Toward a Tobacco-Free California Stategies for the 21st Century by gdf57j


									TOWARD A
Strategies for the 21st Century

                    Tobacco Education and Research
                    Oversight Committee
                    January 2000
                                               Toward a Tobacco-Free California: Strategies for the 21st Century. 2000-2003   i

    On the tenth anniversary of          • Members of the Master Plan                   Tobacco Education
the passage of Proposition 99 (the         Work Group: David M. Burns,                  and Research Oversight
Tobacco Tax and Health Protection          M.D., Jennie R. Cook, Gus T.                 Committee, 1999
Act of 1988), the Tobacco Education        Dalis, Ed.D., Stanton A. Glantz,
and Research Oversight Committee           Ph.D., and Dorothy P. Rice;
(TEROC) presents this fifth Master                                                      Jennie R. Cook, Chair
                                         • Susanne Hildebrand-Zanki,
Plan pursuant to its legislative man-                                                   Voluntary Health Organization
                                           Ph.D., University of California,
date (California Health and Safety         Tobacco-Related Disease
Code Section 104350-104480). As                                                         Lourdes Baézconde-Garbanati, Ph.D.
                                           Research Program;
directed by the Legislature, this                                                       Voluntary Health Organization
                                         • Gerald Kilbert, Ed.D. and Rae
Master Plan highlights the accom-
                                           Kine, California Department of               David M. Burns, M.D.
plishments and lessons learned by
                                           Education, Healthy Kids                      Tobacco Related Disease Research
California’s Tobacco Control Program
                                           Program Office;                              Program
during its ten-year history, and sets
forth policy and budgetary recom-        • Jon Lloyd and Bill Ruppert,
mendations for the future.                 California Department of Health              Gus T. Dalis, Ed.D.
    TEROC’s recommendations are            Services, Tobacco Control                    California Department of Education
intended to enhance the California         Section, and others in the
Tobacco Control Program’s effective-       Tobacco Control Section, in par-             Thomas C. Paton
ness in meeting the Legislature’s          ticular Dileep G. Bal, M.D., Doug            General Public
mandate to reduce tobacco use in           Robins, April Roeseler, Carol
California. To date, we are more than      Russell, Robin Shimizu, and                  Dorothy P. Rice
half-way toward our goal of a tobac-       Colleen Stevens;                             Professional Education
co-free state—per capita cigarette       • The local programs in schools
use has declined by 52%. To contin-        and communities throughout                   George R. Rutherford, M.D., M.P.H.
ue the significant movement toward         California, without whom the                 University Faculty
a tobacco-free California, TEROC           Tobacco Control Program would
strongly recommends that tobacco           not exist.                                   James W. Stratton, M.D., M.P.H.
settlement resources be used to                                                         California Department of Health Services
                                             Finally, our appreciation is
increase funding for the program.        extended to Lisa K. Hunter, Ph.D.,
    We would like to thank the many                                                     Kenneth A. Wesson
                                         Health & Education Communication
individuals and their staffs for their                                                  Target Population Group
                                         Consultants, Berkeley, who served
commitment to tobacco control and        as consultant to the Committee and
for their contributions to this plan.    drafted this plan.
                                         — Jennie R. Cook, Chair
                                           January 2000
“Baby In Playpen”

Television Ad, 1995

Statewide Media Campaign
                                                                                                                      Table of Contents   iii

Table of Contents
Foreword .....................................................................................................    i

Executive Summary .................................................................................              1

Chapter 1
Proposition 99 and Tobacco Control in California...........................                                      7
Establishment of the Program ....................................................................                7
Program Components..................................................................................             7

Chapter 2
Ten Years of Progress .............................................................................              11
Progress toward the Goal: Prevalence and Consumption........................                                     11
Changes in the Social Environment ...........................................................                    15
Program Accomplishments .........................................................................                16

Chapter 3
Progress Toward TEROC’s 1997-2000 Recommendations.............                                                   21

Chapter 4
Lessons Learned in Tobacco Control ..................................................                            33
Overall Lessons from the Program.............................................................                    33
Lessons in Health Education ......................................................................               33
Lessons in Tobacco-Related Disease Research.........................................                             35

Chapter 5
Strategies for the 21st Century:
TEROC’s Recommendations for 2000-2003 .......................................                                    37

References .................................................................................................     47

Television Ad, 1998

Statewide Media Campaign
                                                                                                  Executive Summary           1

Executive Summary
    On the tenth anniversary of the      year 1998-99 alone, annual per capi-    Master Plan in 1997, the context for
passage of Proposition 99 (the           ta consumption decreased by 11.5%.      tobacco control in California has
Tobacco Tax and Health Protection             Adult smoking prevalence in        undergone major changes. Among
Act of 1988), the Tobacco Education      California has dropped by more than     these is the national tobacco settle-
and Research Oversight Committee         25% (from 26.7% in 1988 to 18.4%        ment, in which the major tobacco
(TEROC) presents this fifth Master       in 1998), at a rate faster than the     companies agreed to pay hundreds
Plan pursuant to its legislative man-    nation (prevalence in the United        of millions of dollars annually to
date. As directed by the Legislature,    States went from 30.2% in 1988 to       California and other states to settle
this Master Plan highlights the accom-   24.7% in 1997). Smoking prevalence      lawsuits accusing the tobacco indus-
plishments and lessons learned by        in 1998 translates to about 4.4 mil-    try of fraudulently deceiving the
California’s Tobacco Control Program     lion smokers in California.             public and causing serious harm. In
during its ten-year history, and sets         Between 1990 and 1993, the         1998, they signed the Master
forth policy and budgetary recom-        prevalence of cigarette smoking         Settlement Agreement with 46 state
mendations for the future.               among youth aged 12-17 changed
                                         little. Since 1995, the youth smoking
Background                               prevalence in the state has declined
    The California Tobacco Control       by 12%. In general, youth prevalence
Program was launched in the Spring       has remained much lower than in
of 1990, and became the largest          the rest of the country—for example,
tobacco control program in the world.    among 10th grade youth who smoked
California’s strategy is to create a     in the past 30 days, smoking preva-
social milieu and legal climate in       lence increased by 6.7 percentage
which tobacco use is regarded as         points in California from 1991 to
unacceptable. The program is imple-      1996, as compared with 10.2 per-        “Industry Lies.” Billboard, 1999 Statewide
mented through statewide public          centage points in other states.         Media Campaign.
health and education networks and             The reduction in tobacco con-
supported by a research compo-           sumption has led to immediate           attorneys general. Among its provi-
nent. California’s program is now an     health benefits for Californians. For   sions, the settlement requires the
internationally recognized model of      example, smoking cessation pro-         industry to stop using billboard ads
statewide tobacco control.               duces almost immediate reductions       as of April 22, 1999, and prohibits
                                         in heart attacks and strokes and low    advertising and promotion strategies
Progress Toward a                        birth-weight infants. Lung and          that target youth.
Tobacco-Free California                  bronchus cancer rates in California         Since the settlement, the indus-
    When the Legislature passed AB       declined 14.4% between 1988 and         try has mounted a massive public
75 in 1989, it set the goal of reduc-    1996, compared with a decrease in       relations campaign to clean its cor-
ing tobacco use in California by 75%     selected other states of only 4%.       porate image. The message is that
by the end of 1999. Over ten years,      Women in California experienced a       tobacco use is a fun, hip, and fully
California has made impressive           decrease in lung cancer incidence of    legal activity for people 18 years of
progress toward its ambitious goal.      6.7%, compared with an increase in      age or older. While running ads sup-
    Per capita cigarette use has         other states of 9.3%.                   posedly demonstrating their
declined by more than a half, and                                                good-citizen concern about smoking
smoking among Californians has           Changes in the Social                   by minors, the tobacco companies
decreased at a rate faster than that     Environment                             have sharply intensified their ad
of the rest of the nation. In fiscal        Since the publication of the last    campaigns targeting women and
Strategies for the 21st Century – 2000-2003

                                              “Oral obsession had its place when you were young. At your age, it’s ridiculous. STOP SMOKING!”
                                              Health Through Art: Signs of Recovery, Alameda County Health Department, Oakland, California.
                                              ethnic populations. Knowing that          Tobacco Control Program has many           1996 and 1998. In these coun-
Toward a Tobacco-Free California:

                                              youth “model up” to young adults,         other notable achievements. Among          ties, the percentage of adults
                                              the industry has also mounted lavish      these are:                                 who asked someone else not to
                                              advertising and promotional cam-                                                     smoke also increased.
                                                                                        • The California Clean Indoor Air
                                              paigns that reach young adults in
                                                                                          Act (AB 13) was successfully          • The vast majority of Californians
                                              bars, night clubs, and other venues
                                                                                          implemented. The Act includes           (83% nonsmokers, 52% smokers)
                                              of the young single night life.
                                                                                          the smoke-free bar-restaurant           were not exposed to secondhand
                                                  Another important change in
                                                                                          provision that went into effect         smoke at home or at work.
                                              California is the Proposition 10
                                                                                          on January 1, 1998.
                                              (California Children and Families                                                 • Sixty-six percent of all
                                              Act) tobacco tax increase of 50 cents     • 74 policies and other local laws        Californians in 1998 prohibit
                                              per pack of cigarettes passed by            restricting tobacco advertising         smoking in their homes. The
                                              voters in the November 1998 elec-           have been passed by California          proportion of smokers who pro-
                                              tion. Although Proposition 10 funds         cities and counties.                    hibit smoking in their homes
                                              early childhood programs, the voter-                                                increased from 22.1% in 1994 to
                                                                                        • According to the independent
                                              imposed tax is evidence of the strong                                               38.3% in 1998, a 73.3% increase.
                                                                                          evaluation of the program, there
                                              anti-tobacco mood in California. How-                                               Non-smokers who prohibit smok-
                                                                                          are statistically significant rela-
                                              ever, an industry-backed campaign in                                                ing in their household also
                                                                                          tionships between program
                                              support of an initiative to strike down                                             increased, from 63.2% in 1994 to
                                                                                          activities and smoking behavior.
                                              Proposition 10 is already underway,                                                 73.4% in 1998, a 16% increase.
                                                                                          For example, in counties where
                                              with the outcome to be decided in
                                                                                          more adults were exposed to           • Approximately 89% of children
                                              the March 2000 election.
                                                                                          tobacco control messages                under 6 years of age, and 87% of
                                                                                          through at least two different          all children and adolescents
                                              Program Accomplishments
                                                                                          components (media, community,           were protected from secondhand
                                                 In addition to the significant
                                                                                          and/or school), adult smoking           smoke in the home in 1996.
                                              progress made toward reducing cig-
                                                                                          prevalence declined between
                                              arette consumption, the California
                                                                                                 Executive Summary      3

• Almost 9 out of 10 Californians           to students in grades 5, 7, 9, and      placenta to adversely affect
  (87.7%) in 1998 preferred to eat          11 to assess alcohol, tobacco,          pregnancy outcome; and how
  in smoke-free restaurants.                and other drug use.                     best to intervene with smokeless
                                                                                    tobacco users such as high school
• Illegal sales of cigarettes to         • The Tobacco Education Ethnic
                                                                                    and college athletes. Research
  minors dropped sharply from              Networks launched campaigns
                                                                                    on secondhand smoke is cited in
  30% in 1996 to 13% in 1998.              against secondhand smoke
                                                                                    nearly every chapter of the
                                           (such as the African American
• Approximately 26% of the teens                                                    CalEPA report on environmental
                                           Tobacco Education Network’s
  who received cessation counsel-                                                   tobacco smoke.
                                           campaign, “Not in Mama’s
  ing from the California Smokers’         Kitchen”) and promoting a             • Research is more closely
  Helpline achieved a 90-day quit          tobacco-free lifestyle (such as         linked to practice through the
  success.                                 the Hispanic/Latino Tobacco             establishment of the Community-
                                           Education Network’s World               Academic Research Awards
• Ninety-seven percent of all school
                                           No Tobacco Day).                        (CARA) and the School-Academic
  districts have a tobacco-free pol-
                                                                                   Research Awards (SARA).
  icy prohibiting the use of tobacco     • Research funded by the Tobacco-
  by all students, school staff, par-      Related Disease Research
                                                                                 Lessons Learned in
  ents, and visitors in district owned     Program (TRDRP) has led to
                                                                                 Tobacco Control
  or leased buildings, on district         significant contributions to the
                                                                                     Many lessons have been learned
  grounds, and in district vehicles.       knowledge of the consequences
                                                                                 in ten years about what works and
                                           of tobacco use. For example,
• Forty-six percent of all school                                                does not work in tobacco control.
                                           research has discovered how
  districts have administered the                                                Overall lessons from California show
                                           nicotine affects the brain; how
  California Healthy Kids Survey                                                 that a tobacco control program works
                                           smoke components cross the

“Truth Versus Advertising.” Print Ad, 1998 Statewide Media Campaign.
                                              best when it engages the public from     school-based program staff should        Recommendation 2:
                                              the beginning, aggressively exposes      participate in training and the          Expand the Tobacco Control
                                              tobacco industry deception and           infrastructure network developed         Program and strengthen its funda-
                                              influence, actively advocates for        for community-based activities.          mental structure, focus, and key
                                              smoke-free indoor policies, educates         An effective tobacco research        messages. The program should (a)
                                              about the public health importance       program should support a compre-         continue to anticipate, vigorously
                                              of increasing the cost of tobacco,       hensive and balanced research            expose, and counter tobacco indus-
                                              and involves the entire public.          portfolio; be prepared to carry out      try tactics; (b) continue to press for
                                                  An effective community-based         an extensive outreach effort to          smoke-free workplaces, public
Strategies for the 21st Century – 2000-2003

                                              program must be large enough to          increase proposals in social, behav-     places, events, schools, and homes;
                                              compete effectively with the tobac-      ioral and policy areas; fund the best    (c) increase population-based
                                              co industry, even though it does not     in relevant biomedical research;         smoking cessation activities through
                                              match the industry dollar for dollar.    and work closely with the agencies       the media campaign, the California
                                              It employs an anti-tobacco media         administering the health education       Smokers’ Helpline, and coordination
                                              campaign that has a broad, general       components of the tobacco control        at the local community level; and
                                              market focus that directly confronts     program.                                 (d) implement strategies (including
                                              the tobacco industry and its surro-                                               youth anti-tobacco advocacy to pro-
                                              gates. It emphasizes the negative        Strategies for the 21st                  mote smoke-free environments) to
                                              aspects of tobacco use for every-        Century: TEROC’s                         reduce youth demand for tobacco,
                                              one—adults and youth alike;              Recommendations for                      rather than focusing primarily on
                                              promotes smoke-free environments,        2000-2003                                youth access.
                                              and strengthens the nonsmoking               TEROC recommends that the
         4                                    norm and rights of nonsmokers. An        California Tobacco Control Program       Recommendation 3:
                                              effective program coordinates its        build on its numerous significant        Continue to strengthen and increase
Toward a Tobacco-Free California:

                                              media campaign closely with com-         strengths, and adopt the aggressive      accountability of school-based
                                              munity-based activities, and             tone and rapid response that have        tobacco use prevention education
                                              responds quickly to changing indus-      characterized its most notable suc-      programs, consistent with principles
                                              try strategies with new media            cesses. Most important, TEROC            of effectiveness.
                                              messages. It emphasizes reducing         strongly recommends that approxi-
                                              youth demand for tobacco in addi-        mately 20% of the resources from         Recommendation 4:
                                              tion to reducing youth access, and it    the tobacco settlement payments to       Increase collaboration and commu-
                                              uses youth organizations and schools     the state be allocated on an annual      nication among and between
                                              for youth-specific programs that uti-    basis to increase the program’s abili-   school-based and public health-
                                              lize research-based strategies.          ty to counter the tobacco industry’s     based tobacco control programs.
                                                  Effective school-based tobacco       continued aggressive marketing of
                                              control programs seek broad              tobacco in California, and to help       Recommendation 5:
                                              community involvement and are            those who use tobacco products           The University of California’s
                                              integrated with other community-         break the chains of their addiction.     Tobacco-Related Disease Research
                                              based tobacco control programs.          (The full text of these recommenda-      Program should continue to encour-
                                              They concentrate activities in           tions appears in Chapter 5.)             age and fund research that makes
                                              middle/junior and senior high schools,                                            specific contributions to tobacco
                                              rather than elementary schools, and      Recommendation 1:                        control.
                                              adopt strategies that research shows     Increase funding for the California
                                              to be effective. They utilize a          Tobacco Control Program so that it       Recommendation 6:
                                              competitive grants model in addi-        can build on past successes and          The Administration should implement
                                              tion to funding allocations based        take advantage of new opportunities      policies and procedures to assure
                                              on entitlement formulas. Finally,        to reduce tobacco consumption            rapid development and approval of
                                                                                               Executive Summary       5

the media campaign to permit the        rate compliance with the California   Recommendation 10:
campaign to respond quickly to the      Smoke-free Workplace Act in deci-     Continue to coordinate Proposition
changing environment.                   sions regarding bar license           99-financed programs with State,
                                        approvals, suspensions, and           Federal, and other tobacco control
Recommendation 7:                       renewals.                             initiatives.
Medically-mediated nicotine-depen-
dent treatment should be a benefit      Recommendation 9:                     Recommendation 11:
of the health care delivery system.     The California Children and           Settle the outstanding litigation left
                                        Families State Commission should      over from the previous
Recommendation 8:                       encourage local commissions to        Administration to increase funding
The Department of Alcoholic             include objectives for tobacco con-   for tobacco control efforts.
Beverage Control should incorpo-        trol in their strategic plans.

