As a lawyer, activist, and executive at nonprofit organizations, Cliff Douglas fought the tobacco industry for decades. He sued cigarette makers, cultivated whistle-blowers who exposed industry secrets, and led the campaign to ban smoking on airlines, back when smoke-free workplaces were rare.
In October, though, Douglas surprised some of his allies in the anti-smoking movement by becoming president and CEO of the Foundation for a Smoke-Free World, a nonprofit created and entirely funded by Philip Morris International, one of the world’s largest tobacco companies.
The 65-year-old Douglas, who previously worked for the American Cancer Society and the American Lung Association, says he isn’t going over to the other side. To the contrary, he sees his new job as the continuation of his anti-smoking work.
He joined the foundation only after its board agreed to make a clean break from Philip Morris : The foundation plans to change its name, bring on new directors, and decline any tobacco money in the future, hoping to remove any stain on its reputation. Douglas will then try to bring together foundations, nonprofits, public-health experts, elected officials, regulators, and academics in a renewed effort to curb death and disease caused by smoking.
It won’t be easy.
The difficulty is, anti-smoking groups aren’t just fighting the tobacco companies these days. They’re fighting, sometimes bitterly, among themselves.
“I’m under no illusions about the challenges,” Douglas says.
The stakes are high. Smoking remains the leading cause of preventable death in the United States, killing about 480,000 people a year, according to the Centers for Disease Control. Smoking causes more deaths in the United States than alcohol, drug overdoses, gun violence, auto accidents, and AIDS combined.
To succeed, Douglas will have to work through what he calls the “very fraught, polarized environment” that hampers the nonprofits, foundations, governments, and academics who work on tobacco control. They have fractured over tobacco harm reduction — the idea that people who cannot or will not quit smoking should be provided with alternatives, notably e-cigarettes, which deliver nicotine without burning tobacco.
Bloomberg Philanthropies and the nonprofits it supports — the Campaign for Tobacco-Free Kids and long-established groups like the American Cancer Society, the American Lung Association, and the American Heart Association — have campaigned relentlessly to limit access to e-cigarettes. Living up to its name, the Campaign for Tobacco-Free Kids has focused narrowly on what it continues to describe as a “youth e-cigarette epidemic,” even though vaping by teens has fallen by more than 60 percent since its peak in 2019. They argue that e-cigarettes will lead to a new generation addicted to nicotine, even if they are not smoking.
Backed by $300 million in Bloomberg philanthropic money, along with political donations from Michael Bloomberg, the anti-vaping groups have helped convince five states – California, Massachusetts, New Jersey, New York, and Rhode Island – to ban the sale of flavored e-cigarettes. The nonprofit Truth Initiative goes further, saying it is “committed to making tobacco use and nicotine addiction a thing of the past,” which would require removing all e-cigarettes from the market. Some cities, including San Francisco, have already done so.
Douglas and his allies in the harm-reduction camp say that’s been nothing short of disastrous. Bans on flavored e-cigarettes, which now cover nearly 40 percent of the country, have been associated with increased sales of conventional cigarettes, according to several academic studies and financial analysts.
“These bans disincentivize the far safer product and move people back to a product that’s going to kill one in two of them,” Douglas says.
The argument threatens to derail progress on one of the most successful public health campaigns in history. The percentage of Americans who smoke has dropped from 42 percent in 1964, when the first Surgeon General’s report warned of the dangers of smoking, to less than 12 percent. But the arrival of e-cigarettes fractured opponents of smoking, especially after startup company JUUL marketed its vapes with high nicotine levels to young people, infuriating activists and regulators.
“I can’t think of any other field of public health that has been so divided,” says Charles Gardner, a former program officer at the Foundation for a Smoke Free World and a global-health expert who previously worked at the Rockefeller and UBS Optimus foundations.
