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Special communication
Philip Morris International-funded ‘Foundation for a Smoke-Free World’: analysing its claims of independence
  1. Yvette van der Eijk1,
  2. Lisa A Bero2,
  3. Ruth E Malone3
  1. 1 Center for Tobacco Control Research and Education, University of California, San Francisco, California, USA
  2. 2 Charles Perkins Centre and and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
  3. 3 Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California, USA
  1. Correspondence to Professor Ruth E Malone, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco CA 94123, USA; ruth.malone{at}ucsf.edu

Abstract

The Foundation for a Smoke-Free World was launched in September 2017 with an announced 12-year funding commitment of $1 billion from Philip Morris International (PMI). The Foundation claims that its governing documents (certificate of incorporation, bylaws and a pledge agreement) ensure that it has an independent research agenda and stringent protections from conflicts of interest. We analysed the text of these governing documents. Their provisions have multiple loopholes, particularly regarding conflicts of interest. Further, these documents cannot substitute for other important documentation such as information about PMI’s internal business case for investing $1 billion in the Foundation, an unwaivable conflict of interest policy, annual disclosure statements, copies of pre-Foundation establishment correspondence between key individuals, all signed contracts or salary information, none of which, as of July 2018, the Foundation has made publicly available. Even if these were released, however, it is problematic that the Foundation’s fundamental purpose was decided on and its leader selected following a tobacco company-paid, privately negotiated arrangement with the Foundation’s president. It cannot be regarded as independent.

  • tobacco industry
  • electronic nicotine delivery devices
  • harm reduction
  • end game

https://doi.org/10.1136/tobaccocontrol-2018-054278

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    Introduction

    The Foundation for a Smoke-Free World (hereafter, the Foundation or FSFW) was launched in September 2017 with Derek Yach, a former WHO officer, as its founder-president.1 According to its website, FSFW is ‘an independent, non-profit organisation’2 which plans to eliminate smoking worldwide by supporting ‘tobacco harm reduction’ and identifying alternative livelihoods for tobacco farmers.2 The Foundation was launched with a 12-year funding commitment from Philip Morris International (PMI) of $1 billion (US$80 million/year),1 3 an estimated 0.1% of PMI’s revenues.4 5

    Public health advocates, researchers (including one of the authors of this paper), health organisations and universities have criticised FSFW as a public relations ploy to boost PMI’s corporate image and possibly produce misleading science,4 6–9 while PMI continues to attack effective tobacco control policies and profit from cigarette sales.4 10 The WHO Framework Convention on Tobacco Control (FCTC) Secretariat expressed concern that the Foundation would undermine FCTC implementation, ‘particularly through the Foundation’s contentious research programmes’,7 and warned parties to the FCTC against collaborating with it.11 World Conference on Tobacco or Health 2018 organisers prohibited Foundation-affiliated individuals from attending, consistent with long-standing policy barring tobacco industry-funded attendees, and the officially adopted conference declarations stated: ‘We urge governments, scientists, research entities, foundations, and civil society organizations to reject or cease engagement with the Philip Morris International-funded Foundation for a Smokefree World and other initiatives of the tobacco industry.’8 12

    Yach has strongly contested these criticisms. In September 2017, he replied to the FCTC Secretariat that the Foundation, ‘through its governing documents, has fully insulated itself from the influence of the tobacco industry.’13 In January 2018, in an open letter on the Foundation’s independence and governance, Yach further argued that FSFW’s board of directors is ‘subject to a stringent conflict of interest policy’ and that ‘no Board member can have ties to tobacco companies’.14 On its website, FSFW claims that ‘…the grant terms, Bylaws, and non-profit status of the Foundation preclude PMI or other tobacco industry representatives from involvement in Foundation governance, or from having any influence over the Foundation’s funding decisions, strategy, or activities.’15 The Foundation asserts it has ‘an independent research agenda, independent governance, ownership of its data, freedom to publish, and protection against conflicts of interest’.2

    We explored these claims through an analysis of the text of the Foundation’s governing documents (certificate of incorporation, bylaws, pledge agreement) and other Foundation materials available on the website as of 24 July 2018. We discuss FSFW’s establishment within the broader context of accepted standards for non-governmental organisation (NGO) transparency and independence,16 17 the FCTC, the history of tobacco industry-funded research and the core tenets of the global tobacco control movement.

