Tob Control 19:i3-i15 doi:10.1136/tc.2009.030809
  • Research paper

The quarter that changed the world

Open Access
  1. David Burns2
  1. 1California Department of Public Health, California Tobacco Control Program, Sacramento, California, USA
  2. 2Family and Preventive Medicine, University of California San Diego, San Diego, California, USA
  1. Correspondence to April Roeseler, California Department of Public Health, California Tobacco Control Program, PO Box 997377, MS 7206, Sacramento, CA 95899-7377, USA; april.roeseler{at}
  1. Contributors Both authors contributed to the conception and design, acquisition of data or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version published.

  • Received 3 April 2009
  • Accepted 7 September 2009


Background The California Department of Public Health (CDPH), California Tobacco Control Program (CTCP) is one of the longest-running comprehensive tobacco control programmes in the USA, resulting from a 1988 ballot initiative that added a 25-cent tax on each pack of cigarettes and a proportional tax increase on other tobacco products. This programme used a social norm change approach to reduce tobacco use.

Methods The operation, structure, evolution, programme dissemination and results are reviewed.

Results The sustained programme implementation has reduced adult per capita cigarette consumption by over 60% and adult smoking prevalence by 35%, from 22.7% in 1988 to 13.8% in 2007. From 1988 to 2004, lung and bronchus cancer rates in California declined at nearly four times the rate of decline seen in the rest of the USA and the programme is associated with an $86 billion savings in healthcare costs. Youth smoking rates among 12–17 years olds are the second lowest in the nation.

Conclusions The social norm change approach is effective at reducing tobacco consumption, adult smoking and youth uptake. This approach resulted in declines in tobacco-related diseases and is associated with savings in healthcare expenditures. In considering CTCP's effectiveness, the takeaway message is that it should be viewed as a unified programme rather than a collection of independent interventions. The programme was designed and implemented as one where the parts complement and reinforce each other. Its effectiveness is dependent on its comprehensive strategy rather than any one part of the intervention.


  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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