Veterans' views on military tobacco use and tobacco control policy.

National military and veteran service organizations (MVSOs) have the potential to be advocates for stronger military tobacco control. This study consisted of qualitative analysis of interviews with 5 MVSO leaders (or their designees) and 6 focus groups conducted with veterans, to explore the opinions of MVSO leaders and veterans about military tobacco use and tobacco control policy, and to assess their current knowledge, attitudes, and likelihood of engaging with civilian tobacco control. Themes discussed include the impact of tobacco use on the military mission and on veterans; the possibility of stronger military tobacco control policies; and the idea that such policies would affect the rights of military personnel. Participants considered whether tobacco use impacts the military mission in the most literal sense (e.g., giving away patrol locations), ignoring larger scale effects on long term health and costs. While familiar with tobacco's impacts on veterans' health, MVSO leaders did not endorse stronger policies, although some veterans did. Participants were largely unaware of the impact of tobacco use on military readiness. Establishment of better alliances among MVSOs and civilian public health groups for mutual education about tobacco's many negative effects on the military's mission may be necessary to achieve a tobacco-free military.

Turning negative into positive: public health mass media campaigns and negative advertising.

Literature suggests that 'negative advertising' is an effective way to encourage behavioral changes, but it has enjoyed limited use in public health media campaigns. However, as public health increasingly focuses on non-communicable disease prevention, negative advertising could be more widely applied. This analysis considers an illustrative case from tobacco control. Relying on internal tobacco industry documents, surveys and experimental data and drawing from political advocacy literature, we describe tobacco industry and public health research on the American Legacy Foundation's "truth" campaign, an example of effective negative advertising in the service of public health. The tobacco industry determined that the most effective advertisements run by Legacy's "truth" campaign were negative advertisements. Although the tobacco industry's own research suggested that these negative ads identified and effectively reframed the cigarette as a harmful consumer product rather than focusing solely on tobacco companies, Philip Morris accused Legacy of 'vilifying' it. Public health researchers have demonstrated the effectiveness of the "truth" campaign in reducing smoking initiation. Research on political advocacy demonstrating the value of negative advertising has rarely been used in the development of public health media campaigns, but negative advertising can effectively communicate certain public health messages and serve to counter corporate disease promotion.

"Working to shape what society's expectations of us should be": Philip Morris' societal alignment strategy.

BACKGROUND: A key element of Philip Morris's (PM's) corporate social responsibility initiatives is "societal alignment", defined as "strategies and programs to meet society's expectations of a responsible tobacco company". This study explored the genesis and implementation of Philip Morris' (PM) societal alignment efforts. METHODS: The study retrieved and analysed approximately 375 previously undisclosed PM documents now available electronically. Using an iterative process, the study categorised themes and prepared a case analysis. RESULTS: Beginning in 1999, PM sought to become "societally aligned" by identifying expectations of a responsible tobacco company through public opinion research and developing and publicising programs to meet those expectations. Societal alignment was undertaken within the US and globally to ensure an environment favourable to PM's business objectives. Despite PM's claims to be "changing", however, societal alignment in practice was highly selective. PM responded to public "expectations" largely by retooling existing positions and programs, while entirely ignoring other expectations that might have interfered with its business goals. It also appears that convincing employees of the value and authenticity of societal alignment was difficult. CONCLUSIONS: As implementation of the Framework Convention on Tobacco Control proceeds, tobacco control advocates should closely monitor development of such "alignment" initiatives and expose the motivations and contradictions they reveal.

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.

Fiscal versus social responsibility: how Philip Morris shaped the public funds divestment debate.

Calls for institutional investors to divest (sell off) tobacco stocks threaten the industry's share values, publicise its bad behaviour, and label it as a politically unacceptable ally. US tobacco control advocates began urging government investment and pension funds to divest as a matter of responsible social policy in 1990. Following the initiation of Medicaid recovery lawsuits in 1994, advocates highlighted the contradictions between state justice departments suing the industry, and state health departments expanding tobacco control programmes, while state treasurers invested in tobacco companies. Philip Morris (PM), the most exposed US company, led the divestment opposition, consistently framing the issue as one of responsible fiscal policy. It insisted that funds had to be managed for the exclusive interest of beneficiaries, not the public at large, and for high share returns above all. This paper uses tobacco industry documents to show how PM sought to frame both the rhetorical contents and the legal contexts of the divestment debate. While tobacco stock divestment was eventually limited to only seven (but highly visible) states, US advocates focused public attention on the issue in at least 18 others plus various local jurisdictions. This added to ongoing, effective campaigns to denormalise and delegitimise the tobacco industry, dividing it from key allies. Divestment as a delegitimisation tool could have both advantages and disadvantages as a tobacco control strategy in other countries.

