“Our Reach Is Wide by Any Corporate Standard”: How the Tobacco Industry Helped Defeat the Clinton Health Plan and Why It Matters Now

GOVERNMENT, POLITICS AND LAW

The Wide Reach of the Tobacco Industry

‘‘Our Reach Is Wide by Any Corporate Standard’’:How the Tobacco Industry Helped Defeat theClinton Health Plan and Why It Matters NowLaura E. Tesler, PhD, and Ruth E. Malone, PhD, RN

Contemporary health care

reformers, like those who pro-

moted the failed Clinton era

plan, face opposition from

multiple corporate interests.

However, scant literature has

examined how relationships

between corporations and

other stakeholders, such as

think tanks and advocacy

groups, shape health care re-

form debate.

We show how the 2 biggest

US tobacco companies, Philip

Morris and RJ Reynolds, and

their trade association coordi-

nated in mobilizing ideologi-

cally diverse constituencies to

help defeat the Clinton plan.

Unwittingly perhaps, some

reform supporters advanced

the tobacco industry’s public

relations blitz, contributing to

perceptions of public opposi-

tion to the plan.

As the current reform debate

unfolds, this case highlights

the importance of funding

transparency for interpreting

the activities of think tanks,

advocacy groups, and ‘‘grass-

roots’’ movements. (Am J Pub-

lic Health. Published online

ahead of print May 13, 2010:

e1–e15. doi:10.2105/AJPH.

2009.179150)

HEALTH CARE REFORM IS AN

Obama administration priority.1

The Clinton Health Care SecurityAct, the last federal attempt atcomprehensive reform, failed topass in 1994. That plan, introducedin September 1993,2 representeda compromise between constituen-cies favoring government-guaran-teed universal coverage and thosefavoring free-market competition. Itproposed universal coveragethrough ‘‘managed competition’’:competing government-regulatedprivate plans.2 To be fundedthrough employer mandates, busi-ness and health care providercharges, and a 75-cent per packtobacco excise tax,2 the plan initiallyreceived strong public support.However, ensuing compromisessatisfied few, and criticisms that hadbegun months earlier continued:diverse constituencies intensifiedpublic relations and lobbying ef-forts.2,3 Ultimately, Congress aban-doned the legislation; efforts toenact alternatives failed.2

Media coverage of Obama’s ef-forts suggests that, as for the Clin-ton plan, corporate influence andcontention over financing posechallenges.2,4–10 Previous research

on the Clinton plan’s demise faultedits complexity, divisions amongreform supporters, and the admin-istration’s failure to effectivelycommunicate the plan’s features, en-abling opposition to mobilize.3,11–17

Although lobbying and advertisingby multiple corporate interests alsoplayed important roles,13,18–20 scantliterature has examined how rela-tionships between corporations andother stakeholders, such as thinktanks, advocacy groups, and ‘‘grass-roots’’ movements, affected reformdebates.

We explore how the 2 biggestUS tobacco companies, PhilipMorris and RJ Reynolds, and theirnow-defunct trade association, theTobacco Institute, worked to-gether to mobilize right-leaningthink tanks and smokers’ rights,labor, and left-leaning public pol-icy groups to help defeat theClinton plan. Through a coordi-nated, nationwide initiative, theindustry helped persuade policymakers that considerable publicopposition existed to both a fund-ing mechanism—a tobacco excisetax increase—and the plan asa whole. This case offers lessonsfor the current health care debate,

highlighting the importance offunding transparency for inter-preting activities of think tanks,advocacy groups, and ‘‘grassroots’’movements and the need for ad-vocacy organizations to considerhow accepting corporate dona-tions may compromise theiragendas.

DATA COLLECTION ANDANALYSIS

Between January 2008 andJune 2009, we searched the Leg-acy Tobacco Documents Library(http://legacy.library.ucsf.edu),which includes more than 10 mil-lion internal tobacco industrydocuments obtained following the1998 Master Settlement Agree-ment.21,22 Using snowball sam-pling,21,23 we identified documentsdated 1992–1995, beginning withsearch terms including ‘‘Clintonplan’’ and extending to names oforganizations and industry person-nel. Searches produced approxi-mately 7000 hits. Reviewing indexentries and page content to excludeduplicate or irrelevant documentsyielded a final sample of approxi-mately 500 documents. We

Published online ahead of print May 13, 2010 | American Journal of Public Health Tesler and Malone | Peer Reviewed | Government, Politics and Law | e1

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http://ajph.aphapublications.org/cgi/doi/10.2105/AJPH.2009.179150

searched LexisNexis, NewsBank,and ProQuest Newspapers data-bases for related coverage on third-party allies and the Web sites ofidentified organizations.

We used an interpretive ap-proach for data collection andanalysis.24 Iteratively reviewingsuccessive collections of documents,we summarized, discussed, and re-vised ongoing interpretations, con-sidered emergent themes, andidentified gaps. We continued untilthe last wave of data collectionyielded no new information.24–26

We organized documents chrono-logically, constructing timelines ofevents, and assembled a case his-tory.24,26,27

FINDINGS

Although tobacco companiesshared other industries’ concernsabout the plan’s potential impacton businesses, the proposed excisetax spurred their activities.28,29

Tobacco companies had monitoredhealth care legislation since at leastthe mid-1970s, when tobacco ex-cise taxes were first proposed asa funding mechanism.30,31 Paid byconsumers, excise tax increases re-sult in declining cigarette sales,threatening tobacco companyprofits.32–35 During the 1980s,federal and state legislators in-creasingly used excise taxes both asa politically popular alternative toother forms of taxation and asa health policy mechanism to re-duce cigarette consumption.36 By1992, more than 20 national andstate health care reform bills wereunder development, several includ-ing cigarette tax increases.37

During the early 1990s, lowpublic approval ratings and

a negative image diminished PhilipMorris’s credibility,38 limiting itsoptions for publicly opposing healthcare reform. Given its vested in-terests in minimizing tobacco taxesand its concerns about tobaccocontrol initiatives included in mosthealth care legislation,28 PhilipMorris sought to influence thehealth care reform debate throughthird parties. As Philip Morris’sWashington relations directorKathleen Linehan explained, ‘‘PM[Phillip Morris] has been and con-tinues to work behind the scenes toachieve its strategic objectives andkeeps its public visibility on thehealthcare reform issue verylow.’’28 Likewise, RJ Reynoldssought to ‘‘explore existing organi-zations we might join/influence . . .

[a] credible, non-tobacco voice forhearings and for generating infor-mation on issue to media, op-eds,letters, etc.’’39 In March1993, whenthe Clinton administration publiclysuggested cigarette excise taxes tofund health care,40 the 2 companiesjoined forces to ‘‘develop a coordi-nated plan.’’29

The resulting ‘‘PM/RJR To-bacco Task Force’’ included rep-resentatives from both companies,the Tobacco Institute, and 4 publicrelations firms (Figure 1).41–43

Company and Tobacco Institutepersonnel held weekly meetings.44

Their work plan included solicitingsupport from credible ‘‘messagecarriers,’’45 including tobaccofarmers and industry suppliers (e.g.,suppliers of seed, pesticides, andpaper), think tanks, advocacygroups, smokers, other businesses,and organized labor.41,46 To appealacross the ideological spectrum, thetask force initially selected 4 corearguments: excise taxes were unfair

to the country’s 50 million smokers,were regressive for the poor, werelikely to encourage a black market,and could result in more than785000 tobacco-related jobs lostbecause of reduced cigarettesales.43,47 Later arguments attackedthe Clinton plan more broadly,claiming it would create new bu-reaucracy and limit health careoptions.48,49

Task Force Responsibilities

Task force members createda liaison with third-party allies onthe basis of the strengths of theirpreexisting contacts (Table 1).‘‘Leveraging’’ relationships alreadyestablished through its corporatecontributions department, PhilipMorris prioritized the funding ofright-leaning think tanks and anti-tax organizations ideologically op-posed to tax increases and gov-ernment regulation, ‘‘strategicallydirecting certain of our assets . . .

consistent with Philip Morris’ po-sitioning on the healthcare is-sue.’’50 RJ Reynolds coordinatedlocal-level ‘‘coalition-building,’’ hir-ing the Ramhurst Corporation,a firm started by former RJ Rey-nolds employees,51–53 to work withlocal antitax groups, tobacco indus-try-affiliated businesses such as re-tailers, and smokers’ rights groups(SRGs). Since 1988, RJ Reynoldshad organized hundreds of SRGsnationwide; by 1991, it had usedSRGs to ‘‘respond to swiftly emerg-ing issues’’ with ‘‘grassroots’’ actionon175 federal, state, and local levelissues.54 The Tobacco Institutesought to mobilize labor unions andleft-leaning policy organizationswith whom it had already estab-lished relationships through its um-brella organization, the Labor

Management Committee.41,55 TheLabor Management Committee hadbeen developing these relationshipssince its creation in 1984, persuad-ing 5 unions to join its board,56

providing funding to labor-alignedpolicy organizations, and mediatingmost communications through paidconsultants with preexisting unionor policy group affiliations.36,56–61

