California's Tobacco Control Saga

Prologue: California voters, employing their favorite method for sending a message to policymakers, approved a ballot initiative (Proposition 99) in 1988 that created the single largest anti-tobacco public health intervention of its kind. The initiative called for earmarked taxation to prevent youths from starting to smoke and to assist smokers in abandoning their unhealthy addiction. But, in a free capitalistic society, where economic interests are often pitted against other values, the tobacco control program ran into trouble on a variety of fronts. The surprising nature of the struggle was captured by the actions of the California Medical Association (CMA), which joined the tobacco industry in supporting the efforts of Gov. Pete Wilson's administration to divert more than $100 million in cigarette tax revenues away from tobacco education and research to fund indigent medical care. This move put the CMA at odds with many of its traditional allies in the tobacco control arena, such as the American Heart Association and the American Lung Association. In this paper Tom Novotny and Mike Siegel strive to disentangle the complicated history of the program and evaluate its success. Novotny, a physician and epidemiologist, was a member of the Proposition 99 evaluation advisory committee and is a respected participant in the debates surrounding the effects and control of tobacco. He spent four years in the Office on Smoking and Health at the Centers for Disease Control and Prevention (CDC) and is now the CDC liaison officer to the School of Public Health at the University of California, Berkeley. He also heads the interdisciplinary master of public health program. Siegel is also a physician-epidemiologist. He recently completed a two-year fellowship at the CDC's Office on Smoking and Health where he conducted research on the effects of government antismoking policies. He is currently a research associate at Boston University's School of Public Health. Abstract: The California tobacco control program known as Proposition 99 was established in 1989 using a portion of a twenty-five-cent increase in the cigarette tax. With an initial availability of more than $ 150 million, tobacco control was the state's single most important public health activity. Health and medical care programs also were supported by the tax. Despite sustained public support, the tobacco control component was weakened by political actions of the tobacco industry and also by the competing efforts of organized medicine and the lack of support from the executive and legislative branches of government. Nevertheless, Proposition 99 succeeded in reducing exposure to environmental tobacco smoke, cigarette consumption, and smoking prevalence among adults in California.