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How the tobacco industry began funding courses for doctors

Earlier this year, the largest tobacco company in the world paid millions to fund continuing medical education courses on nicotine addiction —16,000 physicians and other health care providers took them.

From the 1930s to the 1950s, tobacco companies regularly advertised in medical journals, promoting their brand of cigarettes as the healthier choice. More doctors smoke Camels, they touted. Philip Morris cigarettes don't cause throat irritation. Menthol cigarettes might even cure the common cold.

These may seem like quaint anecdotes from another era, but the tobacco industry continues to solicit allies from the medical community.

In its latest tactic, Philip Morris International, the world's largest tobacco company, succeeded in funding a series of continuing medical education courses on the online platform Medscape, a leading for-profit provider of free continuing medical education. Physicians are required to complete a certain number of continuing medical education hours to keep their licenses up to date, which may cost thousands of dollars a year for paid courses.

From late February to April, some 16,000 physicians and other health care providers took the free Philip Morris-funded courses.

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On the surface, these online courses, aimed at providers and certified by the Accreditation Council for Continuing Medical Education, provided expert information on helping patients with tobacco use and nicotine addiction. But it was not by accident that many of the educational messages aligned with the tobacco industries' aim to keep people hooked on their products.

"They've done something that is truly outrageous," said Robert Jackler, MD, professor emeritus of otolaryngology at Stanford Medicine, who is an expert in tobacco advertising. He is the co-author, with Pamela Ling, MD, PhD, a professor of medicine at the University of California, San Francisco, of an opinion article published July 8 in the Journal of the American Medical Association highlighting the more egregious examples of bias in these Medscape courses.

One course, Harm Reduction from Tobacco, taught that "The health goal of all smokers should be smoke-free, not tobacco/nicotine abstinent."

"Only purveyors of tobacco products would assert that sustaining nicotine addiction should be the primary goal in optimizing health -- addiction is not wellness," Jackler said.

Another course, called Nicotine Misperceptions, dismissed the adverse effects of nicotine on the developing teenage brain, stating that "none of this has ever been demonstrated in humans," despite copious human data to the contrary. In the course quiz, there's a question on how a patient who smokes one pack of cigarettes a day, and whose father died of lung cancer, can reduce his cancer risk. None of the answer choices advised quitting tobacco products, instead suggesting pipe smoking, e-cigarettes or cutting down to half a pack a day. 

"The tobacco industry has a long history of corrupting science and creating false narratives with invalid science," Jackler said. "Clearly, the tobacco industry should have no role in educating health care practitioners about nicotine products because they have a huge and unresolvable conflict of interest."

Clearly, the tobacco industry should have no role in educating health care practitioners about nicotine products because they have a huge and unresolvable conflict of interest.

Robert Jackler

We spoke to Jackler about the controversy, the consequences and how Philip Morris was allowed to be involved in medical training in the first place. This Q&A has been edited for length and clarity.

Why were these continuing medical education courses targeted by the tobacco industry?

The tobacco industry is seeing a decline in sales of their traditional combustible cigarettes.

As profits are threatened, companies are introducing a whole network of products -- e-cigarettes, heated tobacco, oral pouches -- under the seductively appealing guise of harm reduction. Supposedly, you take a two-pack-a-day smoker, give them an e-cigarette to satisfy their nicotine addiction, and they'll cut down on or quit cigarette smoking. Unfortunately, for most people, that doesn't happen. It's just another way to sustain and further nicotine addiction.

Robert Jackler

The world is becoming more hostile to smokers -- you can't smoke in restaurants or bars; you can't smoke in offices, parks, public spaces, sporting events and airplanes. Filling in those discontinuities of nicotine addiction with alternative forms of nicotine delivery deepens addiction and makes quitting even harder.

The tobacco industry uses harm reduction in public relations campaigns and to lobby for more permissive regulations from the government. They create philanthropic foundations with benign-sounding names like the Foundation for a Smoke-Free World. And now they're giving money to for-profit continuing medical education companies.

All of these are funded by the tobacco industry to carry the corporate narrative that enables them to keep selling cigarettes, to keep people addicted and to recruit nicotine addicts.

What are the quality standards for continuing medical education?

The American Council of Continuing Medical Education began in the early 1980s to implement a series of protections to keep the content of educational programs apart from commercial funding. That's gradually tightened over the years. There must be a robust disclosure of any financial support as well as content validation. The course slides and the faculty are carefully reviewed, with full disclosure of any commercial associations on the part of the faculty.

