TOBACCO, LAWYERS, AND PUBLIC HEALTH
Junking Science to Promote Tobacco
Derek Yach, MBChB, MPH and Stella Aguinaga Bialous,
DrPH, MScN, RN
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 its
practices, the toll of tobacco-related disease and death continues to
grow worldwide, and the industry continues to use a vast array of
strategies to promote its products and increase profits. This
commentary discusses the ways the tobacco industry has created
controversy about risk assessment and about the scientific evidence
of the health hazards of secondhand smoke.
The authors recommend that policymakers be more vigilant and that
they demand transparency about affiliations and linkages between
allegedly independent scientists and tobacco companies. They also
urge policymakers to be prepared for new and continuing challenges
posed by the tobacco industry, because, despite the industry's
claims, there is little evidence of fundamental change in its
objectives.
TOBACCO COMPANIES CLAIM that they have changed. They assert
that their efforts to undermine global tobacco control policy are a
product of a past era and that now they seek to engage in
constructive dialogue with the World Health Organization (WHO) and
national governments.1
Unfortunately, the reality is that the consequences of their actions
continue. Four million deaths per year, 1.2 billion smokers in the
world today, and high rates of youth smoking are in part the result
of the failure of governments to implement tobacco control policies
that are known to work. And governments' inaction is largely a result
of decades of tobacco companies' untoward influence.
Among the lingering effects of tobacco companies' actions are the
insidious ways in which the public health policy agenda and the media
debate about tobacco have been influenced. In this issue of the
Journal, Ong and Glantz highlight one aspect of industry influence
with respect to epidemiologic standards of causality.2
The authors show that tobacco companies carefully planned to
undermine accepted epidemiologic practices and hoped that by
partnering with a broad range of academic and private commercial
interests, they could create confusion about the role of epidemiology
and risk assessment in public policy development. The ultimate goal
of the industry was to promote the trivialization of the risk of
tobacco use, stating that nearly everything from eating Twinkies to
crossing the street was harmful, and that tobacco was just one more "risky
pleasure."
Ong and Glantz's work needs to be considered within the broader
concerted efforts of the tobacco companies to influence public policy
in a manner detrimental to public health. The release of tobacco
industry documents following US litigation provides us with access to
a snapshot of the truth. These documents show a nearly 50-year effort
to improve public relations, rather than public health.
One example, from 1977, is Operation Berkshire,3
which shows how 7 of the world's largest tobacco companies colluded
to promote doubt about tobacco and health. These companies created
the International Committee on Smoking Issues (later the
International Tobacco Information Center) to internationally
coordinate a network of national manufacturers' associations to block
tobacco control measures. In another example, Philip Morris convened
a meeting of its top executives in 1988 in Boca Raton, Fla, to
develop an action plan aimed at attacking WHO's tobacco control
programs at the national level and targeting the structure,
management, and resources of the WHO.4
These documents show the lengths the tobacco industry went to in
its attempt to thwart the International Agency for Research on
Cancer's epidemiologic research on secondhand smoke and lung cancer
in Europe.5
They show how linkages were created between tobacco companies and the
chemical, food, pesticide, and utility industries, as well as how the
tobacco industry developed its "scientific" strategy.
The industry documents, described in The Cigarette Papers6
and most recently summarized in A Question of Intent: A Great
American Battle With a Deadly Industry,7
tell about the scope and depth of the tobacco companies' ability to
recruit scientists from the ranks of the most prestigious academic
institutions. Tobacco companies sought to create doubt where
scientific consensus existed. To do so, they enlisted scientists in
their cause. This way, the industry voice would be heard but the
industry would not be directly involved, as tobacco industry funding
often remained undisclosed in publications and participation in
public forums.
The consultants, grantees, and speakers who were willing to work
for the industry came from some of the best academic centers in the
United States and abroad. For example, the US Tobacco Institute had a
team of academics and scientists, "faculty members of prestigious
universities and medical schools," to assist in responding to the US
Environmental Protection Agency's risk assessment methodologies,
among other things.8
Although the US Tobacco Institute was forced to close as a condition
of the 1998 Master Settlement Agreement,9
equivalent agencies still operate in major tobacco markets around the
world, where the degree of intimacy between certain scientists and
tobacco companies is not widely known.