    FSFW’s certificate of incorporation and bylaws

    The Foundation’s establishment and activities

    According to its certificate of incorporation, FSFW is a non-profit organisation created ‘exclusively for charitable, scientific and educational purposes’. This includes, ‘without limitation, to support independent scientific research free from the influence of any commercial entity that may be affected by the research outcome’.18

    The Foundation has seven purposes:

    1. Make grants ‘to support research and projects regarding alternatives to cigarettes and other combustible tobacco products and how to best achieve a smoke-free world and advance the field of tobacco harm reduction’.

    2. Fund research and publish reports on ‘among other things, the attitudes and opinions of the general public towards tobacco harm reduction’.

    3. Fund scientific verification studies on ‘the impact of smoke-free and reduced risk products on public health outcomes’.

    4. Inform the general public on ‘the activities of the tobacco industry, other commercial entities and other stakeholders’ in tobacco harm reduction.

    5. Research ‘the effect of the reduced demand for leaf tobacco on farmers’, and ‘explore and promote sustainable agricultural and nutritional alternatives for tobacco farmers’.

    6. Research ‘the management of smoke-free and reduced risk products-related waste materials’.

    7. Hold ‘global conferences, forums, panels and similar programs’ on tobacco harm reduction and ‘how to best realize a smoke-free world’.18

    In meeting its purposes, FSFW is ‘authorized and empowered to pay reasonable compensation for services rendered’.18 However, while the website now indicates that board members will be paid $50 000 annually, with more for the chair,19 information about President and staff salaries and the terms of any specific hiring or prehire agreements is missing. No information about incentives or gifts is posted.

    FSFW cannot ‘participate in or intervene in… any political campaign’,18 but it is unclear whether ‘participation’ or ‘intervention’ could include providing support for charities or social activities favoured by policy-makers or candidates,20 thereby gaining valuable access to policy-makers. Further, much tobacco control policy results from agency regulations, not legislation (bills passed), so FSFW could potentially use its funding to influence the tobacco regulatory agenda. This could replicate now-discredited models of the past: tobacco companies previously attempted to influence second-hand smoke regulations by generating research suggesting that second-hand smoke was not harmful, and submitting commentary to discredit independent research suggesting that it was.21

    The Foundation’s personnel

    The certificate of incorporation grants the board of directors ‘all powers conferred by law to manage the [Foundation] and its activities’.18 According to the bylaws, directors ‘manage and control all of [the Foundation’s] property and assets’22 and ‘oversee all aspects of the process for screening, reviewing and awarding grants and other distributions’.22 Directors will be elected by other directors22 who may also remove them from office ‘with or without cause’.22 Directors may appoint advisor directors who ‘shall serve at the pleasure of the directors and may be removed with or without cause at any time’.22 The president (Yach) will direct, manage and control the Foundation, ‘subject to the overall guidance and supervision of the Board’.22

    As of July 2018, according to the website, the Foundation had six board members, two of whom previously worked for PepsiCo, where Yach was formerly employed. Only one appears to have previous tobacco expertise; namely advocacy for crop diversification in Africa. The two members with medical/health expertise, Dr Marian Jacobs, who was elected to the board in January 2018, and Dr Michael Sagner, who according to minutes attended meetings from November 2017 to May 2018,23–25 are no longer listed on the website. Board minutes from March 2018 state that Dr Jacobs resigned ‘following pressure and personal attacks from critics of the Foundation’.26 Recruitment of more well-known tobacco control leaders for board positions may have been difficult due to the highly negative response from the global tobacco control community to the Foundation’s tobacco industry funding. However, given the board’s direct oversight of ‘all aspects’ of the grants process, this lack of expertise is concerning and suggests the board may over-rely on Yach’s expertise and opinion.

    While the bylaws are inexplicit about how the board should be initially formed, the frequently asked questions (FAQ) section on the website now indicates that Yach ‘in an independent manner’ selected the initial board members and states that subsequent members will be board-approved.27 It is unclear what ‘an independent manner’ means in this context. As the individual who coordinated privately with PMI the planning of the Foundation, which will provide him, as its self-announced president, with income and generous travel funds, Yach is in an extraordinarily powerful position to influence all Foundation activities and thereby has a clear economic incentive against naming to the board members likely to hold diverging interpretations of what constitutes a tobacco harm reduction agenda. This is at the least a situation that creates a perception of non-independence and potential conflict of interest.

