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When researchers accept funding from the tobacco industry, do ethics go up in smoke? Biologist Gordon Sato, PHD, director of the W. Alton Jones Cell Science Center in Lake Placid, NY, tells the story of Ignaz Semmelweis and his money ma- chine. It seems that the Hungarian ob- stetrician was called on the carpet by the dean of his medical school for ac- cepting money from a manufacturer of condoms. "The dean told Semmelweis 'We can't accept money from them.' Semmelweis said, 'Don't worry. In my basement, I have a machine where you put dirty money in on top and it comes out clean on the bottom.' " Sato is making a point: In his opin- ion, how research money is used, not its source, is the important thing. Sato is sensitive about funding because he serves as a member of the Scientific Advisory Board of the Council for To- bacco Research-USA, the biomedical research arm of the tobacco industry. While universities are under siege to sell off their stock in companies that do business with racist South Africa, and the warning flags have been hoisted about university financial relations with corporate America, the cigarette industry's efforts to launder its tobacco- stained profits in research go virtually unnoticed. The scientific community has yet to reach a consensus on whether the source of funds in itself can sully a project. Abbott Lawrence Lowell, president of Harvard University from 1909 until 1933, used to say that he would accept money from anyone as long as they did not tell him how to spend it. But if he were at the helm today, some faculty members might question whether tak- ing money from a tainted source does not somehow taint the recipient. At Yale University, investigators can no longer do classified government re- search, because such work is considered antithetical to the free flow of scientific information. At Tufts University, a flap occurred in 1977 when Philippines dic- tator Ferdinand Marcos offered to en- dow a chair in his own name in the F;etcher School of Law and Diplomacy. Some Tufts faculty members argued that taking Marcos' money would le- gitimize a bloody regime. Tufts Presi- dent Jean Mayer, PnD, asked, "Does accepting money from the Carnegie Foundation mean endorsing the shoot- ing of miners? Does accepting money from the Rockefeller Foundation mean endorsing monopolistic practices? Ob- viously, we will not accept money from any and every source. But how do you draw the line?" When it comes to tobacco, virtually no lines have been drawn. NOBLE RESEARCH? Cigarettes remain a legal product in this country, and the tobacco compan- ies are happy to spend some of their pYofits on research programs and, ap- parently, most researchers would be happy to take it. When Philip Morris, the makers of Marlboro and other brands of ciga- rettes, held a symposium for scientists from government, academia, and in- dustry in 1981 in Richmond, VA, two Nobel laureates-physicists Rosalyn A. Yalow, PHD, of the Veterans Hospi- tal, Bronx, developer of the first appli- cation of the radioimmunoassay, and Alan M. Cormack, msc, of Tufts, whose work led to the development of computerized tomographic scanning- were among the researchers present. The tobacco companies have a knack for sponsoring the stars of science as well as of the performing arts and sports. The industry-funded Council for To- bacco Research (CTR) boasts that it was among the patrons who supported the Nobel prize-winning immunology research by Baruj Benacerraf, MD, chairman of the department of pathol- ogy at Harvard Medical School. Some researchers may have reservations about taking tobacco-industry money, but the New York-based council's sci- entific director, Sheldon C. Sommers, i® I ~® I ~ ~ THE FOURTH PHUP iY}Of2RIS SCIENCE SYMPOSIUM OCTOIER 29. 1981 Tobacco company-sponsored conference. All in the name of science? htD, said he personally knows only one. Perhaps only one institution in the world, the University of Sydney in Aus- tralia, has publicly disclosed its debate over the ethics of accepting tobacco money. According to the Medical Journal of Australia (1982; 2:391- 392), the university decided in 1982 to turn down financial support from any tobacco company if the firm is publicly identified as the source. In calling for this action, cardiologist Gaston Bauer, warden of the clinical school at Royal North Shore Hospital, pointed out that by refusing funds the university would "gain the respect of the community." According to Sommers, a consulting pathologist at Lenox Hill Hospital, New York, "Ten, 15 years ago, there were some organizations, such as Rockefeller University, that didn't want CTR money, but that's all gone by. [Now,J there's not a single organi- zation, a university, a research insti- tute, a college, that turns down the money." Rockefeller University apparently has changed its tune, because it now has an RJ Reynolds Research Fellowship. Current projects funded by the CTR are being conducted at New England Deaconess Hospital, the University of California at Berkeley, Sidney Farber Cancer Institute, Johns Hopkins On- cology Center and the university's School of Hygiene and Public Health, Yale University School of Medicine, Harvard Medical School, and Albert Einstein College of Medicine. The smoky trail of funding can be followed down many other prestigious corridors. And researchers in growing numbers are seeking funding from tobacco com- panies. There are at least two reasons for this. The first is that the tobacco in- dustry has been increasing its invest- ment in research at the same time gov- ernment funds have diminished. Sec- ond, the Council for Tobacco Research has been attracting accomplished scien- tists to its board and gaining publicity for its research funding efforts. Som- mers said the CTR has seen an increase in applicants as federal sources for re- search funding have dried up. "We are in a world where the National Institutes of Health are slowly making it more difficult to get rnoncy. And the side ef- JULY 1985/NEW YORK STATE JOURNAL OF 1fEDIC1NE 451 UMI Article Clearinghouse has reproduced this material with permission of the copyright owner. Further reproduction is prohibited.

