TOBACCO, LAWYERS, AND PUBLIC HEALTH |
Derek Yach is with the World Health Organization, Geneva, Switzerland. Stella Aguinaga Bialous is a public health policy consultant in San Francisco, Calif.
Correspondence: Requests for reprints should be sent to Derek Yach, MBChB, MPH, Executive Director, Noncommunicable Diseases and Mental Health, World Health Organization, 1211 Geneva 27, Switzerland (e-mail: yachd@who.int).
ABSTRACT
Despite the tobacco industry's claims that it has changed itspractices, the toll of tobacco-related disease and death continuesto grow worldwide, and the industry continues to use a vastarray of strategies to promote its products and increase profits.This commentary discusses the ways the tobacco industry hascreated controversy about risk assessment and about the scientificevidence of the health hazards of secondhand smoke.
The authors recommend that policymakers be more vigilant andthat they demand transparency about affiliations and linkagesbetween allegedly independent scientists and tobacco companies.They also urge policymakers to be prepared for new and continuingchallenges posed by the tobacco industry, because, despite theindustry's claims, there is little evidence of fundamental changein its objectives.
TOBACCO COMPANIES CLAIM that they have changed. They assertthat their efforts to undermine global tobacco control policyare a product of a past era and that now they seek to engagein constructive dialogue with the World Health Organization(WHO) and national governments.1 Unfortunately, the realityis that the consequences of their actions continue. Four milliondeaths per year, 1.2 billion smokers in the world today, andhigh rates of youth smoking are in part the result of the failureof governments to implement tobacco control policies that areknown to work. And governments' inaction is largely a resultof decades of tobacco companies' untoward influence.
Among the lingering effects of tobacco companies' actions arethe insidious ways in which the public health policy agendaand the media debate about tobacco have been influenced. Inthis issue of the Journal, Ong and Glantz highlight one aspectof industry influence with respect to epidemiologic standardsof causality.2 The authors show that tobacco companies carefullyplanned to undermine accepted epidemiologic practices and hopedthat by partnering with a broad range of academic and privatecommercial interests, they could create confusion about therole of epidemiology and risk assessment in public policy development.The ultimate goal of the industry was to promote the trivializationof the risk of tobacco use, stating that nearly everything fromeating Twinkies to crossing the street was harmful, and thattobacco was just one more "risky pleasure."
Ong and Glantz's work needs to be considered within the broaderconcerted efforts of the tobacco companies to influence publicpolicy in a manner detrimental to public health. The releaseof tobacco industry documents following US litigation providesus with access to a snapshot of the truth. These documents showa nearly 50-year effort to improve public relations, ratherthan public health.
One example, from 1977, is Operation Berkshire,3 which showshow 7 of the world's largest tobacco companies colluded to promotedoubt about tobacco and health. These companies created theInternational Committee on Smoking Issues (later the InternationalTobacco Information Center) to internationally coordinate anetwork of national manufacturers' associations to block tobaccocontrol measures. In another example, Philip Morris conveneda meeting of its top executives in 1988 in Boca Raton, Fla,to develop an action plan aimed at attacking WHO's tobacco controlprograms at the national level and targeting the structure,management, and resources of the WHO.4
These documents show the lengths the tobacco industry went toin its attempt to thwart the International Agency for Researchon Cancer's epidemiologic research on secondhand smoke and lungcancer in Europe.5 They show how linkages were created betweentobacco companies and the chemical, food, pesticide, and utilityindustries, as well as how the tobacco industry developed its"scientific" strategy.
The industry documents, described in The Cigarette Papers6 andmost recently summarized in A Question of Intent: A Great AmericanBattle With a Deadly Industry,7 tell about the scope and depthof the tobacco companies' ability to recruit scientists fromthe ranks of the most prestigious academic institutions. Tobaccocompanies sought to create doubt where scientific consensusexisted. To do so, they enlisted scientists in their cause.This way, the industry voice would be heard but the industrywould not be directly involved, as tobacco industry fundingoften remained undisclosed in publications and participationin public forums.
The consultants, grantees, and speakers who were willing towork for the industry came from some of the best academic centersin the United States and abroad. For example, the US TobaccoInstitute had a team of academics and scientists, "faculty membersof prestigious universities and medical schools," to assistin responding to the US Environmental Protection Agency's riskassessment methodologies, among other things.8 Although theUS Tobacco Institute was forced to close as a condition of the1998 Master Settlement Agreement,9 equivalent agencies stilloperate in major tobacco markets around the world, where thedegree of intimacy between certain scientists and tobacco companiesis not widely known.
As discussed by Ong and Glantz, the use of front groups andconsultants is a wellestablished tobacco industry practice toavoid dealing with its lack of public credibility. Scientistswere constantly at hand to assist in maintaining the industry-createdcontroversy on the tobacco and health issue.