Tobacco Money
The mission of the Foundation for a Smoke Free World, which Philip Morris started in 2017, is to reduce deaths and diseases caused by smoking. It focuses largely but not entirely on reduced-risk nicotine products, a category that includes e-cigarettes, oral tobacco, and “heat not burn” products that warm up tobacco without burning it.
This aligns with the goals of the company, which says that its future depends on replacing cigarettes with the smoke-free products that it sells. Philip Morris International promised that the foundation would be independent and said it would fund it with $80 million a year for 12 years.
Anti-smoking groups called the foundation a public-relations stunt, noting that the tobacco industry has a long history of creating front groups to push its agenda.
If Philip Morris truly wants a smoke-free world, they said, it should stop making and selling cigarettes. Joanna Cohen, a professor of disease prevention at the Bloomberg School of Public Health at Johns Hopkins University, and the school’s dean, Ellen MacKenzie, urged universities and nonprofits around the world to shun the foundation. Others attacked the foundation’s first president, Derek Yach, a former executive with the World Health Organization and the Rockefeller Foundation.
“I expected the opposition,” Yach says, “but I didn’t expect it to be as vociferous and strong.”
The foundation funded research on the health effects of smoke-free nicotine products and published reports on tobacco use in low- and moderate-income countries. It created the Tobacco Transformation Index, which ranks the world’s largest tobacco companies on their progress toward harm reduction as they sell safer products. It started a program in Malawi to help tobacco farmers find alternative livelihoods and examined misperceptions about nicotine, which, while addictive, does not cause cancer.
But the mainstream tobacco-control groups turned out to be right when they charged that the foundation was dependent on Philip Morris International. The company cut its annual donations from $80 million to $40 million in 2020. Yach left in 2021, and the foundation has had little impact on the harm-reduction debate — not that anything else has, as positions on both sides have hardened.
Douglas says the foundation is now independent because it has severed all ties with Philip Morris — after accepting $122.5 million, which he characterized as a severance payment. His allies say that the tobacco industry has no more influence over the foundation than the auto industry has over the Ford Foundation or the oil industry has over the Rockefeller Foundation and that Douglas’s history as an anti-smoking crusader should ease worries about his loyalties.
“No single person had done more to make America hostile to tobacco than Cliff Douglas,” wrote investigative reporter Dan Zegart in his 2000 book, Civil Warriors: The Legal Siege on the Tobacco Industry.
But some anti-tobacco campaigners remain skeptical, to say the least. Yolonda Richardson, president of the Campaign for Tobacco Free Kids, and Deborah Arnott, chief executive of a British health charity called Action on Smoking and Health, told Reuters that the foundation was tainted by accepting tobacco money and could not be seen as independent.
The American Cancer Society, Bloomberg Philanthropies, Tobacco-Free Kids, and Truth Initiative declined to comment to the Chronicle. So did Cohen, the Johns Hopkins professor, who wrote an influential academic paper laying out criteria for accepting tobacco-industry funding for research and has worked with colleagues on both sides of the harm-reduction debate.
Douglas would like his critics to reserve judgment. “I’m asking those who feel doubt at this early stage to not merely rely on what I say but to watch what we do,” he says.
Vaping vs. Smoking
What, then, will the foundation do?
Douglas intends to mount an effort to correct widespread and dangerous misunderstandings about the relative risks of conventional cigarettes, e-cigarettes, and nicotine. There are no safe tobacco products; all fall along what’s called a continuum of risk. Nicotine pouches and gums are widely accepted because, unlike e-cigarettes, they have been approved as smoking-cessation medicines by the FDA.
That said, the vast majority of scientific experts and government agencies, including the Centers for Disease Control, say that vaping is safer than smoking, although its long-term effects remain unknown.
Public opinion surveys, however, show that Americans mistakenly believe that e-cigarettes are as harmful or more harmful than conventional cigarettes. Misinformed smokers, therefore, have no reason to switch to the safer product.
