Commentary: How Nurses Can Help Grow the Anti-Tobacco Industry

June 2012Ruth Malone

Anyone who followed the recent battle over Proposition 29, the ballot measure to increase California’s tobacco tax by $1 per pack, is surely aware of the multimillion-dollar campaign against the measure, funded primarily by major tobacco companies R.J. Reynolds and Philip Morris. What many nurses may not realize is the extent to which tobacco companies work to thwart public health measures – locally, nationally and even globally.

Ruth Malone (photo by Elisabeth Fall) I’ve studied the tobacco industry for the last 15 years, mostly by analyzing internal tobacco company documents released as part of multiple legal cases against them. One focus of my work has been exploring the ways tobacco companies actively seek to undermine health policies that could reduce smoking.

All companies seek to sell their products to whoever might buy them, and to increase sales by increasing consumption. One expects that. However, the tobacco industry not only markets its products aggressively (and through insidious means that aim to lure young people with “forbidden fruit” messaging); it also works actively to spy upon, counter and undo the work of public health.

I remember being shocked when I first came across documents describing how tobacco companies sent a public relations consultant to secretly audiotape meetings of Stop Teenage Addiction to Tobacco (STAT), a Boston-based group working on youth smoking prevention in the 1990s. I read the secret reports the consultant wrote on how hard it was to keep the tape recorder hidden [1]. But that was only the beginning.

Tobacco companies have long joined together to collectively fight public health measures. My research team’s work also uncovered information about the series of global, cross-company organizations the industry formed to work against what it calls the “anti-tobacco industry,” or “ATI” [2].

What is the ATI? According to internal tobacco company documents, the ATI comprises numerous public health groups supporting strong tobacco control measures, including major medical, nursing and public health organizations – right up to the World Health Organization, which the industry has repeatedly tried to discredit and undermine. Public health, it turns out, is seen by tobacco companies as having “clearly opposing interests.”

The tobacco industry also actively tries to undo nurses’ efforts at the individual level. For example, tobacco companies know that many people who smoke try to quit at New Year’s or on their birthday, times that nurses often encourage their patients to set as quit dates. We discovered that tobacco companies sent consumers discount coupons and other promotional offers at these specific times, hoping to weaken people’s resolve to become tobacco-free [3].

Nurses need to learn more about the tobacco industry so that we can all further educate the public [4]. The tobacco disease epidemic that killed 100 million people worldwide during the last century was actually created by tobacco companies. Yes, people used tobacco and suffered diseases from it before the rise of commercial cigarette companies. But they did not use it in such large numbers or so frequently, the products were not engineered to increase addictiveness and deep inhalation, and there were not so many aggressive efforts to promote its use.

In the 1800s, lung cancer was a rare disease; now it kills more women than breast cancer. We simply can’t afford another century like the last one, which is why nurses must not only help people stop smoking, but begin to help the public understand the role of the tobacco industry and why tobacco control policy measures – like higher tobacco taxes, which reduce consumption – are so important.

Nurses can do this in multiple ways. For example, when counseling smokers to quit, nurses can remind them that they don’t want to keep giving their money to companies that have lied and deceived so many people about how deadly their products are. Nurses can also alert smokers to watch out for industry-initiated efforts to discourage them from quitting.

Focusing on the industry helps empower smokers to understand that tobacco addiction isn’t merely a problem of their own individual bad choices, but of choices tobacco companies made – first in engineering products to maximize their addictiveness and then in promoting them so effectively. For example, so-called “light” (or “low-tar”) cigarettes have been found to actually deliver higher levels of nicotine than “regular” cigarettes of the same brand, and were marketed heavily to older smokers. Why would this be, since tar and nicotine normally track together? Because higher levels of nicotine make these cigarettes harder to quit.

In pediatric and adolescent health, nurses can remind kids that the tobacco industry needs “replacement smokers” to make up for all those who die every year, and that it counts on getting enough of them by making smoking look like a cool, edgy, “adult” thing to do. Evidence shows that this message is more effective with adolescents than warning them about health risks.

My colleagues and I recently published a review summarizing the robust evidence that tobacco industry denormalization messages – that is, public health messages aimed at helping people realize that the tobacco industry is not a normal business – enhance tobacco control efforts and are associated with reduced smoking prevalence, reduced intention to smoke and increased intention to quit [5]. Tobacco companies spent most of the last century trying to convince us, first, that smoking wasn’t harmful, and then that it was still acceptable to continue selling a product that killed approximately half its consumers when used as intended – a product that is the single most deadly consumer product ever made. Cigarettes would never be allowed on the market if introduced today. It’s time to say: this is not a normal business; it is a dying business.

In the community, nurses can become active members of their local tobacco control coalition (contact your local department of public health to learn more) and use their advocacy skills to work for policy changes, such as limiting the number of tobacco retail outlets, extending smoke-free policies or increasing tobacco taxes. We cannot end the tobacco epidemic one smoker at a time. Important though these efforts are, the reality is that policy change reduces smoking prevalence more rapidly than individual-level interventions.

The Nightingales Nurses provides resources to help nurses learn more about the tobacco industry and their own important roles in the “anti-tobacco industry.” Tobacco Free Nurses also provides resources for nurses to help their patients become tobacco-free.

I hope for a day when every nurse will find a way to integrate education about the tobacco industry into his or her practice, and when all nursing organizations will devote sustained attention to ending this industrially produced epidemic.

Ruth Malone is professor and chair, Department of Social & Behavioral Sciences, UCSF School of Nursing. Internationally recognized as an expert on the tobacco industry, she is currently studying the tobacco industry’s “corporate social responsibility” initiatives and their implications for public health policy, the industry and US military tobacco control, and why some businesses abandon tobacco sales. Her research is funded by the National Cancer Institute and the California Tobacco-Related Disease Research Program. She has served as an expert consultant to the CDC, the US Department of Justice and the World Health Organization. Since 2009, she has served as editor-in-chief of the leading international tobacco control policy journal, Tobacco Control, published by the BMJ Group.


1. Malone RE. Tobacco industry surveillance of public health groups: The case of STAT and INFACT. American Journal of Public Health. 2002;92(6):955-60.

2. McDaniel PA, Intinarelli G, Malone RE. Tobacco industry issues management organizations: Creating a global corporate network to undermine public health. Globalization and Health. 2008;4:2.

3. Cataldo JK, Malone RE. False promises: The tobacco industry, “low tar” cigarettes, and older smokers. Journal of the American Geriatrics Society. 2008;56(9):1716-23.

4. Malone RE. Nursing’s involvement in tobacco control: Historical perspective and vision for the future. Nursing Research. 2006;55(4 Suppl):S51-7.

5. Malone RE, Grundy Q, Bero LA. Tobacco industry denormalisation as a tobacco control intervention: A review. Tobacco Control. 2012;21(2):162-70.