Ruth E. Malone

Tobacco industry documents: treasure trove or quagmire?

The release of over 27 million pages of internal tobacco industry documents as a result of discovery processes in The State of Minnesota and Blue Cross and Blue Shield of Minnesota versus Philip Morris et al and other legal cases has provided tobacco control researchers and advocates with unprecedented opportunities to understand more about the inner workings of the industry. Documents are available for public viewing at the Minnesota Tobacco Document Depository, which opened in Minneapolis in 1998, at the Guildford Document Depository in Guildford, England, and on the world wide web, accessible through http://www.TobaccoArchives.com/ and other sites. In addition, through websites, users can get access to documents produced under the state litigation in Washington, Mississippi, Florida, and Texas, and selections from the British American Tobacco documents housed at Guildford, UK. (see “other tobacco documents resources”, below). Though the vast majority of documents are from the Minnesota case, which resulted in the release of documents from Philip Morris, RJ Reynolds, American Tobacco, Lorillard, the Tobacco Institute, Brown and Williamson, and the Council on Tobacco Research, collections continue to become available in conjunction with other legal cases. Given the enormous numbers of documents that are available, the collections may prove to be either a treasure trove of information valuable for tobacco control research and advocacy, or a quagmire of quantity into which researchers sink in despair. In this article, we discuss differences between searching for documents at the depository and on various online sites and suggest some practical strategies that may help researchers be more productive while using these collections. The depository is located in Minneapolis in a business park near the University of Minnesota. The number of computer terminals available for public searching is limited, so it is usually necessary to make reservations in advance of a visit to ensure …

The Outing of Philip Morris: Advertising Tobacco to Gay Men

OBJECTIVES This case study describes the events surrounding the first time a major tobacco company advertised in gay media. METHODS We analyzed internal tobacco company documents, mainstream newspapers, and the gay press. RESULTS Philip Morris was unprepared for the attention its entry into the gay market received. The companys reaction to this incident demonstrates that its approach to the gay community both parallels and diverges from industry strategies toward other marginalized communities. CONCLUSIONS The tobacco industrys relationship to the gay community is relatively undeveloped, a fact that may provide tobacco control advocates an opportunity for early intervention. The gay communitys particular vulnerabilities to the industry make development of gay tobacco control programs crucial to reducing gay smoking prevalence and industry presence in the community.

Marketing to the marginalised: tobacco industry targeting of the homeless and mentally ill.

Objectives: To describe the tobacco industry’s relationships with and influence on homeless and mentally ill smokers and organisations providing services to them. Methods: Analysis of internal tobacco industry documents and journal articles. Results: The tobacco industry has marketed cigarettes to the homeless and seriously mentally ill, part of its “downscale” market, and has developed relationships with homeless shelters and advocacy groups, gaining positive media coverage and political support. Discussion: Tobacco control advocates and public health organisations should consider how to target programmes to homeless and seriously mentally ill individuals. Education of service providers about tobacco industry efforts to cultivate this market may help in reducing smoking in these populations.

“It’s Like Tuskegee in Reverse”: A Case Study of Ethical Tensions in Institutional Review Board Review of Community-Based Participatory Research

Community-based participatory research (CBPR) addresses the social justice dimensions of health disparities by engaging marginalized communities, building capacity for action, and encouraging more egalitarian relationships between researchers and communities. CBPR may challenge institutionalized academic practices and the understandings that inform institutional review board deliberations and, indirectly, prioritize particular kinds of research. We present our attempt to study, as part of a CBPR partnership, cigarette sales practices in an inner-city community. We use critical and communitarian perspectives to examine the implications of the refusal of the university institutional review board (in this case, the University of California, San Francisco) to approve the study. CBPR requires expanding ethical discourse beyond the procedural, principle-based approaches common in biomedical research settings. The current ethics culture of academia may sometimes serve to protect institutional power at the expense of community empowerment.

African American leadership groups: smoking with the enemy

Background: Among all racial and ethnic groups in the USA, African Americans bear the greatest burden from tobacco related disease. The tobacco industry has been highly influential in the African American community for decades, providing funding and other resources to community leaders and emphasising publicly its support for civil rights causes and groups, while ignoring the negative health effects of its products on those it claims to support. However, the industry’s private business reasons for providing such support were unknown. Objective: To understand how and for what purposes the tobacco industry sought to establish and maintain relationships with African American leaders. Methods: Review and analysis of over 700 previously secret internal tobacco industry documents available on the internet. Results: The tobacco industry established relationships with virtually every African American leadership organisation and built longstanding social connections with the community, for three specific business reasons: to increase African American tobacco use, to use African Americans as a frontline force to defend industry policy positions, and to defuse tobacco control efforts. Conclusion: As the tobacco industry expands its global reach, public health advocates should anticipate similar industry efforts to exploit the vulnerabilities of marginalised groups. The apparent generosity, inclusion, and friendship proffered by the industry extract a price from groups in the health of their members. Helping groups anticipate such efforts, confront industry co-optation, and understand the hidden costs of accepting tobacco industry largesse should be part of worldwide tobacco control efforts.