Joint membership of labor unions inthis association conferred on it le-gitimacy and the appearance ofautonomy.36,61,62 Previous researchhas examined the industry’s fund-ing and tactical relationships withboth independent SRGs and indus-try front groups for other legislativeissues.51,52,63–67

Whereas right-leaning thinktanks funded by Philip Morrisalready opposed the Clinton plan,the Tobacco Institute faced thechallenge of soliciting assistancefrom organizations considered tobe key plan supporters.11However,in response to earlier legislationproposing cigarette taxes, TobaccoInstitute staff had already begunstrategizing. In January1992, SusanStuntz, Tobacco Institute vice pres-ident of public affairs and LaborManagement Committee treasurer,noted, ‘‘Although the labor move-ment and many interest groupshave stood firmly against excisetaxes as a mechanism for raisinggeneral revenues, many of thesegroups view healthcare financing asa fundamentally different issue.’’37

Therefore, the Tobacco Institutesought to establish common groundby ‘‘encouraging’’ organizations toback ‘‘a comprehensive healthcarereform package that includes . . .

funding through broad-based pro-gressive taxes instead of regressiveexcise taxes’’ and by working with


e2 | Government, Politics and Law | Peer Reviewed | Tesler and Malone American Journal of Public Health | Published online ahead of print May 13, 2010

them to identify alternative fund-ing.68

Media Outreach

The industry embarked ona media blitz with anti–excise taxmessages and other criticisms ofthe Clinton plan. From 1993 to1994, at least 28 tobacco indus-try–funded think tanks, antitaxgroups, labor organizations, andleft-leaning organizations pub-lished studies or organized con-ferences (Table 1). Some, such asAmericans for Tax Reform andCitizens for a Sound Economy,sponsored paid print and radioadvertising and direct mail cam-paigns.69 Organizations garneredmajor US newspaper coveragethrough op-eds, interviews, and re-ports.70–83 Targeting social conser-vatives who might otherwise sup-port ‘‘sin taxes,’’ Philip Morrisfunded a 6-part miniseries on theClinton plan by the Free CongressFoundation, aired on its NationalEmpowerment Televisionnetwork.84–86 An Alexis deTocqueville Institute critique of theClinton plan brought author inter-views on right-leaning radio, in-cluding a syndicated broadcast to1000 religious stations.70,87–89

Philip Morris also collaborated withthe right-leaning Manhattan Insti-tute, providing ‘‘off-the-record’’ in-put to one of its fellows, BetsyMcCaughey, for her widely readClinton plan critique published inThe New Republic.69,90

To generate the appearance of‘‘grassroots’’ opposition to excisetaxes, RJ Reynolds’s Ramhurst co-ordinators worked with SRGs tohold press conferences and rallies,issue press releases, and conductmedia interviews.91–103

Note. PM = Phillip Morris; RJR = RJ Reynolds.

Figure 1—1993 Philip Morris documents (a) showing the Joint PM/RJR Tobacco Task Force concept and

(b) listing the members of the Task Force and their roles for public relations and lobbying activities.



TABLE 1—Activities of Tobacco Industry Supported Groups

OrganizationaPrimary

Liaison

Research and

Policy Publications

Conference

or Forum

Media

Outreachb Politicalc

Right-leaning organizations

Acton Institute PM X124,236

Alexis de Tocqueville Institute PM X69,70,237,238 X69,70,87,124,236 X70,125,126

American Enterprise Institute PM X69,239 X71,81,240–242

Americans for Tax Reform PM X243 X50,69,124,236,244–249 X250–253

Citizens for a Sound Economy PM X69,254 X69,247,248,255–264 X69,127,256,260,263,265–270

Claremont Institute PM X50,69,127 X45,69,271

Consumer Alert PM X69 X69,124

Free Congress Foundation PM X69,84–86,127

Heartland Institute PM X127 X69 X69,85,272

Heritage Foundation PM X69,85,236,273–276 X69,78,80,274–286 X286

Hoover Institute PM X69

Mackinac Center for Public Policy PM X69,236 X69,124

Manhattan Institute PM X69,74–76,85,90

National Journalism Center PM X69,84,127,236 X69,85

National Center for Policy Analysis PM X287–289 X69,124,278,290–297 X69

National Policy Forum PM X69

Pacific Research Institute for Public Policy PM X69 X69

Philanthropy Roundtable PM X69,85

Pioneer Institute for Public Policy Research PM X69

Reason Foundation PM X298

Tax Foundation PM X69,299,300 X301 X69,300,302–306

Left-leaning organizations

A. Philip Randolph Institute TI-LMC X165,183,307–310

Citizen Action TI-LMC X183 X82,83,163,170,189–191,233,311–316 X77,82,83,163,170,180,183,233,308,309,312–314,317,318

Citizens for Tax Justice TI-LMC X183,308,309,319 X308 X308,320

Coalition of Labor Union Women TI-LMC X168,169,182,321,322 X170,321,322 X170,308,309

Coalition on Human Needs TI-LMC X128

Economic Policy Institute TI-LMC X188,323 X77,180,317,318

Institute for Research on the Economics of Taxation PM X69,85 X45,324

Labor Council for Latin American Advancement TI-LMC X183,186,308,309

League of United Latin American Citizens PM X41,325 X326,327 X328

National Council of Senior Citizens TI-LMC X182,321 X311,321 X183,317

New Jersey Citizen Action TI-LMC X166,329 X166,168

Wisconsin Citizen Action TI-LMC X313,330 X313

Smokers’ rights groups

State and local chapters in 44 US states RJR- Ramhurst X91–93,96–98,100–103,137,140,144,153,154 X91–93,96–103,107,132,133,136–138,144,148–155

Note: PM = Philip Morris; RJR = RJ Reynolds; TI-LMC = Tobacco Institute Labor Management Committee. Sources cited do not include all the internal industry documents and news coverage identifiedthrough searches but rather a representative sample.aAll organizations except smokers’ rights groups received funding from Philip Morris, RJ Reynolds, or the Tobacco Industry Labor Management Committee between 1992 and1994.127,131,173,214,215,238,325,331–340 However, documents provide evidence that industry-funded consultants (the Ramhurst Corporation) helped organize smokers’ rights groups and coordinated theiractivities.91,96–102,104–109,111,113,114,117,132–144,146,150,151,153–155,157,341–345

bMedia outreach activities included publishing articles, op-eds, and letters to the editor; conducting interviews; sponsoring paid advertising; and issuing press releases and solicited or unsolicited positivecoverage of the organization’s policy papers that critiqued the Clinton health plan or endorsed an alternative health plan.cPolitical activities included lobbying; disseminating policy papers, letter to the editors, and op-eds to elected officials and their staff members; and organizing rallies, protests, and constituent letters andtelephone calls to elected officials in opposition to the Clinton health plan.



Consultants provided groups withpetitions104–106 and held trainingsessions on excise taxes, healthcare reform, and communicatingwith media.92,104,107–115 SRGs re-ceived a briefing book containingtalking points, media guides, andresources about speaking opportu-nities.110 To facilitate letter-writingcampaigns, RJ Reynolds staff pre-pared 80 unique ‘‘Letters to theEditor’’ templates for SRGs andsamples of letters to elected offi-cials.116–121 When Clinton formallyannounced the health care plan inSeptember 1993,122 SRGs alonegenerated more than 300 mediahits, including op-eds, talk showinterviews, and press releasecoverage.92

Mobilizing the Political Right

Philip Morris and RJ Reynoldscollaborated on tax increase alertsto 50 million US consumers intheir databases, who reportedlysent approximately 50000 lettersto Congress.29,44,123 For politicallysympathetic elected officials (par-ticularly those representing tobaccostates), the companies shared lob-bying responsibilities.41,44,69,124 Tosupplement direct outreach, PhilipMorris organized grassroots lobby-ing by right-leaning think tanks.48

At Philip Morris’s request, for ex-ample, Heartland Institute staff metwith 2 Republican congressmen‘‘to encourage opposition to theClinton plan and FET [Federal Ex-cise Tax] hikes.’’85 The Alexis deTocqueville Institute distributedstudies and op-ed pieces to Con-gress members through 4 ‘‘DearColleague’’ letters; 2 senators whoserved on its board entered Alexisde Tocqueville Institute pieces intothe Congressional Record.70,125,126

Citizens for a Sound Economyhelped organize protests at townhall meetings (sessions betweenelected officials and constitu-ents).69,127

Mobilizing the Political Left

Labor Management Commit-tee–funded organizations enjoyedcredibility within DemocraticParty circles, Tobacco Institutenoted in reports to member com-panies,128 and were well positionedto influence policy makers. Formerpersonnel of some organizationshad been appointed to high-rankingparty and Clinton administrationpositions. Former Citizens for TaxJustice executive director DavidWilhelm, for example, wasappointed Democratic NationalCommittee chair.128 Tobacco Insti-tute personnel were initially con-cerned that left-leaning allies wouldbe reluctant to criticize the Clintonplan. However, Tobacco Institutepresident Sam Chilcote reported inFebruary 1993 that Wilhelm hadinformed Tobacco Institute staffthat he advised the Citizens forTax Justice executive director not togive Clinton a ‘‘honeymoon’’ periodbut to ‘‘keep the heat on the WhiteHouse through the media,’’ becausethis empowered cabinet memberswho opposed excise taxes.128

