Month: June 2020

In Latin America there is an established, stable vaping market that coexists with laws banning commercial sales of vaping products. This is the case in all Latin American countries except Costa Rica and Colombia. The informal “no-regulation” environment which has served vapers and the vaping industry in Latin America—and in many Lower and Middle Income Countries (LMICs) around the world—is very different from the environment in high income countries like the United States, Canada, and most European countries.

These prohibitions are not strictly enforced most of the time, as law enforcement is lax and regulating bodies that should enforce them do not have the resources and personnel to do it (there is no comparison with the FDA). While e-cigarette sales are, strictly speaking, outside the law, they are not black market operations run by organized criminals, but small businesses run by vendors acting within the large unregulated informal markets prevalent in the region.

Opposition to vaping has been (and still is) harsh and visceral, but it is restricted to organized anti-tobacco groups claiming to fight the tobacco industry (which they erroneously claim promotes vaping). These are non-governmental organizations (NGOs) sponsored by Bloomberg Philanthropies and associated charities like the Campaign for Tobacco-Free Kids, acting in synergy with small but influential groups of health professionals clustered in the tobacco control sections of government public health institutions.

The so-called EVALI crisis in the U.S. provided a “perfect storm” that disrupted the previous “no-regulation” calm in Latin America. EVALI pushed the anti-vaping message to the highest levels of government and generated a public reaction of fear and suspicion against vaping. (Two factors probably mitigated this crisis to some extent: (1) no EVALI cases occurred in the region, and (2) the onslaught against vaping was directly identified with the governments, which are deeply mistrusted by large sectors of the public.)

Once the COVID-19 pandemic reached Latin American countries (by early March 2020), the EVALI-motivated attacks ceased; because health institutions suddenly had to deal with a real global pandemic, they were forced to temporarily put vaping on the back burner. Anti-vaping groups would have liked to use COVID-19 as a new vape bashing opportunity to continue the EVALI onslaught, but they had to face the fact that the data unequivocally showed other factors (old age, diabetes, obesity) being more determinant risk factors than vaping (or even smoking). This, together with the absence of registered records of seriously ill or dead vapers from COVID-19, has so far prevented them from repeating the EVALI trick.

Billionaire Michael Bloomberg is a well known public figure in the U.S. However, most Americans are unaware of the overwhelming influence of his philanthropy on public health policies (sugar, food and tobacco/nicotine) in Latin America and in LMICs elsewhere in the world. This influence is exerted through the political framework of the World Health Organization (WHO), either directly or indirectly via various Bloomberg-funded NGOs.

There are structural reasons for Bloomberg’s philanthropy to focus its efforts on LMICs: (1) these countries often welcome external private funds given the chronic lack of resources and personnel in their health ministries and public health institutions, and (2) most governments of LMICs are non-democratic regimes, with vertical, non-transparent public health bureaucracies always ready for wheeling and dealing. Thus, all it takes for a policy to be officially enacted is to lobby and convince the head of government, or a sufficiently influential group among high-ranking health officials.

To get an idea of the type of the policies on vaping (and other non-combustible nicotine and tobacco products) that Bloomberg’s philanthropy recommends for the LMICs through the WHO, it is useful to examine the document entitled “When bans are best,” produced by The Union, a private agency openly funded by Bloomberg. The Union offers a full policy blueprint for dealing with e-cigarettes and heated tobacco products (HTPs, also known as heat-not-burn tobacco products), advising LMIC governments that bans are preferable to regulation.

The Union justifies outright prohibition with arguments allegedly based on the need to comply with the tobacco control policy advice of the Framework Convention for Tobacco Control (FCTC), an international treaty on tobacco regulation sponsored by the WHO, which has been signed by more than 180 countries, including most LMICs. At first sight these arguments might look reasonable, but a closer look reveals that they are real recipes for disaster.

