Editorials

WHO faces up to its tobacco links

Report provides compelling evidence for transparency about competing interests

Five years ago I wrote a critique of the World Health Organization in the BMJ.¹ One of my sources was a report by an American economist, Richard Tollison, which tore apart the WHO's budgetary priorities. Tollison's main claim was that too little of the WHO's money was spent on improving health in the developing world.² One statement quoted in the BMJ ran, "The poorest nations in WHO are interested in basic public health, and not in the more exotic forays of WHO into the public health issues of the modern industrialised West."³ What I and the BMJ and its readers didn't know, because the report didn't say, was that Tollison was in the pay of British American Tobacco. Nor did we know that such covert funding of "independent" commentators was just one part of an elaborate campaign by the tobacco industry to discredit the WHO and divert money and attention away from tobacco control activities.

The WHO has been concerned for some time about the poor success of its anti-tobacco initiatives. The forced disclosure last year of 35 million pages of confidential tobacco industry documents alerted the WHO to the possibility of direct interference and led its director general, Dr Gro Harlem Brundtland, to set up an independent inquiry. The four external experts published their report this week.⁴ In it they conclude: "To many in the international community, tobacco use prevention may be seen as a struggle against chemical addiction, cancers, cardiovascular diseases and other health consequences of smoking. This inquiry adds to the mounting evidence that it is also a struggle against an active, organised and calculating industry."

The report gives insights into the lengths to which an industry may go to protect its interests and into the methods it uses. Although influential, Tollison was a minor player compared with Paul Dietrich, an American lawyer with long term undisclosed ties to tobacco companies. According to the report, Dietrich's role was to undermine the WHO's credibility, raise questions about its mission, and redirect its priorities away from tobacco control. Dietrich himself denied links with the tobacco industry when interviewed by the inquiry committee. But the industry documents present a picture of a lengthy financial relationship in return for advising tobacco companies, writing articles attacking the WHO (published in major US newspapers), giving media briefings, and speaking at conferencesall in the guise of an independent expert. In 1990, while receiving a monthly retainer from British American Tobacco, he was appointed to the development committee of the Pan American Health Organization, which also serves as the WHO's regional office for the Americas. Documents from British American Tobacco credit him with persuading the Pan American Health Organization to remove tobacco control from that year's priorities, in favour of immunisation and cholera campaigns.

Tobacco companies used institutions as well as individuals to influence policy decisions. It not only funded apparently independent organisations such as the Institute for International Health and Development, described as a non-profit foundation "devoted to examining public health and developing policies affecting developing nations," but also influenced the policies of other United Nations agencies. Lobbying by the International Association of Tobacco Growers, secretly funded by the tobacco industry, persuaded the Food and Agriculture Organization and the World Bank to shift emphasis from the health consequences of smoking to the economic benefits of tobacco growing. Developing countries were also successfully lobbied to resist tobacco control for economic reasons.

The industry used different tactics in a notorious campaign to undermine a multicentre case-control study on passive smoking, run by the International Agency for Research on Cancer. These included using paid scientists to extract confidential information from participating researchers, setting up a coalition of scientists to raise questions about the validity of the study's methods, and running a media campaign to misrepresent the study's results. Although the industry did not succeed in delaying or altering the results of the study,⁵ it did manipulate media accounts of the findings, leading many to believe that the study failed to show a relation between environmental tobacco smoke and lung cancer.

The committee of experts concludes that the WHO needs to strengthen its policies on conflict of interest. At present only the most senior officials have to declare personal financial interests. The committee recommends that all staff, consultants, temporary advisers, and members of expert committees should be required to do so, with clear and well enforced penalties for those who violate the rules. The WHO should also prohibit anyone who works for them from having financial ties with tobacco companies. The committee also suggests making it a condition of employment that after leaving the WHO staff will not contact the WHO on behalf of tobacco companies for at least two years and that in any subsequent dealings they will declare any tobacco company ties. The WHO should also educate scientists and collaborators about the need for vigilance when dealing with the tobacco industry.

The WHO has already acted on the report's first recommendation by releasing the report immediately and encouraging wide coverage. This confirms WHO's commitment to transparency. The release is notable for the lack of any accompanying comment from the WHO itself, suggesting a willingness to await the public's response before deciding how to respond.

The WHO can perhaps take some comfort from the seriousness with which the tobacco industry viewed its antitobacco campaign, at a time when many were discounting the WHO as a spent force. If nothing else, the shock of these findings, in particular the scale and intensity of the industry's campaign, should serve to make the WHO more streetwise. But the lessons are generalisable beyond the WHO. In any area of commercial interest there will be activities that fall below good corporate practice. UN secretary general Kofi Annan will no doubt have this in mind as he plans his "global contract" with multinational companies and the labour and environment movements later this year. The report's findings add to our understanding of the insidious influence of financial interests in science.^6-8 They also confirm the need for everyone involved in forming public policy and in doing or interpreting research to adopt and enforce stringent ethical standards, and in particular to be alert to their own and other people's conflicts of interest.

Fiona Godlee, editorial director (medicine). 

BioMed Central, London W1P 6LB (fiona{at}biomedcentral.com)

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