Literature review and summary of perceptions, attitudes, beliefs, and marketing of potentially reduced exposure products: communication implications.

Potentially reduced exposure products (PREPs) have continued to enter the market during the 1990s and first part of the 21st century. Attempts by the tobacco industry to develop and market products with implied reductions in adverse health effects (i.e., harm reduction) are not new. Over the last half of the 20th century, the tobacco industry developed and marketed several products that purported to reduce the health risks associated with smoking cigarettes. Among these were filtered cigarettes in the 1950s and light and ultra-light cigarettes in the 1970s and 1980s. This review summarizes published and unpublished research that is directly relevant to the marketing, advertising, and communication about PREPs. The marketing strategies for these new products do not appear to differ from those used by the tobacco industry for light and ultra-light cigarettes. Although smokers report not using the new products in large numbers because of dissatisfaction with taste, they are interested in using products with reduced risk. Despite the absence of explicit health claims by the industry for PREPs, many smokers believe that these products are safer based on the advertising claims of reduced exposure and a belief that claims are approved by the government. No data are available to indicate that PREPs are useful for prevention or cessation of smoking, nor does specific research exist to suggest what health communication messages will provide smokers with accurate information about these products.     

Asian herbal‐tobacco cigarettes: “not medicine but less harmful”?

Objective

To describe the development and health claims of Asian herbal‐tobacco cigarettes.

Methods

Analysis of international news sources, company websites, and the transnational tobacco companies'' (TTC) documents. PubMed searches of herbs and brands.

Results

Twenty‐three brands were identified, mainly from China. Many products claimed to relieve respiratory symptoms and reduce toxins, with four herb‐only products advertised for smoking cessation. No literature was found to verify the health claims, except one Korean trial of an herb‐only product. Asian herbal‐tobacco cigarettes were initially produced by China by the 1970s and introduced to Japan in the 1980s. Despite initial news about research demonstrating a safer cigarette, the TTC analyses of these cigarettes suggest that these early products were not palatable and had potentially toxic cardiovascular effects. By the late 1990s, China began producing more herbal‐tobacco cigarettes in a renewed effort to reduce harmful constituents in cigarettes. After 2000, tobacco companies from Korea, Taiwan, and Thailand began producing similar products. Tobacco control groups in Japan, Taiwan, and Thailand voiced concern over the health claims of herbal‐tobacco products. In 2005, China designated two herbal‐tobacco brands as key for development.

Conclusion

Asian herbal‐tobacco cigarettes claim to reduce harm, but no published literature is available to verify these claims or investigate unidentified toxicities. The increase in Asian herbal‐tobacco cigarette production by 2000 coincides with the Asian tobacco companies'' regular scientific meetings with TTCs and their interest in harm reduction. Asia faces additional challenges in tobacco control with these culturally concordant products that may discourage smokers from quitting.     

Reducing the addictiveness of cigarettes

OBJECTIVE—To assess the feasibility of reducing tobacco-caused disease by gradually removing nicotine from cigarettes until they would not be effective causes of nicotine addiction.
DATA SOURCES—Issues posed by such an approach, and potential solutions, were identified from analysis of literature published by the US Food and Drug Administration (FDA) in its 1996 Tobacco Rule, comments of the tobacco industry and other institutions and individuals on the rule, review of the reference lists of relevant journal articles, other government publications, and presentations made at scientific conferences.
DATA SYNTHESIS—The role of nicotine in causing and sustaining tobacco use was evaluated to project the impact of a nicotine reduction strategy on initiation and maintenance of, and relapse to, tobacco use. A range of potential concerns and barriers was addressed, including the technical feasibility of reducing cigarette nicotine content to non-addictive levels, the possibility that compensatory smoking would reduce potential health benefits, and whether such an approach would foster illicit ("black market") tobacco sales. Education, treatment, and research needs to enable a nicotine reduction strategy were also addressed. The Council on Scientific Affairs came to the following conclusions: (a) gradually eliminating nicotine from cigarettes is technically feasible; (b) a nicotine reduction strategy holds great promise in preventing adolescent tobacco addiction and assisting the millions of current cigarette smokers in their efforts to quit using tobacco products; (c) potential problems such as compensatory over-smoking of denicotinised cigarettes and black market sales could be minimised by providing alternate forms of nicotine delivery with less or little risk to health, as part of expanded access to treatment; and (d) such a strategy would need to be accompanied by relevant research and increased efforts to educate consumers and health professionals about tobacco and health.
CONCLUSIONS—The council recommends the following: (a) that cessation of tobacco use should be the goal for all tobacco users; (b) that the American Medical Association continue to support FDA authority over tobacco products, and FDA classification of nicotine as a drug and tobacco products as drug-delivery devices; (c) that research be encouraged on cigarette modifications that may result in less addicting cigarettes; (d) that the FDA require that the addictiveness of cigarettes be reduced within 5-10 years; (e) expanded surveillance to monitor trends in the use of tobacco products and other nicotine-containing products; (f) expanded access to smoking cessation treatment, and strengthening of the treatment infrastructure; and (g) more accurate labelling of tobacco products, including a more meaningful and understandable indication of nicotine content.


