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Question: Case Study 5 The Tylenol Crisis: How Ethical Practices Saved Johnson & Johnson from Collapse 1. Trace the genesis and growth of Johnson and Johnson. How did the Tylenol crisis affect the onward growth march of J&J? 2. Explain in your own words the Tylenol crisis. What were the factors that accentuated the crisis? 3. Discuss the impact of the strategy adopted

Case Study 5 The Tylenol Crisis: How Ethical Practices Saved Johnson & Johnson from Collapse

1. Trace the genesis and growth of Johnson and Johnson. How did the Tylenol crisis affect the onward growth march of J&J?

2. Explain in your own words the Tylenol crisis. What were the factors that accentuated the crisis?

3. Discuss the impact of the strategy adopted by Johnson & Johnson to recall the Tylenol capsules in the aftermath of the news that seven patients died after using them to cure their headache and illness.

4. What was the strategy adopted by Johnson & Johnson to win back public trust? Did it have the desired impact?

5. Explain in your own words the story of how ethical practices saved Johnson & Johnson from virtual collapse

Answer 1 : In 1982, Johnson & Johnson's Tylenol medication commanded 35 per cent of the US over-the-counter analgesic market - representing something like 15 per cent of the company's profits. Unfortunately, at that point one individual succeeded in …

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Right Attitudes

Ideas for Impact

Tylenol Made a Hero of Johnson & Johnson: A Timeless Crisis Management Case Study

March 11, 2021 By Nagesh Belludi Leave a Comment

Crisis needn’t strike a company solely because of its own neglect or disaster. Sometimes, situations emerge where the company can’t be blamed—but the company realizes quickly that it’ll get much blame if it fumbles the ball in its crisis-response.

Ever since cyanide-laced Extra-Strength Tylenol killed seven people in Chicago in 1982, corporate boards and business school students have studied the response of Johnson & Johnson (J&J,) Tylenol’s manufacturer, to learn how to handle crises . The culprits are still unknown almost 40 years later.

Successful Crisis Management: Full Responsibility, Proactive Stance

In 1982, Tylenol commanded 35 percent of the over-the-counter analgesic market in America. This over-the-counter painkiller was the drugmaker’s best-selling product, and it represented nearly 17 percent of J&J’s profits. When seven people died from consuming the tainted drug, Time magazine wrote of the tragedy’s victims,

Twelve-year-old Mary Kellerman of Elk Grove Village took Extra-Strength Tylenol to ward off a cold that had been dogging her. Mary Reiner, 27… had recently given birth to her fourth child. Paula Prince, 35, a United Airlines stewardess, was found dead in her Chicago apartment, an open bottle of Extra-Strength Tylenol nearby in the bathroom. Says Dr. Kim [the chief of critical care at Northwest Community Hospital]: “The victims never had a chance. Death was certain within minutes.”

A panic ensued about how widespread the contamination may be. Moreover, Americans started to question the safety of over-the-counter medications.

Advertising guru Jerry Della Femina declared Tylenol dead:

I don’t think they can ever sell another product under that name. There may be an advertising person who thinks he can solve this, and if they find him, I want to hire him because then I want him to turn our water cooler into a wine cooler.

The ‘Grand-Daddy’ of Good Crisis Response

• J&J acted quickly , with complete candidness about what had happened, and immediately sought to remove any source of danger based on the worst-case scenario. Within hours of learning of the deaths, J&J installed toll-free numbers for consumers to get information, sent alerts to healthcare providers nationwide, and stopped advertising the product. J&J recalled 31 million bottles of Tylenol capsules from store shelves and offered replacement products free of charge in the safer tablet form. J&J did not wait for evidence to see whether the contamination might be more widespread.
• J&J’s leadership was in the lead and seemed in full control throughout the crisis. James Burke , J&J’s chairman, was widely admired for his leadership to pull Tylenol capsules off the market and his forthrightness in dealing with the media. (The Tylenol crisis led the news every night on every station for six weeks.)
• J&J placed consumers first . J&J spent more than $100 million for the recall and relaunch of Tylenol. The stock had been trading near a 52-week high just before the tragedy, dropped for a time, but recovered to its highs only two months later.
• J&J accepted responsibility . Burke could have described the disaster in many different ways: as an assault on the company, as a problem somewhere in the process of getting Tylenol from J&J factories to retail stores, or as the acts of a crazed criminal.
• J&J sought to ensure that measures were taken to prevent as far as possible a recurrence of the problem. J&J introduced tamper-proof packaging (supported by an expanded media campaign) that would make it much more difficult for a similar incident to occur in the future.
• J&J presented itself prepared to handle the short-term damage in the name of consumer safety. That, more than anything else, established a basis for trust with their customers. Within a year of the disaster, J&J’s share of the analgesic market, which had fallen to 7 percent from 37 percent following the poisoning, had climbed back to 30 percent.

Business Principles Should Hold True in Good Times and Bad

When the second outbreak of poisoning occurred four years after the first, Burke went on national television to declare that J&J would only offer Tylenol in caplets, which could not be pulled apart and resealed without consumers knowing about it.

Burke received the Presidential Medal of Freedom in 2000. He was named one of history’s ten most outstanding CEOs by Fortune magazine in 2003. In Lasting Leadership: What You Can Learn from the Top 25 Business People of Our Times (2004,) Burke emphasized,

J&J credo has always stated that the company is responsible first to its customers, then to its employees, the community and the stockholders, in that order. The credo is all about the consumer. [When those seven deaths occurred,] the credo made it very clear at that point exactly what we were all about. It gave me the ammunition I needed to persuade shareholders and others to spend the $100 million on the recall. The credo helped sell it. Trust has been an operative word in my life. It embodies almost everything you can strive for that will help you to succeed. You tell me any human relationship that works without trust, whether it is a marriage or a friendship or a social interaction; in the long run, the same thing is true about business.

Idea for Impact: A Crisis Makes a Leader

The first few days after any disaster or crisis can be a make-or-break time for a company’s and its leaders’ reputation. The urgency experienced during a crisis often gives leaders the go-ahead to enact change faster than ever before.

