A Cigarette Manufacturer and a Managed Care Company Collaborate to Censor Health Information Targeted at Employees

Abstract

A review of internal tobacco company documents showed that the tobacco company Philip Morris and the insurance company CIGNA collaborated to censor accurate information on the harm of smoking and on environmental tobacco smoke exposure from CIGNA health newsletters sent to employees of Philip Morris and its affiliates. From 1996 to 1998, 5 of the 8 CIGNA newsletters discussed in the internal tobacco documents were censored.

We recommend that accrediting bodies mandate that health plans not censor employee-directed health information at the request of employers.

AS A LEADING CAUSE OF numerous cancers and cardiovascular diseases, cigarette smoking kills more than 400 000 Americans each year.1 Exposure to environmental tobacco smoke is estimated to cause 3700 lung cancer deaths and more than 50 000 deaths from heart disease in adults each year in the United States.2 Environmental tobacco smoke is also causally associated with low birthweight and sudden infant death syndrome among infants and with acute lower respiratory infections, asthma attacks, and middle ear infections among children.3

In this article, we report an unusual agreement between the nation’s largest cigarette manufacturer, Philip Morris, and the nation’s third largest publicly traded managed care organization, CIGNA. Philip Morris benefits managers and CIGNA employees collaborated to censor accurate information about the harm of smoking and environmental tobacco smoke exposure from CIGNA newsletters sent to employees of the tobacco company and its affiliates.

REVIEW OF DOCUMENTS

In 1998, litigation brought by the Minnesota attorney general and BlueCross BlueShield of Minnesota against the tobacco industry ended in a settlement after a 4-month trial. The Minnesota settlement required that the tobacco companies make their millions of pages of previously unreleased documents publicly accessible in document depositories located in Minneapolis, Minn, and Guildford, England. The defendants also were ordered to deliver to the Minnesota Tobacco Document Depository hard copies of all documents produced in any subsequent smoking and health litigation in the United States.

We reviewed a subset of the documents produced from the litigation involved with Blue Cross and Blue Shield of New Jersey et al. v Philip Morris et al. located at the Minnesota Tobacco Document Depository in Box 20368 of the Philip Morris collection. After the initial discovery of documents detailing the arrangement between Philip Morris and CIGNA, we searched for additional documents at the industry’s document Web site, the Tobacco Archives (http://www.tobaccoarchives.com). We searched the files of a Philip Morris benefits manager, Lisa Halle, relating to CIGNA using the search strings “Area: Halle, L” and “Fname: CIGNA.” This search generated 176 documents. “Area” referred to the source of the document at the time of its collection, and “Fname” was the file name from which the document originated.

In addition, we requested copies of the quarterly Well-Being newsletters distributed to Philip Morris employees from 1996 to 1998 that were not included in the files of the Minnesota Tobacco Document Depository. The CIGNA Healthcare Office informed us that the newsletters were “not available.”

OVERVIEW OF THE ARRANGEMENT BETWEEN PHILIP MORRIS AND CIGNA

The documents we reviewed revealed that, from 1996 to 1998, CIGNA and Philip Morris worked together to censor information on smoking and health that was to be published in CIGNA’s quarterly health newsletter Well-Being, sent to thousands of employees of Philip Morris USA and its affiliated companies, Miller Brewing Companies and Kraft General Foods. The arrangement between Philip Morris and CIGNA involved the active participation of employees from both the tobacco company and the health insurer.

Initially, employees of the Philip Morris Benefits Department reviewed editions of the newsletter in search of “objectionable” material.4 If a problem was discovered, CIGNA gave Philip Morris 2 options: the tobacco company could either block the Well-Being issue from reaching its employees or could replace the article with alternate content.4 “Local” articles (i.e., those targeted to specific geographic regions) that were found “offensive” would be replaced at no charge.4 If problems were found in a “national” article (i.e., an article circulated to all regions of the United States), Philip Morris was required to pay CIGNA an extra $3000 to replace the article.4 A Philip Morris Benefits Department employee described the editing process as follows:

The process of reviewing articles and making a recommendation to send or skip a [sic] issue varies, depending on content. Typically, it is immediately clear if something is objectionable. Other times, it may require discussion with others and management. . . . Some smoking references may be minor and not blatantly offensive.4

CIGNA employees responsible for Well-Being assisted Philip Morris’s censoring arrangement by highlighting articles or material contained within articles that they thought the tobacco company might find objectionable. For example, regarding an article titled “Breathe Easier: Four Ways to Help Your Child Manage Asthma,” a CIGNA employee wrote to a Philip Morris employee: “Please take a look at 7, the asthma piece. It mentions cigarette smoking as a possible trigger for an attack, I thought I should bring that to your attention.”5

Similarly, another CIGNA employee wrote to the Philip Morris Benefits Department, “One article I want to bring your attention to is the national piece on high blood pressure. It advises those who have high blood pressure to quit. Other than that, I think everything should be appropriate for the Philip Morris employees.”6

