Big tobacco, global health, and the limits of shared value

WASHINGTON — On the evening of Sept. 23, 2018, Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization, known to most as “Dr. Tedros,” did something he has done nearly 20,000 times: He tweeted.

“I have cancelled my participation in the @ConcordiaSummit after the tobacco industry, which profits from destroying health, announced it is sponsoring the event. #NoTobacco #BeatNCDs #UNGA,” Tedros wrote.

The Concordia Summit is one of the marquee events that cling to the U.N. General Assembly in September. It serves as an annual physical manifestation of Concordia itself — a nonprofit organization founded in 2011, whose leadership council includes former heads of state, university presidents, board chairs of multinational corporations, and NGO founders. The organization’s aim is to foster public-private collaboration, and it leans heavily on the concept of “shared value,” which envisions businesses moving beyond corporate social responsibility to put positive social impact at the center of their business models.

As the traditional cadre of global development NGOs, U.N. agencies, and government donors have grown more willing to open their doors to the private sector, events such as the Concordia Summit serve as opportunities to convene a diverse group of participants and highlight cross-sectoral partnerships.

The world’s more “enlightened” companies — and the ones that want to be seen that way — show up to explain how they are broadening their ambitions in ways that allow them to profit from solving the world’s problems, rather than from creating them. That is what Philip Morris International, the world’s largest international tobacco company, had in mind when it agreed to sponsor Concordia’s 2018 summit.

For the past few years, Philip Morris International, which produces cigarette brands including the iconic Marlboro, has been rolling out a radical new corporate strategy. The company’s current leadership says they want to replace cigarettes with supposedly less-harmful tobacco products. In an effort to accelerate the transition to a “smoke-free” future, PMI has poured billions of dollars into the development of an e-cigarette called iQOS which heats tobacco into a vapor, instead of burning it to produce smoke.

"I believe that there will come a moment in time where we have sufficient adoption of this alternative product and sufficient awareness to start envisaging, together with governments, a phase-out period for cigarettes," CEO André Calantzopoulos told BBC Radio in 2016.

Calantzopoulos has worked to reposition PMI at the forefront of a tobacco “harm reduction” agenda. That has involved a broad corporate rebranding, which aims to position the company as a research and development pioneer with health and sustainability at the core of its business strategy. PMI’s website is practically devoid of any images of its cigarette brands, even though they are currently available in 180 countries. In their place, scientists in white lab coats arrange test tubes under the motto “designing a smoke-free future.”

As the tobacco giant has recast itself as a health research and development pioneer, it has sought to make inroads into a global health community that considers PMI one of its most reviled enemies.

Many were surprised in early September when PMI announced that it hired Aaron Sherinian, a veteran global development communications leader who has worked at the United Nations Foundation, to help mend relationships and foster collaboration between big tobacco and global health. Despite being excluded from attending the World Economic Forum annual meeting in Switzerland, in January, PMI went to Davos and distributed a white paper titled “Public Health — Much Harder than Rocket Science.” It concluded that public health authorities alone cannot compel people to make better health choices — they need consumer goods companies to help.

According to PMI’s leaders, if the world’s largest tobacco company can convince 1 billion smokers to switch from combustible cigarettes to smoke-free alternatives, they can usher in a new era for tobacco and save millions of lives in the process. Health and anti-smoking advocates, they argue, should see PMI’s pivot as an historic opportunity to change the prognosis for smoking-related disease and, potentially, save millions of lives.

All they have to do is overcome their fear of working with a company that has, for more than a century, undermined health policy, obscured science, and actively profited from one of the most harmful products on the planet.

At the Concordia Summit, in a “flash talk,” Calantzopoulos described his vision of a world in which PMI and global health organizations might work together, with PMI bringing new and safer products to market, while public institutions help create a more conducive regulatory environment for e-cigarettes to allow that to happen.

“How can we implement the right regulatory framework to maximize switching to better products while minimizing any unintended public health consequences?” he asked.

