Long Read

Tobacco Companies Targeting Health Professionals

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A long history of targeting doctors

Health professionals, including medical doctors, dentists and pharmacists,1 have been targeted by tobacco companies, to help promote their products and to attempt to build trust and credibility. This has been primarily in the service of their own business goals, rather than to improve health outcomes for individuals or populations.

A trustworthy salesforce

(Source: Stanford Research into the Impact of Tobacco Advertising (SRITA) collection – Advice for patients)

In the 1930s tobacco companies began targeting cigarette advertising at doctors, many of whom were themselves smokers.23 They used images of doctors in product advertising,3 and placed advertisements in medical journals which aimed not just to persuade doctors to switch to their brands, but also to recommend them to their patients.34 As Jackler and Ayoub (2018) point out, the goal was to use doctors as a potential “sales force”, to mitigate negative publicity and reduce public fears.4 The substantial advertising fees passed to medical societies by journals provided a way for tobacco companies to try to limit potential opposition among the medical community.4

The promotion of doubt

Although warnings about the harms of smoking began much earlier,5 in the 1950s the risks became unavoidably clear.6 Research in the UK – conducted on doctors – provided evidence of the link between smoking and lung cancer,78 confirmed by research conducted in the US.91011

With this increasing awareness of the harms of smoking, doctors had began to object to the presence of tobacco advertising in their medical journals. Although some journals continued to accept tobacco industry money into the 1960s, the increasing backlash led tobacco companies – on the advice of their public relations (PR) consultants – to begin sponsoring medical research, set up their own research organisations, and produce and disseminate their own scientific publications.412 From the late 1950s to the end of 1960s the Tobacco Institute, with the help of PR company Hill & Knowlton, sent its free magazine Tobacco and Health Research to tens of thousands of doctors, dentists and medical schools.13 However much of the funded research was focused on the basic science of cancer, rather than the harms of tobacco, with the ultimate purpose of manufacturing doubt.12 In an internal memo a Hill & Knowlton consultant described how best to present articles published in the magazine:

“The most important type of story is that which casts doubt in the cause and effect theory of disease and smoking.(…) the headline should strongly call out the point – Controversy! Contradiction! Other Factors! Unknowns!”1415

A major turning point for the medical profession came in the early 1960s.6 In 1962 the UK Royal College of Physicians published a report which concluded that cigarette smoking caused lung cancer.1617 Two years later the US Surgeon General’s report stated unequivocally that smoking caused lung cancer, throat cancer, and chronic bronchitis, and was strongly linked to heart disease.1819 Although even that did not stop the tobacco industry questioning whether cigarettes really were unhealthy.6 As late as 1968 Hill & Knowlton were suggesting that contributions to Smoking and Health should query the validity of disease outcome data and suggest alternative explanations for cancer and death.1314

While it was by this time even harder for companies to deny direct health implications for smokers, the impacts on bystanders became a new and fertile area in which to sow seeds of doubt. Tobacco companies sponsored multiple symposia on second-hand smoke (also known as environmental tobacco smoke, or ETS)2021 between the mid-1960s and 1990s, in some cases without disclosing this sponsorship, and they paid for scientific consultants to attend these events.22232425 Companies then published proceedings in special issues of medical journals, without peer review, enabling them to disseminate their own, unmediated research direct to health professionals as well as policy makers. 2223

There is also a history of tobacco companies targeting the dental profession. For example, up to the early 1970s, Philip Morris had a partnership with the American Dental Association’s periodontal research centre, and the Council for Tobacco Research supported its dental student research programme.2627

Doctors on the witness stand

Tobacco companies have long tried to recruit doctors to help defend their interests in legal cases.4 As Jackler and Samji (2012) note, from the 1940s to the 1960s tobacco companies aimed to make use of the “authority and prestige of otolaryngologists”,28 and a number of these ear, nose and throat (ENT) specialists testified in court, including against the 1964 US Surgeon General’s report.28 The strategy continued throughout the following decades with physicians at times acting as witnesses for tobacco companies in the US and elsewhere.12293031

Even into the 2000s a small group of ENT specialists were representing the interests of tobacco companies in the US courts, stating that heavy smoking was not likely to have caused individual patients’ cancers.283233

The industry has also made use of medical historians.3435 Robert Procter (2006) describes how Philip Morris’ “Project Cosmic”, which ran from the late 1980s to early 1990s, aimed to create a global network of scientists and historians who would write “histories casting the industry in a favourable light”, with some going on to testify on behalf of tobacco companies.34

Attempting to influencing science and professional practice

As well as using the image of doctors to promote smoking, and defend its interests in court, the tobacco industry has long targeted health professionals as part of its broader strategy to influence science. The intention has been two-fold, firstly, to disseminate industry-favourable science to these individuals in attempts to influence their professional practice, and secondly, to encourage them to disseminate their messages via their professional networks, to policy makers and to the public.

