Tobacco industry influence in low- and middle-income countries in the ASEAN region: Qualitative interviews with tobacco control experts during the COVID-19 pandemic.

INTRODUCTION: While most Association of Southeast Asian Nations (ASEAN) countries have adopted the Framework Convention on Tobacco Control (FCTC), implementation and enforcement of measures are lacking in some low- and middle-income countries (LMICs) in the region. This study aimed to describe: 1) how the tobacco industry has undermined tobacco control efforts and adapted its tactics in response to the COVID-19 pandemic and other external factors, 2) the political factors that hinder progress, and 3) the expert recommendations to overcome challenges of tobacco control in the ASEAN region. METHODS: During the COVID-19 pandemic, qualitative interviews were conducted with tobacco control experts to explore their perspectives and recommendations to address the barriers and challenges of tobacco control in ASEAN LMICs. RESULTS: Eleven tobacco control experts participated in interviews. Five themes emerged from the data: 1) a shift to below-the-line marketing and digital technologies to target youth; 2) industry develops new tactics to undermine tobacco control; 3) cigarette packet branding - the last remaining marketing channel; 4) political factors hindering tobacco control; and 5) broader involvement and collaboration in tobacco control. CONCLUSIONS: The tobacco industry continues to undermine tobacco control in ASEAN LMICs, shifting its marketing, corporate social responsibility (CSR) and lobbying tactics in response to changing regulations, digital technologies, and the COVID-19 pandemic. While lack of government leadership also hinders progress, full adoption of the FCTC and increased collaboration in tobacco control are recommended to overcome these issues.

A call to ban the sale of tobacco products.

Tobacco is both toxic and addictive. Mounting evidence shows that tobacco use has a detrimental impact on almost every aspect of human health, causing or worsening deadly public health crises from the cancer epidemic to the COVID-19 pandemic. However, while tobacco use is a threat to both personal and public health, it continues to surge across the world, especially in China and other low- and middle-income countries. To this end, this article argues in favor of using a ban on the sale of all tobacco products as a practical solution to the global tobacco use epidemic. It is our hope that insights provided by our work will inspire swift policy actions in countries such as China and beyond to curb the tide of rising tobacco consumption, so that populations around the world could be better shielded from the pervasive and long-lasting damage that tobacco products cause or compound.

How Big Oil is manipulating climate science

The UK has a new king (doi:10.1136/bmj.o2196),1 one who believes that modern medicine must combine the “best of new technology and current knowledge with ancient wisdom” (doi:10.1258/jrsm.2012.12k095),2 and a new prime minister, Liz Truss, who promises to deliver, deliver, and deliver (doi:10.1136/bmj.o2147).3 England has a new health secretary, with a worrying track record on health (doi:10.1136/bmj.o2193).4 The US has introduced a law that limits the profiteering of drug companies(doi:10.1136/bmj.o2163).5 Scotland is considering legalising assisted dying (doi:10.1136/bmj.o2205).6 And The BMJ has appointed three new columnists (doi:10.1136/bmj.o2201, doi:10.1136/bmj.o2195, doi:10.1136/bmj.o2206).789 And yet, covid persists in posing questions that are difficult to answer (doi:10.1136/bmj.o2183),10 including the merits and role of testing (doi:10.1136/bmj-2022-071215, doi:10.1136/bmj.o2055).1112 A plan to solve the workforce crisis has many obvious factors to consider yet remains elusive (doi:10.1136/bmj-2022-072977)13;new evidence underscores the worrying link between doctors’ burnout and deterioration in patient care (doi:10.1136/bmj-2022-070442, doi:10.1136/bmj.o2157)1415;health service whistleblowers still receive shoddy treatment (doi:10.1136/bmj.o2187)16;and people at the end of life continue to struggle to benefit from palliative care (doi:10.1136/bmj.o2202).17 Another constant in our ever changing world is industry’s attempts to manipulate science, behaviour that we would now describe as disinformation. Two particular areas of focus are the push for fracking, something of which Liz Truss has spoken favourably—despite evidence pointing to climate harm from methane leaks (doi:10.1136/bmj.k2397)19—and for developing carbon capture technology, a response to carbon emissions that has seen universities receive huge donations even though industry’s internal documents accept that carbon capture doesn’t make economic or environmental sense. Evidence of attempts to manipulate science were persuasive in our decision to stop publishing research funded by the tobacco industry (doi:10.1136/bmj.f5193).20 We already support divestment from fossil fuels, and this new investigation is another spur for medical and healthcare organisations to join us (doi:10.1136/bmj.m167).21 Our policy is also to decline all research funded by companies that produce fossil fuels, although their involvement in research into alternative green energy solutions makes this calculus more complex.

