The AMA's Cigarette PAC.

Why does the American Medical Association support pro-tobacco candidates?

During the campaign season that culminated in November's election, those senators who blocked comprehensive tobacco control legislation sponsored by Arizona Republican John McCain were rewarded with thousands of dollars in contributions from cigarette manufacturers--and thousands more from U.S. physicians.

Strange bedfellows, indeed. According to Federal Election Commission records published by the Center for Responsive Politics, the American Medical Association's political action committee (known as "AMPAC") gave over $8,500, on average, to senators facing reelection who helped kill McCain's proposal in June. The defeat of this legislation, which would have increased cigarette taxes and granted the Food and Drug Administration authority to regulate tobacco products, effectively ended tobacco control efforts in the 105th Congress.

By comparison, AMPAC gave less than $2,500, on average, to senators up for reelection who had tried to move the McCain bill forward. That's more than a 3:1 ratio in favor of pro-tobacco senators and begs the question: Why does a group that represents 250,000 physicians preferentially fund the supporters of an industry that annually kills 400,000 Americans?

No scientific reversal explains the AMA's backing of tobacco's friends on Capitol Hill. The nation's largest physicians group remains committed, in the words of a recent leader, to "take the war to the tobacco companies in every way that we can." In addition to supporting anti-smoking initiatives, the AMA has called for investors to divest from tobacco stocks and for politicians not to accept money from the tobacco industry. After the Senate vote in June, Dr. Randolph D. Smoak, Jr. of the AMA's Board of Trustees, declared that his organization "deeply regrets the Senate's failure to pass landmark anti-tobacco legislation."

Yet not a month later, AMPAC contributed thousands to help pro-tobacco Senators Kit Bond from Missouri and Sam Brownback from Kansas beat back Democratic challengers. The PAC then went on to give the legal maximum--$10,000--to Ben Nighthorse-Campbell, a Colorado Republican who voted to block the McCain proposal and who faced an anti-tobacco opponent.

In the 1997-98 campaign, AMPAC did not support Nevada Sen. Harry Reid, a Democratic floor leader for tobacco legislation who declared in the Senate that "every day we waste in this Congress on something other than tobacco, we are addicting 3,000 children." But AMPAC did contribute the full $10,000 to Reid's challenger John Ensign, a House member who publicly opposed comprehensive tobacco control in May "because as soon as you support a cigarette tax, the tobacco states come back and say, `Let's go for a gaming tax.'"

Politics, not science, explains the seemingly strange PAC contributions of a medical organization that has never fully reconciled its dual goals of supporting the health of Americans and protecting the income of physicians. About 50,000 AMA members contribute directly to AMPAC, which is officially affiliated with the AMA and overseen by a board appointed by the AMA's own board of trustees. AMPAC works with state medical societies to identify candidates for its generous support. In 1997-98, AMPAC contributed over $2.3 million to federal candidates, placing it in the top 10 of all national political action committees, according to the Center for Responsive Politics. Despite the AMA's claim that AMPAC is bipartisan, over two-thirds of its direct contributions (and 98 percent of its soft money for political parties) wind up in Republican pockets. AMPAC's treasurer, Kevin Walker, is a former Republican campaign operative who confided to Campaigns & Elections magazine in 1995 that his political heroes are Ronald Reagan and Margaret Thatcher.

AMPAC's promotional material states that its goal is "to support and elect pro-medicine candidates on the federal level." But while the AMA's official slogan is "physicians dedicated to the health of America," AMPAC's might as well be, "You don't have to be anti-tobacco to be pro-medicine."

In the late '80s and early '90s, the AMA strongly fought limits on physician charges under the Medicare program, and AMPAC contributions flowed generously to political conservatives who opposed government intervention in the health care market. These representatives generally backed the tobacco industry. As a result, AMPAC wound up giving larger contributions to House members who voted to use federal funding for promotion of tobacco exports--despite an AMA policy opposing such legislation. (I first reported this finding with my father, a Baltimore psychiatrist, in the New England Journal of Medicine in 1994.)

After the Republicans took over Congress, the AMA set its sights on achieving its long sought-after goal of tort reform. To convince Congress to limit non-economic (also known as "pain and suffering") damages in malpractice suits to $250,000, the group led what its newspaper called an "intense lobbying effort" consisting of phone banks, fax alerts, and full-page advertisements "starring a cadre of former federal health luminaries."

AMA-backed malpractice legislation came to a vote twice in the 104th Congress--with AMPAC watching closely. House members who voted for malpractice limits both times received an average of $6,885 in the 1996 campaign, compared to $3,647 if they voted for it once, and $553 if not at all. Just a coincidence? AMPAC treasurer Walker told Campaigns & Elections that his "best day" on the job came when the House finally passed the $250,000 liability cap. And an editorial in the AMA's newspaper specifically credited the victory to the "long-term commitment of time and financial resources needed to open and maintain access to lawmakers."

House members who voted for the AMA's malpractice limits also tended to back Big Tobacco--probably because many supporters of limited liability for doctors also want the same for cigarette manufacturers. As a result, in the 1996 campaign, AMPAC contributed over twice as much, on average, to opponents of FDA regulation of tobacco products as to supporters. A statistical analysis (that I published in the American Journal of Public Health) demonstrated that AMPAC's marked preference for pro-tobacco members could be attributed entirely to their positions on AMA-backed malpractice legislation.

Despite a lobbying blitz from the AMA, legislation limiting malpractice awards died in the Senate. No surprise then that AMPAC heavily favored presumably "pro-medicine" Senate candidates over their anti-tobacco counterparts in the subsequent election.

When made aware of AMPAC's record on tobacco, AMA leaders have not pointed to any election time or place where their PAC's contributions have actually supported the public health. Instead, they've argued that to contrast public health goals and AMPAC contributions "is to compare not apples and oranges but apples and hippopotamuses." By compartmentalizing public health and professional activities, the AMA hopes to be seen as an advocate for patients as well as an effective trade organization for physicians. Thus, Dr. Smoak of the Board of Trustees, a South Carolina surgeon who once headed his state's chapter of the American Cancer Society, is also praised on the AMA's web site for leading AMPAC (at a time the group gave significantly more to tobacco supporters in Congress).

But the AMA can only ignore the hippopotamus in its boardroom for so long. AMPAC's bankrolling of tobacco industry allies undermines many dedicated physicians at the AMA who hope to use the authority of the organization to further the public health. How seriously can elected officials take the health exhortations of an organization that gives out contributions based on support for physicians' financial interests and not patients' well being?

AMPAC dollars may even give election-time cover to pro-tobacco candidates. In the 1998 campaign, New York Democrat Edolphus Towns was criticized by an opponent for receiving thousands in tobacco contributions and voting consistently to support the industry. Towns defended himself by citing all the money he had received from medical PACs (which included the AMA), adding, "If you're talking about dollars to influence, then I would have to be called the healthcare congressman."

The AMA loses credibility as a public health organization every time its PAC conspires to keep the Marlboro Man's friends in Congress. Yet if the nation's largest physician organization led other health care PACs in divesting politically from pro-tobacco representatives, then the amount of campaign funding available to advance the public health would dwarf even cigarette manufacturers' contributions.

Sound crazy? It'd just be a group of doctors taking their own medicine.

JOSHUA SHARFSTEIN is a resident at the Boston Medical Center.