Anticipating Formula Industry Strategies and Countering Them

Health professionals should prepare talking points for interview situations, contact with the press, or meeting with legislators or public health officials and avoid being drawn into debates that make them appear to be zealots. The following are common industry assertions and claims by opponents followed by useful responses.

Industry Assertion: Attempts to ban free formula gift packs are “anti-business;” formula companies have a responsibility to communicate their product innovations
Counter: Permitting the practice undermines the public health, which is costly, unethical, and, ultimately, bad for business. Marketing to mothers through the health care system exploits women’s fears and insecurities during the transition to motherhood

Industry Assertion: The Ban the Bags movement is anti-choice.
Counter: We avoid engaging in any exchange that borrows the language of the abortion debate. If necessary, identify your refusal to engage in a discussion using this language precisely because it co-opts the emotional language of the other, totally unrelated issue.
Appropriate response: Regulating advertising that negatively affects the health of vulnerable women and children has little to do with personal choice. It is about prohibiting unethical marketing practices to vulnerable populations.

Industry Assertion: Creating government regulations to control marketing practices is intrusive and unnecessary.
Counter: Market forces cannot be depended upon to protect vulnerable populations. Because the infant is most affected when breastfeeding is undermined, regulation is a sensible measure to protect the public health. This issue is similar to the regulations concerning exposure to passive smoke.

Industry Assertion: Ban the Bags makes women feel guilty.
Counter: Health professionals work hard to help women breastfeed, and are well aware of the problems that can occur to prevent success. What we seek to prevent is the deliberate undermining of breastfeeding by an industry that profits when breastfeeding fails. Industry would not provide the bags if they did not subvert breastfeeding. The “guilt” argument is used to dodge the issue of failure to fully inform women of the risks of formula feeding.

Industry Assertion: Ban the Bags is elitist because it deprives poor women of a free present they look forward to receiving.
Counter: Undermining breastfeeding and depriving low-income families of the numerous health and economic protections that breastfeeding provides is profoundly exploitative, especially to non-Hispanic black women, who have the lowest breastfeeding rates in the US. The increased health care costs incurred by the uninsured burden the whole country. These bags are NOT free! We are all paying for their hidden costs in terms of a seriously strained health care system.

Industry Assertion: Maternal employment, not formula gift bags, is the major barrier to breastfeeding, especially for working class women with few workplace accommodations.
Counter: Society needs to work harder to ensure that employed mothers and their babies have equal rights with regard to the opportunity to breastfeed. Women planning to return to jobs deserve the right to establish a full milk supply. Early formula supplementation interferes with the establishment of a full milk supply and can compromise their ability to continue breastfeeding when they return to work.

Industry Assertion: Formula is safe and healthy, and many US citizens were raised on it.
Counter: An epidemic of childhood obesity demands that we re-examine the foods and feeding methods that currently predominate. Breastfeeding is one of the stated “pillars” of the US Public Health system’s childhood anti-obesity campaign. The US healthcare system spends an additional $3 billion on diseases and conditions that are increased due to not breastfeeding

Hospital Assertion: We need to give out these bags to obtain discounted materials and supplies when purchasing items from pharmaceutical companies.
Counter: This practice may violate OIG, Anti-Kickback and FTC gifts and advertising prohibitions.

Hospital Assertion: We have a contract with formula companies. Under the contracts clause of the US Constitution, a government agency is barred from impeding that contract
Counter: Allow the contract to run out and do not renew it. It is unethical to place commercial interests above patient interest.

Hospital Assertion: The Department of Public Health should not be regulating commercial endeavors as long as they are consistent with hospital operations and not related to harming the health or safety of a patient
Counter: Patient health and safety can be compromised by failure to exclusively breastfeed or from contaminated powdered infant formula that is not sterile

Hospital Assertion: Removal of the bags interferes with the doctor patient relationship and restricts physicians from counseling patients with whatever type of information on infant feeding options that they believe is necessary
Counter: The bags in no way interfere with the communication between health care providers and patients. Discharge bags are a marketing tool to cause mothers to purchase expensive brands of infant formula under the guise of a medically sanctioned and recommended action

Hospital Assertion: Discharge bags are given when women leave the hospital, therefore they cannot negatively influence breastfeeding behavior while in the hospital.
Counter: While some progress has been made increasing breastfeeding initiation rates, few women are exclusively breastfeeding by the end of the 2nd week postpartum. Formula samples in the discharge bags may undermine mothers decision to exclusively during the vulnerable time when they are transitioning home. Exclusive breastfeeding confers the greatest benefits to mothers and babies.