“Leather Jacket.” Print Ad and Billboard, 1997 Statewide Media Campaign.

Television Ad, 1997

Statewide Media Campaign.
                                                                         Chapter 1 — Proposition 99 and Tobacco Control in California              7

Proposition 99
and Tobacco Control in California
    When the people of California                  Establishment of the                             Education and Research accounts is
passed Proposition 99, the Tobacco                 Program                                          carried out by the Tobacco Education
Tax and Health Protection Act of                       In November 1988, California                 and Research Oversight Committee
1988, they created a comprehensive                 voters approved the historic ballot              (TEROC), whose members are
program to address the devastating                 initiative called Proposition 99 that            appointed by the Governor, the
and costly toll of tobacco use on the              increased the tax on each pack of                Legislature, and the Superintendent
health of Californians. The history                cigarettes sold in California by 25              of Public Instruction.
of the program is the story of cease-              cents, effective January 1, 1989. The                The Tobacco Control Section
less struggle against an industry that             proposition established the Cigarette            (TCS) of the California Department
has deceived the public about the                  and Tobacco Products Surtax Fund,                of Health Services (DHS) adminis-
health effects and addictiveness of                and specified that the funds would               ters the public health aspects of the
its products, and persists in aggres-              be spent for: Health Education                   program. This network includes 61
sively marketing those products to                 (20% for community and school-                   local health departments, four eth-
addict new generations of young                    based tobacco education and                      nic networks, 11 regional community
Californians.                                      prevention programs); Research                   linkage projects, approximately 90
    This Master Plan expresses the                 (5% for research on tobacco-related              community-based organizations, a
Tobacco Education and Research                     diseases); Hospital Services (35%
Oversight Committee’s assessment                   for treatment of medically indigent
of the program’s progress and pro-                 hospital patients); Physician
vides recommendations on how it can                Services (10% for treatment of
be improved. This is the fifth Master              medically indigent patients by
Plan in the history of the Tobacco                 physicians); Public Resources (5%
Control Program, and is written as the             for the protection of wildlife habitat
program reaches its tenth anniver-                 and programs to enhance park and
sary. The plan provides a brief                    recreation resources); and Unallo-
overview of the program, reports on                cated (25% to be distributed by the
progress towards the legislative goal              Legislature to any of the other
of reducing tobacco consumption in                 accounts).
the state by 75% within a decade,1
and describes other major accom-                   Program Components
plishments since the inception of                                                                   World No Tobacco Day. American Lung Association
                                                       The Tobacco Control Program                  Superior Branch, North Valley Region.
the program.2 The plan also presents               was launched in the Spring of 1990
an analysis of the valuable lessons                with funds from the Health                       statewide media campaign, and
that have been learned along the                   Education Account. It became                     other statewide support systems.
way, and sets forth recommenda-                    the largest tobacco control program                  The Healthy Kids Program Office
tions to guide the program over the                in the world. Oversight of the pro-              (HKPO) of the California
next three years.                                  grams funded by the Health                       Department of Education (CDE)

1   Health and Safety Code Sections 104350-104480.
2   Previous Master Plans provide complete descriptions of the history and structural components of the Tobacco Control Program. They are avail-
    able from the Tobacco Control Section, Department of Health Services, Sacramento, CA, (916) 327-5425.
                                                               administers the school-based com-         Tobacco-Related Disease Research                     Figure 2
                                                               ponent of the program, which              Program is listed on page 38 of this
                                                                                                                                                              Tobacco Use Prevention
                                                               involves 58 county offices of educa-      report. Figures 1, 2, and 3 show the
                                                                                                                                                              Education Funding Components,
                                                               tion and nearly 1,000 school districts.   comparative allocations for program
                                                                                                                                                              California Department of
                                                                   The University of California          components for these three institu-
                                                                                                                                                              Education, 1999–2000 (millions)
                                                               administers the Tobacco-Related           tions.
                                                               Disease Research Program (TRDRP)
                                                               with funds from the Research              Figure 1                                                                           Grades 4-8
                                                               Account. TRDRP funds research                                                                                                 22% ($6)
                 Strategies for the 21st Century – 2000-2003

                                                                                                                                                                    Grades 9-12
                                                                                                         Tobacco Control Section                                  Competitive Grants
                                                               that leads to improved approaches                                                                     54% ($15)
                                                                                                         Funding Components, Department
                                                               to the prevention, diagnosis, and
                                                                                                         of Health Services, 1999–2000
                                                               treatment of tobacco-related illness
                                                               and to increasing the effectiveness
                                                               of the California Tobacco Control                                                                   Administration 3% ($1)
                                                                                                                                                                 Other Local Assistance 2% ($.8)
                                                               Program.                                                             Local Lead Agencies            County Offices of Education 14% ($3.8)
                                                                                                            Competitive Grants
                                                                   The current budget for Fiscal Year         29% ($17.7)              29% ($17.4)
                                                                                                                                                                               Innovative Programs 5% ($1.5)
                                                               1999-2000 for the Department of
                                                               Health Services, the California                        Media Campaign
                                                                                                                       33% ($19.6)
                                                               Department of Education, and the

                                                                                                                             Administration 2% ($1.0)
                                                                                                                                       Evaluation 7% ($4.4)

Toward a Tobacco-Free California:

                                                               “Coffin.” Billboard, 1999 Statewide Media Campaign.
                                                      Chapter 1 — Proposition 99 and Tobacco Control in California    9

Figure 3                                  California’s strategy is to create a social milieu and legal climate in
                                          which tobacco use is regarded as unacceptable—to denormalize smoking
Tobacco-Related Disease Research
                                          and other tobacco use. This approach engages everyone—smokers and
Program Funding Components,
                                          nonsmokers alike.
University of California, 1999-2000
(millions)                                The community-based component of the Tobacco Control Program has
                                          four broad priority areas:
                         Administration   • Eliminate exposure to secondhand smoke
                           5% ($.3)

                                          • Counter pro-tobacco influences
     Competitive Research Grants
             95% ($5.7)                   • Reduce the marketing and illegal sale of tobacco to youth
                                          • Provide cessation services
                                          The program’s media campaign promotes three core messages that are
                                          reinforced by local program activities:
    The activities of these three
institutions together create a            • The tobacco industry lies
statewide coordinated, comprehen-         • Secondhand smoke kills
sive program that has changed
social norms toward a smoke-free          • Nicotine is addictive
California.                               The school-based component of the program seeks to reduce the use of
                                          tobacco by youth by providing students with information and skills to
                                          help them resist the tobacco industry.
                                          The goals of the research component of the program are to enhance under-
                                          standing of tobacco use and tobacco-related diseases, and to develop more
                                          effective interventions for their prevention and treatment.

Television Ad, 1998

Statewide Media Campaign.
                                                                                                         Chapter 2 — Ten Years of Progress         11

Ten Years of Progress
     The California Tobacco Control                    This is twice as great as the                 population. For example, smoking
Program is an internationally recog-                   decline during the same period                cessation produces almost immedi-
nized model of statewide tobacco                       in the rest of the nation. In fiscal          ate reductions in heart attacks and
control. In the ten years of its exis-                 year 1998-99 alone, annual per                strokes (Lightwood and Glantz,
tence, the program has made substan-                   capita consumption dropped                    1997) and low birth weigh infants
tial progress towards a tobacco-free                   by 11.5%.                                     (Lightwood, Phibbs, and Glantz,
California. This chapter describes                                                                   1999). The California Tobacco Control
                                                   • Adult smoking prevalence in
changes in smoking prevalence and                                                                    Program has prevented 98,100 hos-
                                                     California has dropped by more
cigarette consumption, changes in                                                                    pitalizations for heart attacks and
                                                     than 25% (from 26.7% in 1988
the social environment regarding                                                                     strokes (Lightwood and Glantz,
                                                     to 18.4% in 1998), at a rate
tobacco, and some of the major pro-                                                                  1997). The Department of Health
                                                     faster than the nation (preva-
gram accomplishments that are                                                                        Services estimates that the declines
                                                     lence in the United States went
leading to a tobacco-free California.                                                                in smoking prevalence over the past
                                                     from 30.2% in 1988 to 24.7% in
                                                                                                     ten years will save $3.2 billion in
                                                     1997). Smoking prevalence in
Progress Toward the                                                                                  direct medical costs.
                                                     1998 translates to about 4.4
Goal: Prevalence and                                                                                     Lung and bronchus cancer rates
                                                     million smokers in California.
Consumption                                                                                          in California declined 14.4% between
    When the Legislature passed AB                 • Between 1990 and 1993, the                      1988 and 1996, compared with a
75 in 1989, it set the goal of reducing              prevalence of cigarette smoking                 decrease in SEER regions of only
tobacco consumption in California                    among youth 12-17 years of age                  4%.3 While women in California
by 75% by the end of 1999. By com-                   changed little. Since 1995, the                 experienced a decrease in lung
parison, the Health Objectives for                   youth smoking prevalence in                     cancer incidence of 6.7%, women
the Nation seek to reduce adult                      California has declined by 12%.                 in other SEER regions experienced
smoking prevalence to a level of                     In general, youth prevalence in                 an increase of 9.3%.
15% by 2000. California has made                     California has remained much                                                4
                                                                                                     Adult Smoking Trends
impressive progress toward its                       lower than the rest of the coun-
                                                                                                         In 1988, 26.7% of California
ambitious goal. Per capita cigarette                 try (for example, among 10th
                                                                                                     adults smoked, compared with
use has declined by more than a half                 grade youth, the prevalence of
                                                                                                     18.4% in 1998. This is considerably
since the program was launched in                    those who smoked in the past 30
                                                                                                     lower than the latest (1997) nation-
1989, and smoking among Calif-                       days increased by 6.7 percentage
                                                                                                     al figure of 24.7%. Figure 4
ornians has decreased at a rate faster               points in California from 1991 to
                                                                                                     compares adult smoking prevalence
than that of the rest of the nation.                 1996, as compared with 10.2 per-
                                                                                                     for California and the United States
                                                     centage points in other states).
      Since the passage of Prop 99:                                                                  between 1974 and 1998.
                                                      The reduction in tobacco con-
• The per capita consumption of
                                                   sumption has led to immediate
  cigarettes has declined 52%.
                                                   health benefits for the California

3   Surveillance, Epidemiology, End Results (SEER) registries in Connecticut, Detroit, Hawaii, Iowa, New Mexico, Seattle, Utah, and Atlanta were
    compared with the California Cancer Registry for this analysis.
4   Data for adult smoking behavior come from the California Adult Tobacco Survey (CATS), conducted annually since 1994 by the Cancer
    Surveillance Section of the DHS; and the California Tobacco Survey (CTS), conducted in 1990, 1992, 1993, 1996, and 1998 by the University of
    California, San Diego. These surveys are conducted with random samples of households through computer assisted telephone household
    interviews. CATS has a sample of 4,000 adults per year; CTS has 78,000 adults in each survey.
                                              Figure 4
                                              Adult Smoking Prevalence for California and the United States, 1974–1998


                                              PREVALENCE (%)
Strategies for the 21st Century – 2000-2003

                                                                              United States

                                                                  74     75   76   77      78   79   80   81   82   83   84    85   86     87   88 89 90 91 92 93 94 95 96 97 98
                                                                     Source: 1990-1993 CTS is weighted to 1990 California population, 1994-1998 BRFS/CATS is weighted to the 1990 California
                                                                     popultiaon. U.S. and California data from 1997 to 1988 from NHIS. Note definition change in 1995 to include more occasional

                                                 Since the passage of Proposition 99 in 1988, California’s annual adult per
                                              capita cigarette consumption declined 52% from 126.6 packs per year to 61.3
                                              packs per year. For the twelve months ending June 30, 1999 there was an
                                              11.5% decline in the adult per capita consumption rate compared to the
                                              twelve months ending June 30, 1998. Per capita consumption in the United
12                                            States went from 154.8 packs per year in 1988 to 106.8 packs per year in
                                              1999. Figure 5 displays the rate of cigarette consumption between 1980 and
Toward a Tobacco-Free California:

                                              1999 in California and the United States.

                                              Figure 5
                                              Adult Per Capita Consumption of Packs of Cigarettes, California and the
                                              United States, Fiscal Years 1980–1998



                                                                              United States
                                                                80/81 81/82 82/83 83/84 84/85 85/86 86/87 87/88 88/89 89/90 90/91 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99
                                                                     Source: CA — California State Board of Equalization (packs sold). California Department of Finance (population).
                                                                     U.S. — U.S. Department of Agriculture. Note that CA data is by fiscal year (July 1 – June 30) and U.S. data is by clendar year.

                                                 Since 1990, the prevalence of smoking has declined in each age group
                                              except for those between the ages of 18-24. Rates for ages 25-64 appear to
                                              have changed little since 1994, but these trends are affected by a change in
                                              the definition of “smoker” in 1996 to include more occasional smokers, which
                                                                                                                                                  Chapter 2 — Ten Years of Progress       13

increases the prevalence of smoking by approximately 1%. Rates for the 18-
24 age group rose above the rates for the 25-44 and 45-64 age groups after
1995, and are increasing. The actual increase is less than it appears in Figure
6 because of the change in definition. Figure 6 shows adult smoking preva-
lence by age group between 1990 and 1998.

Figure 6
California Smoking Prevalence by Age Group, 1990–1998




                 1990               1991         1992           1992           1994           1995           1996           1997           1998
                      Source: 1990-1993 CTS is weighted to 1990 California population. 1994-1998 BRFS/CATS is weighted to the 1990 California
                      popultiaon. Note definition change in 1995 to include more occasional smokers.

                 The prevalence of smoking among adult males and females has declined
substantially since 1990, but the prevalence of smoking for both genders has
remained fairly stable since 1994. Males have had consistently higher smoking
prevalence rates than females with approximately the same difference in
                                                                                                                                                   Tehama County Health Agency,
prevalence in 1990 as in 1998.                                                                                                                     STATIS (Stand Tall Against Teen Issues),
                                                                                                                                                   RB Round-up Parade.

Figure 7
California Adult Smoking Prevalence by Gender, 1990–1998





                 1990               1991         1992           1992           1994           1995           1996           1997           1998
                      Source: 1990-1993 CTS is weighted to 1990 California population. 1994-1998 BRFS/CATS is weighted to the 1990 California
                      popultiaon. Note definition change in 1995 to include more occasional smokers.
                                                                                      Between 1990 and 1998, the prevalence of smoking declined among the
                                                                                  major racial and ethnic groups. However, between 1994 and 1998, rates for all
                                                                                  the groups except Hispanic did not change significantly. The rates for
                                                                                  Hispanic Californians rose from 12% in 1994 to 15% in 1998. The prevalence
                                                                                  for Non-Hispanic whites changed little from 1994 to 1998, hovering around
                                                                                  20%, the highest rates among the four race/ethnicity groups presented. For
                                                                                  African Americans, the prevalence rate was highest in 1997 at 25% and
                                                                                  declined to 19% in 1998. Asian/others have the lowest smoking rates at 13%
Strategies for the 21st Century – 2000-2003

                                                                                  in 1998.

                                                                                  Figure 8
                                                                                  California Age-Adjusted Smoking Prevalence by Race/Ethnicity,

                                                                                      PREVALENCE (%)


                                                                                                                    African American
14                                                                                                      5
Toward a Tobacco-Free California:

                                                                                                       1994                            1995                           1996                          1997                           1998
                                                                                                            Source: 1994-1998 BRFS/CATS is weighted to the 1990 California popultiaon. Note definition change in 1995 to include more
                                                                                                            occasional smokers.

