Non-scientific communications

Many issues of journals “Наука кардиология” [Cardiology Science], “Наука пулмонология” [Pulmonology Science] contain articles, interviews and other informational materials prepared by PMI or published with their support. This is how the promotion of heated tobacco products in Bulgaria arrives to the medical and scientific community alongside a wave of industry-sponsored content not just around mass media, but also in scientific journals. We shall examine here critical examples of such narratives aimed at the medical and scientific community. It aims to present some of the more prevalent claims circulating around medical and other expert audiences.

Drawing from a comprehensive analysis of articles published in the journal Cardiology Science between 2020 and 2022, we trace the dissemination of these claims and raise questions as to the ethics involved. The purpose is to shed light onto the potential influence of industry-sponsored content on scientific discourse, public and regulatory debates and overall public health outcomes. For this purpose we look into several high profile sources of information for medical professionals and scientists

Tracing reduced harm in scientific publications

In its issue 5 of 2020, Cardiology Science published an interview conducted by PMI of Dr. Gizelle Baker, then director for global scientific engagement at the company. A disclaimer at the end of the article, entitled important information states:

Тhe material was compiled with the support of Philip Мorris International. This material is prepared with the aim of publication and dissemination of scientific information and not for advertising and marketing purposes related to products containing tobacco or nicotine. The content of the material is not and should not be considered an offer or solicitation to sell the products of PMI or its affiliates. Furthermore, the Content is not and should not be construed as a promise, endorsement, specification or warranty in relation to products of PMI or its affiliates.

“Наука кардиология” (Cardiology Science) has been distributed among medical specialists in cardiology and other fields of medicine. The journal has developed not only as a scientific publication, but also as a journal providing practical guidance to its readers.[1] It is published by Arbilis – one of the leading publishers of medical scientific and practical literature – medical periodicals, textbooks, collections, monographs, etc.the main goal of the company – increasing the qualifications of Bulgarian medical doctors.[2] The website offers advertisers an opportunity to publish one page of scientific/PR text.[3] In 2019, the journal reached over 8000 doctors in Bulgaria.[4]

The same interview was published verbatim as an advertorial in 2022 on the website of the Bulgarian Hospital Association (BHA).[5] Their disclaimer states:

The material is published with the support of Philip Morris Bulgaria.
The articles published in the “Science and Innovations” section are provided by the authors of the relevant materials, who are responsible for the accuracy of the content”

The Bulgarian Hospital Association (BHA) [Българска болнична асоциация] defines its mission as follows: “We are united of the idea of developing a better healthcare system in Bulgaria.” The association is open to all medical facilities – for inpatient and outpatient care – regardless of ownership – private, municipal or state. It currently has 38 members.

A common interview

Dr. Baker’s interview is divided into 8 parts: What are heated tobacco products (HTP); How do these products work?; Are HTP the same as electronic cigarettes?; Are HTP safer than cigarettes?; Are consumers of HTP exposed to new chemical substances?; Is the use of HTP common among non-smokers and young people?; and finally – Further reasoning.

With regards to the working of HTP, the claim is that the process of heating as opposed to burning, results in the production of an aerosol, which contains nicotine and much lower concentrations of harmful substances compared to regular cigarette smoke. It is recognized that HTP products vary in design, heating temperatures, heat source and each require separate study.

The purpose of the new HTP is to contribute to better health outcomes for adult smokers who switch completely because they can significantly reduce exposure to toxic substances in cigarette smoke known to cause smoking-related diseases.

The interview also cites some findings from the US Food and Drug Administration (FDA). In relation to the finding that concentrations of several substances in the aerosol are higher than in cigarette smoke: “these substances are present at low concentrations and the potential effects are compensated by the significant reduction in the number and concentrations of HPHCs (harmful and potentially harmful constituents) in combustible cigarettes”. With regards to second-hand smoking, the FDA’s comment: “reduced exposure to HPHCs (harmful and potentially harmful constituents) also benefits people passively exposed to aerosolized EHTPs [electronic HTPs] compared to environmental tobacco smoke

Finally, another point frequently propagated by the industry relates to the idea that not all tobacco products are the same. They are places on a continuum of risk…Regulations considering relative risk can help encourage adult smokers who do not stop smoking to switch to better alternatives.