ENDS advertising expenditures in English language media in the USA, 2015-2020.

BACKGROUND: Electronic nicotine delivery system (ENDS) advertising is associated with ENDS purchase and use. This study assessed trends in ENDS advertisement (ad) expenditures in the USA from 2015 to 2020 overall, by media channel and by advertiser. METHODS: Data came from Numerator, which conducts surveillance of ads and estimates expenditures. The estimates are dollars spent (adjusted to 2020) by the advertiser for each ad occurrence for print, radio, television and digital (online, mobile) media channels. ENDS ad expenditures were assessed by quarter, media channel and the top five advertisers based on ad occurrences. RESULTS: Overall ENDS ad expenditures increased from $38 million in 2015 to $217 million in 2019 before decreasing to a low of $22 million in 2020. By media channel, print expenditures led the channels with more than twice as much spent as television, four times more than radio and 10 times more than digital. By advertiser, JUUL led in ENDS ad expenditures from 2015 to 2020 with almost $189 million spent, followed by British American Tobacco (BAT, $105 million) and Imperial Tobacco ($62 million). CONCLUSIONS: Overall ad expenditures were relatively stable from 2015 to mid-2018 when large expenditures by JUUL and subsequent expenditures by BAT and Imperial Tobacco led to expenditure highs in 2019. E-cigarette and vaping-associated lung injury (EVALI), the JUUL self-imposed ad suspension and COVID-19 likely all played a role in advertising lows in 2020. The absence of popular Puff Bar brand ads from the traditional media channels studied highlights the importance of monitoring direct and indirect advertising on newer media channels like social media.

The new tobacco products in the new era

Since its first emergence in Dec. 2013, heated tobacco products (HTPs) have been rapidly spread in Japan, accounting for the majority of world market share. According to the National Health and Nutrition Survey in 2019, 27% of male and 25% of female adult tobacco users used HTPs and the percentage reached 50% among youths. This “new” type of tobacco has tremendous impacts on tobacco control both in terms of science and society. From a viewpoint of monitoring, it is becoming harder and harder, to accurately grasp its prevalence due to rapid changes in the products' line-up and appearance. This also make it difficult to perform chemical analyses of the products. HTPs are becoming a loophole of the new national clean air policy that started in Japan in Apr. 2020 and related ordinances on a municipality level. Under the pandemic of COVID-19, Tobacco industry is promoting HTPs by making them look like a solution for the restriction of the place of tobacco use. HTPs contains many harmful or potentially harmful substances including carcinogens but are promoted as less harmful products. Those misleading promotions are being conducted utilizing the lack of mandatory regulations on the advertisement and promotion in Japan.

'To be honest, I'm really scared': perceptions and experiences of intimidation in the LMIC-based tobacco control community.

BACKGROUND: It is well-evidenced that environmental or human rights advocacy comes with risks for those involved. Much less is known about the risks of tobacco control advocacy despite the emphasis on tobacco industry conduct. This study explores the experiences and perceptions of intimidation among members of the tobacco control community in low- and middle-income countries (LMICs). METHODS: We interviewed six experts representing each of the World Health Organization (WHO) regions to inform an online survey conducted among the LMIC-based tobacco control community. Thematic analysis was used for analysing qualitative data while quantitative data were analysed descriptively. RESULTS: Twenty-three participants from five WHO regions completed the survey. Almost three-quarters of survey participants reported that they, or another member of the tobacco control community in their country, had experienced intimidation. The most frequently reported forms of intimidation were discreditation on social or traditional media, legal threats/action and threatening messages. Physical intimidation, theft/burglary, cyberattacks and surveillance were individually rare but reported collectively by over 40% of participants. Results suggested intimidation might be increasing and changing in nature, and undermines tobacco control efforts: it affects organisations' capacity and agenda, their ability to build relationships with those needed to advance policy, as well as the well-being of individuals. Participants used a range of strategies in response to intimidation and reported that they would benefit from better support. CONCLUSION: This exploratory study suggests that intimidation is a crucial challenge for the tobacco control community. There are several measures the global tobacco control community could take, including establishing an international support mechanism and building capacity to deal with intimidation and draw attention to it.

