The hidden power of corporations

Among its many tactics, the tobacco industry has long been using corporate social responsibility activities to present a sanitized and soft public image while they continue to produce and promote their lethal products.(1) As fantastic as these may sound, their camouflaged efforts can cause substantial damage to public health through interference in public policy. The latest example is the ‘donation’ offered to Pakistan’s Prime Minister Imran Khan’s fund to build a new dam to solve the country’s energy and water crisis.(2) This happened a few days after the administration took a U-turn on their flagship policy of introducing ‘health levy’ on cigarettes as a way to increase public revenue and expenditure on health.(3)

Approximately, one in five adults in Pakistan consume tobacco on a regular basis which leads to more than 160,000 deaths every year.(4) Pakistan, a signatory to the WHO Framework Convention to Tobacco Control (FCTC), has introduced a number of laudable measures to reduce tobacco-related harm in recent years including smoking ban in public places, restricting cigarette sale in packs of 20 only and increasing the size of pictorial health warning on cigarette packs. However, the country has taken regressive steps on tobacco taxation, which is generally considered to be the most effective policy tool to curb tobacco use. In 2017, Pakistan’s government introduced a three-tiered tax system, which allowed tobacco companies to shift many of their popular products from the second (higher tax) to the third tier (low tax), which was associated with an increase in cigarette consumption and profits for the tobacco industry and a substantial fall in public revenues.(5) Recently, the government has also allowed companies to start re-manufacturing cigarettes in packs of 10 for ‘export’ purposes, which might be brought back into the internal Pakistani markets, as many anti-tobacco campaigners fear.

On the other hand, the tobacco industry has recently expanded their influence through corporate social responsibility activities, widely reported in Pakistan’s media. These include offering cigarette gift packs to Pakistan Naval Forces and Prime Minister’s house, building a cigar lounge for members of parliament inside the Parliament House, setting up mobile hospitals and computer centers, launching tree plantation campaigns and sponsoring conferences and sign boards for public bodies. It, therefore, comes as no surprise that Pakistan’s progress on tobacco control policies has slowed down. As an example, recent legislation to increase the size of pictorial warning was delayed and finally abandoned. Another is the U-turn on ‘health levy’, in response to which the Federal Board of Revenue reiterated that ‘increasing tobacco taxes might lead to illicit tobacco trade’ a line often used by the industry and almost always refuted by independent experts.(6)

According to article 5.3 of the WHO FCTC, activities that are described as “socially responsible” by the tobacco industry, fall within the Convention’s definition of advertising, promotion and sponsorship. The Framework recommends countries ensure that all branches of government don’t endorse, support, form partnerships with or participate in activities of the tobacco industry described as socially responsible. According to the Framework, all of the above listed activities would be in violation with this agreement. It is possible that Pakistan’s Prime Minister may not have been made aware of country’s obligations under the Framework. Furthermore, Prime Minister’s recent acceptance of the ‘donation’ from tobacco industry is also incongruous with his lifelong campaign against cancer and his recent commitment to anti-tobacco advocacy. We would therefore expect him to return this ‘donation’ and expose the true nature of the ‘merchants of death’ hidden underneath the cloak of corporate social responsibility.

1. Friedman LC. Tobacco industry use of corporate social responsibility tactics as a sword and a shield on secondhand smoke issues. J Law Med Ethics 2009;37(4):819-27. doi: 10.1111/j.1748-720X.2009.00453.x
2. Junaidi I. Activists in shock over tobacco firm’s donation for dams fund. Dawn 2019.
3. FBR Opposes Imposing Sin Tax On Cigarettes. Urdu Point 15th April. 2019.
4. Saqib MAN, Rafique I, Qureshi H, et al. Burden of Tobacco in Pakistan: Findings From Global Adult Tobacco Survey 2014. Nicotine Tob Res 2019;21(1):136. doi: 10.1093/ntr/ntx282
5. Ali K. NAB inquiry reveals tobacco firms’ profits increased by 218pc. Dawn 2018.
6. Joossens L, Merriman D, Ross H, et al. The impact of eliminating the global illicit cigarette trade on health and revenue. Addiction 2010;105(9):1640-9. doi: 10.1111/j.1360-0443.2010.03018.x

McKee and colleagues usefully draw attention to corporate strategies that serve shareholder interests at the expense of public health; these impacts are often obscured by sophisticated marketing and public relations (1). Of particular interest is why so many of us, including doctors, fail to recognise this common pattern; as we are part of the problem, an understanding of this ‘blindspot’ and its determinants is needed to guide management.

Several psychological mechanisms are relevant. First, as a species we are notably poor at recognising our vulnerability to persuasion. Complementing this lack of insight, we doctors like to think that our clinical decisions are based on scientific rationality (2); marketers reinforce this vanity with carefully curated ‘evidence’, often coupled with images that appeal to our healing role. Seeing ourselves as rational prescribers, we rankle at suggestions that we are influenced by marketing but, somewhat ironically, denial of vulnerability is itself a key risk factor for being influenced (3).

A related problem arises from conflicts of interest in medicine and, controversially, how these should be identified and managed. Disclosing conflicts, as McKee and colleagues note, is necessary but not sufficient to manage associated bias (4). As with vulnerability to persuasion, we are also rather better at reckoning conflicts in our colleagues than ourselves (5). This blindspot also plays a role in distorting the medical literature, as can be seen from authors’ disclosures that downplay relationships, financial and otherwise, with for-profit corporations (6). The tendency to sanitise our links to vested interests is hard to resist; by outwardly satisfying ethical and editorial requirements, it helps us to feel better and to get published, while keeping corporate power hidden from view.

1. McKee M, Steele S, Stuckler D. The hidden power of corporations. BMJ 2019;364:l4.
2. Mansfield PR, Lexchin J, Wen LS, Grandori L, McCoy CP, Hoffman JR, et al. Educating health professionals about drug and device promotion: advocates' recommendations. PLoS Med 2006;3:e451.
3. Sagarin BJ, Cialdini RB, Rice WE, Serna SB. Dispelling the illusion of invulnerability: the motivations and mechanisms of resistance to persuasion. J Pers Soc Psychol 2002;83:526-41.
4. Loewenstein G, Sah S, Cain DM. The unintended consequences of conflict of interest disclosure. JAMA 2012;307:669-70.
5. Steinman MA, Shlipak MG, McPhee SJ. Of principles and pens: attitudes and practices of medicine housestaff toward pharmaceutical industry promotions. Am J Med 2001;110:551-7.
6. Menkes DB, Masters JD, Broring A, Blum A. What Does 'Unpaid Consultant' Signify? A Survey of Euphemistic Language in Conflict of Interest Declarations. J Gen Intern Med 2018;33:139-41.