The UCSF Center for Tobacco Control, Research and Education hosted it's Annual Tobacco Documents Workshop on May 8, 2015. At the Workshop, public health advocates and scholars from across the United States learned the history of the Legacy Tobacco Documents Library (LTDL), as well as how to search the LTDL to further the cause of tobacco control and promote public health in their own communities.

1. Putting the tobacco industry’s
words to work for you
13th Annual Tobacco Documents Workshop, May 8, 2015
Center for Tobacco Control Research & Education
Naphtali Offen, UCSF

2. Acknowledgments
 LEGACY
 Jonathan Leff
 Karen Williams
 Richard Barnes
 Rachel Taketa
 Libby Smith
 Phil Gardiner
 Valerie Yerger
 Stan Glantz
 Ruth Malone

3. Workshop goals
 Introduction to documents
 Tobacco-related cutting-edge issues:
 Cigarette filters
 Menthol
 E-cigarettes
 FDA attempts to regulate tobacco
 End game strategies

4. Day’s agenda
 Introduction
 Break
 Four presentations
 Lunch break / socializing
 After-lunch speaker
 Break
 Hands-on workshop in lab
 Wrap-up / networking here

5. Introduction to the
tobacco documents
 How we acquired them
 What is in the collection
 Why they are valuable

6. How we acquired them
 State Attorneys-General sued major
tobacco companies to recover Medicaid
funds spent treating tobacco disease.
 The industry produced truckloads of
documents for trial.
 Case was settled in 1998 with the Master
Settlement Agreement (MSA).

7. Master Settlement Agreement
original signatories
 American Tobacco
 Brown & Williamson
 Lorillard Tobacco
 Philip Morris
 RJ Reynolds
 Center for Indoor Air Research
 Council for Tobacco Research
 Tobacco Institute

8. Terms of MSA
 $206 billion payments to states over 25 years
 Industry-affiliated groups disbanded
 Ad restrictions
 Funding of Legacy
and…
 Tobacco industry documents produced for
trial must be made public!

9. Initial access to documents
 Repositories in Minn.; Guildford, UK.
 Cumbersome process (time, expense)
 Tobacco company internet sites
 Time limited (through 2010)
 Not user-friendly, different interfaces
 Searchable only via metadata
 Occasionally documents would vanish

10. Legacy Tobacco Documents
Library (LDTL) at UCSF
 Advantages:
 Housed at one site - UCSF
 Available in perpetuity
 User-friendly / intuitive
 Full-text searchable!

11. Limitations of
Tobacco Documents
 Don’t know what is missing
 Largely limited to discovery documents
 International documents spotty
 Newer documents more circumspect

12. What is in the collection
 14.5 million+ documents
 87 million+ pages
 7500+ audio-visual items
 45 separate collections

13. Document subjects
 Marketing, advertising and public relations
 Research and development
 Customer research
 Lobbying, legislative and legal efforts

14. Document formats
 Letters, memos and faxes
 Marketing plans
 Meeting minutes and presentations
 Court transcripts
 Invoices, statements
 Newspaper articles/clippings
 Diaries and notes
 Junk

15. Why they are valuable
 Glimpse into workings of entire industry
Expose industry lies and tactics
Identify industry attempts at
destabilizing tobacco control
Identify and expose industry front
groups and allies

16. Why is this important?
[PM 1996] fir75c00
Exposing its bad behavior
is feared by the industry.

17. Three simple rules
 Say what the document is
 Say what it means
 Say what the implications are

18. [PM 1992] ngr62e00
Expose industry tactics

19. A Gay Cigarette?
[PM 1992] cmv24e00

20. “Own” what market?
[PM 1992] oui58e00

21. What’s the story?
What it is:
 PM wanted to “own” the gay market,
but…
What it means:
 PM didn’t want to be associated with it
What the implications are:
 PM may not be the corporate ally the gay
community thinks it is

22. Identify destabilizing attempts
[PM 1997] ayg53a00

23. What’s the story?
What it is:
 A plan to counter the effectiveness of
tobacco control advocates
What it means:
 Tobacco industry has ulterior motives
when trying to form alliances with
tobacco control organizations
What the implications are:
 Tobacco control should avoid working
with the industry

24. Identifying industry allies
and front groups
“The whole question of getting
third-party assistance … is to
give us clout, to give us
power, to give us credibility, to
give us leverage, to give us
access where we don’t
ordinarily have access
ourselves.”
PM 1984 fxz88e00

25. Exposing front groups
no-smoke.org

26.  Lawsuits
 Counter-advertising
 Community engagement
 Legislation
 Policy debates
Additional document uses

27. Lawsuits
Department of Justice vs. Philip Morris et al.
“Defendants' internal documents and
research…reveal their continued recognition that
smoking causes serious adverse health effects
and their fear of the impact of such knowledge
on litigation.”
- Judge Gladys Kessler, Aug. 2006

28. Counter-advertising
American Legacy Foundation (truth® campaign)
[RJR 1995] mum76d00
Sub-Culture Urban
Marketing
Targets: gay men in
San Francisco’s
Castro area and
homeless men in
the city’s Tenderloin
neighborhood

29. In 1995 a major tobacco company
planned to boost cigarette sales by
targeting homeless people. They called
their plan "Project SCUM: Sub Culture
Urban Marketing."

