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The World Health Organization's World No Tobacco Day 2020 Campaign Exposes Tobacco and Related Industry Tactics to Manipulate Children and Young People and Hook a New Generation of Users

2020; Elsevier BV; Volume: 67; Issue: 3 Linguagem: Inglês

10.1016/j.jadohealth.2020.06.026

1879-1972

Simone St Claire, Ranti Fayokun, Alison Commar, Kerstin Schotte, V. Prasad,

Air Quality and Health Impacts

There are 1.3 billion tobacco users worldwide. That number might be even larger if tobacco did not kill half of its users [[1]WHO global report on trends in prevalence of tobacco use 2000–2025. 3rd ed. World Health Organization, Geneva2019Google Scholar]. Every 4 seconds, tobacco is responsible for another premature death [[2]GBD 2017 Risk Factor CollaboratorsGlobal, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden Of Disease Study 2017. Institute for Health Metrics and Evaluation, Seattle, WA2018Google Scholar]. For decades, the tobacco industry has deliberately used aggressive, duplicitous, and well-resourced tactics to hook generations of users to nicotine and tobacco, driving the global tobacco epidemic. This is primarily achieved through engineering and manipulating of products to sustain addiction, with young people being the main target. The strategy is to replace smokers and ensure market sustainability by making the products appealing and attractive to new and existing users, especially youth. In 1984, R.J. Reynolds stated, "younger adult smokers are the only source of replacement smokers… If younger adults turn away from smoking, the industry must decline" [[3]Tobacco company quotes on marketing to kids. Campaign for tobacco-free kids, fact sheet.https://www.tobaccofreekids.org/assets/factsheets/0114.pdfDate accessed: May 19, 2020Google Scholar]. Such strategies to engage children and adolescents before they are fully aware of the ramifications of their actions have been successfully used by the industry since the 1970s and are still in use today. Over the last decade, as the awareness of the harms of tobacco use has grown and global tobacco control efforts have intensified, the social acceptability of tobacco use has declined, directly impacting the sale of the most popular product—the cigarette. To maintain its profitability, the multi-billion-dollar industry has aggressively started to look for newer markets in low- and middle-income countries and also come up with innovative and creative ways to stay relevant and to keep its products on the market. Thus, it has been trying to reinvent itself by introducing a new portfolio of products, presenting itself as part of the solution to combat the tobacco epidemic, which it created in the first place. The strong marketing and promotional strategy of the tobacco industry has led to an increase in nicotine and tobacco product use among youth globally [4Cullen K.A. Ambrose B.K. Gentzke A.S. et al.Notes from the field: Use of electronic cigarettes and any tobacco product among middle and high school students - United States, 2011–2018.MMWR Morb Mortal Wkly Rep. 2018; 67: 1276-1277Crossref PubMed Scopus (374) Google Scholar, 5Gorini G. Gallus S. Carreras G. et al.Prevalence of tobacco smoking and electronic cigarette use among adolescents in Italy: Global Youth Tobacco Surveys (GYTS), 2010, 2014, 2018.Prev Med. 2020; 131: 105903Crossref PubMed Scopus (7) Google Scholar, 6Global Youth Tobacco SurveyFact sheet: Georgia.2017https://extranet.who.int/ncdsmicrodata/index.php/catalog/536Date accessed: May 18, 2020Google Scholar, 7Global Youth Tobacco SurveyFact sheet: Georgia.2014https://extranet.who.int/ncdsmicrodata/index.php/catalog/535/related_materialsDate accessed: May 18, 2020Google Scholar, 8Coombs J. Bond L. Van V. Daube M. "Below the Line": The tobacco industry and youth smoking.Australas Med J. 2011; 4: 655-673Crossref PubMed Scopus (10) Google Scholar, 9Sinha D.N. Singh P.K. Thakur J. Trend of tobacco use and exposure to secondhand smoke among students aged 13–15 years in India and selected countries of the South-East Asia region.Indian J Community Med. 2011; 36: S78-S80Crossref PubMed Scopus (5) Google Scholar, 10McDaniel P.A. Malone R.E. "What is our story?" Philip Morris's changing corporate narrative.Am J Public Health. 