Admittedly, the Tylenol case study is more clear-cut than most crises because, from the get-go, it is clearly evident that criminals, not Johnson & Johnson, were responsible for the poisoning and the withdrawal of Tylenol from stores was comparatively easier to execute.

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News | Tragedy, then triumph: How Johnson & Johnson made sure Tylenol survived the Tylenol murders

Diane Elsroth of Peekskill, New York, shown in a 1980 high school yearbook photo, died at age 23 in February 1986 after taking a cyanide-laced Extra-Strength Tylenol capsule.

Kevin Boyd / Chicago Tribune

Less than two months after the murders, Johnson & Johnson introduced triple-sealed, tamper-resistant packaging.

Carl Hugare / Chicago Tribune

Three caskets are carried into St. Hyacinth Catholic Church in the Avondale neighborhood for the funeral of Adam, Stanley and Terri Janus, all victims of poisoned Tylenol.

Michael Budrys / Chicago Tribune

Chicago Archbishop Joseph Bernardin, center, blesses the Janus family caskets as they are carried out of St. Hyacinth Catholic Church.

Alojza Janus, center, is supported by son-in-law Marian Czyz and husband Tadeusz at the mass for her sons Adam and Stanley Janus, as well as for Stanley's wife, Terri. Another son, Joseph Janus, is seen at right.

A casket is carried out of St. Hyacinth Catholic Church after the funeral Mass for Adam, Stanley and Terri Janus.

Chicago Tribune archive

Seven people died in 1982 from cyanide poisoning after ingesting tainted Tylenol. From clockwise top left are Adam Janus, Mary McFarland, Mary "Lynn" Reiner, Terri and Stanley Janus, Paula Prince and Mary Kellerman.

A crowd watches as one of three caskets containing members of the Janus family is carried out of St. Hyacinth Catholic Church.

Helena and Jan Tarasewicz, center left, the parents of Theresa "Terri" Janus, grieve at the funeral Mass for Terri, her husband Stanley and her brother-in-law Adam Janus at St. Hyacinth Catholic Church.

Don Casper / Chicago Tribune

Chicago resident Paula Prince bought a tainted bottle of Tylenol at the Walgreens at Wells Street and North Avenue.

Phil Greer / Chicago Tribune

Ty Fahner, who was Illinois' attorney general and headed the multiagency task force investigating the Tylenol poisonings, recently described Johnson & Johnson as "a wonderful, willing partner" with law enforcement.

James Mayo / Chicago Tribune

Johnson & Johnson held a nationwide news conference via satellite on Nov. 11, 1982, to announce Tylenol's new tamper-resistant packaging. Journalists watched in Chicago at the Palmer House hotel.

Teresa Janus, the widow of Tylenol victim Adam Janus, is helped out of St. Hyacinth Catholic Church with her daughter Kathy in hand after his funeral Mass.

Charles Osgood / Chicago Tribune

These Tylenol capsules were connected with one of the 1982 poisonings. Cook County doctors found that the capsule at right contained cyanide, which has a grainier texture than the medicine shown at left.

Dr. Edmund Donoghue, right, then the deputy chief medical examiner in Cook County, discusses the Tylenol poisonings on Sept. 30, 1982. At left are Michael Schaffer, the toxicologist who tested the capsules, and Dr. Barry Lifschultz.

Nancy Chen of the Cook County medical examiner's office holds up test tubes containing the analyzed contents of Extra-Strength Tylenol capsules. The darker specimen at right was found to contain cyanide.

Charlie Knoblock / AP

Chicago Archbishop Joseph Bernardin, center, blesses one of the three caskets containing members of the Janus family at a funeral Mass held Oct. 5, 1982, in Chicago.

A photograph of a television screen shows the specific lot number for a batch of Extra-Strength Tylenol that was the first to be recalled.

A still from a drugstore camera shows Paula Prince, center in suit, as she buys a bottle of tainted Tylenol in 1982 at the Walgreens near her home in Chicago.

Alojza Janus, center, who saw two sons fall victim to poisoned Tylenol, is helped by her son-in-law Marian Czyz, left, and her husband, Tadeusz, outside St. Hyacinth in Chicago.

Alojza Janus, center, grieves with her husband, Tadeusz, at right, at St. Hyacinth Catholic Church. They are the parents of Tylenol victims Adam and Stanley Janus.

Quentin C. Dodt / Chicago Tribune

Chicago Mayor Jane Byrne, at right, holds a midnight news conference about a Chicago woman dying from tainted Tylenol. Chicago police Superintendent Richard Brzeczek is at left. Byrne is wearing a formal dress she'd donned for an evening event.

Stacey Wescott / Chicago Tribune

Terri and Stanley Janus on their wedding day. "I thought they would have a long, good life together," said Terri's friend Sandy Botwinski, who was a bridesmaid.

Charlie Knoblock/AP

Chicago City Health Department employees test Tylenol capsules for cyanide at a city laboratory.

John Dziekan / Chicago Tribune

A pharmacist checks lot codes on boxes of Extra-Strength Tylenol. The initial recalls were limited to certain batches of the product.

Three hearses line up outside St. Hyacinth Catholic Church, where the Mass for Adam, Stanley and Terri Janus was held.

Chicago police Officer Sam Barsevich takes inventory of Tylenol bottles that residents turned in at his station.

Ernie Cox Jr. / Chicago Tribune

Johnson & Johnson CEO James Burke talks about Tylenol on "The Phil Donahue Show" in Chicago on Nov. 15, 1982. The company recalled all Tylenol capsules in the wake of seven deaths but soon sought to rebuild its bestselling brand.

Charles Knoblock / AP

Helena Tarasewicz, mother of Tylenol victim Terri Janus, weeps over her daughter's casket during graveside services at Maryhill Cemetery in Chicago.

Terri Janus' parents, Jan and Helena Tarasewicz, from left, grieve at the mass for their daughter at St. Hyacinth Catholic Church.