30. Community engagement
Brochures

31. Community engagement
Media advocacy

32. Community engagement
Taking documents to community
[RJR 1988] tsn54d00

33. Legislation
 FDA given limited authority over tobacco
products (2009)
 Controversial among advocates
 Philip Morris promoted it
Documents reveal why (McDaniel, PA &
Malone, RE, “Understanding Philip
Morris's pursuit of US government
regulation of tobacco”, Tob. Control, 2005)

34. PM’s Perspective
Regulation can give us an opportunity
to move down the road toward
corporate normalcy. … If we remain
unregulated, our critics will be able to
continue to define us as a member of
a rogue industry and this will affect
how we are viewed by legislators,
regulators, opinion leaders, and,
significantly, the general public.

35. Policy debate:
smoking in movies
[B&W 1983] mfs93f00

36. Tips
 Decide what you want to focus on
 Look for evidence in the documents
 Find corroboration elsewhere, such as:
 Research papers
 News reports
 Organization records
 Government records
 Interviews

37. Conclusion
 Study the industry as it
has studied us.
 Learn what they know
and what they fear
 Beat them with their
own words.

38. Tobacco industry and smoker
attitudes toward
cigarette butt waste
Elizabeth A. Smith, Ph.D.
University of California, San Francisco
California Tobacco Related Disease Research Program Grant #17IT-0014
National Cancer Institute Grant #120138

41. The cigarette butt problem
 Non-biodegradable cigarette butts
are the most littered item in beach
and community clean-ups.
 Butts contain toxins that leach into
soil or water, endangering
microorganisms and fish.

43. What about humans?
 No evidence filters make cigarettes
any safer.
 Filters may be linked to shift from
squamous cell cancer to
adenocarcinoma.

44. Cigarette butts & industry
 Tobacco industry research is usually
ahead of tobacco control research.
 Understanding the industry’s
knowledge and concerns can help
shape effective tobacco control
initiatives.

45. Methods
 “Snowball” search techniques
 Terms include “butts,”
“biodegradable,” and “filter”
 690 relevant documents, most from
mid-1990s, including strategy
documents and focus group studies

46. Industry fears about litter
hvx21b00
myz37c00
vec52c00

47. Smoker beliefs about butts
 Most know filters are not biodegradable
 Most are oblivious to toxicity of butts
[hwx33d00 ]
[lof43d00]

48.  “While virtually all respondents felt
that litter . . . was the result of
apathy, laziness, and insensitivity,
most smokers admitted that they do
litter with cigarette butts.” [mbj05c00]
Littering

49. Why do smokers litter?
 “The process of flicking a cigarette to
the ground and then stepping on it is
 a natural extension of the defiant/
rebellious smoking ritual.”
 a conscientious thing to do.” [mbj05c00]
 Littering facilitates denial
[mbj05c00]

50. “What else am I going
to do with them?”
 Smokers say they wish they didn’t:
 “have to bury the butt in the bushes”
 “have to throw them on the ground”
 “have to throw the butt out the window”

51. Option 1: No more filters
myl38c00

52. Option 2: Biodegradable filters
 Improve smoker and industry image
[nuz30c00; ouu74a99]
 Prepare for or pre-empt regulation
requiring biodegradability [rvj95a99]
 Avoid ‘green’ backlash [eij43d00]

53. But . . .
[vec52c00]
[dty03f00]
[myl38c00]
[myl38c00]

54. What’s their motivation?
“When all discarded filter tips look
alike to the public the fact that some
degrade more quickly than others
may be of academic interest only, if
the majority do not. For certain it is
fanciful to expect gratuitous
attribution of success from the public
through elimination of only a small
part of the problem.”
[tvj95a99]

55. . . . plus
 Industry doesn’t know how to make a
biodegradable filter
 Biodegradability does nothing about
toxicity of contents of butts

56. Option 3: Change behavior
 Anti-litter campaigns
 Pocket ashtray distribution
 Permanent ashtray installation

57. Development of anti-litter
campaign slogans
 Smokers are sensitive and defensive
 Cannot “single out” smokers as litterers
 Cannot equate smoking with littering
 Cannot imply that the smoker “had
participated in littering behavior”.

58. Smokers’ favorite slogan
 “A little thought, a lot less litter”

59. Anti-litter campaigns: images
mnt37d00

60. “Completely rejected”
[mnt37d00]

61. Pocket ashtrays

62. Pocket ashtrays
 RJ Reynolds distributed millions
(many branded)
 No real evaluation data
 Some smokers like them; claim to use
them
 Some do not want to carry butts around:
“dirty,” “smelly,” “unsanitary”

63. Permanent ashtrays

64. Permanent ashtrays
 Philip Morris installed in cities around
the country [khp35c00]
 No evaluation data
 Advantages for industry:
 make it “more convenient” to smoke [vwo06c00]
 signal permission to smoke [kll65a00]
 institutionalize smoking areas [vhq83c00]

65. Make industry responsible
for toxic butts
 Industry fears being forced to take
responsibility for butts.
 Smoker psychology suggests
changing behavior will be difficult.
 Efforts have focused on “litter”, not
“toxic” issue.

66. Eliminate filters
 California legislation
 AB 48 (Mark Stone, D-Monterey Bay)
 Prohibits single-use filter made of any
material, including cellulose acetate, or
other fibrous plastic material.
 Start the conversation
 Make that alliance!

