In part 2 of this conversation, Peter Beckett speaks with Dr Derek Yach, former Head of Tobacco Control at the World Health Organization and founding president of the Foundation for a Smoke-Free World. They discuss the moment his thinking diverged from the mainstream tobacco control narrative, the evidence from Sweden and snus, the rise of vaping and heated tobacco, the politics around WHO and Bloomberg-funded activism, and why he believes harm reduction and vaccines are the two biggest underused tools in global public health.
The last time we spoke, we went through your early life, WHO, and your time there. This time, I want to look a little bit at the point at which your thinking diverged from what remains the dominant tobacco control narrative — which is that the objective is the end of nicotine, rather than the end of nicotine-related harm. Was there a moment you can point to when you thought, “Shit, this is going in the wrong direction, and I need to make a decision about whether or not I’m willing to put up with it”?
Yeah. I think there were two points, and they were about a decade apart. By 2005 I’d left WHO and was giving my first talk at an SRNT meeting in Prague, reflecting on progress. This was twenty years ago. I gave a speech then — it was actually written up in Tobacco Control (which years later, I became banned from).
The key concerns I raised then were: first, that complacency was creeping into the tobacco control movement; and second, that there was a clear emergence of new products starting to appear. This was twenty years ago, and we needed to keep our eye on the ball and separate the way we thought about nicotine — which was not the problem — from tobacco, which was the problem. At the time, it was interesting.
Then in 2015, I was asked by The Spectator, a fairly conservative British magazine, to write a piece on what we were missing in tobacco control and what was happening with vapes.So for the first time in a decade, I dug back into the field and saw what was going on in Europe. I went back to the snus data and realised, mea culpa, I had sat in WHO years earlier when people presented the Swedish data from the 70s, 80s, and 90s! We regarded it as an industry trick.
That data told us that Sweden had the lowest cancer rates in Europe. Smoking rates among men had gone down dramatically over the decades, while smoking among women had gone up because they were not using snus. The net benefit Sweden was seeing showed that it probably had some of the best health outcomes in Europe, heavily driven by the drop in cigarette smoking. At the time – as is the case today – Sweden had a carve-out allowing snus use, while the rest of the EU banned it. Lars Ramstam was the person who tried to persuade WHO to study the snus evidence seriously. He is in his 90s today.
I realised that while snus was cutting cancer rates compared to smoking, vapes could be even more effective, potentially without any tobacco at all. So I wrote this article basically saying: harm reduction’s time has come. I didn’t think much of it, but it ended up being the most downloaded article in Spectator Health. And it led to a phone call from the PMI cCEO’s office – Andre Catzanopolous – saying he wanted to talk.
So the old enemy reached out…
We spoke for almost a year and a half. He insisted I see the research laboratories. I had no idea what IQOS was, it had just been launched in Japan. I went several times, immersing myself in understanding why it was succeeding there. I was blown away by the quality of the research.
I brought in some heavyweight molecular biologists and analytic chemists to interpret the findings, they said, “This is the real deal.” These people were seriously engineering a product of the future that would take out the dangers.
At the time Bonnie Herzog, then at Wells Fargo, wrote a prophetic piece saying that within a decade, these products would probably be the major source of revenue for PMI. That really got me into it. It gave me, as a public health person, a chance to have the greatest impact on any public health problem, exceeding vaccines. I’d always been interested in big epidemiological challenges and there was no question, this was the way to go.
When I told my WHO colleagues we were launching the Foundation for a Smoke Free World (which was financed by Phillip Morris International), I was told by very senior people “We understand your rationale. We won’t go after you, but we can’t support you given the links.”
But that’s not what happened. Bloomberg came on board, putting up $20 million to fight against it, and then a billion, funding campaigns worldwide through groups like the Campaign for Tobacco-Free Kids. I got what I can only describe as a fatwa issued by WHO’s executive board. Letters to deans of public health schools told people explicitly not to work with me, saying it would undermine public health. Over time, some of that was rolled back over time, as people realised it was academic, undemocratic, and disgusting, but the seed had been planted: oppose and don’t engage. Over the decade, things have only become more polarised, even as the data has become more powerful and convincing: my most recent estimates tell me that we could save up to 100 million lives by 2060 if the world embraces harm reduction.
