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April 29th, 2016:

Whistleblower Stanton Glantz Reflects on Tobacco Control Progress, Emerging Challenges

The name Stanton Glantz is revered by community health advocates and dreaded by the tobacco industry.

The University of California-San Francisco professor and distinguished tobacco control researcher led the movement to call out deceptive marketing messages disseminated by Big Tobacco companies and expose the dangers of tobacco products during the 1990s. His research illuminated the risks associated with secondhand smoke, as well as the correlation between high smoking rates and heart attack deaths in populations. His research has shown the power of strong smoke-free laws in reducing cardiovascular disease.

But despite progress made in the past 20 years to subdue persuasive marketing tactics from the tobacco industry, the work isn’t complete in states like Kentucky, where tobacco-related illness is the leading cause of preventable death. On April 28, Glantz addressed unfinished business in the fight against tobacco and identified modern threats posed by the tobacco industry during his keynote address at the Kentucky Center for Smoke-Free Policy’s annual conference titled “Mobilizing an Army of Smoke-free Advocates.” He commended community advocates in all corners of Kentucky for protecting individual rights to clean air and healthy environments for the more than 70 percent of Kentuckians who aren’t smokers.

“The whole battle is a battle about social norms and social acceptability, and once you win these fights, and you have a law that’s sticking —which takes a while — you don’t go back. And the tobacco companies understand that, and that is why they fight so hard,” Glantz said during his keynote address. “In the end, when you win, you’ve won. And the fight itself is an important part of making these laws work.”

After a stack of papers known as the “cigarette papers” landed at his doorstep in 1994, Glantz analyzed thousands of documents to build evidence against cigarette companies. The documents revealed that tobacco executives were aware of the dangers of their products while using aggressive marketing tactics to put these products in the hands of young adults and adolescents. Glantz published a groundbreaking book, The Cigarette Papers, as an indictment against the tobacco executives and marketers who were misleading the public.

Health experts and smoke-free advocates, including Glantz, have witnessed a resurgence of tobacco industry marketing efforts to target young people and normalize the use of the latest dangerous tobacco product on the market — electronic smoking devices or e-cigarettes. Glantz applied the lessons he learned through exposing the secrets of Big Tobacco in the 90s to the tobacco challenges of today, and said the dangers of tobacco marketing still persist in American society. He also discussed strategies for researchers, activists, and health care workers to resist pro-tobacco sentiments and reduce the burden of tobacco-related illness in their communities.

The KCSP also recognized efforts to promote the health across Kentucky by honoring local communities and municipalities that enacted smoke-free legislation in the past year. The City of Pikeville and the City of Ashland received awards for amending legislation to include e-cigarettes in their smoke-free ordinances. Hazard Community and Technical College received the 2016 Tobacco-free Campus Award. The City of Middlesboro earned the 2016 KCSP Smoke-free Indoor Air Excellence Award for passing a smoke-free workplace ordinance in May 2015.

The 2016 Smoke-free Youth Advocate Award went to the 2015 Middlesboro Destination Imagination Team, a nonprofit group comprising seven fourth- and fifth-graders, their parents, and teachers. The group delivered a presentation about the hazards of secondhand to the Middlesboro City Council and garnered more than 400 signatures for a petition supporting smoke-free legislation, which was adopted in May 2015.

“Embracing this year’s theme of mobilizing an army to end the burden of tobacco, we’re keenly aware of the fact that the tobacco companies have not loosened their grip in Kentucky,” Ellen Hahn, director of the KCSP and the Marcia A Dake Professor in the UK College of Nursing, said. “We’re proud of the communities that are taking a stand against tobacco in all its forms, and it is exciting to see children and adults alike making a big difference in their communities. Still, as Stan Glantz said in his keynote address, our work isn’t finished in Kentucky or across the nation.”

The Kentucky Center for Smoke-free Policy, housed in the UK College of Nursing, conducts research, collects data, and provides resources and strategies to assist advocates working on smoke-free campaigns across Kentucky. The conference was sponsored by UK HealthCare.

