In the tobacco control world, it's hard to find a more controversial figure than Derek Yach.
After starting his career fighting both South African tobacco companies over smoking and a white apartheid government for the health of black South Africans, Derek Yach went on to become one of the main architects of the WHO tobacco treaty. He later received flack for joining PepsiCo at a time in the belief that health could often be better served by working with problem companies instead of against them. While continuing, obviously, to sell Pepsi, the company ditched trans fats, cut some unhealthy lines and invested in new, healthier products.
The most controversial move for this anti-tobacco warrior was accepting a position to set up and run the Foundation for a Smoke Free World (FSFW) - a foundation funded by Philip Morris International, the maker of Marlboro cigarettes.
With Derek now having left the Foundation for a Smoke-Free World and, I hope, able to speak freely about it, I caught up with him to talk about the foundation, its impact on trust in tobacco harm reduction science, opposition to vaping and much more. Here you’ll find a round up of the interview, followed by the transcript for those of you who want the full, fascinating detail.
We meet by video link, struggling a little to hear as fighter jets roar over my house in the rainy Welsh countryside. Derek is relaxed and personable, with a light South African accent and the build of a keen swimmer.
I’ve often felt sceptical about the tobacco industry’s motives when it comes to harm reduction products. What, I wanted to know, was PMI’s motives in setting up the Foundation for a Smoke-Free World with the promise of a billion dollars in funding?
Derek pointed out that first, while a billion dollars sounds a lot, it's modest compared to the billions PMI had poured into research into alternatives to cigarettes. Secondly, the foundation formed part of a strategy to move from heavily regulated combustible products to devices that will generate profits for the longer term:
“It's 100% commercial… they don't see themselves as angels solving a public health problem. Instead, they want to see their companies remain commercially viable and, in the process, cut the risks of the old products. They see the two going hand in hand.”
Alternative nicotine products form only one part of their plan, and the research they are conducting could eventually help them to transform into a life science company.
Over the past few years, I’ve seen the foundation fund some superb scientists, resulting in research that should have led to a greater acceptance of reduced harm products such as vape devices.
Unfortunately, those same scientists have endured vicious personal and professional criticism for taking money, albeit indirectly, from PMI. Many researchers in the field are now blocked from conferences, while high-quality studies are discounted and discredited because they are considered tainted by tobacco money.
Derek didn’t agree that PMI’s plans had backfired, but did admit they had not expected the scale of the opposition.
“I think what we underestimated was the vociferousness with which the Bloomberg foundation, Matt Myers and the Tobacco Free Kids movement would actually go after ad hominem attacks on individual researchers and scientists… the level of harassment was something which I had never experienced, and which I didn’t expect.”
At a time when almost every independent vaping brand is being wiped out by regulations in the USA - even while tobacco products are being approved - I wanted to know if tobacco companies were deliberately seeking regulations that would hand them market dominance.
Derek did see tobacco dominance as a problem.
“In any market you tend to see far more innovation when there’s more players. And so from that point of view it probably will slow down innovation, but that doesn't necessarily mean it's going to be a disaster for harm reduction.”
However, he didn’t see this dominance as deliberate, but rather as a consequence of the huge funds tobacco companies were putting into research and development. He advised SMEs to pool their resources to fund research and to find the angles and innovations that can help them be successful.
We also discussed the reason for the opposition to vaping, an opposition Derek believes is partly to blame for a black and white approach to public health, but also due to the fact that the very people who need help - smokers and vapers - are scorned and sidelined. Only when we include the people affected by our actions, he argued, can we come up with policies that will help them.
I titled this blog post: Can vapers trust big tobacco? The answer, for me, remains no. I am sure, for example, tobacco companies will seek to dominate the nicotine market if they are given a chance at the expense of competition and innovation.
At the same time, Derek makes a strong argument that where commercial considerations and public health align, we should make use of these companies' vast pockets and technical expertise for research and public good. But to get the full benefit of this, I think we have to find a way of funding the scientists without damaging their reputation and besmirching their research in the process.
