Letter to the Foundation for a Smoke Free World about money, governance, conflicts and Philip Morris International by Clive Bates For some, it would be better to waste a billion dollars Go straight to letter (PDF) or cover note and letter So, a big tobacco company puts up $1 billion over twelve years to fund a foundation with an objective “to accelerate global efforts to reduce health impacts and deaths from smoking, with the goal of ultimately eliminating smoking worldwide“. I certainly share that goal or something like it (see my ‘endgame’ scenario), and would like to see plenty of money spent wisely on pursuing that cause. But then there is the issue of a big tobacco company putting up the money. Should it be dismissed as the obviously flawed work of evil-doers? Or is the opportunity too important to pass over? It appears that there are many people and organisations who would like this initiative fail and would prefer to see $1 billion wasted. I don’t agree with them. At all. When $1 billion is in play, I think there is an ethical imperative to try to make it work in the cause of reducing disease and premature death. To me, that imperative is just an extension of a public health professional obligation to consider every reasonable and ethical option to reduce the toll of death and disease caused by smoking (and it is smoking, not tobacco or nicotine that does the real harm). And that includes improving the base of knowledge about how to achieve it through harm reduction strategies based on nicotine without smoke. It happens that the tobacco company in question, Philip Morris International (PMI), has stated that its objective is similar: We will be far more than a leading cigarette company. We’re building PMI’s future on smoke-free products that are a much better choice than cigarette smoking. Indeed, our vision – for all of us at PMI – is that these products will one day replace cigarettes. Funding the foundation is part of its commitment to this stated aim. So, the objectives of the foundation, the tobacco company’s strategy and legitimate public health goals are aligned. Surely everyone should be happy? Ah, not so fast. Not everyone is happy. There is the small matter of trust, and a history of industry deceit… And what about present day conduct? In my view, these reasons are not sufficient to dismiss or delegitimise this foundation as unworkable or unethical. Let’s work through some of the arguments. Independence of the foundation The important thing: the Foundation for a Smoke-Free World is not Philip Morris International. They are separate entities. The Foundation and its Board of Directors have no responsibility for the past record of PMI nor its present conduct. They may be able to influence PMI’s future practices beneficially – at least that is the idea. I think the relevant question is whether PMI can exert a distorting influence over the foundation to support a harmful agenda, and thereby render the foundation’s output untrustworthy and worthless or damaging. To pursue this question, seven of us have written a letter to the foundation to set out twelve proposals that we believe would greatly strengthen the claim to true independence and credibility. That can be done by recognising that the foundation and PMI are not the same thing; by making the transfer of money complete and irrevocable; avoiding potential for future conflicts of interest; placing all funds under the control a high quality board of directors focussed on public health goals; by adopting best grant-giving practice; and by the foundation opening itself up to external scrutiny, including involvement of SRNT. We hope the foundation will take this as a constructive challenge and respond accordingly. I believe that if it heeds this advice, it will have addressed almost all the credible concerns that have been raised. If the foundation is truly independent of PMI and there are no material conflicts of interest, then objections about PMI can no longer apply, just as they do not apply to the tobacco money that funds the Truth Initiative or finances FDA and, through NIH, funds much of the tobacco control research in the United States. So, it cannot be inherently unethical or wrong to rely on money that has come from sales of cigarettes, can it? Because so many in tobacco control already do? It depends on how the money has been made independent of the interests of the company. a letter regarding the financing and governance arrangements of the Foundation for a Smoke Free World. As you will be aware, the Foundation has created significant controversy in the tobacco and nicotine research and policy fields since its launch. We write to present a constructive challenge to the financing and governance arrangements of the Foundation. In the letter, we outline a series of proposals that we believe, if adopted, would address several substantive and credible concerns that have been raised. If such conditions were met, we believe individuals and organisations would have a more complete picture and be in a better position to evaluate or re-evaluate their approach to the Foundation. We look forward to receiving your substantive response. Yours sincerely David Abrams Clive Bates Jean François Etter Lynn Kozlowski AG Tom Miller Ray Niaura David Sweanor Attached letter: Foundation for a Smoke Free World and Philip Morris International [paste:font size="4"]“I’m against it because the tobacco industry is involved” The main argument above is that the foundation is a distinct entity and its relationship to the industry funder can and should be isolated through financial and governance arrangements. But how should we look at the industry’s approach here? I mentioned the history of deceit. Please see my earlier work on this with Andy Rowell: Tobacco Explained: the truth about the tobacco industry in its own words. But should tobacco industry history determine how we approach the present and the future? It should inform what we do, but I don’t think it should determine what we do. Otherwise we are making an a priori assertion that nothing much can change in the business models and conduct of these companies, ever. But things are changing rapidly. Existing and emerging disruptive technologies – vapor, smokeless, heated tobacco – are already forcing change in the market and challenging the incumbent companies. We should expect more change, perhaps radical change, in the way these companies approach their business. That increasingly means