The Epidemic During the Pandemic: Assessing the Federal Drug Administration's Efforts to Curb Youth Smoking After Passage of HR2339 by Congress

The act sought to improve Food and Drug Administration (FDA) regulation ofthe marketing, sale, makeup, safety, and study of electronic nicotine delivery systems (ENDSs). Since the passage ofthe act, the United States has made some progress in limiting youth access to flavored ENDSs. Factors influencing youth tobacco use included flavoring in tobacco products, product marketing and access, and misconceptions about health risks.5 Studies also show that tobacco industry profits from the sale of ENDSs have increased since the passage of HR2339 and through the COVID-19 pandemic. Public health advocates must quickly respond to tobacco industry marketing tactics by debunking misleading campaigns promoting new synthetic nicotine and "tobacco-free" products attempting to circumvent regulation.8 Along with increases in taxes on ENDSs and enactment of policies restricting the sale of flavored products at the local level, such actions can help protect young people from the harms caused by tobacco products and help discourage them from ever starting at all. ,4jPH CORRESPONDENCE Correspondence should be sent to Michael D. Celestin Jr, PhD, NCTTS, CHES, Behavioral and Community Health Sciences Program, School of Public Health, Louisiana State University Health Sciences Center New Orleans, 2020 Gravier St, 3rd Floor, New Orleans, LA 70112 (e-mail: mceles@lsuhsc.edu).

Tobacco Control—Lighter Side: 30th Anniversary Cartoons

Correspondence to Stan Shatenstein, Deputy News Editor, Tobacco Control, Montreal, Quebec, Canada;shatensteins@sympatico.ca For the past 30 years, Tobacco Control (TC) has been one of few leading scientific journals to include editorial cartoons in its pages. Tobacco Industry and Tobacco Control Smoking and the Movies Long before Jurassic Park IV could be imagined, smoking had made a notable comeback in films like Avatar, where growing tobacco would have been near impossible or an extraordinary waste of precious agricultural land, and in the original Jurassic Park, Samuel L Jackson recalls that director Steven Spielberg gave him ‘the worst-tasting fake cigarettes ever’, knowing that Jackson had quit smoking and did not want to suffer a relapse in real life. Lawsuits In 2005, the Supreme Court of Canada unanimously upheld British Columbia’s Tobacco Damages and Health Care Costs Recovery Act, making it possible for the province to continue to seek redress from the tobacco industry.

South Asia's evolving tobacco hydra: moving from quandary to hope.

The South Asian region occupies a unique place in global tobacco control because of a broad spectrum of widely used tobacco products and the consequent mix of local and transnational tobacco industries. Cigarette use is especially high among males in many countries, while bidis are widely used in India, Bangladesh and Sri Lanka, and are very inexpensive. Smokeless tobacco use is a global problem, but the bulk of use is in South Asia and there is emerging promotion of newly developed tobacco and nicotine products across the region. With the transnational cigarette industry contributing a significant amount in taxes, the bidi industry employing millions of workers and many farmers engaged in tobacco farming, the industry is powerful and exploits this when countering proposed advancements in tobacco control policy. Despite industry interference and major challenges, this region has achieved remarkable successes in tobacco control, including large pictorial warnings that cover up to 80%-90% of the pack in some countries, stringent rules on depiction of tobacco in movies, bans on advertising and promotion, and smoke-free public places. Key challenges include increasing the tax component of retail prices and reducing tax concessions, regulating newly developed products and countering the aggressive tactics of the tobacco industry. Strategies to advance tobacco control in the region may also include standardised packaging of tobacco products, sustained mass media campaigns to warn the population of the harms of tobacco use and promote use of available cost-covered cessation services, and supply-side measures such as vendor licensing.

Tobacco control in Asia-Pacific: wins, challenges and targets.

For many decades, the international tobacco industry has set its sights on Asia, due to the large population numbers, the high prevalence of male smokers who might shift to its brands, and the extremely low number of female smokers who could possibly be induced into starting smoking. Because of US trade threats against several Asian countries in the 1980s, Asia became quickly aware that tobacco control involved politics, legislation, economics and trade. Several Asian jurisdictions pioneered tobacco control measures, and the Western Pacific is still the only WHO region where all countries have ratified the WHO Framework Convention on Tobacco Control (FCTC). Progress needs to be accelerated to reduce the still high male smoking prevalence and maintain the low female prevalence by fully implementing the WHO FCTC as part of achieving sustainable development, even while grappling with the looming epidemic of new products, holding the companies accountable, and protecting tobacco control policies against constant industry interference.