67. E-Cigarettes: The Vapor This Time?
Phillip S. Gardiner, Dr. P. H.
Policy and Regulatory Sciences Program Officer, Tobacco Related
Disease Research Program (TRDRP) University of California
Office of the President
University of California San Francisco (UCSF)
Center for Tobacco Control Research & Education
Annual Tobacco Documents Workshop
San Francisco, California
May 8, 2015

68. From Whence E-cigarettes
• 2003: Chinese pharmacist, Hon Lik, is credited
with conceptualizing and producing the first
modern Electronic Cigarette

69. E-Cigarettes
• Nicotine Addiction: The Next Generation
– Aerosolizes Nicotine Laced Propylene Glycol,
Glycerin, and Flavorings
– Long Term Health Impact Unknown
– Cessation Aid or Promoter of Nicotine Addiction
and Continued Tobacco Use
– Explosion in Popularity especially among youth;
Emergence of a New Vaping Subculture
– Little Regulation

70. E-Cigarettes: A Moving Target
• 400+ makes and models
– Closed systems; cig-a-likes
– Open systems; tanks
– Hookah Pens, Vape Pens
• 7700+ Flavorings
– Menthol
– All Banned FDA flavors
• Tax the Liquid; the Nicotine; the Device

71. Component Parts E-Cig-a-Likes

72. E-Cig Tank Systems; Mods

73. E-Pens; E-Hookah Pens
• Cherry, Chocolate,
• Vanilla, Bubblegum

74. E-Cigars
• Swisher Sweets E-cigars (Swisher
International)

75. The E-Cigarette Explosion
• Market Size Continues to Increase
– retail sales are over $2B currently;
– $10B by 2017.
• E-cigs could surpass consumption of
conventional cigs within the next decade (by
2023). (Herzog, 2014)

76. E-Cigarette Advertising Triples, 2011
to 2012
• “Overall, e-cigarette advertising expenditures
across media channels tripled from $6.4
million in 2011 to $18.3 million in 2012
– 80 unique brands
– blu eCigs dominated ad spending, comprising
76.7% of all e-cigarette advertising
– Highest in Magazines and TV; Lowest in
Newspapers
• (Kim et al., 2014)

77. E-Cigarette Advertising Doubles, 2012
to 2013
• E - cigarette manufacturers have significantly
increased marketing spending, more than
doubling expenditures between 2012 and
2013.
In total, six e cigarette companies spent
$59.3 million in 2013 to market e-
cigarettes
(Durbin et al., 2014)

78. Kids Exposed to E-Cig Ads
• Between 2011 and 2013 exposure to e-
cigarette TV ads increased by:
– 256% among adolescents ages 12 to 17
– 321% among young adults, ages 18 to 24.
• Approximately 76% of the ads seen by each of
the two age groups occurred while watching
cable networks
– (Duke et al., 2014)

79. Youth E-Cig Use Continues to Rise
• Youth Smoking Rates Fall; E-Cigarette Use Rises
– Tobacco Use 22.9% in 2013 - -24.3% in 2011.
– E-Cigarettes Use Tripled to 4.5% in 2013 from 1.5% in
2011.
– 13% of High School Students
• (CDC, 2014; CDC 2015)

80. Youth Using E-Cigarettes More than
Regular Cigarettes
• 8th Grade: 9% e-cigarette; 4% regular
cigarettes
• 10th Grade: 16% e-cigarette; 7% regular
cigrettes
• 12th-Grade: 17% e-cigarette; 14% regular
cigarettes (MTF, 2014)

81. Enter the tobacco industry
• Lorillard (LO)
– Acquired the Blu E-Cigs in April 2012 for $135M.
• Reynolds American (RAI)
– Vuse: Microprocessor Controlled
• Altria Group (MO)
– MarkTen; Rolled out 2014
• NJOY (privately held)
– Ex Surgeon General Carmona; other personnel includes Several
Ex-Altria Execs.
• Logic (privately held)

82. tobacco industry Taking Over the E-
Cigarette Industry
• Convenience Store Sales Volume
– Reynolds Vuse 30.1%
– Lorillard blu 21.6%
– Logic* Logic 14.5%
– Altria Mark Ten 10.9%
– NJOY* NJOY 4.4%
– (Herzog, March, 2015) * Privately held

83. Vape Shops on the Rise
• The "Starbucks of e-vapor“
– It is estimated that there are somewhere between
5,000-10,000 vape shops in the U.S.
– Tank systems; Refills; Mix-your-Own
– Vapers can hang out, work, socialize and vape
– Purchase products; sample new ones
– Eating and Drinking
– (Herzog, 2014)

84. New Bluetooth E-Cigarette Lets You Vape AND
Receive Calls, Listen to Music

85. Cloud Contests

86. E-Cigarette Liquid: The “Juice”

88. E-Cigarette Liquid: The “Juice”
• E-Cigarette Liquid contains:
– Nicotine, extracted from tobacco leaves
• Large variation in content between and within brands
(Cheah et al 2012; Trtchounian et al 2011; Goniewicz et al 2013)
• Lethal if ingested; 60 mg Adult; 6 mg Children
• Detrimental to fetuses (Martz, 2009)
• Tobacco specific nitrosamines (TSNAs) (Laugesen, 2008;
Westenberger, 2009; Goniewicz et al 2013)
• 1.2mg of nicotine in each cigarette, or 24mg of nicotine
per pack (1.2mg x 20 cigarettes)= ~ 1 e-cigarette

89. Nicotine Is Not Benign
• Nicotine can be acutely toxic; Poisonous and addictive
• Nicotine activates multiple biological pathways through
which smoking increases risk for disease.
• Nicotine exposure during fetal development has a lasting
adverse consequences on brain development and
contributes to multiple problematic birth outcomes
including low birth weight and still birth
– RSG, 2014

90. E-Cigarette Liquid: The “Juice”
• E-Cigarette Liquid contains:
– Propylene Glycol - the vapor; the fog
• FDA approved food additive (humectant, solvent for
colors and flavors), cosmetics, and medicines.
• Short term exposure causes eye, throat, and airway
irritation (Wieslander et al 2001; Vardavas et al 2012,)
• Long term exposure can result in children developing
asthma. (Choi et al 2010)
• Chemical composition changes when heated (Henderson
et al, 1981)

