Influencing Physicians

The tobacco industry's efforts to influence physicians began with the publication in 1954 of a booklet entitled A Scientific Perspective on the Cigarette Controversy (5). The booklet was merely one part of a large-scale public relations campaign being organized on behalf of the industry by the firm of Hill and Knowlton to counteract the emerging evidence of the health dangers of smoking (see chapter 2). According to a May 3, 1954, memorandum from Hill and Knowlton to the Tobacco Industry Research Committee (TIRC), the publisher of the booklet, it was released on April 14, 1954, and 205,000 copies were printed. It was sent to 176,800 doctors (general practitioners and specialists as well as the deans of medical and dental colleges), members of Congress, and 15,000 members of the press. As noted in a "Confidential" memorandum from Hill and Knowlton to the TIRC on August 17, 1954 (reporting the firm's activities through July 31, 1954), the booklet contained quotations from three dozen research and medical authorities, culled from both domes-

tic and foreign sources. The booklet "was held necessary and urgently timely to present to leaders of public opinion the fact that there was no unanimity among scientists regarding the charges against cigarettes" (5).

The documents contain evidence of continuing efforts by the tobacco industry to influence physicians over the next few decades. An untitled and undated document, apparently from about 1970, summarizes various proposed advertising strategies for the tobacco industry and B&W's analysis of them (see chapter 5); one item relates to "Communications with Physicians":

The need was felt for directing printed material to MDs on research efforts and studies which cast doubt on anti-smoking theory. Talk centered on reinstituting the [Tobacco] Institute's "Tobacco and Health Research" publication [which was distributed quarterly to more than 100,000 physicians in the late 1950s and early 1960s]. Our [i.e., B&W's] opinion was that a better approach would be to run a paid insert in some medical journals (particularly the well-read "Medical Economics" [a "throw-away" journal that focuses on how physicians can increase their incomes]) rather than direct mail pieces, which would probably end up in wastebaskets. We were in favor of a pilot study to determine the best method and, indeed, the feasibility of this type of communications. {2112.04, p. 2}

Thus, as in 1954, the tobacco industry was not content to influence physicians by passively responding to inquiries or communicating with them through the media. Rather, the industry was considering proactive steps, at substantial expense, to communicate directly with physicians.

Brown and Williamson also studied physicians' attitudes about cigarette smoke, to see what physicians were telling their patients and what their attitudes toward a safer cigarette would be. In March 1979 Dugan/Farley Communications Associates presented a report to B&W on a series of interviews with physicians {2127.01}. The emphasis the interviewers placed on "gasses" suggests that this was a marketing study for the Fact brand, which B&W had on the market at that time (see chapter 4). The interviewers found that doctors generally had poor success encouraging people to quit smoking, and that virtually all physicians were aware of conditions besides lung cancer linked to cigarette smoking. Despite this knowledge, fewer than one-third were aware that carbon monoxide is a problem or that other gases are linked with other diseases. Dugan/Farley's report concludes:

The "concept" of a cigarette that is low in tar and nicotine with a filter that greatly reduces known deleterious gasses was exposed to them [the doctors]. It was generally well received.

...

At this early stage in our research there seems to be hope for an educational program that would lead to acceptance by the medical profession of a "safer" cigarette. {2127.01, pp. 10, 11}

Medical textbooks at the time advised physicians to recommend low-tar cigarettes if a patient was not able to stop smoking. The marketing company's interviews with physicians introduced them to the concept of toxic gases in cigarette smoke, a problem they had not usually considered. Once confronted by this new problem with tobacco smoke, physicians responded favorably to the idea of a low-tar cigarette that also reduced "deleterious gasses." As it happened, B&W had such a product already on the market, Fact cigarettes, and the competition did not. However, B&W apparently was unable to capitalize on this insight, since Fact never attracted enough sales to warrant continued support. Indeed, this marketing study may have been part of a last-ditch effort to revive the brand. Nonetheless, the vignette well illustrates the underlying health benefit B&W promised in a low-delivery cigarette and, if the market research was, indeed, for Fact, it also shows that, with the Purite filter of Fact, the company made an additional health claim: that lower levels of certain toxic gases are better for the consumer.

