ABSTRACT

Objective.

To document tobacco industry strategies to influence regulation of new and emerging tobacco and nicotine products (NETNPs) in Latin America and the Caribbean.

Methods.

We analyzed industry websites, advocacy reports, news media and government documents related to NETNPs, focusing on electronic cigarettes and heated tobacco products. We also conducted a survey of leading health advocates. We applied the policy dystopia model to analyze industry action and argument-based strategies on NETNP regulations.

Results.

Industry actors engaged in four instrumental strategies to influence NETNP regulation – coalition management, information management, direct involvement in and access to the policy process, and litigation. Their actions included: lobbying key policy-makers, academics and vaping associations; providing grants to media groups to disseminate favorable NETNP information; participating in public consultations; presenting at public hearings; inserting industry-inspired language into draft NETNP legislation; and filing lawsuits to challenge NETNP bans. The industry disseminated its so-called harm reduction argument through large/influential countries (e.g., Argentina, Brazil, and Mexico). Industry discursive strategies claimed NETNPs were less harmful, provided safer alternatives, and should be regulated as so-called harm reduction products or have fewer restrictions on their sale and use than those currently in place.

Conclusion.

Our analysis provides a better understanding of industry strategies to undermine tobacco and nicotine control. To help counter industry efforts, health advocates should proactively strengthen government capacities and alert policy-makers to industry attempts to create new regulatory categories (so-called reduced-risk products), provide misleading information of government authorizations of NETNPs, and co-opt so-called harm-reduction messages that serve the industry’s agenda.

Keywords
Electronic nicotine delivery systems; vaping; tobacco control; tobacco industry; Latin America; Caribbean

RESUMEN

Objetivo.

Documentar las estrategias de la industria tabacalera para influir en la regulación de los productos de tabaco y nicotina novedosos y emergentes (PTNNE) en América Latina y el Caribe.

Métodos.

Se analizaron los sitios web de la industria, los informes de defensa de la salud, los medios de información y los documentos gubernamentales relacionados con los PTNNE, prestando especial atención a los cigarrillos electrónicos y los productos de tabaco calentado. También se realizó una encuesta a líderes de la promoción de la salud. Aplicamos el modelo de distopía política para analizar las estrategias de acción y argumentación de la industria en relación con la regulación de los PTNNE.

Resultados.

Las partes interesadas de la industria recurrieron a cuatro estrategias instrumentales para influir en la regulación de los PTNNE: gestión de coaliciones, gestión de la información, participación directa y acceso al proceso de formulación de políticas, y litigios. Sus acciones incluyeron: trabajar con los principales responsables de la formulación de políticas, académicos y asociaciones de vapeo; conceder subvenciones a grupos de medios de comunicación para que difundan información favorable a los PTNNE; participar en consultas públicas; realizar presentaciones en audiencias públicas; introducir un lenguaje inspirado por la industria en la legislación sobre los PTNNE; y presentar demandas judiciales para dificultar las prohibiciones de los PTNNE. La industria difundió su argumentación, denominada de reducción de daños, en países grandes e influyentes como, por ejemplo, Argentina, Brasil y México. Las estrategias discursivas de la industria afirmaban que los PTNNE eran menos nocivos, proporcionaban alternativas más seguras y debían regularse del mismo modo que los denominados productos de reducción de daños o tener menos restricciones que las vigentes en la actualidad para su venta y consumo.

Conclusión.

Este análisis permite comprender mejor las estrategias de la industria para socavar el control del tabaco y la nicotina. Para contribuir a contrarrestar los esfuerzos de la industria, los defensores de la salud deberían fortalecer activamente las capacidades gubernamentales y alertar a los responsables políticos de los intentos de la industria de crear nuevas categorías reglamentarias (los denominados productos de riesgo reducido), proporcionar información engañosa sobre las autorizaciones gubernamentales de los PTNNE y apropiarse de los denominados mensajes de reducción de daños que responden a la agenda de la industria.

Palabras clave
Sistemas electrónicos de liberación de nicotina; vapeo; control del tabaco; industria del tabaco; América Latina; Región del Caribe

RESUMO

Objetivo.

Documentar as estratégias usadas pela indústria do tabaco para influenciar a regulamentação de produtos novos e emergentes de tabaco e nicotina (NETNPs, sigla em inglês) na América Latina e no Caribe.

Métodos.

Foram analisados sites do setor, relatórios de ativistas, notícias em meios de comunicação e documentos governamentais relacionados aos NETNPs, com foco em cigarros eletrônicos e produtos de tabaco aquecido. Também foi realizada uma pesquisa com ativistas importantes na área da saúde. O modelo de distopia política foi utilizado para analisar as ações e as estratégias baseadas em argumentos do setor para a regulamentação de NETNPs.