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.

The perimetric boycott: a tool for tobacco control advocacy.

OBJECTIVES: To propose criteria to help advocates: (1) determine when tobacco related boycotts may be useful; (2) select appropriate targets; and (3) predict and measure boycott success. METHODS: Analysis of tobacco focused boycotts retrieved from internal tobacco industry documents websites and other scholarship on boycotts. RESULTS: Tobacco related boycotts may be characterised by boycott target and reason undertaken. Most boycotts targeted the industry itself and were called for political or economic reasons unrelated to tobacco disease, often resulting in settlements that gave the industry marketing and public relations advantages. Even a lengthy health focused boycott of tobacco industry food subsidiaries accomplished little, making demands the industry was unlikely to meet. In contrast, a perimetric boycott (targeting institutions at the perimeter of the core target) of an organisation that was taking tobacco money mobilised its constituency and convinced the organisation to end the practice. CONCLUSIONS: Direct boycotts of the industry have rarely advanced tobacco control. Perimetric boycotts of industry allies offer advocates a promising tool for further marginalising the industry. Successful boycotts include a focus on the public health consequences of tobacco use; an accessible point of pressure; a mutual interest between the target and the boycotters; realistic goals; and clear and measurable demands.

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.

"Creative Solutions": selling cigarettes in a smoke-free world.

OBJECTIVE: To analyse the development and execution of the "Creative Solutions" Benson & Hedges advertising campaign to understand its social, political, and commercial implications. METHODS: Searches of the Philip Morris documents and Legacy Tobacco Documents websites for relevant materials; Lexis/Nexis searches of major news and business publications; and denotative and connotative analyses of the advertising imagery. RESULTS: Philip Morris developed the Creative Solutions campaign in an effort to directly confront the successes of the tobacco control movement in establishing new laws and norms that promoted clean indoor air. The campaign's imagery attempted to help smokers and potential smokers overcome the physical and social downsides of smoking cigarettes by managing risk and resolving internal conflict. The slogans suggested a variety of ways for smokers to respond to restrictions on their habit. The campaign also featured information about the Accommodation Program, Philip Morris's attempt to organise opposition to clean indoor air laws. CONCLUSION: The campaign was a commercial failure, with little impact on sales of the brand. Philip Morris got some exposure for the Accommodation Program and its anti-regulatory position. The lack of commercial response to the ads suggests that they were unable to successfully resolve the contradictions that smokers were increasingly experiencing and confirms the power of changing social norms to counter tobacco industry tactics.

From adversary to target market: the ACT-UP boycott of Philip Morris.

BACKGROUND: In 1990, the AIDS Coalition to Unleash Power (ACT-UP) sparked a year long boycott of Philip Morris's Marlboro cigarettes and Miller beer. The boycott protested the company's support of Senator Jesse Helms (R-North Carolina), a leading opponent of AIDS funding and civil rights for lesbian, gay, bisexual and transgender (LGBT) people. ACT-UP demanded that Philip Morris sever its ties with Helms and acknowledge its responsibility to the LGBT community and to people with AIDS. OBJECTIVE: To assess the impact of the boycott on the LGBT community, the tobacco industry, and the tobacco control movement; and to determine what lessons tobacco control advocates can extract from this case. DATA SOURCES: Internal tobacco industry documents and newspaper archives. METHODS: Search of tobacco industry documents websites using "boycott", "ACT-UP", "gay", and other terms. RESULTS: Philip Morris used the boycott to its own advantage. It exploited differences within the community and settled the boycott by pledging large donations to combat AIDS. Through corporate philanthropy, Philip Morris gained entrée to the LGBT market without appearing gay friendly. Many LGBT organisations, thirsty for recognition and funding from mainstream corporations, welcomed Philip Morris's overtures without considering the health hazards of tobacco. CONCLUSIONS: Unless the goal of a boycott is to convince the tobacco industry to abandon tobacco altogether, such actions invite the industry to expand its marketing under the guise of philanthropy. Tobacco control advocates should be clear about goals and acceptable settlement terms before participating in a boycott of a tobacco company.