BUYING SCIENTISTS
The tobacco industry continues to fund, directly or indirectly,prestigious academic centers and scientists in its effort toachieve scientific credibility.10 Among the notable academicsenlisted by the industry are professors such as A. R. Feinsteinof Yale University, editor of the Journal of Clinical Epidemiology,who on many occasions has presented the argument that the epidemiologicmethods used to assess the risk of passive smoking are inadequate.In a 1992 article, Feinstein supported the tobacco industry'sright to defend itself against the label of "bad guy" and criticizedthe "current atmosphere [in which a tobacco industry] consultant'sstature, credibility, and integrity become instantly impugnedand tarnished by the depravity of associating with the tobacco‘bad guy.'"11 He did not mention, however, that he wasa tobacco industry consultant and the recipient of highly secret"special project" awards.6,12–14
One prestigious US institution that has received funds fromPhilip Morris and its subsidiaries is the Harvard Center forRisk Analysis, whose former director, John Graham, has assistedPhilip Morris with risk communication about environmental tobaccosmoke and has on many occasions requested funds for the center.15–18Among several other sources of corporate support, the centercurrently has an unrestricted grant from the Philip Morris subsidiaryKraft Foods and a restricted grant from the Risk Science Instituteof the International Life Sciences Institute (ILSI).19 In March2001 President Bush nominated John Graham to be administratorof the Office of Information and Regulatory Affairs of the Officeof Management and Budget.20 This office reviews and approves—orblocks—all major federal regulations. The consumer advocacygroup Public Citizen criticized the nomination on the basisof the links between Graham and corporate funding.21,22
The above cases exemplify the tobacco industry's reach intothe scientific community and have to be considered within abroader discussion about the influence of private corporatefunding on academic research and policies addressing fundingdisclosure. The debate over conflict of interest between academiaand private commercial interests is gaining visibility. In arecent article in the Journal of the American Medical Association,the dean of the Harvard medical school stated that more safeguardsagainst conflict of interest are necessary.23 Nils Hasselmo,president of the Association of American Universities, was quotedas saying that "it's the responsibility of the university toserve the public good. The public relies on universities forthe greatest degree of objectivity, rather than for informationthat may be slanted by financial interests."24
How this debate will influence future tobacco industry fundingof academia remains to be seen. Even more important is how academiais going to respond to offers from the tobacco industry. Thedebate is not yet over. The March 2001 newsletter of California'sTobacco-Related Diseases Research Program was entirely dedicatedto the discussion of the implications of tobacco industry fundingof science.25 Recently, despite much criticism and the resignationof faculty members, Nottingham University in England accepted£3.8 million from British American Tobacco to create anInternational Centre for Corporate Social Responsibility.26–30
DISTORTING RISK
There are many groups and consultants who were funded by theindustry, both directly and through subsidiary companies, andwho provided the tobacco industry with ample material, in theform of testimony, reports, and other publications, to fighttobacco policy and regulations. For example, ILSI and its RiskScience Institute—a nonprofit worldwide scientific researchfoundation focusing on the areas of nutrition, food safety,toxicology, risk assessment, and the environment31—gavethe tobacco industry an opportunity to blend secondhand smokingrisks with other low-dose risks and continue to create doubtand controversy about the harms of secondhand smoke.32 ILSIis a particularly relevant example, given that it has a formalrelationship with WHO and IARC and thus offered the tobaccoindustry the potential for additional access to these institutions.33,34(Note: Since the writing of this commentary, ILSI executiveshave agreed to review all aspects of their affiliations withcommercial interests.)
In addition to creating front groups and contributing fundsto groups that have a mission broad enough to carry some ofthe tobacco industry's goals, the tobacco companies also usepublications by allegedly independent think tanks, such as theVirginia-based Alexis de Tocqueville Institution. This group's1994 report "Science, Economics, and Environmental Policy: ACritical Examination"35 criticizes the US Environmental ProtectionAgency's risk assessment methods in 4 areas: environmental tobaccosmoke, radon, pesticides, and hazardous cleanup. It dismissesin its first chapter the agency's risk assessment of environmentaltobacco smoke, using arguments similar to the tobacco industry's"junk science" arguments described by Ong and Glantz.