Resultados.

Os agentes do setor utilizaram quatro estratégias instrumentais para influenciar a regulamentação de NETNPs: gestão de coalizões; gestão de informações; envolvimento direto e acesso ao processo de formulação de políticas; e ações legais. As ações dos agentes incluíram: trabalhar com os principais formuladores de políticas, acadêmicos e associações de cigarros eletrônicos; conceder subsídios a grupos de comunicação para disseminar informações favoráveis aos NETNPs; participar de consultas públicas; fazer apresentações em audiências públicas; inserir linguagem gerada pela indústria na legislação de NETNPs; e entrar com ações judiciais para contestar proibições de NETNPs. O setor disseminou seu argumento de “redução de danos” em países grandes e influentes (por exemplo, Argentina, Brasil e México). As estratégias discursivas do setor afirmavam que os NETNPs eram menos prejudiciais, ofereciam alternativas mais seguras e deveriam ser regulamentados como “produtos de redução de danos” ou ter menos restrições à venda e ao uso do que as atualmente em vigor.

Conclusão.

Nossa análise oferece uma melhor compreensão das estratégias usadas pelo setor para enfraquecer o controle do tabaco e da nicotina. Para ajudar a combater os esforços do setor, os ativistas em saúde devem fortalecer de forma proativa a capacidade dos governos e alertar os formuladores de políticas sobre as tentativas da indústria de criar novas categorias regulatórias (os chamados “produtos de risco reduzido”), fornecer informações enganosas sobre as autorizações governamentais de comercialização dos NETNPs e cooptar mensagens de “redução de danos” para atender aos interesses do setor.

Palavras-chave
Sistemas eletrônicos de liberação de nicotina; vaping; controle do tabagismo; indústria do tabaco; América Latina; Região do Caribe

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) has helped accelerate the adoption of evidence-based tobacco control policies globally (¹1. Hiilamo H, Glantz SA. Implementation of effective cigarette health warning labels among low and middle income countries: state capacity, path-dependency and tobacco industry activity. Soc Sci Med. 2015;124:241–5. https://doi.org/10.1016/j.socscimed.2014.11.054
https://doi.org/10.1016/j.socscimed.2014... ). An important contributing factor to this success is the adoption of measures in alignment with FCTC Article 5.3, which requires Parties to protect tobacco control policies from tobacco industry interference (²2. WHO Framework Convention on Tobacco Control. Guidelines for implementation of Article 5.3. Geneva: World Health Organization; 2013 [cited: 2023 Nov 1]. Available from: https://fctc.who.int/publications/m/item/guidelines-for-implementation-of-article-5.3
https://fctc.who.int/publications/m/item... ). These measures have minimized the industry’s influence over FCTC-based policies (³3. Ralston R, Bialous S, Collin J. Firm foundation or neglected cornerstone? The paradox of Article 5.3 implementation and the challenge of strengthening tobacco control governance. Tob Control. 2022;31(Suppl 1):S1–S4. https://doi.org/10.1136/tobaccocontrol-2022-057344
https://doi.org/10.1136/tobaccocontrol-2... ).

Tobacco companies have introduced and heavily promoted new and emerging tobacco and nicotine products (NETNPs), including electronic cigarettes and heated tobacco products, using various tactics that could undermine achievements in tobacco and nicotine control (⁴4. Crosbie E, Severini G, Beem A, Tran B, Sebrie EM. New tobacco and nicotine products in Latin America and the Caribbean: assessing the market and regulatory environment. Tob Control. 2023;32(4):458–66. https://doi.org/10.1136/tobaccocontrol-2021-056959
https://doi.org/10.1136/tobaccocontrol-2... ). In September 2017, Philip Morris International launched and continues to be the only funder of the Foundation for a Smoke-free World (⁵5. Tobacco tactics. Foundation for a Smoke-Free World [internet]. Bath: University of Bath; 2023 [cited: 2023 Nov 10]. Available from: https://tobaccotactics.org/article/foundation-for-a-smoke-free-world/
https://tobaccotactics.org/article/found... ). This foundation is allegedly an independent organization that funds research to reduce smoking-related harms but it continues to coordinate with Philip Morris International (⁶6. van der Eijk Y, Bero LA, Malone RE. Philip Morris International-funded “Foundation for a Smoke-Free World”: analysing its claims of independence. Tob Control. 2019;28(6):712–8. https://doi.org/10.1136/tobaccocontrol-2018-054278
https://doi.org/10.1136/tobaccocontrol-2... ), British American Tobacco, Japan Tobacco International, and Imperial Brands which have also launched campaigns to promote NETNPs (⁷7. Cavale S. UK ad watchdog bans BAT from Instagram e-cigarette promotion. Reuters. 18 December 2019 [cited: 2023 Aug 10]. Available from: https://www.reuters.com/article/us-britishamericantobacco-asa-idUSKBN1YM00L/
https://www.reuters.com/article/us-briti... ).