c~o (9b~erv+er I `~ Causes Of Cancer Re_main Unknown ~ =---- 1 Lu~ car,cer/~~kin~ tS,k Industry, Goyertvnent Apr®« H®aR Disease 'Risk Faator' Meds&Fams UrAvwwn : Inn ~ The Tobacco Observer, tobacco industry publication, reports on smoking and health. The Cuncii for Tobacco Research's Scientific Director Sheldon Sommers, tiro, gave this testimony at Congressional hearings on warning labels: "Cigarette smoking has not been scientifically established to be a cause of chronic diseases, such as cancer, cardiovascular disease, or emphysema. Nor has It been shown to affect pregnancy outcome advarsely." fect is that we attract more applicants," he said. The tobacco industry has nearly dou- bled its funding of CTR research to $9 million since 1980. CTR funds about 40% of its 200 applicants per year, com- pared with a 20% funding level in many parts of NIH. NOT ,IUST SMOKING Since it was founded in 1954, CTR claims to have spent $83 million on 865 projects in 279 medical schools, hospi- tals, and research institutions. Though the bulk of the money has been devoted to issues of smoking and health, the council-with the blessing of its benc- factors-has recently become a general biomedical research group, devoting about half of its funds to research unre- lated to smoking. The council pays a stipend of $7,000 per year to its mem- bers. Epidemiologist Gary Friedman, MD, assistant director of the Department of Medical Methods Research, Kaiser Foundation Research Institue, Oak- land, CA, a former grantee, said, "We were very concerned that they would try to influence the results. I can't speak for everything the tobacco industry supports, but that particular group, the Council for Tobacco Research-USA, seems to be an independent group that is trying to sponsor good studies. They did not say anything to us about what to publish or what not to publish. They did not try to influence us in any way." Friedman noted that several studies published by his group found harmful effects from tobacco. The council may have avoided criti- cism, in part, because the researchers it funds follow a practice known as "pig- gybacking" or mingling money from a variety of sources. The council's annual report shows that it is co-funding re- search with the American Cancer Soci- ety, the National Science Foundation, the National Institutes of Health, and other leading organizations. Joanne Luoto, MD, director of the US Office of Smoking and Health, stat- ed that the council "is buying legitima- cy when its funds are mixed with those from NCI and other federal agencies." Sommers said that piggi, 'backing used to feed the fires of hostility be- tween the council and the Ameri~an Cancer Society. However, the animos- ity has abated in recent years. In fact, Joann Schellenbach, director of press relations for the American Cancer So- ciety in New York, said of the council, "They're legitimate. We're very critical of the tobacco industry in terms of their advertising practices and many other things that they do. But here's an area where they seem to be doing something by the book and promulgating good re- search. So I guess we can't criticize them across the board." Historically, tobacco companies, like many other firms, bought research and used it to peddle their products. Scien- tific studies of tar and nicotine content of cigarettes often have been the subject of advertisements. Philip Morris adver- tisements of the 1930s, 1940s, and 1950s, as in one that appeared in The Laryngoscope, told physicians that they could use their "scientific knowledge" to help their patients "discriminate be- tween mere claim and basic facts" made in cigarette promotion. The blurb concluded, "Test Philip Morris on pa- tients suffering from congestion of the nose and throat due to smoking. Verify for yourself Philip Morris superiority." (see also NY State J Med 1983; 83:1347-1352) But today's battle to win hearts and minds through the research sponsored by the Council for Tobacco Research and the individual tobacco companies is more subtle and sophisticated. By de- sign or default, the tobacco industry seems to be reaping a bonus of good public relations for being a patron of re- search, just as it does from sponsoring art exhibitions, ballet, orchestra and sporting events. AND ON AND ON Why would the tobacco industry take the risk of sponsoring research that could place its product in an unfavor- able light? Joseph Cullen, PHD, deputy director of the National Cancer Institute, be- lieves that the industry wins even when the research turns up negative findings. He maintains that the research always breeds other research, so that the com- panies can k~cp saying that major ques- tions about tobacco remain unan- swered. "As long as they keep funding JULY 1985/NEW YORK STATE JOURNAL OF MEDICINE 453