Citizen Action also enjoyeda high profile among congressio-nal staff and the Clinton adminis-tration.129,130 Tobacco Institutestaff noted that Citizen Action per-sonnel visited the White Houseregularly to discuss health care.131

Citizen Action also lobbied theHouse Ways and Means Commit-tee, arguing that excise taxes wouldhurt the middle class,128 and helda briefing opposing excise tax health

care funding for 300 house mem-bers, staff, labor unions, and interestgroups.128

Mobilizing ‘‘Grassroots’’

Movements

To influence policy makers andpublic opinion about excise taxesin general and the Clinton planspecifically, RJ Reynolds’sRamhurst coordinators met withexisting SRGs, helped create atleast 20 new ones,99,107,113,132–137

trained leaders, and coordinatedstatewide coalition meetings inat least 44 states (see Table1).51,52,114,133,137–140 Coordinatorsalso held ‘‘smokers’ rights meet-ings’’ in regions lacking formalgroups; participants signed peti-tions or wrote letters to con-gressmembers.99,133,141–144 Coor-dinators were urged to maintaina variety of SRG activities targetingelected officials:

We won’t make an impressionwith congressmen with one ortwo blow-out events. Rather wewill make our point by hittinghis/her office with a barrage ofletters one week, petitions thenext, a well-designed question-naire the next, some media hitsnext, steady opposition madeknown via town meetings andother personal visits. . . .145

By February 1994, SRGs hadreportedly made at least 20000phone calls to Congress mem-bers, sent 100000 letters, andattended 140 town hall meet-ings nationwide.92 In reports toRJ Reynolds, Ramhurst charac-terized several meetings as con-frontational.107,115,146,147 In April1993, for example, MinnesotaSmokers’ Coalition membersattended a town hall meeting withSenator Paul Wellstone (D, MN),

presented 50000 petition signa-tures, and solicited his position oncigarette taxes. When the senatoraffirmed support for the tax, ‘‘whatshould have been a friendly townmeeting in his home town turnedhostile and Wellstone abruptlyended the meeting and left. . . .’’107

A Ramhurst coordinator reportedlearning that Congressman TimJohnson (D, SD) had describedhis town hall meetings in late 1993as

not only the worst 4 weeks of hispolitical career but the worst 4weeks of his life. . . . Our groupsshould be commended for theirefforts for being in his face ev-erywhere he went. . . . He cer-tainly will be thinking about thepolitical ramifications of support-ing the presidents [sic] plan as it isnow.147

SRG members met withelected officials locally, ex-pressing home state opposi-tion.93,94,101,107,109,137,144,148–155

In April 1994, SRGs in North andSouth Dakota organized a 2-weekprogram targeting Senate FinanceCommittee members Tom Daschle(D, SD) and Kent Conrad (D,ND).150 Groups submitted formalresolutions against excise taxes tothe senators’ offices and activatedphone trees.101,150 Ultimately, onegroup met with Senator Daschle,136

and another received a responsefrom Senator Conrad’s office indi-cating ‘‘he wants to get a healthcarebill passed that has no new taxes.’’101

By June 1994, Ramhurst reported,Conrad had expressed opposition tothe entire Clinton health plan dur-ing 3 town meetings attended by‘‘hostile’’ crowds.115

SRGs also targeted eventswhere the Clintons were pro-moting health care reform. In



September 1993, 2 Florida-basedSRGs and ‘‘volunteers from RJR[RJ Reynolds] field sales’’ stageda protest outside the buildingwhere ABC’s Nightline programwas conducting a town hall meet-ing with President Clinton, draw-ing coverage from rival me-dia.91,156 A Ramhurst coordinatororganized an antitax rally at thesite of a Kansas City health careforum attended by Hillary Clin-ton and Senator Bob Dole,157

and a Kentucky SRG burned aneffigy of the first lady at a rallyattended by elected officials of bothparties.154,158,159

Promoting Alternatives

In a strategy to either minimizethe proposed excise tax increase ordefeat the Clinton plan altogether,Philip Morris funded right-leaningpolicy organizations to organizeconferences critiquing the planand promoting free-market alter-natives.69 Philip Morris also‘‘worked with’’ the National Centerfor Policy Analysis and the HeritageFoundation in the developmentand promotion of alternative healthcare proposals.69

The Tobacco Institute providedfunding and public relations sup-port to left-leaning groups pres-suring the Clinton administrationtoward a single-payer plan.160–176

By early 1994, the Clinton plan’smost significant left-leaning rival,the McDermott-Wellstone single-payer plan, was supported by morethan 90 congress members.177–179

Although an insufficient numberfor bill passage, it constituteda powerful minority.179 At the La-bor Management Committee’s re-quest, several left-leaning groupsrequested appearances before the

House Ways and Means Commit-tee in November 1993, opposing‘‘regressive elements of the Clintonplan including tobacco taxes.’’180

Public relations firm Ogilvy, Adams,& Rinehart, hired by the LaborManagement Committee,160,181,182

met with organizations to help themprepare and publicize their state-ments.180,183–185 In testimony, Citi-zen Action, the Coalition of LaborUnion Women, the A. PhilipRandolph Institute, the LaborCouncil for Latin American Ad-vancement, and the NationalCouncil for Senior Citizens miti-gated support for the Clinton planby framing it as an acceptable buttemporary alternative to singlepayer.186 All explicitly criticized thetobacco excise tax.186

Ironically, whereas the Clintonplan proposed a 75-cent per packtax increase, a $2 per pack in-crease was added to the single-payer legislation in early 1994.187

Citizen Action had initiallyclaimed it would not support leg-islation with a cigarette tax in-crease188 but continued to endorseMcDermott-Wellstone, limiting itssupport for the Clinton plan.189–192

Although in one respect this con-flicted with the Tobacco Institute’sagenda, support for rival plans stillserved tobacco industry interests bymaintaining divisions among left-leaning constituents, helping defeatthe Clinton plan; indeed, the To-bacco Institute continued to fundCitizen Action the followingyear.193,194

Epilogue

By September 1994, the Clin-ton plan was ‘‘dead.’’20 Althoughmultiple factors accounted for itsdefeat, the tobacco industry

credited itself with a significant role.According to Philip Morris’s Line-han, the

industry was confronted witha multitude of healthcare reformproposals, the majority of whichrelied heavily on increased to-bacco excise taxes. . . . With thevaluable assistance of tobaccogrowers, industry suppliers, third-party activists and congressionalallies, the industry worked to de-feat these tax proposals.195

Philip Morris viewed its fundingof right-leaning groups as moneywell spent. An internal companypresentation commented, ‘‘Thequestion is fairly asked, are wegetting enough out of groups wesupport. . . . Our reach is wide byany corporate standard.’’196 RJReynolds was similarly pleased withthe SRGs’ results: ‘‘We chased‘Clintoncare’ I all over the countryand the ‘beast’ is currently hiding ina cave, somewhere inside a belt-way.’’197 Although SRGs helpedpersuade elected officials thatwidespread public opposition toexcise taxes existed, RJ Reynolds’sown data showed that in late 1994,69% of Americans still supportedincreasing tobacco taxes to fundhealth care.198

Although taxes on tobacco,alcohol, and sugared soft drinkshave been identified as potentialfunding mechanisms for currenthealth care reform, to date theyhave not been included.199 Al-though the tobacco industry may,therefore, have little incentive tofund third-party allies to opposepresent reforms, several organiza-tions that received tobacco industryfunding to help defeat the Clintonplan have publicly opposed ele-ments of the current legisla-tion.9,200–207 None of these groups

publicly disclose their fundingsources through Web sites or an-nual reports.

In addition, as occurred withthe Clinton plan, numerous op-posing coalitions and ‘‘grassroots’’groups have appeared.208 PatientsUnited Now and Patients First werecreated by Americans for Prosper-ity,209–211 formerly Citizens fora Sound Economy,212 the singlelargest recipient of Philip Morrisfunding to generate opposition tothe Clinton plan.127,213,214 Theseand other groups have deployedsimilar tactics, including organizingprotests at town hall meetings215

and hanging a Congress member ineffigy,216,217 just as an SRG burnedan effigy of Hillary Clinton.158 Sev-eral organizations claiming to rep-resent grassroots or popular move-ments have ties with corporateinterests across multiple industries,including FreedomWorks, anotherCitizens for a Sound Economy spin-off.218–220 Conservatives for Pa-tients’ Rights has disclosed that itsfounder, formerly chief executiveofficer of Columbia/HCA Health-care Company, contributed ap-proximately $5 million but pro-vided no details on the remaining75% of its $20 million bud-get.221,222 Betsy McCaughey, towhom Philip Morris provided inputfor a Clinton plan critique, recentlypublished articles opposing thecurrent legislation,223–225 just be-fore resigning from a medicaldevice corporation to ‘‘avoid theappearance of a conflict of inter-est.’’226 Although media coveragehas noted participation of industriesor individuals with close industryties in some coalitions,227–229 notall articles make these ties ex-plicit.230–232



DISCUSSION

The tobacco industry’s successin mobilizing opposition to theClinton plan among ideologicallydiverse constituencies under-scores the challenge of overcom-ing corporate efforts to obstructhealth care reform. By encourag-ing organizations to focus onpoints of contention, the tobaccoindustry fostered a climate inwhich inaction seemed preferableto the solidarity needed for reformlegislation to pass. Key to thetobacco industry’s strategic alli-ances was its ability to keep theserelationships largely hidden. Per-ceptions of these groups as auton-omous and representing the‘‘public interest’’ enhanced thecredibility of the industry mes-sages they carried.