91. E-Cigarette Liquid: The “Juice”
• E-Cigarette Liquid contains:
– Glycerin: A humectant used instead of or in
combination with propylene glycol in EC fluids for
aerosol production.
– FDA Approved for ingestion.
– Slightly hazardous in case of skin and eye contact,
ingestion, and inhalation; prolonged exposure
may cause organ damage.
– Metals
• Tin particles found in E-liquid (Williams et al., 2013)

92. E-Cigarette Liquid: The “Juice”
• E-Cigarette Liquid contains:
– Flavorants. Key one Menthol; Candy flavoring
• Anesthetic effects,; promotes deeper inhalation; greater cell
permeability
• Allows the poison to go down easier!
– Not GRAS! Ingestion vs. Inhalation
– 7000+ flavors; appeals to kids (bubblegum,
strawberry, gummy bears, etc.)
– Exotic for adults (Sex on the Beach, Aces and 8’s)
• Mix your Own (ala roll your own)

93. The Aerosol: Its Not Just Water Vapor
• E-Cigarette Aerosol Contains:
–Propylene glycol, glycerol, flavorings, and
nicotine, which are found in the e-liquid,
are also found in the e-vapor
–May contain Propylene oxide
–Volatile Organic Compounds: Benzene
and Toluene

94. The Aerosol: Its Not Just Water Vapor
• E-Cigarette Aerosol Contains:
– Carbonyl Compounds: Formaldehyde,
acetaldehyde, and acrolein
– Metals: tin, silver, iron, nickel aluminum, sodium,
chromium, copper, magnesium, manganese, lead,
potassium and silicate nanoparticles
– Tobacco specific nitrosamines (TSNAs)
carcinogenic compounds found in tobacco and
tobacco smoke.
• (Schripp et al, 2012: Westenberger 2009; Goniewicz et al, 2013;
Williams et al, 2013; Henderson, 1981)

95. E-Cigarette Emit Metals used in Their
Manufacturing
• Zinc and Nickel concentrations were found to be higher in e-
cigarette emissions compared to conventional Cigarette
emissions, originating from the cartridges holding the e-
liquids.
• “Considering the potential adverse health effects associated
with the inhalation of these metals (particularly Ni and Zn,
and the emission observed both in our analysis as well as the
study by Williams et al.13), attention should be directed
toward eliminating the use of these metals in the cartridges
during the manufacturing process of e-cigarettes.”
– (Saffari et al., 2014)

96. E-Cigarettes: The Second Generation
• 1st Generation:
– Cig-a-likes; Most Toxins Emitted in the Aerosol
Lower than Regular Cigarettes (Goniewicz et al., 2013)
– Aerosolizing Temperature 40 – 65c
• 2nd Generation
– Tank Systems; refillables
– Some Toxins Emitted Approaching Levels found in
Regular Cigarettes
– Aerosolizing Temperatures >65c

97. As Battery Voltage Increase, Toxins
Increase
• On Average, Toxins were 13 – 807 Fold Lower
than Tobacco Cigarettes
• However, when voltage was increased from
3.2 to 4.8V:
– 4 to over 200 times increase in formaldehyde,
acetaldehyde, and acetone levels
– The levels of formaldehyde were in the range of
levels reported in tobacco smoke
(Kosmider et al., 2014)

98. Combustion; Heating; Aerosolizing
• Cigarettes burn tobacco at ~ 900˚ Celsius
• Heated Tobacco Products
• E-Cigarettes aerosolize nicotine laced
propylene glycol at 40 – 65˚ Celsius *
• * 1st Generation

99. E-Cigarettes are Sooo Last Year
Heat not Burn

100. Marlboro Heatstick
Heat not Burn

101. Reynolds Revo
Heat not Burn

102. Heat not Burn
• 8 major studies conducted by PMI in 2012
• Findings:
– Heat not burn had significantly lower emissions
of key toxins compared to regular cigarettes
• Philip Morris’ Marlboro HeatStick; Test
Marketing Nagoya Japan and Milan Italy,
November2014
• Reynolds ‘ Revo; Test Marketing Wisconsin,
2015

103. Secondhand Exposure to Vapors From
Electronic Cigarettes (Czogala et al, 2013)
• The average concentration of nicotine
resulting from smoking tobacco cigarettes was
10 times higher than from e-cigarettes
(31.60±6.91 vs. 3.32±2.49 µg/m
• 7xs more Particulate matter
• Still, in a room of 5 to or more e-cigarette
users, nicotine and particulate matter levels
are above healthy levels

104. Secondhand Vaping and Nicotine
• Similar nicotinergic impact as tobacco
cigarettes
• e-Cigarettes and tobacco cigarettes generated
similar (p > 0.001) effects on serum cotinine
levels
– (Flouris et al., 2013)

105. Secondhand Vaping and Nicotine
• The levels of airborne nicotine and cotinine
concentrations in the homes with e-cigarette
users were significantly higher than control
homes. “Our results show that non-smokers
passively exposed to e-cigarettes absorb
nicotine.”
– (Fernandez et al., 2014)