                                                                                  Youth Smoking Trends5
                                                                                      Youth continue to become addicted to tobacco. Between 1990 and 1993,
                                                                                  smoking among youth aged 12-17 remained relatively steady at around 9% at
                                                                                  a time when teen smoking was increasing nationally. Between 1993 and 1995
                                                                                  adolescent smoking prevalence increased from 9% to 12.1%. Since 1995, 12-
                                                                                  17 year old smoking prevalence declined by 12%.6

                                              “Oakland A’s Strike Out Smoking.”
                                              American Lung Association and       5          Data on youth smoking prevalence come from the California Youth Tobacco Survey (CYTS),
                                              Alameda County Tobacco Control,                conducted annually with 2,000 youth (aged 12-17) by the Cancer Surveillance Section of the
                                              1999.                                          DHS; and from the California Tobacco Survey (CTS) conducted annually with 6,000 youth by
                                                                                             the University of California, San Diego.
                                                                                  6        The increase from 1993 to 1994 corresponds with a change from CTS to CYTS data. Part of
                                                                                           the increase may be an artifact of slight differences between the two surveys in data collec-
                                                                                           tion methods and protocols. In addition, caution must be exercised when comparing
                                                                                           California youth smoking data with youth smoking data for other states, the nation as a
                                                                                           whole, or other countries because survey methods may be different (for example, telephone
                                                                                           versus classroom-administered surveys).
                                                                                                                                               Chapter 2 — Ten Years of Progress      15

Figure 9                                                                                                                                    Changes in the Social
30-Day Smoking Prevalence for California 12–17 Year Olds,
                                                                                                                                                Since the publication of the last
Telephone Survey, 1990–1998
                                                                                                                                            Master Plan in 1997, the context for
                                                                                                                                            tobacco control in California has
                                                                                                                                            undergone some major changes.
                                                                                                                                            Among these changes is the nation-
                                                                                                                                            al tobacco settlement. The major

                                                                                                                                            tobacco companies agreed to pay
                  6                                                                                                                         hundreds of millions of dollars
                              CTS/CYTS                                                                                                      annually to California and other
                  3                                                                                                                         states to settle lawsuits accusing the
                                                                                                                                            tobacco industry of fraudulently
                 O                                                                                                                          deceiving the public and causing
                 1990              1991             1992          1992           1994           1995            1996          1997   1998
                                                                                 YEAR                                                       serious harm by promoting the use
                      1990-1993 CTS weighted to 1990 California population with 4 race and 2 age groups.                                    of unsafe products. In November
                      1994-1998 CYTS weighted to 1990 California population with 4 race and 3 age groups.
                                  is 95% Confidence Limits
                      Note: The break in the trending indicates the change in surveys.
                                                                                                                                            1998, they signed the Master
                                                                                                                                            Settlement Agreement (MSA) with
    No differences exist in youth smoking prevalence between males and                                                                      46 state attorneys general.
females. Whites have had the highest youth smoking prevalence, followed by                                                                      In addition to the payments, the
Hispanics, Asians/others and African Americans. Differences by age group                                                                    MSA mandates changes in the
also exist. Since 1994, smoking prevalence in the 14-15 and 16-17 age groups                                                                behavior of the industry, including
has declined but in the 12-13 age group it has increased.                                                                                   specific prohibitions against adver-
    Data that allow comparison of smoking rates among California tenth                                                                      tising and promotion strategies that
graders with smoking rates among tenth graders outside California from 1991                                                                 target youth. The most visible is the
to 1996 indicate that the rates of smoking among the California youth are                                                                   elimination of tobacco ads on bill-
substantially lower.                                                                                                                        boards, effective April 22, 1999. The
                                                                                                                                            MSA also requires the tobacco
Figure 10                                                                                                                                   industry to fund an independent
                                                                                                                                            foundation (subsequently named
Percent of Tenth Grade Youth Who Smoked During the Past 30 Days,
                                                                                                                                            the American Legacy Foundation)
                                                                                                                                            for five years to carry out a large
                                                                                                                                            national anti-tobacco media cam-
                 30                                                                                                                         paign directed at youth. The annual
                                                                                                                                            settlement payments to California
                                                                                                                                            start out at nearly $1 billion and

                                                                                                                                            decline in future years in proportion
                 15                                                                                                                         to declines in tobacco sales. Half of
                              Other States
                                                                                                                                            the annual payments to California
                              California                                                                                                    will go to local governments and
                                                                                                                                            half to the state. The payments may
                 O                                                                                                                          be used as the recipients choose.
                 1991                        1992                   1993                     1994                      1995          1996
                                                                                 YEAR                                                           The settlement provisions will have
                      Source: Monitoring the Future Survey, 1992-1996 (a national classroom-administered survey).                           an impact on the policy environment,
                                                                                                                                            the media campaign, and local pro-
                                                                                                                                            gram planning in California. While
                                                                                                                                            the settlement dollars are large, they
                                                                                                                                            in fact represent only about 30 cents
                                                                                                                                            on the dollar repayment for the costs
                                                                                                                                            imposed by the tobacco industry on
                                              taxpayers for tobacco-related med-                   The tobacco industry is sponsor-                through at least two different
                                              ical services (Zhang et al., 1999). It            ing an initiative (Proposition 28) on              components (media, community,
                                              is still imperative that every effort be          the March 2000 ballot to repeal the                and/or school). Only 2% of
                                              made to reduce tobacco use as                     Proposition 10 tobacco tax increase.               adults, 5% of 8th graders and
                                              quickly as possible.                              Should their efforts succeed, tobac-               4% of 10th graders report no
                                                  Since the settlement, the                     co consumption will increase to the                exposure to any programs (pre-
                                              industry has mounted a massive                    benefit of the tobacco industry and                liminary results, Wave 2 Data,
                                              public relations campaign to clean                the detriment of the health of the                 Independent Evaluation).
                                              its corporate image. The message                  people of California.
Strategies for the 21st Century – 2000-2003

                                                                                                                                               • In counties with high multi-com-
                                              is that tobacco use is a fun, hip,
                                                                                                                                                 ponent exposure, adult smoking
                                              and fully legal activity for people               Program Accomplishments
                                                                                                                                                 prevalence declined between
                                              18 years of age or older. While                       In addition to these major changes
                                                                                                                                                 1996 and 1998. In these counties
                                              running ads supposedly demon-                     in the greater tobacco landscape, the
                                                                                                                                                 there were increases in the per-
                                              strating their good-citizen concern               Tobacco Control Program has re-
                                                                                                                                                 centage of adults who asked
                                              about smoking by minors, the                      duced illegal sales of tobacco to youth,
                                                                                                                                                 someone else not to smoke. By
                                              tobacco companies have sharply                    assisted communities in passing
                                                                                                                                                 comparison, in counties with low
                                              intensified their ad campaigns                    anti-tobacco ordinances, increased
                                                                                                                                                 to moderate multi-component
                                              targeting women and ethnic popu-                  the number of work sites and homes
                                                                                                                                                 exposure, adult smoking preva-
                                              lations. Knowing that youth also                  that are smoke-free, and successful-
                                                                                                                                                 lence remained constant or
                                              “model up” to young adults, the                   ly countered pro-tobacco influences
                                                                                                                                                 increased (preliminary results,
                                              industry has also mounted lavish                  in communities in every region of
                                                                                                                                                 Wave 2 Data, Independent
                                              advertising and promotional cam-                  the state. In addition, the indepen-
16                                            paigns that reach young adults in                 dent evaluation of the program shows
                                              bars, night clubs, and other venues               that there are statistically significant       • The proportion of smokers who
Toward a Tobacco-Free California:

                                              of the young single night life.                   relationships between these out-                 prohibit smoking in their homes
                                                  Another important change in                   comes and program activities.7                   increased from 22.1% in 1994 to
                                              California is the tobacco tax increase                Among the program’s notable                  38.3% in 1998, a 73.3% increase.
                                              passed by voters in the November                  achievements are these:                          The proportion of non-smokers
                                              1998 election. Effective on January 1,                                                             who prohibit smoking in their
                                                                                                • The California Clean Indoor Air
                                              1999, Proposition 10, the California                                                               household also increased, from
                                                                                                  Act (AB 13) was successfully
                                              Children and Families Act, increased                                                               63.2% in 1994 to 73.4% in 1998,
                                                                                                  implemented. The Act includes
                                              the California tobacco surtax by 50                                                                a 16% increase. Sixty-six percent
                                                                                                  the smoke-free bar and bar-
                                              cents per pack of cigarettes and an                                                                of all Californians in 1998 prohib-
                                                                                                  restaurant provision that went
                                              equivalent amount on other tobacco                                                                 it smoking in their homes
                                                                                                  into effect on January 1, 1998.
                                              products. Although Proposition 10                                                                  (Department of Health Services,
                                              funds early childhood programs, the               • 74 policies and other local laws               1999).
                                              voter-imposed tax is evidence of the                restricting tobacco advertising
                                                                                                                                               • Approximately 89% of children
                                              strong anti-tobacco mood in                         have been passed by California
                                                                                                                                                 under 6 years old, and 87% of all
                                              California, and the increased cost of               cities and counties (Technical
                                                                                                                                                 children and adolescents were
                                              tobacco itself is already making                    Assistance Legal Center, 1999).
                                                                                                                                                 protected from secondhand
                                              inroads into consumption.
                                                                                                • Most Californians were exposed                 smoke in the home in 1996.
                                                                                                  to tobacco control messages

                                              7   Extensive detailed evaluation about the Tobacco Control Program may be found in two recent reports that are available from the Tobacco
                                                  Control Section, Department of Health Services. They are Tobacco Control in California: Who’s Winning the War? (An Evaluation of the
                                                  Tobacco Control Program, 1989-1996) (University of California, San Diego); and The Final Report of the Independent Evaluation of the
                                                  California Tobacco Control Prevention and Education Program: Wave I Data, 1996-1997 (The Gallup Organization). Results from the
                                                  Wave 2 Data from the Independent Evaluation Consortium are forthcoming.
                                                                                                              Chapter 2 — Ten Years of Progress   17

Figure 11                                                              was 12.5% (Centers for Disease         school (preliminary results, Wave
                                                                       Control, 1997).                        2 Data, Independent Evaluation).
Percent of Smokers Who Live
with Children and Also Prohibit                                     • The percent of smokers who           • More than 9 out of 10 adults
Smoking in Their Home,                                                prefer to eat in restaurants that      (91%) saw or heard at least one
1994-1998                                                             are smoke-free substantially           general media campaign ad in
                                                                      increased from 44.3% in 1994 to        1998; 95% of eighth graders and
          50                                        47.7%
                                            44.2%                     63.7% in 1998. For non-smokers,        of tenth graders were exposed to
          40                36.9%
                                    39.0%                             the percent that prefer to eat in      at least one ad (preliminary
                                                                      smoke-free restaurants has been        results, Wave 2 Data,

                                                                      stable at around 93%. Almost 9         Independent Evaluation).
          20                                                          out of 10 Californians (87.7%) in
                  12.4%                                                                                    • Adults and youth with greater
                                                                      1998 prefer to eat in smoke-free
          10                                                                                                 exposure to the media were
                                                                      restaurants (Department of
                                                                                                             more likely to have anti-tobacco
                  1996      1994 1995 1996 1997 1998                  Health Services, 1999).
                  U.S.               California
                                                                                                             attitudes and beliefs, and adults
           Source: U.S. combined BRFS data; CA-CATS.                • Opinion leaders in education,          were more likely to prefer
           Prepared by: California Department of Health Services,
           Tobacco Control Section, December 1999.                    law enforcement, government,           smoke-free bars (preliminary
                                                                      business, and the media have a         results, Wave 2 Data,
• The proportion of smokers with                                      high level of awareness of and         Independent Evaluation).
  children living with them who                                       participation in tobacco control
                                                                                                           • Adults with greater media cam-
  prohibit smoking in their home                                      activities, and have high exposure
                                                                                                             paign exposure were more likely
  rose from 36.9% in 1994 to 49.6%                                    to and recall of the statewide
                                                                                                             to ask someone not to smoke;
  in 1998 (Department of Health                                       media campaign. They support
                                                                                                             youth with greater exposure had
  Services, 1998; California Adult                                    the smoke free bar law. They also
                                                                                                             lower rates of tobacco use (ciga-
  Tobacco Survey, 1998). As shown                                     support policies to conduct
                                                                                                             rettes, cigars, and smokeless
  in Figure 11, the comparable rate                                   youth-buy stings, reduce smok-
                                                                                                             tobacco) in the past 30 days
  for the nation as a whole in 1996                                   ing on TV and in films, and ban
                                                                                                             (preliminary results, Wave 2
                                                                      tobacco promotional items at
                                                                                                             Data, Independent Evaluation).

          Chico Heat baseball players, “Spit-Free Ambassadors.”
                                              CALIFORNIA’S                             • On May 31, 1999, the joint ethnic   The California Joint Ethnic Tobacco
                                              ETHNIC NETWORKS                            networks gathered together to       Education Network’s Statement is:
                                                  To assure that the Tobacco             celebrate World No Tobacco Day,
                                                                                                                             United in Truth
                                              Control Program is meeting the             with a focus on the entertainment
                                                                                                                             (Are You Listening?)
                                              needs of the state’s diverse ethnic        industry. Two individuals from
Strategies for the 21st Century – 2000-2003

                                                                                                                                 We, the Joint Ethnic Networks of
                                              population, the program’s competitive      the Screen Actor’s Guild spoke
                                                                                                                             the State of California, representing
                                              grant program specifically targets         to over 100 multi-ethnic youth
                                                                                                                             African Americans, African nation-
                                              ethnic populations in funding              about ways to contact the enter-
                                                                                                                             als, American Indians, Asians,
                                              community-based tobacco control            tainment industry to discuss
                                                                                                                             Pacific Islanders and Hispanic/Latinos,
                                              projects. To facilitate these programs     tobacco use and portrayal in the
                                                                                                                             come today united in truth, and
                                              effectively, four ethnic networks are      industry.
                                                                                                                             speak with one voice to expose the
                                              funded as convener organizations for
                                                                                       • November 9, 1999, the joint         deliberate manipulation by the
                                              African Americans, Hispanic/Latino
                                                                                         ethnic networks held a press        tobacco industry of our women, our
                                              populations, Asian/Pacific Islanders,
                                                                                         conference in Los Angeles to        children, our families and our com-
                                              and American Indians. These orga-
                                                                                         address issues such as Philip       munities. While tobacco companies
                                              nizations work to build a strong
                                                                                         Morris’s $40 million Virginia       try to blind our people by misrepre-
                                              statewide coalition among their
                                                                                         Slims ad campaign, Marlboro         senting themselves as good
                                              respective populations that will help
                                                                                         Milds, ETS, and the current         corporate citizens, they continue to
18                                            develop the leadership capacity of
                                                                                         activities of this corporation to   push their deadly products targeting
                                              their communities, stimulate coordi-
                                                                                         cleanse its public image. Over 30   ethnic communities. Are you listen-
Toward a Tobacco-Free California:

                                              nated tobacco control activities, and
                                                                                         community-based organizations       ing? The tobacco industry’s bottom
                                              promote the development of effec-
                                                                                         and over 16 media outlets were      line is profit, not the health and
                                              tive community-based tobacco
                                                                                         brought together for an aware-      well-being of people of color. No
                                              control projects. Each network is
                                                                                         ness campaign.                      dollars or public relations campaign
                                              funded to support mini-grants.
                                                                                                                             can buy credibility, erase the pain,
                                                  The ethnic networks have shown       • In August, 1998, a Multiethnic
                                                                                                                             heal the wounds or bring back lives
                                              they are very effective in promoting       Youth Summit was held for over
                                                                                                                             lost to the tobacco industry. We
                                              program objectives in their respective     100 Hispanic/Latino, African
                                                                                                                             stand in support of FDA regulation,
                                              communities. They have also acted          American, American Indian, and
                                                                                                                             in support of the research on sec-
                                              as a powerful force in joint efforts,      Asian/Pacific Islander youth.
                                                                                                                             ondhand smoke and in support of
                                              as in the following initiatives:           This advocacy training confer-
                                                                                                                             exposing the continued blatant,
                                                                                         ence was planned, organized,
                                                                                                                             deceptive marketing to communities
                                                                                         and delivered by youth.
                                                                                                                             of color. The rich traditions of our
                                                                                                                             elders, our languages, and our her-
                                                                                                                             itage are ours to pass on, not the
                                                                                                                             tobacco industry’s to distort. Are
                                                                                                                             you listening? We have spoken!
                                                                                          Chapter 2 — Ten Years of Progress    19