Given the evolving landscape of NETNPs, governments have been tasked with regulating these products. The WHO FCTC Conference of the Parties (COP), which is the WHO FCTC governing body and regularly reviews and reaches consensus on its implementation, has provided regulatory assistance on NETNPs. The 6th, 7th, and 8th COP in 2014, 2016, and 2018 adopted decisions urging parties to regulate electronic nicotine delivery systems and electronic non-nicotine delivery systems (usually referred as electronic cigarettes) and heated tobacco products through restrictions or bans on their commercialization and use (⁸8. World Health Organization. WHO report on the global tobacco epidemic, 2021: addressing new and emerging products. Geneva: WHO; 2021 [cited: 2023 Aug 15]. Available from: https://iris.who.int/handle/10665/343287
https://iris.who.int/handle/10665/343287... ). As of November 2023, countries in Latin America and the Caribbean, which includes all 35 Member States of the Pan American Health Organization (PAHO) except the United States and Canada, have taken different approaches to regulating these products, either banning their sale or allowing it while adopting one or more measures fully or partially (⁹9. World Health Organization. WHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. Geneva: WHO; 2023 [cited: 2023 Aug 10]. Available from: https://iris.who.int/handle/10665/372043
https://iris.who.int/handle/10665/372043... ). These measures include bans on the use of these products in public indoor areas, bans on advertising, promotion and sponsorship, the application of health warnings on packaging, and age restrictions on the sale of these products. Heated tobacco products are generally considered to fall, at least implicitly, under the purview of tobacco control measures in line with the FCTC when implemented by countries. Regarding electronic cigarettes, a concern is the absence of regulatory frameworks in 13 countries in Latin America and the Caribbean, indicating insufficient country-level action to address these products.

Every country in Latin America and the Caribbean has ratified the FCTC except Argentina, Cuba, Dominican Republic, and Haiti and they have had success in implementing many FCTC-based polices, including tobacco advertising bans (¹⁰10. Crosbie E, Gutkowski P, Severini G, Pizarro ME, Perez S, Albuquerque de Figueiredo B, et al. Progress in adopting bans on tobacco advertising, promotion, and sponsorship in the Americas: lessons from Uruguay and Argentina. Rev Panam Salud Publica. 2022:46:e102. https://doi.org/10.26633/RPSP.2022.102
https://doi.org/10.26633/RPSP.2022.102... ), large pictorial health warning labels (¹¹11. Crosbie E, Erinoso O, Perez S, Sebrie EM. Moving in the right direction: progress of tobacco packaging and labeling in the Americas. Rev Panam Salud Publica. 2022:46:e196. https://doi.org/10.26633/RPSP.2022.196
https://doi.org/10.26633/RPSP.2022.196... ), tobacco excise taxes (¹²12. van Walbeek C, Filby S. Analysis of Article 6 (tax and price measures to reduce the demand for tobacco products) of the WHO Framework Convention on Tobacco Control. Tob Control. 2019;28(Suppl 2):S97–S103. https://doi.org/10.1136/tobaccocontrol-2018-054462
https://doi.org/10.1136/tobaccocontrol-2... ), and smoke-free policies (¹³13. Eckford R, Severini G, Sebrié EM, Muggli ME, Beem A, Rosen D, et al. The U.S. Food and Drug Administration’s Authorization of “reduced exposure” claims for Iqos: implications for regulation in Latin America. Rev Panam Salud Publica. 2022;46:e155. https://doi.org/10.26633/RPSP.2022.155
https://doi.org/10.26633/RPSP.2022.155... ). This success has prompted the industry to redirect its marketing practices, for example, increasing NETNP marketing on social media, especially targeting young people (¹⁰10. Crosbie E, Gutkowski P, Severini G, Pizarro ME, Perez S, Albuquerque de Figueiredo B, et al. Progress in adopting bans on tobacco advertising, promotion, and sponsorship in the Americas: lessons from Uruguay and Argentina. Rev Panam Salud Publica. 2022:46:e102. https://doi.org/10.26633/RPSP.2022.102
https://doi.org/10.26633/RPSP.2022.102... ). This strategy includes Philip Morris International’s attempt to advocate for relaxation of tobacco control regulations in Latin America and Caribbean countries for its IQOS by promoting misleading information based on a 2020 United States Food and Drug Administration (FDA) decision not to allow Philip Morris International to use a “reduced risk” marketing claim for its IQOS (¹⁴14. Eckford R, Severini G, Sebrie EM, Muggli ME, Beem A, Rosen D, et al. United States Food and Drug Administration’s authorization of reduced exposure claims for IQOS®: implications for regulation in Latin America. Rev Panam Salud Publica 2022;46:e155. https://doi.org/10.26633/RPSP.2022.155
https://doi.org/10.26633/RPSP.2022.155... ).