     

Whither tobacco product regulation?

Despite decades of industry innovation and regulatory efforts, the harmfulness of conventional cigarettes has not changed. There are several pitfalls in this area, including the long time lag before health impacts of product regulatory changes become apparent, the danger of consumers deriving false reassurance of lesser harm in the interim period, the lack of relevant expertise and the lack of an internationally agreed and evidence-based strategic approach. Articles 9 and 10 of the Framework Convention on Tobacco Control provide the potential for such a global strategy, and knowledge and research has increased significantly over recent years. However, there are huge opportunity costs in implementing product disclosure and regulatory strategies: most national regulators have very limited human and financial resources, which should be focused on other evidence-based tobacco control interventions. We believe therefore that it is now time to abandon the notion of safe or safer cigarettes while moving consumers towards cleaner nicotine products as soon as possible. In parallel to this, we recommend a number of other strategies be implemented including: reducing the appeal of all tobacco products, forbidding new tobacco products or brand variants being marketed without evidence of reduced harm, appeal or addictiveness, and developing a tobacco industry resourced, but industry independent, Framework Convention on Tobacco Control global repository to assist national regulators in understanding and regulating the products on their markets.     

美国烟草业的挑战和减害研究的历史与现状

回顾了自20世纪50年代吸烟与健康科学研究兴起以来美国烟草业所面临的种种挑战,以及面对这些挑战美国烟草业采取的对策:客观承认吸烟的危害,树立良好的负责任的公众形象,加强吸烟与健康及减害理论与技术的研究,积极开发低危害卷烟产品。     

Tobacco industry successfully prevented tobacco control legislation in Argentina

Objective: To evaluate how transnational tobacco companies, working through their local affiliates, influenced tobacco control policymaking in Argentina between 1966 and 2005. Methods: Analysis of internal tobacco industry documents, local newspapers and magazines, internet resources, bills from the Argentinean National Congress Library, and interviews with key individuals in Argentina. Results: Transnational tobacco companies (Philip Morris International, British American Tobacco, Lorillard, and RJ Reynolds International) have been actively influencing public health policymaking in Argentina since the early 1970s. As in other countries, in 1977 the tobacco industry created a weak voluntary self regulating code to avoid strong legislated restrictions on advertising. In addition to direct lobbying by the tobacco companies, these efforts involved use of third party allies, public relations campaigns, and scientific and medical consultants. During the 1980s and 1990s efforts to pass comprehensive tobacco control legislation intensified, but the organised tobacco industry prevented its enactment. There has been no national activity to decrease exposure to secondhand smoke. Conclusions: The tobacco industry, working through its local subsidiaries, has subverted meaningful tobacco control legislation in Argentina using the same strategies as in the USA and other countries. As a result, tobacco control in Argentina remains governed by a national law that is weak and restricted in its scope.     

Courtesy and the challenges of implementing smoke-free policies in Japan.

For decades, the tobacco companies have developed a worldwide campaign to oppose the creation of smoke-free environments. Public health efforts to promote clean indoor air have been uneven throughout the world, and in few places have such efforts faced as many challenges as in Japan. The Japanese market is dominated by Japan Tobacco, which is partly owned by the government, and Philip Morris International is also present in Japan. Japan Tobacco and Philip Morris International have developed campaigns promoting courtesy and tolerance that, until recently, seem to have resonated well with the public. The companies also have supported research promoting ventilation and have funded consultants to act as experts in the area of second-hand smoke exposure. Japan is a critical country to study, partly because of the strength of Japan Tobacco in the country and the growth of Japan Tobacco International in Southeast Asia and the rest of the world, and partly because of Japan's ratification of the World Health Organization Framework Convention on Tobacco Control. This paper uses tobacco industry documents to provide an overview of the tobacco industry's scientific and political efforts to stifle the development of clean indoor measures in Japan. Learning past industry strategies may assist policymakers and advocates in the development of future public health activities.     