2015; 105: e68-e75Crossref PubMed Scopus (1) Google Scholar]. An overview of the three major categories of portfolio products and their health risks are summarized below:1.Conventional tobacco products, such as cigarettes, smokeless tobacco, and waterpipe tobaccoCigarette smoking is the most common form of tobacco use worldwide. Other tobacco products include waterpipe tobacco (commonly known as shisha or hookah), various smokeless tobacco products (chewing tobacco, snus, and snuff), cigars, cigarillos, roll-your-own tobacco, pipe tobacco, bidis, and kreteks.The tobacco epidemic is one of the biggest public health challenges the world has ever faced, killing more than eight million people globally every year [[2]GBD 2017 Risk Factor CollaboratorsGlobal, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden Of Disease Study 2017. Institute for Health Metrics and Evaluation, Seattle, WA2018Google Scholar]. Nearly all tobacco use begins in childhood and adolescence, and early onset provides more life-years to tobacco use, increasing the risk of developing tobacco-related diseases [[11]U.S. Department of Health and Human ServicesPreventing tobacco use among youth and young adults. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2012Google Scholar]. Tobacco use among youth increases the risk of reduced lung function, impaired lung growth, and early onset of chronic respiratory disease [[11]U.S. Department of Health and Human ServicesPreventing tobacco use among youth and young adults. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2012Google Scholar]. Starting to smoke in childhood doubles the risk of premature death [[12]Thomson B. Rojas N.A. Lacey B. et al.Association of childhood smoking and adult mortality: Prospective study of 120,000 Cuban adults.Lancet Glob Health. 2020; 8: e850-e857Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. The lungs continue to grow well into adulthood, but inhaling the toxic substances of tobacco smoke slows this process and causes potentially irreversible lung damage [[11]U.S. Department of Health and Human ServicesPreventing tobacco use among youth and young adults. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2012Google Scholar]. Tobacco is deadly in any form, whether smoked or unsmoked. Tobacco smoke contains more than 7000 chemicals, including some known to cause cancer and the use of smokeless tobacco products has been linked to health problems, and sometimes death [[13]U.S. Department of Health and Human ServicesHow tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2010Google Scholar]. Furthermore, second-hand smoke has been linked to several adverse health outcomes, including death [[14]U.S. Department of Health and Human ServicesThe health consequences of smoking: 50 years of progress. A report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2014Google Scholar].2.Heated tobacco productsHeated tobacco products (HTPs) are like all other tobacco products—inherently toxic, contain carcinogens, and expose users to toxic emissions, many of which cause cancer.HTPs are tobacco products that produce aerosols containing the highly addictive substance, nicotine, and toxic chemicals, some of which are carcinogens (i.e., substances that can cause cancer in humans) which is inhaled by the user [[15]WHOHeated tobacco products information sheet. World Health Organization, Geneva2018https://www.who.int/tobacco/publications/prod_regulation/heated-tobacco-products/en/Date accessed: May 18, 2020Google Scholar]. Currently, there is no evidence to demonstrate that HTPs are less harmful than conventional tobacco products, and they contain chemicals not found in cigarette smoke, which may have associated health effects [[15]WHOHeated tobacco products information sheet. World Health Organization, Geneva2018https://www.who.int/tobacco/publications/prod_regulation/heated-tobacco-products/en/Date accessed: May 18, 2020Google Scholar].3.E-cigarettesElectronic nicotine delivery systems and electronic non-nicotine delivery systems, more commonly referred to as e-cigarettes, are devices that heat a liquid to create an aerosol that is inhaled by the user. E-cigarettes do not contain tobacco but typically contain nicotine and toxic substances that are harmful to health [[16]WHOElectronic nicotine delivery systems and electronic non-nicotine delivery systems (ENDS/ENNDS). Report by WHO, Conference of the Parties to the WHO Framework Convention on