Research on NETNPs globally has primarily focused on their potential health risks (¹⁵15. Kopa-Stojak PN, Pawliczak R. Comparison of effects of tobacco cigarettes, electronic nicotine delivery systems and tobacco heating products on miRNA-mediated gene expression. a systematic review. Toxicol Mech Methods. 2023;33(1):18–37. https://doi.org/10.1080/15376516.2022
https://doi.org/10.1080/15376516.2022... ) and marketing (¹⁶16. Lyu JC, Huang P, Jiang N,Ling PMl. A systematic review of e-cigarette marketing communication: messages, communication channels, and strategies. Int J Environ Res Public Health. 2022;19(15):9263. https://doi.org/10.3390/ijerph19159263
https://doi.org/10.3390/ijerph19159263... ). Only a few studies have examined NETNPs in Latin America and Caribbean countries (⁴4. Crosbie E, Severini G, Beem A, Tran B, Sebrie EM. New tobacco and nicotine products in Latin America and the Caribbean: assessing the market and regulatory environment. Tob Control. 2023;32(4):458–66. https://doi.org/10.1136/tobaccocontrol-2021-056959
https://doi.org/10.1136/tobaccocontrol-2... , ¹⁷17. Gottschlich A, Mus S, Monzon JC, Thrasher JF, Barnoya J. Cross-sectional study on the awareness, susceptibility and use of heated tobacco products among adolescents in Guatemala City, Guatemala. BMJ Open. 2020;10(12):e039792. https://doi.org/10.1136/bmjopen-2020-039792
https://doi.org/10.1136/bmjopen-2020-039... ). This study aims to expand on this limited research by analyzing key tobacco industry strategies on NETNP regulation in Latin America and the Caribbean.

METHODS

Data collection

Between January and August 2022, we reviewed news media, tobacco industry websites, government documents, and advocacy reports available through Google using standard snowball search methods (¹⁸18. Malone RE, Balbach ED. Tobacco industry documents: treasure trove or quagmire? Tob Control. 2000;9(3):334–8. https://doi.org/10.1136/tc.9.3.334
https://doi.org/10.1136/tc.9.3.334... ). Initial search terms (in English and Spanish) included: “electronic cigarettes”, “e-cigs”, and “heated tobacco products”. Published documents in the Latin America and Caribbean region or that mentioned this region were included. Analysis only focused on electronic cigarettes and heated tobacco products since oral nicotine products or other new products were just beginning to enter the region at the time of this study (¹⁹19. Duren M, Atella L, Welding K, Kennedy RD. Nicotine pouches: a summary of regulatory approaches across 67 countries. Tob Control. 2023:tc-2022-057734. https://doi.org/10.1136/tc-2022-057734
https://doi.org/10.1136/tc-2022-057734... ). We found 81 documents of which 63 were considered relevant. Between September and October 2022, we surveyed leading health advocates in Latin America and the Caribbean who were identified through media searches, author networks, and snowball sampling. Respondents were invited by email to complete an online questionnaire on NETNPs. The questionnaire asked them which companies had been involved in trying to influence the regulation process of NETNPs in Latin American and Caribbean countries and what had been their arguments and actions for supporting and opposing NETNP regulations. We received 15 survey responses from 14 countries (Argentina, Bolivia (Plurinational State of), Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, Guatemala, Jamaica, Mexico, Paraguay, Peru, and Uruguay). Health advocates also provided 22 documents of which 14 were considered relevant to the study’s objective.