MATERIAL CENSORED

Five of the 8 CIGNA newsletters discussed in the internal tobacco documents published between 1996 and 19984,7,8 were censored by Philip Morris. For example, in 1996 the spring issue of Well-Being was sent to employees only after CIGNA had deleted an advertisement for a free Time-Life Video series. The 30 videos, developed and narrated by former US Surgeon General C. Everett Koop, addressed several health issues including asthma in children, breast cancer, high blood pressure, stroke, osteoporosis, skin cancer, and prostate cancer.4 The members of the Philip Morris benefits team internally discussed their reservations in regard to making the tapes available to employees, citing C. Everett Koop as “an obvious concern.”9 One employee stated, “The sensitivity to this decision [of including the Time-Life videos in the newsletter] is Time-Life’s selection of a spokesperson, Dr. C. Everett Koop. Because of Dr. Koop’s stance against smoking, there is some reservation about the content with the videos.”10

Philip Morris and CIGNA agreed that the Philip Morris Benefits Department would review the 30 videotapes and screen them for “sensitive/offensive” material.10 If no such references existed, they would consider making the nonoffensive tapes available to employees in some way other than in the newsletters.10 The subsequent Well-Being issue (summer 1996) was not sent to Philip Morris employees because “several articles contained anti-smoking references,” and Philip Morris did not want its employees to see the Time-Life Video advertisement.4 The documents we reviewed showed that the Time-Life videos were eventually offered in the fall 1996 newsletter, without complaints from employees.11

The director of employee benefits at Philip Morris, John Gavin, decided not to release the winter 1996 issue of Well-Being because the tobacco company did not want to pay $3000 to replace the article “A Breath of Fresh Air,” which contained “objectionable content.”12 He wrote:

It contains some objectionable content referencing smoking. Specifically, the article lists “cigarette smoking” as one of the irritants in the environment which can trigger an asthma attack. The article goes on to say “Do not allow smoking in your home or in any other environment that you can control.” It will cost $3000 to replace this national article with a satisfactory alternative. It is my recommendation we forego the winter edition due to content, as I do not think the cost justifies this mailing.12

In 1997, the summer issue was not published because one of the national articles scheduled to be included contained “an objectionable reference to secondhand smoke.”13

Two issues were censored in 1998 before being sent out to plan participants. Philip Morris benefits manager Halle told CIGNA to “delete reference to smoking in 3rd paragraph” in the article titled “Help Yourself to a Healthy Life” that appeared in the fall 1998 issue.14

In addition, in a spring 1998 article titled “Coping With Your Child’s Ear Infection,” Halle again asked CIGNA to edit, at no cost, a reference to environmental tobacco smoke: “[R]emove the words ‘and those who are exposed to secondhand smoke.’ You had already pointed out that language. Removing this reference does not alter the integrity of the article and I’d feel better if this piece were removed.”15 The article, in the form seen by Philip Morris employees, noted 3 practices that may prevent middle ear infections: (1) teaching the child to blow his or her nose, (2) encouraging the child to sleep with a pillow, and (3) teaching the child good hand washing practices.16 Advice to limit exposure to environmental tobacco smoke did not appear in the newsletter.

THE AGREEMENT’S END

The documents we reviewed showed that in the spring of 1999, Philip Morris, Kraft, and Miller decided to no longer send edited versions of the health newsletters to employees.17 A Philip Morris benefits employee stated, “We really cannot censor anymore anyway, per the AG [attorney general] agreement.”18 Signed in November 1998, the Master Settlement Agreement between members of the tobacco industry and 46 US attorneys general prohibits suppression of information pertaining to the health hazards and consequences of tobacco use.19

SIGNIFICANCE OF FINDINGS

As we have reported, Philip Morris colluded with CIGNA over a period of at least 3 years to withhold accurate information about the health hazards of smoking and environmental tobacco smoke exposure from its employees. The number of people affected is potentially very large. Philip Morris USA employs approximately 9100 people,20 while Miller and Kraft employ 8000 and 117 000, respectively.21,22 Information is not available on numbers of dependents of direct employees or how many of these individuals were covered by CIGNA as opposed to another insurer.

Although this article reports in-depth document research on this issue, some of the details of the scheme were first reported in the Minneapolis Star Tribune in February 2000.23 At that time, a Philip Morris spokeswoman explained that the company simply did not want to disseminate information that was “offensive or annoying to our employees.”23 New documents delivered to the Minnesota depository in 2003 detailed internal communications regarding contact made by the Star Tribune reporter. The documents show that the Philip Morris spokeswoman made the following statement:

I said this decision [to censor the health newsletters] reflected both HR [human resources] and senior management’s desire to be responsive to employee concerns over the prevalence of anti-tobacco sentiment. I also said that the health risks of smoking are very well-known and we believe that people should be educated on this topic, and, in fact, we dedicated significant space on our web site to the health risks of smoking.24

That the company would claim to advocate for public education on the health effects of smoking and yet withhold such information from its own employees is consistent with the corporate culture at Philip Morris. We suspect that, contrary to former Philip Morris CEO Geoffrey Bible’s public statement—“First and foremost, the company wants the truth told”25—the real reason for the arrangement described here involved the fact that this truthful information was actually “offensive and annoying” in regard to Philip Morris’s public relations strategy. Philip Morris USA believes in “operating with integrity, trust, and respect, both as individuals and as a company.”26 These values are impossible to reconcile with the unusual arrangement outlined here.