Industry-favourable science has long included evidence which obscures the harms of its products, as in the case of ETS, and framed the industry as a legitimate partner in science. In more recent years it has related increasingly to the promotion of its newer nicotine and tobacco products – as solutions to the tobacco epidemic the industry itself has created.3637 Multiple medical schools have banned tobacco industry funding of research.13

Journals such as The BMJ (formerly British Medical Journal), Thorax and Heart have developed policies around the publication of tobacco-funded research,383940 as per the implementation guidelines for article 12 of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). However, this is an increasingly challenging task, particularly as tobacco companies diversify into health technologies and pharmaceutical products.4142

  • To read more about how and why the industry attempts to influence the whole system of science (what is researched, how research is conducted, disseminated and interpreted, and whether and how it is used in policy and practice) see Influencing Science.

‘Key Opinion Leaders’

The term Key Opinion Leader (KOL) originates in communications theory from the 1940s, and was put into practice by the pharmaceutical industry in the 1950s.4344454647 The theory is that people might be more influenced by trusted figures in their networks than by other methods of communication such as advertising.4347 In the pharmaceutical industry, KOLs might be invited to participate in research projects, join advisory boards, be asked to endorse reports, or speak about industry-funded initiatives – including at sponsored conferences and promotional events.4546 They could be offered free dinners, expenses-paid visits to research facilities, or even be asked to endorse specific products.4345 Scher and Schett (2021) have argued that KOLs are essentially marketing tools, and their purpose has become “enhancing and perpetuating profit rather than innovation and critical thinking”.44 Additional challenges have emerged with the rise of social media, and more recently the use of artificial intelligence (AI) to identify potential KOLs.44

Tobacco companies have funded and co-opted health professionals as KOLs – credible-sounding voices able to promote the industry’s scientific messages in scientific and policymaking contexts, while distancing these messages from industry.364849 For example, at British American Tobacco (BAT) subsidiary Nicoventures, the role of a Senior International Engagement Manager involved working on the “global nicotine KOL ecosystem to facilitate smoking cessation and serve public health”.5051 PMI has also invited doctors to visit its Cube research facility in Switzerland.52

Irrespective of a commitment to principles of ethical behaviour, some individual physicians could still be vulnerable to well-planned and resourced influence from commercial actors.4353 In 2012, there was widespread condemnation in the US, when a doctor – who at the time was a member of a state health advisory board – appeared to have been recruited to represent tobacco company interests, appearing in industry-funded advertisements opposing cigarette tax increases.5455 While this specific scenario may be rare, as long as doctors continue to be the most trusted profession globally,565758 tobacco companies are likely to keep trying to recruit them to represent their interests. And, with increasing industry focus on ‘tobacco harm reduction’ there is some evidence of success.

Misappropriation of harm reduction

The concept of harm reduction has long been used in public health to refer to policies and programmes which aim to reduce the harms caused by communicable diseases, for example from drug addiction and sexual activity. It is also used to refer to the reduction of death and disease from tobacco use.59 However, tobacco companies have misappropriated the concept of tobacco harm reduction,6061 and incorporated it into their corporate websites, social media and other external communications, as a way to legitimise their business activities while attempting to sow division within public health.606263646566 Tobacco companies use their own research into newer tobacco and nicotine products, and research they have commissioned or funded, to support their ‘reduced risk’ narratives,6267 which they feature on their own science websites.68697071

However, the WHO urges caution.7273 The evidence shows that tobacco companies target health professionals to encourage them to endorse and promote the use of these newer products, with the ultimate aim of maintaining their profits, not – as they frequently claim – improving public health.676074

Front groups and secret consultancies

Approaches to potential KOLs in the field of health might be made indirectly, via front groups or other third parties,75 such as the PMI-financed Foundation for a Smoke-Free World (FSFW was relaunched in May 2024 as Global Action to End Smoking, which as of its last financial statements remains funded by PMI).  Or companies may work through less well-known subsidiaries, via paid consultants acting as intermediaries, or with funded think tanks, where tobacco company involvement may be unclear.

Health professionals should be aware that tobacco companies are also trying to make ‘common cause’ with broader harm reduction initiatives, including on drug addiction, alcohol and sexual health, and cynically targeting specific communities. (See for example PMI’s ‘Less Harmful Coalition’ in Canada, and tobacco-funded think tank R Street Institute’s ‘Safer from Harm’ activities in the US).

TCRG research with leaked documents from Japan, published in 2024, showed how Philip Morris Japan (PMJ) employed a consultancy to build a network of KOLs in the fields of science, medicine and public health. Their role would be to disseminate PMJ’s research and messaging around harm reduction and newer products at academic events and to media.7677 According to a PMJ discussion document, the consultancy was also charged with “[b]uilding relationships with dentistry, insurance and pharmacists”.7678

Countering industry influence

Smoking rates among doctors and other health professionals have generally declined since the 1950s, although prevalence varies by region, gender and specialism.798081 Although smoking rates remain high in some countries, doctors have become less likely to recommend the use of tobacco products to their patients and play an increasing role in smoking cessation and prevention, and the development of public health policy.

