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Tob Control 7:397-408 doi:10.1136/tc.7.4.397
  • Special Communication
  • Special communication

Tobacco control advocates must demand high-quality media campaigns: the California experience

  1. Edith D Balbach,
  2. Stanton A Glantz
  1. Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California, USA
  1. Dr ED Balbach, Community Health Program, Tufts University, 112 Packard Avenue, Medford, Massachusetts 02155, USA;ebalba01{at}emerald.tufts.edu

    Abstract

    OBJECTIVE To document efforts on the part of public officials in California to soften the media campaign’s attack on the tobacco industry and to analyse strategies to counter those efforts on the part of tobacco control advocates.

    METHODS Data were gathered from interviews with programme participants, direct observation, written materials, and media stories. In addition, internal documents were released by the state’s Department of Health Services in response to requests made under the California Public Records Act by Americans for Nonsmokers’ Rights. Finally, a draft of the paper was circulated to 11 key players for their comments.

    RESULTS In 1988 California voters enacted Proposition 99, an initiative that raised the tobacco tax by $0.25 and allocated 20% of the revenues to anti-tobacco education. A media campaign, which was part of the education programme, directly attacked the tobacco industry, exposing the media campaign to politically based efforts to shut it down or soften it. Through use of outsider strategies such as advertising, press conferences, and public meetings, programme advocates were able to counter the efforts to soften the campaign.

    CONCLUSION Anti-tobacco media campaigns that expose industry manipulation are a key component of an effective tobacco control programme. The effectiveness of these campaigns, however, makes them a target for elimination by the tobacco industry. The experience from California demonstrates the need for continuing, aggressive intervention by non-governmental organisations in order to maintain the quality of anti-tobacco media campaigns.

    In 1988 California voters enacted Proposition 99, an initiative that raised the tobacco tax by $0.25 and allocated 20% of the revenues to anti-tobacco education.1 In its first years, this dedicated tax generated over $100 million per year for anti-tobacco education, making it the largest tobacco control programme in the world.2 For the supporters of the Proposition 99 education programmes, however, the passing of the initiative was just the first step in securing a strong anti-tobacco education programme; the legislature still had to appropriate the money to the programme and the administration had to implement it. In the first authorising legislation—Assembly Bill 75 (AB75)—the tobacco industry tried to prevent any of the education money from being spent on an anti-tobacco media campaign, but it failed, due to the obvious and heavy-handed tactics it used to influence the legislature and the nearness of the election.2 3

    The California Department of Health Services (DHS), one of the agencies charged with programme implementation under AB75, envisioned delivering an aggressive anti-tobacco programme that combined statewide media with local community-based activities.4 5 Under Governor George Deukmejian (Republican), DHS moved quickly to implement the media campaign. The Request for Proposals was released on 1 December 1989, 59 days after Deukmejian signed the appropriations bill, with responses from advertising agencies due on 10 January 1990. The advertising agency keye/donna/perlstein was selected to run the media campaign on 26 January,6 and the first advertisements were released 73 days later, on 10 April 1990,7 accompanied by a full-page newspaper advertisement on 11 April 1990 (figure 1 and box).

    The Proposition 99 media campaign took a substantially different approach than previous anti-tobacco education campaigns had. As recounted by Paul Keye, one of the principals in the advertising firm:

    “The cigarette companies were never in any of the advertising agency’s original thoughts or conversations with the Department of Health Services. You can’t find the topic in our first work.  . . . What happened was that—as we dug into each topic—there, right in the middle of everything were the Smokefolk, making their quaint, nonsensical arguments and—by sheer weight of wealth and power and privilege—getting away with it.  . . . Frankly, the tobacco industry pissed us off. They insulted our intelligence.”8

    So, instead of traditional public health messages that “tobacco is bad for you”, Keye started the campaign on the tack of directly attacking the tobacco industry, a strategy that DHS soon adopted and advocated.3 8 The aggressive tone of the media campaign is credited with contributing to a tripling of the rate of decline of tobacco consumption in California.9-11

    First, the smoke. Now, the mirrors.

    In less than a generation, the bad news about cigarettes has become no news. Most Americans—even the very young—know the unavoidable connection between smoking and cancer, smoking and heart disease, smoking and emphysema and strokes.