Tobacco Control, Seventh Session, FCTC/COP/7/11.2016https://www.who.int/fctc/cop/cop7/FCTC_ COP_7_11_EN.pdfDate accessed: March 13, 2020Google Scholar,[17]WHOElectronic nicotine delivery systems. Report by WHO, Conference of the Parties to the WHO Framework Convention on Tobacco Control, Sixth Session, FCTC/COP/6/10 Rev.1.2014https://apps.who.int/iris/handle/10665/147110Date accessed: March 13, 2020Google Scholar].In combination with tobacco smoking, which is the practice of the majority of e-cigarette users, the health effects of two or more products are combined [[18]Wang J.B. Olgin J.E. Nah G. et al.Cigarette and e-cigarette dual use and risk of cardiopulmonary symptoms in the Health eHeart Study.PLoS One. 2018; 13: e0198681PubMed Google Scholar]. Evidence on the harmful health effects of e-cigarettes is mounting, as their use has been associated with heart disease [[19]Alzahrani T. Pena I. Temesgen N. Glantz S.A. Association between electronic cigarette use and myocardial infarction.Am J Prev Med. 2018; 55: 455-461Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar] and lung disorders [[20]Wills T.A. Pagano I. Williams R.J. Tam E.K. E-cigarette use and respiratory disorder in an adult sample.Drug Alcohol Depend. 2019; 194: 363-370Crossref PubMed Scopus (71) Google Scholar]. They pose significant risks to pregnant women who use them, as they can damage the growing fetus [[16]WHOElectronic nicotine delivery systems and electronic non-nicotine delivery systems (ENDS/ENNDS). Report by WHO, Conference of the Parties to the WHO Framework Convention on Tobacco Control, Seventh Session, FCTC/COP/7/11.2016https://www.who.int/fctc/cop/cop7/FCTC_ COP_7_11_EN.pdfDate accessed: March 13, 2020Google Scholar].E-cigarettes are particularly dangerous when used by children and adolescents. Nicotine is highly addictive and can have long-lasting, damaging effects on brain development [[21]Morean M.E. Krishnan-Sarin S. O'Malley S S. Assessing nicotine dependence in adolescent E-cigarette users: The 4-item Patient-Reported Outcomes Measurement Information System (PROMIS) Nicotine Dependence Item bank for electronic cigarettes.Drug Alcohol Depend. 2018; 188: 60-63Crossref PubMed Scopus (42) Google Scholar,[22]England L.J. Aagaard K. Bloch M. et al.Developmental toxicity of nicotine: A transdisciplinary synthesis and implications for emerging tobacco products.Neurosci Biobehav Rev. 2017; 72: 176-189Crossref PubMed Scopus (85) Google Scholar]. Furthermore, there is a growing body of evidence in some settings that never-smoker minors who use e-cigarettes at least double their chance of starting to smoke conventional tobacco cigarettes later in life [[23]WHO report on the global tobacco epidemic, 2019. World Health Organization, Geneva2019Google Scholar]. In addition, exposure of children to the liquid contained in e-cigarettes could pose serious risks to children if they leak or children swallow the liquid [[24]WHOQ&A on E-cigarettes: How risky are they?.2020https://www.who.int/news-room/q-a-detail/e-cigarettes-how-risky-are-theyDate accessed: May 25, 2020Google Scholar]. Some e-cigarettes have also been reported to cause serious injuries, including burns, through fires and explosions [[24]WHOQ&A on E-cigarettes: How risky are they?.2020https://www.who.int/news-room/q-a-detail/e-cigarettes-how-risky-are-theyDate accessed: May 25, 2020Google Scholar]. Using manipulative marketing tactics and social positioning techniques, the industry has effectively targeted children and adolescents with this expanded portfolio of products that threaten their future [[25]Stopping Tobacco Organizations and ProductsAddiction at any cost: Philip Morris International Uncovered.2019https://exposetobacco.org/wp-content/uploads/STOP_Report_Addiction-At-Any-Cost.pdfDate accessed: March 13, 2020Google Scholar]. Tobacco and related industries have a well worked out strategy and calculated approach to expand their market share with existing and newer products and also to expand to new markets, especially in low- and middle-income countries [[25]Stopping Tobacco Organizations and ProductsAddiction at any cost: Philip Morris International Uncovered.2019https://exposetobacco.org/wp-content/uploads/STOP_Report_Addiction-At-Any-Cost.pdfDate accessed: March 13, 2020Google Scholar,[26]Daube M. Moodie R. Exit strategy: We can do it for COVID-19, why not