Conclusion

Difficult as it may be for tobacco control advocates to demand accountability, tobacco control programs will not survive if the nongovernmental organizations that care about the program will not protect it. The preservation of the intent and spirit of these programs will not occur simply because an initiative is approved by the voters. This approval is a powerful force, but it must be used effectively by those who accept the responsibility for defending the public interest. Exercising oversight over the elected and appointed officials who had authority over the tobacco control program was even more challenging for the public health groups than getting the program enacted.

In the years immediately following an election or legislative action to create a tobacco control program, the effort to keep the will of the voters before the Legislature is not difficult, since both the press and the public are likely to be paying attention. But voter approval is likely to become less obvious and thus less powerful over time, and tobacco control advocates need to seek ways to keep the public informed and involved on the tobacco issue. If advocates instead retreat to playing only the insider political game, they will probably fail. They must be willing to withstand and embrace the controversy that the tobacco industry and its allies will generate.

The California story illustrates a few simple rules for beating the tobacco industry:

1. The public is public health's best asset. Keep the fight public and the public engaged.

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2. The tobacco industry will try to work in the shadows and through intermediaries. Confront these groups and force them apart from the tobacco industry.
3. The early implementing phases of tobacco control legislation are very important. Bad precedents, once set, are exceptionally hard to reverse. Avoid compromises early in the process.
4. Do not be afraid of controversy; use it.
5. Press for and defend high-quality programs. Beware of reasonable-sounding compromises in the anti-tobacco program (such as concentrating on kids or avoiding attacks on the tobacco industry), even when these suggestions come from “friends” in the health department.
6. The battle does not end when a tobacco control initiative is passed.
7. The battle does not end when the Legislature enacts implementing legislation, even if it is a good bill.
8. The battle does not end when the health department or schools implement a good program.
9. The battle never ends.

When the health groups are willing to take the risks and make the financial and other commitments necessary to confront the tobacco industry and its allies, the health groups can win despite the industry's superior economic resources. One only needs to visit a smoke-free bar in California to understand how dramatically reality has changed since a small group of activists met in Peter Hanauer's living room with the odd idea that people had a right to breathe clean indoor air.

They have shown over and over again that you can beat the tobacco industry.