Feds look to ban menthol tobacco products

Les Hagen fully supports Ottawa’s plan to end the sale of menthol cigarettes across Canada. He’s the Executive Director of Action on Smoking and Health, and says that menthol and flavored tobacco products are popular among young smokers.

“This is a very very significant measure to keep tobacco companies from targeting youth in this manner. So it’s a very significant step. Obviously Alberta and a number of provinces have already moved on this issue, but we’re delighted to see new national standards.”

Hagen says that smokers are very “brand loyal” and therefore he doesn’t foresee a spike in cross border movement of illegal menthol cigarettes coming up from the U-S.

“Well, some people, if they try hard enough will still be able to get menthol cigarettes, yes, but the experience here in Alberta shows that’s very much the exception to the rule.”

Hagan adds that this move will reposition Canada as a leader in the fight to eliminate tobacco use by being the first nation to ban menthol flavored tobacco.

Can e-cigarette makers stub out addiction concerns?

As vaping culture grows and big tobacco piles in with huge ad budgets, worry over nicotine use lingers

The medical report published this week which finds that vaping could save millions of lives and should be encouraged could be read as a victory for the Marlboro Man of our times, who has swapped his horse for a helicopter and become a woman.

Perhaps you’ve seen the glossy new TV ad, below, and its evocation of an age when cowboys sold a deadly lifestyle. In summary: helicopter corrals cows under big skies, lands next to massive rock; pilot wearing stetson gets out, pulls down bandana and puts an electronic cigarette in her mouth. Its tip glows blue before the setting sun catches the vapour cloud as she exhales.

It’s big-budget and kind of beautiful. But the ad, for Blu eCigs, part of Imperial Tobacco, comes at a tricky time in the rise of an awkward object. Conceived as a nicotine vehicle to deliver the physical, social and chemical appeal of smoking without the aftertaste of death, the electronic cigarette, used by an estimated 2.6 million people in Britain, has rapidly spawned a sub-industry and vaping culture.

But like a curious teenager clutching an Embassy behind a bike shed, we don’t quite seem to know what to do with these new sticks, or what the risks might be. Just as the the Royal College of Physicians (RCP) called on Thursday for the promotion of vaping in the biggest report of its kind, new rules are about to make e-cigarettes harder to buy – and kill off the Blu Woman before she’s even got going.

The EU Tobacco Products Directive, which comes into force on 20 May, will, among other things, outlaw the advertising of electronic cigarettes on TV, radio and in newspapers. It will also set a limit on the nicotine content of the liquid used in the devices, which use a small, battery powered heating element to create the inhalable vapour (the “e-liquid” or “juice” is a blend of organic compounds, natural or synthetic flavourings and nicotine).

The directive follows years of conflicting advice and regulation. There is no public ban on e-cigarettes but local policy varies. You can vape to your lungs’ content inside a Westfield shopping centre, but stray over the carpet into a Starbucks and you’re banned. Doctors haven’t been able to agree either. In 2014, the World Health Organisation said vaping could be dangerous. A year later, Public Health England said it was 95% less harmful than smoking, but its evidence was subsequently doubted in the Lancet.

Perhaps Prof John Britton, chair of the RCP’s tobacco advisory group, which produced the new report, can help navigate this fug of confusion. “A lot of it is psychological,” he says. “There are people who feel sustaining nicotine addiction is wrong. I’ve had those conversations at conferences over coffee, and nobody has seen the irony in it.”

Nicotine isn’t something to seek out but “like caffeine, if it is used in the doses in which smokers use it, it is not significantly hazardous,” Britton adds. “The important thing is to separate it from the smoke, which is what electronic cigarettes do.”

The RCP report “lays to rest almost all of the concerns over these products”, including any suggestion that secondhand vapour can be harmful. But it will be harder to stub out the connotations of smoking. Almost 10 years after the public smoking ban, and more than half a century after the RCP’s pivotal 1962 report, Smoking and Health, which changed our relationship with cigarettes for ever, we are bound to doubt a solution that looks like the problem. Moreover, as the tobacco multinationals catch up with a runaway trend, and sell that solution as a lifestyle, we are understandably wary of the motivations of an industry which has not always welcomed the advice of doctors.