All of the major points in the interview will be reiterated and expanded by the industry in subsequent indepth publications.

Studies allege reduced harm

The the first sentence of a publication published in Cardiology Science[6] and MedicalNews[7] reads: “Heated tobacco technologies can play an important role in reducing tobacco harm

The methodology employed is the use of real life, actual use data i.e. results of using the product in real conditions. The journal introduces three separate studies, which are linked together in order to derive the conclusion.

The first study, carried out by independent researchers from the American Cancer Society finds that cigarette sales in Japan fell by 9.5% following the introduction of HTPs into the market. In their own conclusion, the authors of the research point out that “The net population health impact, however, cannot be assessed without resolving several key uncertainties related to the direct harms of IQOS and the precise patterns of both smoking and IQOS use.

The journal article does not link such data to substantiate the claim that THS (Tobacco Heating Systems) can reduce tobacco harm. Instead, it puts forward medical data on certain smoking-related diseases from two databases – Medical Data Division and Japan Medical Data Centre. Reportedly, the data shows a decline in hospitalizations of patients with chronic obstructive pulmonary disease (COPD), including exacerbations and those with ischemic heart disease. For the former, the tendency of raising hospitalization begins to decline after 2017 – following HTP’s introduction into the market. It is unclear who had compiled the data, however the text does state that “this type of research carries a number of restrictions and it is important to note that the results do not show a causal link”.

The article backs up the assumption that THS leads to fewer hospitalizations for COPD by including findings from a clinical research by the Center of Excellence for the Acceleration of Harm Reduction – CoEHAR. The participants in the study were divided into two groups of 19 people each – those who switched to THS and significantly decreased smoking of conventional cigarettes and the other who continued smoking regular cigarettes. Health indicators of both groups got examined three times in the span of three years. The comparison showed “the use of THS leads to a decrease in the exacerbations of COPD symptoms by over 40%”.

The article concludes that “Not only is the entry of THS into the Japanese market the likely cause of the decline in cigarette sales, but it is also connected to the decline in hospitalizations of patients with COPD and ischemic heart disease.” Linking all the data presented above it states: “the body of evidence collected to date on THS, including experimental and actual use data, is in favor of the possibility of harm reduction”.

Even though the article maintains caution by adding ‘the possibility’ in its overall conclusion and other instances in the text, it appears that the logical rationale intentionally overlooks relevant questions regarding harm reduction. Some of these questions, such as the precise smoking patterns of HTP and conventional cigarette users, highlighted by the researchers from the American Cancer Society in one of the studies mentioned above. The omission raises serious concerns around the choice of methodology as the spread of deceiving information within the medical community may severely influence not only public perceptions, but also public health outcomes.

Science and news

Subsequent articles published during the same year in issues 4 and 6 of Cardiology Science8 describe clinical studies carried out by PMI: „Improvement in 8 biomarkers for cardiovascular disease, respiratory disease, or cancer when switching from cigarette smoking to smokeless alternatives“ and “Development of a multicellular model to evaluate the anti-inflammatory effects of natural compounds with a modulating effect on the immune system”.

The text of the former article has also been disseminated around news media channels including Medicalnews.bg[9] and Capital[10].

The first one, Medical News [Медицински новини], is a specialized news platform for medical doctors. The services provided by Medical News Ltd. include access to specialized information, access to specialized medical news, access to educational medical materials, receiving a weekly newsletter with medical news etc, The self-defined purpose of Medical News Ltd. is to connect medical specialists in Bulgaria, provide them with the most up-to-date information and create conditions for online-based continuing medical education.[11] The website presents itself to advertisers as “a comprehensive solution that provides you with an ideal opportunity to reach healthcare professionals and their patients as a target group”.[12]

The second source, Capital [Капитал] is already familiar from Chapter 2 – a leading weekly news magazine by business publisher Economedia. Their portfolio includes the most influential economic publication Capital and the news site Dnevnik. According to their own estimates Economedia reaches 1 800 000 readers per month. They are popular primarily amongst educated citizens with higher economic and social status.[13] Capital certainly cannot be considered a scientific or medical publication. Even its periodical supplement Health – where the article in question appeared – is targeted predominantly at health managers and entrepreneurs, rather than scientists and researchers.