“We are ready and willing to talk with people across all sectors and of all points of view, including those who disagree with us. My ask is for everyone here today to carefully consider the role that smoke-free alternatives can play in achieving global health goals,” Calantzopoulos said.

The leader of WHO — whose landmark Framework Convention on Tobacco Control explicitly prohibits industry interference in health policy — would not even enter the building.

Foundation aims to ‘improve global health’

Calantzopoulos and his team are not blind to big tobacco’s history. In their effort to salvage any remaining common ground for collaboration, they have taken steps to put some distance between the corporation and the scientific basis for policies that might favor a smoke-free tobacco future.

In 2017, PMI pledged $80 million a year for 12 years to establish the Foundation for a Smoke-Free World, whose mission is “to improve global health by ending smoking in this generation.” The foundation claims total independence from PMI, though the tobacco company remains its sole funder and that funding is contingent on the foundation continuing to pursue its original mission, which is inarguably aligned with PMI’s new corporate strategy.

For many anti-smoking advocates, the Foundation for a Smoke-Free World is just the latest incarnation of a familiar tobacco industry tactic — creating front organizations to produce self-serving “science,” muddy policy, and put a compassionate face on a health-destroying industry. WHO has issued guidance to its partners in the health community not to work with the foundation.

Philip Morris International claims that this time is different. The company, its leaders argue, is no longer trying to dodge the fact that its core product is harmful to human health, but is instead trying to redirect its research, development, and market influence toward a new product that can help the very people whom cigarettes are currently killing.

The Foundation for a Smoke-Free World is meant to provide a neutral ground for independent research into the health benefits and risks of smoke-free tobacco products, promote projects to help tobacco farmers find alternative livelihoods, and even conduct investigations into ongoing tobacco industry efforts to undermine public health.

The foundation also represents a highly controversial argument: that it is possible for the global health community and the world’s largest international tobacco company to share common goals. There may not be anyone with more at stake in the credibility of that argument than a South African doctor named Derek Yach, president of the Foundation for a Smoke-Free World.

The tobacco fight

Yach grew up in apartheid-era Cape Town with an eye for the ways that political inequality could destroy black South Africans’ health. He joined protests as a university student, and in medical school was counseled to study public health and epidemiology because of his passion for agitating against systemic injustice.

After earning a master’s in public health at Johns Hopkins University, he returned to the South African Medical Research Council in 1985 with a mission to “make waves,” and convinced his boss to fund a study into the effects of political violence on health. But as a white South African, he found himself shut out by the international health community, which rejected his papers from leading academic journals and barred him from attending their conferences.

“If I was white, because I was white, I had to be bad, because I continued to live and work in a country shunned by the rest of the world for its racist policies,” Yach wrote in his memoir, “Project Unthinkable,” published in late 2018.

While still a university student, Yach began to dispute tobacco companies’ arguments that cigarettes were not harming people in a country with so many other more pressing health problems. He campaigned against the Rembrandt Tobacco Corporation and in a meeting with the Afrikaans-owned multinational’s CEO, chided the company’s claims that employing black South Africans made them good corporate citizens.

“All that is great, but it doesn’t take away from the fact that your product is killing people,” Yach told him.

In 1995, Yach received a call from WHO to move to Geneva and become the first South African since the end of apartheid to work there.

Yach’s recollections are full of criticism of WHO’s “labyrinthine bureaucracy,” and he does not shy away from naming names, directing some of his harshest fire at former Director-General Hiroshi Nakajima, under whom, Yach wrote, “WHO practically absolved itself of any responsibility to do anything with tobacco control, period.”

He complained that the organization should have paid more attention to the threat posed by noncommunicable diseases in developing countries, and that the reports he produced containing that message “should have been a call to action.”

“Although we demonstrated repeatedly that noncommunicable diseases, from obesity to lung cancer, were proliferating throughout the world, we found ourselves largely sidelined — forgotten siblings toiling away in a division that was largely invisible to the rest of the organization,” he wrote.

