Correspondence
Another perspective on
the Foundation for a
Smoke-Free World
Much has, and is, being said about the
Foundation for a Smoke-Free World,1
an independent foundation funded
by Philip Morris International, but one
elemental point has been overlooked.
A principal focus of the foundation, as
stated on its website, is on treatment
of addicted smokers to decrease
mortality, including promoting the
switch to reduced-risk products, such
as e-cigarettes. Geoffrey Rose, in his
masterful monograph The Strategy
of Preventive Medicine, pointed to
the so-called risk paradox, giving the
example “whereby it was seen that
many people exposed to a small risk
may generate more disease than a few
exposed to a conspicuous risk. Applied
in reverse to prevention, this means
that when many people each receive
a little benefit, the total benefit may
be large.”2 As a theoretical example, a
5% lowering of mean blood pressure
across a population could achieve a
30% reduction in stroke, compared
with a 15% reduction if all cases of
hypertension were treated.
In Rose’s bell curve, a wholesale
shift to the left of the entire curve
will achieve more than will a focus on
the right-hand tail. When applied to
public health measures—such as bans
on public smoking, which address
smoking-related mortality—this
approach will shift the curve of tobacco-
use prevalence, and thus mortality,
to the left, which should in turn yield
a greater effect than will treating
cigarette smokers who are struggling
to quit. A prime example of this is
the reduction in the number of heart
attacks witnessed in many parts of the
world after bans on public smoking
were introduced.3 More recently, results
from various meta-analyses also show
reductions in perinatal and childhood
respiratory diseases.4 Although some
individual patients in a clinical setting
might benefit from e-cigarettes and
www.thelancet.com Vol 391 January 6, 2018
other novel products, this does not
mean that these electronic nicotine
delivery systems (ENDS) should be
promoted, marketed, or sold to the
general population.
In light of these findings, the goals
of the Foundation for a Smoke-Free
World seem far less benign, even
before considering the involvement of
the tobacco industry. Unlike standard
nicotine replacement therapy,
counselling, and quitting cold turkey,
e-cigarettes and heat-not-burn
tobacco products maintain nicotine
addiction. And unlike methadone,
which is the cheapest manufactured
drug in the USA and used as an
example by ENDS advocates,5 there
is a huge profit to be made by the
tobacco industry in prolonging
nicotine addiction. Decades ago,
an industry executive said bluntly,
“Nicotine is addictive. We are, then,
in the business of selling nicotine.”6
Whatever reduction in mortality is
possibly achieved by ENDS would be
offset to some degree by continued
nicotine use, by non-smoking adol­
escents becoming addicted and
switching to regular cigarettes (which
is already occurring), and by any long-
term toxicity associated with the
ENDS products.
There are far better and more
thoroughly tested ways to spend
US$1 billion if the goal is to reduce
smoking morbidity and mortality.
To cite Geoffrey Rose again: “Mass
diseases and mass exposures require
mass remedies. A targeted approach
may assist but it cannot be sufficient.”2
It is possible that the Foundation for a
Smoke-Free World will come up with
some grand strategy other than to
offer a platform for its sponsor’s latest
products; this remains to be shown.
I declare no competing interests.
Norbert Hirschhorn
bertzpoet@gmail.com
London, UK
1 The Lancet. Tobacco control: a foundation too
far? Lancet 2017; 390: 1715.
2 Rose G. The strategy of preventive medicine.
Oxford: Oxford University Press, 2009.
3 US Department of Health and Human Services.
The health consequences of smoking—50
years of progress. A report of the Surgeon
General. Rockville: Public Health Service Office
4
of the Surgeon General, 2014: 435–42.
Faber T, Kumar A, Mackenbach JP, et al. Effect
of tobacco control policies on perinatal and
child health: a systematic review and
meta-analysis. Lancet Public Health 2017;
2: e420–37.
5 Campbell H. Methadone, needle exchanges
and e-cigarettes: Puritanism as policy. July 16,
2016. https://www.acsh.org/news/2016/07/
10/methadone-needle-exchanges-and-e-
cigarettes-puritanism-as-policy (accessed
Dec 1, 2017).
For more on Foundation for
6 Hirschhorn N. Evolution of the tobacco
industry positions on addiction to nicotine.
a Smoke-Free World see
www.smokefreeworld.org
A report prepared for the Tobacco-Free
Initiative, World Health Organization. Geneva:
World Health Organization, 2008: 5.
WHO washes its hands
of older people
Older people (≥60 years) constitute
more than 12% of the world’s
population, which will rise to
16·5% by 2030.1 This age group will
represent 10% of the population
Sturti/Getty Images
in less developed regions by 2030.
Although older people account for
a greater proportion of the global
burden of disease and health-care
needs than younger people, their
positive societal contribution should
not be overlooked. This age group
often provide unpaid care for children
or grandchildren, or other adults with
disabilities. Improved health of older
people is an essential goal to reduce
health-care costs and maintain the
societal support older people provide.
Although WHO has begun to address
this key global challenge over the past
decade, the proposed 13th General
Programme of Work 2 makes no
reference to older people or conditions
associated with later life, such as
dementia, which is unacceptable. If
the proposed programme is approved,
it will considerably diminish WHO’s
global authority and will brand itself
as a champion of age discrimination.
We therefore urge that WHO rectify
this oversight and revise the proposed Submissions should be
made via our electronic
programme to include substantial plans submission system at
relating to the health of older people http://ees.elsevier.com/
and challenges of an ageing population. thelancet/
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