      • Research funded by the Tobacco-                 cells, and creating a new class      neering studies that demon-
        Related Disease Research Program                of anticancer agents (Illudins)      strated how smoke behaves
        has led to significant contribu-                which are more toxic than            and is distributed through
        tions to the knowledge of the                   conventional chemotherapy.           buildings via ventilation sys-
        consequences of tobacco use.                                                         tems, to studies that showed
                                                     — The relationships of smoking
        Sample research topics include:                                                      the detrimental health effects
                                                       by pregnant women and
                                                                                             of secondhand smoke expo-
          — How nicotine affects the                   adverse health effects on preg-
                                                                                             sure. The work of TRDRP
            brain, the receptors involved,             nancy outcome, how smoke
                                                                                             researchers is cited in nearly
            the mode of action of nicotine             components cross the placen-
                                                                                             every chapter of the CalEPA
            on the receptors, the conse-               ta, and when during the
                                                                                             report on environmental
            quences of brain changes in                pregnancy exposure to smoke
                                                                                             tobacco smoke, and also
            response to nicotine expo-                 is the most detrimental.
                                                                                             formed the scientific basis for
            sure, and the addictive nature
                                                     — Who uses smokeless tobacco            California’s Clean Indoor Air
            of nicotine.
                                                       products and how best to              Act (AB 13).
          — Improving the risk, diagnosis,             intervene with users such as
                                                                                          — Research has identified risk
            and treatment of diseases                  high school and college ath-
                                                                                            factors that promote smoking
            attributable to smoking, such              letes. Research has led to
                                                                                            behavior and developed tai-
            as emphysema, heart disease,               interventions that have been
                                                                                            lored interventions that are
            and cancer. Research on novel              adopted by the national
                                                                                            linguistically and culturally
            cancer treatments include                  Association of College and
                                                                                            appropriate, contributing to
            using the body’s immune sys-               High School Athletes.
                                                                                            understanding differences in
            tem to fight tumor growth,
                                                     — Research on secondhand               smoking patterns and preva-
            genetically altering cancer
                                                       smoke, beginning with engi-          lence among California’s
                                                                                            diverse racial and ethnic pop-
                                                                                          — Policy research showed that
                                                                                            (1) smoking bans in restau-
                                                                                            rants did not reduce
                                                                                            revenues; (2) a 10% increase
                                                                                            in cigarette prices would
                                                                                            lead to an average drop in
                                                                                            consumption of 4%, research
                                                                                            that was used to estimate
                                                                                            the impact of the MSA in
                                                                                            California; (3) in 1993, the
                                                                                            direct cost of smoking in
                                                                                            California was $264 per
                                                                                            capita and $1,981 per smok-
                                                                                            er for a total of $8.7 billion
                                                                                            on tobacco-related health
                                                                                            care, of which 43% is born
“Kick Butts.” American Lung Association Billboard.                                          by public sources.
“Nicotine Soundbites.”

Television Ad, 1994

Statewide Media Campaign
                                                      Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations   21

Progress Toward TEROC’s 1997-2000
   In its last Master Plan, Renewing         — Voice (television, outdoor): a
the Commitment, TEROC made                     series of ads that present real
ten recommendations for the years              people who have suffered real
1997-2000. This chapter assesses               losses because of tobacco
the progress made regarding these              use. Two ads include brothers
recommendations.                               who lost their dad to cancer.
Progress Toward                              — I Miss My Lung, Bob
                                                                                    The American Nonsmokers’
Recommendation 1:                              (print/outdoor): a satire of
                                                                                    Rights Foundation’s Community
Vigorously expose                              the Marlboro ads with a cow-
tobacco industry tactics.                      boy describing another               Advocacy Mobilization Project
    Much progress has been made                consequence of smoking.              (CAMP) helps agencies eliminate
statewide and at the local level toward                                             and/or expose tobacco industry
                                          • Several ads exposing the tobacco        interference in California. When pro-
this recommendation. Exposing
                                            industry were also produced for
tobacco industry tactics remains a                                                  tobacco influences in the community
                                            various ethnic communities; for
priority of the Tobacco Control                                                     are identified, the project develops
Program, and further gains are                                                      and implements appropriate strate-
expected.                                    — Puppet Show (television,             gic responses. Materials that assist
                                               Asian American): the manip-          communities include fact sheets
Media Campaign
                                               ulative tactics of the industry      on recent industry activities in
• As recommended by TEROC,                     are exposed as children
                                                                                    California, and two video documen-
  several ads produced during the              watching a puppet show find
                                                                                    taries (“Fighting Back: Communities
  first years of the Tobacco Control           themselves manipulated by
                                                                                    Beating Big Tobacco” and “The
  Program that confront tobacco                strings held by the hands of a
  industry tactics have been re-               tobacco industry executive.          Hidden War: Big Tobacco Fights
  approved for use. Among these                                                     Back.”)
                                             — Leather Jacket (print/outdoor,
  effective and hard-hitting televi-
                                               Hispanic): the consequences
  sion ads are “Insurance,” “Nicotine
                                               of tobacco use are under-
  Sound Bites,” “Industry Spokes-
                                               scored with the skeletal
  person,” and “A Few More Good
                                               remains of a young smoker, still
  Years.” The billboard, “Lies,” was
                                               wearing the leather jacket pur-
  also re-approved.
                                               chased with tobacco coupons.
• New general-market ads were                  The text reads, “Are you dying
  aired in 1998 and 1999 that                  for this leather jacket?”.
  expose the tactics used by the
                                          Project SMART (Sponsorship
  tobacco industry:
                                          Mission: Avoid Reliance on
   — They’re Getting Smarter              Tobacco) Money
     (television): an ad that                 Project SMART Money is a
     demonstrates how the indus-          statewide campaign to eliminate or
     try continually changes its          prevent tobacco sponsorship, phil-
     tactics to attract new young         anthropy, and signage from public
     smokers.                             sport, civic and cultural events and
                                              The Tobacco Industry              organizations. Approximately 13%       toward the tobacco industry increased
                                              Monitoring Project is a           of the events in California received   from 1996 (83%) to 1998 (90%).
                                              Proposition 99 effort of the      tobacco sponsorship in 1996—
                                              Annenberg School for              primarily sports, auto, or boating     Progress Toward
                                              Communication at the              events (Independent Evaluation         Recommendation 2:
                                              University of Southern
                                                                                1998). Tobacco companies also use      Press for smoke-free
                                                                                sponsorships and charitable dona-      workplaces and homes.
                                              California (with Social
                                                                                tions to improve their image in the      Substantial progress has been
                                              Marketing Associates and          community. Project SMART Money         made in the establishment of
Strategies for the 21st Century – 2000-2003

                                              Hodgson Communications).          goals are to counter and diminish      smoke-free workplaces and homes:
                                              The project reviews past and      the prestige of the tobacco industry
                                              present tobacco industry                                                 • In January 1998, the final phase
                                                                                in the community’s eyes, and
                                                                                                                         of the California Clean Indoor Air
                                              marketing, business, and          decrease and eventually eliminate
                                                                                                                         Act (AB 13) went into effect
                                              public influence practices,       tobacco industry sponsorship of
                                                                                                                         when smoking in bars and bar-
                                              and discloses its findings to     public events. A community assess-
                                                                                                                         restaurant combinations became
                                              the public. Selected project      ment was conducted to identify
                                                                                                                         illegal. Implementation of this
                                              activities include on-site        tobacco industry sponsored events,
                                                                                                                         law is supported through media
                                              and Internet investigations       and strategies to wean these com-
                                                                                                                         campaign ads, local publicity,
                                              of documents from the             munity events from dependency on
                                                                                                                         bartender and bar employee
                                                                                tobacco dollars have been created
                                              Minnesota tobacco trial and                                                education, and enforcement
                                                                                by each community.
                                              other tobacco industry docu-                                               efforts.
                                              ments released from other         School-based Programs
22                                                                                                                     • In 1998, the vast majority of
                                              lawsuits; investigation of           The Independent Evaluation of
                                                                                                                         California adults (83% nonsmok-
                                                                                the Tobacco Control Program found
Toward a Tobacco-Free California:

                                              the use of the Internet by the                                             ers, 52% smokers) were not
                                              industry to market its prod-      that the percentage of 8th graders
                                                                                                                         exposed to secondhand smoke at
                                                                                who reported negative attitudes
                                              ucts and promote a “smoking                                                home or at work.
                                              culture;” review of significant
                                              new tobacco industry adver-       The Tobacco-Free Challenge Project.
                                              tising campaigns that
                                              attempt to manipulate specif-
                                              ic target audiences; and
                                              investigation of other topics
                                              such as tobacco industry
                                              retail distribution practices,
                                              slotting and point of
                                              purchase practices, and phil-
                                              anthropic and community
                                           Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations   23

• Sixty-six percent of all             Three projects funded by the California Department of Education
  Californians in 1998 prohibited      educate students about tobacco industry tactics. The Triple T
  smoking in their homes. Smokers      Project (Teens Tackle Tobacco), developed by the Napa County
  who prohibit smoking in their        Office of Education and the Napa Valley Unified School
  household increased 73.3% from       District, engages students in projects that require personal state-
  1994 to 1998. Non-smokers who
                                       ments in the form of bumper stickers, bus placards, posters,
  prohibit smoking in their house-
                                       mobile murals, promise letters, and/or storybooks with tobacco-
  hold have also increased 16%
  from 1994 to 1998 (Department
                                       free messages. Modeled after strategies utilized by the tobacco
  of Health Services, 1999).           companies and media to “hook” young people on tobacco, the pro-
                                       ject employs the same techniques, with students working to get
• Counties that put the most effort    tobacco-free “advertisements” out to their friends, family, and
  into their secondhand smoke
  programs showed the most change
  between 1996 and 1998 in reduc-      San Mateo County Office of Education’s Anti-Tobacco Media
  ing exposure at home and work.       Blitz is a social marketing campaign for high schools which uses
• In 1998, close to 88% of             many different media formats to create anti-tobacco messages to
  Californians prefer to eat in        students. The program’s goal is to design and implement a student-
  smoke-free restaurants. The per-     produced anti-tobacco media campaign that counters the pro-tobacco
  cent of smokers that prefer to       messages in many different formats—graphics, live performances,
  eat in restaurants that are smoke-   video and audio playbacks, music, and peer-led discussion.
  free substantially increased from
  44.3% in 1994 to 63.7% in 1998.
                                       The Rim of the World Unified School District’s Project
  For non-smokers, the percent         A•B•C•D (Analyze, Beware, Create, Disseminate) provides
  that prefer to eat in smoke-free     hands-on training for students in grades 7–8 to build strategies in
  restaurants has been stable at       reducing the acceptance and use of tobacco. Students learn to ana-
  around 93% (Department of            lyze and beware of the dangers inherent in tobacco use and
  Health Services, 1999).              understand the role the media plays in influencing tobacco-related
                                       behavior. They use multi-media techniques to create counter-tobac-
• According to recent surveys,
  Hispanics and those with less        co-use public service announcements, and they disseminate
  education are at highest risk for    anti-tobacco messages to their school community by participating
  exposure to secondhand smoke         in computer animation, video production, web page development,
  at work. Males, African              and marketing workshops.
  Americans, and those with a
  high school education are at
  highest risk for exposure to sec-
  ondhand smoke at home.
• There is increased community
  pressure for smoke-free toddler
  playgrounds, outdoor group
  events, shared living facilities
  (apartments, condominiums),
  lobbies, and bus stops.
                                              The Tobacco Education Media Campaign created a variety of          Progress Toward
                                              ethnic television, radio, billboard and print ads that address     Recommendation 3:
                                              secondhand smoke. Among the ads produced between 1997 and          Accelerate cessation
                                              1999 are:                                                          of smoking in persons
                                                                                                                 between the ages of
                                              Long Ride (African American television ad): Secondhand             20 and 39.
                                              smoke and its link to the onset of asthma is revealed in a             Smoking prevalence rates stabi-
                                              father-son relationship.                                           lized for 25-44 year olds (20.2% in
                                                                                                                 1996 to 20.4 % in 1998), but preva-
Strategies for the 21st Century – 2000-2003

                                              Too Little (African American television ad): Secondhand
                                                                                                                 lence in 18-24 year olds rose from
                                              smoke and its link to bronchitis is revealed in a mother-          20.6 % in 1996 to 22.0% in 1998.
                                              daughter relationship.                                             Although rates for young adults
                                              Showed Me the Way (African American print/outdoor ad):             aged 20 to 39 were not reduced,
                                                                                                                 both the community-based and
                                              The positive influence of a non-smoking parent is displayed as
                                                                                                                 research components of the pro-
                                              an adult son proclaims, “My father never had to tell me not to
                                                                                                                 gram are devoting considerable
                                              smoke. He showed me the way.”
                                                                                                                 resources to cessation efforts.
                                              Gravesite (Hispanic television ad): A man kneeling beside          • Eight studies on youth cessation
                                              the grave of a recently lost loved one expresses dismay that his     are funded by the Tobacco-
                                              cigarette smoking caused that death.                                 Related Disease Research
                                                                                                                   Program (TRDRP). Specific
                                              Auction (Hispanic radio ad): At an auction, bidders are
24                                                                                                                 target audiences are Spanish-
                                              offering the diseases of loved ones in exchange for being able
                                                                                                                   speakers, athletes, substance-
                                              to smoke.
Toward a Tobacco-Free California:

                                                                                                                   abusing adolescents, Lake County
                                              Crowded Room (Asian American radio ad): The dangers of               (rural) adolescents, and teens in
                                              secondhand smoke are revealed in a spot designed to educate          general. Among the media being
                                              smokers about not lighting up in public places.                      tested are websites and a three-
                                                                                                                   dimensional “chat room.”
                                              You’re Not the Only One Being Harmed (Asian American
                                                                                                                 • Radio and print ads promote
                                              print/outdoor ad): A foreground image of a father-figure smok-
                                                                                                                   smoking cessation and the
                                              ing is contrasted by a family in the background, who is              California Smokers’ Helpline. For
                                              suffering from the smoke.                                            example, Jungle and A Way Out
                                                                                                                   of the Smoking Jungle are ads
                                                                                                                   directed at Asian Americans that
                                              The Fresno County Economic Opportunities Commission                  offer a cessation solution to
                                              Rural Tobacco Prevention Program targets Spanish-speak-              those who feel “lost in a jungle”
                                              ing pregnant women, their infants, and the family for an             of smoking. This campaign
                                              innovative program to reduce exposure to secondhand smoke.           sparked the greatest volume of
                                              Individual mothers-to-be and their partners sponsor a “baby          calls to the Asian Helpline.
                                              shower” in their home and provide a meal for their guests. At      • A media campaign funded by
                                              the shower, harmful effects of secondhand smoke on the mother        Proposition 10 will include many
                                              and her unborn baby, as well as other children and family            ads on tobacco control, in partic-
                                              members are discussed. Techniques on how a mother could              ular to promote smoking
                                              deal with someone smoking in her home are also demonstrat-           cessation to pregnant women.
                                              ed, and each participant receives a baby shower cake and             The ads will refer viewers to the
                                              incentives for their participation; the baby receives a t-shirt      California Smokers’ Helpline.
                                              stating “I’m smoke free.”                                          • The California Smokers’ Helpline
                                                                                                                   has offered smoking cessation
                                             Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations   25

   counseling services statewide         “Smoke-Free Nightspots Are Good for Health and Good for
   since 1992. A Teenline has been       Business,” says BREATH—The California Smoke-Free Bar
   in operation since June 1996.         Program. This project of the American Lung Association of
   About 100 teen smokers called         Contra Costa-Solano is funded to conduct educational
   the Helpline each month.              programs and work with the hospitality industry as well as
   Approximately 27% of the teens
                                         government and private entities across the state to support
   who received Helpline counsel-
                                         smoke-free bars, gaming clubs, and nightspots. The project
   ing achieved a 90-day quit
                                         has created BREATH Membership Coalitions of bar and
                                         bar/restaurant employees in three regions of the state, and
• Medi-Cal has started to pay for        founded Musicians for Smoke-Free Air. City attorneys, county
  Nicotine Replacement Therapy in        counsels and district attorneys, bar owners and employees,
  conjunction with counseling, with
                                         and Proposition 99 grantees have attended BREATH trainings
  the California Smokers’ Helpline
                                         throughout the state. The project also responds to individual
  acting as the primary source of
                                         requests for assistance.
  the required counseling.