106. • Propylene glycol
• glycerin
• Flavorings (many)
• Nicotine
• NNN
• NNK
• NAB
• NAT
• Ethylbenzene
• Benzene
• P,m, xylene
• Toluene
• Acetaldehyde
• Formaldehyde
• Naphthalene
• Styrene
• Benzo(b)fluoranthene
• Benzo(ghi)perylene
• Acetone
• Acrolein
• Silver
• Nickel
• Tin
• Sodium
• Strontium
• Barium
• Aluminum
• Chromium
• Boron
• Copper
• Selenium
• Arsenic
E-Cig Aerosol Composition
• Cadmium
• Silicon
• Lithium
• Lead
• Magnesium
• Manganese
• Potassium
• Titanium
• Zinc
• Zirconium
• Calcium
• Iron
• Sulfur
• Vanadium
• Cobalt
• Rhubidium
Compounds in yellow are from FDA 2012,
Harmful and Potentially Harmful
Substances – Established List
• Chlorobenzene
• Crotonaldehyde
• Propionaldehyde
• Benzaldehyde
• Valeric acid
• Hexanal
• Fluorine
• Anthracene
• Pyrene
• Acenaphthylene
• Acenapthene
• Fluoranthene
• Benz(a)anthracene
• Chrysene
• Retene
• Benzo(a)pyrene
• Indeno(1,2,3-
cd)pyrene

107. Second Hand Vaping:
The Take Home Message
“Overall, the e-cigarette is a new source of
VOCs and ultrafine/fine particles in the indoor
environment. Therefore, the question of
“passive vaping” can be answered in the
affirmative. However, with regard to a health-
related evaluation of e-cigarette consumption,
the impact of vapor inhalation into the human
lung should be of primary concern” (Schripp,
et al., 2012).

108. E-Cigarettes Source of Thirdhand
Smoke Exposure
• Conclusions: This study indicates that there is
a risk of thirdhand exposure to nicotine from
e-cigarettes. Thirdhand exposure levels differ
depending on the surface and e-cigarette
brand.
• Future research should explore the potential
risks of thirdhand exposure to carcinogens
formed from nicotine released from e-
cigarettes (Goniewicz and Lee, 2014)

109. Health Effects of E-Cigarettes
• Long Term Health Effects are unknown
• Short-term Health Effects include:
– Decreased Fractional exhaled Nitric Oxide (FeNO)
[a measure of lung function retardation]
– Increased respiratory resistance
– Decreases in the eye’s tear film stability
– Acute nicotine poisoning
– (Vardavas, 2012; Norback and Lindfren, 2001)

110. Health Effects of E-Cigarette
• Constricts peripheral airways, possibly as a
result of the irritant effects of propylene
glycol, which could be of particular concern in
people with chronic lung disease such as
asthma, emphysema, or chronic bronchitis.
– (Vardavas, 2012)

111. Health Effects of E-Cigarette
• Adversely effects epithelial functions of young
people.
• Even nicotine-free e-liquid promotes pro-
inflammatory response and HRV infection.
• Both e-liquid without nicotine and with nicotine
inhibits lung innate immunity (e.g., SPLUNC1)
that is involved in lung defense against HRV
infection.
• “These findings strongly suggest the deleterious
health effects of e-cigarettes in the airways of
young people.” (Wu, et al., 2014)

113. Calls to California Poison Control
Centers Concerning E-Cigs
2010 4
2011 12
2012 19
2013 thru Feb 2014 155
(F. Lee Cantrell California Poison Control System, 2014)

114. From Whence E-cigarettes
• 2003: Chinese pharmacist, Hon Lik, is credited
with conceptualizing and producing the first
modern Electronic Cigarette

115. Non-Combustible Cigarettes - Vaping
1980
• Title: Non-Combustible Cigarettes - "Vaping"
– Author: Felton, DG
– Corporate Author:
– Date: 19800313
– Bates: 109876582-109876588
– Collection: British American Tobacco
– Bookmark:
http://legacy.library.ucsf.edu/tid/lsl80a99

116. Non-combustible Cigarette: Alternative
Method of Nicotine Delivery
• Presentation by Dr . Norman L . Jacobson of
San Antonio to a meeting of the American
College of Chest Physicians at Houston on 4-
8th November, 1979

117. Origins of the Terms Vaping and
Vapers
• This presentation describes a practical and
apparently satisfying method of administering
nicotine by nicotine vapour inhalation via a
non-combustible cigarette, hereafter referred
to as an NCC
• To simplify description, we will hereafter refer
to nicotine vapour inhalation through an NCC
as vaping and people who inhale nicotine
vapour as vapers .

118. The Aerosol This Time? Precaution
Advised
• E-Cigarette Vapor
– Concentrations of pollutants and carcinogens less
than in cigarettes
– Great variation within and between products; no
product standards
– Renormalization; youth uptake on the rise
– Intermediate and long term health effects
unknown
– Maybe safer, but this doesn’t mean safe

119. Thank You!
TRDRP
Research for a Healthier California
www.trdrp.org
phillip.gardiner@ucop.edu
Grant Funding
Cutting Edge Research
Scientific Conferences
Dissemination of Research Findings

120. THE “ENDGAME”:
LET’S START WITH MENTHOL
Valerie B. Yerger, ND
Tobacco Documents Workshop
Center for Tobacco Control Research & Education
May 8, 2015

121. WHY WE SHOULD START WITH
MENTHOL: “THE TOP 10”

122. #10
Menthol makes smoking easier

123. Publicly Say,
“Menthol is Just a Flavor”
• “The is no evidence that menthol has any effect on
the smoker other than the effect…on the taste and
flavor of the cigarette.” (RJ Reynolds, 1982)
• “Menthol is a flavor…PM USA only adds menthol to
the flavor recipes of cigarettes.” (Jane Y. Lewis, Senior Vice
President, Altria Client Services, PM USA; TPSAC Meeting, July
15, 2010)
tid/xro95d00