Johnson & Johnson CEO James Burke holds the tamper-resistant packaging developed for Tylenol in late 1982 in an attempt to save the brand.

Pharmacist Dennis Jordan, right, checks lot codes on bottles of Extra-Strength Tylenol at the Westmont Pharmacy as he removes them from the shelves on Sept. 30, 1982.

The law firm Corboy & Demetrio sued Johnson & Johnson in 1983 over the Tylenol poisonings. A box of documents was photographed this year at the firm's offices.

Fred Jewell/AP

Jose Rosa, right, was one of hundreds of Chicago city employees and volunteers to distribute warnings about cyanide-laced Tylenol in fall 1982. Here, he offers a Spanish-language flyer to Luisa Acevada.

Extra-Strength Tylenol capsules had been laced with cyanide. And they were killing people in the Chicago area.

The news was already starting to get out, thanks to a dogged City News reporter, but there had been no public announcement. Someone needed to warn the public, Donoghue’s colleagues told him. Someone needed to hold a press briefing.

They looked at Donoghue, the 37-year-old deputy chief medical examiner who was in charge that day only because their boss was out of town. He didn’t disagree. He knew they couldn’t sit on this information, not with lives still at risk.

Before holding the briefing, he reached out to executives at McNeil Consumer Products, the Johnson & Johnson subsidiary that manufactures Tylenol. The company had learned about the poisonings only a short time earlier when a reporter called J&J for comment. Company leaders were still trying to wrap their heads around the situation.

They said they understood Donoghue had an important job to do. They just wanted to know: Did he have to say it was Tylenol, specifically? Wasn’t it a little premature?

Donoghue asked them to come up with a better alternative. The executives said they couldn’t.

“What I liked about it was when they said, ‘We can’t,’ ” Donoghue said. “That was practically giving me permission to do it.”

At 9 a.m., Donoghue and two colleagues stepped in front of television cameras and announced the Tylenol deaths.

The announcement sent Tylenol — the country’s top-selling pain reliever — into a tailspin from which many predicted it could not recover.

The fact that it did has become the subject of numerous books and college lectures, held up as a shining example of corporate ethics and crisis management. The safety seals the company introduced after the killings are found on all manner of over-the-counter medications and food products today, making tamper-evident packaging one of the horrific crime’s most enduring legacies.

A Johnson & Johnson spokesperson declined to answer Tribune questions about events related to the poisonings. Instead, she issued a statement lauding the company’s response.

“Our highest responsibility has always been the health and safety of our consumers,” the statement read. “While this tragic incident remains unsolved, this event resulted in important industry improvements to patient safety measures including the creation of tamper-resistant packaging.”

But as is so often the case, there’s more to the story.

‘You take care of this’

As Donoghue made his announcement, Johnson & Johnson executives huddled in CEO James Burke’s fifth-floor office in New Brunswick, New Jersey. J&J had acquired McNeil Laboratories in 1959 and soon began selling Tylenol over the counter through the newly formed McNeil Consumer Products. Its aspirin-free acetaminophen product now dominated the market for nonprescription pain relievers.

David Collins, the recently appointed chairman of McNeil Consumer Products, was among those in the meeting. As he remembers it, the executives had no idea what to do.

Crisis management hadn’t entered the corporate vernacular yet, but this was a crisis and they needed to manage it.

Burke turned and pointed to Collins.

“You take care of this,” Burke said, according to Collins. “This is your responsibility.”

An Oak Park native, Collins immediately took the corporate helicopter to the McNeil headquarters in Fort Washington, Pennsylvania, where a significant number of the company’s Extra-Strength Tylenol capsules were produced. The executives established a war room at the plant, giving themselves a dedicated space to discuss potential strategies and options for internal investigations.

Collins told the Tribune he immediately recognized that the crisis couldn’t be managed from corporate boardrooms on the East Coast. He needed to be closer to the epicenter, which at that time was the Cook County morgue near the intersection of Polk and Wood.

“It was pretty clear to me that I had to go to Chicago, that this thing was so important we couldn’t rely on secondhand reports,” Collins said. “But obviously we needed to begin right away and establish some kind of communication with the key people on the West Side of Chicago.”

Collins called his college roommate Paul Noland, a Chicago-area attorney with connections to law enforcement and an understanding of how the city worked. Noland had just opened a law office in Wheaton with Francis “Mike” Heroux, whose friendship with Noland and Collins stretched back to their days at Fenwick, a Catholic high school in Oak Park.

He asked Noland and Heroux to find out whatever they could — and quickly.

Heroux hustled over to the morgue, arriving about 30 minutes after the news conference.

Donoghue took him into the lab, where the toxicologist who worked through the night analyzing capsules from two tainted bottles explained what he found. He had run tests on three capsules from each bottle, and two of those capsules — one from each bottle — had tested positive for cyanide. Heroux stayed about a half-hour and left.

“You know, my dear old mother always said, ‘Trust everybody, but cut the cards.’ All they wanted to do is see the cards we were holding,” Donoghue said. “And once they realized, they left very quickly. There was no point for them to be there.”

Heroux, who died in 2008, didn’t stop looking for answers, though. Two more cyanide-related deaths would soon be confirmed in DuPage County, and Heroux represented the hospital where one of those two victims died. With the health care privacy act known as HIPAA still 14 years away, he was able to use his contacts there to gather information.

“We had more facts than anybody,” Noland recently told the Tribune.

Indeed, Elmhurst Detective Jim O’Brien told the FBI on Oct. 2, 1982, that most of his knowledge about the death of Mary Sue McFarland — a divorced mother of two small boys — came from the coroner and an unnamed Johnson & Johnson attorney.

Law enforcement records show that a J&J attorney came to the Elmhurst Police Department on the morning of Oct. 1 and wanted to share the results of his own investigation. According to the police report, the attorney said he had determined that McFarland had an Anacin bottle in her purse with the tainted Tylenol inside.

In reality, it was a Dristan bottle that held the poisoned capsules, but otherwise the lawyer’s information was spot-on. And it bothered the detective.