Progress Toward
Recommendation 4:                        “STARS For the 21st Century”—Seeking Tobacco
Strengthen school-based                  Alternatives with Realistic Solutions is a project of the
tobacco use prevention                   American Lung Association of Sacramento designed to
education programs                       decrease tobacco use in entertainment productions. Among the
consistent with emerging                 project’s activities are a “young ambassadors” campaign to
research.                                reach studio and network executives and creative talent advo-
   There has been some progress          cates for increasing the number of movies and television
toward this recommendation:              programs with zero tobacco use, and an After Oscars Smoke-
• The prevalence of youth smoking        free Gala will offer a smoke-free environment to actors,
  is lower in California than in other   writers, and directors.
  states. The average difference
  between California and other
  states between 1991 and 1996           Since 1991, staff of the Ventura County Public Health
  was 6.5 percentage points for 8th      Tobacco Education Program and the Ventura County
  graders and 9.1 percentage points      Superintendent of Schools Office have created and conduct-
  for 10th graders (Monitoring the
                                         ed facilitator trainings for a peer-conducted cessation
  Future Survey, 1991-1996).
                                         program called “Tobacco? No, Thanks!” (TNT). During the
  Overall youth smoking prevalence
  in California (age 12-17) has
                                         past two years of its implementation, TNT has produced an
  declined 12% since 1995.               overall quit rate of roughly 35% and nearly 50% of the entire
                                         participant group reported reduced consumption. The partner-
• The California Student Survey          ship between public health and the schools, and the use of
  (Attorney General’s Office)
                                         peers in implementing the program, have contributed to the
  showed a 2% decrease in 30-day
                                         success of this cessation program.
  smoking prevalence rates for
  students in grades 7 and 11
  between 1995 and 1997, while
  national rates for youth in grade
  8 increased during the same
• 97% of school districts have a
  tobacco-free policy prohibiting
                                              “No Ifs, Ands, or Butts,” developed by the Culver City                   the use of tobacco by all stu-
                                              Unified School District, is a holistic approach to tobacco pre-          dents, school staff, parents, and
                                              vention and reduction through on-site cessation, after-cessation         visitors in district-owned or
                                              support groups, intensive education, peer counseling, special-           leased buildings, on district
                                              ized programs for pregnant/parenting teens, risk reduction               grounds, and in district vehicles.
                                                                                                                       District and county office super-
                                              through intervention, and strong support systems.
                                                                                                                       intendents must sign an
                                                                                                                       assurance that their tobacco-free
                                                                                                                       policy is being enforced.
Strategies for the 21st Century – 2000-2003

                                              Smokeless School Days (Learning How to Kick Butts),                      Enforcement problems are iden-
                                              developed by the Los Gatos-Saratoga and Campbell Union                   tified through the coordinated
                                              High School Districts, has proven to be a successful alternative         compliance review or individual
                                              to punitive disciplinary measures directed at students caught            complaints. The percentage of
                                              using tobacco on campus. The program goals are to bring stu-             school districts certified as
                                              dents closer to deciding to quit and to provide students with the        tobacco-free by CDE increased
                                              tools to do so. It has been included in the American Cancer              from 95% to 97% in 1999.
                                              Society’s “Resource Guide to Youth Tobacco Cessation.”                • By December 1999, 46% of
                                                                                                                      school districts have adminis-
                                                                                                                      tered the California Healthy Kids
                                              The Medicine Wheel Project, developed by the Resources for              Survey. The self-report instru-
                                              Indian Student Education, works to prevent the use of com-              ment is for grades 5, 7, 9, and
                                              mercial tobacco products while emphasizing “who” Indian people          11, and gives an assessment of
                                              are, the traditions of sacred plants, how Indian students empow-        alcohol, tobacco and other drug
                                                                                                                      use. The extended tobacco mod-
Toward a Tobacco-Free California:

                                              er themselves through leadership and role modeling within their
                                              community. The program goal is to empower youth to make edu-            ule is required for districts that
                                                                                                                      received TUPE competitive
                                              cated, healthy choices which honor a traditionally-based lifestyle.
                                                                                                                      grant funds.
                                                                                                                    • A CDC guideline for instructional
                                              “The Basement Bums” Adventures in Life Skills, developed                content of tobacco use preven-
                                              by the San Francisco Unified School District, is an engaging            tion education specifies teaching
                                              CD-ROM educational series presenting real-life scenarios to             “negative physiologic and social
                                              middle school students while teaching important life skills such        consequences of tobacco use,
                                                                                                                      social influences on tobacco use,
                                              as communication. The program goal is to provide innovative
                                                                                                                      peer norms regarding tobacco
                                              technology and extension activities to enhance health education
                                                                                                                      use, and refusal skills.” Eighty-
                                              programs aimed at reducing tobacco use among youth.                     eight percent of 5th, 8th, and
                                                                                                                      10th grade teachers provided
                                                                                                                      instruction about negative physi-
                                              Project LIFE (Look Into Future Effects), developed by the               ologic consequences of tobacco
                                              Poway Unified School District, is a full semester class offered         use; 64% social influences; 57%
                                              for credit at continuation high schools. The course work focuses        social consequences; 50% peer
                                              on Biology, English, and elective credits for community service.        norms; 51% refusal skills.
                                              Other highlights include weekly interaction with seniors at a         • CDE is publishing Getting
                                              residential care facility, hospital tours, guest speakers, and          Results: California Action
                                              adventure learning. The program goal is to reduce and/or elimi-         Guide to Tobacco Use
                                              nate tobacco use among teens.                                           Prevention Education and pro-
                                                                                                                      viding accompanying training to
                                                                                                                      county offices of education and
                                                                                                                      districts to help them select
                                            Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations        27

   research-based strategies and       The Missing Link (Personal/Social Skills Lessons) is a
   materials for tobacco use pre-      set of nine middle school and nine high school personal/
   vention education. The Healthy      social skills lessons that were developed by the Los Angeles
   Kids Resource Center provides       County Office of Education. The lessons are intended to
   research summaries of effective     augment prevention curricula, and are research-based and
   programs, and the Healthy Kids
                                       user friendly. The program goal is to empower students with
   Program Dissemination Center
                                       the skills needed to prevent, delay, and/or reduce involvement
   gives information about where
   effective programs can be seen
                                       with tobacco as well as alcohol, other drugs, and violence. A
   in action.                          controlled evaluation of the lessons demonstrated significant
                                       impact on students’ marijuana use, combined alcohol and
• In TUPE-funded projects, school      tobacco use, and attitudes toward tobacco use.
  districts are required to:
   — base programs on assessment
     of the tobacco-related behav-
     ior of students                   Project SCAT (Schools and Community Against
   — establish measurable goals        Tobacco), developed by the Nevada Joint Union High
     and objectives                    School District, involves students and adults in a collabora-
                                       tive effort to influence attitudes about tobacco use. Program
   — design and implement pro-
                                       components are designed to reach a wide representation of
     grams based on research or
                                       school and community residents through several venues:
     evaluation that provides evi-
     dence that the programs           interactive sessions presented by parent educators and youth
     prevent or reduce tobacco         educators to elementary and middle school students; the
     use among youth                   Lifesaver Lab, a health science experience for upper elemen-
                                       tary students; public service announcements and dramas
   — evaluate programs periodical-
                                       involving middle and high school students aired on local
     ly to assess progress, and
                                       radio stations; and a mock trial related to a tobacco issue
     strengthen the goals and the
     program accordingly
                                       that is produced for the community by high school students,
                                       local attorneys and a judge.
• The Tobacco-Related Disease
  Research Program (TRDRP) cre-
  ated a new research award
  mechanism designed for schools
  and academic institutions to
  work together. The School-
  Academic Research Award
  (SARA) is co-funded by TRDRP
  and the California Department of
  Education. Grants from SARA
  will increase research-based
  prevention and cessation
• Funding for high school grants
  has been released on time at the
                                       “Like Father, Like Daughter.” Billboard, 1995 Statewide Media Campaign.
  beginning of each fiscal year dur-
  ing the last two years.
                                              Project CHALK, developed           Progress Toward                            Progress Toward
                                              by the Public Health               Recommendation 5:                          Recommendation 6:
                                              Institute and funded by the        Implement more effective                   Generate and adopt addi-
                                              Tobacco-Related Disease            control of tobacco sales                   tional smoking prevention
                                              Research Program, focuses on       to minors.                                 and cessation strategies
                                              the community surrounding             Substantial progress has                that are relevant to the
                                              stores that sell tobacco to        been achieved toward this recom-           many racial and ethnic
                                                                                 mendation:                                 populations in California.
                                              minors. Community resi-
                                                                                                                              Substantial progress has been
Strategies for the 21st Century – 2000-2003

                                              dents distributed flyers and       • Illegal sales to minors dropped
                                                                                                                            made toward this recommendation:
                                              posters that encouraged the          sharply from 30% in 1996 to
                                              community to speak up and            13% in 1998.                             • The Tobacco Education media
                                              object when they observe a                                                      campaign has produced a variety
                                                                                 • The Attorney General’s Office
                                              sale of tobacco to a child.                                                     of ethnic television, radio, out-
                                                                                   has pursued enforcement action
                                                                                                                              door and print ads since the
                                                                                   against five of the larger whole-
                                                                                                                              campaign began in 1990 to
                                                                                   salers/distributors who did not
                                                                                                                              address specific tobacco issues
                                                                                   fulfill the legal requirement to
                                                                                                                              with various ethnic communities.
                                                                                   report the names of all retailers
                                              One way to implement effec-                                                     Ads are produced by advertising
                                                                                   to whom they supply tobacco
                                              tive control of tobacco sales to                                                agencies that target a specific
                                              minors is to educate elected                                                    ethnic group. Examples of many
                                                                                 • Although the rate of illegal sales         of these ads are given in previ-
                                              officials and other key opinion
28                                                                                 as measured in annual purchase-            ous sections of this report.
                                              leaders who make and enforce
                                                                                   attempt surveys has gone down,
                                              policies. The Educating Key                                                   • In May 1999, the African
Toward a Tobacco-Free California:

                                                                                   preliminary data from the Inde-
                                              Opinion Leaders project                                                         American Tobacco Education
                                                                                   pendent Evaluation (1999) show
                                              of the American Lung                                                            Network began a campaign
                                                                                   that 89% of tenth grade youth
                                              Association of California                                                       called “Not in Mama’s Kitchen”
                                                                                   reported in 1998 it is still easy to
                                                                                                                              to address the serious issue of
                                              works to increase support for        obtain tobacco products from com-
                                                                                                                              environmental tobacco smoke.
                                              community norm change                mercial as well as social sources
                                                                                                                              Over 1,400 pledges to celebrate
                                              strategies among these leaders       (e.g., friends, family, or strangers).
                                                                                                                              a smoke free Mother’s Day were
                                              through enforcement of exist-        Most commonly, teens obtain their
                                                                                                                              received in response to 10,000
                                              ing tobacco control policies         cigarettes from non-commercial
                                                                                                                              cards that were mailed.
                                              (such as smoke-free work-            sources, especially from friends.
                                              places, illegal sales to minors,                                              • As part of the Asian and Pacific
                                                                                 • In this recommendation, TEROC
                                                                                                                              Islander Tobacco Education
                                              and advertising and sponsor-         noted that DHS’s ability to con-
                                                                                                                              Network’s (APITEN) campaign
                                              ship restrictions); and through      duct random compliance checks
                                                                                                                              to encourage organizational and
                                              development of strategies such       is limited because the Expanded
                                                                                                                              festival adoption of tobacco con-
                                              as prohibiting self-service dis-     Exchange Agreement allowing
                                                                                                                              trol policies, the Hmong New
                                              plays and addressing tobacco         the State Board of Equalization
                                                                                                                              Year Celebration in Fresno
                                              licensing issues.                    to share tobacco tax receipt
                                                                                                                              adopted a tobacco-free policy.
                                                                                   information with DHS had not
                                                                                   been approved. The agreement             • The American Indian Tobacco
                                                                                   to share information recom-                Education Network (AITEN) is
                                                                                   mended by TEROC as a means                 conducting a campaign to
                                                                                   to increase the effectiveness of           increase smoke-free policies on
                                                                                   the implementation of the                  tribal lands, and to establish
                                                                                   STAKE Act has still not been               smoke-free areas and events at
                                                                                   reached.                                   pow-wows and other tribal gath-
                                                    Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations   29

• The Hispanic/Latino Tobacco              tobacco use; ethnic differences         A tobacco control project
  Education Network (H/LaTEN)              in cigarette smoking dynamics           in Long Beach, Khmers
  Youth Council worked with various        among youth; tobacco control in         Against Tobacco spon-
  Spanish language radio station           Latino communities; predictors          sored by the Cambodian
  disc jockeys in Southern                 of smoking in Latino and African        Association of America,
  California to promote a tobacco-         American youth; preventing
                                                                                   is helping Cambodian tem-
  free lifestyle and cessation             smoking in California Pacific Rim
                                                                                   ples adopt a smoke-free
  messages on World No Tobacco             youth; and smoking cessation in
  Day. Live radio interviews were          the Vietnamese community.
                                                                                   policy for the outside areas
  conducted among youth advo-                                                      immediately adjacent to
  cates. In April 1999, the H/LaTEN                                                the temple, and to offer
                                        Progress Toward                            smoking education and
  recognized the Hispanic/Latino
                                        Recommendation 7:                          prevention classes on the
  Tobacco Free Advocates of the
                                        Link Proposition 99-
  Century—62 heroes/sheroes in                                                     premises. Presentations to
                                        financed research and
  the categories of youth leaders,                                                 Buddhist monks and their
                                        evaluation efforts closely
  parents, community leaders,                                                      lay counterparts, ajars,
                                        with Tobacco Control
  media representatives, business                                                  about the Cambodian cul-
                                        Program activities.
  representatives, and sports fig-                                                 ture, Buddhism, and
                                            Major progress can be reported
  ures who are living examples of                                                  tobacco control are the first
                                        in linking research and evaluation to
  tobacco-free role models and
                                        action.                                    steps toward meeting the
                                                                                   project’s objectives.
                                        • Results of the Independent
• Research projects funded by the
                                          Evaluation of the Tobacco Control
  Tobacco-Related Disease
                                          Program are used by the Depart-
  Research Program investigate
                                          ment of Health Services and the
  racial and ethnic differences in
                                          California Department of
  the use, prevention, and cessa-
                                          Education to modify their tobacco
  tion of tobacco. For example, one
                                          control activities. For example, the
  study tests the hypothesis that
                                          Educating Key Opinion Leaders
  racial discrimination accounts for
                                          Project (described previously)
  differences between Caucasians
                                          was developed in response to
  and African Americans in smok-
                                          Wave 1 findings of the Independent
  ing prevalence, age of initiation
                                          Evaluation that a high percentage
  of smoking, degree of nicotine
                                          of opinion leaders in the state
  addiction, difficulty quitting
                                          favored individual rather than
  smoking, and stage of readiness
                                          population-based strategies for
  to quit smoking. The researchers
                                          reducing tobacco use.
  hypothesize that African
  Americans who experience fre-
                                        • The Tobacco-Related Disease
  quent discrimination differ from
                                          Research Program (TRDRP)
  Caucasians on all five variables.
                                          established Community-
  Data from this research can be
                                          Academic Research Awards
  used to design new, culturally-
                                          (CARA) to stimulate and sup-
  tailored smoking prevention and
                                          port collaborations between
  cessation programs for African
                                          community-based organizations
                                          and academic investigators to
   Other studies investigate topics       perform scientifically rigorous
   such as smoking and depression         research. Research supported
   in Chinese Americans; Hmong            by this program investigates
   cultural practices and patterns of     tobacco control issues that are
                                                 identified as important by specif-    a result of a tobacco surtax increase   1, 1999, expressed concerns about
                                                 ic communities in the state, are      and a manufacturers’ price increase     the settlement and briefly explored
                                                 likely to produce results that are    caused by the Master Settlement         the advisability of backing out of it.
                                                 meaningful to specific communi-       Agreement.                              He has since established a Tobacco
                                                 ties, and use methods that are                                                Litigation Unit in the Department of
                                                                                       • Voters passed Proposition 10 in
                                                 relevant, culturally sensitive, and                                           Justice which he plans to maintain
                                                                                         November 1998 to increase the
                                                 appropriate in terms defined and                                              over the coming years to ensure
                                                                                         tax on cigarettes by 50 cents per
                                                 accepted by the interested com-                                               tobacco industry compliance with
                                                                                         pack, and an equivalent amount
                                                 munities.                                                                     the Master Settlement Agreement
Strategies for the 21st Century – 2000-2003

