Appeal to American Public Health Association to promote public health not the deception of the tobacco industry

Tue, Feb 2, 2021


Kathleen Ruff,

The tobacco epidemic is one of the biggest public health threats the world has faced, killing more than 8 million people a year. 80% of the deaths are in low and middle income countries (1).

Because of the tobacco industry’s long, thoroughly documented, continuing use of deceptive tactics to target youngsters and sabotage effective public health protections (2,3), countries around the world in 2003 enacted an international law – the Framework Convention on Tobacco Control (4). The Convention addresses the key obstacle to protecting populations against tobacco: the tobacco industry itself. The Convention requires that the 181 countries who have ratified the Convention must not engage or collaborate with the tobacco industry or organizations funded by the tobacco industry.

The tobacco industry has worked tirelessly to sabotage the Convention (5, 6, 7).

The United States is one of very few countries who have not ratified the Convention. Instead, it has tried along with the tobacco industry to undermine the Convention. This US history of  prioritizing corporate interests ahead of human health makes it all the more important that public health organizations in the United States, such as the American Public Health Association (APHA), demonstrate strong public leadership to support the world’s landmark public health Convention.

Sadly, the APHA is doing the opposite.

The WHO has asked public health organizations to reject any involvement with entities funded by the tobacco industry and, in particular, not to engage with the Foundation for a Smoke-Free World, which has been set up with just under one billion dollars of funding from Philip Morris International, one of the world’s biggest tobacco companies (8).

The WHO states that any collaboration by a country with the Foundation for a Smoke-Free World would constitute a clear violation of the Convention. The WHO prohibits the Foundation from participating in any discussions regarding government regulations over the industry’s traditional and novel products, such as cigarettes, flavoured cigarettes, e-cigarettes and heated tobacco products (9).

The world’s leading public health organizations, such as the World Federation of Public Health Associations (10), the Union for International Cancer Control (11), the International Network for Epidemiology in Policy (12), the World Heart Federation (13), the Global Coalition for Circulatory Health (13), as well as leading US health organizations such as the American Cancer Society (14), the American Heart Association (15) and the American Thoracic Society (16), have condemned the Foundation for a Smoke-Free World as an attempt by the tobacco industry to undermine public policy and block government regulations over their products.

All these leading public health organizations reject any interaction with the Foundation.

Sadly, the APHA is doing the opposite.

In June 2020, the APHA’s journal, the American Journal of Public Health (AJPH), invited and published submissions from the President of the Foundation for a Smoke-Free World, Dr. Derek Yach, and others funded by tobacco interests to discuss which public health controls should be adopted for e-cigarettes. In his text that the AJPH published, Yach put forward the agenda of the tobacco industry – that e-cigarettes are beneficial, that flavours should not be regulated, that regulations would simply increase the black market – and sought to discredit “many tobacco control non-governmental organization activists”, claiming that they create public misconception and alarmism (17).

The editor-in-chief of the AJPH, Dr. Alfredo Moravia, refused to publish submissions from the International Network for Epidemiology in Policy and the APHA Epidemiology Section and other scientists who opposed the journal’s decision to invite and publish the message of the tobacco industry. The reason given for this refusal was that he disagreed with their viewpoint. Dr. Moravia acknowledged that the submissions the AJPH published from the Foundation for a Smoke-Free World and others funded by the tobacco industry were, in fact, putting forward the opinion, positions and strategies of the tobacco industry. He stated that he supports publishing the tobacco industry’s opinion.

The AJPH, with the support of the APHA, has for the past seven months refused to allow any transparency or any open discussion of the policy they have adopted: a policy that directly violates the position of the WHO, the Convention on Tobacco Control and leading public health organizations.

In September 2020, dozens of public health scientists in South Africa, the United States, Australia, the UK and other countries submitted a letter (18) to the editor-in-chief of the AJPH, requesting that the journal reverse its policy of collaboration with the tobacco industry and its front groups. On October 20, 2020, the executive director of the APHA, Dr. Georges Benjamin, the editor-in-chief of the AJPH and the Chair of the AJPH Editorial Board, Dr. Gopal Sankaran, sent a letter to the scientists on APHA letterhead rejecting their request (19).