This “fatwa”, if it happened in any other field, would be scandalous. And these are people you worked with for decades and considered friends?
I hired many of them while I was at WHO!
I don’t understand the psychology of it. I’ve been doing this for thirteen years, the lobbying and regulatory side, and I cannot get into the heads of the other side. What are they telling themselves?
I constantly think about that because I was in the mindset, as we spoke about earlier, that the strategic change we made at WHO was to avoid attacking the smoker and rather demonize the industry. That was a big strategic decision. And it meant that I sat in the very committees where decisions were made to not allow researchers who were getting money from tobacco to get public funds. Cancer Research UK was the first to do it, and I sat on their board and went along with it.
Our argument was very simple, and it was based on one line: there is an irreconcilable difference between the goals of public health and tobacco control. That’s the line used to justify the bans and everything else. And that line was true until twenty years ago. As new products started showing efficacy, benefits, reductions, it became very clear to me that we have to revisit that, which is perfectly fine in science and research and policy.
But the mindset, though, remember that WHO and much of public health has been very steeped in a general distrust of industry, going back not to the tobacco wars, actually, but to the infant formula debacles and the Nestlé boycott of the eighties. Many of those same people then expanded into tobacco and alcohol and many even into pharma. Today, they are a hardened group of fringe lefty public health people.
The leadership of public health grew up in that era of the late nineties and so on, where being anti-industry in general was more the norm than the exception. I led the work on the only UN inquiry into an industry, which was the tobacco industry, which was done by WHO and showed very deep, long-standing efforts to subvert public policy.
I’d say if you want to get into their mindset, they’re almost close to the flat earth–type people who need to be asked the question: “What evidence do you need to have to know that we don’t live on a flat earth?”
At the same time, the tobacco control leadership has moved from being focused on cancer, cardiovascular, the health issues of adults and how you deal with them and the real need to save lives, to a lofty policy set of goals where they feel more comfortable in the areas of tax, marketing policies, and restrictive access. And they forgot that in the end, we also are about trying to get individual smokers to quit or to switch, and the individual smoker became demonized in the process.
The Smoke-Free World Foundation, now Global Action, which you’ve left, seems to be in terminal decline. Why does it feel like something didn’t quite go right in that project? And what can we learn from it? Was it suffocated by PMI’s slightly odd corporate culture? What happened? What can we learn from it?
My own personal experience was that we were never suffocated by anything by PMI. It was a very open relationship in the way we built the Foundation. The moment it was built, the board was completely independent of PMI. There was no link back to them. The claims we made of independence were genuine and true. The initial board was, in fact, very much focused on the legal governance issues to make sure it was independent.
But what I think we all underestimated was the vociferous, unbelievable amount of money that [Michael] Bloomberg was going to put into making sure it didn’t work, because they saw it as such an existential threat to the entire enterprise. And could we have anticipated it? I think we could have anticipated some, but I don’t know that there’s ever been an example of a billionaire putting money into universities to run stop campaigns and demonize everybody associated with it, and put hundreds of millions of dollars into media outlets around the world, often unbeknownst to the public, funding researchers from every part of the world to actually go after anything that was supported by the Foundation.
And so I think in many ways, you could say, well, despite all that, certainly in the years I was there, we were able to support very good grantees. But I certainly can say, and, you know, I have no links or reason to be supportive of PMI, that original vision, I think, was sound. We needed to fund entities to do independent research on harm reduction, particularly in third-world countries. That remains a high priority.
But if you are constantly being attacked, vilified, whatever, you’ve probably got to keep thinking, are there other ways to do it? I hope that there will be other ways in which funders, whether it’s industry or not, will actually support that very vision.We still have a massive gap in research capability in the countries with the highest smoking rates compared to the US, UK, New Zealand. And remember that the smoking rates we’re dealing with in some parts of the world are in excess of sixty percent in men in Indonesia, fifty percent in China, forty percent in many parts of Eastern and Central Europe. So we’re talking about smoking rates and levels that were last seen in the UK sixty years ago and thinking that we’re gonna be able to suddenly make that go away.
The only way to make it go away is to use the leapfrogging capability of harm reduction products, which cuts through all of this and actually puts the marketing, delivery, uptake in the hands of market forces and not government.