The article in Capital is labeled as a marketing publication under the media outlet’s rules for Native packages, already described in Chapter 1, therefore it is an advertorial. The disclaimer of Medicalnews articles states: “The material is published with the support of Philip Morris Bulgaria”.

“Relative risk – providing context for better understanding”

The article entitled “Relative Risk – providing context for better understanding”[14] uses the concept of relative risk as a scientific measure to derive a risk spectrum for smoking. The text is published verbatim in Capital[15], MedicalNews[16], and by the Bulgarian Hospital Association[17]. The claims made aim to distinguish tobacco products from one another: „for adult smokers who would otherwise continue to smoke, switching to scientifically proven smoke-free alternatives has the potential to reduce their risk of developing serious tobacco-related diseases“.

Even though the article clearly states that quitting smoking is the best health option, the risks associated with smoke-free alternatives are not identified. Instead, it refers to a research, which “suggests that emissions from nicotine vaporizers (such as e-cigarettes) and tobacco heating devices contain carcinogens, but at much lower concentrations than those found in cigarette smoke.” The conclusion entitled “harm reduction equation” states “the more individuals choose the lower-risk alternative rather than continuing to smoke, the greater the harm reduction impact will be for the entire population”.

Perhaps the biggest impact on shifting perceptions are the graphics, again identical in all publications, which portray a risk spectrum:

Source: Science Cardiology, Issue 5, 2021, at. p. 247; MedicalNews, (4.11.2021); Bulgarian Hospital Association (13.06.2022)
Source: Capital, December 2021

The publication in Capital is an advertorial, the publication in the other sources states: “The material is published with the support of Philip Morris Bulgaria”.

Conclusions

This brief analytical comparison of promotional articles in scientific and popular medical outlets reveals the tobacco industry’s tactics of spreading its self-funded studies. Rather than reporting on clinical trials carried out in Bulgaria, journals and magazines targeting medical practitioner audiences, such as Cardiology Science, Bulgarian Hospital Association and MedicalNews, enable a consistent presence of PMI-sponsored publications from a prominent medical journal featuring studies carried out in other countries.

Paradoxically, identical content, originating from PMI, is disseminated by a business audience oriented mass medium such as Capital. The articles by Capital are clearly advertorial and the website offers transparency about advertising packages18.

After having established utter disregard of journalistic professional and ethical norms in Chapter 1, here we come across a similar lack of integrity with regard to scientific content.

Placing advertorial content within medically affiliated sources, especially when those are specifically compiled and freely distributed amongst medical professionals, poses a range of ethical questions19. In the absence of any ethical or professional oversight, the publishing of sponsored content raises concerns regarding conflict of interest among medical professionals and scientists, who believe that the regular publications of claims about possible health harm reduction without editorial intervention compromises scientific communication.

This imbalance in the information space amongst expert audiences as well as the wider public requires careful scrutiny and a counter-source able to present the full picture around the actions and credibility of industry-funded research. In the current national climate this and other forms of retribution are problematic due to a variety of factors most prevalent of which – the funding of private media. ⭓