Things changed with the appointment of Gro Harlem Brundtland in 1998, who designated tobacco one of her two big “pathfinder” projects. Brundtland appointed Yach as director of WHO’s Tobacco Free Institute, where he helped create initiatives that would lead, a year later, to the formation of the Framework Convention Alliance on Tobacco Control, a coalition supporting stronger tobacco control policy.

Yach, meanwhile, suggested that Brundtland put together an independent study of the tobacco industry’s subversion of WHO policies, which ultimately uncovered a well-funded and wide-ranging effort to distort scientific studies, reduce funding to WHO’s scientific and policy initiatives, pit other U.N. agencies against WHO, and “convince officials and politicians in developing countries that WHO wanted to implement a First World agenda at the expense of their own Third World populations,” Yach wrote. “We were going to stop them.”

In the course of negotiating its landmark tobacco control treaty, WHO invited tobacco companies to participate in a few cases, in hopes of finding “some kind of nexus where we could work together,” Yach wrote. Instead of sending scientists, the companies sent public relations representatives, and any attempts at collaboration proved futile.

That was the first time Yach encountered the concept of “harm reduction” as an aspect of tobacco control, through presentations about new products the companies were working on to reduce tobacco-related disease. At the time, these presentations were “sloppy and insubstantial — mostly, if not entirely, spin,” he wrote.

Negotiations over the tobacco control treaty took three years, eventually devolving into a “mad scramble” as the process drew to a close. Yach, under Brundtland’s direction, battled back against last minute demands for changes and additions to the treaty text, until, on May 21, 2003, at the 56th World Health Assembly in Geneva, 192 countries signed on in unanimous approval of the WHO Framework Convention on Tobacco Control.

Roadblocks

The end of Brundtland’s tenure later that year marked the beginning of the end of Yach’s moment in the sun at WHO. Under the new director-general, Lee Jong-wook, Yach was transferred to a workspace in the “middle of nowhere” known as the “waiting room.” Where once he had a close relationship with the director-general, and responsibility for a team of 250, now Yach answered his own phone and — from his office “with a window that looked out on a very busy parking lot” — oversaw a single staff researcher.

Once again, Yach found his work on the prevention and control of chronic diseases getting shoved into the corner of an institution focused on other health challenges.

He soon left for a tenured professor position at Yale University, where his frustrations would only continue. Yach encountered “a university bureaucracy that expected me to produce while setting roadblocks every step of the way.”

Yach did not last long at Yale — “I realized that life with tenure was not for me,” he wrote — but in 2005, he received a phone call from Judith Rodin, at the time the new president of The Rockefeller Foundation, who wanted him to be her global health director. Yach accepted, and relocated to an office at the foundation’s headquarters on Fifth Avenue. But this match was also not to be.

Roughly a year after Yach joined Rockefeller, Warren Buffet pledged $31 billion to the Bill & Melinda Gates Foundation, setting off what Yach described as “a scramble to keep up with the Gates Foundation Joneses.”

Rockefeller, according to Yach, “had become so consumed with funding and with the visibility given the foundation’s projects in the media” that they felt they could no longer compete against Gates in the health field.

“We’d have to find something else — causes such as ‘resilience-building’ … With my public health expertise and emphasis on prevention, I didn’t fit in,” he wrote.

By 2006, Yach was still trying to keep NCDs on the Rockefeller agenda. He emailed a director at WHO and asked him to pressure Rockefeller’s regional Nairobi and Bangkok offices to support a meeting that Yach wanted to organize among foundation heads working on NCDs.

After sending the email, Yach was promptly called into the office of Rockefeller’s general counsel and fired for insubordination.