Evidence that The Union’s recommendations are taken seriously by health authorities in Latin America is furnished by the gradual hardening of recent anti-vaping legislation, which fits a clear prohibition strategy in the region. A concrete example is the Mexican prohibition of importing e-cigarettes and heated tobacco products (and their consumables), enacted by a presidential decree on February 19. The Mexican government received official praise on May 31 (the WHO’s World No Tobacco Day) from the WHO for having enacted this import ban.

Besides the predictable false claim (present in practically all documents from the WHO) that ENDS are some sort of conspiratorial Trojan horse created by Big Tobacco to recruit new consumers by enticing youth, the document produced by The Union argues that banning ENDS is preferable to regulating them for these reasons:

• The political and social context of LMICs is different from that of the U.K., where tobacco control institutions are strong and the objectives of the FCTC are efficiently implemented. As a contrast, says The Union, tobacco control institutions in LMICs are weak. Therefore, a regulation providing legal access to non-combustible consumer nicotine products (whose safety and harm reduction is questionable anyway, according to The Union) would make the local tobacco control institutions of LMICs even weaker, which would further decrease their compliance with FCTC policies. In other words, vaping products are an unaffordable distraction that will prevent full FCTC implementation in LMICs
• Regulating vaping products is complicated and costly, and will deprive the health ministries and public health institutions in LMICs of many resources that are badly needed to reinforce and strengthen tobacco control institutions to achieve the fulfilment of FCTC objectives
• Institutions in LMICs are weak (as opposed to institutions in the U.K.), hence if vaping products are not banned they would be, most likely, regulated under a vulnerable framework. Since public corruption is rampant and law enforcement is lax, it is very likely that the resulting e-cigarette regulation in LMICs would contain many legal loopholes which would allow the industry to operate and interfere with tobacco control efforts.

While these arguments do contain a nucleus of truth, a closer examination reveals their high damage potential.

First and foremost, the document starts with a false premise by denying that usage of e-cigarettes is vastly safer than tobacco cigarette smoking, something that is a fact, not a hypothesis or a theoretical possibility.

Second, it is true that tobacco control goals are not as efficiently implemented in LMICs as in the U.K. It is also true that health ministries are poor in resources. However, these conditions furnish the ideal scenario favoring regulation that would provide adult smokers legal access to vaping products. Regulating and not banning e-cigarettes would allow smokers, out of their own initiative and without cost to public resources, to choose to switch to lower risk products. If effective tobacco control means fewer smokers, vaping creates a win-win situation that strengthens tobacco control without depriving local public health institutions of scarce resources.

Third, prohibition is much more costly than regulation in terms of public resources: it needs to be enforced and policed, and it deprives governments of needed tax revenues. Also, given the rampant corruption in public institutions of LMICs, the resources saved by avoiding regulation will not likely be redirected to tobacco control. The cost balance in the regulation vs prohibition debate cannot be based only on tobacco control objectives as defined by the FCTC. It must also factor in the whole range of adverse effects of prohibitions: black markets, criminality, lack of quality control, and increased underage usage. Definitely a lose-lose situation.

Fourth, prohibition of vaping products favors tobacco cigarette smoking, as vaping products compete with tobacco cigarettes—hardly a gain for the advancement of tobacco control. Health ministries in LMICs do not even need to promote e-cigarettes, but simply regulate their market and concentrate only on prosecuting the remaining illegal sector. Health authorities can advance in pursuing the FCTC goals by focusing on those who continue to smoke.

The main flaw of The Union’s recommendations (and all similar policy documents on vaping produced by WHO bureaucrats and Bloomberg-funded agencies) is a lack of proper consideration of the reality of markets and consumers in LMICs. Aside from the social harms they may cause, their policy recommendations will very likely crash against the realities in countries like Mexico, India, Brazil, South Africa or Nigeria. It is very unethical to regard the probable adverse (unintended) consequences as mere collateral damage worth accepting as part of the glorious quest to create a nicotine-free world.

Bloomberg and tobacco control fellow travelers dismiss all criticism as naïveté or by accusing critics of being tobacco industry fronts. However, as well intended as it may be, funding by Bloomberg’s philanthropy must be declared as a major conflict of interest, and it must be subjected to the same scrutiny and accountability as any other source of funding.