  1. Arbilis website, [Available from:] https://arbilis.com/uslugi/izdatelstvo/spisaniya/nauka-kardiologiya-2/
  2. Arbilis website, [Available from:] https://arbilis.com/za-nas/
  3. Arbilis website, [Available from:] https://arbilis.com/za-reklamodateli/
  4. Academy Cardiology Foundation website, [Available from:] https://bg-cardio-fondation.com/programs-nk/
  5. Bulgarian Hospital Association, (10.01.2022), Reducing harm from tobacco, [Available from:] https://bba-bulgaria.com/namalyavane-vredata-ot-tyutyuna
  6. Cardiology Science, (2022), Real Life Data – Tobacco Heating Systems (HTS), issue 3, p.142, published by Arbilis, Sofia, Bulgaria
  7. MedicalNews, (10.08.2022), Real Life Data – Tobacco Heating Systems (HTS), Category: Top chosen [Available from:] https://medicalnews.bg/2022/08/10/%d0%b4%d0%b0%d0%bd%d0%bd%d0%b8-%d0%be%d1%82-%d1%80%d0%b5%d0%b0%d0%bb%d0%bd%d0%b8%d1%8f-%d0%b6%d0%b8%d0%b2%d0%be%d1%82-%d1%81%d0%b8%d1%81%d1%82%d0%b5%d0%bc%d0%b8-%d0%b7%d0%b0-%d0%bd%d0%b0%d0%b3%d1%80/
    And subsequently on 15.08.2022, Category: News, Top Chosen [Available from:]
    https://medicalnews.bg/2022/08/15/%d0%b4%d0%b0%d0%bd%d0%bd%d0%b8-%d0%be%d1%82-%d1%80%d0%b5%d0%b0%d0%bb%d0%bd%d0%b8%d1%8f-%d0%b6%d0%b8%d0%b2%d0%be%d1%82-%d1%81%d0%b8%d1%81%d1%82%d0%b5%d0%bc%d0%b8-%d0%b7%d0%b0-%d0%bd%d0%b0%d0%b3%d1%80-2/
  8. Cardiology Science, (2022), Issue 4 at p. 190-192; and Issue 6 at p. 274-275.
  9. Medical News, (09.05.2022), Improvement in 8 biomarkers for cardiovascular, respiratory disease or cancer when switching from cigarette smoking to smokeless alternatives, [Available from:] https://medicalnews.bg/2022/05/09/%D0%BF%D0%BE%D0%B4%D0%BE%D0%B1%D1%80%D0%B5%D0%BD%D0%B8%D0%B5-%D0%B2-8-%D0%B1%D0%B8%D0%BE%D0%BC%D0%B0%D1%80%D0%BA%D0%B5%D1%80%D0%B0-%D0%B7%D0%B0-%D1%81%D1%8A%D1%80%D0%B4%D0%B5%D1%87%D0%BD%D0%BE-%D1%81/
  10. Capital, (31.05.2023), A large clinical trial with 984 people in the US showed: Improvement in 8 biomarkers for cardiovascular disease, respiratory disease or cancer, [Available from:] https://www.capital.bg/politika_i_ikonomika/zdraveopazvane/2023/05/31/4479321_mashtabno_klinichno_prouchvane_s_984_dushi_v_sasht/
  11. MedicalNews website, [Available from:] https://medicalnews.bg/privacy-policy/
  12. MedicalNews website, [Available from:] https://medicalnews.bg/advertise/
  13. Capital Insights website, [Available from:] https://kinsights.capital.bg/about/
  14. Cardiology Science, (2021), Relative Risk – providing context for better understanding, issue 5, at p. 246-248, published by Arbilis, Sofia, Bulgaria
  15. Capital Health, Special edition, (December 2021), Relative Risk, at p.94-95, published by: Ikonomedia AD, Sofia, Bulgaria
  16. MedicalNews, (04.11.2021), Relative Risk, Category: Closed, News, [Available from:] [Registration as a medical practitioner/student required]: https://medicalnews.bg/2021/11/04/%d0%be%d1%82%d0%bd%d0%be%d1%81%d0%b8%d1%82%d0%b5%d0%bb%d0%b5%d0%bd-%d1%80%d0%b8%d1%81%d0%ba/
  17. Bulgarian Hospital Association, (13.06.2022), Relative Risk, [Available from:] https://bba-bulgaria.com/otnositelen-risk
  18. Capital, Native adds, [Available from:] https://www.economedia.bg/native/
  19. Both Cardiology Science and MedicalNews offer free subscriptions to medical practitioners and students.