Implications of the federal court order banning the terms “light” and “mild”: what difference could it make?

Federal District Judge Gladys Kessler found that the major American tobacco companies violated the Racketeer Influenced and Corrupt Organizations Act, defrauding the public by deceptively marketing "light" cigarettes. Judge Kessler's ruling prohibits the defendant tobacco companies from implying health benefits through using misleading terms such as "light", "mild" or "low-tar", or through other indirect means. This ruling could be interpreted narrowly as simply prohibiting certain words, or could be interpreted broadly as prohibiting implying health benefits by any other means, including colour, numbers or images. It is important to include indirect communications, as tobacco companies easily circumvent narrow advertising bans. A narrow interpretation would be inconsistent with the court's comprehensive factual findings of fraudulent intent by the industry. A broad interpretation of the Order, including existing brands, line extensions and new tobacco products such as potential reduced exposure products that are marketed as "cigarettes", Judge Kessler's order could make a substantial contribution to protecting health.     

Brand differences of free-base nicotine delivery in cigarette smoke: the view of the tobacco industry documents

The recent availability of internal tobacco industry documents provides significant insight into industry knowledge and manipulation of tobacco smoke delivery. One critical area of research is the role of smoke chemistry in determining the absorption and effects of smoke constituents, especially harm producing or pharmacologically active compounds. Independent scientific research has suggested that the nicotine dosing characteristics, hence the addiction potential of cigarettes, may be determined in part by the amount of free‐base nicotine in cigarette smoke and its effects on the location, route, and speed of absorption in the body and on the sensory perception effects of the inhaled smoke. Tobacco industry documents describe the use of a number of methods internally for measuring free‐base nicotine delivery. These include the common use of cigarette “smoke pH” as a means to estimate the fraction of free‐base nicotine in the particulate matter (PM) in cigarette smoke, as well as efforts to measure free‐base nicotine directly. Although these methods do not provide accurate absolute measures of free‐base nicotine in smoke, consistencies observed in the findings across the various manufacturers indicate: (1) real relative differences in the acid/base chemistry of the smoke from different brands of cigarettes; (2) a connection between differences in free‐base levels and brand‐dependent differences in sensory perception and smoke “impact”; and (3) levels of free‐base nicotine that are greater than have typically been publicly discussed by the industry. Furthermore, the results of these methods are generally consistent with those of a recent study from the Centers for Disease Control and Prevention which directly measured the free‐base fraction of nicotine across a range of cigarette types. Consideration of the likely fundamental importance of free‐base nicotine levels in cigarette smoke, together with the efforts discussed in the tobacco industry documents to measure such levels, indicates that the public health community would benefit from additional research to assess directly the delivery of free‐base nicotine in cigarette smoke across brands. This may be especially useful for those products (“light”, “ultralight”, “reduced carcinogen”, etc) that have been promoted, either explicitly or implicitly, as “harm reducing”.     

A comparison of US and Norwegian regulation of coumarin in tobacco products

Objective: This paper examines policy processes regarding why the USA and Norway have not regulated coumarin in tobacco.

Design: A qualitative analysis of all tobacco industry documents regarding coumarin since the 1950s from the 1998 US Master Settlement Agreement and subsequent legal settlements. Additional data were collected from newspaper reports, general internet search engines, journal articles, scholarly reports, court cases, statutes, regulations, and informal correspondence with tobacco control experts in Norway.

Main outcome measure: An overview, summary, and analysis of all documents related to coumarin.

Results: In the USA from 1954 until 1985 when coumarin was reportedly removed from domestic cigarettes, but not from pipe tobacco until 1996, and not at all from imported Indian bidi cigarettes, regulatory efforts were stymied. In Norway, from 1973 to the present, the tobacco industry has never disclosed whether its tobacco products contain coumarin. In both the USA and Norway, the extreme delay and lack of vigorous evidence gathering and significant remedies were caused by tobacco industry assertions that revealing tobacco additives was a violation of trade secrets, and by weak regulatory authority and efforts to regulate coumarin.