As discussed by Ong and Glantz, the use of front groups and
consultants is a wellestablished tobacco industry practice to avoid
dealing with its lack of public credibility. Scientists were
constantly at hand to assist in maintaining the industry-created
controversy 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 to achieve
scientific credibility.10
Among the notable academics enlisted by the industry are professors
such as A. R. Feinstein of Yale University, editor of the Journal
of Clinical Epidemiology, who on many occasions has presented the
argument that the epidemiologic methods used to assess the risk of
passive smoking are inadequate. In a 1992 article, Feinstein
supported the tobacco industry's right to defend itself against the
label of "bad guy" and criticized the "current atmosphere [in which a
tobacco industry] consultant's stature, credibility, and integrity
become instantly impugned and tarnished by the depravity of
associating with the tobacco ‘bad guy.'"11
He did not mention, however, that he was a tobacco industry
consultant and the recipient of highly secret "special project"
awards.6,12–14
One prestigious US institution that has received funds from Philip
Morris and its subsidiaries is the Harvard Center for Risk Analysis,
whose former director, John Graham, has assisted Philip Morris with
risk communication about environmental tobacco smoke and has on many
occasions requested funds for the center.15–18
Among several other sources of corporate support, the center
currently has an unrestricted grant from the Philip Morris subsidiary
Kraft Foods and a restricted grant from the Risk Science Institute of
the International Life Sciences Institute (ILSI).19
In March 2001 President Bush nominated John Graham to be
administrator of the Office of Information and Regulatory Affairs of
the Office of Management and Budget.20
This office reviews and approves—or blocks—all major federal
regulations. The consumer advocacy group Public Citizen criticized
the nomination on the basis of the links between Graham and corporate
funding.21,22
The above cases exemplify the tobacco industry's reach into the
scientific community and have to be considered within a broader
discussion about the influence of private corporate funding on
academic research and policies addressing funding disclosure. The
debate over conflict of interest between academia and private
commercial interests is gaining visibility. In a recent article in
the Journal of the American Medical Association, the dean of
the Harvard medical school stated that more safeguards against
conflict of interest are necessary.23
Nils Hasselmo, president of the Association of American Universities,
was quoted as saying that "it's the responsibility of the university
to serve the public good. The public relies on universities for
the greatest degree of objectivity, rather than for information
that may be slanted by financial interests."24
How this debate will influence future tobacco industry funding of
academia remains to be seen. Even more important is how academia is
going to respond to offers from the tobacco industry. The debate is
not yet over. The March 2001 newsletter of California's
Tobacco-Related Diseases Research Program was entirely dedicated to
the discussion of the implications of tobacco industry funding of
science.25
Recently, despite much criticism and the resignation of faculty
members, Nottingham University in England accepted £3.8 million from
British American Tobacco to create an International Centre for
Corporate Social Responsibility.26–30
DISTORTING RISK
There are many groups and consultants who were funded by the
industry, both directly and through subsidiary companies, and who
provided the tobacco industry with ample material, in the form of
testimony, reports, and other publications, to fight tobacco policy
and regulations. For example, ILSI and its Risk Science Institute—a
nonprofit worldwide scientific research foundation focusing on the
areas of nutrition, food safety, toxicology, risk assessment, and the
environment31—gave
the tobacco industry an opportunity to blend secondhand smoking
risks with other low-dose risks and continue to create doubt and
controversy about the harms of secondhand smoke.32
ILSI is a particularly relevant example, given that it has a formal
relationship with WHO and IARC and thus offered the tobacco
industry the potential for additional access to these institutions.33,34
(Note: Since the writing of this commentary, ILSI executives
have agreed to review all aspects of their affiliations with
commercial interests.)
In addition to creating front groups and contributing funds to
groups that have a mission broad enough to carry some of the tobacco
industry's goals, the tobacco companies also use publications by
allegedly independent think tanks, such as the Virginia-based Alexis
de Tocqueville Institution. This group's 1994 report "Science,
Economics, and Environmental Policy: A Critical Examination"35
criticizes the US Environmental Protection Agency's risk assessment
methods in 4 areas: environmental tobacco smoke, radon, pesticides,
and hazardous cleanup. It dismisses in its first chapter the agency's
risk assessment of environmental tobacco 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 in its
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 have been involved
with different tobacco companies' activities.36
The report's principal reviewer, Dr Fred Singer, was involved
with the International Center for a Scientific Ecology, a group that
was considered important in Philip Morris' plans to create a group in
Europe similar to The Advancement for Sound Science Coalition (TASSC),
as discussed by Ong and Glantz.37,38
He was also on a tobacco industry list of people who could write
op-ed pieces on "junk science," defending the industry's views.39
The junk science saga continues. In February 2001, on the Web site
JunkScience.com, Martha Perske provided a critique of studies linking
passive smoking and lung cancer.40
In the article, she grossly misstates the WHO's work in this field.