Publicly, little has been said in the sci- entific community about the possible compromise represented by the accep- tance of funding from the tobacco indus- try. Privately, however, scientists point to the ethical problem that would arise for a colleague financed by an industry, who discovers that his research is being used in advertisements or public relations. Yet this is precisely the modus operandi of the Tobacco Institute (TI), the infor- mation arm of cigarette manufacturers. Both the TI and the Council for Tobacco Research (CTR) are funded by the tobac- co industry. Extensive coverage of the views of researchers who have received grants from the CCR has been carried in the Tobacco Observer, the bi-monthly newspaper of the TI that is sent to jour- nalists, Congressmen, and thousands of other government officials. Few if any of these researchers are identified as having received remuneration from the CTR for travel or research. In contrast to the de- scription of scientists who testify in sup- port of stricter measures to discourage smoking as ",-nti-smokers," tobacco in- dustry-financed researchers and others who oppose such measures are described as eminent, noted, or prominent authori- ties, experts, and scholars. In addition to the Tobacco Observer, numerous tracts and pamphlets are dis- tributed by the TI to tell "the other side" of the smoking "controversy: " A review of the Tobacco Observer since its inception in 1976 (with the front-page headline, "Pesty anti-smokers blasted") reveals several techniques employed time and again, including the following: • Highlighting proponents of the theory that genetics or personality are linked to diseases that most other research has attributed to smoking. This theory goes something like this: "People are science, it makes them look like they truly are concerned and interested in what the truth and the facts are," added Cullen. "They have some terrific people on their board. It is in their [the tobacco industry's] interest to look honest, to look as if they are scientifically curious about the real truth." Luoto agreed, saying, "Funding re- search helps the industry keep alive the notion that the dangers of smoking are still in question. As long as they keep funding research and people keep doing research, even if it's into the subcellular molecular basis of carcinogenesis, John Q. Public is not going to know that dis- The research game born with a predisposition to smoke and to get lung cancer-and often these are the same persons." • Pointing to the limitations of research, especially that which has implicated smoking as a major cause of lung can- cer and heart disease, while praising research into the role of stress, anger, chemicals, occupation, eating habits, air pollution, and radiation as the cul- prits in these diseases. • Claiming that the Tobacco Institute is not responding to the various reports and statements of the Surgeon Gener- al, but rather that it is making a "con- tribution to the public dialogue" on the question of whether cigarette smoking is a cause of disease. • Likening measures to restrict smoking in public places to the segregation of blacks; and suggesting that victims of lung cancer are being made to bear guilt for having smoked, and that this alleged situation is akin to the scape- goating and massacre of Jews during outbreaks of plague in the Middle Ages. • Citing the opinion of researchers in areas other than their field of exper- tise, such as Ernst Wynder, tvtD, one of the early discoverers of the link be- tween smoking and lung cancer, to support the tobacco industry view that advertising does not influence people to smoke and should not be banned. • Conversely, citing the opinion of ex- perts in a given field to deny the very influence of that field (eg, the research director of the Advertising Associ- ation, the British and European lobby- ing arm of the advertising business, who suggested in Congressional testi- mony that "cigarette advertisements do not sell the idea of smoking. They are not intended to sell the idea of smoking. They are intended to sell brands and that is what they do"). • Pointing to newspaper articles report- ing on research that either does not tinction so he's going to think, `Hmmm, they haven't proved that it causes can- cer yet.' They're using research funds directly or indirectly to further their aims. It's