“O’Brien expresses his own concern about the attorney conducting (an) investigation in this matter inasmuch as it appeared to him that the attorney may be destroying fingerprints or other valuable evidence during the course of his investigation,” the report stated.

It’s a rare piece of criticism of Johnson & Johnson among the thousands of police records obtained by the Tribune. Others involved in the original Tylenol investigation praised the company for its response. O’Brien died in 2002.

In the very beginning, Collins said, the authorities didn’t know how to deal with Johnson & Johnson, whose employees and plants still needed to be investigated. He says the corporation leaned on Noland and Heroux’s connections to local law enforcement to help form a relationship with the task force.

Collins said the company voluntarily provided lists of disgruntled current and former employees, as well as unhappy customers. It was a start of an unusual partnership between the police and a company amid an investigation that had not yet determined whether the murders had happened while the bottles were under J&J’s control.

“We were polite, but one of the points we made was, guys, look, you know squat about this business,” Collins said. “You have no idea where to look. You have no idea the questions to ask. We’re the only ones who do. And if you don’t allow us to work with you on this, you’re cutting off your nose to spite your face. And that really made sense to them.”

Ty Fahner, then the Illinois attorney general and head of the multiagency task force investigating the poisonings, described J&J as “a wonderful, willing partner” with law enforcement. At the request of state authorities, the company offered a $100,000 reward on Oct. 1 for information leading to the conviction of whoever was responsible for the poisonings.

“They couldn’t have been better,” Fahner said of company executives.

‘Pull all your product’

By the afternoon of Oct. 1, there were six confirmed cyanide deaths: McFarland, Mary “Lynn” Reiner, 12-year-old Mary Kellerman and Adam, Stanley and Theresa Janus.

Johnson & Johnson quickly recalled more than 93,000 bottles from the batch of Tylenol connected to the Janus and Kellerman deaths. The company later expanded it to another 171,000 bottles with the same lot number as the one McFarland purchased.

The company also shut down the production of all Tylenol capsules while executives debated its packaging and marketing strategy internally. Though the FDA was pushing for a nationwide recall on Extra-Strength Tylenol capsules, the federal agency also wanted to assure the public that it could trust over-the-counter pain medication.

A spokesperson for the FDA, Bill Grigg, went on “Nightline” on Oct. 1 and shot down the possibility that the tampering took place at the McNeil Consumer Products plants. In a recent interview with the Tribune, Grigg said he knew that more investigative work had to be done, but he also understood that Americans were panicking.

“I think we got about 5,000 calls just in the next couple of days,” he said. “And many people didn’t have anything in their medicine cabinets but Tylenol. And even if they did have something else, they were suspicious. We did try to promote the idea that tablets could be safe, but people were already frightened.”

Fahner and other Illinois public health officials went much further than either the federal government or the manufacturer, telling people to throw away their Tylenol or turn it in to their local police department.

“People were terrified,” Fahner said. “And as soon as we got the word out that Tylenol had been laced (with cyanide), people said, ‘What do we do?’ I said, ‘Well, if you’ve got any in your medicine cabinet, or if you have any anywhere, either put it in a plastic bag and keep it or throw it away. Do not use it.’ “

Fahner said Johnson & Johnson’s chairman, James E. Burke, called him during the early days of the investigation and asked how he could help. Fahner recalled having just one request:

“Pull all your product from the shelf,” he told Burke.

It took a few days, but Burke eventually agreed to recall all Tylenol capsules.

The final Tylenol death was confirmed on the evening of Oct. 1, when 35-year-old flight attendant Paula Prince was found dead in her Old Town condominium. Chicago police Detectives Jimmy Gildea and Charlie Ford discovered a bottle of Tylenol on her bathroom vanity and a Sept. 29 receipt from a nearby Walgreens on the kitchen counter.

Prince’s poisoning would bring the death toll to seven.

On the way to the medical examiner’s office, the detectives got a radio call. Dispatch wanted them to know that police Superintendent Richard Brzeczek and Mayor Jane Byrne would be meeting them at the morgue — a kind of attention they had never experienced in their careers.

Byrne and Brzeczek had been at a retirement party for a top-ranking police officer at Navy Pier. They arrived at the morgue wearing formal attire and grim expressions. Cook County Medical Examiner Robert Stein, who was also wearing a tuxedo from an earlier engagement, showed them some Tylenol capsules that appeared hastily put together.

Autopsy results would confirm the next day that Prince had been fatally poisoned with cyanide. By then, the public already knew that — because Byrne held a rare midnight news conference to announce the death.

Wearing a frilly evening gown, Byrne sat in front of the microphones and began talking. Brzeczek, dressed in a jacket and tie, stood next to her.

“It was getting to be somewhat of a media circus (that week) because everyone was running around doing press conferences. And she said, ‘We’re going to have a press conference too,’ ” Brzeczek said. “As it turned out, all the TV stations interrupted their network broadcasting and the press conference went live all over the country.”

Byrne made nationwide news again the next morning when she took the most aggressive step since the killings began:

She banned the sale and distribution of Tylenol in Chicago.

Noland, the attorney, was at a party in Glen Ellyn on the night of Oct. 1 when he received word that Byrne was looking to speak with him. When they connected, Byrne said she wanted to see him the next morning in her office.

Noland showed up at City Hall, where Byrne told him of her plan to ban Tylenol. Noland called his longtime friend Collins, who was in an emergency board meeting with other Johnson & Johnson executives.

They quickly formed a position: The company could support pulling Extra-Strength capsules from the store shelves, but they opposed a full ban. Under Byrne’s proposed order hospitals couldn’t use Tylenol 3, the country’s most prescribed analgesic.

Collins said he wanted to explain to the mayor that withdrawing all Tylenol-branded products would present health problems for a lot of people and cause difficulties for medical centers.

The men didn’t think it would help, but they knew the mayor casually. Byrne’s late husband, Bill, had been best friends with Collins’ older brother.