Multi-Technology Driven R&D Cost Improvement Scheme and Application Utility of EESP in Energy-Intensive Manufacturing Industry

Facing the sustainable use of electric power resources, many countries in the world focus on the R&D investment and application of electrochemical energy storage projects (i.e., EESP). However, the high R&D cost of EESP has been hindering large-scale industrial promotion in the energy-intensive manufacturing industry represented by the tobacco industry. Reducing and controlling the R&D cost has become an urgent problem to be solved. In this context, this paper innovatively proposes a multi-technology driven R&D cost improvement scheme, which integrates WBS (i.e., Work Breakdown Structure), EVM (i.e., Earned Value Method), BD (i.e., Big Data), and ML (i.e., Machine Learning) methods. Especially, the influence of R&D cost improvement on EESP application performance is discussed through mathematical model analysis. The research indicates that reducing EESP R&D costs can significantly improve the stability of EESP power supply, and ultimately improve the application value of EESP in energy-intensive manufacturing industries. The R&D cost management scheme and technical method proposed in this paper have important theoretical guiding values and practical significance for accelerating the large-scale application of EESP.

Reframing the banning of flavored tobacco in unprecedented times- an example from California's Senate bill 793.

Several cities, but only two U.S states, have passed a law banning the sales of flavored tobacco products. It has been suggested that framing tobacco control policy solely in terms of the youth could send the erroneous message that tobacco use is an acceptable behavior for adults. This study was intended to compare the framing of policy between California's Senate Bill (SB) 38 and 793. Seven audio files of hearings on SB-38 (N = 2) and SB-793 (N = 5), held between March 2019 and August 2020, were transcribed and coded for youth issues and the unprecedented events of 2020 that shaped society's views of health and racial/social justice. The Framework Method was used for organizing and analyzing content of the legislative hearings. Many of the same arguments pertaining to youth were presented in hearings on the two bills. The one notable difference was legislators' sense of obligation to younger constituents, which was expressed in hearings on SB-793, but not SB-38. The hearings on SB-793 also differed with respect to greater discussion about the relevance of a tobacco flavor ban to society as a whole. These discussions revolved around the COVID-19 pandemic and potential impact of a ban on communities of color. Discussions on SB-793 about the larger societal impact of flavored tobacco may be a more effective strategy than focusing exclusively on the youth. Thus, legislators from other U.S. states who are contemplating a statewide ban should consider reframing the issue according to California's SB-793.

IQOS marketing strategies at point-of-sales: a cross-sectional survey with retailers.

BACKGROUND: The point-of-sale (POS) is adapting to marketing restrictions, societal changes and the inclusion of new products, such as heated tobacco products (eg, Philip Morris International's (PMI) IQOS device and HEETS sticks). We aimed to assess (1) PMI's influences on IQOS/HEETS POS marketing and (2) the implications of the new legislation (POS display ban and plain packaging) for retailers. METHODS: A cross-sectional survey of 43 IQOS/HEETS POS owners/managers in five Israeli cities assessed POS and participant characteristics, marketing strategies, attitudes towards IQOS, and POS implications of the legislation and COVID-19, including industry reactions. Bivariate analysis explored differences between POS selling of the IQOS device versus POS selling of HEETS only. RESULTS: A higher proportion of those carrying IQOS (n=15) (vs HEETS only) had special displays (100% vs 17.9%, p<0.001) and interacted with specific IQOS salespersons (73.3% vs 28.6%, p=0.013). Common promotions were financial incentives based on HEETS sales for retailers (37.5%) and price discounts on HEETS for customers (48.7%). Most indicated positive attitudes towards IQOS (72.1%; eg, 'less harmful'), opposition to the legislation (62.7%), limited government assistance to implement the legislation (62.8%), and industry provision of display cases and/or signage to comply with the legislation (67.4%). CONCLUSION: PMI uses similar tactics to promote IQOS at POS as they previously used for combustible products, including direct promotional activities with retailers, and circumvented legislation by using special displays and signage. Governments need to ban these measures and support retailers with clear practical guidance regarding the implementation of marketing restrictions at POS.