124. But Confidentially Say,
“Menthol Makes Smoking Easier”
The whole smoking experience [with menthol]…thus becomes
much more pleasant. Negatives are minimized (tobacco taste
and harshness); positive attributes are superimposed
(coolness and menthol taste). (British American Tobacco Company,
1982)
Adding menthol to cigarettes masks the harshness of tobacco
and provides an “extra something,” which make cigarettes
more desirable to some smokers. (Roper Organization, 1979)
tid/tss75e00
tid/raf36a99

125. Cooling Effects of Menthol
• “Menthol has properties of a drug,” including cooling
effects (Roper Organization, 1979)
• Menthol’s cooling effect alleviates nicotine’s irritating
effect (RJ Reynolds, 1983)
• Even at low or subliminal levels, menthol reduces
“nasal sting, tongue bite, and harshness” (RJ Reynolds,
1986)
tid/tss75e00
tid/kcl3900
tid/eax18c00

126. #9
Menthol keeps smokers
smoking

127. Menthol Inhibits Smoking Cessation
• Perceived health benefits or belief that menthol will
reduce negative health effects of smoking
• When a smoker has a cold or sore throat, menthol
makes it easier to keep smoking in spite of discomfort
• Due to the odor of its smoke, menthol cigarettes are
perceived to be more socially acceptable to others
than non-mentholated cigarettes
[tid/boo21a00]
[tid/fcb49d00]
[tid/dfl76b00]

128. #8
Menthol is more than a flavoring;
it’s important to the industry

129. Menthol Modulates Nicotine’s Effects
(Philip Morris, 1991)

130. Menthol Stimulates the Trigeminal Nerve
• Of interest to the tobacco
industry because nicotine
also stimulates this nerve
• Essential to eliciting a liking
response for a tobacco
product
• Menthol found to be a
“partial replacement” for
nicotine [tid/use78e00]
[tid/asz71f00]
[tid/feu54d00]

131. #7
Menthol extends beyond
cigarettes to other
tobacco products

132. These are NOT Cigarettes

133. Menthol e-Cigarettes

134. #6
Menthol is present even in
nonmenthol tobacco products

135. All Tobacco Products Contain Menthol
Menthol content of US tobacco products
Product Menthol (mg)
Regular (non-menthol) cigarettes 0.003
Menthol cigarettes (weak effect) 0.1-0.2
Menthol cigarettes (strong effect) 0.25-0.45
Pipe tobacco 0.3
Chewing tobacco 0.05-0.1
Hopp, 1993

136. “Menthol at very low levels is sometimes
used in nonmenthol brands.”
William R. True,
Senior Vice President of R&D,
Lorillard,
FDA TPSAC Meeting, July 2010

137. #5
Menthol disproportionately
affects some groups

138. Smoking Prevalence by Race
Menthol vs. Non-Menthol Use in Adults
0%
5%
10%
15%
20%
25%
White African
American
Hawaiian Hispanic Asian
24%
84%
53%
38%
24%
76%
16%
47%
62%
76%
Non-Menthol
Menthol
Smoking Incidence from NHIS 2009; menthol preference from NSDUH 2009

139. Menthol Cigarette Use Among Youth (%)
Hersey J, et al. (2006) Are menthol a starter product for
youth?
Nicotine and Tobacco Research. 8(3):403-413.

140. #4
Menthol is a social justice issue

141. Menthol = Health Disparities
• African Americans bear a
disproportionate burden of
tobacco-related diseases
and death
• 83% African American
smokers consume menthol
brands
• Inner city neighborhoods
targeted with menthol
marketing

142. Lung, Bronchus Cancer Death Rates (per 100,000)
United States, 2011
(Nat’l Program Cancer Registries)
0
10
20
30
40
50
60
70
80
White African
American
Hispanic Asian/Pacific
Islander
American
Indian/Alaska
Native
Male
Female

143. #3
Because WE CAN keep menthol
out of our communities

144. Family Smoking Prevention and
Tobacco Control Act, 2009
Gives the Food and Drug Administration (FDA)
the authority to regulate tobacco products

145. Family Smoking Prevention and
Tobacco Control Act, 2009
Allows FDA to require new restrictions and changes
to tobacco products to protect the public health

146. Family Smoking Prevention and
Tobacco Control Act, 2009
Prohibits the manufacture of all cigarettes with
candy, fruit, or clove flavorings (menthol excluded)

147. Tobacco Products Scientific Advisory
Committee (TPSAC)
• Established by the “Tobacco Control Act” to
advise the FDA
• Mandated to produce report about impact of the
use of menthol in cigarettes on the public health,
including “such use among African Americans,
Hispanics and other racial and ethnic minorities”

148. Findings from TPSAC Report:
July 21, 2011
• Menthol linked to youth initiation and increased
nicotine addiction
• Menthol linked to higher rates of smoking and
decreased success in quitting
• “Removal of menthol cigarettes from the
marketplace would benefit public health in the
United States”
http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMe
etingMaterials/TobaccoProductsScientificAdvisoryCommittee/UCM2
47689.pdf

149. FDA Releases Independent Review:
July 23, 2013
• Likely associated with increased smoking initiation
and progression to regular cigarette smoking
• Greater addiction and less successful cessation,
especially among African Americans
• Likely that menthol cigarettes pose a public health
risk above that seen with nonmenthol cigarettes
• Validates TPSAC report released two years earlier
FDA. Preliminary scientific evaluation of the possible public health
effects of menthol versus nonmenthol cigarettes. Silver Springs,
MD. July 23, 2013.