Conclusion: Vigorous and expeditious regulatory investigations and remedies for harmful additives in tobacco, such as coumarin, can protect the public health. Astute insider and outsider political advocacy by health advocates is required to hold elected officials and civil servants publicly accountable for failing to enact disclosure laws and to engage in effective regulatory efforts.

     

Tobacco industry consumer research on socially acceptable cigarettes

Objective: To describe tobacco industry consumer research to inform the development of more "socially acceptable" cigarette products since the 1970s. Methods: Analysis of previously secret tobacco industry documents. Results: 28 projects to develop more socially acceptable cigarettes were identified from Philip Morris, RJ Reynolds, British American Tobacco, and Lorillard tobacco companies. Consumer research and concept testing consistently demonstrated that many smokers feel strong social pressure not to smoke, and this pressure increased with exposure to smoking restrictions. Tobacco companies attempted to develop more socially acceptable cigarettes with less visible sidestream smoke or less odour. When presented in theory, these product concepts were very attractive to important segments of the smoking population. However, almost every product developed was unacceptable in actual product tests or test markets. Smokers reported the complete elimination of secondhand smoke was necessary to satisfy non-smokers. Smokers have also been generally unwilling to sacrifice their own smoking satisfaction for the benefit of others. Many smokers prefer smoke-free environments to cigarettes that produce less secondhand smoke. Conclusions: Concerns about secondhand smoke and clean indoor air policies have a powerful effect on the social acceptability of smoking. Historically, the tobacco industry has been unable to counter these effects by developing more socially acceptable cigarettes. These data suggest that educating smokers about the health dangers of secondhand smoke and promoting clean indoor air policies has been difficult for the tobacco industry to counter with new products, and that every effort should be made to pursue these strategies.     

European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health

Rationale: This statement is an updated version of one released by the same authors in February 2003. The statement was produced to follow up the Royal College of Physicians (RCP) Tobacco Advisory Group report "Protecting smokers, saving lives: the case for a tobacco and nicotine regulatory authority",¹ which argued for an evidence based regulatory approach to smokeless tobacco and harm reduction and posed a series of questions that regulators must address in relation to smokeless tobacco.

The purpose of this statement is to provide arguments of fact and principle to follow the RCP's report and to outline the public health case for changing existing European Union (EU) regulation in this area. A review of regulation in relation to harm reduction and regulation of tobacco products other than cigarettes is required in Article 11 of EU directive 2001/37/EC,² and this is a contribution towards forming a consensus in the European public health community about what policy the EU should adopt in the light of this review, or following ongoing legal action that may potentially strike out the existing regulation altogether.

Public health case: We believe that the partial ban applied to some forms of smokeless tobacco in the EU should be replaced by regulation of the toxicity of all smokeless tobacco. We hold this view for public health reasons: smokeless tobacco is substantially less harmful than smoking and evidence from Sweden suggests it is used as a substitute for smoking and for smoking cessation. To the extent there is a "gateway" it appears not to lead to smoking, but away from it and is an important reason why Sweden has the lowest rates of tobacco related disease in Europe. We think it is wrong to deny other Europeans this option for risk reduction and that the current ban violates rights of smokers to control their own risks. For smokers that are addicted to nicotine and cannot or will not stop, it is important that they can take advantage of much less hazardous forms of nicotine and tobacco—the alternative being to "quit or die"... and many die. While nicotine replacement therapies (NRT) may have a role in harm reduction, tobacco based harm reduction options may reach more smokers and in a different, market based, way. Chewing tobacco is not banned or regulated in the EU but is often highly toxic, and our proposal could remove more products from the market than it permitted.

Regulatory options: We believe that the EU policy on smokeless tobacco should adapt to new scientific knowledge and that the European Commission should bring forward proposals to amend or replace Article 8 of directive 2001/37/EC with a new regulatory framework. Canada has developed testing regimens for tobacco constituents and these could be readily adapted to the European situation. A review of EU policy in this area is required no later than December 2004, and we believe the Commission should expedite the part of its review that deals with harm reduction and regulation of tobacco products other than cigarettes so as to reconsider its policy on smokeless tobacco. We held this view before Swedish Match brought its legal proceedings to challenge EU legislation and we will continue to hold these views if its action fails.