On November 3, 2020 Philip Landrigan, Richard Lemen and Kathleen Ruff sent a submission (20) to the APHA Board of Directors asking that they hold a transparent discussion of this critical public health issue and adopt a policy to support the WHO request that public health organizations not collaborate with the tobacco industry or its front groups. The Board of Directors did not respond.

On January 6, 2021, a letter was sent (21) to each of the APHA executive directors and to each of the AJPH Editorial Board members asking that they:

  • Adopt a formal APHA policy position joining the World Health Organization, the World Federation of Public Health Associations and leading, respected public health organizations across the United States and around the world in their rejection of any collaboration with or funding from the tobacco industry or its front groups.
  • Direct the editors of AJPH to issue a printed statement in the journal and to list this statement in Pub Med retracting the articles it published by Dr. Derek Yach and other individuals and organizations funded by the Foundation for a Smoke-Free World and other arms of the tobacco industry in its June 2020 issue.

At its meeting on January 11, 2021, the APHA Executive Board discussed the letter. To date, they have not acknowledged or responded to the letter and have not disclosed their decision.

Lack of transparency

The decision taken by the APHA to oppose the call of the WHO, the Framework Convention on Tobacco Control and leading public health organizations not to collaborate with the tobacco industry or its front groups is a serious, disturbing matter.

What is additionally troubling is that the decision has been taken without any transparent discussion or process. Nobody knows when, why, how or by whom this decision was taken. There is no record of it. To date, the APHA and the AJPH have permitted no open discussion of it.

Refusal of transparency is incompatible with public health protection.

On December 22, 2020, the World Federation of Public Health Associations, of which APHA is a member organization, issued a Statement  calling on all public health associations to reject all collaborations with the tobacco industry and tobacco industry front groups (10). In their Statement, the WFPHA called on public health associations to deepen transparent discussions about this important public health issue within their organizations.

Sadly, the APHA is doing the opposite.

Undermining public health

When accountability is not present, we know there is no true commitment.

The evidence is clear that the tobacco industry is spending millions of dollars to attract a new generation of youngsters to tobacco. An aggressive and seductive mass marketing campaign – “Don’t be a maybe. Be Marlboro” – carried out by Philip Morris International uses exciting photos of youngsters with a powerful psychological message that if you smoke Marlboro cigarettes, you will be irresistibly sexually attractive, you will break through your inhibitions and enjoy fantastic experiences, you will be admired and make your mark on the world, you will enjoy freedom, you will achieve your dreams (22, 23, 24, 25, 26). What youngster could resist such exploitation of their youthful insecurities of being a social and sexual failure and such powerful emotional manipulation? These tactics used by PMI are shameful.

Public health organizations that have social status and privilege have a duty not to close their eyes to gross misconduct that causes massive harm to public health. They have a responsibility not to act disingenuous in the face of clear wrongdoing.

It is beneficial to PMI to fund an organization with a beautiful name, a pretty narrative and a purported altruistic goal of wanting to stop tobacco smoking, while at the same time promoting PMI’s agenda to undermine health regulations and portray anti-tobacco groups as extremists, as does the Foundation for a Smoke-Free World. A prominent public health organization, such as the APHA, has a duty to address the evidence, not the pretty words. The evidence shows that PMI, while virtuously claiming to be dedicated to stopping tobacco use, is doing the exact opposite. It is carrying out aggressive, multi-million dollar marketing campaigns to entice a new generation of youngsters to take up smoking, particularly in low income countries where enforcement of health protections is weak.

Why is the APHA closing its eyes to the evidence of PMI’s wrongdoing? Why is it not holding PMI accountable for its actions and instead giving PMI the gift it most desires: the gift of unwarranted legitimacy for its front group as a bona fide, trustworthy participant in shaping public health policy? Why is APHA empowering a leading threat to public health?