The full interview
Please note that I haven’t included everything from the transcript - which, at 9,000 words, is long even for us (although at the time, the hour we’d scheduled really didn’t seem enough!) In particular, I have excluded some parts which are already well covered in Derek’s book, Project Unthinkable.
PMI has invested in safer alternatives, but the majority of their revenue still comes from the sale of a product that kills many of their customers - and even while they announce they want smoking to be obsolete, they continue to market cigarettes in third world countries. Smoking rates are still at record levels across the world. What do you think their motivation was for investing a billion dollars in this foundation?
PMI had invested billions into alternative tobacco products, so while the investment in the foundation wasn’t small it was relatively modest compared to the massive investments into research into safer nicotine alternatives they were making year on year.
The billions going into R & D were just one part. Think of it all being part of a bigger scheme to try and end their combustibles. So I think the reason was very clear: it was to expand the science and research around harm reduction and to carry out independent studies to verify whether these products really had benefits or not. They also wanted to understand things like public perception of risk and also, through my insistence, to address what impact the success of this would have on farmers in places like Malawi.
And why would they do that? Well, I think they would do it as part of a broad-based portfolio of trying to strengthen their own science and research on products by changing some of their marketing practices.
Getting back to some of your more specific questions, smoking rates today globally are going down slowly, but they are going down and I think we are over the peak. Even WHO stats show we are down from a peak of around 1.3 or 1.2 billion to around 1.1 billion - and that’s in the face of an increasing population. But you're absolutely right, 80% of all combustible users are in low middle-income countries where most of the reduced risk products are not available.
But PMI and the other companies are making progress. What was the percentage of revenue coming from combustibles for the different companies in 2015? It was looking very low. And so where are we today? PMI is now just passing the 30% mark, so that's not a trivial amount.
In 10 countries, they make more money from IQOS than they do from combustible products. And in a place like Japan, that's 70%. With BAT it’s about 12 or 14%. This is incredibly fast compared to, say, the pace we're seeing on electric cars. I think if the regulatory environment in many of the low to middle-income countries was more favourable we would see far faster progress.
In your book you talked about this being their Kodak moment. The tobacco companies either have to move fast into a new product area or see their existing market taken away from them.
My question is, how does the foundation tie into that?
I think it is one aspect of a broad communications science policy approach. What’s more, unless you have scientists and researchers in low middle-income countries working on these areas, you won't have people who are trusted by those governments.
That’s based on previous experience working with HIV where people in these countries didn’t trust the research done by developed countries. That’s also why Bloomberg related funding initiatives have gone after low middle-income countries - not to carry out research but to put in place advocacy to talk about the dangers and the hazards. To counter that, you can't just have international research, you need local people actually taking data to their Ministry of Health and showing them the benefits. That was the vision of the foundation.
The foundation has undoubtedly funded a huge amount of good research, but that’s come at a cost too. Scientists involved have received both personal and professional attacks on them and their reputation. Valuable research has been discredited, and some of the world’s best scientists in the field have been barred from conferences. Indeed, one contact estimated that 50% of the scientists in the field have been discredited because of PMI funding. Do you think PMI’s plans have backfired?
No, I don't think so. I think what we underestimated was the vociferous with which the Bloomberg foundation, Matt Myers, the Tobacco Free Kids movement would actually go after ad hominem attacks on individual researchers and scientists. Of course, there have been some very hostile attacks, attacks on myself, and in fact on every single person the foundation has funded.
I think today there are two very different issues that are the source of hostility. I think the bigger one for many people is the disbelief that harm reduction makes sense for tobacco control. And that is independent of who's funding it. That's why you get attacks on really reputable, outstanding scientists across the world who carry out research showing the dangers of banning flavours leading to increased smoking, for example.
It’s also why people are not willing to take account of the incredible British research showing the benefits of these devices in the US environment. The US tends to be focused primarily on kids and the vague protection that we need to give to kids as opposed to their adult parents who will have enormous benefits from getting on to reduced-risk products.