    The bylaws indicate that the FSFW will have Audit and Science Oversight Committees. These committees, notably, are not independent of the board: committee members will be appointed by the board, and where committees have no director-members, they will have no authority over Foundation management.22 The Audit Committee is responsible primarily for accounting and financial reporting,22 while the Science Oversight Committee has vaguely worded ‘responsibilities and duties as may be prescribed by the Board of Directors from time to time’.22

    It is unclear from the bylaws whether the Science Oversight Committee will make decisions about research funding. Although this committee will be composed of ‘independent and experienced researchers, scientists and policy experts’, it will also include one or more directors and ‘shall be chaired by a member of the Board of Directors’.22 The Board also may remove any committee members, ‘at any time, with or without cause’.22 (As of this writing, there was no listing on the website of Science Oversight Committee members, although minutes of a December 2017 board meeting24 note that a two-member ‘Public Health Grant Committee’, consisting of Yach and (the now-departed) Sagner, had been constituted.)

    Conflicts of interest

    Yach claims that board members cannot have tobacco industry ties,14 but we were unable to find any formal documentation of this rule in the governing documents. While as discussed below, the bylaws do include a conflict of interest policy, it focuses on financial ties and not on other types of ties that might exist (for example, friendships or scientific collaborations, shared participation in other organisations); further, conflicts may be waived by majority board vote. If the majority of directors should have a conflict of interest, but agree not to interpret it as such, there is little to stop them from silencing or removing anyone on the board or committees who disagrees with their views. This setup is similar to the Center for Indoor Air Research (CIAR) and the early Council for Tobacco Research (CTR), two former tobacco industry-funded research bodies that produced research serving industry interests through both what they did and did not fund.28 29 Further, the board can accept any ‘contribution, gift, bequest or devise for the general purposes or for any special purpose’ of the Foundation.22 Previously, CTR and CIAR funded peer-reviewed projects and ‘special projects’ which were not reviewed by the scientific board but by tobacco industry lawyers. These were used to enhance industry credibility, provide good publicity and, in the case of CIAR, divert attention away from the harms of second-hand smoke.28 29 While the ‘Board Governance Policy’ document19 says the board is ‘subject to a strict conflict of interest policy’, there is no link to such a policy as a separate document.

    The conflict of interest policy in the bylaws notes that the policy intends ‘to protect the Corporation’s interest when it is contemplating entering into a transaction or arrangement that might benefit the private interest of a Director, officer, member of a committee with Board-delegated powers, a staff member…or any of their first-degree relatives’.22 ‘Financial interest’ is defined as an existing or potential ownership, investment or compensation arrangement in any entity with which the Foundation has a transaction or agreement, or ‘an ownership or investment interest in a tobacco and/or nicotine-containing products company or in any commercial entity involved in the tobacco reduction or cessation field or that otherwise may be affected by the scientific research conducted or funded by the [Foundation]’.22 ‘Compensation’ includes direct or indirect funding, gifts or favours ‘that are substantial in nature’.22 The bylaws do not articulate what constitutes ‘substantial’ or ‘affected by the scientific research’, creating potential loopholes. More concerning, such financial interests are not strictly considered a bar: they can be waived by the board or ‘appropriate committee’.22

    Where a financial interest exists, the person must disclose this to the board or [relevant] committee members.22 Then, ‘if a more advantageous transaction or arrangement is not reasonably attainable under circumstances that would not give rise to a conflict of interest’,22 ‘disinterested’ directors will vote on whether ‘the transaction or arrangement is in the [Foundation’s] best interest, for its own benefit and whether the transaction is fair and reasonable’.22 The bylaws do not define the precise meaning of these terms and do not require independent review of the conflict, making it easy to waive the conflict and likely uncomfortable for fellow board members to not do so.