Philip Morris’s Project Sunrise: weakening tobacco control by working with it

Objective: To analyse the implications of Philip Morris USA’s (PM’s) overtures toward tobacco control and other public health organisations, 1995–2006. Data sources: Internal PM documents made available through multi-state US attorneys general lawsuits and other cases, and newspaper sources. Methods: Documents were retrieved from several industry documents websites and analysed using a case study approach. Results: PM’s Project Sunrise, initiated in 1995 and proposed to continue through 2006, was a long-term plan to address tobacco industry delegitimisation and ensure the social acceptability of smoking and of the company itself. Project Sunrise laid out an explicit divide-and-conquer strategy against the tobacco control movement, proposing the establishment of relationships with PM-identified “moderate” tobacco control individuals and organisations and the marginalisation of others. PM planned to use “carefully orchestrated efforts” to exploit existing differences of opinion within tobacco control, weakening its opponents by working with them. PM also planned to thwart tobacco industry delegitimisation by repositioning itself as “responsible”. We present evidence that these plans were implemented. Conclusion: Sunrise exposes differences within the tobacco control movement that should be further discussed. The goal should not be consensus, but a better understanding of tensions within the movement. As the successes of the last 25 years embolden advocates to think beyond passage of the next clean indoor air policy or funding of the next cessation programme, movement philosophical differences may become more important. If tobacco control advocates are not ready to address them, Project Sunrise suggests that Philip Morris is ready to exploit them.

Tobacco industry denormalisation as a tobacco control intervention: a review

Objective To conduct a review of research examining the effects of tobacco industry denormalisation (TID) on smoking-related and attitude-related outcomes. Methods The authors searched Pubmed and Scopus databases for articles published through December 2010 (see figure 1). We included all peer-reviewed TID studies we could locate that measured smoking-related outcomes and attitudes toward the tobacco industry. Exclusion criteria included: non-English language, focus on tobacco use rather than TID, perceived ad efficacy as sole outcome, complex program interventions without a separately analysable TID component and non peer-reviewed literature. We analysed the literature qualitatively and summarised findings by outcome measured. Results After excluding articles not meeting the search criteria, the authors reviewed 60 studies examining TID and 9 smoking-related outcomes, including smoking prevalence, smoking initiation, intention to smoke and intention to quit. The authors also reviewed studies of attitudes towards the tobacco industry and its regulation. The majority of studies suggest that TID is effective in reducing smoking prevalence and initiation and increasing intentions to quit. Evidence is mixed for some other outcomes, but some of the divergent findings may be explained by study designs. Conclusions A robust body of evidence suggests that TID is an effective tobacco control intervention at the population level that has a clear exposure–response effect. TID may also contribute to other tobacco control outcomes not explored in this review (including efforts to ‘directly erode industry power’), and thus may enhance public support and political will for structural reforms to end the tobacco epidemic.

Children's Secondhand Smoke Exposure in Private Homes and Cars: An Ethical Analysis

Secondhand smoke (SHS) exposure is a known cause of disease among nonsmokers, contributing to lung cancer, heart disease, and sudden infant death syndrome, as well as other diseases. In response to the growing body of scientific literature linking SHS with serious diseases, many countries, states, and cities have established policies mandating smoke-free public spaces. Yet thousands of children remain unprotected from exposure to SHS in private homes and cars. New initiatives targeting SHS in these spaces have raised ethical questions about imposing constraints on private behavior. We reviewed legislation and court cases related to such initiatives and used a principlist approach to analyze the ethical implications of policies banning smoking in private cars and homes in which children are present.

Understanding Philip Morris’s pursuit of US government regulation of tobacco

Objective: To investigate Philip Morris’s support of US Food and Drug Administration (FDA) regulation of tobacco products and analyse its relationship to the company’s image enhancement strategies. Data sources: Internal Philip Morris documents released as part of the Master Settlement Agreement. Methods: Searches of the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) beginning with such terms as “FDA” and “regulatory strategy” and expanding to include relevant new terms. Results: Philip Morris’s support for government regulation of tobacco is part of a broader effort to address its negative public image, which has a damaging impact on the company’s stock price, political influence, and employee morale. Through regulation, the company seeks to enhance its legitimacy, redefine itself as socially responsible, and alter the litigation environment. Whereas health advocates frame tobacco use as a public health policy issue, Philip Morris’s regulatory efforts focus on framing tobacco use as an individual choice by informed adults to use a risky product. This framing allows Philip Morris to portray itself as a reasonable and responsible manufacturer and marketer of risky products. Conclusions: Philip Morris’s ability to improve its image through support of FDA regulation may undermine tobacco control efforts aimed at delegitimising the tobacco industry. It may also create the impression that Philip Morris’s products are being made safer and ultimately protect the company from litigation. While strong regulation of tobacco products and promotion remain critical public health goals, previous experiences with tobacco regulation show that caution may be warranted.

Death at a discount: how the tobacco industry thwarted tobacco control policies in US military commissaries

Background: The US military is perhaps the only retailer consistently losing money on tobacco. Military stores (commissaries and exchanges) have long sold discount-priced cigarettes, while the Department of Defense (DoD) pays directly for tobacco-related healthcare costs of many current and former customers. Tobacco use also impairs short-term troop readiness. Objective: To examine the long struggle to raise commissary tobacco prices and the tobacco industry’s role in this policy effort. Methods: Analysis of internal tobacco industry documents, searches of government and military websites and newspaper databases, and interviews with key informants identified in the documents. Results: Efforts to raise commissary tobacco prices began in the mid-1980s. Opposition quickly emerged. Some military officials viewed tobacco use as a “right” and low prices as a “benefit”. Others raised issues of authority, and some saw the change as threatening the stores. The tobacco industry successfully exploited complex relationships among the Congress, the DoD, commissaries, exchanges and private industry, obstructing change for over a decade. Leadership from the Secretary and Assistant Secretaries of Defense, presidential support and procedural manoeuvring finally resulted in a modest price increase in 1996, but even then, high-level military officials were apparently threatened with retaliation from pro-tobacco Congressmen. Conclusions: The longstanding military tradition of cheap cigarettes persists because of the politics of the military sales system, the perception within the military of tobacco use as a right, and tobacco industry pressures. Against its own best interests, the US military still makes tobacco available to service members at prices below those in the civilian sector.