tobacco?.2020https://insightplus.mja.com.au/2020/19/exit-strategy-we-can-do-it-for-covid-19-why-not-tobacco/Date accessed: May 25, 2020Google Scholar]. The tobacco industry has a long-standing history of misleading the public about the risks associated with other tobacco products. Between the 1950s and 1970s, the industry introduced cigarette filters and "light" and "mild" cigarettes as evidence mounted around the harms of tobacco, which it promoted as an alternative to quitting, while being fully aware that those products were not less harmful to health [[13]U.S. Department of Health and Human ServicesHow tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2010Google Scholar]. Today, the industry continues misleading the public by suggesting that some tobacco products are less harmful than others before the body of evidence on the harms of these products can be fully established. Traditional forms of advertising, promotion, and sponsorship by the tobacco industry are well-known billboards, radio and television advertisements, point-of-sale displays, brand sharing, brand stretching, and event sponsorship (Table 1) . However, the industry is continuing to look at new opportunities aimed at making nicotine and tobacco products appealing, sustaining use. This is with the primary objective of maximizing profit irrespective of the harms caused by these products, especially to young people.Table 1Tobacco and related industry strategies to increase adolescent use of nicotine and tobacco products globallyAdvertisingDigital and social media advertising: Tobacco and related industries have strategically used digital and social media platforms to reach younger generations [[25]Stopping Tobacco Organizations and ProductsAddiction at any cost: Philip Morris International Uncovered.2019https://exposetobacco.org/wp-content/uploads/STOP_Report_Addiction-At-Any-Cost.pdfDate accessed: March 13, 2020Google Scholar], including through their favorite apps and video games [[27]Navarro M.A. O'Brien E.K. Hoffman L. Cigarette and smokeless tobacco company smartphone applications.Tob Control. 2019; 28: 462-465Crossref PubMed Scopus (3) Google Scholar,[28]Truth InitiativeSome video games glamorize smoking so much that cigarettes can help players win.2018https://truthinitiative.org/research-resources/tobacco-pop-culture/some-video-games-glamorize-smoking-so-much-cigarettes-canDate accessed: March 5, 2020Google Scholar].Product placement in entertainment media, such as television and cinema [[29]WHOTobacco advertising, promotion and sponsorship: Depiction of tobacco in entertainment media. Report by WHO, Conference of the parties to the WHO framework convention on tobacco control, Seventh session, FCTC/COP/7/38.2016Google Scholar]: Children and adolescents who watch movies and television shows containing depictions of smoking are at an increased risk of initiating smoking. In 2018, at least half of the movies with depictions of tobacco were youth-rated [[30]Polansky J.R. Driscoll D. Garcia C. Glantz S.A. Smoking in top-grossing US movies 2018. UCSF: Center for Tobacco Control Research and Education, 2019https://escholarship.org/uc/item/55x9b9c1Date accessed: March 13, 2020Google Scholar], and the number of depictions of tobacco in youth-rated films has grown 63% since 2015 [[31]Polansky J.R. Glantz S.A. What is Hollywood Hiding?. UCSF: Center for Tobacco Control Research and Education, 2020https://escholarship.org/uc/item/3pw661mgDate accessed: March 13, 2020Google Scholar].PromotionFree product samples and merchandise: The tobacco industry also promotes their products by distributing free samples and merchandise with tobacco logos. In more than 50 countries, at least 10% of students aged 13–15 years reported ever being offered a free cigarette by a tobacco company representative. In more than 120 countries, at least 1 in 10 students aged 13–15 years reported having an object with a tobacco company logo [[32]Centers for Disease Control and PreventionNational Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, Global Tobacco Surveillance System Data (GTSSData).https://www.cdc.gov/tobacco/global/gtss/gtssdata/index.htmlDate accessed: February 19, 2020Google Scholar].SponsorshipScholarships and school programs: Tobacco and e-cigarette-related entities have offered scholarships and paid schools for the opportunity to speak in classrooms or