The Half-Truth Initiative: How an Anti-Smoking Group Lost Its Way

    The most famous anti-smoking campaign in history was branded, simply, as @truth. It was launched in 2000 by the American Legacy Foundation, a nonprofit organization funded with $1.5 billion from the proceeds of a class-action suit against Big Tobacco companies. Legacy and its advertising agency, Crispin Porter & Bogusky, produced hard-hitting TV commercials, including one called “Body Bag” in which young people piled bags of dead bodies outside the headquarters of Philip Morris, in a graphic reminder that smoking kills.

    The industry hated the campaign, and for good reason. One in five teenagers then smoked. Over time, the work of the Legacy Foundation, which has been renamed Truth Initiative, helped to drive teen smoking to historic lows, according to researchers who studied the @truth campaign.

    Last year, a mere 1.5 percent of middle school and high school students reported smoking in the past 30 days, according to the latest government survey.

    “This is an amazing success story,” Robin Mermelstein, a former president of the Society for Research on Nicotine and Tobacco (SRNT), the world’s leading professional society focused on nicotine and tobacco, told Filter. “There should be a lot of cheering for the steep and consistent decline in teen tobacco use.”

    In a rational world, Truth Initiative would celebrate this victory and continue its anti-smoking work. Instead, it redirected its fire at a new target: e-cigarettes. To the dismay of many public health experts, Truth Initiative has become an implacable opponent of vaping, exaggerating the dangers of e-cigarettes and downplaying evidence that vaping has displaced smoking among both teens and adults.

    “We’re not talking misinformation. We’re talking disinformation. This is willful misrepresentation of facts.

    “They have spun and ignored the science to cherry pick only information and data that supports the ideology of prohibition,” said David Abrams, a professor of public health at New York University, who previously directed the research arm of Truth Initiative, known as the Schroeder Institute.

    Sally Satel, a psychiatrist and a fellow at the American Enterprise Institute who writes about medicine and culture, accuses anti-vaping groups of “disseminating half-truths, non-sequiturs, and brazen falsehoods.” About Truth Initiative, she told Filter: “We’re not talking misinformation. We’re talking disinformation. This is willful misrepresentation of facts. It’s mind-blowing.”

    Just last month, Truth Initiative hailed the FDA’s decision to shut down e-cigarette maker Juul (which is currently on hold) as “a major public health victory.” Juul surely led young people to take up vaping but just as surely has helped adult smokers to quit combustible cigarettes, which are lethal.

    Truth is not alone in its opposition to vaping. Its allies include Bloomberg Philanthropies, the Campaign for Tobacco-Free Kids, Parents Against Vaping E-cigarettes, the American Heart Association, American Lung Association and American Cancer Society.

    Their anti-vaping campaigns have had tragic consequences. Millions of Americans believe, wrongly, that vaping is as dangerous or more dangerous than smoking. As a consequence, smokers are less likely to switch to vaping as a way to quit. Elected officials have banned flavored vapes—vastly preferred by adults who switched from cigarettes—in four states and more than 300 localities, including, most recently, Los Angeles. Under pressure from regulators, vape shops that served former smokers have closed, and federal law prohibits delivery of vaping products through the mail.

    Truth Initiative remains the largest anti-tobacco nonprofit in the US. It is essentially accountable to no one.

    Robin Koval, a former advertising agency executive who has been the CEO of Truth Initiative since 2013, says that the nonprofit’s turn against vaping has been driven by evidence.

    “The science is becoming clearer and clearer about the risks versus the potential benefits of e-cigarettes,” Koval said, when we spoke last year. Koval did not respond a request for an interview for this story. Neither did Mike Moore, the former Mississippi attorney general who now chairs the board of Truth Initiative.

    Truth Initiative remains the largest anti-tobacco nonprofit in the US, with net assets of $893 million and annual spending of $94  million, according to its most recent audited financial statement. It is essentially accountable to no one.


    A Rocky Start

    Like most startups, American Legacy Foundation got off to a rocky beginning. Money wasn’t the problem. Between 1998 and 2003, the nation’s four largest tobacco companies paid Legacy between $275 million and $290 million a year as part of the so-called Master Settlement Agreement (MSA) that resolved a civil suit brought against the industry by 52 state and territory attorneys general. American Legacy collected another $96 million from smokeless tobacco companies, as part of a second lawsuit. It raised more money on its own, and bought two expensive office buildings in downtown Washington—one for its own use, the other to generate rental income. So much money sloshed around American Legacy that an  “unauthorized diversion of assets” of about $3.4 million by a trusted employee went undetected for years.