Two years later, on April 29, 1981, G. E. Stungis, B&W's director of marketing research services, sent a "Limited" memorandum to Dr. I. W. Hughes, J. Alar (president and chief operations officer), and Ernest Pepples. In this memo Stungis discusses the possibility of marketing low-tar cigarettes through a Medical Communications Program {2129.01}. First, Stungis presents some background:

Up to now we have bits/pieces of how "Medical Communications Program" (MCP) may operate. Several optional and indeed variations within options exist ... all with cost structure implications.

Currently a number of assumptions exist ... by necessity at this stage. In this document Benefits Research will not be dealt with directly; consequently, we take as a given that:

There is [sic ] indeed benefits associated with smoking along the lines of stress/mastery.

There is a stable , sound and controllable benefits research team that is operative.

The output of the Benefits Research is technically sound.

Appropriate information channels with associated controls are indeed "assets in place".

Opposition counter measures developed [emphasis in original]. {2129.01, p. 1}

Using a communications diagram and an explanatory text, Stungis next describes an "MCP Model." In both the diagram and the text, he distinguishes between the "General Smoking Public" and "Extreme Concerned Smokers." The diagram pictures communications running among "Health/Medical," "Benefits Research Program," "Extreme Concerned Smokers," and "General Smoking Public." The text, which is written in shorthand form, reads as follows:

Benefits Research conducted in conjunction with credible asset . Results of Benefits Research are communicated through two controlled information channels ... devices for physician[s] and extreme concerned smokers. Physician community, accepts/refers in an interactive sense with smoking public and initiates information diffusion or so-called word of mouth process. To operate, the entire system must be continually driven. At introductory stage (time period?) referred smoking product would be only distributed through outlets associated closely with Health/Medical System [emphasis in original]. {2129.01, p. 2}

In conjunction with the model, Stungis notes that the following assumptions operate:

However, these assumptions are far from exhaustive:

Our earlier work (qualitative) with physicians provided clues ... no more, no less. We should pursue fairly rapidly to tighten up loose points above as well as uncover latent issues. Suggested further research work is:

Quantitative Study among Physicians ... primary objective would be to determine willingness on part of physicians to consider alternatives to consumables that affect patients' health and well being ... eg., cigarettes, coffee, etc. ... Properly designed study should confirm/refute assumption 1 through 3.

Qualitative Studies—Peripheral Health/Medical Systems (Pharmacist[s], Nurses, etc.) ... primary objective is to determine attitudes toward alternative risk/benefit consumables. This phase similar to early qualitative physician study. Would in all probability require quantitative follow up.

Consumer Qualitative Study ... primary object would be to obtain clues as to how effective physicians would be in convincing patients to use alternative products for improving his/her lifestyle management. Would require quantitative follow up [emphasis in original]. {2129.01, pp. 3–4}

Finally, Stungis outlines the cost estimates of the proposal {2129.01, p. 4}.

By 1981 several epidemiological studies had demonstrated that the tar reductions of the previous generation did not markedly reduce the risk of lung cancer (6), and internal BAT studies beginning around 1974 had shown that smokers of low-tar cigarettes compensate for the weaker smoke by smoking more intensively, in order to maintain their accustomed nicotine levels, and thereby lose much of the supposed benefit of low-tar brands (see chapter 3). Despite these findings, B&W apparently continued its efforts to sell low-tar cigarettes through the medical profession. Stungis's proposed Medical Communications Program may have been organized around the Barclay brand, B&W's "99% tar free" cigarette. Whatever specific brand, though, the concept belies any pretense that low-tar cigarettes are not about health. The MCP was organized to influence physicians to recommend certain types of cigarettes, if not specific brands, on the basis of their perceptions of health benefits.

These documents corroborate the impression that low tar and "low gas" were intended as a health benefit and demonstrate that B&W at least considered marketing these benefits to physicians. The documents do not indicate whether the MCP was ever actually put in practice. Its existence as a concept and the physician survey about "deleterious gasses," however, reveal that B&W, at least internally, considered marketing particular types of cigarettes as intended to prevent disease. This intent to provide health benefits (whether or not the products actually provided any), in turn, would have made the brands that were to be detailed through the MCP, as well as the "low gas" brand (probably Fact), drugs under the Food, Drug and Cosmetic Act.