Complementing this is when people doing the research are funded by or are associated with industry and when the two come together it’s a double whammy. But even so, there are plenty of discussions between people who are funded by industry and serious scientists in tobacco harm reduction. But they tend to be discussions in corridors, informal chats, discussions, symposia where there isn't much public discussion. But still, the level of harassment was something which I had never experienced, and which I didn’t expect.
What’s also terrible in the USA is the attacks on the vaping industry. I know it’s being challenged at the moment but it does look like almost every independent brand will be destroyed, wiped out. We’re seeing effective modern devices being banned - but at the same time we are seeing big tobacco products, such as IQOS, being approved. Is this coincidence, or do you think tobacco companies are actively seeking to remove competition from the independent vape industry?
Yes, I think it is a danger, and I also think there are a couple of realities. I’ve worked in food and pharmacy and this isn’t unusual. The tobacco companies have invested heavily in this area, using complex systems biology. They have invested big time not just for this product area, but in the future of medicine and biomedicine that are going to have enormous benefits. The small and medium enterprises are going to have great difficulty being able to compete at that level of science.
However, I worry about the debate and the argument you see coming from the harm reduction world that the tobacco companies are out to get them. They're not. I don't think that they are deliberately trying to kill you off. They're trying to move the entire ship, but at a very different level of investment in R&D and science, which the small ones will never be able to compete in.
I think the smaller companies need to think more strategically about how they could be getting their own strengths together, working together as groups to get the scale to do some of the research needed. That’s important because the cutting edge of innovation doesn't necessarily come from big companies. It comes from small startups. It comes from the groups who've got some crazy wacky idea like Hon Lik [inventor of the first modern electronic cigarette], or the people in Stanford who did the first work on Juul. It could be a decent disposable product or a biodegradable product, something that can have a patent structure.
We can also see this in more industries previously dominated by a handful of giants, such as the beverage companies, and the product range was alright but it wasn’t fantastic. Now more smaller companies are breaking through. Smaller companies with much less money can do innovative research around specific areas, but they have to be much more strategic and realise the main opposition are WHO policies that are trying to ban and prohibit.
In other industries, larger established players have lobbied for regulations which have then forced out smaller companies, gaining market dominance in the process. I’ve heard there are similar moves happening with vaping in the UK and Europe. What if that happened - if we saw what was happening in the USA replicated across the world? Does it matter for harm reduction? What do you think the implications would be?
The big brands in this field will end up having a very large market share. That means they will reach a large number of consumers, but choice will be limited, some innovation will be limited. Remember, this is a very concentrated market already - for example, 44 or 45% of all cigarettes are produced by the Chinese state monopoly. If you take the top six or seven companies, you've got 75/85% of the market. That's not healthy from a competition point of view, or for a breakthrough innovation point of view.
In any market, you tend to see far more innovation when there’s more players. And so from that point of view it probably will slow down innovation, but that doesn't necessarily mean it's going to be a disaster for harm reduction.
I think it's the nature of a transforming sector that there are going to be opportunities for small companies, but they need to lean on the science and the technology and the patent issues.
One big area is the recyclability of products. What are we going to do with all the plastic and pods and all of these things? Well, that is something that probably doesn't take a huge company to solve.
The research and development the tobacco companies have been doing hasn’t just been for the last ten years, has it? It’s been going on for decades - in fact, the research into less harmful products began even before tobacco companies admitted cigarettes were harmful.
Yes, I’m just talking about the really big investment that has been going on for the last ten years, the creation of a research facility in Lausanne and a step up in Southampton, the 500 or so additional scientists they employed.
Do you think that that investment would have happened if vaping hadn't come along and started to grow rapidly?
I think so. I certainly think these were already in the works and they didn't know that these e-cigarettes were going to take off the way they did.
I'm not as black and white about the tobacco industry as some. I know there's people in the tobacco industry who don't ultimately want to be involved in an industry which kills its customers, but this is about commercial consideration, isn’t it?