    Commercials ran on MTV and during the Super Bowl.

    “Going from nothing to a $100 million budget in a matter of three years was a challenge,” Cheryl Healton, a public health expert who was chief executive of American Legacy from 1999 through 2013, told Filter.

    American Legacy built upon a version of the anti-smoking “truth” campaign developed by Crispin Bogusky in the late ’90s in Florida, which had settled its suit against the tobacco industry ahead of other states. The campaign was run like a business, according to Jeffrey Hicks, president of Crispin Bogusky.

    “Advertisements were produced with some of the hottest commercial directors in the industry, web sites were created using the newest types of animation, and research was conducted by companies that had perfected their craft while working on some of the largest teen targeted private sector brands in the country,” Hicks wrote in Tobacco Control. Commercials ran on MTV and during the Super Bowl.

    An evaluation of the Florida campaign published in the Journal of the American Medical Association in 2000 found that “a comprehensive, youth-led program, incorporating multiple approaches to youth tobacco use prevention and reduction, can be successful.” Surveys found that current cigarette use declined by 40 percent among middle school students and by 18 percent among high school students.

    The anti-smoking work of Truth Initiative has been one reason why teen smoking has declined sharply.

    The impressive results out of Florida gave Healton and her colleagues at American Legacy the confidence to roll out their new @truth campaign across the country. They developed edgy spots of their own. In a radio commercial, an actor playing a dog walker makes a phone call to Lorillard, a tobacco company that later merged into Reynolds American, offering to sell dog urine to the company. “Dog pee is full of urea,” he explains. “That’s one of the chemicals in cigarettes.”

    Lorillard sued, arguing that the ads violated a provision of the Master Settlement that prohibits vilification of the industry. “Once again you have chosen an approach of deception, vilification and untruth,” a company executive wrote in a letter to Healton. Lawsuits between the tobacco companies and American Legacy dragged on for years, costing both sides millions in legal fees, but in no case did a judge rule in favor of the industry.

    The anti-smoking work of Truth Initiative has been one reason why teen smoking has declined sharply. Truth Initiative says its work “has prevented millions of young people from becoming smokers, including 2.5 million between 2015 and 2018 alone.”


    A Total Makeover

    In 2012, Healton announced that she would leave American Legacy to become dean of a new school of public health at New York University. A committee led by Tom Miller, the Legacy board chair and longtime attorney general of Iowa, identified three possible successors—one with a background in public health, one with expertise in policy and a third, Koval, from the world of advertising. Koval was co-founder and CEO of the Kaplan Thaler Group, a billion-dollar agency that worked for such companies as Wendy’s and Aflac.

    Koval, a branding expert, changed the name of American Legacy to Truth Initiative. “Robin did a total makeover,” said a former Legacy board member, who asked not to be identified so as not to affect their career in tobacco control. “She changed the name. She changed the staffing. She changed the location. She changed everything.”

    The biggest single issue facing the board was the idea of harm reduction.

    The Truth Initiative board changed, too. While the job of board chair had  previously rotated among members, Mike Moore, the former attorney general of Mississippi, took over as chair from Tom Miller in 2017. He remains board chair today. A longtime tobacco warrior, Moore was the first attorney general to sue the cigarette companies for the costs of treating smoking-related illnesses.

    The biggest single issue facing the board was the idea of harm reduction, which, in the world of tobacco control, means encouraging smokers who would like to quit but who cannot do so to get nicotine via alternatives, like vapes, instead. Tom Miller was—and is—a supporter of harm reduction, as were the scientists inside Truth Initiative.

    “If we are able to switch adult smokers to e-cigarettes, we could save lives—perhaps millions—while still recognizing that e-cigarettes are not totally harmless,” Miller wrote in the American Journal of Public Health in June 2020.

    Mike Moore and Nancy Brown, the CEO of the American Heart Association, wanted Truth to take a hard line against e-cigarettes. They serve on the board of the Campaign for Tobacco-Free Kids as well on the Truth board. They are influenced by Matthew Meyers, the founder and president of the Campaign for Tobacco-Free Kids, who has supported efforts to ban vapes.

    For a time, Koval was open to harm reduction. In 2016, Truth Initiative convened a two-day conference called “Rethinking Nicotine” at a Ritz Carlton hotel in Georgetown. Respected scholars and activists discussed the role that e-cigarettes could play in curbing smoking.