This report has been widely used by the tobacco industry inits quest to dismiss the hazards of environmental tobacco smoke.And although no direct financial link has been established,several members of the report's academic advisory board havebeen involved with different tobacco companies' activities.36The report's principal reviewer, Dr Fred Singer, was involvedwith the International Center for a Scientific Ecology, a groupthat was considered important in Philip Morris' plans to createa group in Europe similar to The Advancement for Sound ScienceCoalition (TASSC), as discussed by Ong and Glantz.37,38 He wasalso on a tobacco industry list of people who could write op-edpieces on "junk science," defending the industry's views.39
The junk science saga continues. In February 2001, on the Website JunkScience.com, Martha Perske provided a critique of studieslinking passive smoking and lung cancer.40 In the article, shegrossly misstates the WHO's work in this field. Perske has noformal scientific training and her one publication in the peer-reviewedliterature is a letter to the editor—which appeared, incidentally,in the journal edited by Alvan Feinstein.41 She describes herselfas a "smokers' advocate," but industry documents show that shestayed in close contact with Philip Morris, asking for theirreview of and comments on her activities.42
The goal of the tobacco industry's "scientific strategy" wasnot to reveal the truth but to protect the industry from lossof revenue and to prevent governments from establishing effectivetobacco control measures. The industry's goals of creating doubtand controversy and placing the burden of proof on the publichealth community in policy forums have, therefore, met witha certain degree of success. Tobacco control policies are notbeing implemented worldwide at the rate that current scientificknowledge about the dangers of tobacco warrants. But this scenariois changing as the negotiations for the Framework Conventionon Tobacco Control continue to advance. The Framework Conventionon Tobacco Control marks the first time the WHO has used itstreaty-making right to support member states in developing alegally binding instrument in the service of public health.Negotiations are progressing well, and it is likely that memberstates will vote on ratification of the convention in mid-2003.
What do the revelations about tobacco company actions mean forpublic health policy? In general terms, they call for policymakersto demand complete transparency about affiliations and linkagesbetween allegedly independent scientists and tobacco companies.Academic naïveté about tobacco companies' intentionsis no longer excusable. The extent of the tobacco companies'manipulation needs to be thoroughly exposed, and students ofmany disciplines (public health, public policy, ethics, andlaw, to name a few) should be provided with the evidence thatis increasingly available through the tobacco industry documents.
Initiatives such as the American Legacy Foundation's $15 milliongrant to the University of California, San Francisco, to establishthe Legacy National Documents Library and the Center for TobaccoControl Research and Education43 must be lauded. The foundation'sexample should be followed by other donor institutions thatwant to address international public health issues seriously.After all, every gain in tobacco control in the United Statesis an incentive for tobacco companies to globalize their operations.
Strict codes of conduct are needed to protect the integrityof the public health policy process from undue influence, especiallyfrom the likes of the secret and deleterious influences thatwere brought to bear over decades by the tobacco industry. Ethicscommittees need to consider conflict of interest as importantas patient confidentiality.26,44
NEW AND CONTINUING CHALLENGES
For tobacco control research, the challenges are not over, butthey have changed. No longer will tobacco companies disputethe scientific evidence that active smoking of traditional cigarettescauses harm. However, they continue to deny the scientific evidenceabout the harm caused by exposure to secondhand smoke and continueto suggest ventilation as an alternative to smoking bans inpublic places.45,46 Added to the debate is the issue of determiningwhether and how newly developed tobacco products confer reducedharm. The tobacco companies' investment, statements, and researchin this field make it clear that they regard new "reduced harm"products as an important strategic and financial priority. Butwhat standards of proof will be used to measure reduced harm?
In anticipation of this shift in focus, WHO has establisheda scientific advisory committee on tobacco product regulationto address these very issues. This committee has met with certaintobacco company scientists. On February 22, 2001, the Instituteof Medicine released a report calling for strict scientificanalysis and regulatory policy of tobacco products that claimto be "less harmful" than products currently available on themarket.47 On the same day, Philip Morris announced that it isfollowing other tobacco companies and intends to launch a "safer"cigarette in 2 years.48 It is noteworthy that recent reportson these "safer" cigarettes address only the carcinogenic propertiesof tobacco and largely ignore the fact that cancer is but onein a long list of diseases caused by passive and active smoking.
Whereas in the past it was public health scientists who raisedthe alarm and called for solutions, it is now predominantlyindustry scientists who claim to have found solutions. The burdenof proof of reduced harm must rest on the tobacco industry,and the public health community must take the proactive stepof developing internationally accepted means of verifying whetherany tobacco product can truly be labeled safer than another.Tobacco companies will find that the epidemiologic standardsthey so vigorously opposed (for example, dismissal of studieswith odds ratios of less than 2) are the very standards theywill need to use to demonstrate whether their new products areindeed safer.
Footnotes
Note. The opinions expressed in this commentary are those ofthe authors and do not necessarily reflect the position of theWorld Health Organization.
D. Yach developed the concept of the paper and the first draft.Both D. Yach and S. A. Bialous performed the document researchand prepared and revised the final manuscript.
Accepted for publication July 5, 2001.
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