I think it's 100% commercial consideration. I think if you listen to speeches by the past and current management, they don't see themselves as angels solving a public health problem. Instead, they want to see their companies remain commercially viable and, in the process, cut the risks of the old products. They see the two going hand in hand.
They’re looking 15 - 20 years into the future and believe that the regulatory environment is going to become much, much harsher. They have to think about an alternative approach that's going to keep the business moving, and I think they've decided on a twin track approach.
The first is to get these reduced-harm products moving, and that’s very tough in this environment. The second is to look at what else they can use the research they have spent ten or twelve years on. That starts explaining why PMI and other tobacco companies are acquiring respiratory medicine and cardiovascular companies and getting into the dynamics of the tobacco plant.
Long term, they could be transforming into life science companies. It seems absurd to think that today with 70% of revenues still coming from combustibles, but in a decade more than half their income will be coming from non-combustibles.
I think we often don't take the long view that these companies do. And one thing that struck me was how the planning is decades ahead, whereas advocates are thinking about this year and this year’s legislation.
If you look at the long trend, most of the leading companies are getting out of combustibles and getting into not just harm reduction products, but into other health-related areas. What does that mean? We don't quite know yet.
What would your advice be to a vaping/THR advocate who is approached by the tobacco industry with an offer of support?
I would say go for it as long as you don't lose your independence and your independent brand.
I’ve seen it before in the food industry, and what small companies needed was two things. They needed more capital to really get to scale. And they needed access to distribution. Small companies have a lot of difficulty getting the wide distribution capabilities that big ones have built over years and they need access to science and research at a higher level.
Just make sure that the brand and what it stands for and the values remain true.
I was thinking more about the people who are speaking up about vaping, who are challenging Bloomberg and the WHO. My worry is that you can't take up that support and be independent and have an independent voice. There was an example of someone in your book who was defending the tobacco industry on the principle of liberty and it turned out he was being paid thousands of dollars every month.
That was Roger Scruton, a well known British philosopher paid by Japan Tobacco. He was continuing to write for the Wall Street Journal and others without disclosing the payments - when this became public he lost his contracts. Of course, that doesn’t mean his views weren’t sound.
It depends on where you are. If you're in academia and you take up an offer to go to Philip Morris and they pay you to go and see their plants, you have to declare it. And yes, people are going to make all sorts of accusations that you are in bed with them. The same is true for journalists.
If you've got the funding to actually pay for yourself and not be funded, so it's not the funding issue, but you get to see the laboratory. Is that better? Well, some people would say that is marginally.
If you don't go, what are you doing? You're simply blocking yourself off from advancement in science. My own view is that anybody has an opportunity to visit these research laboratories and speak to the scientists they're not speaking to. People should go and ideally they should go armed with the best scientists they can have on their team. And you should tell people what you learned. And some will be critical and say you are terrible.
But what are you supposed to do? Just ignore it? Ignore the reality? I think the world is worse off if we do that. Instead, we need to look and investigate and be curious.
Although there's a difference between simply going to visit or accepting financial support in terms of having an independent voice.
Yes, I think that’s why I said it’s better if you’re able to self fund it yourself, but don’t turn it down because you are fearful. That’s a self-fulfilling prophecy.
I don’t know if it’s about being fearful, I think it’s about wanting to make a difference. If you accept funding, then in some circles what you say could make less of a difference, because, whether it’s perception or reality, you have lost your independence.
This has been a very intense debate, and it reminds me of decisions 20 years ago by organisations like Cancer Research not to fund scientists who were also funded by the tobacco industry. That was the first time that ever happened and I was on the committee that made that decision all those years. But that was at a time when we didn’t have harm reduction research going on, and there wasn't the option to actually get out of combustibles and save lives.
Look at the rationale used - that there is an irreconcilable conflict between public health and tobacco. But harm reduction is eroding that irreconcilable conflict. I think that requires us to rethink the decision of groups like Cancer Research UK and the British Medical Journal. They focus on tobacco control and, of course, it's now spilling over into saying, in general, accepting money from any industry is bad and taints you whether it's tobacco, food, pharma, you can't be trusted. Your science can't be trusted.