Data analysis

To analyze industry strategies, we applied a policy dystopia model, which was first developed to identify tobacco industry strategies to counter marketing bans and taxation based on a systematic review of the literature on tobacco industry strategies (²⁰20. Ulucanlar S, Fooks GJ, Gilmore AB. The policy dystopia model: an interpretive analysis of tobacco industry political activity. PLoS Med. 2016;13(9):e1002125. https://doi.org/10.1371/journal.pmed.1002125
https://doi.org/10.1371/journal.pmed.100... ). Using the policy dystopia model, we categorized tobacco industry strategies by: discursive (argument-based) strategies that the industry uses to exaggerate the potential cost of a proposed policy, while denying or dismissing its potential benefits; and instrumental (action-based) strategies that the industry uses to influence policy-makers and other stakeholders against regulating tobacco and nicotine products in alignment with the FCTC and COP decisions (²⁰20. Ulucanlar S, Fooks GJ, Gilmore AB. The policy dystopia model: an interpretive analysis of tobacco industry political activity. PLoS Med. 2016;13(9):e1002125. https://doi.org/10.1371/journal.pmed.1002125
https://doi.org/10.1371/journal.pmed.100... ). Two of the authors coded all of these documents to ensure there was some mention of industry involvement in the regulation process of NETNPs or to highlight industry activity. Coding consisted of applying the policy dystopia model to identify key industry arguments and actions. Disagreement was resolved through discussion (not quantified). These documents were further categorized by health advocate responses that were tailored towards key industry arguments and actions outlined in the policy dystopia model.

Ethics

Health advocates included in the survey gave written consent to participate in the study in accordance with a protocol approved by the University of Nevada, Reno Committee on Human Research (IRBNET ID: 1962498-1).

RESULTS

Industry instrumental (action-based) strategies

Industry actors engaged in four instrumental strategies, including coalition management, information management, direct involvement in and access to the policy process, and litigation (Table 1).

Coalition management. Based on the policy dystopia model, industry coalition management consisted of forming and supervising coalitions that provided alternative and more credible platforms for their arguments. This included transnational tobacco companies working with electronic cigarette companies, business groups, think tanks, scientists, and high-ranking policy-makers. Media sources and surveyed health advocates reported that the former President of Spain (2004–2016) lobbied on behalf of tobacco companies to promote NETNPs in Peru and reject further NETNP restrictions in Chile (²¹21. Foundation for a Smoke-Free World. Awarded grants [internet]. Foundation for a Smoke-Free World; 2022 [cited: 2022 Sep 10]. Available at: https://www.smokefreeworld.org/awarded-grants/
https://www.smokefreeworld.org/awarded-g... , ²²22. IQOS, el caballo de troya de la tabacalera Philip Morris – Coltabaco [IQOS, the Trojan horse of the tobacco company Philip Morris – Coltabaco] [internet]. Cuestion Publica; 2020 [cited: 2022 Jul 13]. Available from: https://cuestionpublica.com/iqos-caballo-de-troya-de-la-tabacalera/
https://cuestionpublica.com/iqos-caballo... ). Industry actors also made alliances and received support from medical schools and professional health science associations to hold so-called academic events in Colombia and Costa Rica that downplayed NETNP harms. New vaping groups emerged in Paraguay and Colombia to oppose potential NETNP regulations.

Information management. The industry took a comprehensive approach to information management to produce and widely disseminate favorable information related to NETNPs. To construct an alternative evidence base, the industry initially produced their own information. For example, Philip Morris International’s Foundation for a Smoke-free World provided grants to media groups in Argentina and Mexico to produce favorable information about NETNPs’ harm reduction. Genuine harm reduction strategies are a valid public health approach with addictive substances that aim to reduce the various harms from drug use. They are grounded in the principles of social justice, and are evidenced-based and informed by the needs of local communities. The industry has co-opted the term harm reduction to advance their own agenda and promote widespread and unrestricted access to addictive products. They particularly target young people and paradoxically also non-smokers. Industry actors and their allies have disseminated and amplified this information to the media, policy-makers, and the public to support their efforts. The industry and its allies used other countries’ regulatory frameworks for NETNPs as a reference to promote them. They provided misleading information about the regulations and overlooked the distinct regulatory systems of those countries. In some instances, industry actors cherry-picked claims from prominent medical schools and respected organizations, including the WHO Regional Office for Europe and the Royal College of Physicians among others, to support their efforts. For example, in Trinidad and Tobago, industry actors cited claims from doctors at Johns Hopkins arguing “regular tobacco cigarettes contain 7,000 chemicals” and that NETNPs “expose you to fewer toxic chemicals than traditional cigarettes”. However, these same doctors concluded that using NETNPs is not safe and they have hooked a new generation on nicotine.