Bill Byrne, the Collins brothers and Noland all went to the University of Notre Dame together. In Chicago politics, there were few more powerful fraternities in 1982 than the Fighting Irish alumni. When they spoke, Collins said, Mayor Byrne greeted him warmly, even inquiring about the health of Collins’ mother.

Then she turned him down flat.

“She was pleasant but unyielding,” said Noland, who went on to become a DuPage County judge. “Let me put it that way.”

Saving the brand

From the start, law enforcement and FDA investigators publicly doubted the capsules had been contaminated at the production plant.

They doubled down on that position after Reiner and McFarland’s deaths because their bottles both came from a McNeil facility in Round Rock, Texas. The Kellerman and Janus bottles were manufactured in Pennsylvania.

Not until Oct. 5, 1982, nearly a week after the victims swallowed their fatal doses, did a task force representative visit one of the plants.

Michael Schaffer, chief toxicologist of the Cook County medical examiner’s office, toured the McNeil facility in Pennsylvania to see if the potassium cyanide kept on the premises could have crept somehow into the production line. The company used the chemical to test the lead content of an ingredient used to make the medication.

After spending a morning there, he ruled out the possibility that bottles were contaminated during manufacturing, telling reporters that “no human hands touch the Tylenol or its ingredients in the automated mixing and packaging process.”

However, he also found that the potassium cyanide was kept in three unlocked quality control laboratories. More than 1,000 people had unfettered access to those labs, according to the company.

FDA testing found the cyanide kept on the McNeil property didn’t have the same trace element pattern — a sort of chemical fingerprint — as the poison placed in the capsules. Either way, a McNeil spokesperson said the firm would keep the cyanide locked up going forward.

The early exoneration from both the FDA and the Tylenol task force proved invaluable to Johnson & Johnson, whose executives knew they couldn’t rebuild their bestselling brand if the public thought the poisonings occurred while the capsules were under their control.

“It couldn’t just be us. It had to be the FDA,” Collins told the Tribune. “The FDA had to come along and say, ‘No, this is not a product problem.’ “

On the same day as Schaffer’s visit, Johnson & Johnson recalled all Tylenol capsules. In addition to pulling the medicine off shelves, it sent 450,000 notices to health professionals, hospitals and customers saying they were taking it “all back, lock, stock and barrel,” records show.

The company also offered to replace the worrisome capsules with the safer tablet form for free. It marked the first mass recall in U.S. history, involving more than 31 million bottles and costing the company $100 million.

“We were trying our darndest to get them removed from the American market,” George Frazza, Johnson & Johnson’s general counsel, testified in 1983. “And, as it turned out, we did a pretty good job.”

The recall announcement, however, was unpopular on Wall Street, where J&J’s stock continued to drop and marketing experts predicted the quick demise of Tylenol. The medication’s share of the market dropped from 37% in September 1982 to about 7% in the following months.

Bottles of Tylenol that weren’t tossed out were sent to Johnson & Johnson, the FDA and various other government laboratories for testing. J&J performed its testing at a corporate distribution center in suburban Lemont, where more than 10 million capsules were checked for cyanide, according to federal records.

On Oct. 21, a Johnson & Johnson employee detected cyanide in a bottle that had been returned to a Dominick’s on Chicago’s North Side. Eleven of the 50 capsules inside were poisoned, according to a police report.

Days later, on Oct. 25, cyanide was detected in another 50-count bottle that had made its way back to McNeil Consumer Products as part of the recall, investigative records show. The wife of a DuPage County judge had bought the Extra-Strength Tylenol on Sept. 29 at Frank’s Finer Foods in Wheaton and later turned it in to her local police department.

James Zagel, who was head of the Illinois state police at the time of the murders, testified in 1983 that he had worked closely with Johnson & Johnson in the investigation’s earliest days. He said he approved of the decision to let the company test the capsules even as authorities were looking to see if a disgruntled J&J employee was behind the poisonings.

“They set this program up in consultation with members of the task force, so we would keep as good a record as we could of where the capsules came from,” he told a jury during the 1983 trial of James Lewis , who tried to extort money from J&J after the poisonings.

Testing eventually identified eight poisoned bottles — five connected to fatal poisonings and three that surfaced after the murders.

At this point, McNeil employees worried that Tylenol wouldn’t survive as a brand. Production was halted indefinitely, investigators had swarmed the campus and tainted capsules were still being found.

Prominent advertising executive Jerry Della Femina predicted consumers would not see the Tylenol name, in any form, on store shelves within a year. A name so closely associated with death, he said, was unsellable.

“There may be an advertising person who thinks he can solve this, and if they find him I want to hire him, because then I want him to turn our water cooler into a wine cooler,” Della Femina told The New York Times on Oct. 8, 1982.

McNeil executives printed and posted the quote all over their offices. Collins said they used it for inspiration as they developed strategies to restore public confidence. The company did consider renaming Tylenol, Collins said, but a name change was rejected largely because of the “stubborn Irish pride” of many of the company’s decision makers who didn’t want to admit defeat.

Instead, the company’s key initiative involved developing tamper-evident packaging to help consumers feel safe enough to take Tylenol again. The Cook County Board of Commissioners already had passed an ordinance requiring safety seals on all medicines, food products and some cosmetics, and the FDA had begun working on federal legislation, though it wouldn’t be passed until 1989.

Collins told the Tribune that the company had been considering these safety measures for years but the poisonings served as the impetus for finally adopting them.

In consultation with the FDA, Collins said, a McNeil task force worked in the company’s research lab to develop packaging that could not be sabotaged.

Less than two months after the murders, Johnson & Johnson introduced triple-sealed packaging that included a box with glued flaps, tight plastic wrap around the bottle cap and a foil seal covering the mouth of the bottle. Labeling on the box and bottle warned consumers not to use the medicine if “safety seals” were broken.

“It was a serious effort because we figured we know more about this package than anybody and if we can’t get into it, the chances are that somebody else can’t get into it either,” Collins said. “We came up with what we thought was effective, tamper-evident packaging and reintroduced the product to the market as capsules.”