These findings demonstrate theneed for full disclosure of corporatefunding sources in publications,congressional testimony, and lob-bying. As Balbach and Campbellobserved, ‘‘Acceptance of fundingis less important than the transpar-ent admission of funding sour-ces.’’36 Transparency is critical tothe passage of health care reformlegislation, because arguments ad-vanced by interest groups shouldbe evaluated in light of their cor-porate sponsors’ agendas. Althoughthe tobacco industry may not havethe same vested interests in influ-encing the health care reform ef-forts of the Obama administration,other industries appear to be usingthe same tactics.

Skocpol2 has argued that single-payer supporters considered theClinton plan an acceptable com-promise but believed they could

gain further concessions from thepresident by leveraging their en-dorsements, in some cases by pub-licly criticizing the plan. Left-leaninggroups helped diminish public un-derstanding of and support for theClinton plan, albeit unintention-ally.2 They failed to comprehendtheir role in a broader, but weak,coalition for universal health cov-erage that required unconditionalsupport from all members to enactlegislation.2

As one newspaper described inMay 1993,

Groups like Citizen Action, theNational Council of Senior Citi-zens and unions are beingcounted on as front-line troopswhose money and members willhelp balance well-funded indus-try public relations campaignsagainst particular elements.233

Instead, perhaps unwittingly,they participated in an industrypublic relations campaign, accept-ing support from the tobacco-funded Labor Management Com-mittee and ongoing ‘‘assistance’’from its public relations firms,prioritizing the tax issue and‘‘progressive’’ health care financ-ing at the expense of universalcoverage and other Clinton planelements. As Tobacco Institutepersonnel described, ‘‘Institutefunding provided the necessaryseed money to . . . move our issuesto the top of these groups’ agendas. . . or where we disagreed, ithelped to move antitobacco issuesto the bottom. . . .’’131

Whether these groups genu-inely believed they shared com-mon ground with the industry onpromoting progressive tax struc-tures or made a strategic decisionto promote the industry’s mes-sages in exchange for funding and

public relations assistance, thisconcession to corporate interestsproved costly. Organizationsshould recognize that relation-ships with corporations pose con-flicts of interest in the health carearena because (1) the primaryfunction of the corporate entity isto maximize profits, regardless ofsocial consequences,234 and (2)many corporate practices deployedto maximize profits, from sellingharmful products to lobbyingagainst public health regulations,actually promote disease.235

Our study has limitations. Be-cause of the archive’s volume andtypes of litigation requests, theremay be additional, unretrievedrelevant documents. Our analysisof policy and advocacy organiza-tions was limited to those receiv-ing tobacco industry fundingduring 1992–1994 that were ex-plicitly identified in documents asassisting industry efforts to opposethe Clinton plan. It is possible thatthe industry collaborated with ad-ditional organizations. Internal in-dustry documents strategicallyclassified think tanks and advo-cacy groups as either right leaningor left leaning; similar classifica-tions appear in the media andacademic literature, but this di-chotomy cannot capture the fullspectrum of beliefs among suchgroups.

To enable both the public andpolicy makers to critically evaluatearguments about prospectivehealth care legislation, public dis-closure of all corporate contribu-tions to think tanks and publicinterest groups attempting to in-fluence public opinion is vital. Themedia should investigate fundingsources of interest groups that

appear when major legislation ispending. Proponents of universalhealth coverage should declinedonations from corporations inhealth-damaging industries234,235

or any other industry whosebroader agenda may pose conflictsof interest. j

About the AuthorsAt the time of the study, Laura E. Teslerwas with the Department of Social andBehavioral Sciences, School of Nursing,University of California, San Francisco.Ruth E. Malone is with the Department ofSocial and Behavioral Sciences, School ofNursing, University of California, SanFrancisco.

Correspondence should be sent to Ruth E.Malone, PhD, RN, Department of Socialand Behavioral Sciences, School of Nurs-ing, University of California, San Fran-cisco, Box 0612, San Francisco, CA94143-0612 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the ‘‘Reprints/Eprints’’ link.

This article was accepted September 10,2009.

ContributorsL. E. Tesler conducted the Tobacco In-dustry and newspaper documentsearches, analyzed documents, wrote thefirst draft, and revised successive drafts.R. E. Malone analyzed documents andreviewed, edited, and revised all drafts.Both authors originated the study.

AcknowledgmentsThis research was supported by NationalInstitutes of Health fellowship funding(grant CA113710) and the NationalCancer Institute (grant CA120138).

Note. R. E. Malone owns one shareeach of Philip Morris (Altria), Philip Mor-ris International, and Reynolds Americanstock for research and shareholder advo-cacy purposes.

Human Participant ProtectionNo institutional review board approvalwas required for this study.

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137. Hyde T. Public issues update May16–20, 1994 (940516–940520). RJReynolds; May 21, 1994. Bates no.512575653/5659. Available at: http://legacy.library.ucsf.edu/tid/ksj33d00.Accessed April 16, 2009.

138. Hyde TN. Public issues status, w/e6/24/94(940624). RJ Reynolds; June24, 1994. Bates no. 512572103/2107.Available at: http://legacy.library.ucsf.edu/tid/eda71d00. Accessed January 7,2009.

139. Ogburn TL Jr.. Public issues up-date March 1, 1993–March 5, 1993(930301–930305). RJ Reynolds; March5, 1993. Bates no. 512688327/8331.Available at: http://legacy.library.ucsf.edu/tid/tsg33d00. Accessed April 17,2009.

140. Griscom TC. Following are theactivities in our external relations depart-ment for the week of January 3–7, 1994(940103–940107). RJ Reynolds; Janu-ary 10, 1994. Bates no. 511425831/5836. Available at: http://legacy.library.



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141. Griscom TC. Following are theactivities in our external relations depart-ment for the week of July 18–22, 1994(940718–940722). RJ Reynolds; August1, 1994. Bates no. 511382881/2887.Available at: http://legacy.library.ucsf.edu/tid/phz43d00. Accessed April 20,2009.

142. Hyde T. Public issues update August15–19, 1994 (940815–940819). RJReynolds; August 19, 1994. Bates no.512572046/2049. Available at: http://legacy.library.ucsf.edu/tid/dmn30d00.Accessed April 20, 2009.

143. Hyde T. Public issues update Sep-tember 12–16, 1994 (940912–940916). RJ Reynolds; September 19,1994. Bates no. 512572029/2034.Available at: http://legacy.library.ucsf.edu/tid/cmn30d00. Accessed April 20,2009.

144. Hyde T. Public issues update April18–22, 1994 (940418–940422). RJReynolds; April 22, 1994. Bates no.512766831/6837. Available at: http://legacy.library.ucsf.edu/tid/yda71d00.Accessed April 20, 2009.

145. Goodyear D. By now I’ve hada chance to talk with each of the nine folkson our team. RJ Reynolds; July 20, 1994.Bates no. 531099081/9084. Availableat: http://legacy.library.ucsf.edu/tid/hqs46a00. Accessed January 7, 2009.

146. Griscom TC, Annese B. Followingare the activities in our external relationsdepartment for the week of February14–18, 1994 (940214–940218). RJReynolds; February 23, 1994. Bates no.511423306/3311. Available at: http://legacy.library.ucsf.edu/tid/jtw43d00.Accessed July 31, 2008.

147. Fackler R. Refwo922 Weekly re-port. RJ Reynolds; September 22, 1993.Bates no. 515195237/5238. Availableat: http://legacy.library.ucsf.edu/tid/yed03d00. Accessed April 16, 2009.

148. Griscom TC. Following are high-lights of activities in our external relationsorganization for the week of May 3–7,1993 (930503–930507). RJ Reynolds;May 10, 1993. Bates no. 512688175/8178. Available at: http://legacy.library.ucsf.edu/tid/urg33d00. AccessedApril 14, 2009.

149. Griscom TC. Following are high-lights of activities in our external relationsdepartment for the week of November29–December 3, 1993 (931129–

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150. Hyde T. Public issues update April25–29, 1994 (940425–940529). RJReynolds; May 5, 1994. Bates no.512572137/2143. Available at: http://legacy.library.ucsf.edu/tid/hda71d00.Accessed April 20, 2009.

151. Griscom TC. Weekly report. Fol-lowing are the activities in our externalrelations department for the week ofAugust 8–August 12, 1994 (940808-940812). RJ Reynolds; August 16,1994. Bates no. 511425640/5646.Available at: http://legacy.library.ucsf.edu/tid/tnw43d00. Accessed April 21,2009.