    Where a conflict is suspected but not declared, the board or relevant committee will ‘afford the person an opportunity to explain the alleged failure to disclose’.22 If the person has a conflict and still fails to disclose, and this is discovered, the board will ‘take whatever disciplinary action, corrective action, or both, it deems appropriate’.22 If the board decides no action is necessary, the person with the conflict of interest can still potentially continue his/her FSFW work. There is no description of how conflicts of interest deemed acceptable should be identified and managed; for example, whether they would be publicly disclosed or if conflicted members would be prohibited from participating in decisions, beyond the decision about the conflict itself. Minutes of meetings with the board and committees with board-delegated powers will contain names of people with a conflict of interest, the nature of the interest, ‘any action taken to determine whether a conflict of interest was present, and the Board’s or committee’s decision as to whether a conflict of interest in fact existed, and whether to waive it’.22 It is not clear, however, whether all minutes of these meetings will be made publicly available. To date, there is no discussion of such conflicts posted.

    The bylaws provide that Foundation directors, officers, members of a committee with board-delegated powers and staff will sign annual statements affirming compliance with the conflict of interest policy and disclose any conflicts of interest. This includes disclosure of ownership or investment interests in tobacco or tobacco harm-reduction companies, as well as ‘salary or wages, remuneration, consulting fees, honoraria, expert testimony fees or speaking engagement fees’ received from tobacco or e-cigarette companies.22 Although disclosure of financial ties of all committee members, grant reviewers and grantees could enhance transparency, disclosure does not eliminate bias, particularly if the financial ties are not publicly disclosed, nor reviewed by an independent committee,30 and when directors may simply waive conflicts.31 Nor does disclosure fully explain the role of conflicted individuals in the research process.32 As of July 2018, the website included no disclosure statements.

    Scientific integrity

    The bylaws state that the board, or a board-designated committee, will ‘oversee all aspects of the process for screening, reviewing and awarding grants and other distributions’22 and that this process will ‘be conducted in a transparent manner and include explicit and clear guidelines for grant applications’22 based on ‘explicit, well established scientific criteria’.22 The bylaws also state that the Foundation will ‘identify the feasibility of incorporating additional independence and transparency elements, or other best practices, into the process for screening, reviewing and awarding grants’.22 The grant policies and procedures posted on the Foundation website33 include general language regarding scientific standards and research ethics, but as of July 2018, we could find no mention of the specific established scientific criteria that will be used to evaluate proposals. Notably, the tobacco industry has been involved in changing standards for scientific review in its favour.34–36 If the Foundation found it ‘infeasible’ to incorporate more specific and binding independence and transparency elements, the bylaws do not require them.

    The bylaws have been modified once for undisclosed reasons. Where before 19 September 2017 the bylaws stated: ‘no resources shall be devoted to the potential impact of that research on the image of the tobacco industry’, they now state that the Foundation will ‘not take into account’ such impacts.22 This appears to potentially contradict the Foundation’s purposes 2 and 4: to publish reports on attitudes and opinions towards harm reduction, and to ‘inform’ the public on tobacco industry activities.

    Pledge agreement

    In January 2018, the Foundation released a ‘pledge agreement’ for its $1 billion funding arrangement with PMI,37 38 although it could be surmised that some other agreement must presumably have been secured before the public announcement of the Foundation in September 2017. If such a prior agreement existed, it is not posted. Yach claims that the pledge agreement ‘provides that PMI’s contributions cannot be used or portrayed as a commercial endorsement of any of its products',14 although the pledge agreement also states that PMI’s funding is contingent on the Foundation working towards its stated purposes37 38 which, as discussed above, include promotion of tobacco harm-reduction activities (a recognised form of industry CSR).18 Another commentator39 has drawn attention to the fact that the pledge agreement contains several significant provisions aimed at ensuring that the Foundation does not deviate from the purposes PMI agreed to support, and that vague language about ‘freedom and independence’ cannot trump specific legal language about the contingent nature of the PMI-provided funding.

    The FAQs section

    An FAQs section is now featured on the Foundation website ‘to provide clarity for all interested parties on the most commonly asked questions’.27 One of these relates to the Foundation’s independence from PMI, and the answer assures readers that the board, management and staff have no ‘representation or ties to PMI or the tobacco industry’.27 However, as noted above, we could find nothing in the governing documents nor in the board governance policy that explicitly precludes such ties, provided they are disclosed.

    Assessing FSFW policies and practices against standards of transparency and independence

    Transparency, accountability and integrity are guiding principles for NGOs, according to the World Association of Non-Governmental Organizations.40 Examples of standards for evaluating NGO adherence to established principles, and how FSFW policies and practices compare to these standards, are listed in table 1.