     

Smokers' beliefs about the relative safety of other tobacco products: findings from the ITC collaboration.

Most tobacco control efforts in western countries focus on the factory-made, mass-produced (FM) cigarette, whereas other tobacco products receive relatively little attention. Noncombusted tobacco products (i.e., referred to as smokeless tobacco), particularly Swedish-style snus, carry lower disease risks, compared with combusted tobacco products such as cigarettes. In this context, it is important to know what tobacco users believe about the relative harmfulness of various types of tobacco products. Data for this study came from random-digit-dialed telephone surveys of current smokers aged 18 or older in Australia, Canada, the United Kingdom, and the United States. Three waves of data, totaling 13,322 individuals, were assessed. Items assessed use of and beliefs about the relative harms of cigars, pipes, smokeless tobacco, and FM and roll-your-own cigarettes, as well as sociodemographics and smoking behaviors. Cigars (2.8%-12.7%) were the other tobacco products most commonly used by current cigarette smokers, followed by pipes (0.3%-2.1%) and smokeless tobacco (0.0%-2.3%). A significant minority of smokers (12%-21%) used roll-your-own cigarettes at least some of the time. About one-quarter of smokers believed that pipes, cigars, or roll-your-own cigarettes were safer than FM cigarettes, whereas only about 13% responded correctly that smokeless tobacco was less hazardous than cigarettes. Multivariate analyses showed that use of other tobacco products was most strongly related to beliefs about the reduced harm of these other products. Use of other tobacco products was low but may be growing among smokers in the four countries studied. Smokers are confused about the relative harms of tobacco products. Health education efforts are needed to correct smoker misperceptions.     

Understanding Philip Morris's pursuit of US government regulation of tobacco

Objective: To investigate Philip Morris's support of US Food and Drug Administration (FDA) regulation of tobacco products and analyse its relationship to the company's image enhancement strategies.

Data sources: Internal Philip Morris documents released as part of the Master Settlement Agreement.

Methods: Searches of the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) beginning with such terms as "FDA" and "regulatory strategy" and expanding to include relevant new terms.

Results: Philip Morris's support for government regulation of tobacco is part of a broader effort to address its negative public image, which has a damaging impact on the company's stock price, political influence, and employee morale. Through regulation, the company seeks to enhance its legitimacy, redefine itself as socially responsible, and alter the litigation environment. Whereas health advocates frame tobacco use as a public health policy issue, Philip Morris's regulatory efforts focus on framing tobacco use as an individual choice by informed adults to use a risky product. This framing allows Philip Morris to portray itself as a reasonable and responsible manufacturer and marketer of risky products.

Conclusions: Philip Morris's ability to improve its image through support of FDA regulation may undermine tobacco control efforts aimed at delegitimising the tobacco industry. It may also create the impression that Philip Morris's products are being made safer and ultimately protect the company from litigation. While strong regulation of tobacco products and promotion remain critical public health goals, previous experiences with tobacco regulation show that caution may be warranted.

     

Smoking,social class,and gender: what can public health learn from the tobacco industry about disparities in smoking?

Objective: To discover how the tobacco industry considers social class and gender in its efforts to market cigarettes in the USA, particularly to socially disadvantaged young women. Methods: A systematic on-line search of tobacco industry documents using selected keywords was conducted, and epidemiological data on smoking rates reviewed. Results: The two largest cigarette manufacturers in the USA consider "working class" young adults to be a critical market segment to promote growth of key brands. Through their own market research, these companies discovered that socially disadvantaged young women do not necessarily desire a "feminine" cigarette brand. Conclusions: Considering the tobacco industry''s efforts, alongside the persistent and growing disparities in cigarette smoking by social class, and the narrowing of differences in smoking by gender, it is concluded that additional tobacco control resources ought to be directed toward working class women.     

Playing hide-and-seek with the tobacco industry.