Undermining democracy

A key tactic employed by PMI and the tobacco industry is to have tobacco and their other harmful products treated as trade issues not health issues. They exert their influence to have government delegations  made up of representatives of government trade ministries, not health ministries. They fight to have tobacco included under trade treaties, then launch legal cases to overthrow public health protections passed democratically by governments. This costs developing countries millions of dollars of public funds which they can ill afford. For six years, PMI spent US$ 24 million using an investment treaty in seeking to force the government of Uruguay – a country with fewer than four million inhabitants – to annul its regulations requiring large graphic health warnings and a ban on misleading packaging (27).

It is obscene that PMI exercises its massive corporate power to argue that its profits should override democracy and public health. Luckily, PMI lost its legal case against the government of Uruguay.

But PMI continues to spend US$ millions in attempts to overturn government regulations that protect health.

Presently in California a coalition composed of Philip Morris USA, R.J. Reynolds Tobacco Company and other tobacco companies has been created  to block a law passed by the California legislature to ban flavored tobacco products, including candy-flavored e-cigarettes and menthol cigarettes (28). The proponent of the law, former Senator Jerry Hill, states: “We know the average age youth begin smoking is 13 years and over 80% start by smoking a flavored tobacco product.  Big Tobacco is addicting and killing a new generation on flavored tobacco.” (29)

The chair of the Behavioral Health Commission of San Bernardino County, Monica Caffey, says: “Candy-flavored products hook kids on nicotine. Tobacco companies know this. Using flavors like cotton candy, bubble gum and gummy bears, they have created an epidemic of e-cigarette use among our youth. One in five high school students now use vape products and 81% who have ever used a tobacco product started with a flavored one. I know that in addition to harming teens’ developing lungs, these tobacco products contain enormous amounts of nicotine that completely rewire adolescents’ developing brains, creating irreversible cognitive changes and potentially leading to years of further addiction.”  (30)

The coalition has, however, succeeded in stopping the law from going ahead. Instead it will go to a referendum in 2022.

The coalition chose a pretty name – the California Coalition for Fairness. It claims to be pursuing altruistic goals but is promoting the commercial interests of its funders, just as the Foundation for a Smoke-Free World does. Tobacco companies have given the Coalition over $20 million to block the law. It should be noted how the Coalition is putting forward the same arguments that the AJPH published on behalf of the Foundation for a Smoke-Free World: that flavours should not be regulated, that their flavoured products are not intended for youth, that regulations would simply increase the black market, and that the regulations passed by the California government are too extreme.

Key questions

The leadership of the APHA has adopted a policy of engaging with and giving legitimacy to the message of the tobacco industry aimed at subverting public health protections. The APHA has held no open discussion of this policy. Yet it is one of the most important public health issues of our times. Tobacco kills millions every year. The evidence shows not only that tobacco kills but also the key challenge of our times: that the tobacco industry exerts its corporate power to overrule democracy and public health; that it uses immoral tactics to manipulate youngsters” psychological vulnerabilities in order to entice them to smoke; that it practices deception to subvert public understanding and government policy through scientists and front groups it funds.

It is to be hoped that among the membership of the APHA there are many who support the Framework Convention on Tobacco Control and the call of the WHO, the World Federation of Public Health Association and the world’s leading health organizations not to engage with and legitimize the tobacco industry and its front groups.

It is to be hoped that among the membership of the APHA there are many who believe that the APHA should hold a transparent discussion to determine its policy on this critical public health issue.

It is to be hoped that they will raise their voices and insist that the APHA join with international and US public health organizations to support the Framework Convention on Tobacco Control and call on the US government to join the rest of the world in ratifying it.

In this way, the APHA would be showing public health leadership that would bring it credit.