    View this table:
    Table 1

    Standards for NGO transparency and independence versus FSFW practices

    Discussion

    Our analysis does not support Yach’s claims that the Foundation’s governing documents ensure complete independence, transparency and protection from tobacco industry influence.2 13 41 The documents’ provisions, particularly those related to conflicts of interest and scientific integrity, are inexplicit, contradictory and contain loopholes. For example, conflicts of interest may be waived; despite language about conflicts, there is no explicit rule barring staff or board members from having tobacco industry ties.

    Second, even if the documents were revised to include better protections from industry influence, the entire organisation was apparently developed privately by Yach and PMI, with no outside oversight. Given that Yach himself gains financial benefits, appointed the initial board members and clearly depends on maintaining positive relations with PMI in order to sustain the funding, the organisation in its current configuration cannot be judged independent by any reasonable standard.

    In terms of transparency, documentation that, as of July 2018, remained absent from the Foundation’s website includes its code of conduct, committee charters, whistleblower procedures, executive compensation, financial statements and other recommended elements.42 Given the Foundation’s emphasis on transparency,2 and since FSFW is exclusively funded by a tobacco company with a long history of using its research to undermine public health, transparency would be expected to go far beyond the norm.

    The Foundation should release and call on PMI to release all notes, memos, emails, correspondence and payment information between Yach and PMI regarding planning for and setting up the Foundation, complete details of its $1 billion contractual agreement, copies of all agreements or contracts signed by Yach with PMI, all correspondence between Yach and other parties related to the Foundation, PMI’s internal business case for investing $1 billion and information on how FSFW’s purposes were determined. The Foundation should also release additional information on its board, including their disclosure statements, since they will have near-complete control over Foundation activities. This information should clarify how the Foundation will ensure that this board is free from tobacco industry influence, given that it will be made up solely of individuals who are by definition agreeable to accepting tobacco industry funding.

    The Foundation’s underlying assumption that the urgency for a particular version of tobacco harm reduction justifies partnering with the tobacco industry to achieve a ‘smoke free world’ through tobacco harm reduction raises other concerns within the broader context of industry activities. PMI has a clear business motive for promoting use of its products, including both cigarettes and ostensibly ‘reduced harm’ products, whether or not advantageous to public health. While it is quite possible that other products can be made that are less harmful, PMI has made no concessions to stop promoting combustible cigarettes, and continues its activities opposing FCTC policy implementation.43 Tobacco companies have long discussed strategically employing tobacco harm reduction to try to establish themselves as partners in public health efforts, improve their damaged corporate image and as a wedge issue to divide the public health community.44 45 Clearly, the Foundation’s very establishment was not independent of the tobacco industry. The FSFW’s activities are entirely compatible with and may enhance current tobacco industry public relations messaging.

    This, in turn, highlights the fundamental and perhaps intractable problem with the Foundation: its funding arrangement. Regardless of what additional information is released, Yach’s decision to negotiate privately with PMI to determine its purposes and establish FSFW contravened a long-established tenet in tobacco control against accepting tobacco industry funding. Thus, anyone affiliated with the Foundation will already have a bias favouring the tobacco industry’s claim that it is legitimately ‘part of the solution’, even though PMI continues to oppose FCTC tobacco control measures.4 (Eg, in a 2014 internal presentation, PMI described the FCTC as a ‘regulatory runaway train’43 and as recently as 2016, PMI was executing an elaborate strategy to undermine FCTC discussions at the 7th Conference of the Parties to the FCTC in India.)43

    Implementation guidelines for Article 5.3 of the FCTC state that ‘there is a fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests’.46 Yach and the Foundation appear to take the position that this is no longer true. Yet, tobacco industry interference is the primary reason why the FCTC’s evidence-based tobacco control measures remain poorly implemented in many places.47 Despite the FAQ’s claim that the Foundation ‘unequivocally’ supports the FCTC, Foundation personnel have made numerous statements minimising its impact. Yach and vice president of strategic partnerships, Elizabeth Thompson (who is no longer listed on the website), have claimed that FCTC implementation has ‘stalled’,48 requiring a ‘fresh’ approach—namely, an industry-compatible version of tobacco harm reduction.41 48 Yach also claimed, in justifying the need for the Foundation, that ‘most development agencies, international research bodies, and regional development banks are stepping back from commitments made during the FCTC negotiations’.41 (In fact, this statement was refuted by the author of the paper Yach cited to support it; the statement has since been eliminated in a correction.)49 50 The Foundation’s objectives are also far from being ‘squarely in line with the FCTC and Article 5.3’, as Yach claims.41 The FCTC secretariat has characterised the Foundation as unwelcome: a ‘clear attempt to breach the WHO FCTC by interfering in public policy’.7