You need to put into place the laws, the conflict of interest, the full disclosure. You need to make sure that in the end, whatever research comes out will be judged on the basis of the methods. But our entire endeavour to make progress in science has always relied upon funding from the industry. Yes, of course, government has always been important. But we've always accepted that, provided the oversight and the control ensures that you don't have these conflicts adversely affecting it, and you have a balanced approach, that we should accept the results. That's how we've made progress in sustainable energy and transport, and all these other areas.
In your book, you talk about the black and white view some health activists take towards the world. For example, you worked at Pepsico at a time when they were removing trans fats and other unhealthy products from their foods, divesting unhealthy businesses and investing in healthier lines, and much more - yet at the same time people said you couldn’t impact change from within. While I don’t want this to be turned into an apology for the tobacco industry, I am interested in why this black and white attitude towards health exists, and how it impacts attitudes towards safer nicotine products today?
You know, I think part of it goes back to the way we tackle public health. The initial focus of public health has always been infectious diseases where many of the issues are more black and white. You're either infected or you're not infected, you're going to get vaccinated, or you're not going to get vaccinated.
As we started moving out of infectious diseases into complex behaviours and chronic diseases, every one of these chronic diseases is driven by a wide range of risks for which we would ideally want people to do the perfect thing - for example, your 10,000 steps a day. There's less tolerance for accepting that we are all frail human beings and we're all struggling in that grey zone.
In that grey zone, we’re all trying to do a little more, and you have to accept that moving people through that continuum of low to middle risk is of huge value at a population level.
I think that we still don't really have a tolerance and an understanding of how tough it is to change complex behaviours. We really need to accept that people don't act in their best long term interests. We need to use nudges, incentives, disincentives, a whole range of things, to help them overcome their initial response to do what is not in their best interest long term. That is why the structure of the programmes at companies like Vitality [a health and life insurance company] have included incentivising healthy behaviours or diets.
I think that level of sophistication hasn't been applied in areas like tobacco, and I think in public health training. It hasn't really been properly tried.
If we get back to harm reduction, we’re now thinking about products. But the first harm reduction approach is to smoke less. And I can tell you that the mantra of WHO was there is no safe level of smoking. On the one hand that is true, if you smoke one cigarette a day, you've got an increased risk compared to a non smoker. But your risk at five a day of lung cancer is going to be a fraction of someone smoking two packs a day. We didn't say that and we still don't say that enough. That's cutting your risk dramatically.
The message is still there, I’ve heard it at conferences, that it makes no difference whether you smoke one cigarette or twenty - which defies all logic.
Look at previous epidemiology and the British Doctors Study. If you're smoking under five or ten a day and you quit before you’re 40, your long term probability of increased risk is virtually zero compared to if you continue smoking. Those messages that it doesn’t matter how much you smoke are harmful.
Reduction messages give hope to people that yes, they may be smoking in their teens, but if you actually quit by the time you're in your 20s or 30s, you actually can recover all the benefits. Or you cut back dramatically.
Instead, people are saying one cigarette a day - and it could be on a weekend with buddies at a party - is as bad as a pack and a half a day. That's just scientifically wrong and it’s bad to send a message like that out to people. What do they do? They say, “well, it doesn't matter whether I smoke one or 20, so I'll smoke 20”.
It’s an incredibly harmful message, and I think it must go back to a time when people were fighting against smoking and smoking was so bad it became okay to lie about it with things like third hand smoke. But these lies have been extended to vaping and now they’re causing harm.
In fact, only yesterday I heard from one of our customers that her daughter in Australia has gone back to smoking because she couldn’t get a prescription. These people who are vociferously opposed to electronic cigarettes, people like Bloomberg and people in the WHO, do they honestly believe all they say or do they understand the harm they are doing and just not care?
