Total recall: How the Tylenol murders of 1982 ushered in tamper-resistant packaging

Product recalls challenge manufacturers and can reshape the competitive and regulatory landscape. This new feature looks at how brands manage crises.

Brand: Tylenol

Recall Issued: October 5, 1982

Scope: 31 million bottles of Tylenol products

Lethal dose: Mary Kellerman, 12, who lived in a Chicago suburb, awoke on the morning of September 29, 1982, with a sore throat and runny nose, so her parents told her to take a Tylenol. Her father, Dennis Kellerman, heard her go into the bathroom, and then he heard something drop.

“So I opened the bathroom door, and my little girl was on the floor unconscious,” he told the Chicago Tribune. “She was still in her pajamas.” Mary died that morning.

It turned out that the Tylenol had been laced with cyanide. In the next few days, six more people in the Chicago area would die from using the product.

As the FBI, the US Attorney’s office, and Chicago-area police investigated leads, executives at Johnson & Johnson, which made Tylenol under its McNeil division, scrambled to respond. At the time, Tylenol commanded a 37% share of the analgesic market.

“A flat prediction I’ll make is that you will not see the name Tylenol in any form within a year,” Jerry Della Femina, then-chairman of ad agency Della Femina Travisano Partners, told the New York Times at the time. “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.”

Prognostications aside, the crisis was just beginning. Before it was over, tamper-resistant packaging, a foreign concept at the time, would be required by the FDC for most OTC products. And a new standard for crisis communications would be set.

The recall: Johnson & Johnson could have argued that it wasn’t to blame, since the Tylenol apparently was tainted after it was on store shelves.

However, as Alan Hilburg, who advised J&J at the time as an executive at PR firm Burson-Marsteller, told the Times in 2019, “We concluded we were never going to be judged by what caused the problem. We were always going to be judged on how we responded to it.”

That response:

• J&J issued a nationwide recall of 31 million bottles of Tylenol capsules from stores, with a retail value of $100 million (about $307 million today).
• Executives appeared on shows including ABC’s Nightline, assuring products wouldn’t return until safeguarded with something truly novel at the time: tamper-resistant packaging.

The comeback: On November 11, 1982, 43 days after the first Tylenol deaths, J&J unveiled “triple-sealed tamper-resistant packaging” for products, which would return to store shelves in a few weeks.

• Boxes would be glued shut, bottles would have plastic seals covering their caps, and foil sealing their mouths.

Tylenol’s market share plunged from 37% to 7% during the crisis. Just a year later, it had climbed back to 30%.

Decidedly less successful was law enforcement: the killer was never found.

But Time called J&J’s response “a model for effective corporate crisis management.” It “made a hero of Johnson & Johnson,” the New York Times declared. The Department of Defense even teaches a case study about the incident to public affairs officers.

In 1983, with J&J’s crisis behind it, its advertising agency, Compton Advertising, sent Della Femina a water cooler filled with wine.

“I drank the wine and toasted them,” Della Femina told the Times.

Joining the resistants. The FDA never got around to requiring tamper-resistant packaging for food, but brands embrace the safeguards anyway. Try to remember the last time a carton of milk didn’t have both a little hula hoop that broke free of the cap when you unscrewed it and a pull tab.

Class dismissed: While often lauded for being a textbook model of how it handled the crisis in 1982, J&J hasn’t always followed its own example.

• In 2010, J&J recalled millions of bottles of Tylenol, Motrin, and Benadryl, for—unlike 1982—problems of its own doing, including possibly being too potent and containing what J&J called “tiny particles.”
• The deputy FDA commissioner at the time, Joshua Sharfstein, told a congressional hearing about “growing concerns about the quality of the company’s manufacturing process.”

“J&J’s quick response to the 1982 cyanide sabotage of the Tylenol supply remains a case study of good corporate crisis response,” Jim Edwards wrote on the CBS News website in 2010. “Now Tylenol is looking like a case study in how to trash a brand through indolence and lack of attention to detail.”