1) WHO, Tobacco: Key Facts, 27 May 2020,

2) Gilmore A, Big tobacco targets the young in poor countries – with deadly consequences. The Guardian, December 1, 2015,

3) WHO, Tobacco industry interference with tobacco control, 2008,

4) WHO Framework Convention on Tobacco Control,

5) Boseley S, Philip Morris waging global effort to hobble anti-smoking treaty, files show, Guardian, July13, 2017,

6) Kalra A et al. Documents reveal Philip Morris’ campaign to subvert the world’s anti-smoking treaty, July 13, 2017,

7) Letter from major public health organizations around the world asking UN Secretary-General to call out tobacco industry deadly manipulations and misinformation, May 5, 2020,

8) WHO Statement on Philip Morris funded Foundation for a Smoke-Free World, 28 September 2017,

9) Cullinan K. Ex-WHO man banned from tobacco conference. 7 March 2018.

10) World Federation of Public Health Associations, Rejecting All Collaborations of Public Health Organizations with the Tobacco Industry, December 22, 2020,

11) Union For International Cancer Control, UICC issues warning about the Foundation for a Smoke-Free World, 20 October, 2020,

12) International Network for Epidemiology in Policy, Resolution in support of International Prohibitions on Public Health Collaborations with Tobacco Industry and its Affiliates, 16 December 2020. Policy Resolutn Supporting PHlth Prohibitions Any Tobacco Industry Collaboration_master_05Jan2021.pdf

13) The Lancet, Statement by the Global Coalition for Circulatory Health and the World Federation of Public Health Associations, October 14, 2017, Condemning industry attempts to subvert public policy for a tobacco-free world,; Supplementary Appendix,

14) Statement by American Cancer Society,

15) Statement of Campaign for Tobacco-Free Kids, American Cancer Society Cancer Action Network, American Heart Association and American Lung Association, Philip Morris Declares the “Year of Unsmoke,” But Launches New Cigarette in Indonesia and Sells Over 700 Billion Cigarettes a Year Worldwide, April 18, 2019.

16) American Thoracic Society. ATS President Clarifies the Society’s Position on the “Foundation for a Smoke-Free World“.

17) Erkkila B. E, Kovacevic P. I. , Yach D. Restricting flavors in ends could have repercussions beyond youths’ use. AJPH, June 2020, Vol 110, No. 6, page 777-778.

18) Vallone D. et al, Letter to Morabia, A, Editor-in-chief, AJPH, September 21, 2020,

19) Benjamin G., Morabia A., Sankaran G, letter to Vallone et al, October 20, 2020,

20) Ruff K, Landrigan PJ, Lemen RA, Submission to APHA Board of directors, November 3, 2020,

21) Landrigan PJ, Lemen RA, Ruff K, Letter to APHA Executive Board Members and AJPH Editorial Board members, January 6, 2021.

22) Stanford Research into the Impact of Tobacco Advertising. “Marlboro’s latest campaign, Be Marlboro, is replete with youth-oriented images and themes that strongly suggest to young people that they should smoke Marlboro cigarettes”.

23) University of Bath. Tobacco Tactics. Be Marlboro: Targeting the World’s Biggest Brand at Youth, 21 December 2020,

24) Philip Morris’ Be Marlboro Campaign “Aimed Unashamedly at Young People”. BBC Report.June 16, 2014,

25) Moss C, Inside the ‘Be Marlboro’ parties Philip Morris throws for teenagers — but doesn’t want you to know about, Business Insider, 15 May 2015,
26) The Guardian, Sarah Boseley, March 12, 2014, Marlboro marketing campaign aimed at young people, anti-tobacco report says.

27) Olivet C, Villareal A, Who really won the legal battle between Philip Morris and Uruguay?, The Guardian, July 28, 2016,

28) California Flavored Tobacco Products Ban Referendum (2022),

29) Times of San Diego, Attempt to Overturn Ban on Flavored Tobacco Sales Qualifies for 2022 Ballot, January 23, 2021,

30) Caffey M, Referendum against ban on flavored tobacco is a referendum against our kids. CalMatters, January 11, 2021,

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