“There’s a suspicion of a commercial, consumer-led rather than medical response,” Britton accepts. “And there are arguments that these products are being used to promote smoking subconsciously … and that the tobacco industry will exploit them to sell more tobacco, particularly in countries with poorer governance.” The professor of epidemiology welcomes proportionate regulation, including the ad ban, as well as theforthcoming move to allow doctors to prescribe licensed vape kits. But while 200,000 children still take up smoking every year in Britain, he believes the participation even of public health villains is a price worth paying if it reduces illness and about 100,000 deaths a year (that’s about one every five minutes).

“We still have nearly 9 million people smoking tobacco every day when we’ve known what to do about it pretty much since 1962,” Britton says. “That’s a reflection of an abject failure of health policy. We’re reducing the number of young people taking up smoking, but we’re not that much better at helping them quit. That’s why the e-cigarette is such a powerful new tool.”

Marc Michelsen is, unsurprisingly, inclined to agree. “We have had an issue with public trust,” admits the public affairs executive at Fontem Ventures, the Dutch firm which owns Blu, and is an “arms-length subsidiary” of Imperial, the British tobacco company. “But a lot of that comes from a lack of scientific understanding.” Blu is delighted with the RCP report, but less keen on the advertising ban. “If you inhibit advertising, fewer people will buy the product and that can’t be good,” adds Michelsen, who denies that Blu’s commerical is a barely veiled Marlboro reboot. “I think it’s pure Mad Max,” he suggests (I must have missed the pastoral scenes in Fury Road). “This campaign is not about the past, we’re looking forward.”

What do vapers think, and who are they anyway? The majority of electronic smokers buy mass-produced products in supermarkets or online, and don’t think a great deal about them beyond their health and financial savings (£200 a month for a 20-a-day smoker, according to vape sites). But a vaping scene has unexpectedly mushroomed to the extent that, for many vapers, nicotine has become a secondary interest.

At the Vape Emporium, a London-based online store with boutiques at Hampstead and Richmond, a vape consultant will talk you through a menu of handcrafted e-pipes and more than 200 flavoured e-liquids. Perhaps you’d like to try the VG by Simple Chocolaccino, which “blends caramel, chocolate, coffee and biscuit for a divine morning vape”. “We now have juices that only contain 1.5mg of nicotine, which is tiny,” says Andy Logan, the emporium’s co-founder. A 24mg/ml mix compares to a strong cigarette, he explains (the new rules will set the maximum at 20mg). “And some people are taking zero nicotine now because they just don’t need it but still enjoy vaping.”

Logan, who set up as an online store in 2013 and is looking for new shopfronts, says vapers follow a familiar path. “At the start they’re adamant they don’t want any funny flavoured rubbish and go for a strong, tobacco-style vape. But after a few weeks they’re trying some crazy flavours and dropping the nicotine because they’ve got their tastebuds back.” Flavour seekers tend to favour fruit, pudding (doughnuts and cakes are popular) or mint and vanilla perfumes, he adds. Some go further, vaping socially in cafes and clubs and discussing equipment and blends. Logan has just exhibited at the second Vape Jam UK, a three-day expo at London’s ExCel centre attended by 300 companies and clubs. “I took my fiancee on the Sunday,” he says. “She had no idea this subculture exists. It’s quite amazing.”

Logan says his customers range from an insanely knowledgable 94-year-old woman to a businessman who comes in for a puff while his driver idles outside in a Bentley.

Vaping is increasingly popular among young people (it is illegal to sell to under-18s), he adds. Meanwhile, the public response to vaping – while still generally somewhere between curious and hostile – is catching up with its rise in popularity. “I still can’t go to a party without facing a barrage of questions, but it is changing,” Logan says.

As a culture emerges and big tobacco piles in with huge advertising budgets, do we risk discouraging nicotine quitting, or even drawing non-smokers into addiction? “Our annual survey of 12,000 adults suggests the level of vaping among non-smokers is steady at about 0.2%, says Hazel Cheeseman, director of policy at Ash, the smoking health charity.