that the past will be a poor guide to the future. Take for example, the following statement from WHO FCTC guidelines on implementing Article 5.3 on which many, including WHO base their objections to the foundation. Principle 1: There is a fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests. That was not true even when it was agreed in 2008. If you want to find the lowest smoking rate in the developed world (7% adult smoking prevalence, 2017), it is in Sweden. The reason for this spectacular success is a tobacco product made by a tobacco company acting in the interest of its shareholders – and it has been highly positive for public health. That was true and obvious to any objective observer in 2008. Sweden is a kind of proof-of-concept – it suggests there is vast potential for non-combustible products to displace combustibles, driven by competition and innovation. It clearly can be in the tobacco industry’s interests to align with a public health objective. Really. If that approach makes more money, reduces legal liability, is a response to consumers migrating to vaping as a consumer choice, or their competitors (other tobacco companies or non-tobacco vape companies) are going to take market share, these companies will pursue the non-combustible market. It is ridiculous to assert that these dynamics will always be fundamentally and irreconcilably in conflict with public health. See my posting: Pariahs, predators or players? The tobacco industry and the end of smoking on how I think the companies are thinking. A challenging dialogue with Big Tobacco (and tobacco control) While drafting this letter, we received a great deal of advice and some of it was helpful. But a recurring theme was that the tobacco industry needs to be challenged over a mismatch between its fine words about the future and its actual real-world on-the-ground conduct. In response, we closed the letter with the following: Further, we believe this should become part of a wider dialogue about the role and conduct of the tobacco industry with respect to the Foundation’s goal “to accelerate global efforts to reduce health impacts and deaths from smoking, with the goal of ultimately eliminating smoking worldwide” and the industry’s efforts to undermine and legally challenge the tobacco control agenda developed in the FCTC. And it is true… there is scope for a much tougher, more pragmatic and effective dialogue between genuine public health advocates and the tobacco industry about phasing out cigarettes. But that will require candour and open-mindedness on all sides – industry, consumers, regulators and public health. If the aim is to reduce disease at the greatest possible rate, then we need to understand what each party can and cannot do: there is no point, for example, in pretending that tobacco companies can just stop producing cigarettes. Their executives would be fired, the companies taken over, or the assets sold to someone else – and not much would change. But if they can’t instantly pull out of cigarettes, what can they do? They can shift the market from combustibles to non-combustibles. In doing that, they can be aided or thwarted by regulators and tobacco control activists. Any tobacco control activists entering such a dialogue should expect to be challenged on their own role in opposing harm reduction and keeping cigarettes in a dominant position. At the same time, what anti-smoking policies should the tobacco industry accept are effective and legitimate, and stop opposing? Who in tobacco control really knows systematically what they are doing in the present? We also need real clarity about goals. For me, the goal is the reduction of the disease burden and other serious harms – and this has primacy over all others. But if your goal is ending nicotine use, tobacco use or destroying the tobacco industry, then you’ll likely end up with more harm and disease as you will forego the harm reduction strategy. See my posting: Who or what is the World Health Organisation at war with? What of the opponents to the foundation? Despite a lot of noisy opposition from predictable sources, many thoughtful experts have quite properly reserved judgement, waiting to see the arrangements in detail so that independence of the foundation and its financing and governance can be assessed fairly and with more complete information about its organisational design. So, I think there are three categories of opposition, at present: Premature judgement. I suspect many otherwise level-headed commentators were caught off guard by a bungled launch that came out of the blue for many. Asked to take a view, they rushed to judgement before the necessary facts were available to come to a properly reasoned perspective. Whether there is a material conflict of interest depends in detail on how this foundation is set up – and that detail is not yet clear and the board is not yet in place to endorse it. It is this group that I hope will re-evaluate their initial reactions and make a fair assessment based on more complete information. Abstinence-only activists. Others just oppose tobacco harm reduction for their own reasons, and there is no need to rehearse those reasons again here. For them, a tobacco industry link is a useful, easy and lazy justification for opposition without having to discuss or disclose their underlying abstinence-only philosophy. They will never be convinced by showing the foundation is independent and properly governed, because that is not their real objection in the first place. They just don’t want $1 billion spent on research into something they don’t like, however good or independent the research is. Veterans of the tobacco wars. For some old-school tobacco warriors, it’s more about how it feels than whether to think it through, and it feels good to be out there fighting Big Tobacco even if it is a pointless war with only civilian casualties. I’m hoping at least to engage this group in discussion about the tobacco industry and the best strategy for dealing with the companies during the disruption of this industry. A different kind of war is needed now: a war on harm. And that might require some uncomfortable or strange alliances. Disclosure: other than counting Derek Yach as a friend since we both worked on the gestation and birth of the FCTC, I have no connection with the foundation and I have no plans at present to apply to be on its staff or board, or to apply for grant funding. However, I wish the initiative well.