It may surprise few people in the public health community that a transnational tobacco company took steps to suppress information on the health consequences of smoking and environmental tobacco smoke exposure, but most would be surprised that a health care organization would cooperate in such an arrangement. Aside from the unethical, yet predictable, nature of such an endeavor, Philip Morris’s actions also may be viewed as illegal according to the Employee Retirement Income Security Act of 1974, a federal law that protects individual health plan participants by setting minimum standards for a wide range of private-sector health plans (e.g., pension plans, health benefit plans). As a provider of health benefits, the company acts in a fiduciary capacity in regard to its employees. Philip Morris’s censorship of important and accurate health information violates those duties. According to Employee Retirement Income Security Act of 1974 guidelines, fiduciaries must “avoid conflicts of interest,” and “they may not engage in transactions on behalf of the plan that benefit parties related to the plan, such as other fiduciaries, services providers, or the plan sponsor.”27

That a health insurer would collaborate with a tobacco company in suppressing important and accurate health advice from its beneficiaries is more surprising. CIGNA currently manages health plans that cover 14 million Americans, and it contracts with 3600 hospitals and 288 000 physicians.28 CIGNA’s agreement with Philip Morris not only violated the ethical obligation of a health care insurer to provide truthful information to patients but also undermined even the minimal assurances given to Philip Morris employees about the nature of their CIGNA plan. The director of employee benefits at Philip Morris wrote to workers that the company contracts with managed care plans that have an “emphasis on preventive care.”29 The reported censorship of Well-Being articles on the importance of quitting smoking for preventive health care or the hazards of environmental tobacco smoke exposure clearly undermines this principle.

CIGNA’S PARTICIPATION

There are several possibilities that could explain CIGNA’s active role in this scheme. First, the entire agreement might have been an unfortunate error in judgment by a few employees. If this were true, then CIGNA would have distanced itself quickly from the agreement with Philip Morris and perhaps disciplined the employees involved. This apparently did not happen. When the joint censorship of the health newsletters with the tobacco company was reported in the press, CIGNA defended the arrangement. A spokesman said, “We work with our customers to try and help them meet their business needs.”23 Surely CIGNA leadership must have realized that such censorship, if made public, would erode employee and public trust, yet the altering of newsletters continued until Philip Morris ended the practice.

A second possibility is that CIGNA’s participation in the censorship was a means to provide service to its corporate client Philip Morris. An employer-based health care system creates an incentive for insurers to cater to employers more than to individual patients. The reason is simple: a dissatisfied employer can cost an insurer millions of dollars in revenue by choosing to contract with a different company, whereas a worker may have no such option. Approximately 2 in 5 workers who receive health benefits are not given a choice of insurer by their employer.30 Yet, despite these incentives, it is difficult to imagine that many health plans would withhold information about the harm of smoking or environmental tobacco smoke at the request of a leading tobacco company.31

A third and related possibility is that, to maximize profits, CIGNA was willing to overlook this censorship of health information. CIGNA, whose corporate motto is “A Business of Caring,” is an investor-owned health plan that does not have the same statutory obligations to act in the public interest as a not-for-profit plan. In fact, CIGNA profits when Philip Morris profits. According to published reports, the insurer owned at least $57 million in Philip Morris stock in 199532 and $38.6 million in 1999.31 Some studies have shown that for-profit hospitals, health plans, nursing homes, and dialysis facilities provide lower quality care than not-for-profit plans.33–36 CIGNA’s actions in this case may provide an example of how a profit-seeking business culture might respond to profits rather than quality of care.

These hypotheses, as well as other alternative explanations, cannot be proven without additional information. We urge CIGNA to release all of its records regarding this censorship of health information.

CONCLUSION

Without accessibility to Philip Morris’s internal documents, the public may never have learned of the deal between Philip Morris and CIGNA. However, there are several limitations inherent to articles based on these documents.37–39 For example, in this report, based on a small subset of the 50 million or so documents currently available, we concentrated on files related to CIGNA, and we did not uncover any documents that contradicted our findings. When queried by the media, neither company publicly denied the arrangement.

The irony of the agreement between Philip Morris and CIGNA is that it was called off by the tobacco company, not by the health insurer. While this arrangement no longer exists, the potential for similar arrangements involving other industries is a matter of concern. Have paint manufacturers asked for censorship on the hazards of lead paint? Have gun makers asked that their employees not read about statistics on gun-related violence? Further research in this area might be illuminating.

At a minimum, we believe that national accrediting bodies such as the National Committee on Quality Assurance should mandate that health plans not censor employee-directed health information at the request of employers. This simple step, if enforced, should help US workers breathe a little easier.