As some countries have allowed the sale of NETNPs, the industry has used these decisions to advocate further for authorization throughout Latin America and the Caribbean, particularly where NETNPs sales are banned. Despite the decision of the United States FDA in 2020 not to allow Philip Morris International to use a “reduced risk” marketing claim for its IQOS (¹⁴14. Eckford R, Severini G, Sebrie EM, Muggli ME, Beem A, Rosen D, et al. United States Food and Drug Administration’s authorization of reduced exposure claims for IQOS®: implications for regulation in Latin America. Rev Panam Salud Publica 2022;46:e155. https://doi.org/10.26633/RPSP.2022.155
https://doi.org/10.26633/RPSP.2022.155... ), the industry promoted the FDA’s authorization to sell NETNPs, especially heated tobacco products, as harm-reduced products and healthier alternatives to conventional tobacco products (e.g., cigarettes). In particular, Philip Morris International provided a grant to Vida News LLC (²¹21. Foundation for a Smoke-Free World. Awarded grants [internet]. Foundation for a Smoke-Free World; 2022 [cited: 2022 Sep 10]. Available at: https://www.smokefreeworld.org/awarded-grants/
https://www.smokefreeworld.org/awarded-g... ), a media hub, to promote this misleading information and communicate information about harm reduction in Latin American and Caribbean countries (¹⁴14. Eckford R, Severini G, Sebrie EM, Muggli ME, Beem A, Rosen D, et al. United States Food and Drug Administration’s authorization of reduced exposure claims for IQOS®: implications for regulation in Latin America. Rev Panam Salud Publica 2022;46:e155. https://doi.org/10.26633/RPSP.2022.155
https://doi.org/10.26633/RPSP.2022.155... ). In March 2021, Uruguay’s presidential decree enabled marketing of heated tobacco products as a new alternative that exposed users to less toxic substances. The health ministry referred to the FDA decision and used references employed by Philip Morris International when questioned about the motivation for the decree. The industry and its allies then used this decision to advocate for lifting sales bans on heated tobacco products in Panama and Brazil.

Direct involvement and access. Direct involvement and access to the policy process was reported in each of the countries studied, most frequently in Argentina, Brazil, Chile, Colombia, Mexico, and Panama. The most common strategy consisted of traditional direct lobbying and influencing policy-makers and participating in formal policy processes such as submitting comments through public consultations, requesting hearings with government officials, and making statements and presentations at public hearings on NETNP proposals. Other key routes for access to policy-makers included establishing connections with high-level officials such as in Colombia (²²22. IQOS, el caballo de troya de la tabacalera Philip Morris – Coltabaco [IQOS, the Trojan horse of the tobacco company Philip Morris – Coltabaco] [internet]. Cuestion Publica; 2020 [cited: 2022 Jul 13]. Available from: https://cuestionpublica.com/iqos-caballo-de-troya-de-la-tabacalera/
https://cuestionpublica.com/iqos-caballo... ), participating in public hearings in Brazil, and sending letters or requests to policy-makers about NETNP regulations in Mexico and Panama. In Colombia, Mexico, and Panama, weak industry-inspired bills were introduced at the same time as COP decisions and FCTC-based tobacco and nicotine control bills, which is a standard industry strategy to create confusion among policy-makers (²³23. Crosbie E, Sebrie EM, Glantz SA. Tobacco industry success in Costa Rica: the importance of FCTC Article 5.3. Salud Publica Mex. 2012;54:28–38.). In addition, a bill was submitted in Colombia with at least 20 pages of the same pro-industry language used in a bill in Mexico, including the word “Mexico” instead of Colombia (Severini L and colleagues, unpublished paper, 2023).

Litigation. In Mexico, industry actors filed legal challenges to the NETNP ban. The industry alleged the ban was unconstitutional because it violated the freedom of trade and non-discrimination provisions. There have been some decisions that favor the industry but they only affect those companies that filed challenges. As of March 2023, more than 200 cases are still pending about NETNP regulations.

Industry discursive (argument-based) strategies

In their discursive strategies, tobacco industry actors used a series of proactive key arguments to support lifting NETNP bans and reactive key arguments to oppose NETNP regulations and bans (Table 2).

Support for lifting bans/relaxing regulations on NETNPs. The most commonly reported industry arguments centered on harm reduction where they argued that NETNPs were less harmful and safer for health and the environment than conventional tobacco products. Other prominent arguments included that NETNPs should be regulated as reduced-risk products, or regulated with fewer restrictions on their sale, marketing, and use than those currently in place, and that NETNP devices provide access to new technology and science.