                                                                                         on cigars, pipe tobacco and
                                                                                                                               provisions, including the restrictions
                                              • Through CARA and other award             smokeless tobacco. This tax
                                                                                                                               on the marketing of tobacco prod-
                                                mechanisms, TRDRP has funded             went into effect on January 1,
                                                                                                                               ucts to youth.
                                                behavioral research that has             1999.
                                                direct application to program
                                                                                       • The Proposition 10 tax increase
                                                interventions. Twenty-nine per-
                                                                                         triggered an additional               Progress Toward
                                                cent of the 1999 research awards
                                                                                         Proposition 99 increase in the        Recommendation 10:
                                                were for this type of research (out
                                                                                         tax on non-cigarette tobacco          Coordinate Proposition
                                                of 66 new projects, 7 were for
                                                                                         products equivalent to 50 cents       99-financed programs
                                                social/behavioral/youth research,
                                                                                         per pack, effective July 1, 1999.     with other State and
                                                5 were CARA awards, and 7 were
                                                                                         Thus, for non-cigarette tobacco       Federal tobacco control
                                                related to public policy).
                                                                                         taxes (which account for about        initiatives.
                                              • TRDRP and the California                 10% of tobacco sales), an                 California’s Tobacco Control
30                                              Department of Education have             increase of $1.00 has been            Program has a history of coordinat-
                                                created the School-Academic              achieved.                             ing its efforts with other initiatives
Toward a Tobacco-Free California:

                                                Research Award (SARA) that is                                                  such as the Robert Wood Johnson’s
                                                                                       • The Master Settlement
                                                designed for schools and acade-                                                Smokeless States Program, the Next
                                                                                         Agreement caused the tobacco
                                                mic investigators to work                                                      Generation Alliance, and tobacco
                                                                                         companies to increase the
                                                together.                                                                      control initiatives sponsored by the
                                                                                         wholesale price of a pack of ciga-
                                                                                                                               Centers for Disease Control and
                                              • TRDRP also established disserta-         rettes by 45 cents, effective
                                                                                                                               Prevention (CDC), the U.S. Depart-
                                                tion research awards to support          December 1999. The companies
                                                                                                                               ment of Education, the Center for
                                                the dissertation research of doc-        have raised the price further
                                                                                                                               Substance Abuse Prevention, and
                                                toral candidates who wish to             since then.
                                                                                                                               the National Cancer Institute. The
                                                pursue tobacco-related research.
                                                                                                                               program has recently created rela-
                                                In this category, research on the      Progress Toward
                                                                                                                               tionships with several new efforts:
                                                application of social/behavioral       Recommendation 9:
                                                sciences and public policy areas       The California Attorney                 • Master Settlement Agreement:
                                                is encouraged.                         General should oppose                     CDC is leading an effort to
                                                                                       any settlement of tobacco                 encourage settling states to
                                                                                       litigation that benefits the              devote a portion of their tobacco
                                              Progress Toward                          tobacco industry.                         settlement payments each year
                                              Recommendation 8:                           Attorney General Dan Lungren           to tobacco control and other
                                              Increase the surtax on                   chose to sign the Master Settlement       public health initiatives. The
                                              tobacco products by at                   Agreement in November, 1998               Department of Health Services,
                                              least $1.00 per pack.                    despite opposition by TEROC and           Tobacco Control Section
                                                 The purchase prices of tobacco        the greater national public health        (DHS,TCS) is assisting states in
                                              products increased substantially as      community. Attorney General Bill          designing effective tobacco con-
                                                                                       Lockyer, who took office on January       trol programs.
                                                Chapter 3 — Progress Toward TEROC's 1997-2000 Recommendations      31

• The California Department of       • DHS,TCS is working with the            regulation of cigarettes as drug
  Education’s TUPE program             CDC to make California’s tobac-        delivery devices. Currently, this
  relies heavily on CDC’s guide-       co surveillance data more              involves enforcement of the fed-
  lines for school-based tobacco       comparable to those of the fed-        eral requirement that tobacco
  use prevention education pro-        eral government and other states.      retailers check the identification
  grams. CDE staff are in close                                               of anyone attempting to purchase
                                     • DHS,TCS is working closely with
  communication with CDC’s                                                    tobacco products who appears to
                                       the American Legacy Foundation
  Office on School Health and                                                 be 26 years of age or less.
                                       that was set up under a provi-
  attend relevant national meet-
                                       sion of the Master Settlement       • The Tobacco-Related Disease
  ings and conferences.
                                       Agreement to administer a             Research Program (TRDRP)
• DHS,TCS has a new grant from         national tobacco research and         interacts with and coordinates
  CDC to provide technical assis-      tobacco use prevention program        communication with the National
  tance to other states working to     targeting youth.                      Cancer Institute, National
  set up their own tobacco control                                           Institute of Drugs and Alcohol,
                                     • DHS (through its Food and Drug
  program. TCS staff attend and                                              and the Network of Tobacco Use
                                       Branch) has a contract with the
  participate in CDC sponsored                                               Research Funders (NOTURF) to
                                       federal government to carry out
  workshops, conference, and tele-                                           increase the utility of tobacco-
                                       enforcement of parts of the U.S.
  conferences.                                                               related research dollars.
                                       Food and Drug Administration’s
“Industry Spokesman.”

Television Ad, 1990/1999

Statewide Media Campaign.
                                                                       Chapter 4 — Lessons Learned in Tobacco Control   33

Lessons Learned in Tobacco Control
    Many lessons have been learned       smoke and restrict tobacco product         to $20.59 by the tobacco indus-
in ten years about what works and        marketing and sales.                       try (Pierce et al., 1998b).
does not work in tobacco control.           Overall lessons from California
The most important lesson of the         show that a tobacco control pro-
California experience is that it is      gram works best when it:
possible to rapidly reduce tobacco
                                         • Engages the public from the
consumption despite the aggressive,
                                           beginning, as with the political
lavishly funded marketing and pro-
                                           campaign for the Proposition 99
motion of tobacco products that
continues in the state even today.
                                         • Increases the cost of tobacco,
Overall Lessons from                       such as the tax increases from
the Program                                Proposition 99 and Proposition
    The increased cost of tobacco          10;
products from the Proposition 99
                                         • Involves the entire public,
tax, and most recently from the
                                           particularly the nonsmoking
additional Proposition 10 tax, has
                                           majority, to reinforce the idea of       Advertisement, California
clearly contributed to the declines
                                           a smoke free society.                    Smokers Helpline
in consumption seen in California
during this period. Analysis of a lon-
                                         Lessons in Health                       • Employs an anti-tobacco
gitudinal sample of data from the
                                         Education                                 media campaign with a
California Tobacco Survey gives fur-
                                             California’s Tobacco Control          broad, general market focus
ther insight into what elements of
                                         Program conducts health education         that directly confronts the
the program have been successful
                                         through community-based and               tobacco industry and its sur-
(Pierce et al., 1994). The predictors
                                         school-based programs. There are a        rogates. The California media
of progress towards cessation are
                                         number of lessons that are specific       campaign and local programs
having a smoke-free workplace,
                                         to each arena.                            stress nonsmoking norms and
believing that secondhand smoke is
                                                                                   educate the public and policy
dangerous (not just annoying), liv-      Community-Based Prevention
                                                                                   makers about the dangers of
ing in a smoke free home, and               An effective community-based
                                                                                   passive smoking. Comparisons of
having available cessation support       tobacco control program:
                                                                                   California’s results to other
such as that offered by the
                                         • Is large enough to compete              states indicate that a general
California Smokers’ Helpline.
                                           effectively with the tobacco            market campaign emphasizing
    Local tobacco control programs
                                           industry, even though it does           the tobacco industry’s deceptive
and the statewide media campaign
                                           not match the industry dollar           practices and the critical impor-
have clearly played a major role in
                                           for dollar. In the early years of       tance of smoke-free indoor
this progress by helping shape the
                                           the California program (1989-           environments is more effective
discussion over tobacco issues with
                                           93), expenditures were                  than a youth-centered campaign
strong anti-industry messages, by
                                           approximately $3.35 per capita,         that concentrates on preventing
emphasizing the adverse health
                                           compared to $17.50 by the               kids from buying cigarettes
effects of secondhand smoke and
                                           tobacco industry. In the later          (Department of Health Services,
the addictiveness of tobacco, and by
                                           years (1993-96), California only        1998). This conclusion stands in
advocating for policies that protect
                                           spent $2.08 per capita compared         stark contrast to the prevailing
Californians from secondhand
                                                 national rhetoric, which sug-      • Promotes smoke-free envi-                the media campaign and other
                                                 gests that all public health can     ronments, and strengthens                statewide activities with the
                                                 hope to do is prevent kids from      the nonsmoking norm and                  community-based programs that
                                                 starting to smoke and waiting a      rights of nonsmokers.                    are key to program success.
                                                 generation for the problem of        Promoting smoke-free environ-
                                                                                                                            • Emphasizes reducing youth
                                                 tobacco use to resolve. There is     ments is a powerful intervention
                                                                                                                              demand for tobacco in addi-
                                                 no reason to wait this long.         to reduce tobacco consumption
                                                                                                                              tion to reducing youth access
                                                 Teens are best spoken to as          and increase smoking cessation.
                                                                                                                              to tobacco. The success in
                                                 adults and addressed as an ele-      Public appreciation of the dan-
Strategies for the 21st Century – 2000-2003

                                                                                                                              reducing the frequency with
                                                 ment of a larger campaign.           gers of secondhand smoke can
                                                                                                                              which stores sell to minors has
                                                                                      lead to the voluntary adoption of
                                              • Emphasizes the negative                                                       not resulted in reductions in
                                                                                      a smoke-free home policy even
                                                aspects of tobacco use for                                                    either the ease with which ado-
                                                                                      in homes occupied by smokers.
                                                everyone—adults and youth.                                                    lescents can obtain cigarettes or
                                                                                      In California, the resulting explo-
                                                In the media campaign, youth                                                  in adolescent smoking preva-
                                                                                      sion in local clean indoor air
                                                are most influenced by mes-                                                   lence. Promising approaches for
                                                                                      ordinances, followed by the state
                                                sages directed at the general                                                 reducing adolescents’ demand
                                                                                      smoke-free workplace law, pro-
                                                population, rather than by ads                                                for tobacco include involving
                                                                                      tected nonsmokers from
                                                speaking directly to them. The                                                youth in policy advocacy and
                                                                                      secondhand smoke and created
                                                tobacco industry uses the                                                     linking school- and community-
                                                                                      an environment that made it eas-
                                                “You’re too young to smoke”                                                   based programs. Clearly, the
                                                                                      ier for people to stop smoking.
                                                message to make youth see                                                     program must also continue to
                                                smoking as a way to “enter the      • Responds quickly to changing            address the factors in the social
                                                adult world.” The program             industry strategies with new            environment that are creating
                                                should counter this approach by       media messages. The period of           and reinforcing youth demand
Toward a Tobacco-Free California:

                                                emphasizing the negative              greatest decline in tobacco use         for tobacco products, including
                                                aspects of tobacco use for            was associated with the ability of      product price, sales practices,
                                                everyone—adults and youth—            the program to develop and              advertising and promotional
                                                and by offering youth entry to a      place ads quickly, and to adjust        activities, and the modeling of
                                                smoke free adult world.               counter-messages and respond            tobacco-use behavior on televi-
                                                                                      rapidly to changing strategies of       sion and in movies.
                                              • Coordinates the media cam-
                                                                                      the tobacco industry. When the
                                                paign closely with                                                          • Uses youth organizations and
                                                                                      process became bogged down
                                                community-based activities                                                    schools for youth-specific
                                                                                      with many levels of approvals,
                                                that support statewide mes-                                                   programs that utilize
                                                                                      months to years passed between
                                                sages locally. While the media                                                research-based strategies.
                                                                                      new ads. The media lost its flexi-
                                                campaign is the most visible                                                  These are particularly appropri-
                                                                                      bility to counter the tobacco
                                                component of the California                                                   ate venues for youth-specific
                                                                                      industry and support the needs
                                                Tobacco Control Program, the                                                  programs that utilize effective
                                                                                      of the local programs. When the
                                                community-based programs are                                                  research-based education strate-
                                                                                      approval process for the media
                                                equally important. The media                                                  gies for engaging youth in
                                                                                      campaign and other program
                                                campaign helps educate the                                                    anti-tobacco advocacy and lead-
                                                                                      activities is streamlined (in
                                                public and create an environ-                                                 ership activities.
                                                                                      terms of numbers of people who
                                                ment supportive of tobacco
                                                                                      are involved and length of time       School-Based Prevention
                                                control, but the local communi-
                                                                                      for approval), the program is            Effective school-based tobacco
                                                ty programs make the
                                                                                      able to respond to the tobacco        control programs—which in
                                                permanent social change that is
                                                                                      industry quickly and effectively.     California are called Tobacco Use
                                                moving tobacco use out of
                                                                                      A streamlined approval process        Prevention Education programs:
                                                                                      also allows good integration of
                                                                       Chapter 4 — Lessons Learned in Tobacco Control    35

• Seek broad community                      of the competitive grants model      • Support a comprehensive and
  involvement and are integrat-             improves program effectiveness         balanced research portfolio
  ed with other                             in grades 6 through 8.                 which divides the available
  community-based tobacco                                                          resources equally between
                                         • Participate in training and
  control programs. Messages in                                                    social/behavioral and policy
                                           the infrastructure network
  the school programs should                                                       research on the one hand and
                                           developed for community-
  stress the same themes that                                                      biomedical and nicotine depen-
                                           based activities. Personnel
  work in the community and                                                        dence research on the other.
                                           from school-based tobacco
  media components of the pro-
                                           control programs should be            • Be prepared to carry out an
  gram so that school and
                                           knowledgeable about and                 extensive outreach effort to
  community activities reinforce
                                           included in public health               increase the quantity and quality
  each other. These themes
                                           training and the infrastructure         of proposals in the social, behav-
  include the social denormaliza-
                                           network that support com-               ioral, and policy areas, especially
  tion of tobacco use and the
                                           munity-based activities.                with respect to studying tobacco
  serious health risks of exposure
                                           Alternatively, staff from local         use. Such outreach expands and
  to secondhand smoke.
                                           community-based programs                supports the research infrastruc-
• Concentrate activities in                should be knowledgeable about           ture in social/behavioral and
  middle/junior high and high              and attend county and/or school         policy sciences and encourages
  schools, rather than elemen-             district tobacco use prevention         investigators in these fields to
  tary schools. Very young                 education training.                     submit proposals.
  children are generally anti-
                                         • Adopt strategies that                 • Fund the best in relevant
  tobacco and there is little room
                                           research shows to be effec-             biomedical research that helps
  for a program effect. While theo-
                                           tive. There is research evidence        elucidate the mechanisms of
  retically desirable to start anti-
                                           that information-only instruction-      tobacco’s detrimental health
  tobacco education early, there
                                           al approaches to tobacco use            effects, and improves early diag-
  is no evidence that this effect
                                           prevention are ineffective.             nosis and effective treatments
  carries over into adolescence,
                                           Programs that utilize social influ-     for tobacco-related diseases.
  when tobacco becomes an issue.
                                           ence approaches and couple
  Scarce resources are better                                                    • Work closely with the agen-
                                           information with the develop-
  spent on older children.                                                         cies administering the health
                                           ment of personal and social skills
                                                                                   education components of the
• Utilize a competitive grants             show remarkable results in
                                                                                   tobacco control program to
  model in addition to funding             deterring tobacco use by youth.
                                                                                   ensure that information is dis-
  allocations based on entitle-
                                                                                   seminated and to stay apprised
  ment formulas. Funding                 Lessons in Tobacco-
                                                                                   of emerging research issues that
  allocations based on enrollment        Related Disease Research
                                                                                   should be addressed. Research
  (or other entitlement formulas)           Many lessons about tobacco
                                                                                   that investigates newly emerging
  do not necessarily lead to effective   research have been learned by the
                                                                                   areas, such as cessation pro-
  tobacco control programs unless        University of California’s Tobacco-
                                                                                   grams for youth, tobacco control
  effective accountability procedures    Related Disease Research program.
                                                                                   in health care settings, cultural
  are utilized. TEROC also believes      A tobacco research program should:
                                                                                   determinants of tobacco use,
  that the increased accountability
                                                                                   and targeted interventions in
                                                                                   diverse communities should be
“I Miss My Lung, Bob.”