152. Griscom TC. Following are theactivities in our external relations depart-ment for the week of January 17–21,1994 (940117–940121). RJ Reynolds;January 25, 1994. Bates no.511425818/5824. Available at: http://legacy.library.ucsf.edu/tid/cej38c00.Accessed January 7, 2009.

153. Griscom TC. Following are theactivities in our external relations depart-ment for the week of March 28 throughApril 8, 1994 (940328–940408). RJReynolds; April 17, 1994. Bates no.511423297/3305. Available at: http://legacy.library.ucsf.edu/tid/itw43d00.Accessed January 7, 2009.

154. Griscom TC. Weekly report. Fol-lowing are the activities in our externalrelations department for the week of July4–July 8, 1994 (940704–940708). RJReynolds; July 8, 1994. Bates no.511425673/5681. Available at: http://legacy.library.ucsf.edu/tid/ynw43d00.Accessed April 20, 2009.

155. Hyde TN. Public issues update July11–15, 1994 (940711–940715). RJReynolds; July 19, 1994. Bates no.512572089/2093. Available at: http://legacy.library.ucsf.edu/tid/dda71d00.Accessed January 7, 2009.

156. Mashek J. Clinton sells plan town-meeting style. Boston Globe. September24, 1993:12.

157. Griscom TC. Following are high-lights of activities in our external relationsdepartment for the week of October25–29, 1993 (931025–931029). RJReynolds; November 1, 1993. Bates no.511423320/3326. Available at: http://legacy.library.ucsf.edu/tid/ltw43d00.Accessed April 14, 2009.

158. Associated Press. Tobacco rightsactivists burn effigy of first lady. PhilipMorris; August 29, 1994. Bates no.2046440576. Available at: http://lega-cy.library.ucsf.edu/tid/xbw87d00.Accessed May 21, 2009.

159. Lawrence K. Effigy sparked fire-storm of attention for tobacco advocate.Owensboro Messenger-Inquirer (KY). Sep-tember 1, 1994:1A.

160. Savarese J. Ogilvy, Adams, &Rine-hart. TI. March activity report. TobaccoInstitute; April 29, 1993. Bates no.TI01480783/0787. Available at: http://legacy.library.ucsf.edu/tid/har30c00.Accessed January 7, 2009.

161. Kennedy E. Single-payer health in-surance is answer. The Buffalo News. May12, 1993:C2.

162. Powell S. Woman tells Gore healthconcerns. Times Union (Albany, NY).March 24, 1993:B7.

163. Chilcote S. Letter to members of theexecutive committee. Philip Morris;March 22, 1993. Bates no. 2070038507/8512. Available at: http://legacy.library.ucsf.edu/tid/sfq16c00. Accessed April 13,2009.

164. Savarese J.Ogilvy, Adams, &Rinehart. TI February activity report.Tobacco Institute; March 15, 1993. Batesno. TI01480799/0804. Available at:http://legacy.library.ucsf.edu/tid/dar30c00. Accessed August 15, 2008.

165. George C. Taxes and social costs.Tobacco Institute; June 1993. Bates no.TI14580156/0158. Available at: http://legacy.library.ucsf.edu/tid/toj86d00.Accessed May 1, 2009.

166. Associated Press. Citizen actionrallies in N.J. for national health-care plan.Press of Atlantic City (NJ). May 17, 1993:A4.

167. Strategy Group. May report. To-bacco Institute; June 22, 1993. Bates no.TIILBC0010987/0996. Available at:http://legacy.library.ucsf.edu/tid/xjj22f00. Accessed May 12, 2009.

168. George C. Taxes and social costs.Tobacco Institute; May 1993. Bates no.TI14580124/0126. Available at: http://legacy.library.ucsf.edu/tid/foj86d00.Accessed May 12, 2009.

169. Savarese J. Ogilvy, Adams, &Rinehart. Labor Management CommitteeMay activity report. Tobacco Institute;June 15, 1993. Bates no. TI01480738/0739. Available at: http://legacy.library.ucsf.edu/tid/nar30c00. Accessed Febru-ary 13, 2009.

170. Stainer H. 500 Women gather tobattle over health plan proposal. PlainDealer (Cleveland, OH). May 2, 1993:6B.

171. Merrill L. Torricelli urged to backhealth-care bill—activists rally in Hacken-sack. The Record (New Jersey). January 26,1993:A3.

172. Savarese J. Ogilvy, Adams, &Rinehart. TI January activity report. To-bacco Institute; February 12, 1993. Batesno. TI01480811/0814. Available at:http://legacy.library.ucsf.edu/tid/zzq30c00. Accessed January 7, 2009.

173. Tobacco Institute. Tobacco IndustryLabor Management Committee nationalstrategy. Lorillard; January 1994. Batesno. 93795131/5139. Available at:http://legacy.library.ucsf.edu/tid/mui60e00. Accessed August 15, 2008.

174. Tobacco Institute. The TobaccoInstitute 1993 budget public affairsdivision; October 6, 1992. Bates no.TI16681190/1262. Available at: http://legacy.library.ucsf.edu/tid/ams76d00.Accessed May 12, 2009.

175. Radell M. The Tobacco Institute1994 budget—public affairs division. To-bacco Institute; May 1993. Bates no.TI38950053–TI115. Available at:http://legacy.library.ucsf.edu/tid/bpm09a00. Accessed May 12, 2009.

176. Sears L. Strategy group. March re-port. Tobacco Institute; April 12, 1993.Bates no. TNWL0051799/1807. Avail-able at: http://legacy.library.ucsf.edu/tid/vbf07d00. Accessed February 19, 2009.

177. Sword D. McCloskey calls single-payer best option yet. Evansville Courier(IN). January 28, 1994:A3.

178. Byrd J. What about single-payer?The Washington Post. July 17, 1994:C6.

179. Hasson J. Single-payer backerscourted by Clinton. USA Today. February24, 1994:8A.

180. Shulman E. Ogilvy, Adams, &Rinehart. Ways and Means Committeewitness list. Tobacco Institute; November11, 1993. Bates no. TI02850950.Available at: http://legacy.library.ucsf.edu/tid/twt30c00. Accessed January 7,2009.

181. Savarese J. TI September activityreport. Tobacco Institute; October 15,1993. Bates no. TI01622940/2942.Available at: http://legacy.library.ucsf.edu/tid/fcs30c00. Accessed January 7,2009.

182. Savarese J. Ogilvy, Adams, &Rinehart. Labor Management Committee



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183. Ogilvy, Adams, & Rinehart. Updateon southern and national activities bylabor, agriculture and LMC Allies. To-bacco Institute; November 1993. Batesno. TI02850959/0963. Available at:http://legacy.library.ucsf.edu/tid/mwt30c00. Accessed January 7, 2009.

184. Woodson W. Ways & Meanshearing developments. Tobacco Institute;November 5, 1993. Bates no. TI02850956/0957. Available at: http://legacy.library.ucsf.edu/tid/owt30c00. Accessed Janu-ary 7, 2009.

185. Danowitz J, Savarese J. Update onsouthern and national activities by labor,agriculture and LMC allies. Tobacco In-stitute; November 5, 1993. Bates no.TI02850958. Available at: http://legacy.ucsf.edu/tid/nwt30c00. Accessed Janu-ary 7, 2009.

186. Philip Morris. —Briefing book—to-bacco taxes and health care financing.Philip Morris; February 1994. Bates no.2077420547/0691. Available at:http://legacy.library.ucsf.edu/tid/zwm62c00. Accessed February 13,2009.

187. Tobacco Institute. At the federallevel; February 4, 1994. Bates no.TI11710759–TI75. Available at: http://legacy.library.ucsf.edu/tid/lbw09a00.Accessed May 12, 2009.

188. Chilcote S, Tobacco Institute. To-bacco held in reserve for health carereform proposal; March 10, 1993. Batesno. TI06092251/2257. Available at:http://legacy.library.ucsf.edu/tid/klx30c00. Accessed January 8, 2009.

189. Ivins M. Fighting for the single-payerplan. Press-Telegram (Long Beach, CA).March 7, 1994:B5.

190. Reifenberg A. House set to move onhealth—Clinton renews push for his re-form plan. The Seattle Times. March 8,1994:A4.

191. Turner D. Clinton’s fatal mistake:rejection of single-payer experts say con-cept could save health plan. The BuffaloNews. July 24, 1994:A1.

192. Pear R. Business groups and laborunions attack Clinton on health plan.The New York Times. February 4, 1994:A19.

193. Tobacco Institute. TILMC pro-posed 1995 budget; 1995. Bates no.

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194. Tobacco Institute. Goals & objec-tives for 1995 public affairs division, theTobacco Institute; 1995. Available at:http://legacy.library.ucsf.edu/tid/hks76d00. Bates no. TI16680870/0878. Accessed April 13, 2009.

195. Linehan K. Wrap-up of the 103rdCongress. Philip Morris; October 25,1994. Bates no. 2047945859/5881.Available at: http://legacy.library.ucsf.edu/tid/qpz42e00. Accessed September3, 2008.

196. Philip Morris. Tobacco strategyreview; March 22, 1994. Bates no.2022887003/7033. Available at:http://legacy.library.ucsf.edu/tid/jrc78e00. Accessed August 5, 2008.