As mentioned before, the industry commonly cited alleged benefits from other countries that had allowed the sale of NETNPs. This strategy included the use of general talking points expressed in Brazil, Costa Rica, Mexico, and Panama such as “the U.K. Department of Health’s harm reduction approach has been successful”, “electronic cigarette use has shown to decrease the number of smokers in the U.K.”, and “NETNPs have helped lower the sales of conventional tobacco products in Japan”. In Brazil, Chile, Colombia, Mexico, and Uruguay, the industry specifically referenced the FDA’s decision on heated tobacco products and IQOS, arguing these products contain 90–95% lower levels of harmful chemicals than cigarettes and will not negatively affect indoor air quality. In other instances, Philip Morris International and Imperial Brands argued that relaxed NETNP regulations would help regulate products, collect taxes, reduce the black market, and prevent illegal trade from the United States and the United Kingdom of Great Britain and Northern Ireland, among others. In Brazil, British American Tobacco argued that there was no sense in allowing the so-called combustible products and not allowing non-combustible products referencing the United Kingdom’s approach to regulating NETNPs. In Brazil, Chile, and Mexico, Philip Morris International expressed its vision of a smoke-free world by claiming that it would stop selling conventional cigarettes in an effort to launch NETNPs.

Opposition to further regulation on or banning of NETNPs. The most commonly reported industry arguments again centered on its so-called harm-reduction approach. Industry actors referenced other government approaches as a rationale to restrict further regulations, arguing that NETNPs are effective in smoking cessation, and provide innovative and technological solutions for implementing modern public health policies. Industry actors also downplayed the harmful effects of NETNPs, rejected that NETNPs were a gateway to conventional products, and denied that they targeted young people.

Similar to opposition to conventional tobacco regulations (²³23. Crosbie E, Sebrie EM, Glantz SA. Tobacco industry success in Costa Rica: the importance of FCTC Article 5.3. Salud Publica Mex. 2012;54:28–38.–²⁵25. Bhatta D, Crosbie E, Bialous S, Glantz S. Tobacco control in Nepal during a time of government turmoil (1960–2006). Tob Control. 2020;29(5):548–55. https://doi.org/10.1136/tobaccocontrol-2019-055066
https://doi.org/10.1136/tobaccocontrol-2... ), the industry argued that NETNP bans would increase illicit trade and were unconstitutional. In Colombia, Costa Rica, Mexico, Panama, and Trinidad and Tobago, industry representative argued an NETNP ban would generate a black market and negatively impact tax revenues and public health, arguments that were echoed by policy-makers. In Panama, the industry argued that a bill banning electronic cigarettes violated international treaties and the Panamanian Constitution “since every person has the right to health”.

DISCUSSION

This regional analysis demonstrates how the tobacco industry aggressively attempts to undermine measures in line with the FCTC by trying to lift NETNP bans and weaken or push for weaker regulations. This is evident by active industry campaigns in several Latin American and Caribbean countries and their use of conventional and innovative strategies to argue for the introduction and promotion of new products. This approach includes creating new regulatory categories (e.g., so-called reduced-risk products), producing information with new partners (e.g., vaping associations), and issuing new sets of arguments (e.g., alleged harm reduction).

Industry actors seem to concentrate their efforts in larger and more influential countries such as Argentina, Brazil, and Mexico and countries considered diffusion hubs such as Costa Rica, Jamaica, and Uruguay. In particular, Philip Morris International is aggressively pushing heated tobacco products based on the success of commercializing these products in certain countries. This initially began in Asia and Europe (²⁶26. Stoklosa M, Cahn Z, Liber A, Nargis N, Drope J. Effect of IQOS introduction on cigarette sales: evidence of decline and replacement. Tob Control. 2020;29(4):381–7. https://doi.org/10.1136/tobaccocontrol-2019-054998
https://doi.org/10.1136/tobaccocontrol-2... ) and was followed by the FDA’s decision on IQOS (¹⁴14. Eckford R, Severini G, Sebrie EM, Muggli ME, Beem A, Rosen D, et al. United States Food and Drug Administration’s authorization of reduced exposure claims for IQOS®: implications for regulation in Latin America. Rev Panam Salud Publica 2022;46:e155. https://doi.org/10.26633/RPSP.2022.155
https://doi.org/10.26633/RPSP.2022.155... ) and Uruguay’s recent reversal of the ban on heated tobacco products. While similar attempts failed in Mexico and Brazil, it appears that the industry is using cases they consider “victories” to proactively push for lax NETNP regulations, as seen in more recent attempts in Costa Rica, Colombia, and Panama. This once again confirms the industry’s practice of disseminating regulatory approaches with a narrative that supports their interests to further promote NETNPs in Latin American and Caribbean countries (²⁷27. Crosbie E, Eckford R, Bialous S. Containing diffusion: the tobacco industry’s multipronged trade strategy to block tobacco standardised packaging. Tob Control. 2019;28(2):195–205. https://doi.org/10.1136/tobaccocontrol-2017-054227
https://doi.org/10.1136/tobaccocontrol-2... , ²⁸28. Crosbie E, Sosa P, Glantz SA. Defending strong tobacco packaging and labelling regulations in Uruguay: transnational tobacco control network versus Philip Morris International. Tob Control. 2018;27(2):185–94. https://doi.org/10.1136/tobaccocontrol-2017-053690
https://doi.org/10.1136/tobaccocontrol-2... ).

