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For more than 2 decades, the California Tobacco Control Program (CTCP) has served the people of California with a comprehensive, integrated approach to tobacco use prevention and control that has demonstrated effectiveness and impact. Moreover, the CTCP has contributed directly and indirectly to the success of other state, federal and international efforts to control what continues to be a leading preventable cause of death and disability worldwide. This Tobacco Control supplement presents a review of the history and key features of the CTCP, and illustrates selected outcomes achieved by the programme. These articles build on the key papers already published in the scientific literature, as well as other accessible documents (see http://www.cdph.ca.gov/programs/tobacco).
In their overview paper, Roeseler and Burns review the ‘programme ideology’ that has long guided the design and implementation of CTCP policy and programme activities.1 Central to this ideology is the use of a social normative approach to address the political, social, economic and media environments that surround all Californians. Although the early battles to implement this ideology—with its emphasis on countering pro-tobacco influences through policy and regulatory changes, mobilisation of local coalitions of public health practitioners, advocates and concerned citizens, and deglamorisation of tobacco use through a hard-hitting media campaign—have receded from the public eye, relentless political challenges to the social normative approach have forced CTCP compromises, especially with regard to the media campaign.2 The programme has garnered strong support among allies within and outside of the public health system, including key members of academe and civil society, and thus has been able to blunt or reverse many of the political assaults on its core principles. One hopes that the papers in this supplement will contribute meaningfully to the growing body of literature that supports the use of a social determinants approach to tobacco control and other public health issues.3 4
The papers published here are filled with examples of innovative tobacco control policy, programmatic activities and socially significant evaluation findings. Some important efforts and impacts are, perhaps, less obvious; for example, a small section of the paper by Roeseler and colleagues is devoted to a description of the CTCP's collaboration with the California Attorney General's Office.5 Among the key findings reported is this statement: “Since 2000, the California Attorney General's Office efforts resulted in 14 successful enforcement actions against tobacco companies totalling more than US$24 million in payments, penalties and fees. Of these payments, nearly US1.9 million was earmarked for tobacco control” (this issue, pXX). Given the need for substantially more resources to counter pro-tobacco industry expenses,6 it would seem that boosting tobacco industry monitoring and enforcement efforts should be a universally high-priority tobacco control activity. Additionally, within Appendix 1 Roeseler et al5 one can find other examples of penalties levied on the tobacco industry as a product of the Attorney General's enforcement of California state laws and the Master Settlement Agreement. Some of these, such as reporting requirements and advance notification of marketing and promotion activities, could serve as models for state and federal enforcement penalties under the Family Smoking Prevention and Tobacco Control Act.7
Another impact of the CTCP has been its influence on public health practice throughout California and beyond. Indeed, an entire generation of local and state-level public health practitioners, researchers, advocates and allies have developed their public health skills working on the CTCP. Many have stayed working on the programme and some have developed into internationally recognised leaders on various aspects of tobacco control. Many others have become members of a workforce diaspora who have carried the CTCP philosophy with them to seed policy and practice evolutions in other public health issue areas within the state and elsewhere. If, as Larry Green observed more than 20 years ago, evidence of programme institutionalisation may be found in the vibrancy of other programmes that have been influenced by staff trained under the original programme, then the CTCP has much to celebrate.8
Despite its demonstrated success, the CTCP can ill-afford to rest on its laurels.9 The tobacco industry continues to spend obscene sums to market their products in California, far outweighing per capita expenditures on state and local tobacco control efforts. Once a leader in total tax as a percentage of retail tobacco price, repeated failures to increase tobacco excise taxes over the past decade has left California well behind other states.10 11 Regardless of whether any future excise tax increases includes an earmark for tobacco control (the most desirable situation), failing to raise tobacco taxes has immediate negative impacts on a state struggling with a severe economic crisis, and could have major long-term impacts if price-sensitive groups increase their tobacco consumption due to decline in the real price of tobacco. Although the CTCP is not directly involved in advocacy for tobacco tax increases, surveillance and evaluation data can and should be used to educate policymakers and the public regarding the need to act.
Likewise, political barriers must be overcome to close loopholes and eliminate unnecessary exemptions in state smoke-free environment laws so the CTCP may continue to proclaim, “Welcome to California. America's Largest Non-Smoking Section.”12 And, addressing the special needs of diverse, vulnerable populations at-risk requires meaningful, sustained involvement by the CTCP with an array of stakeholders and collaborators, many of whom may be justifiably engaged in addressing other health, social and economic issues.
Despite these and other challenges, the papers in this supplement demonstrate that the state of tobacco control in California is healthy, energetic and resilient. It's been an honour to help shepherd these papers from concept to the printed page. Congratulations, CTCP.
Thanks to the 33 non-Californian researchers, practitioners and other tobacco control experts who served as peer reviewers of the papers in this supplement.
Competing interests TR has in the past received and currently receives funding from the California Tobacco Control Program.
Provenance and peer review Commissioned; not externally peer reviewed.
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