“It’s extremely rare and I don’t think that will ever change,” Logan adds, rejecting the gateway hypothesis. And he doesn’t need it to. “If there are nearly 10 million smokers and only 2 million vapers, we’ve still got a massive, long journey to convert the rest,” he says.

Tobacco Use in the USA

Submitted by Julie Russell, RN Tobacco Prevention Specialist Carter, Fallon, & Powder River County

• High school students who are current (past month) smokers: 15.7 percent (boys: 16.4 percent, girls: 15.0 percent); over 2.6 million
• High school males who currently use smokeless tobacco: 14.7 percent (girls: 2.9 percent)
• Kids (under 18) who try smoking for the first time each day: 2,500+
• Kids (under 18) who become new regular, daily smokers each day: 580
• Kids (3-11) exposed to secondhand smoke: 40.6 percent (Black: 67.9 percent White: 37.2 percent)
• Packs of cigarettes consumed by kids each year: approx. 540 million (nearly $1.2 billion per year in sales revenue)
• Adults in the USA who are current smokers: 16.8 percent (men: 18.8 percent, women: 14.8 percent); approx. 40 million
• Adults in the USA who smoke daily: 12.9 percent Deaths & Disease in the USA from Tobacco Use
• People who die each year from cigarette smoking and exposure to secondhand smoke: approx. 480,000+
• Kids under 18 alive today who will ultimately die from smoking (unless smoking rates decline): 5.6 million
• People in the USA who currently suffer from smoking-caused illness: 16 million+ Smoking kills more people than alcohol, AIDS, car accidents, illegal drugs, murders, and suicides combined, with thousands more dying from spit tobacco use. Of all the kids who become new smokers each year, almost a third will ultimately die from it. In addition, smokers lose a decade of life because of their smoking. For every person who dies from smoking, at least 30 more are suffering from serious smoking-caused disease and disability. Tobacco-Related Monetary Costs in the USA
• Total annual public and private health care expenditures caused by smoking: approx. $170 billion – annual federal and state government smoking-caused Medicaid payments: $39.6 billion (Federal share: $22.5 billion per year. States’ share: $17.1 billion) – Federal government smoking-caused Medicare expenditures each year: $45.0 billion – Other federal government tobacco-caused health care costs (e.g. through VA health care): $23.8 billion
• Annual health care expenditures solely from secondhand smoke exposure: $6.03 billion. Not included above are costs from smokeless or spit tobacco use or pipe/cigar smoking.
• Productivity losses caused by smoking each year: $151 billion (only includes costs from productive work lives shortened by smoking-caused death. Not included: costs from smoking-caused disability during work lives, smoking-caused sick days, or smoking-caused productivity declines when on the job.) Other non-healthcare costs from tobacco use include residential and commercial property losses from smoking -caused fires, tobacco related cleaning and maintenance, and expenditures through Social Security Survivors Insurance for kids who have lost at least one parent from a smoking-caused death.
• Taxpayers yearly fed/state tax burden from smoking-caused government spending: US$960 per household
• Smoking-caused health costs and productivity losses per pack sold in USA (low estimate):US $19.16 per pack
• Average retail price per pack in the USA (including sales tax): US$5.96 Tobacco Industry Advertising & Political Influence
• Annual tobacco industry spending on marketing its products nationwide: US$9.5 billion ($25+ million each day) Research studies have found that kids are three times as sensitive to tobacco advertising than adults and are more likely to be influenced to smoke by cigarette marketing than by peer pressure; and that a third of underage experimentation with smoking is attributable to tobacco company advertising and promotion.
• Tobacco company PAC contributions to federal candidates, 2014 election cycle: More than US$1.8 million
• Tobacco industry expenditures lobbying Congress in 2014: US$22.0 million.

Heterogeneity in the measurement and reporting of outcomes in studies of electronic cigarette use in adolescents

A systematic analysis of observational studies



To examine consistency between cross-sectional studies of conventional and electronic cigarette use among adolescents in terms of the measurement, analysis and reporting of parameters.


A systematic analysis of cross-sectional studies of conventional and electronic cigarette use in adolescents, to identify measured and reported parameters.

Data sources

Studies examining use of electronic and conventional cigarette use in adolescents were identified by searching the SCOPUS database in August 2015.