He did not go quietly, but threatened the foundation counsel with “profound” repercussions for dismissing “one of the architects of both the Framework Convention on Tobacco Control and the Global Strategy on Diet, Physical Activity and Health.” As a result, Yach managed to secure an extension until he was able to find a new position, and in the meantime Rockefeller seconded him to the Clinton Global Initiative, where he worked “to persuade governments and private industry to come together to tackle major social issues.”

At this point, Yach’s transition from the bureaucratic icons of the traditional global health community to a world in which profit and social impact blend more seamlessly began in earnest.

Whether that marks the beginning of a journey to a future where businesses and public institutions collaborate for the common good, or the beginning of a journey to the dark side is a matter of perspective.

Working with the enemy

Just a few months into his stint with the Clinton Global Initiative, Yach received a phone call from Indra Nooyi, the incoming CEO at PepsiCo, who invited him to visit her. Nooyi had a vision for transforming one of the world’s largest purveyors of junk food and sugar-sweetened beverages into a healthier company.

“I want you to do exactly what you were doing at WHO before you left and do it here for us at PepsiCo,” she told him.

In his book, Yach wonders if he was being used as an industry shill to give a health expert’s endorsement of public relations-driven priorities.

“Had I been hired for the optics? That may have been part of Nooyi’s motivation, but it certainly wasn’t that alone,” Yach wrote, pointing out that Nooyi had sold Pepsi’s stake in fast food companies, and rebranded itself with the message “Performance with Purpose.”

While Yach was at Pepsi, the company launched some healthier product lines, while he worked to create the International Food and Beverage Alliance, an NGO for multinational collaboration, and struggled to gain traction for their healthier foods agenda with WHO.

“I don’t know if it was due to lack of staff or simply lack of interest,” he wrote.

Yach was swiftly denounced by a number of people who previously knew him as a high-level public health expert — though this would only be a small taste of the condemnation to come.

He left Pepsi to join the insurance company Vitality Group, which uses analytics and financial incentives to promote better health behavior — and which he described as a prime example of “shared value” in action. It was at Vitality that Yach publicly supported deploying e-cigarettes as a technological solution for improving smokers’ health. That led to his most controversial decision.

In September 2015, Yach sat down with Calantzopoulos at Philip Morris International's headquarters — known as “The Cube” — in Switzerland. Calantzopoulos, who had taken note of Yach’s position on e-cigarettes, wanted to figure out “how to bridge the divide between accessibility in the public sphere and the product, given our history.”

Among the list of conditions Yach suggested PMI would have to meet in order to win some credibility from the global health community was the establishment of an independent fund. Several months later he left Vitality to run it.

“People will scoff. Of course they will,” Yach wrote. “How, they will ask, can a behemoth that has lied for so long while pushing its tobacco products, despite incontrovertible evidence that they cause users to get sick and die, be part of the solution? It’s a fair question, and I’m not sure if there is a definitive answer. Sometimes, you just have to trust your feelings and what is right there before your eyes.”

Sharing values?

On Jan. 24, Yach, who is no longer permitted to enter the WHO grounds because of his affiliation with a foundation funded by the tobacco industry, sent an open letter to WHO’s executive board, which was gathered in Geneva for its annual meeting.

His purpose in writing was to urge WHO to reconsider its recommendation that researchers and governments not collaborate with the Foundation for a Smoke-Free World, whose sole funder is still Philip Morris International.

Yach described the ongoing health burden smoking creates, outlined why ending smoking should be central to the health agenda, and argued that the foundation is an independent organization capable of moving a stubborn needle toward more effective tobacco control — if only anyone would agree to work with them.

“We hope you will review and consider how best to work with the Foundation to facilitate a rapid reduction in the use of lethal cigarettes. Over the past 12 months, we have made substantial progress in achieving what we pledged to do in support of our mission to end smoking. These efforts need to be fully leveraged by the WHO. Our goal is the same — to end smoking in this generation,” he wrote.

Four days later, 120 global health organizations co-signed another open letter to WHO’s executive board, expressing “grave concern” about the Foundation for a Smoke-Free World’s attempt to open the door to partnership and adamantly urging WHO not to change its position.