    Soon after, though, Juul surged in popularity, setting off what was invariably described as a teen vaping epidemic. In 2018, tobacco giant Altria bought a 35 percent stake in Juul. In 2019, Truth Initiative declared: “JUUL is looking more and more like Big Tobacco.” Along with Mike Moore, Nancy Brown and Matt Myers, Koval came to believe that e-cigarettes were a menace. The battle lines had been drawn.

    “The advocates have taken over from the scientists.”

    Inside Truth Initiative, the culture shifted. Scientists who argued that vaping could become a pathway out of smoking were muzzled and edited, an insider told Filter. They were told that Truth Initiative had to speak with a single voice, opposing e-cigarettes.

    In short order, scientists who together had many decades of experience left the Schroeder Institute. David Abrams, Ray Niaura and Allison Glasser joined Healton at NYU’s public health school. Andrea Villanti left for the University of Vermont, and Jennifer Pearson went to the University of Nevada, Reno. Some had personal reasons to leave, but the upshot was that the Schroeder Institute, which had done independent research and commentary, was absorbed into a program evaluation unit and aligned with Truth’s ideological goals.

    One longtime tobacco-control expert who knows all the players at Truth summed up the changes by saying: “The advocates have taken over from the scientists.”


    A Moral Panic

    Midway through 2020, as the COVID-19 pandemic spread, Truth Initiative published an unsettling warning about e-cigarettes.

    There is “growing evidence vaping can harm lung health and puts users at greater risk of contracting COVID-19,” Truth said. “Those who have ever used e-cigarettes are 5X more likely to contract COVID-19 than those who do not use tobacco products, according to a recent study.”

    The study, published in the Journal of Adolescent Health, had an immediate impact. “Vaping Links to Covid Risk are Becoming Clear,” read a headline in the New York Times. USA Today quoted Dr. Bonnie Halpern-Felsher, an author of the study, as saying: “We need to tell everyone: If you are a vaper, you are putting yourself at risk for COVID-19 and other lung disease.” US Representative Raja Krishnamoorthi and nine US Senators asked the FDA to curb sales of e-cigarettes during the pandemic. Stanford instructor Shivani Gaiha, another study author, said: “This study tells us pretty clearly that youth who are using vapes or are dual-using [e-cigarettes and cigarettes] are at elevated risk, and it’s not just a small increase in risk; it’s a big one.”

    The study said no such thing. It was challenged by scholars who said it relied on implausible, self-reported data that defied common sense. (For example, the study found that past users of e-cigarettes had a higher COVID risk than current users, which is unlikely.) Respected tobacco-control experts, including Abrams, Niaura, K. Michael Cummings and David Sweanor, urged the journal editor to “retract this flawed and misleading paper.”

    This has become a pattern: Draw questionable conclusions from scientific research to attack vaping, and ignore evidence to the contrary.

    “The sensational claim that vaping increases COVID-19 risk for youth and young adults was based on the data which is seriously flawed,” they wrote. “Unreliable papers have no place in the scientific literature.”

    The paper was not retracted. But, in a response to critics, the authors conceded that “our study does not imply causality.”

    By then, the damage had been done. Truth Initiative’s claim about vaping and COVID—which strongly implies causation—remains on its website. It is one of many reasons why so many Americans believe that e-cigarettes are more dangerous than they are.

    This has become a pattern at Truth Initiative: Draw questionable conclusions from scientific research to attack vaping, and ignore evidence to the contrary.

    For example, Truth claims that vaping is a gateway to smoking. “Young people who had ever used e-cigarettes had seven times higher odds of becoming smokers one year later compared with those who had never vaped,” it says. But other studies find that “vaping likely diverts more young people from smoking than encourages them to smoke,” according to a paper by 15 past SRNT presidents. That paper also notes that “smoking among young people has declined at its fastest rate ever during vaping’s ascendancy,” making the gateway claim highly unlikely.

    Last fall, as concerns grew about depression and anxiety among young people during the COVID-19 pandemic, Truth Initiative declared that vaping was making matters worse. In an elaborate campaign featuring national TV ads, a Manhattan storefront and a Times Square billboard, Truth created a fake company called Depression Stick with its own Twitter account that sold vapes in flavors like Citrus Sadness and Disappoint-mint, and ran commercials asking “Why be happy when you can be sad?”

    “Vaping nicotine can amplify feelings of depression and anxiety,” one commercial said.