Billboard, 1998

Statewide Media Campaign.
                                         Chapter 5 — Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003       37

Strategies for the 21st Century:
TEROC’s Recommendations
for 2000-2003
    TEROC recommends that the               secondhand smoke, and thereby to           • funding enforcement of tobacco
California Tobacco Control Program          further reduce the incidence of lung         control laws that cannot be fund-
build on its numerous significant           cancer, heart disease, emphysema,            ed with Proposition 99 money;
strengths, and adopt the aggressive         and other tobacco-related deadly dis-
                                                                                       • increasing program capacity to
tone and rapid response that have           eases. In doing so, it will increase the
                                                                                         reach high-risk diverse popula-
characterized its most notable suc-         substantial benefits already gained in
                                                                                         tions of California.
cesses. Most important, TEROC               reducing suffering, loss of life, and
strongly recommends that approxi-           economic costs caused by tobacco.            The Master Settlement Agree-
mately 20% of the resources from            Increased funding will strengthen          ment, while providing approximately
the tobacco settlement payments to          tobacco control efforts by:
the state be allocated on an annual
                                            • increasing the capacity to assist
basis to increase the program’s abili-
                                              smokers of all ages in quitting;
ty to counter the tobacco industry’s
continued aggressive marketing of           • increasing the reach and fre-
tobacco in California, and to help            quency of the media campaign
those who use tobacco products                which is needed to effectively
break the chains of their addiction.          counter the massive marketing
                                              and public relations activities of
Recommendation 1:                             the tobacco industry, and to
Increase funding for the                      prompt increased quit attempts
California Tobacco Control                    by smokers;                              Health Through Art: Signs of Recovery, Alameda
Program so that it can                                                                 County Health Department, Oakland, CA.
                                            • increasing activities directed
build on past successes
                                              toward enactment of local tobac-
and take advantage of                                                                  $1 billion a year for state and local
                                              co control policies, especially
new opportunities to                                                                   California governments, only reim-
                                              policies establishing smoke-free
reduce tobacco                                                                         burses taxpayers about 30 cents on
                                              public areas and policies restrict-
consumption rapidly.                                                                   the dollar for the cost to taxpayers
                                              ing point of sale advertising;
    TEROC recommends that the                                                          for treating tobacco-related illness-
annual funding for the California           • increasing the capacity of the           es. Failure to reduce tobacco use
Tobacco Control Program from                  Department of Health Services            will condemn California taxpayers to
Proposition 99 be augmented by                to coordinate with local projects        more than a $2 billion annual sub-
$105 million from the tobacco settle-         and schools;                             sidy of the tobacco industry through
ment payments to the State of                                                          Medi-Cal and other government pay-
                                            • increasing program presence in
California. There are several critical                                                 ments. Every dollar spent on the
                                              middle and high schools where
reasons for this request. In general,                                                  California Tobacco Control Program
                                              adolescents are most vulnerable
this increase in funding will expand                                                   saves $3 in medical costs and anoth-
                                              to emulating what they perceive
the overall capability of California’s                                                 er $5 in smoking-attributable
                                              as adult behaviors and to finding
tobacco control efforts to further                                                     indirect costs (Department of
                                              ways to rebel;
reduce tobacco use and exposure to                                                     Health Services, 1999).
                                                  Most important, the California       control programs (Centers for                grams recommended by TEROC
                                              Tobacco Control Program has saved        Disease Control, 1999). TEROC                (using the 1999-2000 budget
                                              lives and improved the health of         considered these recommendations             amount of $126,800,000 as the pre-
                                              Californians, and will continue to       in writing this Master Plan. In gener-       augmentation base) is $231,793,000,
                                              do so.                                   al, TEROC’s recommended                      which is slightly above CDC’s mini-
                                                  The U.S. Centers for Disease         budgetary amounts are slightly               mum recommendation of
                                              Control and Prevention has published     above the minimum levels recom-              $211,403,000. This is well below the
                                              “best practice” recommendations for      mended by the CDC.                           CDC’s maximum recommended
                                              program components and funding               The total budget for tobacco             budget level of $545,492,000 for a
Strategies for the 21st Century – 2000-2003

                                              levels for effective state tobacco       control and tobacco research pro-            state with California’s population.

                                                    Recommended Budget for the California Tobacco Control Program, Based on CDC’s Best Practices
                                                                                           (in thousands)

                                                                                                                         CDC            CDC
                                                                             99-00      00-01          00-01        Best Practices Best Practices
                                                                            Current   Additional   New Proposed    Recommendation Recommendation
                                               Budget                       Budget    Funds (GF)    Budget Total         Low            High        Comments

                                               UC Research                  36,726      7,500         44,226            N/a             N/a         20% increase to cover infla-
                                                                                                                                                    tion since Prop 99 passed
                                                                                                                                                    (allowing for drop in tobacco

                                               California Department        27,044      6,000         33,044           25,663          38,494       20% increase to cover inflation
                                               Of Education (CDE)                                                                                   since Prop 99 passed
38                                             Local Assistance                                                                                     (allowing for drop in tobacco
                                                                                                                                                    consumption) plus for adding
Toward a Tobacco-Free California:

                                                                                                                                                    grades 6-8 to high school
                                                                                                                                                    competitive grant program.

                                               TCS staff support            3,224      2,000          5,224                                         Staff for CDE and TCS to
                                               CDE staff support              967        500          1,467                                         administer increase in pro-
                                                                            4,191      2,500          6,691            7,179           19,235       gram funding and for CDE to
                                                                                                                                                    administer competitive grants.

                                               TCS Local Programs—          35,116     62,000         97,116          117,899         346,204       To cover LLA enforcement of
                                               includes LLAs, competitive                                                                           existing local ordinances and
                                               grants, enforcement,                                                                                 AB 13, increase for Helpline
                                               statewide, and cessation.                                                                            cessation services, TCS
                                                                                                                                                    technical assistance/-
                                                                                                                                                    statewide services, etc.

                                               TCS media                    17,816     22,000         39,816           32,269          96,805       TCS statewide media to
                                                                                                                                                    increase reach into rural and
                                                                                                                                                    ethnic communities, and to
                                                                                                                                                    increase youth advocacy for
                                                                                                                                                    reducing demand.

                                               TCS evaluation                3,905      5,000         8,900            14,357          38,470       Independent evaluation of
                                                                                                                                                    schools, local programs,
                                                                                                                                                    media. Increase evaluation
                                                                                                                                                    efforts to obtain county and
                                                                                                                                                    ethnic specific data.

                                               Food and Drug STAKE           2,000        0           2,000            14,036          26,284
                                               Act compliance

                                               Total UC                     36,726      7,500         44,226            N/a             N/a

                                               Total TCS/CDE                90,072     97,500        187,567          211,403         565,492

                                               Total Overall                126,798    105,000       231,793          211,403         565,492
                                        Chapter 5 — Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003     39

Recommendation 2:                          interventions will “spill down” to        ensure that new techniques to pro-
Expand the Tobacco                         younger ages (i.e., 12-17), since         mote tobacco to youth are not
Control Program and                        teens view young adults as role mod-      employed.
strengthen its fundamen-                   els. Moreover, the tobacco industry           In addition, the industry contin-
tal structure, focus, and                  presents smoking as a way for teens       ues to promote tobacco in ways not
key messages.                              to “grow up,” and TEROC believes          prohibited by the settlement. For
    The California Tobacco Control         that this type of youth-focused cam-      example, tobacco industry cam-
Program follows a research-based           paign will therefore be more effective    paigns of “accommodation” of
comprehensive approach that utilizes       than a teen-focused campaign which        smokers continue, and bars are
multiple channels of intervention—         could be inadvertently reinforcing        increasingly used as venues for
the media; community-based                 the industry’s message.                   advertising and promotions such as
organizations; schools; universities;          All statewide and local activities    distribution of free cigarettes.
public health departments at the           should continue to communicate            TEROC recommends that these and
state, regional and local levels; and      and reinforce the media campaign’s        other new industry tactics be
numerous other state departments,          key messages:                             exposed and countered through the
agencies, organizations and commis-                                                  statewide media campaign, enforce-
                                           • The tobacco industry lies.
sions. The program operates at                                                       ment of smoke-free bars, and other
statewide, regional, and local levels      • Nicotine is addictive.                  appropriate local efforts.
to reach the general population of
                                           • Secondhand smoke kills.                 b. Continue to press for smoke-
California. The increased budget
                                                                                        free workplaces, public
TEROC is recommending will greatly             TEROC also recommends that
                                                                                        places, events, schools, and
increase the program’s ability to          the program continue to implement
expand and strengthen its successful       strategies to counter tobacco indus-
structure, focus, and messages, and        try tactics, promote smoke-free               Secondhand smoke is the third
to effectively coordinate its numer-       environments, and support tobacco         leading cause of preventable death
ous aspects.                               use cessation. In addition, TEROC         in the nation (Parmley and Glantz,
    The program is based on the            recommends that the program shift         1991). TEROC recommends that
belief that the primary prevention of      the emphasis of its focus on reduc-       California continue its campaign for
smoking initiation is best accom-          ing youth access to reducing youth        smoke-free workplaces and homes
plished by incorporating youth as          demand for tobacco. The recom-            by increasing public education
part of a larger movement to a             mendations on program focus are           about the effects of secondhand
smoke-free society for everyone.           described below.                          smoke, and enforcing policies relat-
TEROC recommends that the pro-                                                       ed to secondhand smoke. There are
                                           a. Continue to anticipate, vigor-
gram’s activities and messages                                                       several actions to be taken.
                                              ously expose, and counter
continue to be crafted to reach a                                                        Parents should be educated in
                                              tobacco industry tactics.
broad general audience of all ages                                                   culturally and linguistically appropri-
and to account for linguistic and              The Master Settlement Agreement       ate ways about the effects of
cultural factors.                          signed by the California attorney         secondhand smoke on their children
    Within this broad focus, specific      general and the tobacco industry on       and other family members, and
program components should also             November 23, 1998 mandates                encouraged to make their homes and
address groups whose current               changes in the behavior of the            cars smoke free. This will not only
smoking prevalence is dispropor-           tobacco industry in the state, and        protect nonsmoking adults, children,
tionately high. For example, in 1998       specifically prohibits the tobacco        and youth from secondhand smoke,
smoking prevalence in young adults         industry from using advertising and       but also help smokers to stop.
(ages 18-24) was 22%, higher than          promotion strategies that target              Efforts to fully implement and
for any other adult age group and          youth. TEROC recommends that              enforce state and local smoke-free
higher than in 1997. New media ads         tobacco control advocates closely         workplace laws should be continued
and other programmatic efforts             monitor industry activities in order      and extended. This should include
should be designed for this group of       to expose lack of adherence to the        attention to voluntary policies among
young adults. The effect of these          provisions of the Agreement, and to       Indian nations for environments that
                                              are free of commercial tobacco. The       campaign, coupled with the                     Efforts to reduce youth access to
                                              Attorney General’s Office should          California Smokers’ Helpline and           tobacco succeeded in lowering the
                                              continue to encourage local district      supported at the community level,          rate of illegal sales in California to
                                              attorneys to prosecute violations of      is a cost-effective process for help-      13% in 1998. Large randomized trials
                                              the California Smoke-free Workplace       ing large numbers of people stop           (Rigotti et al., 1997) that successfully
                                              Act (Labor Code 6404.5).                  smoking. TEROC recommends sev-             reduced buy rates by teens, howev-
                                                  Local efforts should also be          eral steps.                                er, failed to demonstrate a decrease
                                              directed at increasing the number of          First, the media campaign should       in youth smoking. One reason
                                              smoke-free zones and venues at            place additional emphasis on mes-          seems to be that a relatively large
Strategies for the 21st Century – 2000-2003

                                              outdoor locations, for example,           sages that promote cessation and           proportion of teens who smoke do
                                              amusement parks, fair grounds,            the California Smokers’ Helpline.          not purchase the cigarettes they
                                              concerts, sporting events, etc.           However, when cessation ads are            smoke. Fifty-eight percent of teens
                                              Efforts should be made to increase        aired, the Helpline is inundated with      who had ever smoked say they get
                                              the number of smoke-free apart-           calls. Current funding limitations for     their cigarettes from others such as
                                              ments, townhouses, and condos that        the Helpline prevent promoting it as       friends and family members (Pierce
                                              provide smoke-free units, prevent         heavily as would be optimal to maxi-       et al., 1998a). In addition, the strong
                                              seepage between housing with              mize the number of people who stop         emphasis on reducing youth access
                                              shared walls, and do not share ven-       smoking every year. In addition, a         is leading to counterproductive
                                              tilation systems.                         new Proposition 10 media campaign          strategies such as criminalizing chil-
                                                  Finally, specific efforts should be   plans to refer viewers to the              dren, and has shifted the focus to
                                              directed at teens in both DHS and         Helpline, which will greatly increase      children rather than the tobacco
                                              CDE programs to reduce their              the number of calls. The Helpline          industry.
40                                            acceptance of secondhand smoke.           capacity needs to be expanded to               The most effective use of
                                              These should include involving            serve the full demand that can be          resources to decrease smoking is to
Toward a Tobacco-Free California:

                                              youth in advocacy activities around       generated by the media campaign.           reduce demand. TEROC therefore
                                              secondhand smoke, and assisting               As a necessary step in the cessa-      recommends that strategies to
                                              their efforts to alert other youth of     tion process, local projects (local        reduce youth demand for tobacco
                                              the adverse health effects of expo-       lead agencies, ethnic networks, and        be increased, and that these strate-
                                              sure and their right to smoke-free        competitive grantees) provide              gies include active engagement of
                                              air. Tobacco-free policies in school      direct services to special popula-         youth in anti-tobacco use advocacy
                                              buildings, grounds, and vehicles          tions and coordinate with other            activities.
                                              should be vigorously enforced.            local cessation activities (e.g., hospi-       Program efforts to reduce youth
                                                                                        tal-based cessation services,              access to tobacco should focus on
                                              c. Increase population-based
                                                                                        school-based pre-cessation and ces-        maintaining compliance with federal
                                                 smoking cessation activities
                                                                                        sation programs like Smokeless             and state law. TEROC recommends
                                                 through the media campaign,
                                                                                        Saturdays). Funding for local tech-        that the Administration sign an
                                                 the California Smokers’
                                                                                        nical assistance should be increased       Expanded Exchange Agreement
                                                 Helpline, and coordination at
                                                                                        to meet the anticipated increased          allowing the State Board of
                                                 the local community level.
                                                                                        need generated by the media cam-           Equalization to share tobacco tax
                                                  Smoking cessation is the desired      paign and the Helpline.                    receipt information with the
                                              outcome of all initiatives and activi-                                               Department of Health Services
                                                                                        d. Implement strategies
                                              ties of California’s Tobacco Control                                                 (DHS). This agreement would allow
                                                                                           (including youth anti-tobacco
                                              Program that create new social                                                       DHS to enumerate fully the uni-
                                                                                           advocacy to promote smoke-
                                              norms around the use of tobacco.                                                     verse of tobacco retailers in order to
                                                                                           free environments) to reduce
                                              The California Tobacco Survey                                                        avoid non-response bias in retailer
                                                                                           youth demand for tobacco,
                                              (Pierce et al., 1998a) indicates that                                                compliance estimates, and will
                                                                                           rather than focusing primari-
                                              a large number of smokers are                                                        increase the effectiveness of the
                                                                                           ly on youth access.
                                              poised to quit. Past experience has                                                  STAKE Act implementation.
                                              demonstrated that the media
                                      Chapter 5 — Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003       41