In announcing the new packaging in November 1982, CEO Burke said Johnson & Johnson considered it a “moral imperative as well as good business” to restore Tylenol to the same prominence it held in the market prior to the poisonings.

“All of us can demonstrate a united determination not to allow our lives to be ruled by acts of terrorism, not to allow America to be poisoned the way these seven people were poisoned,” Burke told reporters.

To boost consumer interest, J&J launched a marketing blitz promoting the safer bottles and calling attention to the financial hit the company took from the country’s first mass recall. Burke and other executives gave interviews in which they spoke about corporate responsibility and the Johnson & Johnson credo, a mission statement that puts the people the company serves over profit.

McNeil also offered a free bottle of safety-sealed Tylenol to anyone who called the company and requested one. It installed scores of new phone lines, then recruited staff and their families to answer the phones. In a three-hour interview with the Tribune, Collins became emotional as he recalled the many husbands, wives, uncles, aunts, cousins and children of employees who came in to help.

“And we had a lot of people call us and say, ‘We don’t want a bottle. We just want to thank you.’ So that turned out to be quite a success,” Collins said. “And I think it was a major step forward in reestablishing the confidence of the public.”

Within a year of the murders, Tylenol regained its spot as the country’s top pain reliever. Its market share was 30% by the fall of 1983, a more than 300% increase over its post-poisonings nadir.

Tylenol’s advertising firm sent a barrel of wine to Della Femina, who admitted he was wrong.

“One of the greatest tragedies of my career happened to be one of the greatest triumphs,” Collins said. “To this day, I believe that.”

But 1982 wasn’t the end of fatal Tylenol tamperings.

And a few years later, J&J would be forced to make an even bigger decision than simply redesigning its boxes and bottles.

Another Tylenol death

Less than four years after tamper-evident packaging helped Tylenol regain control of the pain reliever market, another capsule poisoning occurred.

Diane Elsroth, a 23-year-old stenographer, took an Extra-Strength Tylenol capsule while visiting the Yonkers, New York, home of her boyfriend’s parents in February 1986. She was found dead in bed the next day. Investigators later determined the capsule — which came from a newly opened, safety-sealed bottle — had been tainted with cyanide.

Another poisoned bottle was found in a nearby town, and stores began removing the product from shelves.

Johnson & Johnson had another public relations crisis on its hands.

Law enforcement inspected the McNeil plant in Pennsylvania and, unlike Illinois investigators in 1982, did not entirely rule out the possibility that the tainting occurred during the medicine’s production or distribution. However, they agreed it was unlikely.

“Until someone is charged with the crime, we can’t say definitively how it happened,” retired Yonkers police Detective Lt. Jack Roach, who oversaw the investigation, told the Tribune this year. “But it would have been hard, virtually impossible, to put (poisoned capsules) into the lots they were shipped in.”

Congress had passed a law in 1983 making product tampering a federal crime, so the FBI had jurisdiction over the case. The New York agents worked closely with their Illinois counterparts to determine whether the latest incidents could have been carried out by the same person responsible for the 1982 killings.

They reached no definitive conclusion.

The FBI and Yonkers police later concluded the poisoned capsules had been placed in bottles after they reached the store shelves. The feds, at one point, stated that their analysis indicated the killer had removed the bottom of the bottle and inserted the capsules that way.

Roach told the Tribune that his squad found it easy to remove safety seals and put them back on using a soldering iron. He said his detectives became so deft at tearing and repairing the seals, nobody could tell the difference.

Johnson & Johnson did not change its tamper-evident packaging after Elsroth’s death, but it did stop selling pull-apart capsules.

“In hindsight, which is 20-20, I wish we had never gone back to marketing these capsules,” Burke told a New York television station.

The statement offered little solace to Elsroth’s mother.

“It’s just three years too late,” Felicia Elsroth told UPI in response.

The lawsuits

While Wall Street and Madison Avenue celebrated Tylenol’s comeback, the families of the seven Chicago-area victims from the 1982 poisonings pushed to hold Johnson & Johnson accountable for their loved ones’ deaths.

In a lawsuit filed in Cook County, the families argued that Johnson & Johnson and McNeil were culpable for the deaths because they knew the capsules were susceptible to tampering. McNeil sold Tylenol to hospitals in tamper-evident packaging in 1982 but did not offer any such safeguards with its over-the-counter products.

The Kellerman and McFarland families were both represented by Corboy & Demetrio, a prominent firm with a national reputation for successfully taking on big corporations. As part of discovery in the case, J&J turned over records showing that it had received nearly 300 consumer complaints involving tampering, mix-ups or contamination before the killings, reports said.

“It should have alerted McNeil and Johnson & Johnson that any form of tampering was possible,” attorney Michael Demetrio told the Tribune this year. “The ability to have safety seals was already there, but guess what? It costs more to do these things, and that’s a big factor in how these corporations operate.”

Collins told the Tribune that executives could not have imagined such a horrific act before it happened.

“We had to ask ourselves, ‘Why didn’t we foresee this? Was this foreseeable?’ And we never really came up with an answer that persuaded us that we should have foreseen a conclusion,” Collins said. “I mean, this was so outrageous what was done. And look at the technique that was used. We just could not figure out how we could have foreseen this.”

On the eve of trial in 1991, Johnson & Johnson settled with the families of all seven victims. As part of the deal, the amount would remain secret and the corporation admitted no wrongdoing.

Noland told the Tribune that he was disappointed in Johnson & Johnson’s decision to settle.

Demetrio declined to discuss the amount, citing the settlement’s confidentiality clause. At the time the deal was announced, attorneys told reporters that the victims’ children would have their college tuition paid.

The 2012 book “The Tylenol Mafia: Marketing, Murder and Johnson & Johnson” states the families received between $200,000 and $990,000 each. Michelle Rosen, one of Reiner’s daughters, collaborated with author Scott Bartz on the book, which criticized authorities for quickly ruling out the possibility that the tampering occurred in the distribution and repackaging channels.