Thinking the "unthinkable": why Philip Morris considered quitting.

OBJECTIVE: To investigate the genesis and development of tobacco company Philip Morris's recent image enhancement strategies and analyse their significance. DATA SOURCES: Internal Philip Morris documents, made available by the terms of the Master Settlement Agreement between the tobacco companies and the attorneys general of 46 states, and secondary newspaper sources. STUDY SELECTION: Searches of the Philip Morris documents website (www.pmdocs.com) beginning with terms such as "image management" and "identity" and expanding as relevant new terms (consultant names, project names, and dates), were identified, using a "snowball" sampling strategy. FINDINGS AND CONCLUSIONS: In the early 1990s, Philip Morris, faced with increasing pressures generated both externally, from the non-smokers' rights and public health communities, and internally, from the conflicts among its varied operating companies, seriously considered leaving the tobacco business. Discussions of this option, which occurred at the highest levels of management, focused on the changing social climate regarding tobacco and smoking that the tobacco control movement had effected. However, this option was rejected in favour of the image enhancement strategy that culminated with the recent "Altria" name change. This analysis suggests that advocacy efforts have the potential to significantly denormalise tobacco as a corporate enterprise.

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.

Cigar magazines: using tobacco to sell a lifestyle.

OBJECTIVE: To assess the content of two cigar "lifestyle" magazines, Cigar Aficionado and Smoke. DESIGN: Content analysis of cigar focused articles. SUBJECTS: Cigar focused articles (n = 353) from Cigar Aficionado and Smoke magazines. MAIN OUTCOME MEASURES: Primary focus; mention of health effects, environmental tobacco smoke, or scientific research; quotation and description of individuals; characteristics such as sex, age, ethnicity, smoking status, affiliation, and stance towards cigars; and overall image of cigars. RESULTS: Cigar business-focused articles were the largest category (40%, n = 143), followed by articles about cigar events (12%, n = 42). Notable were articles featuring cigar benefits to raise money for health charities. Celebrities were featured in 34% (n = 121) of articles and 96% (n = 271) favoured cigar use. Only four (1%) articles featured health effects of cigars as a primary focus. CONCLUSIONS: Cigar Aficionado and Smoke broke new ground in tobacco marketing by combining promotion of product, lifestyle, and industry in the same vehicle and linking the medium directly to product related events that extended its reach. The creation and marketing of new tobacco use sites challenges the increasing "isolation" of smokers, and positions cigar use as a socially welcome relief from restrictions. Public health advocates should anticipate and challenge other new tobacco marketing vehicles as communications technologies advance and public spaces for smoking shrink.

Cigar risk perceptions in focus groups of urban African American youth.

PURPOSE: To explore cigar use perceptions among urban African American youth. METHODS: A convenience sample (n = 50) of African American volunteer participants, ages 14- 18, participated in six audiotaped focus groups conducted in two California cities. Transcriptions were analyzed using iterative strategies. RESULTS: Most youth believed cigars were harmful to health, yet a disjuncture existed between this abstract belief and the socially embedded understandings revealed in discussions. Some youth felt that cigars were more "natural" and therefore less harmful than cigarettes. For some, that understanding rested on a mistaken assumption that nicotine was an artificial additive not present in cigars. Youth had received little cigar-specific health education. They reported that cigars were easily obtained, noted cigars' social cachet, and drew attention to new brands targeting youth. IMPLICATIONS: Perceptions of risk are not merely interesting "subjective" findings but are important determinants of actual use patterns and may not correlate with abstract beliefs. Recent cigarette brand repositionings, such as Winston's "no additives" campaign, have widely publicized the many substances added to cigarettes. Some youth may take lack of cigar-specific preventive education as an indication that cigars do not contain such substances, including nicotine. Misperceptions about risks of cigar and cigar/marijuana smoking must be addressed through consistent, coordinated, and comprehensive tobacco control efforts for all tobacco products.