an issue that has not been raised before. It is conceivable that they are doing legitimate research while they are getting illegitimate public rela- tions benefit from it." The funding offers the industry an- other bonus: It has culled a group of sci- entists who can testify on the industry's behalf. During cigarette-labeling hear- ings in March 1983, at least nine re- searchers, including CTR's Sommers, who had received council money pre- implicate smoking as a cause of dis- ease or that implicates other, usually rare, suspects. Some of these reports have reached the news media through press releases of the TI. • Fostering the notion that there exists a serious scientific dispute about the risks of smoking, and implying that some scientists (eg, the late Dr Hans Sellye) have considered smoking to have benefits to health. • Suggesting that the emphasis on smoking is diverting attention from other kinds of research such as that re- lated to Alzheimer's disease or inter- feron. (Tobacco companies are in- creasingly funding health research in areas unrelated to smoking.) Although the CTR claims to be an in- dependent research organization funding independent researchers, several mem- bers of its Scientific Advisory Board have been awarded grants from the board. This is not to suggest that the researchers are compromised, but rather that the type of funding in question puts researchers in the position of having to be careful not to be compromised. After comparing the public testimony of researchers receiving funding from the CTR with the use made of that testimony by the TI's Tobacco Ob- server, one might conclude that the tobac- co industry would find it in its best inter- est to fund research only in areas in which it feels safe or has the expectation of being able to use or pubiicize the data. However generous tobacco companies may be to- ward research, and however dedicated their grant recipients may be, the maih concern of tobacco companies is to in- crease the sale of cigarettes-and the main concern of the Tobacco Institute is to help deflect threats to the sale of ciga- rettes, including scientific evidence in- dicting cigarette smoking as the leading preventable cause of death. -Alan Blum, MD sented statements to the House Sub- committee on Health and the Environ- ment. CTR's Sommers discounts these ar- guments, holding that the only purpose of the research is to uncover scientific truths. "We are disease-oriented, not public relations-oriented people as a group," said the pathologist, who be- lieves that tobacco primarily acts in concert with other factors to cause dis- ease. "I'm not a propagandist. I don't give a damn what happens to the tobac- co industry." Cullen believes that despite pressures on researchers to find grants where they 454 NEW YORK STATE JOURNAL OF MEDICINE/JULY 1985

4 F are available, investigators are starting to realize that by accepting tobacco money they arc aiding an industry re- sponsible for 1,000 deaths per day in the United States. "I've been an investi- gator for many years. I wouldn't take a nickel from them," the behavioral psy- chologist said. Fredrick Stare, MD, PHD, founder of Harvard's Department of Nutrition, accepted grants from the council 30 years ago, but says that, with a single exception, he wouldn't touch their mon- ey today. "The case against tobacco wasn't as well documented when I ac- cepted their money as it is now," he said. "I wouldn't accept their money to- day because it would help improve the image of an industry whose main prod- uct is killing so many people. However, therc is an cxception. I'd aceept their money to research tobacco as a food source. Maybe if they could sell tobacco as food for humans or livestock, they wouldn't have to sell it as cigarettes." Howard Wolinsky Howard Wolinsky is the medical re- porter jor the Chicago Sun-Times. Tobacco dilemma intensifying in North Carolina This day in early May many of his fel- low tobacco farmers are well into an- other uncertain season, transplanting tender seedlings from bed to fields; but John Vollmer takes time off to plow a different field. At North Carolina State University in Raleigh, the state's leading agricul- tural school and a stalwart tobacco in- stitution, Vollmer is an emissary. De- spite the setting, he meets not with to- bacco compatriots, but with their long time nemeses, health professionals. About 100 have congregated for a unique North Carolina Health Council Convocation on the tobacco dilemma- a first in the heart of tobacco's domin- ion. Trained in the tobacco leadership program of the