    Yach has also claimed that FSFW is independent because it meets what the Foundation website characterises as ‘the Cohen criteria’ for funding research with tobacco industry money.41 51 Some harm-reduction advocates compare FSFW’s arrangement to that of tax-funded tobacco control programmes. This is a false equivalence that blurs distinctions between legally mandated funding over which the tobacco companies have no control and voluntary funding prearranged with a selected individual for a purpose compatible with industry objectives. The situation would be equivalent only if FSFW had been legally created with tobacco tax dollars provided through a government agency, or with funds from a legally mandated settlement or levy on tobacco company profits directed to an existing agency or non-profit that then openly advertised for and hired personnel. In fact, authors of the paper Yach cites to justify his arrangement have explicitly stated that the FSFW does not meet their criteria.52

    For Yach and PMI, the Foundation is clearly a positive development. It allows Yach a salary and a global leadership platform from which to pursue his vision of tobacco harm reduction. It allows PMI a charitable tax deduction on an outsourced version of its already-existing CSR activities: promoting its commercial product-oriented version of harm reduction, working with tobacco farmers and related front groups, and environmental initiatives.53 It offers the opportunity to externally fund research on its own new products (perhaps even using its own data) and potentially build links with external scientists after a long period of being regarded as a pariah due to its prior scientific deceptions. It exploits divisions within the public health community, helps to create confusion about leadership and furthers a narrow understanding of tobacco harm reduction that favours neoliberal market solutions, rather than policy solutions aimed at getting the most deadly tobacco products further restricted or phased out altogether.54

    Conclusions

    Despite any possible good intentions on the part of Yach and others involved in the Foundation, it cannot be regarded as independent. Absent true independence achieved through structurally separating the funding, priorities and management of the Foundation from the existing prearrangement that clearly benefits Yach and PMI, the FSFW may function operationally to advance and amplify tobacco industry messaging and potentially exacerbate conflicts within public health.

    What this paper adds

    • The Foundation for a Smoke-Free World (Foundation or FSFW), supported exclusively by a $1 billion pledge from Philip Morris International (PMI), claims that its governing documents (certificate of incorporation, bylaws and pledge agreement) ensure that the Foundation is fully independent of tobacco industry influence. We analysed these documents and other website information to appraise this claim, considering standards for independence, the industry’s history of deception and global leadership in tobacco control.

    • The Foundation’s governing documents contain loopholes and lack details, consistency and critical protections from conflicts of interest. Some claims made on the website and in publications, including the notion that board members can have no tobacco industry ties, are not clearly addressed in the governing documents. Beyond the formal documents, the Foundation’s establishment, funding arrangements and mandated purposes demonstrate a lack of independence that the Foundation’s reported actions and the documentary record do not and cannot fully resolve.

    • The Foundation fails to meet standards for independence and cannot be characterised as equivalent to tax-funded tobacco control organisations. Absent true independence achieved through structurally separating the funding, priorities and management of the Foundation from the existing prearrangement that clearly benefits the Foundation president and PMI, the FSFW may function operationally to advance and amplify industry messaging and potentially exacerbate conflicts within public health.

    Acknowledgments

    We would like to thank Jonathan Liberman and Stella Bialous for their helpful feedback and Patricia McDaniel for assistance with formatting references.

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    Footnotes

    • Contributors REM originated the idea for the paper. REM and YvdE conceptualised the paper. All authors analysed the data,wrote the paper, reviewed drafts and approved the final draft for submission.

    • Funding REM’s Mary Harms/Nursing Alumni Endowed Chair funding was used to support YvdK’s work.

    • Competing interests None declared.

    • Patient consent Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement All data used in this analysis—the Foundation for a Smoke-Free World bylaws and certificate of incorporation—are available on the Foundation’s website.