When investigators looked at the distribution and storage routes, they found no indication that the different batches had passed through the same spots at the same time. That, they concluded, made it highly improbable that the bottles would all end up on the shelves of different Chicago-area stores during the same 30-hour window.

Rosen has long pushed back against the investigators’ theory that a “madman” was responsible for placing the bottles on shelves.

“After 40 years, investigators still have been unable to produce a definitive conclusion as to how this crime happened and who did it,” she said in a statement to the Tribune. “By continuing the dead-end track that the investigation has been on, this case will remain unsolved.”

Rosen also has long questioned why Johnson & Johnson was allowed to test the returned capsules, giving the company a quasi-investigative role alongside law enforcement. Records and interviews state the company burned the capsules following testing.

Collins told the Tribune the company destroyed the capsules with law enforcement’s permission at a facility in North Carolina. The entire process, from testing to burning, was monitored by members of the task force, he said.

“They were destroyed because, even in those days, the risk of theft and black market was very real,” Collins said. “So the last thing in the world we wanted to have happened was a story to come out that, you know, 10,000 bottles were stolen.”

Demetrio, a former Cook County prosecutor, challenged the wisdom of letting the corporation play an active role in a police investigation involving its products. However, he said his firm spent nine years looking into the poisonings and shared law enforcement’s view that the poisonings occurred at the store level.

In a war room equipped with a giant map that denoted where each victim bought a tainted bottle, the attorneys practiced how quickly they could pull apart the capsules, pour out the medicine and put them back together. It took most of them about 30 seconds, Demetrio said.

But the families quickly grew tired of theories, he said. They wanted answers about who was responsible for the death.

Neither Demetrio nor law enforcement had any.

“And every time a so-called lead was announced, or a potential suspect was announced, I would get a phone call and they would ask me what I thought,” Demetrio said. “I would constantly caution them not to get too high or too low. I made it clear to them that there was a law enforcement army out there trying to solve these murders.”

The lawsuit, Demetrio said, helped the families understand why Tylenol was susceptible to tampering. But civil cases can only do so much.

“They wanted to know who poisoned the pills, and the police could never definitively say,” he said. “And unfortunately, for the families, they still don’t have any concrete answers.”

Though Tylenol regained the public’s trust, several relatives and friends of the victims told the Tribune they still avoid taking it. A few said they habitually check to see if the seals on bottles are intact; others make sure — when grabbing any item off a shelf — to pick the one farthest back in case those in front have been tainted.

Joseph Janus, whose two younger brothers and new sister-in-law were among the victims, said he doesn’t even like to go into pharmacies and see Tylenol displayed on shelves.

He and his daughter, Monica, said the safety packaging on medicines, food and other grocery items that resulted from their family tragedy is a double-edged sword. Tamper-evident packaging has become such a part of the American consumer experience that they can’t open a sealed jar of peanut butter or a gallon of milk without thinking about the killings.

It’s a near-daily reminder that although the deaths led to a great public benefit, they came at a deep personal cost.

“You look at it and you’re like, ‘That’s because of them,’ ” Monica Janus said of her slain uncles and aunt. “Unfortunately, it happened to our family, but it saved many lives.”

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Home > Honors College > Honors Theses > 3128

Honors Theses

Case study analysis: exploring johnson & johnson's 1982 tylenol contamination crisis and ongoing talcum powder crisis through the six principles of crisis and emergency risk communication.

Caroline Tibbs Follow

Date of Award

Spring 5-6-2024

Document Type

Undergraduate Thesis

Integrated Marketing Communication

First Advisor

Amanda Bradshaw

Second Advisor

Deborah Hall

Third Advisor

Josie Burks

Relational Format

Dissertation/Thesis

In 2002, the Center for Disease Control and Prevention (CDC) developed a new field of communication, called Crisis and Emergency Risk Communication (CERC). With the creation of this new field, the CDC developed a streamlined CERC guidebook in order to provide a standard for the crisis communication strategies and responses of specifically healthcare organizations, but any organization can benefit from utilizing the CERC framework. The CDC also identified six key principles of CERC, which are as follows: response time (“be first”), accuracy (“be right”), credibility (“be credible”), having empathy (“express empathy”), promotion of actions (“promote actions”), and respectfulness (“show respect”).

In a literature review, this thesis explores two case studies, the 1982 Johnson & Johnson Tylenol contamination crisis and the ongoing Johnson & Johnson talcum powder contamination crisis, through the lens of the six principles of CERC. Utilizing both a semi-structured guide and the “think aloud” interview approach, primary data was gathered qualitatively through interviews with 10 University of Mississippi integrated marketing communications students and through interviews with six communications professionals. These interviews were conducted to understand how both communications professionals and students describe the two Johnson & Johnson case studies and how the crisis response varied for each case study. Analysis of this data revealed seven themes that highlight the levels of success of Johnson & Johnson’s responses in adhering to the six CERC principles. Implications include that Johnson & Johnson’s responses to the Tylenol crisis were successful and that their responses to the talcum powder crisis were not successful.

Recommended Citation

Tibbs, Caroline, "Case Study Analysis: Exploring Johnson & Johnson's 1982 Tylenol Contamination Crisis and Ongoing Talcum Powder Crisis Through The Six Principles of Crisis and Emergency Risk Communication" (2024). Honors Theses . 3128. https://egrove.olemiss.edu/hon_thesis/3128

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Johnson & Johnson: The Tylenol Tragedy

By: Stephen A. Greyser

In October 1982, Johnson & Johnson was confronted with a major crisis when seven deaths were attributed to poisoned Tylenol. The case reviews the facts as known a week after the incident occurred,…

• Length: 3 page(s)
• Publication Date: Oct 12, 1982
• Discipline: Marketing
• Product #: 583043-PDF-ENG

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In October 1982, Johnson & Johnson was confronted with a major crisis when seven deaths were attributed to poisoned Tylenol. The case reviews the facts as known a week after the incident occurred, and raises a wide range of questions regarding consumer behavior, corporate responsibility, and competitive reaction.