150. The FDA is able to REDUCE MENTHOL USE
But…it is taking a long, long time
150

151. • From 2010-2050, “9 million people will initiate
smoking because of the availability of menthol
cigarettes”
• Had menthol prohibition gone into effect in 2011,
over 320,000 deaths would be prevented by 2050
• Approximately one-third of those lives saved
would be African American
We CANNOT Wait on FDA to ACT
Tobacco Products Scientific Advisory Committee. Menthol cigarettes
and public health: Review of the scientific evidence and
recommendations, July 21, 2011

152. “We must find ways to protect our young people
before it is too late and addiction becomes part of
their lives…we must do more as a city…we cannot
wait for action from the State or Federal Level.”
Mayor Rahm Emanuel
July 25, 2013
Chicago Mayor Makes Urgent Request to
Health Board and Dept of Public Health

153. Chicago’s Buffer Zone Ordinance
• Creates a 500 ft. buffer zone around Chicago
schools
• Prohibits the sales of ALL flavored tobacco
products, including menthol cigarettes, Black &
Milds, Swisher Sweets, blunt wrappers
– Introduced on Nov 25, 2013
– Adopted Dec 11, 2013
– Effective July 16, 2014

154. Chicago Flavored Tobacco Toolkit
• Ordinance, regulations
• Resolutions
• Mayoral reports on
menthol
• City council agendas
• Public testimonies and
policy briefs
• FDA comments
• Archived webinar
menthol presentations
• Photos
• Press releases; public
responses
• Public education
campaign ads
• Copies of tweets
https://drive.google.com/folderview?id=0Bxndf1MBoZU1aHRsRFpfUZI0RGM&usp=
sharing

155. #2
Menthol brings EVERYONE
to the table

156. www.SavingBlackLives.org

159. MAJOR BLACK ORGANIZATION TAKES
STAND AGAINST TOBACCO

160. Delta Sigma Theta Sorority, Inc.
Urges FDA to Ban Menthol
• April 20, 2013: Berkeley Bay Area Alumnae Chapter
introduced resolution, “Prohibiting the use of menthol as a
characterizing flavor in cigarettes”
• July 15, 2013: Menthol resolution approved at its 51st
national convention in Washington, D.C.
• March 5, 2014: The 16th National President of Delta Sigma
Theta Sorority, Inc. Thelma T. Daley appears at Press
Conference calling for a ban on menthol

162. • “The elimination of menthol in the cigarette
seems to be…something that could be changed.”
• “…Delta Sigma Theta Sorority…will do more
to…move this barrier out of the way so that little
black girls and little black boys may grow up to be
healthier.”
Dr. Thelma T. Daley, 16th National President of
Delta Sigma Theta, March 5, 2014

163. #1
How can we achieve health
equity if tobacco products with
menthol are available?

164. Credit: United Way of the Columbia-Willamette

165. So, Why Start with Menthol?
• Menthol makes tobacco products easier to take up,
easier to smoke, more addictive, and more difficult to
quit
• Youth and minority groups are more likely to use
menthol cigarettes than general population
• Tobacco industry specifically targets menthol brands
to inner city, at-risk youth and marginalized
communities
• Engages communities most burdened by tobacco

166. What can the documents tell us about
the tobacco endgame?
Ruth E. Malone, RN, PhD
Department of Social & Behavioral Sciences
University of California, San Francisco

167. Research colleagues
• Elizabeth Smith, PhD
• Patricia McDaniel, PhD
• Valerie Yerger, ND
• Naphtali Offen, BS
• Dorie Apollonio, PhD
• Vera Harrell, BA
• Anne Lown, PhD
• Brie Cadman, MS
• Quinn Grundy, RN, PhD(c)
• Susan Forsyth, RN, PhD (c)
• Hannah Patzke, RN, BSN
• Norlissa Cooper, RN, MS

168. Funders
• California Tobacco-Related Disease Research
Program (TRDRP)
• National Cancer Institute
• National Institute on Drug Abuse
• Nursing Alumni/Mary Harms Endowed Chair

169. Outline
• Endgame thinking in tobacco control
• Endgame in industry documents
• Types of endgame strategies
• Legal, policy and strategic considerations
• An endgame for the US

171. Australian Council on Smoking & Health Parody of 1953 NYC meeting b/t tobacco
companies and PR firm Hill & Knowlton. Source: tobaccotactics.org

172. Source: Newsbiscuit

173. 2010 Editorial

175. What an endgame is not
• More of the same: Educational programs
telling kids they shouldn’t smoke

176. What an endgame is not

177. What an endgame is not
• More of the same: Telling smokers it is bad for
them and they should quit

178. So…what is an ‘endgame’?
• Initiatives designed to change/eliminate
permanently the structural, political and social
dynamics that sustain the tobacco epidemic, in
order to end it within a specific time.
--Adapted from: Malone, R. E., McDaniel, P. A., Smith, E. A. (2014). Tobacco
Control Endgames: Global Initiatives and Implications for the UK. Cancer
Research UK

179. As usual, industry ahead of us…
PM 2045996032/6062

180. Corporate image: Public
PM 2031599541/9584

181. 181
Endgame in PM documents
PM 2048302297/2344

182. 182 PM 2048302297/2344
•Causes death to smokers,
and nonsmokers. Also
causes annoyance.
Candid observations

183. 183
Our objective should be to
address social acceptability
issue. It will get worse if we
don’t try to do something.
We must give people the
impression that we are more
responsible than they think.
Social acceptability

184. 184
Industry trade-offs
Sooner or later we will lose
advertising. Trade this now in
exchange for immunity on
product liability, or trade
tombstone advertising for this.