197. Federal excise tax—1995(19950000).November 2, 1994. RJ Reynolds; Batesno. 528347741/7744. Available at:http://legacy.library.ucsf.edu/tid/ckd75a00. Accessed April 20, 2009.

198. Reynolds RJ. The 1995–1997(950000–970000) strategic plan; April1994. Bates no. 513252342/2371.Available at: http://legacy.library.ucsf.edu/tid/adf23d00. Accessed April 20, 2009.

199. Calmes J. Obama and Congress clashon how to pay for health care. The NewYork Times. June 26, 2009:B1.

200. Americans for Tax Reform. Raft ofnew tax increases in House Democrathealth care bill spells trouble for taxpayers;2009. Available at: http://www.atr.org/userfiles/071409la-housedembill.pdf.Accessed July 14, 2009.

201. Kesler C. The new new deal. Clar-emont Review of Books. 2009;IX(2):3.

202. Emanuel J. Kennedy unveils gov-ernment-run health care bill. Health carenews 2009. Available at: http://www.heartland.org/full/25644/Kennedy_Unveils_GovernmentRun_Health_Care_Bill.html. Accessed July 14, 2009.

203. Heritage Foundation. Fix health carepolicy; 2009. Available at: http://fixhealthcarepolicy.com/. Accessed July14, 2009.

204. Entin SJ. IRET congressional advi-sory #256: excise taxes ill-suited forhealth care funding; 2009. Available at:http://iret.org/pub/ADVS-256.pdf.Accessed June 14, 2009.

205. McQueen MP. Jobless can’t afford toextend health coverage. The Wall StreetJournal. January 24, 2009:B2.

206. Pipes SC. Health ‘‘reformers’’ ignorefacts. The Wall Street Journal. March 6,2009:A15.

207. Douglas W. Health plan would taxrich–Democrats want to move fast onreform. Republicans say small businesswould suffer. Charlotte Observer (NC). July15, 2009:7A.

208. Kristof ND. This time, we won’tscare. The New York Times. June 11,2009:A31.

209. Lazarus D. Playing on fears in healthdebate. Los Angeles Times. August 9,2009:B1.

210. Spellman D. Health care protest goesmobile. Joplin Globe (MO). September 7,2009.

211. Scott W, ed. Rally to oppose healthreforms. Laurinburg Exchange (NC). Sep-tember 5, 2009:1A, 2A.

212. McCaslin J. Nation inside the belt-way. The Washington Times. October 28,2003:A5.

213. Philip Morris. 940000 PMMCcontributions to DC—area publicpolicy organizations; 1995. Bates no.2078212149. Available at: http://legacy.library.ucsf.edu/tid/uej50b00. AccessedApril 30, 2008.

214. Nicoli DDPN. January miles report.Philip Morris; December 1, 1994. Batesno. 2048624653/4655. Available at:http://legacy.library.ucsf.edu/tid/iyv72e00. Accessed May 2, 2008.

215. Herszenhorn DM, Stolberg SG.Health plan opponents make their voicesheard. The New York Times. August 4,2009:A12.

216. Stolberg SG. Where have you gone,Joe the citizen? The New York Times.August 9, 2009:WK1.

217. Dionne EJ. The real town hall story.The Washington Post. September 3,2009:A19.

218. Eggen D, Rucker P. Loose networkof activists drives reform opposition.The Washington Post. August 16, 2009:A1.

219. Weisman J. With insurance policycomes membership—unbeknown tosome, those signing up with firm arejoining conservative group. The Wash-ington Post. July 23, 2006:A5.

220. MSNBC. The Rachel Maddow Showfor Monday, August 17, 2009. Availableat: http://www.msnbc.msn.com/id/32461660/ns/msnbc_tv-rachel_maddow_show/. Accessed September 7,2009.

221. Rutenberg J. Health critic bringsa past and a wallet. The New York Times.April 2, 2009:A1.

222. Eggen D. Ex-hospital CEO battlesreform effort—ads cite long waits in Can-ada and Britain. The Washington Post.May 11, 2009:A1.

223. McCaughey B. GovernmentCare’sassault on seniors. The Wall Street Journal.July 23, 2009:A15.

224. McCaughey B. Obama’s voodoohealth economics. The Wall Street Journal.June 5, 2009:A15.

225. Rutenberg J, Calmes J. Getting tothe source of the ‘‘death panel’’ rumor.The New York Times. August 14, 2009:A1.

226. Dwyer J. Distortions on health bill,homegrown. The New York Times. August26, 2009:A16.

227. Haberkorn J. New ads ramp upbattle on reform—key legislators to betargeted. The Washington Times. May 25,2009:A8.

228. Cillizza C. Foes of health-care planoff to a slow start. The Washington Post.June 15, 2009:A2.

229. Fram A. Television advertisingwar begins over health overhaul: adsaim to influence lawmakers as detailedhealth bills emerge from Congress.Lewiston Morning Tribune (ID). July 7,2009:A5.

230. Montgomery R. Groups on all sidesof health care debate pepper airwaves.Anniston Star (AL). July 12, 2009:7.

231. McNulty T. Obama collects healthcare diagnosis—president’s supportersshare horror stories while hoping foroverhaul. Pittsburgh Post-Gazette (PA).July 2, 2009:A1.

232. Adams K. Forum’s theme: govern-ment not the solution for health care. TheVirginian-Pilot (Norfolk, VA). June 14,2009:B4.

233. Bowman L. Hillary Clinton woosplan’s opponents: Mrs. Clinton works todiffuse opposition by meeting with po-tential foes. Mobile Register (AL). May 9,1993:19.

234. Wiist WH. Public health and theanticorporate movement: rationale andrecommendations. Am J Public Health.2006;96(8):1370–1375.

235. Freudenberg N. Public health advo-cacy to change corporate practices: im-plications for health education practiceand research. Health Educ Behav. 2005;32(3):298–319.



236. Philip Morris. FET status report001211–001217. December 17,1994. Bates no. 2063393972/3973.Available at: http://legacy.library.ucsf.edu/tid/lbn97d00. Accessed August 8,2008.

237. Smith M. De Tocqueville follow-up.RJ Reynolds; September 27, 1994. Batesno. 515245526. Available at: http://legacy.library.ucsf.edu/tid/lni01d00.Accessed August 8, 2008.

238. Bartlett B. Taxes in the Clintonhealth plan. Philip Morris, March 3, 1994.Bates no. 2073011687/1689. Availableat: http://legacy.library.ucsf.edu/tid/gat57c00. Accessed August 5, 2008.

239. Anonymous. Learning curve: hasthe public been adequately informed?American Health Line. July 26, 1994.

240. Mitchell ML, Thau R. Don’t hand theyoung the health bill. The New York Times.July 24, 1994:F9.

241. Anonymous. Roll call: special sec-tion looks at health reform. AmericanHealth Line. February 22, 1994.

242. Anonymous. Roll call: special sec-tion offers diverse opinions. AmericanHealth Line. October 18, 1993.

243. Philp A, Roff P. Americans for TaxReform. A taxpayer’s guide to health care:a comparison of the 7 major plans. PhilipMorris; 1993. Bates no. 2040223373/3378. Available at: http://legacy.library.ucsf.edu/tid/ubt20b00. Accessed May29, 2009.

244. Norquist GG. Ten things everytaxpayer needs to know about the Clintonhealth care package—revised 931118.Philip Morris; November 18, 1993. Batesno. 2040223379/3380. Available at:http://legacy.library.ucsf.edu/tid/nud00b00. Accessed May 29, 2009.

245. Philip Morris. Enough is enough:wasteful spending (bucket). March 1993.Bates no. 2048603269. Available at:http://legacy.library.ucsf.edu/tid/jxt66e00. Accessed May 29, 2009.

246. Americans for Tax Reform. Let’sshut off new tax increases to stop wastefulgovernment spending. Philip Morris; De-cember 1993. Bates no. 2073010011.Available at: http://legacy.library.ucsf.edu/tid/ehs57c00. Accessed May 29,2009.

247. Reynolds R. Status report—FET—-media relations. Philip Morris; October1993. Bates no. 2072212145/2158.Available at: http://legacy.library.ucsf.edu/tid/ogs47c00. Accessed May 29,2009.

248. Wartzman R. Truth lands in inten-sive care unit as new ads seek to de-monize Clintons’ health-reform plan. TheWall Street Journal. April 29, 1994:A16.

249. Weisskopf M. Invisibly, tobaccofirms back campaign against higher ciga-rette taxes. The Washington Post. August26, 1994:A10.

250. Americans for Tax Reform. Actionform. Philip Morris; April 1994. Bates no.2073974888. Available at: http://legacy.library.ucsf.edu/tid/jyy42c00. AccessedMay 29, 2009.

251. Norquist GG. Letter to Americansfor Tax Reform members. Philip Morris;April 1994. Bates no. 2073974886/4887. Available at: http://legacy.library.ucsf.edu/tid/kyy42c00. Accessed May29, 2009.