Surprisingly, physicians are also misinformed. Surveys of doctors in the United States and around the world have found that most blame nicotine for many of the negative health consequences of smoking. Nicotine is addictive, but other chemicals and carcinogens, particularly those produced by combustion, are the primary causes of tobacco-related disease and death.
“Doctors understand that you shouldn’t be smoking,” says Michael Cummings, a tobacco-control expert at the Medical University of South Carolina. “Unfortunately, they’ve been sold a bill of goods on vaping.”
Misperceptions affect not only patients and the advice they get from doctors but also the beliefs and actions of elected officials who favor an abstinence-only approach to nicotine. “Misunderstanding leads to poor policy,” Douglas says. While concerns about the long-term effects of vaping are valid — again, no tobacco product is safe — studies show that people who switch from conventional cigarettes to smoke-free nicotine products show immediate decreases in biomarkers associated with disease in their blood and urine.
With about $140 million in its coffers — the payment from Philip Morris, along with cash on hand — the foundation will have to make some hard decisions about priorities. It has spent large sums on overhead, consultants, and director pay. The board chair, Pamela Parizek, a Harvard-educated lawyer and CPA, was paid $100,000 a year, according to the foundation’s most recent tax return, and other directors were paid $50,000 or $75,000. Parisek said the director fees, which are higher than those at far larger foundations, were set by the board after an independent comparability study. Douglas will be paid $525,000 annually, compared with $922,000 for Yach.
Douglas will also seek additional funding from foundations and wealthy individuals. The Robert Wood Johnson and the Bill & Melinda Gates foundations have been longtime funders of tobacco control. Open Philanthropy, the philanthropic arm of Facebook billionaire Dustin Moskovitz and his wife Cari Tuna, has considered supporting tobacco control, including harm-reduction efforts.
More than anything else, though, Douglas would like to stop the in-fighting and find common ground with the Bloomberg-funded groups around policies that would keep tobacco and nicotine products away from kids while helping adults kick their smoking habit.
In a 2022 paper in Health Affairs, Douglas and several co-authors recommend reducing the nicotine levels in cigarettes so they become less addictive, imposing larger taxes on cigarettes and smaller ones on e-cigarettes to encourage switching, and limiting the sale of e-cigarettes to adults-only stores. The specifics are not as important as their expectation that tobacco-control advocates can unite around a shared belief that “young people and adults deserve a future free of tobacco-related disease,” they write.
“We should be embracing dialog, not destroying it,” says Scott Ballin, a veteran of the tobacco wars and former vice president of the American Heart Association, who notes that flavored vapes are popular with adult smokers as well as kids. “Vaping products clearly need regulation, but we should be careful not to destroy an industry that could help accelerate the demise of the combustible cigarette.”
Cigarette smoking in the developed world has been declining for many years. In the United States, the number of adult smokers has fallen from 34 million to 28 million while the number of adult vapers has increased from 11 million to 15 million since 2019, according to the CDC. It’s possible but unlikely that these trends are unrelated. Cigarette sales have fallen sharply in Sweden and Japan, where smoke-free nicotine products are popular.
Teen smoking in the United States is down by an astonishing 90 percent in the past two decades; the anti-smoking campaigns of groups like Truth Initiative and the Campaign for Tobacco-Free Kids deserve credit, but the popularity of e-cigarettes surely played a role as well.
Still, Bloomberg Philanthropies and the nonprofits it supports have been peculiarly unwilling to sit down with critics who believe that their anti-vaping crusade may be doing more harm than good. Two years ago, when a group of public-health experts — including Douglas; Cummings; Steven Schroeder, the former president of the Robert Wood Johnson Foundation; Cheryl Healton, the founding president of the Truth Initiative and former dean of the school of public health at New York University; and Kenneth Warner, dean emeritus of the public health school at the University of Michigan — asked to meet privately with Bloomberg to discuss their concerns, he declined.
Douglas was disappointed but undaunted. “Let’s share our perceptions and understanding. Let’s communicate. Let’s talk,” he says. “There are a great many lives at stake.”