    Koval said: “It was time for the tobacco industry to be exposed as a major contributor to the mental health crisis to help end youth vaping.”

    Was vaping, in fact, making young people’s mental health worse, as Truth claimed? Scientists aren’t so sure.

    “I was happy to see the messaging,” says William Lechner, a psychology professor at Kent State University, whose research about depression was cited by Truth Initiative. Smoking or vaping may provide temporary relief but over time “it is unlikely to do anything to make your mental health symptoms better,” Lechner told Filter.

    “This is really dangerous. It is scare-mongering.”

    Maybe so, but the research on nicotine and mental illness is inconclusive. A systematic review of 148 studies reports “inconsistent findings” regarding whether smoking leads to depression and anxiety, or vice versa. A more recent review finds that e-cigarette use is associated with mental health issues but notes that “directionality remains uncertain.” In that light, Koval’s assertion that the tobacco industry is a “major contributor to the mental health crisis” is at best a stretch.

    Caitlin Notley, a professor of addiction studies at the University of East Anglia in the UK, noted that teen vaping fell during the pandemic, while mental health issues rose. That makes it unlikely that vaping contributes to depression or anxiety. She was troubled by Truth’s messaging.

    “This is really dangerous. It is scare-mongering,” Notley said at the 2021 E-Cigarette Summit. “It is scapegoating the behavior [of vaping] rather than dealing with the very real and deeply concerning issue of poor mental health.”


    An Opportunity Lost

    The namesake of the Schroeder Institute is Steven Schroeder, a former board chair of American Legacy, former president of the Robert Wood Johnson Foundation and a professor of health at the University of California, San Francisco.

    Truth Initiative funds programs in adult smoking cessation at a center overseen by Schroeder, so he won’t discuss its work on the record. “I don’t want to bite the hand that feeds us,” he told Filter. Speaking generally about e-cigarettes, he said: “Clearly vaping is not benign, but it is much less toxic than a combustible cigarette. It’s also one way to help smokers quit, and that’s the goal.”

    Lately, Truth Initiative has embraced a broader mission. It strives to “achieve a culture where young people reject smoking, vaping, and nicotine.”

    The question is, why nicotine? Unlike, say, alcohol, nicotine does not by itself cause death or disease; it is the addictive chemical that keeps people smoking, but smokers who die or get sick do so because they absorb the tiny particles, chemicals and gases in smoke. The government recommends that smokers who want to quit combustible cigarettes try nicotine replacement therapies, like gums and patches.

    Back in 2016, Raymond Niaura explored the science of nicotine in a Schroeder Institute paper titled “Re-thinking nicotine and its effects.” The paper found that nicotine, while not completely benign, poses substantially lower risks than smoking. It went on to argue that smokers who are unable or unwilling to quit should be encouraged to use less harmful products containing nicotine, ideally FDA-authorized.

    “Tobacco control’s overarching goal is to save lives as rapidly and effectively as possible,” Niaura wrote. “This will require open minds to rethink the harms of nicotine when it is decoupled from combustible tobacco.”

    “Truth Initiative sold its soul to the ideologies of prohibition.”

    Not long after, it would appear, the rethinking stopped at Truth Initiative. For reasons that aren’t entirely clear—the prospect of Bloomberg money, the influence of Matt Myers, the temptation to respond to middle- and upper-class parents worried about teen vaping—Truth took a hard line against e-cigarettes from which it has never wavered.

    David Abrams, who led the Schroeder Institute for nearly a decade and coined the phrase “half-truth initiative,” says that has been tragic. Had Truth responded to the rise of vaping by urging young people to avoid e-cigarettes while embracing harm reduction for adult smokers, countless lives could have been saved.

    “Truth Initiative sold its soul to the ideologies of prohibition,” Abrams told Filter. “They have missed the opportunity of a century to destroy lethal, combustible cigarettes.”



    Correction, July 28: This article has been edited to more accurately reflect Schroeder’s relationship with Truth Initiative funding.

    Photograph by Jeremy Brooks via Flickr/Creative Commons 2.0

    The Influence Foundation, which operates Filter, has received grants from Altria, Juul Labs, Philip Morris International and Reynolds American. Filter‘s Editorial Independence Policy applies.

    • Marc is a veteran reporter who writes about tobacco control. He has contributed to the New York Times, the Washington Post, the Guardian, Mother Jones and Fortune magazine, where he was a senior writer for 15 years. He lives in Maryland.

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