Reviewed by Karen M. Emmons, PhD, JAMA
Tobacco War, a detailed chronology of 20 years of tobacco control in California, illustrates several key lessons for public health advocates.
The early chapters present more detail about the origins of the California tobacco control movement than many readers may want, although the information is accessible and interesting. The later chapters provide gripping drama that has broad relevance for public health advocates, health care providers, educators, and the general public.
Glantz and Balbach offer rich detail on the politics of the tobacco control movement in California, highlighting the David and Goliath nature of this story. The most important message of their book is that the fight will never be over. It may be tempting to relax concern about tobacco in light of the Master Settlement Agreement (MSA) with the tobacco industry, which requires changes in advertising practices, payments from the industry to states, and creation of a national tobacco education campaign.
However, the history chronicled in Tobacco War illustrates why US citizens must maintain their vigilance and outspoken disgust over the tactics that this industry uses to protect its profits. It is impossible to read this book without becoming outraged at the behavior of the tobacco industry.
The real value, however, is in the clear documentation of how elected officials regularly and repeatedly ignore the mandates of their constituencies for tobacco control in order to support the interests of the tobacco industry.
Glantz and Balbach illustrate several important lessons from California, as summarized below:
Comprehensive statewide tobacco control programs are effective at reducing smoking prevalence. California had the first such program, and subsequently many other states have documented that comprehensive, well-funded programs can substantially reduce smoking prevalence.
The effects of these programs appear to be particularly strong among youth, who are a primary target of the tobacco industry. As a result, state-funded programs are often attacked by states' elected officials:
[The California Tobacco Survey] demonstrated a 17 percent drop in adult smokers between 1987 . . . and 1990. . . . Rather than claiming credit for this stunning public health success, the Wilson Administration attacked [the] result, claiming that the conclusions were overstated.
The tobacco industry will devote massive resources to fight tobacco control programs. The California experience provided the industry with an opportunity to develop and hone strategies for scuttling tobacco control programs. These strategies were then used in other states with similar and often more rapid results.
The tobacco industry has utilized deceptive practices to fight tobacco control. They have developed effective strategies for reaching the legislature and other powerful constituencies in order to divert funds from tobacco control. As Glantz and Balbach note:
[T]he tobacco industry . . . developed a strategic plan to undo Proposition 99 [the voter mandated legislation that created the California Tobacco Control program], with specific plans to divert funds into "acceptable" medical services for children and pregnant women. The industry had started to enlist other powerful players interested in changing the way California government was financed, including the CMA [California Medical Association], the Western Center for Law and Poverty, and other medical interests that the voluntary health agencies hoped would work with them.
By focusing on health-related programs that generally have broad public support, eg, health and insurance programs for children, the industry and its allies have been able minimize public outcry at these tactics. Glantz and Balbach also identify the large number of front groups formed and funded by the industry, which suggest grass-roots support of initiatives and programs that are actually promoted by the industry.
The tobacco industry and its allies in government play hardball; tobacco control advocates' reluctance to do so has contributed to the dismantling of effective programs. As Glantz and Balbach note,
The voluntary health agencies had completely capitulated to the medical interests. In doing so, they abandoned their strongest argument: that the Legislature had an obligation to appropriate Proposition 99 Health Education funds for anti-tobacco education efforts as directed by the voters. Instead, they accepted the reality of insider horse-trading over the budget.
Even when substantial victories occur for the tobacco control movement, the fight is never over. Many of the key players in the tobacco control movement have been reluctant advocates and did not foresee the kinds of long-term, well-financed efforts that were needed to battle the tobacco industry.
The history of tobacco control in California aptly demonstrates how quickly the industry rebounds from even the largest assault and how protection from industry tactics will mean continued battles that require public attention and support.
The events in California that Glantz and Balbach chronicle provide a frightening foreshadowing of the current status of tobacco control in the United States. Strong national tobacco control legislation has not been enacted despite many opportunities to do so.