The majority of continuing health care education is done by institutions like medical schools and hospital systems, including Stanford's, who have a high burden of responsibility for ensuring that there is no commercial bias in the course content. In the past, I served as assistant dean of continuing medical education at Stanford. We had a curriculum committee that first determined where there were knowledge gaps, then we designed the curriculum, and finally, we looked for funding. We did not allow courses to be funded by a single company, and many of our courses had no commercial funding. Physicians usually paid to take these courses, or they were subsidized by departments.

The CME requirements for physicians vary from country to country, and in the U.S., from state to state. In California, licensed health care practitioners must take at least 50 hours of continuing medical education every two years.

There's nothing inherently wrong with doctors and nurses getting free CME from for-profit companies like Medscape, but the curriculum must be fair, balanced and free of commercial bias.

With these standards in place, how was this allowed to happen?

The tobacco industry has vast resources -- billions of dollars to put into marketing and lobbying.

There's a tiny number of experts who have been employed by the tobacco industry for decades and who always support the corporate narrative. They're not well-respected for their scientific rigor by the public health community.

Robert Jackler

There's a tiny number of experts who have been employed by the tobacco industry for decades and who always support the corporate narrative. They're not well-respected for their scientific rigor by the public health community. One is a professor at the University of Louisville who sits in an endowed professorship funded by U.S. Smokeless Tobacco Company and Swedish Match, both owned by Philip Morris. No surprise these ended up being the people who gave these courses.

Medscape claims they asked a bunch of people to teach these courses, and many said no. Well, that should have been a red flag.

When you have a course, especially if anybody's financially conflicted, you are required to have an expert in the subject matter review it. Medscape employs nurses and pharmacists to do reviews -- in this case, two nurses -- but they would not be expected to have sophistication in this particular field to understand what the industry is doing.

Even though the landing pages for these online courses noted they were funded by Philip Morris, the course slides did not, and the faculty didn't disclose their conflicts. We have verbatim transcripts from the courses -- they never mentioned it, even though they had all sorts of conflicts of interest.

Is this the first time that a tobacco company has funded continuing medical education?

I'm unaware of any tobacco company previously having the chutzpah to try to fund accredited continuing medical education of health care workers.

I'm unaware of any tobacco company previously having the chutzpah to try to fund accredited continuing medical education of health care workers.

Robert Jackler

Medscape's initial response was that they followed the standards set by the Accreditation Council for Continuing Medical Education, which had no policy against the tobacco industry funding physician education. Well, that's true, because nobody's ever done it before. That doesn't mean it's right.

We have evidence that it's being done now in other countries, including South Africa and several countries in the Middle East. It's a global campaign, not just in the U.S.

Medscape is only one of many for-profit continuing medical education companies. Philip Morris offered them $2.9 million for a six-month-long online CME program, "The PMI Curriculum for Health Care Providers." Many of the smaller CME companies may be swayed by that kind of money.

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What has changed since Medscape was confronted about these courses and what still needs to happen?

A group of public health researchers, including my co-author Pam Ling and me, began an investigation and worked with a reporter who broke the story in the British Medical Journal in April. Pam and I then held a series of meetings with the manager of Medscape Education.

To Medscape's credit, they quickly admitted they made a mistake in accepting the funding from Philip Morris. They've appropriately taken a series of actions. They've removed the courses. They are returning the money to Philip Morris. They're tightening their process of disclosure and doing more rigorous content analysis.

They are going to reach out to all 16,000 providers who took these courses with apologies that they were sponsored by the tobacco industry and had serious breaches of the doctrine of fairness and balance. As part of their remediation, Medscape is going to self-fund a series of courses on helping patients who are tobacco-addicted, including ways of ceasing smoking and caring for smoking-related diseases.

They were required by the Accreditation Council for Continuing Medical Education to submit a report about these changes. It's over 100 pages.

Our goal is not to throw Medscape under the bus. It's about keeping the tobacco industry out of a place it should never have been in the first place.

The accreditation bodies around the world need to step up and specifically ban funding from the tobacco industry and its many associates. Tobacco is different than other industries. There is but one leading cause of preventable death and suffering in this country, and that is tobacco use, far and away.

Photo: Roman (

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