Oct 12, 1982 (Revised: May 26, 1992)

Discipline:

Geographies:

United States

Industries:

Pharmaceutical industry

Harvard Business School

583043-PDF-ENG

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Dr. Howard Markel Dr. Howard Markel

• Copy URL https://www.pbs.org/newshour/health/tylenol-murders-1982

How the Tylenol murders of 1982 changed the way we consume medication

Early on the morning of Sept. 29, 1982, a tragic, medical mystery began with a sore throat and a runny nose. It was then that Mary Kellerman, a 12-year-old girl from Elk Grove Village, a suburb of Chicago, told her mother and father about her symptoms. They gave her one extra-strength Tylenol capsule that, unbeknownst to them, was laced with the highly poisonous potassium cyanide. Mary was dead by 7 a.m. Within a week, her death would panic the entire nation. And only months later, it changed the way we purchase and consume over-the-counter medications.

That same day, a 27-year-old postal worker named Adam Janus of Arlington Heights, Illinois, died of what was initially thought to be a massive heart attack but turned out to be cyanide poisoning as well. His brother and sister-in-law, Stanley, 25, and Theresa, 19, of Lisle, Illinois, rushed to his home to console their loved ones. Both experienced throbbing headaches, a not uncommon response to a death in the family and each took a Tylenol extra-strength capsule or two from the same bottle Adam had used earlier in the day. Stanley died that very day and Theresa died two days later.

As a result of the crime, makers of Tylenol developed new product protection methods. Photo by Daniel Acker/Bloomberg via Getty Images

Over the next few days, three more strange deaths occurred: 35-year-old Mary McFarland of Elmhurst, Illinois, 35-year-old Paula Prince of Chicago, and 27-year-old Mary Weiner of Winfield, Illinois. All of them, it turned out, took Tylenol shortly before they died.

It was at this point, early October of 1982, that investigators made the connection between the poisoning deaths and Tylenol, the best-selling, non-prescription pain reliever sold in the United States at that time. The gelatin-based capsules were especially popular because they were slick and easy to swallow. Unfortunately, each victim swallowed a Tylenol capsule laced with A lethal dose of cyanide.

McNeil Consumer Products, a subsidiary of the health care giant, Johnson & Johnson, manufactured Tylenol. To its credit, the company took an active role with the media in issuing mass warning communications and immediately called for a massive recall of the more than 31 million bottles of Tylenol in circulation. Tainted capsules were discovered in early October in a few other grocery stores and drug stores in the Chicago area, but, fortunately, they had not yet been sold or consumed. McNeill and Johnson & Johnson offered replacement capsules to those who turned in pills already purchased and a reward for anyone with information leading to the apprehension of the individual or people involved in these random murders.

READ: The ‘awful’ work of the real doctors who inspired M*A*S*H

The case continued to be confusing to the police, the drug maker and the public at large. For example, Johnson & Johnson quickly established that the cyanide lacing occurred after cases of Tylenol left the factory. Someone, police hypothesized, must have taken bottles off the shelves of local grocers and drug stores in the Chicago area, laced the capsules with poison, and then returned the restored packages to the shelves to be purchased by the unknowing victims.

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To this day, however, the perpetrators of these murders have never been found.

One man, James Lewis, claiming to be the Tylenol killer wrote a “ransom” letter to Johnson & Johnson demanding $1 million in exchange for stopping the poisonings. After a lengthy cat and mouse game, police and federal investigators determined that Lewis lived in New York and had no demonstrable links to the Chicago events. That said, he was charged with extortion and sentenced to 20 years in prison. He was released in 1995 after serving only 13 years.

READ MORE: James Lewis, suspect in the 1982 Tylenol murders, dies at 76

Other “copy-cat” poisonings, involving Tylenol and other over-the-counter medications, cropped up again in the 1980s and early 1990s but these events were never as dramatic or as deadly as the 1982 Chicago-area deaths. Conspiracy theories about motives and suspects for all these heinous acts continue to be bandied about on the Internet to this day.

Before the 1982 crisis, Tylenol controlled more than 35 percent of the over-the-counter pain reliever market; only a few weeks after the murders, that number plummeted to less than 8 percent. The dire situation, both in terms of human life and business, made it imperative that the Johnson & Johnson executives respond swiftly and authoritatively.

For example, Johnson & Johnson developed new product protection methods and ironclad pledges to do better in protecting their consumers in the future. Working with FDA officials, they introduced a new tamper-proof packaging, which included foil seals and other features that made it obvious to a consumer if foul play had transpired. These packaging protections soon became the industry standard for all over-the-counter medications. The company also introduced price reductions and a new version of their pills — called the “caplet” — a tablet coated with slick, easy-to-swallow gelatin but far harder to tamper with than the older capsules which could be easily opened, laced with a contaminant, and then placed back in the older non-tamper-proof bottle.

Within a year, and after an investment of more than $100 million, Tylenol’s sales rebounded to its healthy past and it became, once again, the nation’s favorite over-the-counter pain reliever. Critics who had prematurely announced the death of the brand Tylenol were now praising the company’s handling of the matter. Indeed, the Johnson & Johnson recall became a classic case study in business schools across the nation.

In 1983, the U.S. Congress passed what was called “the Tylenol bill,” making it a federal offense to tamper with consumer products. In 1989, the FDA established federal guidelines for manufacturers to make all such products tamper-proof.

Sadly, the tragedies that resulted from the Tylenol poisonings can never be undone. But their deaths did inspire a series of important moves to make over-the-counter medications safer (albeit never 100 percent safe) for the hundreds of millions of people who buy them every year.

Editor’s note: This report has been updated to remove the reported amount of cyanide used.

Dr. Howard Markel writes a monthly column for the PBS NewsHour, highlighting momentous historical events that continue to shape modern medicine. He is the director of the Center for the History of Medicine and the George E. Wantz Distinguished Professor of the History of Medicine at the University of Michigan and the author of “The Secret of Life:  Rosalind Franklin, James Watson, Francis Crick and the Discovery of DNA’s Double Helix” (W.W. Norton, September ’21).

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