For example, although the MSA requires that the industry stop targeting youth, recent studies have documented that print advertising in magazines with high youth readership has increased overall by 33% ($30 million) since the MSA was signed. Advertisements in youth-read magazines for some brands have increased by as much as 75%.1, 2 Ads for some brands reached at least 89% of youth at high frequency (five or more times) in 1999.1, 2
This blatant disregard of the letter and spirit of the MSA should not surprise us. In light of the overwhelming public support in the United States for tobacco control, what is surprising is the lack of legislative or legal response to these actions. Rather than censuring the industry, there has been high praise for Philip Morris' recent decision to suspend advertising in publications with high youth readership.3
Of note, this decision was made after release of studies examining the industry's advertising practices and at the same time that bills are pending in both the US Senate and House that would effectively block the pending federal lawsuit against the tobacco industry.
The California experience as documented in Tobacco War likewise foreshadows the state-level response to the MSA. Of the 29 states that enacted provisions for how to distribute the tobacco settlement money in 1999, only eight set aside enough new funding for strong, comprehensive tobacco prevention and cessation programs.4
In at least one of these states (Massachusetts), the funding was set aside only after a brutal fight in which the governor strongly criticized his state's tobacco control efforts; in less than a year, these funds have already been raided once.
In addition to these eight states with comprehensive programs, only 10 states have dedicated any funds for tobacco prevention programs, although the funding level provided by these states is far below that recommended by the Centers for Disease Control and Prevention. Amazingly, almost 40% of the states that received a portion of the $195 billion settlement have dedicated no funds for tobacco control.
Tobacco War provides clear and compelling documentation of the lessons learned from California and the devastating impact that can result from failure to take an aggressive stand against the tobacco industry. Glantz and Balbach emphasize the importance of keeping the tobacco wars in the public light.
We cannot allow our legislators to engage in private deal making with the industry or to turn a blind eye to the repeated and arrogant violations of the agreements that the industry has made.
The tobacco wars will no doubt continue, and the stakes will grow even higher. We must hold our elected officials accountable to enforce the will of the American publicthe will to prevent our children from becoming addicted to tobacco, to protect our families from exposure to environmental tobacco smoke in public places, and to have our government protect the resources that will protect us from an industry that has proven itself untrustworthy.
A presidential election looms and is likely to be a pivotal moment in the tobacco wars. We must make tobacco control a top election issue. Tobacco War provides an important wake-up call to the nation for an issue that demands every American's attention.
1. Turner-Bowker D, Hamilton WL. Cigarette Advertising Expenditures Before and After the Master Settlement Agreement: Preliminary Findings. Boston: Massachusetts Dept of Public Health; May 15, 2000.
2. American Legacy Foundation statement by Cheryl G Healton, DrPH, president and CEO [press release]. Washington, DC: American Legacy Foundation; May 16, 2000.
3. Attorneys General announce Philip Morris to pull magazine ads with significant youth readership [press release]. Olympia: Washington State Attorney General's Office; June 5, 2000.
4. Campaign for Tobacco-Free Kids Web site. Special report: year in review, 1999. Available at: http://tobaccofreekids.org/reports/yearsinreview/, Accessed June 7, 2000.
Books, Journals, New Media Section Editor: Harriet S. Meyer, MD, Contributing Editor, JAMA; David H. Morse, MS, University of Southern California, Norris Medical Library, Journal Review Editor; adviser for new media, Robert Hogan, MD, San Diego.
Source: Journal of the American Medical Association (JAMA), Tuesday, 8/8/00 by Stanton A. Glantz and Edith D. Balbach, 469 pp, $50, ISBN 0-520-22285-7, paper $19.95, ISBN 0-520-22286-5, Berkeley, University of California Press, 2000.
Many people at the WCTOH wanted to buy the book, but UC Press only arranged for it to be sold for a few hours at the meeting. The easiest way to get it is to check your local bookstore or get it online from Barnes and Noble, http://www.bn.com/ or Amazon, http://www.amazon.com/. (It is a little hard to find on Amazon, but it is there.) You can also get it from the publisher at http://www.ucpress.edu/tobaccowar/