Recommendation 3:                        education be emphasized in the             that CDE make every effort to
Continue to strengthen                   middle/junior high years. In addition,     involve schools in the competitive
and increase account-                    Proposition 99 funds are decreasing.       process, and that districts be
ability of school-based                  In order to maximize the impact and        allowed to use a portion of their
tobacco use prevention                   increase the accountability of the         grades 6-8 entitlement funds to sup-
education programs, con-                 TUPE program, TEROC recommends             port grant-writing for competitive
sistent with principles of               that legislation be enacted to focus its   funds, if this activity does not erode
effectiveness.                           entitlement component on grades 6-8        tobacco prevention activities. In
   The California Department of          for a “basic” program, and to increase     order to administer this program
Education (CDE) administers              its competitive grants program to          effectively, CDE staffing at the state
Proposition 99 funds for Tobacco         include grades 6-12. Two-thirds of         level needs to be increased to both
Use Prevention Education (TUPE).         TUPE funds should be used for mid-         administer and provide technical
Currently, as mandated by law,           dle and high school competitive            assistance to the competitive
grades 4 through 8 receive TUPE          grants, and one-third to entitlement       grantees.
funding as an entitlement (based on      grants for grades 6-8. With such a             To improve the effectiveness of
enrollment) while grades 9-12            system, baseline programs in grades        TUPE, TEROC recommends that
receive funds through a competitive      6-8 could be supplemented with com-        CDE continue to support schools to
grant process.                           petitive grant funds in the crucial        strengthen their programs consistent
   Tobacco becomes a serious issue       middle-school years. Implementing          with the U.S. Department of Educa-
when young people reach adoles-          this recommendation will require           tion’s national Principles of Effective-
cence, and the Centers for Disease       changes to the implementing legis-         ness, which require schools to:
Control and Prevention (CDC) rec-        lation for Proposition 99.
                                                                                    • Base programs on a thorough
ommends that tobacco prevention              TEROC further recommends
                                                                                      assessment of objective data
                                                                                      about the drug, alcohol, tobacco,
                                                                                      and violence problems in the
                                                                                      schools and communities served.
                                                                                    • With the assistance of a local or
                                                                                      regional advisory council, estab-
                                                                                      lish a set of measurable goals
                                                                                      and objectives, and design pro-
                                                                                      grams to meet those goals and
                                                                                    • Design and implement programs
                                                                                      for youth based on research or
                                                                                      evaluation that provides evidence
                                                                                      that the strategies used prevent
                                                                                      or reduce drug use (including
                                                                                      tobacco), violence, or disruptive
                                                                                      behavior among youth.
                                                                                    • Evaluate programs periodically
                                                                                      to assess progress toward
                                                                                      achieving goals and objectives,
                                                                                      and use the evaluation results to
                                                                                      refine, improve, and strengthen
                                                                                      the program, and to refine goals
The Cambodian Association of America’s Kmers Against Tobacco Project con-             and objectives as appropriate.
ducted tobacco education with monks, ajars, and worshipers at Wat
Vipasnaram, Long Beach, CA.
                                              Recommendation 4:                           from recruiting students in school    specific contributions to
                                              Increase the collaboration                  for after-school community advo-      tobacco control.
                                              and communication                           cacy projects, to a project that is       Collaboration should be contin-
                                              among and between                           fully planned and implemented         ued and expanded between TCS,
                                              school-based and public                     by teachers, students, and com-       CDE, and TRDRP to conduct
                                              health-based tobacco con-                   munity-based program staff.           research such as the Community-
                                              trol programs.                           • Conduct cross-program meet-
                                                                                                                                Academic Research Awards (CARA)
                                                  Among the strengths of the                                                    and the School-Academic Research
                                                                                         ings and trainings. TUPE
                                              California Tobacco Control Program                                                Awards (SARA). TRDRP research
Strategies for the 21st Century – 2000-2003

                                                                                         Coordinators from county offices
                                              are the activities at the community                                               should continue to be linked to
                                                                                         of education should participate
                                              level. Public health activities are                                               Tobacco Control Program activities.
                                                                                         in statewide and regional tobac-
                                              planned and implemented by local                                                      There is a need for more research
                                                                                         co control meetings and
                                              lead agencies, regional linkage pro-                                              in the area of social, behavioral, and
                                                                                         summits, which in the past have
                                              jects, ethnic networks, and other                                                 policy change. More of this research
                                                                                         been largely limited to people
                                              community organizations funded by                                                 should address questions about the
                                                                                         associated with the DHS compo-
                                              the Department of Health Services                                                 mechanisms of control and influ-
                                                                                         nent of the California Tobacco
                                              (DHS), while school-based programs                                                ence used by the tobacco industry
                                                                                         Control Program. Representatives
                                              receive funding to districts and                                                  to maintain tobacco-friendly poli-
                                                                                         from the local lead agencies
                                              counties from the California                                                      cies, to influence public opinion, to
                                                                                         should also participate in
                                              Department of Education (CDE).                                                    promote tobacco use by young
                                                                                         statewide and regional tobacco
                                                  While a great deal has been                                                   adults, and to make tobacco retail-
                                                                                         use prevention education work-
                                              accomplished by the statewide pro-                                                ers advertise, promote, and display
                                                                                         shops sponsored by the CDE.
42                                            gram, TEROC believes that it would                                                their products. The research should
                                              be substantially strengthened by         • Facilitate communication               provide timely information that local
Toward a Tobacco-Free California:

                                              increased rapid communication and          within each funding network.           programs can use in their efforts to
                                              collaboration between and among            DHS should increase ways to            reduce the use of tobacco products.
                                              all program entities: DHS, CDE,            facilitate communication
                                              local lead agencies (LLAs), county         between the state and local pro-       Recommendation 6:
                                              offices of education, and other local      grams, and among its contractors       The Administration should
                                              tobacco control programs (including        and grantees. DHS should con-          implement policies and
                                              school-based programs). An increased       tinue to ensure that they are          procedures to assure
                                              budget can greatly improve the pro-        aware of other DHS-funded              rapid development and
                                              gram’s ability to expand collaboration     tobacco activities in their locale.    approval of the media
                                              and communication.
                                                                                          CDE should also increase ways
                                                                                                                                campaign to permit the
                                                  Among the ways to increase com-
                                                                                          to facilitate communication
                                                                                                                                campaign to respond
                                              munication and collaboration are:
                                                                                          between the state and TUPE-
                                                                                                                                quickly to the changing
                                                                                          funded programs, among
                                              • Involve youth in anti-tobacco
                                                                                                                                    In the early years of the pro-
                                                advocacy projects. Research               TUPE-funded programs, and
                                                                                                                                gram, approval of the media
                                                shows that projects that involve          between county offices of educa-
                                                                                                                                campaign was the responsibility of
                                                youth in advocating for anti-             tion and local school district
                                                                                                                                the Department of Health Services
                                                tobacco policies are highly               TUPE coordinators.
                                                                                                                                (DHS) and subject to the same DHS
                                                promising in reducing youth
                                                                                                                                approval procedures and TEROC
                                                prevalence (Edwards et al.,            Recommendation 5:
                                                                                                                                oversight as other aspects of the
                                                1992). Florida’s tobacco control       The University of
                                                                                                                                program. This approval process
                                                program, for example, has used         California’s Tobacco-
                                                                                                                                allowed the campaign to be highly
                                                this approach effectively. Youth       Related Disease Research
                                                                                                                                responsive to the changing world of
                                                advocacy projects are ideal            Program should continue
                                                                                                                                tobacco and to create ads that were
                                                arenas for collaboration between       to encourage and fund
                                                                                                                                both timely and aggressive. It also
                                                schools and public health organi-      research that makes
                                                                                                                                allowed input from local lead
                                                zations. Collaboration can range
                                          Chapter 5 — Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003   43

agencies and community-based
tobacco control projects regarding
the potential effectiveness of ads
with their constituents.
     TEROC appreciates the policy
decision of the current Administration
to allow the presentation of all pro-
posed media campaign projects to
TEROC, as this review is essential
to the exercise of TEROC’s over-
sight function. Nevertheless, the
media approval process remains
slow and cumbersome. As a result,
it is difficult to coordinate the media
campaign with other aspects of the
program and respond to changes in
the tobacco industry’s strategy.
     TEROC recommends that the
Administration implement policies
and procedures to assure rapid
development and approval of the
media campaign, and that TEROC
and local tobacco control programs           “How Many?” Television Ad, 1997 Statewide Media Campaign.
continue to be involved in the devel-
opment of the campaign. Based on             dence treatment or referral ser-          850,000 people who work in the
past experience, TEROC hopes that            vices. TEROC recommends that the          hospitality industry in California.
the total approval process would             State adopt policies to enhance           Moreover, bars are important
take no longer than 30 days. While           nicotine-dependence treatment             venues for current tobacco promo-
the specific policies to achieve this        activities for Medi-Cal beneficiaries     tion, and the tobacco industry has
rapid turnaround are open, TEROC             and health insurance programs for         worked to reduce compliance with
notes that the policy of delegating          state employees. The State should         this law. State and local media cam-
this responsibility to DHS would be          also encourage private insurers to        paigns should create an environment
the simplest and one of proven               provide coverage for nicotine-            that supports and motivates local
effectiveness.                               dependence treatment services as          enforcement efforts.
                                             part of their standard benefit plan.          Discussions with local health
Recommendation 7:                                                                      departments and other local
Medically-mediated                           Recommendation 8:                         enforcement officials suggest that
nicotine-dependence                          The Department of                         involvement of the Department of
treatment should be a                        Alcoholic Beverage                        Alcoholic Beverage Control (ABC)
benefit of the health                        Control should incorpo-                   in smoke-free bar compliance
care delivery system.                        rate compliance with the                  efforts would be beneficial.
    In addition to the efforts of the        California Smoke-free                         TEROC therefore recommends
Tobacco Control Program to promote           Workplace Act in deci-                    that the ABC include compliance
population-based smoking cessa-              sions regarding bar                       with the California Smoke-free
tion, State policies should encourage        license approvals, suspen-                Workplace Act as a criterion for
the inclusion of medically-mediated          sions, and renewals.                      approval, renewal, or suspension of
nicotine-dependence treatment                    Enforcement of smoke-free bar         on-site liquor licenses. Implementing
(NDT) as part of the health care             provisions of the California Smoke-       this recommendation will probably
delivery process. Medi-Cal managed           free Workplace Act should be a            require action by the Governor to
care plan providers are currently            priority. Secondhand tobacco smoke        instruct the ABC to do this.
required to provide nicotine-depen-          is a serious health risk for the
                                              Recommendation 9:                      to increase smoking cessation and          the American Legacy Foundation,
                                              The California Children and            education of the consequences of           and others.
                                              Families State Commission              secondhand smoke to young chil-
                                              should encourage local                 dren are particularly vital for            Recommendation 11:
                                              commissions to include                 families as part of this initiative, and   Settle the outstanding
                                              objectives for tobacco                 recommends that the State                  litigation left over from
                                              control in their strategic             Commission strongly encourage              the previous Administration
                                              plans.                                 local commissions to include tobac-        to increase funding for
                                                  The California Children and        co-related objectives in their             tobacco control efforts.
Strategies for the 21st Century – 2000-2003

                                              Families State Commission is           implementation guidelines.                      There is $32.531 million in
                                              charged with implementing                                                         restricted reserve funds from the
                                              Proposition 10, the Children and       Recommendation 10:                         Americans for Nonsmokers’ Rights
                                              Families Act that is funded by a 50    Continue to coordinate                     (ANR II) lawsuit. Corollary to
                                              cent tax on cigarettes and a com-      Proposition 99-financed                    increasing funding allocations for
                                              mensurate tax on other tobacco         programs with State,                       the program, TEROC recommends
                                              products. This is an early childhood   Federal, and other tobac-                  that the Governor release the ANR
                                              development program, but since it      co control initiatives.                    II restricted reserve funds, and set-
                                              is funded by a tobacco tax, it is          The Proposition 99 tobacco con-        tle the Just Say No to Tobacco
                                              appropriate to include tobacco con-    trol programs are most effective           Dough (SAYNO) suit.
                                              trol elements in its guidelines and    when they link into the energy,                 The plaintiffs in the ANR II law-
                                              programming.                           research, and activities of organiza-      suit (Americans for Nonsmokers’
                                                  The State Commission’s guide-      tions and initiatives with similar         Rights, the American Lung
44                                            lines for implementation of the        goals. The programs have estab-            Association, American Cancer
                                              California Children and Families Act   lished relationships with the              Society, and American Heart
Toward a Tobacco-Free California:

                                              by the county commissions include      voluntary health organizations, the        Association) have all stated in writ-
                                              the following objectives related to    Centers for Disease Control and            ing that they will drop their suit if
                                              tobacco use:                           Prevention, the U.S. Department of         the funds are appropriated as speci-
                                                                                     Education, the Center for Substance        fied in Proposition 99. Thus, there
                                              • Reduce cigarette smoking among
                                                                                     Abuse Prevention, the National             would be no continuing litigation in
                                                pregnant women.
                                                                                     Institutes of Health, the Robert Wood      this case.
                                              • Increase smoking cessation dur-      Johnson Foundation’s Smokeless                  The SAYNO lawsuit, which the
                                                ing pregnancy.                       States Program, including California’s     State won at trial, is under appeal.
                                                                                     Next Generation Alliance, and the          This case seeks reimbursement of
                                              • Increase smoking cessation by
                                                                                     Campaign for Tobacco Free Kids.            the Health Education Account for
                                                new mothers.
                                                                                     TEROC recommends that the pro-             funds alleged to have been illegally
                                              • Increase providers advising          gram continue to actively coordinate       spent on medical services. The ANR
                                                smoking cessation for pregnant       with these initiatives, and to forge       II Restricted Reserve is in the
                                                women and new mothers.               ties with entities such as the new         Health Education Account, and can-
                                                                                     Proposition 10 California Children         not be used to reimburse the Health
                                              • Increase the proportion of pedia-
                                                                                     and Families Commissions (State            Education Account. Thus, regard-
                                                tricians and family physicians
                                                                                     and local), the California Attorney        less of the outcome of the SAYNO
                                                that inquire about second hand
                                                                                     General, the National Association of       litigation, these funds will not be
                                                smoke exposure in the home.
                                                                                     Attorneys General in reference to          involved.
                                                 TEROC believes that objectives      the Master Settlement Agreement,
                                      Chapter 5 — Strategies for the 21st Century: TEROC’s Recommendations for 2000-2003   45

“Zeppo Kicks the Habit.” California Smokers’ Helpline.
“How Many?”

Television Ad, 1997

Statewide Media Campaign.
                                                                                                         References    47

Centers for Disease Control (1997).   Edwards, C.C., Elder, J.P., de Moor,    Parmley, W. and Glantz, S.A. Passive
Morbidity and Mortality Weekly        C., Wildey, M.B., Mayer, J.A., and      smoking and heart disease: Epidem-
Review, 46, 1038-1043.                Senn, K.L. (1992). Predictors of        iology, physiology, and biochemistry.
                                      participation in a school-based anti-   Circulation, 83 (1), 1-12.
Centers for Disease Control and       tobacco activism program. Journal
Prevention (1999). Best practices     of Community Health, 17, 283-           Pierce, J., Evans, N., Farkas, A.J.,
for comprehensive tobacco control     289.                                    Zhu, S.H., Choi, W.S., Berry, C.C.,
programs. Atlanta, GA: U.S.                                                   Distefan, J.M., White, M.M., Soroko,
Department of Health and Human        Independent Evaluation Consortium       S., and Navarro, A. (1998a) Tobacco
Services, Centers for Disease         (1998). Final Report of the Indepen-    control in California: Who’s win-
Control and Prevention, National      dent Evaluation of the California       ning the war? An evaluation of
Center for Chronic Disease            Tobacco Control Prevention and          the Tobacco Control Program,
Prevention and Health Promotion,      Education Program: Wave I Data,         1989-1996. La Jolla, CA: University
Office of Smoking and Health.         1996-1997. Rockville, MD: The           of California, San Diego.
                                      Gallup Organization.
Department of Health Services,                                                Pierce, J., Gilpin, E.A., Emery, S.L.,
Tobacco Control Section (1999).       Independent Evaluation Consortium       White, M.M., Rosbrook, B., and
Fast Facts. Sacramento, CA:           (in press). Final Report of the         Berry, C.C. (1998b). Has the
Department of Health Services.        Independent Evaluation of the           California Tobacco Control Program
                                      California Tobacco Control and          reduced smoking? Journal of the
Department of Health Services         Education Program: Wave 2 Data,         American Medical Association,
(November 1999). Cost benefits of     1998, with Wave 1 and Wave 2            280 (10), 893-898.
the California Tobacco Control        Data comparisons, 1996-1998.
Program, 1990-1998. Analysis by       Rockville, MD: The Gallup               Rigotti, N.A., DiFranza, J.R., Chang,
the Tobacco Control Section, Data     Organization.                           Y., Tisdale, T., Kemp, B., and Singer,
Analysis and Evaluation Unit.                                                 D. (1997) The effect of enforcing
                                      Lightwood, J.M. and Glantz, S.A.        tobacco-sales laws on adolescents’
Department of Health Services,        (1997). Short-term economic and         access to tobacco and smoking
Tobacco Control Section (1998). A     health benefits of smoking cessation:   behavior. New England Journal of
Model for Change: the California      Myocardial infarction and stroke.       Medicine, 337, 1044-1051.
Experience in Tobacco Control.        Circulation, 96 (4), 1089-1096.
Sacramento, CA: Department of                                                 Zhang, X., Miller, L., Max, W., and
Health Services.                      Lightwood, J.M. Phibbs, C., and         Rice, D.P. (1999). Cost of smoking
                                      Glantz, S.A. (1999, submitted).         to the Medicare Program, 1993.
                                      Short-term health and economic          Health Care Financing Review,
                                      benefits of smoking cessation: Low      20 (4), 179-196.
                                      birth weight. Pediatrics.
Front Cover: “Like Father, Like Daughter.” Billboard, 1995 Statewide Media Campaign.

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