Study selection

The selection criteria for studies were: cross-sectional studies, in English, on e-cigarette use in adolescents. Two reviewers independently selected relevant studies from the search. 60 abstracts were identified, from which 31 papers were eligible for review (23 unique studies).

Data extraction

Measured and reported parameters were identified and tabulated. These included the prevalence of cigarette and/ or electronic cigarette use, and the definitions of terms. Data were extracted independently by two reviewers.

Data synthesis

With regards basic parameters of ‘ever’ or ‘current’ use of electronic or conventional cigarettes, there were 31 unique measured parameters across 23 studies. Of 16/23 studies in which authors collected information on dual current use, prevalence was reported in 11/16, with six different definitions of ‘dual use’.


There are substantial differences in measurement and reporting of parameters across observational studies of electronic and conventional cigarette use in adolescents. These studies are at risk of reporting bias, and results are difficult to interpret. A core outcome set that should be measured and reported in all observational studies is required, using structured consensus techniques.

Taxing tobacco

Consider the fact that every fourth cigarette sold in Pakistan is sold illicitly. It comes as no surprise then that the Federal Board of Revenue (FBR) recently ran an ad in all major daily papers asking people to ‘Say no to smuggled/non-duty paid cigarettes’. What was surprising about the advertisement, however, was that it did not feature any of the popularly smuggled brands responsible for illicit sales.

Brands that are popular both in Pakistan and abroad (Marlboro, Dunhill, Benson & Hedges) were nowhere on the ad. The ad conveniently skipped brands like Marlboro, Dunhill and Benson & Hedges, which are also produced locally. On the outset, FBR’s brand choice in the ad might not make sense.

Many of the brands actually featured are so obscure that their trade is negligible. How many people do we know who smoke Pine Slims or More on a regular basis? Have most people even heard of the brand called Pleasure?

But the ad makes sense when we think about how the tobacco industry operates. It follows a simple mechanism: addiction. For local producers of international brands, an ad like this works in their favour.

A smoker who is addicted to an international brand is ready to buy its local version when the smuggled one is not available. In this way, international brands that are smuggled end up creating markets for local versions, while the parent company makes money either way.

Losing billions While Big Tobacco remains a potent a force all over the world, it is particularly powerful in Pakistan where it dominates 81 per cent of the market. At the same time, tobacco is one of our most heavily taxed industries. Last year alone, almost Rs 130 billion were collected from the tobacco giants. An amount that high should make us reflect on the scope of influence these companies potentially wield.

Keep in mind the scale of the tobacco industry- the annual tax imposed on the industry can increase by 25 per cent if illicit sales are curtailed. For now, our national exchequer is losing at least Rs 30 billion annually because of the illicit cigarette business. The government, meanwhile, is trying to broaden its tax base from several avenues; moves like the recent announcement of a banking tax, and the campaign asking consumers to report on restaurants all clearly indicate the government’s
attempt to increase its tax collection.

This is not surprising – the International Monetary fund (IMF) recently asked ( the Pakistani government to impose additional taxes of Rs 160 billion to decrease its budget deficit for the coming year. The government is clearly stepping up its game, but in a country with a theoretically progressive but practically regressive tax system, we really need to see where this show is going.

If the FBR is serious about fixing the loss to the national exchequer, and if Pakistan is to actually tackle the problem of smuggled cigarettes, our government will have to take a firm and principled stand. It needs to introduce a policy against cigarette smuggling, one that is grounded in addressing the root of the problem, and is not partial to certain players. It needs to tackle the problem of smuggled cigarettes across the board. It cannot be manipulated by or cower to certain companies.

But the fact remains that Big Tobacco companies do not want to harm their markets (for smuggled brands), or lose their customers. So while they willingly condemn cigarette smuggling, they overlook brands their own companies produce locally. This is exactly what the FBR did. As long as there is obvious pandering to chosen brands, advertisements like theirs cannot be taken seriously by anyone involved in the trade. Meanwhile, the people of Pakistan will continue losing more and more tax money, and while cigarette smuggling effects the entire tobacco industry as a whole, it’s the homegrown brands and companies that really end up suffering.