after school [[33]Linder R. Philip Morris offers Israeli medical students grants for attending lectures. Haaretz, 2019https://www.haaretz.com/israel-news/.premium-philip-morris-offers-israeli-medical-students-grants-for-attending-lectures-1.8221762Date accessed: March 5, 2020Google Scholar,[34]SEATCATop universities reject big tobacco's research funding. ASEAN Tobacco Control Resource Center, 2017https://seatca.org/top-universities-reject-big-tobaccos-research-fundingDate accessed: March 5, 2020Google Scholar]. They have also sponsored summer camps to spread misconceptions about the risks of e-cigarette use and market their products under the guise of promoting "safer alternatives" to conventional tobacco products [[35]Kaplan S. Juul targeted schools and youth camps, house panel on vaping claims.New York Times. 2019; (Available at:)https://www.nytimes.com/2019/07/25/health/juul-teens-vaping.htmlDate accessed: March 5, 2020Google Scholar].Celebrity and influencer endorsements: "Influencers" on social media who reach and engage children and adolescents are invited by these industries to serve as "brand ambassadors" or offered financial incentives to promote their tobacco products [[36]Majmundar A. Chou C.P. Cruz T.B. Unger J.B. Relationship between social media engagement and e-cigarette policy support.Addict Behav Rep. 2019; 9: 100155Crossref PubMed Scopus (7) Google Scholar,[37]Campaign for Tobacco-Free KidsBig tobacco: Tiny targets.https://www.takeapart.org/tiny-targets/index.htmlDate accessed: March 5, 2020Google Scholar].Other marketing tacticsFlavors that appeal to youth: The tobacco industry has made tobacco products, such as smokeless and waterpipe tobacco, more palatable by marketing them in sweet and fruity flavors, which increase appeal and mask the harsh tobacco taste [[38]Jawad M. Nakkash R.T. Hawkins B. Akl E.A. Waterpipe industry products and marketing strategies: Analysis of an industry trade exhibition.Tob Control. 2015; 24: e275-e279Crossref PubMed Scopus (18) Google Scholar,[39]Kostygina G. Ling P.M. Tobacco industry use of flavourings to promote smokeless tobacco products.Tob Control. 2016; 25: ii40-ii49Crossref PubMed Scopus (22) Google Scholar]. E-liquid flavors are available in a variety of flavors, including those proven to appeal to youth, such as cotton candy and gummy bear [[40]Hsu G. Sun J.Y. Zhu S.H. Evolution of electronic cigarette brands from 2013-2014 to 2016-2017: Analysis of brand websites.J Med Internet Res. 2018; 20: e80Crossref PubMed Scopus (61) Google Scholar].Sleek designs: E-cigarettes and heated tobacco products are extensively promoted as modern, high-tech and high-end lifestyle products, with minimalist designs, and high-profile product launches that portray them as attractive and harmless products.Single stick cigarettes and disposable e-cigarettes: Products have been made more affordable to young people through the sale of single stick cigarettes [[41]WHO Framework convention on tobacco control. World Health Organization, Geneva2003Google Scholar] and disposable e-cigarettes [[42]Williams R. The rise of disposable JUUL-type e-cigarette devices.Tob Control. 2019; Crossref Scopus (13) Google Scholar], which typically lack health warnings. Open table in a new tab The World No Tobacco Day 2020 campaign serves to debunk myths and expose devious tactics used by tobacco and related industries to attract children and young adults. It also raises awareness about the common and covert tactics used by these industries and provides young people with the knowledge required to easily detect and stand up against industry manipulation. This campaign reinforces the World Health Organization's work in assisting country-level implementation of effective policy interventions to reduce the demand for tobacco, thereby promoting well-being and ensuring maximum protection of public health and overall, strengthening tobacco control globally. The World Health Organization calls on all young people to join the fight to become a tobacco-free generation. The world cannot afford another generation deceived and exploited by the lies and subterfuge of the tobacco industry, which pretends to promote freedom of personal choice while really pursuing eternal profits–profits that cost millions of lives every year. (https://www.who.int/news-room/campaigns/world-no-tobacco-day/world-no-tobacco-day-2020).