Philip Morris Com- pany, Vollmer nevertheless appears un- comfortable. Loosening his tie, he warms the too-quiet audience by ac- knowledging, "I've been wanting to sneak off to the men's room for a smoke all morning." He is here to tell them about the oth- er side: what tobacco farmers do and why. He does not dispute the health consequences of smoking; in fact, he ac- knowledges his father has emphysema and that this children are well-schooled in the hazards of smoking. He talks of choice and freedom. He appeals for their understanding, saying, "It's im- portant that we begin to talk to one an- other." No more incongruous scene could have been imagined five years ago in the capital of the nation's leading to- bacco and cigarette producing state. Despite more than 20 years of assault by medical research and surgeon gener- als' warnings, here tobacco remains the golden currency. FADING GLOW The North Carolina tobacco crop is worth about $1 billion a year. Long the leading farm income producer, tobac- co's throne now is being challenged by a fast growing poultry industry. Still, to- bacco represents about 25% of the state's agricultural income and is the mainstay for some 60,000 tobacco farmers. Additionally, five of the na- tion's six cigarette manufacturers have plants in the state. These employ about 25,000 people who take home annual gross wages of about $600 million. In aggregate, the North Carolina tobacco industry from farm to auction ware- house to cigarette factory approaches $2 billion and provides 147,000 jobs. Even though the leaf's glow has faded over the last two decades, it is in- grained in the Carolina heritage. It is money to be sure. But also it is steeped in tradition, pegged to the ritual of the seasons, as Vollmer's slide show demon- strates. It is smothered in lifestyle. It is colored the red, white, and blue of American self-reliance and indepen- dence. The call for a smoke-free society within 15 years is like a declaration of hostilities. Yet, the real battle has been brewing for years and is far more imme- diate. Farmers, cigarette manufacttir- ers, and politicians are trying to fashion a new alliance out of the now divisive and failing tobacco price support and quota program. Price supports are too high, making American tobacco noncompetitive on international markets. Tobacco ware- houses are bulging with government-fi- nanced surpluses. Even though it will mean reduced income, many farmers agree with manufacturers that the sup- port price must come down. Quota own- ers, however, do not favor price support reductions because that will affect the value of their allotments. And farmers are wary of a heavy 25 cent per pound assessment on their leaf sales this year, to guarantee the stabilization program loans. They are pressing for legislation to allow cigarette manufacturers to buy out the surplus leaf at large discounts. That will result in huge program losses at a time when the tobacco program faces its severest criticism in Congress. Not even the experts are willing to pre- dict the outcome. "No NET COST" MAY BE COSTLY At first glance, the tobacco system looks simple; in fact, it is incredibly complex. Created by New Deal legisla- tion in the 1930s, the federal price sup- port system guarantees farmers a price, currently $1.70 a pound for flue-cured tobacco. Leaf, not purchased by tobac- co company buyers at auction, is auto- matically bought up at the federally guaranteed price by the Flue-Cured Cooperative Stabilization Corp. But because the guaranteed price is higher than world prices, and manufacturers have been importing greater amounts of cheaper foreign leaf, the stabilizatiorn program is anything but stable. Its warehouses are filled with 812 million pounds of unsold flue-cured leaf, dating to the 1975 crop. Flue-cured, or bright leaf, is the major ingredient in ciga- rettes. It is the type overwhelmingly grown in North Carolina, with some burl::y tobacco grown in the mountain counties. Burley, also used in cigarette blends, as well as in smoking and chew- ing tobacco, is the most widely grown. Raised in 12 states, including Kansas, Ohio, and Indiana, burley is mainly produced in Kentucky. About 512 mil- lion pounds of burley are in surplus warehouses. Clearing out these large stores through a discount manufactur- ers' buyout will cost, primarily taxpay- ers, an estimated $500 million to 51 bil- lion in fail-;d subsidy loans. Farmers will share the burden for loans made since 1982 when the No Net Cost fea- ture began. It assesses a per pound r JULY 1985/NEW YORK STATE JOURNAL OF MEDICINE 455