“The Devil’s Playbook” is a great read

My definition of a good book on tobacco is that I learn things I didn’t already know from reading it. Lauren Etter’s new book, The Devil’s Playbook, easily meets and surpasses this standard. Deeply researched beginning with key events in the 1980s, she documents the rise and decline on Juul e-cigarettes and how, at least so far, it took Altria (Philip Morris) down with it.

In addition to using the documentary record, she conducted over one hundred interviews with an amazing range of players (including me) on all sides of the story and puts the reader “in the room” to listen in on many key discussions. The result is amazing insights into what all the individual and institutional players were thinking as the story unfolded.

I know and have met most of these players (including some at Juul and a few at Philip Morris) and was generally aware of many aspects of the story. But the details and context that Etter provides broadened and deepened my understanding.

For example, while I knew, from earlier news stories, that Juul founders James Monsees and Adam Bowen had used the UCSF Truth Tobacco Documents Library to learn about nicotine manipulation and tobacco marketing as they developed Juul, I did not fully understand the depth of these efforts or their importance to the development of Juul. (I have always seen the documents as a way for public health to learn from the tobacco industry how to develop better public health programs; it never dawned on me that an upstart tobacco company could use them to develop more addictive tobacco products.)

I also learned that Monsees and Bowen approached Philip Morris years before the deal for Altria to buy a 35% share of Juul was consummated.

While I knew that Altria was forced to write down its investment in Juul, I did not appreciate what a financial disaster it was for Altria and its corporate leadership.

Etter also takes us inside FDA’s thinking about Juul, from its original enthusiasm to its growing recognition that it was a disaster for youth. She also takes us inside the CDC’s investigation of the mysterious lung disease, EVALI, and how it changed the public perception of e-cigarettes.

The list of insights goes on and on.

Having said that, I do have a few quibbles with the book.

Etter did not realize the key role that the tobacco companies had in lobbying the Institute of Medicine when it was preparing its report Clearing the Smoke, particularly the recommendations for a tiered claims system (with separate tiers for exposure and risk, which they believed would ease the process of qualifying for a claim) and license to sell products comparable to existing conventional cigarettes (“substantial equivalence”) without prior regulatory approval. These provisions ended up reflected in the FDA law, and have provided opportunities for Philip Morris to market its heated tobacco product IQOS with claims that most people interpret as reduced risk even though the FDA only allowed reduced exposure claims and specifically disallowed reduced risk claims. I remain very concerned that Juul will win FDA authorization for sales and similar claims.

She also took Philip Morris’ youth smoking prevention programs at face value as good faith efforts to prevent youth smoking when there is a large literature showing that such campaigns were designed to serve political needs and put off effective regulation and displace effective anti-tobacco education.

The appearance of conservative powerhouses and long-time industry allies like anti-tax advocate Grover Norquist also came after the big tobacco companies got into the e-cigarette business, as did Tea Party elements. Their longstanding ties to the big cigarette companies would have been worth mentioning.

But, all these small points in a masterful narrative.

Anyone engaged in the e-cigarette debate, including advocates, researchers and policymakers should read this book to develop a deep understanding for the context of the ongoing debate over these and other new products.

As she notes at the end, all that is keeping Juul alive is the possibility that the FDA will grant it a marketing order by concluding doing so would be “appropriate for the protection of public health.” That is why I said “at least so far, [Juul] took Altria (Philip Morris) down with it.” FDA could still rescue Juul and Altria.

This book adds to the overwhelming case that rescuing the company (and product class) would continue and deepen the ongoing public health disaster that e-cigarettes and other new tobacco products represent.

Published by Stanton Glantz

Stanton Glantz is a retired Professor of Medicine who served on the University of California San Francisco faculty for 45 years. He conducts research on tobacco and cannabis control and cardiovascular disease/

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