The authors argued that the foundation “effectively operationalizes PMI’s corporate affairs strategy to further PMI’s business interests which include the promotion of its heated tobacco products, a market which PMI seeks to dominate.”

“While PMI and its grantee claim a commitment to reducing harm; reports show that PMIs cigarettes continue to be heavily marketed in ways that attract children and undermine public health policy,” they added.

Yach is not asking WHO to partner directly with the foundation, but to stop telling other organizations and researchers they should steer clear as well. In an interview, Yach said that WHO’s approach has been “very extreme,” and that it has caused some people who have associated with the Foundation for a Smoke-Free World to leave their universities and resign from scholarly boards.

“That really is not within the spirit of academic freedom and the rights of people to judge whether they believe that the independence of the funding is actually sufficient for them to go ahead and accept it,” he said.

At the meeting, WHO’s executive board reiterated their position of not working with, or accepting funding from tobacco companies — and not engaging nonstate actors that further the industry’s interests.

Yach has repeatedly pondered this question of whether it matters that tobacco companies — including the one that funds him — might benefit from the foundation’s research and activities related to smoke-free tobacco products.

“If the benefits accrue to all tobacco companies, [if] every single one of them see the writing on the wall and move out of combustible cigarettes, [then] the population, the smoker, is better off for it. If the research shows that there are downsides and there are negatives and there are untoward consequences in kids, we will also be exposing those,” he told Devex.

If tobacco companies stand to benefit from marketing a new product that also holds potential benefits for public health, does it matter? In fact, that is the very definition of “shared value.” The more difficult question is: Can tobacco companies destroy human health, and at the same time work with the health community to destroy it somewhat less.

Among Yach’s detractors — of whom there are many — the problem is not simply that tobacco companies might benefit from the foundation’s activities. The problem is that they find the underlying premise of this work — that tobacco companies including Philip Morris International are now also concerned about improving their customer’s health — to be wholly unbelievable and unsubstantiated by their actual behavior.

“They’re not pivoting away from cigarettes. They’re still selling them. That’s the scam,” said Stanton Glantz, director at the Center for Tobacco Control Research and Education at the University of California, San Francisco.

“It’s all about keeping people smoking cigarettes, and if people are going to quit, to get them to continue buying something from the company rather than quitting. It’s all about holding on to customers. No company is going to voluntarily market a product that’s going to reduce its profitability,” he said.

Yach has given Philip Morris International the benefit of the doubt that with new information about how to cause less harm, they would make the decisions necessary to do so. Most other global health experts — even those who are sympathetic to the concept of tobacco harm reduction — have been far less generous.

“If the tobacco companies were any more socially responsible in any way, I could imagine working with them. But they have demonstrated for 100 years that all they care about is profit,” said William Savedoff, senior fellow at the Center for Global Development.

The debate over e-cigarettes continues to rage, driven by concerns about soaring levels of use among young people.

In April, the U.S. Food and Drug Administration approved Philip Morris International’s application to sell iQOS in the United States, but the FDA is still considering a separate application to allow PMI to market the e-cigarette as a reduced-harm product. Ethiopia, on the other hand, recently passed one of Africa’s strongest anti-tobacco laws, which includes a total ban on heated tobacco products, including e-cigarettes.

According to Glantz, information about the risks posed by heated tobacco products has been accumulating quickly, particularly related to pulmonary and cardiovascular disease. That, he said, should be the true test of Yach’s credibility as an independent proponent for human health.

“As the evidence has been accumulating, has his opinion been changing?” Glantz asked, adding that in his view, “it hasn’t.”

Update, May 29, 2019: This article has been updated to clarify that PMI distributed its white paper during the 2019 WEF meeting in Davos, and was not officially involved in WEF events.

Update, May 28, 2019: This article has been updated to clarify that IQOS is not an acronym, but a brand name.