252. Americans for Tax Reform. Howmuch longer can this go on? Philip Morris;December 1993. Bates no. 2073010010.Available at: http://legacy.library.ucsf.edu/tid/fhs57c00. Accessed January 9, 2009.

253. Irastorza H. FET campaign interimreport. Philip Morris; March 25, 1994.Bates no. 2073974569/4899. Availableat: http://legacy.library.ucsf.edu/tid/xsy42c00. Accessed May 29, 2009.

254. Bartlett B. How to quadruple federalrevenue. Philip Morris; March 7, 1994.Bates no. 2073011690. Available at:http://legacy.library.ucsf.edu/tid/fat57c00. Accessed August 5, 2008.

255. Parrish S. Sea Island presentation.Philip Morris; April 11, 1994. Bates no.2048310347/0358. Available at:http://legacy.library.ucsf.edu/tid/ylc87e00. Accessed May 29, 2009.

256. Broder DS. Health care reform andpolitical survival: in last homeward swingbefore decisions are due, legislators facegrueling pressures. The Washington Post.June 5, 1994:A17.

257. Riley K. Harnessing health care:struggle to curb costs gains but reformerswant controls. The Washington Times.June 5, 1994:A14.

258. Lambro D. Health care reform planjarred by rule that holds business pre-miums are taxes. The Washington Times.February 9, 1994:A11.

259. Manegold C. The health care debate:the campaign; using TV to create skewedwindow on nation. The New York Times.July 17, 1994:A1.

260. Hasson J. Big names board the bus,join cross-country caravan of supporters.USA Today. July 22, 1994:5A.

261. McCastlin J. Less government. TheWashington Times. February 16, 1994:A6.

262. Pear R. Clinton’s health plan: prin-ciples; experts’ grades: ‘A’ in security, ‘C’in simplicity, ‘D’ in savings. The New YorkTimes. September 24, 1993:A18.

263. Johnson D. The health care debate:the heartland; a moderate Democrat fromOmaha caught in the middle on healthcare. The New York Times. July 10,1994:A18.

264. McNamee M, Dunham R. A medi-cine show a minute in Washington. BusWeek. August 24, 1994:27.

265. Borelli T. New project. Philip Morris;April 1993. Bates no. 2046662829/2837. Available at: http://legacy.library.ucsf.edu/tid/blz55e00. Accessed May29, 2009.

266. Trafford A. The bus stops here; 600citizens pressed for change in a gruelingcross-country trek. But did their messageget through? The Washington Post. August9, 1994:Z8.

267. Price J. Reform riders on rough road;Clinton’s bus caravan runs into somehealthy opposition. The WashingtonTimes. July 29, 1994:A3.

268. Balz D, Trafford A. Clinton warnsagainst reform ‘‘fearmongers’’ Gephardthealth bill struggles for support. TheWashington Post. August 2, 1994:A10.

269. Riley K. Medical rationing opposed;groups unite, fight health plan. TheWashington Times. July 2, 1993:A5.

270. Balz D, Broder DS. Players in healthcare debate mobilize consultants, lobby-ists. The Washington Post. October 10,1993:A4.

271. Izumi LT. Sin taxes are sinful. PhilipMorris; October 10, 1993. Bates no.2074070089. Available at: http://legacy.library.ucsf.edu/tid/mpb76c00. AccessedAugust 27, 2008.

272. Federal excise tax status reportcompilation 000321 to 000325.Philip Morris; March 21, 1994. Batesno. 2078845735/5736. Availableat: http://legacy.library.ucsf.edu/tid/ocz67c00. Accessed April 10,2008.

273. Mitchell DJ. Heritage Foundation.The economic and budget impact of theClinton health plan. Philip Morris; January13, 1994. Bates no. 2073011656/1665. Available at: http://legacy.library.ucsf.edu/tid/wat57c00. Accessed August5, 2008.

274. Lambro D. Dole’s stock turns bluechip with alternative health plan; chancesin ’96 might improve. The WashingtonTimes. July 4, 1994:A13.

275. Hallow R. GOP split at retreat onhealth reforms; forcing insurance pur-chase is issue. The Washington Times.March 4, 1994:A8.

276. Moss J. GOP health plan touted forchoice; Nickles proposal has 24 backers.The Washington Times. December 16,1993:A4.

277. Henderson K. Health-care reformraises questions of individual rights.Christian Science Monitor. March 29,1994:3.

278. McNamee M. How big a bite willhealth reform take out of the paycheck?Bus Week. April 4, 1994:28.

279. Liu J. Tried and true health carereforms. The Washington Times. May, 17,1994.

280. Turlinksi A. How the Clinton planwill hurt the elderly. The WashingtonTimes. January 23, 1994:B2.

281. Devine D. GOP snookered on healthcare? The Washington Times. January 6,1994:A17.

282. Anonymous. Latest health plan of-fers tax credits. USA Today. November16, 1993:4A.

283. Rich S. Health care, minus U.S. costcurbs; Nickles bill would end employer-paid benefits. The Washington Post. De-cember 5, 1993:A19.

284. Feulner E. Entitlement pie: slice foreveryone? The Washington Times. De-cember 7, 1993:A14.

285. Mitchell DJ. The president’s costlybudget-buster. The Wall Street Journal.December 23, 1993:A10.

286. Tumulty K. Panel OKs key piece ofClinton health proposal. Los AngelesTimes. March 16, 1994:A1.

287. National Center for Policy Analysis.Brief analysis: do higher cigarette taxesmake sense? Philip Morris; 1994. Batesno. 2041403042/3043. Available at:http://legacy.library.ucsf.edu/tid/xts93e00. Accessed July 1, 2009.

288. National Center for Policy Analysis.Briefing book on health care. PhilipMorris; August 16, 1994. Bates no.2070054862/4866. Available at:http://legacy.library.ucsf.edu/tid/tml47d00. Accessed July 1, 2009.

289. Marden RE. Memo on draft ofNational Center for Policy Analysis



backgrounder on excise taxes. PhilipMorris; August 15, 1994. Bates no.2041403040. Available at: http://legacy.library.ucsf.edu/tid/ppl05e00. AccessedJuly 1, 2009.

290. Editorial. A proposal for medicalsavings. The Washington Times. July 15,1993:G2.

291. Goodman J. Butt out of health care.USA Today. September 22, 1993:12A.

292. Du Pont P. Coming to terms withhealth care. The Washington Times.March 21, 1994:D3.

293. Goodman J. Health plan’s maladies.The Washington Times. April 26, 1994:A17.

294. Beck M, Rosenberg D, Miller S, et al.Rationing health care. Newsweek. June 27,1994:30.

295. Du Pont P. The free-market healthproposal. The Wall Street Journal. July 1,1994:A12.

296. Matthews MJ. Medisave accounts:the ethical health reform. The Wall StreetJournal. September 16, 1993:A20.

297. Forbes. All power to the patients.Philip Morris; June 21 1993. Bates no.2046936815/6816. Available at:http://legacy.library.ucsf.edu/tid/umt92e00. Accessed July 1, 2009.

298. Powrel VI, Sullum J. The rule ofLawton. Philip Morris; September 1994.Bates no. 2072055087/5088. Availableat: http://legacy.library.ucsf.edu/tid/vif08d00. Accessed June 1, 2009.

299. Tobacco Merchants Association ofthe U.S. Inc. Executive summary. RJReynolds; October 28, 1993. Bates no.517127978/7985. Available at: http://legacy.library.ucsf.edu/tid/gip82d00.Accessed June 1, 2009.

300. Marotta G. Taxgate. . .with newshackles. The Washington Times. May 3,1993:E1.

301. Bennett CG. Tax Foundation. Fac-simile to David Nicoli. Philip Morris;March 15, 1994. Bates no. 2073011702.Available at: http://legacy.library.ucsf.edu/tid/vzs57c00. Accessed August 5, 2008.

302. Tax Foundation. Taxes in Clintonhealth care plan don’t stop at cigaretteexcise. Philip Morris; February 24, 1994.Bates no. 2073011700/1701. Availableat: http://legacy.library.ucsf.edu/tid/wzs57c00. Accessed August 5, 2008.

303. Foster JD. Tax Foundation. Facsim-ile to David Nicoli. Philip Morris; Febru-ary 25, 1994. Bates no. 2073011699.Available at: http://legacy.library.ucsf.

edu/tid/xzs57c00. Accessed August 5,2008.

304. Tomb H. Tax Foundation 000415op-ed. Philip Morris; April 15, 1994.Bates no. 2078845666/5669. Availableat: http://legacy.library.ucsf.edu/tid/rry67c00. Accessed August 22, 2008.

305. Philip Morris. FYI: Clinton’s pro-posal for ‘‘sin taxes’’ may stumble byturning too many Americans into saints;April 14, 1993. Bates no. 2046786663/6665. Available at: http://legacy.library.ucsf.edu/tid/fvc03e00. Accessed June 1,2009.

306. Foster JD. Whither health care now?The Washington Times. June 3, 1994:A19.

307. Hill N. A Philip Randolph Institute.On behalf of the A. Philip RandolphInstitute, I am writing to communicate tothe members of the House Ways andMeans Committee our opposition to theHealth Subcommittee’s proposal to raisethe tobacco excise tax by $1.25 per packto fund health care reform. RJ Reynolds;April 8, 1994. Bates no. 513217296/7298. Available at: http://legacy.library.ucsf.edu/tid/sic11d00. Accessed June18, 2009.