Perske has no formal scientific training and her one publication in
the peer-reviewed literature is a letter to the editor—which appeared,
incidentally, in the journal edited by Alvan Feinstein.41
She describes herself as a "smokers' advocate," but industry
documents show that she stayed in close contact with Philip Morris,
asking for their review of and comments on her activities.42
The goal of the tobacco industry's "scientific strategy" was not
to reveal the truth but to protect the industry from loss of revenue
and to prevent governments from establishing effective tobacco
control measures. The industry's goals of creating doubt and
controversy and placing the burden of proof on the public health
community in policy forums have, therefore, met with a certain degree
of success. Tobacco control policies are not being implemented
worldwide at the rate that current scientific knowledge about the
dangers of tobacco warrants. But this scenario is changing as the
negotiations for the Framework Convention on Tobacco Control continue
to advance. The Framework Convention on Tobacco Control marks the
first time the WHO has used its treaty-making right to support member
states in developing a legally binding instrument in the service of
public health. Negotiations are progressing well, and it is likely
that member states will vote on ratification of the convention in
mid-2003.
What do the revelations about tobacco company actions mean for
public health policy? In general terms, they call for policymakers to
demand complete transparency about affiliations and linkages between
allegedly independent scientists and tobacco companies. Academic
naïveté about tobacco companies' intentions is no longer excusable.
The extent of the tobacco companies' manipulation needs to be
thoroughly exposed, and students of many disciplines (public health,
public policy, ethics, and law, to name a few) should be provided
with the evidence that is increasingly available through the tobacco
industry documents.
Initiatives such as the American Legacy Foundation's $15 million
grant to the University of California, San Francisco, to establish
the Legacy National Documents Library and the Center for Tobacco
Control Research and Education43
must be lauded. The foundation's example should be followed by other
donor institutions that want to address international public health
issues seriously. After all, every gain in tobacco control in the
United States is an incentive for tobacco companies to globalize
their operations.
Strict codes of conduct are needed to protect the integrity of the
public health policy process from undue influence, especially from
the likes of the secret and deleterious influences that were brought
to bear over decades by the tobacco industry. Ethics committees need
to consider conflict of interest as important as patient
confidentiality.26,44
NEW AND CONTINUING CHALLENGES
For tobacco control research, the challenges are not over, but
they have changed. No longer will tobacco companies dispute the
scientific evidence that active smoking of traditional cigarettes
causes harm. However, they continue to deny the scientific evidence
about the harm caused by exposure to secondhand smoke and continue to
suggest ventilation as an alternative to smoking bans in public
places.45,46
Added to the debate is the issue of determining whether and how newly
developed tobacco products confer reduced harm. The tobacco companies'
investment, statements, and research in this field make it clear that
they regard new "reduced harm" products as an important strategic and
financial priority. But what standards of proof will be used to
measure reduced harm?
In anticipation of this shift in focus, WHO has established a
scientific advisory committee on tobacco product regulation to
address these very issues. This committee has met with certain
tobacco company scientists. On February 22, 2001, the Institute of
Medicine released a report calling for strict scientific analysis and
regulatory policy of tobacco products that claim to be "less harmful"
than products currently available on the market.47
On the same day, Philip Morris announced that it is following other
tobacco companies and intends to launch a "safer" cigarette in 2
years.48
It is noteworthy that recent reports on these "safer" cigarettes
address only the carcinogenic properties of tobacco and largely
ignore the fact that cancer is but one in a long list of diseases
caused by passive and active smoking.
Whereas in the past it was public health scientists who raised the
alarm and called for solutions, it is now predominantly industry
scientists who claim to have found solutions. The burden of proof of
reduced harm must rest on the tobacco industry, and the public health
community must take the proactive step of developing internationally
accepted means of verifying whether any tobacco product can truly be
labeled safer than another. Tobacco companies will find that the
epidemiologic standards they so vigorously opposed (for example,
dismissal of studies with odds ratios of less than 2) are the very
standards they will need to use to demonstrate whether their new
products are indeed safer.
Footnotes
Note. The opinions expressed in this commentary are those of
the authors and do not necessarily reflect the position of the
World Health Organization.
D. Yach developed the concept of the paper and the first draft.
Both D. Yach and S. A. Bialous performed the document research and
prepared and revised the final manuscript.
Peer Reviewed
Accepted for publication July 5, 2001.
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Bron: American Journal of Public Health - November
2001, Vol 91, No. 11
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