to many people in tobacco control because of the history where they saw that there were so many tricks - the low tar one being perhaps the worst of the lot. … But now when evidence points to [positive] harm reduction effects of nicotine replacement and governments and public officials are still saying E-cigarettes are as dangerous as cigarettes: that is ethically unacceptable. 

Commentary - Professor Martin McKee 

Yach’s comments make clear that a major focus of the Philip Morris Foundation will be on alternative nicotine delivery products. Although he contends that it will go beyond this, many will view this initiative as nothing more than one element of a comprehensive programme to promote these products. He calls for more research, arguing that they have been on the market for such a short time that we have yet to demonstrate their benefits. Yet this is barely credible. They have now been marketed for 13 years yet, in all that time, there has been no high quality evidence from randomised controlled trials to demonstrate their effectiveness as a quitting aid. A substantial number of such trials have been registered, some quite some time ago, but have never reported results. Inevitably, sceptics will ask why. 

Given this dearth of evidence, Yach’s claim that “millions and millions of lives would be saved” by increasing uptake of these products is based on a study whose assumptions, as others have noted, are simply implausible. Indeed, this is the real problem with these products. Take the notorious claim that they are 95% safer than conventional cigarettes. This was derived from a paper in which the authors themselves conceded the conclusions were limited by “the lack of hard evidence for the harms of most products on most of the criteria” and where unanswered questions remain about the possible role to the tobacco industry. In other words, this Foundation seems to be pinning its hopes on products whose safety and effectiveness simply isn’t known, although at least in terms of the accumulating evidence of risks to the cardiovascular system, there are certainly grounds for great caution. Meanwhile, the Philip Morris company continues to devote massive resources to undermining and opposing evidence-measures to reduce smoking, litigation even against governments, and promoting its "core" products in developing countries.

So has Derek Yach told me anything that will lead me to change my mind? No. Those with long memories recall earlier attempts by the tobacco industry to rehabilitate itself. It didn’t work then and, from what we have seen so far, it won’t work now.

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