In its pursuit to resist further NETNP regulations or bans, industry actors have again relied on deceptive and misleading tactics. These tactics include manipulating research findings while funding the research (²⁹29. Gilmore AB, Fooks G, Drope J, Bialous SA, Jackson RR. Exposing and addressing tobacco industry conduct in low-income and middle-income countries. Lancet. 2015;385(9972):1029–43. https://doi.org/10.1016/S0140-6736(15)60312-9
https://doi.org/10.1016/S0140-6736(15)60... ), promoting regulatory decisions while misrepresenting rulings (²⁷27. Crosbie E, Eckford R, Bialous S. Containing diffusion: the tobacco industry’s multipronged trade strategy to block tobacco standardised packaging. Tob Control. 2019;28(2):195–205. https://doi.org/10.1136/tobaccocontrol-2017-054227
https://doi.org/10.1136/tobaccocontrol-2... , ²⁸28. Crosbie E, Sosa P, Glantz SA. Defending strong tobacco packaging and labelling regulations in Uruguay: transnational tobacco control network versus Philip Morris International. Tob Control. 2018;27(2):185–94. https://doi.org/10.1136/tobaccocontrol-2017-053690
https://doi.org/10.1136/tobaccocontrol-2... ), exaggerating claims about the black market despite allegedly continuing to participate in illicit trade (³⁰30. Crosbie E, Bialous S, Glantz SA. Memoranda of understanding: a tobacco industry strategy to undermine illicit tobacco trade policies. Tob Control. 2019;28(e2):e110–e118. https://doi.org/10.1136/tobaccocontrol-2018-054668
https://doi.org/10.1136/tobaccocontrol-2... ), and threatening or resorting to litigation, despite numerous significant judicial decisions upholding evidence-aligned tobacco and nicotine control measures (²⁷27. Crosbie E, Eckford R, Bialous S. Containing diffusion: the tobacco industry’s multipronged trade strategy to block tobacco standardised packaging. Tob Control. 2019;28(2):195–205. https://doi.org/10.1136/tobaccocontrol-2017-054227
https://doi.org/10.1136/tobaccocontrol-2... , ²⁸28. Crosbie E, Sosa P, Glantz SA. Defending strong tobacco packaging and labelling regulations in Uruguay: transnational tobacco control network versus Philip Morris International. Tob Control. 2018;27(2):185–94. https://doi.org/10.1136/tobaccocontrol-2017-053690
https://doi.org/10.1136/tobaccocontrol-2... ). Future research should examine the impact and influence of these actions and arguments on the NETNP regulatory environment.

Limitations

This study is a descriptive account but does not measure the impact of industry and health advocacy actions and arguments on NETNP policy decisions. However, it does provide some evidence to suggest key information and talking points on NETNPs used by the tobacco industry were echoed by some policy-makers, potentially influencing policy decisions.

Conclusion

Industry actors engaged in four instrumental (action-based) strategies to influence NETNP regulations, including coalition management, information management, direct involvement and access to the policy process, and litigation. Industry discursive (argument-based) strategies argued that NETNPs were less harmful, provided safer alternatives and should be regulated as so-called harm-reduction products or with fewer restrictions on their sale, marketing, and use than those currently in place.

To help counter industry efforts and disseminate best practices, especially in low- and middle-income countries, focus should be on proactive health advocacy. Health advocates need to strengthen government capacities and alert policy-makers to industry’s attempts to create new regulatory categories such as so-called reduced-risk product, publicize misleading information of government authorizations of NETNPs, and co-opt so-called harm-reduction messages that serve the industry’s agenda.

Disclaimer.

The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública / Pan American Journal of Public Health and/or those of the Pan American Health Organization and the World Health Organization.

Supplementary material.

Spanish translation provided by the authors.

Acknowledgements.

We thank all of the health advocates in Latin America and the Caribbean for providing information for this study.

REFERENCES

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