The doctors’ manifesto

In 2003, doctors from around the world contributed to a manifesto for global tobacco control.82 As the director general of the WHO at the time, Dr Gro Harlem Brundtland, said:

“Behind this manifesto lies an enormous amount of evidence, of science and of the personal experience of millions of doctors who have watched their patients get ill and die from their tobacco addiction. When a physician speaks, most people take notice. So should policymakers.” 82

Professional organisations have since developed and strengthened their policies, to support public health and limit the influence of the tobacco industry. In May 2005, the World Medical Association (WMA) passed a resolution supporting the implementation of the WHO FCTC,83 which came into force the same year and highlighted the fundamental conflict of interest between tobacco industry interests and public health.848586 In 2007, the WMA adopted a stronger statement directed at national medical associations and physicians.8788 Recommendations for action ranged from prohibiting smoking at medical events, to running education, prevention and cessation programmes.87

The WMA also emphasised the need to be aware of the attempts of industry to market its products to youth, to influence science and manipulate public opinion.87 It makes a recommendation for national medical associations to “[r]efuse funding or educational materials from the tobacco industry, and urge medical schools, research institutions, and individual researchers to do the same.”87 The WMA statement was revised and readopted in 2011, and again in 2022.88 Some have taken action.89

Medical professionals have taken on key roles countering the tobacco industry, highlighting how it perpetuates the tobacco epidemic.869091929394 Others have raised the issue of medical ethics, pointing to the responsibility of doctors to adhere to the ethical principles of their profession – including the duty of care to patients – when moving into policy-related roles.95 But it is not only doctors who have stepped up.

Dentists show their teeth

Attempts have also been made by the dental profession to raise awareness of the industry’s tactics,96 and to counter them. The World Dental Federation (FDI, Fédération Dentaire Internationale) endorses all Articles of the WHO FCTC and adopted a code of practice in 2004 rejecting “any kind of tobacco industry support”.97 Its 2021 policy statement also foregrounds the role of oral health professionals – not the tobacco industry – in cessation and health promotion.9899

In 2023, the International Association for Dental, Oral, and Craniofacial Research (IADR) and the American Association for Dental, Oral, and Craniofacial Research (AADOCR, previously the American Association for Dental Research) adopted a detailed conflict of interest policy relating to tobacco funded research.100

And yet industry attempts to infiltrate and co-opt the medical, dental and other health-related professions continue.

Halting infiltration of medical education

In 2024, Philip Morris International (PMI) funded Medscape, which delivers accredited training programmes to health professionals, to deliver a series of Continuous Medical Education (CME) courses aimed at physicians.67101102103104 This was the first time a tobacco company had openly sponsored such a course in the US.67105

After widespread criticism from doctors and the public health community the courses, referred to internally as the “PMI curriculum”,67102103 were removed and Medscape changed its policy, precluding future tobacco industry funding or collaboration.106

In line with the WHO FCTC, the WHO condemned tobacco industry manipulation of medical education for its own commercial gain, and urged certification bodies to avoid partnerships and to maintain standards of ethics and transparency.107 It has been argued that industry-funded medical education has an inherent conflict of interest as it always promotes the sponsor’s business or products.108109

PMI were also found to have sponsored similar Continuing Professional Development (CPD) activities for medical professionals in South Africa. In 2024, the College of Medicine of South Africa (CMSA) took the position that tobacco companies should be prevented from sponsoring such activities in medical and dental practice, as professional organisations should be promoting high ethical standards and professional conduct.110

Protecting health services – are policies and statements enough?

As well as individual health professionals, some health services remain vulnerable to industry interference. Tobacco companies may approach services directly, or indirectly via third parties,75 in effect trying to circumvent and undermine national regulation and public health programmes.

PMI has lobbied for its heated tobacco product (HTP) IQOS to be used in cessation programmes in multiple countries, including New Zealand,111112 Italy,113 and the UK.114 In 2024, a hospital consultant leading a cessation programme, was contacted by the chief executive of Global Action to End Smoking (previously FSFW, and as of its last financial statements still funded by PMI) offering to discuss grants and a “new educational effort”, stating that it was “also a smoking cessation organisation.”115

Despite evidence of tobacco companies focussing on dentistry, as Tomar (2019) notes, oral health continues to receive little attention in discussions of tobacco product regulation.26 Concerningly, this appears to have left the door open for the tobacco companies to position themselves as experts on oral health and hygiene.76116117

It remains to be seen how much statements and policies developed by medical and dental associations impact on the practices of both the tobacco industry and the health professionals it targets. Training programmes with medical professionals and students can also help to raise awareness of the aims and tactics of the tobacco industry.118

One thing is clear – despite all attempts by tobacco companies to appear as the solution to the problems they have created, as Cummings and colleagues succinctly put it:

“If the past 50 years have taught us anything, it is that the tobacco industry cannot be trusted to put the public’s interest above their profits no matter what they say.” 6

 

For more detail and examples of this industry strategy in practice, see Tobacco Companies Targeting Health Professionals: The Tactics

Further reading & resources

Authors

Karin Silver and Britta K. Matthes

Acknowledgement

Thanks to Tess Legg and Sophie Braznell for support with this article.

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References

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