Despite many peer-reviewed works that draw on tobacco industry documents that have now been made public, questions remain about how complete a picture has emerged. We present a conceptual framework that identifies and evaluates tobacco industry efforts to conceal information. Widespread document destruction like that in recent litigation in Australia is just one of more than a dozen tobacco industry efforts to prevent access, or at least timely access, to documents. Industry efforts range from small, locally employed initiatives to company-wide tactics. Some efforts, such as using "oral only" procedures, scrambling telephone lines, or involving lawyers in scientific projects, are preemptive. Others seek to deal with already existing documents by invoking bogus claims of legal privilege, stipulating "read then destroy" for memos, and rewriting problematic memos. That evidence of concealment has, in fact, been found in tobacco company archives attests to the futility of attempting to control the flow of millions of pieces of paper among tens of thousands of employees. However, researchers have yet to reveal the full story: We know of the industry's failures in concealing information, but not its successes. The industry's objective is not destruction of information per se, but prevention of public disclosure of that information. Exposing the tobacco industry's many approaches to concealment provides greater insight into companies' intentions and potential means for stripping away that concealment.     

Little cigars, big cigars: omissions and commissions of harm and harm reduction information on the Internet.

We conducted a comparative analysis of "harm," "harm reduction," and "little cigar" information about cigars on 10 major English-language health Web sites. The sites were from governmental and nongovernmental organizations based in seven different countries and included "harm" and "harm reduction" information, discussions of little cigars, quantitative estimates of health risks, and qualifying behavioral characteristics (inhalation, number per day). Of the 10 Web sites, 7 offered statements explicitly indicating that cigars may be safer than cigarettes. None of the Web sites reviewed described that little cigars are likely as dangerous as cigarettes. Some Web sites provided quantitative estimates of health risks and extensive discussions of qualifying factors. Reading grade levels were higher than desirable. Extensive and complex information on the reduced risks of cigars compared with cigarettes is available on Web sites affiliated with prominent health organizations. Yet these sites fail to warn consumers that popular cigarette-like little cigars and cigarillos are likely to be just as dangerous as cigarettes, even for those who have never smoked cigarettes. Improvement of these Web sites is urgently needed to provide the public with high-quality health information.     

Electronic nicotine delivery systems: a research agenda

Electronic nicotine delivery systems (ENDS, also called electronic cigarettes or e-cigarettes) are marketed to deliver nicotine and sometimes other substances by inhalation. Some tobacco smokers report that they used ENDS as a smoking cessation aid. Whether sold as tobacco products or drug delivery devices, these products need to be regulated, and thus far, across countries and states, there has been a wide range of regulatory responses ranging from no regulation to complete bans. The empirical basis for these regulatory decisions is uncertain, and more research on ENDS must be conducted in order to ensure that the decisions of regulators, health care providers and consumers are based on science. However, there is a dearth of scientific research on these products, including safety, abuse liability and efficacy for smoking cessation. The authors, who cover a broad range of scientific expertise, from basic science to public health, suggest research priorities for non-clinical, clinical and public health studies. They conclude that the first priority is to characterize the safety profile of these products, including in long-term users. If these products are demonstrated to be safe, their efficacy as smoking cessation aids should then be tested in appropriately designed trials. Until these studies are conducted, continued marketing constitutes an uncontrolled experiment and the primary outcome measure, poorly assessed, is user health. Potentially, this research effort, contributing to the safety and efficacy of new smoking cessation devices and to the withdrawal of dangerous products, could save many lives.     

Whose standard is it,anyway? How the tobacco industry determines the International Organization for Standardization (ISO) standards for tobacco and tobacco products

OBJECTIVE: To describe the extent of the tobacco industry involvement in establishing international standards for tobacco and tobacco products and the industry influence on the International Organization for Standardization (ISO). METHODS: Analysis of tobacco industry documents made public as part of the settlement of the Minnesota Tobacco Trial and the Master Settlement Agreement. Search words included "ISO", "CORESTA", "Barclay", "compensation and machine smoking", "tar and nicotine deliveries", and the name of key players, in different combinations. RESULTS: It is clear that the tobacco industry, through the Cooperation Centre for Scientific Research Relative to Tobacco (CORESTA), play a major role in determining the scientific evidence and suggesting the standards that are eventually adopted as international standards for tobacco and tobacco products in several areas, including the measurement of cigarette tar and nicotine yield. CONCLUSIONS: ISO's tobacco and tobacco products standards are not adequate to guide tobacco products regulatory policies, and no health claims can be made based on ISO's tobacco products standards. There is an urgent need for tobacco control advocates and groups worldwide to be more involved with the work of the ISO, both directly and through their national standardisation organisations.