I wish I knew the answer. There are some people who will admit it privately, and even in some documents, they'll hedge their bets and say, yes, we know that in some settings these cigarettes are going to be good for smokers, but then the policy directive they're pushing is very different.
I wish I really understood why there's this insistence of prohibition and bans in countries like India, and they're seen as a great success. Knowing that first a ban never is a ban in India. So first of all, it's not going to work. And second, knowing that it is sending a terrible message which gets people to think cigarettes must be less harmful.
The surveys that we did at the foundation over the last several years showed that over the course of 2017, the percentage of people who believed cancer was caused primarily by nicotine went up quite dramatically in some countries, and this was complemented by separate studies people had done looking at the fact that 60 to 70% of doctors in India and the US also believe that nicotine is the cause of cancer. That's extraordinary. It means on the one hand, if Bloomberg's goal was to make sure e-cigarettes don't take off, it's a massive success for them to use the disinformation.
Of course, people are returning to smoking, and if you look at the analysts’ report you can see a very significant return to cigarette smoking in some age groups across the US happening as the pressures on e-cigarettes are increasing.
And as you say, of course there’s never a ban because of black market products, but what does happen is you get unregulated products with untested e-liquid in them, and the safety of the product diminishes.
One thing nobody has ever been able to tell me is why Bloomberg is so against vaping. He’s poured a huge amount of money into fighting vaping and reduced harm alternatives. What is the reason behind it? Is this some sort of personal hatred of nicotine?
He is himself a very black and white person. The way he sees the world is right or wrong. And again it comes out of an infectious disease world. Bloomberg's black and white views on tobacco control (just quit) were probably influenced by Tom Frieden (Bloomberg's Commissioner of Health at the New York City Health Department, and later head of the Center for Disease Control and Prevention (CDC)), who is an excellent infectious disease expert but not one who appreciates the complexity of behaviour change.
Both Bloomberg and Friedman also pride themselves on their own physical fitness and their own intolerance of unhealthy behaviours. And they probably don't have much engagement with smokers struggling in their lives or poor communities where they have obesity and smoking and opioids and live in a really tough environment.
It's a simple view. Let's try and just get rid of it [nicotine]. I think part of it is also what has happened in the tobacco control world which surrounds Bloomberg. They have cleansed themselves of smokers. Literally. There are no smokers who inform policy for them now.
Think of HIV/AIDS. One thing we learned is this phrase: nothing for us without us which has now been adopted by vapers. People who are actually suffering daily from the issues you're trying to address. Without them, you're not going to come up with solutions that make sense, and we've known that from HIV/AIDS to cancers to everything else in this field.
Vapers are despised, they're stigmatised. It's probably the most stigmatised group. They are shunned, put off to the side and not engaged in the discussion.
If they did engage, they would realise that if we're really serious about bringing the death rates down, these groups have the solutions and what vapers are using is their struggle to try and reduce smoking and improve their quality of life.
We’re running out of time. I’d love to go over why you joined the foundation, but as you do cover that in your book, can you explain why you left?
Well, I’d been there about 4 and a half years, and if you look at my career I tend to move on around that time. As David Sackett said, after being too long in a field, you become an old fart and you need to make way for young Turks.
I think that that's partly it, as well as the cumulative pressures and also frankly a real huge desire to return to the bigger world of global health and to place tobacco into that bigger context. Because I'm very aware that people who smoke also have a higher probability of less physical activity. Diets are not great. Chronic diseases coming out of the pandemic are at an all time high, and they're getting worse.
We really need to think about how we harness people and forces to actually have an impact. An impact which includes tobacco and smoking, but also takes a broader perspective on chronic diseases. And that's really where I'm hoping to focus for the next few years.
Also, I think it's one thing being a founder and you know, having the vision to create the foundation. I think now it's also important that it assumes its own independent identity, and that also means it'll be even more separated from PMI, because now I have departed that link will be gone.
And do you think they'll succeed in bringing in external funding which is not from PMI but from other sources?
I don't know. I think it's a tough time. I mean, let's just say that there's certainly significant funding for a number of years.