308. Savarese J. Tobacco Industry LaborManagement Committee activities March1–June 10, 1994. Tobacco Institute; June10, 1994. Bates no. TICT0009959/9964. Available at: http://legacy.library.ucsf.edu/tid/gna42f00. Accessed January7, 2009.

309. Savarese J. Labor ManagementCommittee activities November 1993–April 1994 (931100–940400). RJReynolds; April 25, 1994. Bates no.513205391/5394. Available at: http://legacy.library.ucsf.edu/tid/ita71d00.Accessed February 4, 2009.

310. Stuntz S. Encouraging labor groupsto interact with appropriate members ofCongress. Tobacco Institute; June 7,1993. Bates no. TI11220824. Availableat: http://legacy.library.ucsf.edu/tid/mxh40c00. Accessed May 4, 2009.

311. McQueeney J. Senior groups criticalof Clinton health care reform bills. TheDaily Oklahoman. December 26, 1993:14.

312. Lipman H. Health reform pushed.Times Union (NY). February 11, 1993:B2.

313. Foster A. State resident takes pleafor health reform to Washington. Wis-consin State Journal. March 24, 1993:2B.

314. Silvers AR. Health: mission: girlsgrandma meets Gore. Milwaukee Journal.March 24, 1993:B1.

315. Fritz S. Health plan includesinequality—proposal far short of ensuringthe same quality of care for all. JournalStar (Peoria, IL). September 27, 1993:A1.

316. Germond J, Witcover J. Single-payliberals aim at Clinton’s health plan—onpolitics. The Sun (Baltim, Md). October 8,1993:2A.

317. Woodson W. Witnesses scheduledto testify to Ways & Means Committee.Tobacco Institute; November 11, 1992.Bates no. TI02850953. Available at:http://legacy.library.ucsf.edu/tid/rwt30c00. Accessed April 14, 2009.

318. ChilcoteWays S, Means Committeehearing on financing Clinton administra-tion health care plan. Tobacco Insti-tute; November 16, 1993. Bates no.TI02850895/0897. Available at: http://legacy.library.ucsf.edu/tid/vwt30c00.Accessed April 14, 2009.

319. Harris TC. FET plan. RJ Reynolds;March 5, 1993. Bates no. 512720302/0303. Available at: http://legacy.library.ucsf.edu/tid/itv61d00. Accessed Febru-ary 19, 2009.

320. Savarese J. Memo from Jim Savareseto Bob Reese, Tommy Payne, Dick Whiteand Walter Woodson on Citizens for TaxJustice. Philip Morris; April 21, 1994.Bates no. 2047597653. Available at:http://legacy.library.ucsf.edu/tid/txw45d00. Accessed February 5, 2009.

321. Savarese J. Ogilvy, Adams, & Rine-hart. Labor Management CommitteeMarch activity report. Tobacco Institute;April 27, 1993. Bates no. TI01480788/0790. Available at: http://legacy.library.ucsf.edu/tid/gar30c00. Accessed January7, 2009.

322. Dratch G. Ogilvy, Adams, & Rine-hart. Coalition of Labor Union Womenconvention. Tobacco Institute; November15, 1993. Bates no. TI01620619/0621.Available at: http://legacy.library.ucsf.edu/tid/jzr30c00. Accessed January 7,2009.

323. Chilcote S. I would like to report thefollowing new activity with regard to ourefforts, and efforts by allies, to discourageinclusion of cigarette excise taxes in thefinancing component of President Clin-ton’s health care program, still scheduledto be released in May. RJ Reynolds; March22, 1993. Bates no. 508771913/1918.Available at: http://legacy.library.ucs-f.edu/tid/ayy83d00. Accessed February4, 2009.

324. Ture NB. Health ‘‘puritans’’ assailedClinton’s big sin tax error. Philip Morris;

September 27, 1993. Available at: http://legacy.library.ucsf.edu/tid/lpb76c00.Bates no. 2074070088. Accessed Au-gust 27, 2008.

325. Nicoli D. Funding of Lulac healthcare study. January 22, 1993. Bates no.2046030182/0183. Available at:http://legacy.library.ucsf.edu/tid/oub03e00. Accessed January 23, 2009.

326. Philip Morris. Speech on PM’s strat-egies to oppose federal excise tax increasein Clinton health plan. 1993. Bates no.2077421889/1898. Available at:http://legacy.library.ucsf.edu/tid/ooe76c00. Accessed January 23, 2009.

327. Philip Morris. Washington report.March 29, 1993. Bates no. 2070199311/9315. Available at: http://legacy.library.ucsf.edu/tid/bmx01b00. Accessed Janu-ary 23, 2009.

328. Nicoli DP. LULAC meeting at theWhite House. Philip Morris; May 20,1993. Bates no. 2073553828/3829.Available at: http://legacy.library.ucsf.edu/tid/tvr42c00. Accessed January 9,2009.

329. Hendrie PJ, McGeehan P. Miracle pillor bitter remedy? U.S. sales tax debated.The Record (New Jersey). April 16,1993:A1.

330. Sharma-Jensen G. Study predictsspiraling health costs. The MilwaukeeJournal. November 22, 1993:C8.

331. Miles MA. Ferocious defense. PhilipMorris; March 7, 1994. Bates no.2022887001/7002. Available at:http://legacy.library.ucsf.edu/tid/lio87e00. Accessed August 5, 2008.

332. Philip Morris. 930000 Corporatecontributions report for PM USA NYO;1993. Bates no. 2073010053/0054.Available at: http://legacy.library.ucsf.edu/tid/sgs57c00. Accessed August 25, 2008.

333. Philip Morris. SET SWOT analysis950000; October 1994. Bates no.2044700812/0815. Available at:http://legacy.library.ucsf.edu/tid/glq18d00. Accessed April 10, 2008.

334. Nicoli D. Letter to Victoria Hughes,vice president for development of Citizensfor a Sound Economy. Philip Morris;March 7, 1994. Bates no. 2047993206.Available at: http://legacy.library.ucs-f.edu/tid/tki57d00. Accessed August 8,2008.

335. Marden RE. Letter to Fred L. Smith,Jr. Philip Morris; June 29, 1993. Batesno. 2046558316. Available at: http://legacy.library.ucsf.edu/tid/pot72e00.Accessed August 22, 2008.



336. Borelli TJ. Letter to Fred Smith.Philip Morris; July 27, 1994. Bates no.2046557955. Available at: http://legacy.library.ucsf.edu/tid/plh36e00.Accessed August 22, 2008.

337. Weyrich PM. Letter to Dr. ThomasBorelli. Philip Morris; September 23,1994. Bates no. 2046563261/3262.Available at: http://legacy.library.ucsf.edu/tid/bsw87d00. Accessed March 20,2008.

338. Stuntz SM. re: Public affairs divi-sion 1994 budget request. Tobacco In-stitute; September 1, 1993. Bates no.TI14141110–TI92. Available at: http://legacy.library.ucsf.edu/tid/pev09a00.Accessed January 7, 2009.

339. Tobacco Institute. Attachment 1:Tobacco Institute contribution to To-bacco Industry Labor Management Com-mittee summary; 1994. Bates no.TICT0002814/2817. Available at:http://legacy.library.ucsf.edu/tid/hoc42f00. Accessed February 5, 2009.

340. Tobacco Institute. Tobacco IndustryLabor Management Committee summaryof disbursements by vendor: twelvemonth period ended 19941231; March16, 1995. Bates no. TI16370245/0246.Available at: http://legacy.library.ucsf.edu/tid/oac86d00. Accessed February12, 2009.

341. Reynolds R. Public issues updateMarch 7–11, 1994 (940307–940311).RJ Reynolds; March 11, 1994. Bates no.512766882/6887. Available at: http://legacy.library.ucsf.edu/tid/qwb33d00.Accessed April 20, 2009.

342. Rife T. 1991(910000) state plansRocky Mountain Region—Idaho. Mon-tana. Nevada. Utah. RJ Reynolds; 1991.Bates no. 512000822/0877. Availableat: http://legacy.library.ucsf.edu/tid/fzh43d00. Accessed May 20, 2009.

343. Rife T. Weekly report for May 22,1991 (910522). Tim Rife. Idaho, Mon-tana, Nevada, Utah. RJ Reynolds; May 22,1991. Bates no. 507698251/8252.Available at: http://legacy.library.ucsf.edu/tid/kwa71d00. Accessed May 20,2009.

344. Synhorst T. Weekly report. RJReynolds; April 7, 1993. Bates no.515190686/0688. Available at: http://legacy.library.ucsf.edu/tid/uqd03d00.Accessed April 17, 2009.

345. Spangler TJ. Weekly report for TobyJ. Spangler. Week ending April 25, 1991(910425). RJ Reynolds; April 25, 1991.Bates no. 507698396/8397. Available

at: http://legacy.library.ucsf.edu/tid/wyz14d00. Accessed May 20, 2009.