185. Strategies: Dump tobacco
Today all the facts seem to indicate
that tobacco is a could be dying
industry.
I think we all believe that our future
lies outside tobacco, and principally
in the food business. I certainly
believe this.
PM 2023027920/7949

186. Strategies: Dump tobacco
If at the end of two years it looks like it is
not working we should implement Option
A and get rid of the tobacco business.
PM 2023027920/7949

187. Strategies: Skim off tobacco
We should consider the
“unthinkable” – look at the skim
off idea.
PM 2023028192/8203

189. Approaches to endgame
• Regulate product
• Regulate users
• Regulate market

190. Regulate product
• Regulate nicotine levels in manufactured tobacco
products
• Eliminate deceptive filters, reduce pH, reduce
known carcinogens
• Eliminate menthol

191. Regulate Users
• Smoker’s license
• Prescription to purchase

192. Regulate Markets
• Regulated market model
• Cap profits
• Provide market incentives to industry to
reduce consumption
• Permit sales of combustible tobacco products
only in restricted outlets
• Restrict sales to those born before certain
year: “Tobacco free generation” proposal
• Abolish sales of cigarettes

193. Areas of Modest Agreement
• The industrially produced cigarette is the single
most deadly product ever made.
• The tobacco epidemic is a product of the 20th
century
• Use of tobacco and nicotine products by
children is not a good thing.
• Clean indoor air is a good thing.
• No other product shown to kill half its normal
users is widely available on market today.

194. Historical Precedents for Action

195. Driving question
How is it that the single most deadly
product ever made continues to be sold on
every street corner?

196. A possible endgame for the US
• Federal level—FDA: Reduce nicotine in
combustible tobacco; eliminate flavors
• FDA: Regulate ecig marketing
• All levels: Effective, ongoing
countermarketing, incl Tobacco Industry
Denormalization
• Ecigs, NRT available for ‘can’t/won’t quit’

197. A possible endgame for the US
• Local level: Outlet restrictions; plan to phase
out sales of conventional cigarettes; incentives
for retailers to stop selling
• State level: Reduce #, density retail outlets via
increasing cost of licensing, incentives to stop
selling, move toward sales only in state
outlets; raise age of purchase yearly
• Eliminate POS marketing for both cigs & ecigs
• Smokefree laws include ecigs

198. A Modest Proposal
• Consider leveraging e-cigarette ‘moment’ to
achieve phaseout of combustible tobacco
products sales
• Could unite ‘vapers’, harm reduction
advocates and public health
• Incentives for industry to re-tool

199. Policy questions
• Question is no longer whether, but when and
in what sequence
• Which endgame approaches are most
feasible, most expeditious, most simple?
• What models for regulating other deadly
products can be drawn upon?
• How can we craft a new narrative that makes
an endgame for tobacco the only possibility?

200. California
• Second-lowest smoking prevalence in US
• 20-year TC program, dedicated funds from
tobacco tax initiative
• Mass media and community coalitions
• 3 themes: 1) tobacco industry lies; 2) nicotine
is addictive; 3) secondhand smoke kills

201. California
• Top priority: Limit tobacco-promoting
influences by curtailing marketing;
deglamorising; exposing industry practices;
holding industry accountable for impact of its
products. Trial and error philosophy
• Strong smokefree policies, including some
outdoor and MUH
• Has never had major focus on cessation;
primary aim is social denormalisation

202. California
• Next 10 years: Focus on retail setting
• Already has statewide licensing
• Increase costs/renewal frequency
• Limit number or density
• Eliminate coupons/ retail incentives
• Eliminate display
• Tobacco waste stream initiatives

203. POS as critical to Endgame
• Local & state levels:
Reduce number and density of retail outlets
Develop long term plan to phase out sales of
conventional cigarettes
Provide incentives for retailers to stop selling
Raise age of purchase yearly
Eliminate POS marketing for both cigs & ecigs
• All levels: Denormalization
Malone, R. E. (2013). Tobacco endgames: What they are and are not, issues for tobacco control strategic planning,
and a possible US scenario. Tobacco Control,22, i42-i44.

204. Legal considerations
Tobacco Control Legal Consortium Analysis, 2014
• Regulation of retail sales state/local function
• No legal barriers to state or local govts
restricting or prohibiting sales of a tobacco
product
• FDA bill expressly preserves local/state power to
adopt any “measure relating to or prohibiting
the sale” of tobacco products

205. Emerging phenomenon: Some
retailers ending tobacco sales
--Denormalization
“This is how I explained it to my staff here, was
that at one time, we didn’t realize that we
shouldn’t be selling cigarettes, but now it’s more
than obvious.”
Owner, pharmacy 4

206. Retail initiatives: San Francisco
• 2008: Ban on sales in pharmacies
• 2014: Cap of 45 tobacco permits in each of
SF’s 11 districts
• No new permits to restaurants or bars
• Attrition model: gradually reduce # of
outlets

207. New York

208. Elements of a new narrative
• Industrially produced epidemic
• Fundamentally defective product
• We have lost too many loved ones
• Less deadly alternatives exist
• Compare w other dangerous products
phased out or strictly regulated
• Not a “normal business” anymore

209. Public would never stand for this

211. But…PM Public Opinion Data
United States, 2004
Wish there was some way to
eliminate cigarettes 68%
Right and responsible thing to do…
go out of business 59%
tid zpe95a00

213. “You can’t…”
• Have nonsmoking sections in restaurants
• Ban smoking on airplanes
• Have smokefree workplaces
• Have smokefree bars (and pubs!)

214. Imagining things otherwise