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The Players

One of the early California anti-smoking television advertisements, “A Couple More Good Years,” captured the reality of battling the tobacco industry:

ANNOUNCER:

The cigarette business in America is a dying business. But it is still very profitable. Obscenely profitable. So the tobacco companies are able to employ an army of spokespersons to deny the evidence and stall for time.


MALE TOBACCO INDUSTRY SPOKESPERSON:

This is a very complex question. Statistics can't prove a causal relationship between smoking and disease. And there are Constitutional issues here.


FEMALE TOBACCO INDUSTRY SPOKESPERSON:

We're accused of trying to get people to start smoking. We don't. We try to get people to switch. And, it's always been our policy that young people shouldn't smoke.



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ANNOUNCER:

The tobacco companies know the game is up. All they want is a couple more good years.[11]


The tobacco industry is highly motivated and unscrupulous. It has maintained its protected position in American and worldwide society by aggressively and single-mindedly defending its interests.[12] It acts professionally and strategically and thinks in the long term. It has an “army of spokespersons” and analysts and lawyers and public relations experts and lobbyists to protect its profits. The industry skillfully uses these resources to seek out allies within the political, cultural, and even medical communities.

Against this seemingly invincible army is a force made up primarily of well-meaning volunteers with limited experience and resources. While some of these people work in small activist organizations like Americans for Nonsmokers' Rights (ANR) and its predecessors, most are affiliated with the large voluntary health agencies: the American Lung Association (ALA), American Cancer Society (ACS), and American Heart Association (AHA). The large voluntary health agencies have tremendous public credibility and substantial resources, but historically they have been cautious and slow to act. Tobacco is but one priority for these agencies, and the tobacco industry is highly skilled at generating controversy about the political involvement of health groups to limit industry profits. Because the tobacco industry often works through intermediaries, these groups must be willing to confront not only the tobacco industry but also its partners and agents. Doing so is particularly difficult when the industry allies itself with powerful politicians or with groups, such as medical providers, who normally work with the voluntary health agencies. In many ways, the California story is about how the voluntary health agencies gradually developed the courage to enter the fray of hardball politics and do battle with not only the tobacco industry but also its allies.

The effort to pass Proposition 99 attracted a wide variety of players, including public health groups, environmental groups, and medical interests. The voluntary health agencies were willing to work with this mixed bag of partners in what they thought was a straightforward trade—support for the initiative in exchange for some of the money that the tobacco tax would generate. To attract the doctors and hospitals, the voluntary health agencies had dropped their claims on the new tax revenues from 47.5 percent to 20 percent for health education and from 15 percent to 5 percent for research. Naively believing that a deal was a deal, the health groups


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thought they could count on the medical players to support their goals once the initiative passed. Carolyn Martin, a volunteer with the ALA and the first chair of the Tobacco Education Oversight Committee, later summed up the hard lesson learned: “This was the first time money was set aside for tobacco education, and `nice' non-profit voluntaries were not prepared for the vicious, powerball politics that money and tobacco create.”[13]

The California Medical Association (CMA) was ready for the Proposition 99 legislative battle. The CMA was simultaneously working for and against Proposition 99, so it was well positioned regardless of the electoral outcome.[14] The CMA could claim credit for helping with the initiative campaign, thereby securing a seat at the bargaining table when the revenues were divided. The CMA could also claim credit for its efforts to subvert the initiative to avoid alienating the tobacco industry. By the time the tobacco industry was hatching its postelection strategy to counter the effects of Proposition 99, it was talking with the CMA about how to eliminate the Health Education Account money by moving it into medical care.[15], [16] These needs trumped the CMA's concern for public health interventions to prevent and stop tobacco use. Within the legislative process, in fact, the medical groups had more in common with the tobacco industry than with the weaker public health groups.[17], [18] They became even more dangerous when they were joined by the Western Center for Law and Poverty, a liberal group that advocated for health care programs for the poor. It took years for the health groups to accept this fact and recognize that the medical service providers needed to be watched and countered just as the tobacco industry did.


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