Promotional items are inappropriate in a medical environment and should not be used as patient education materials.

Formula reps have unparalleled access to maternity staff in hospitals. Reps are vendors. They should not be treated as part of the healthcare team. They have succeeded in getting hospital staff to market for them. Hospital staff and health care providers should not be acting as formula marketers, nor should they lend their prestige to a product that undermines the health of our nation’s infants and mothers.

Supportive references:

According to the American Academy of Pediatrics, “Prevention is one of the hallmarks of pediatric practice. Documented trends in increasing prevalence of overweight…mean pediatricians must focus preventive efforts on childhood obesity.” Preventive recommendations include: “Encourage, support and protect breastfeeding.” American Academy of Pediatrics, Committee on Nutrition: Prevention of Pediatric Overweight and Obesity, Pediatrics 2003; 112(2):424-429.

“The new multimedia public advertising campaigns may increase the cost of infant formula to the general public” Greer F, Apple R: Physicians, Formula Companies, and Advertising, AJDC 1991; 145:282-286.

“The rate of drug prescriptions by physicians increases substantially after they see sales representatives,21 attend companysupported symposia, or accept samples. The systematic review of the medical literature on gifting by Wazana found that an overwhelming majority of interactions had negative results on clinical care.” Brennan T, Rothman D, Blank L, et al. Health industry practices that create conflicts of interest: A proposal for academic medical centers. JAMA 2007: 295(4):433.

“Gifts cost patients money, and they may change society’s perception of the [medical] profession as serving the best interest of patients.” Chren M, Landefeld S, Murray T: JAMA 1989; 262(24):3448-3451.

“Pharmaceutical companies are not charitable foundations. They do what they do to make money for their stockholders. As a result, they can act in ways that are not in the best interest of patients as a whole.” Kramer, T: Practitioners and the Pharmaceutical Industry, Medscape Psychiatry & Mental Health eJournal 2002; 7(3).

“Companies are responsible for sales agents who engage in improper marketing and promotional activites¦ for example, under new proposed guidelines, “a drug maker cannot give golf balls emblazoned with the company’s name to doctors because the products do not provide a benefit to patients.” Pear R: Drug Industry is Told to Stop Gifts to Doctors. NY Times Oct 1, 2002

Conflict of interest has been defined as “a set of conditions in which professional judgment concerning a primary interest (such as patients’ welfare) tends to be unduly influenced by a secondary interest (such as financial gain) Smith R: Beyond Conflict of Interest, BMJ 1998; 317:291-292.

Nader R. Consumer born every minute. San Francisco Bay Guardian, August 24, 1999.

The US National Immunization Survey (NIS) tracks breastfeeding data. While initation rates indicate that approximately 65% of US children have ever been breastfed, only 60% have ever been exclusively breastfed. By 7 days breastfeeding rates are 59.3%, indicating an early drop off in exclusivity, a trend that continues over the period of the the first 6 months. Only 8% are exclusively breastfed by 6 months. Non-Hispanic blacks have the lowest rates of breastfeeding initiation and continuation. The authors state: “The health care system has an important role to play in the promotion and support of breastfeeding. Maternity care and newborn facilities should follow practices that are conducive to proper lactation, and all health care providers who interact with women or infants should be knowledgeable about breastfeeding and lactation and in providing medical care to breastfeeding women [in order to] identify the social, cultural, economic, and psychological barriers to breastfeeding that all women face, especially black women.” Ruowei L, Zhao Z, Mokdad A, et al. Prevalence of breastfeeding in the United States: The 2001 National Immunization Survey, Pediatrics 2003; 111(5):1198-1201.

Lack of exclusive breastfeeding for 6 months with continued breastfeeding up to one year per child costs the US economy $3.0 billion in medical costs per year, and $14.2 billion costs in premature deaths per year, and 3,340 excess premature deaths per year in women and children. Bartick M, Schwarz B, Green B, et al. Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal & Child Nutrition, 2016: Sept.

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