     Today a surprising number of us can tell you that cigarettes are our #1 preventable cause of death and disability.

     So, we seem to know about the smoke. But what about the really dangerous stuff—all those carefully polished, fatal illusions the tobacco industry has crafted to mess with our minds so they can mess with our lives?

     “Smoking is important. It makes you beautiful and fun and sexy. (Okay, it’s dangerous. But lots of exciting things are dangerous.) Smoking makes you powerful. It says you’re sensitive and grown up.”

     That’s one hell of a message. How can you fight it?

     Today, the California Department of Health Services begins a fifteen month advertising campaign that goes right at the tobacco companies’ predatory marketing—the selective exploitation of minorities, the seduction of the young, the selling of suicide.

     Well, won’t the tobacco industry fight this campaign?

     Sure. The smokescreen has already begun.“This effort pits smokers against non-smokers.”

     Wrong. This program would have never happened without the active support of California’s smokers. Despite their habit, or maybe because of it, they wanted people to know the truth about addiction and discomfort and disease and death. (Ask smokers if they want their children to smoke. Or their grandchildren. Ask them if they’d start smoking if they could have the decision back.)

     “This is a threat to our First Amendment right to advertise a legal product.”

     On the contrary, we intend to make you more aware of the tobacco industry’s advertising. And, if we pinch the right nerve, we expect them to make you more aware of ours.

     This is going to be a media campaign about a media campaign—as much about hype as hygiene. It’s going to talk about a shared community opportunity and a shared community menace.

     There’s never been anything quite like it. But this is California. We don’t need to do it the way it was done before.

    california department of health services

    Figure 1 A copy of the full-page advertisement that ran in newspapers to mark the advent of the media campaign, along with a reproduction of the text from the ad.

    The first television advertisement, “Industry Spokesman” (figure2), portrayed tobacco industry executives discussing the need to hook kids on tobacco, while laughing that, “We’re not in this for our health”. These advertisements generated major controversy, with the tobacco industry complaining publicly that it was inappropriate for government to attack a legal business.12

    Figure 2

    The first advertisement in the California campaign, “Industry Spokesman,” depicted a group of tobacco industry executives sitting around a boardroom joking about recruiting new smokers. Despite being the advertisement with the highest recall in the California programme, the Wilson administration refused to air it.

    The internal response of the tobacco industry was immediate. By 18 April 1990, Samuel D Chilcote Jr, president of The Tobacco Institute, the Washington-based lobbying organisation for the tobacco industry, sent out a memo to members of his executive committee, providing a “further update on our efforts to deal with the anti-smoking advertising campaign in California”. The Tobacco Institute outlined a four-part strategy for dealing with the media campaign. The first part was to encourage the California legislature to intervene, the second part was to cooperate with other groups to encourage them to oppose the campaign, the third was to convince Ken Kizer, the DHS director, to “pull or modify” the advertisements, and fourth was to encourage the governor to intercede against the campaign. Because the Institute believed that Kizer would not modify the advertisements without pressure from the administration and because Deukmejian, as a lame-duck governor, was unlikely to pressure Kizer, it concluded: “It is clear that our efforts should center on the first two strategies”.13

    Since its inception, the media campaign has remained the source of controversy, with California tobacco control advocates working to maintain an aggressive tone and the tobacco industry and its allies seeking to soften the tone and limit the scope of the campaign. These issues marked the debate over the media campaign in 1996–1997. As this paper will document, while health groups succeeded in stopping the explicit legislative restrictions against attacking the tobacco industry that the pro-tobacco forces tried to include in the Budget Act, decisions and processes by the administration of Governor Pete Wilson, who had succeeded Deukmejian, tried to achieve the same goals. Eventually, by mounting outside pressure on the administration, public health groups were able to push the media campaign back towards its original posture. The experience from California demonstrates the need for continuing, aggressive intervention by non-governmental organisations to maintain the quality of anti-tobacco media campaigns.

    Methods

    The information used to prepare this report was gathered from interviews with the participants, direct observation, written correspondence, and media stories. Where media stories have been based on California Public Records Act requests, we have also obtained the documentation on which the storied were based to verify the accuracy of the reported information.

    In addition, internal documents about the 1996–1997 media campaign were released by the Department of Health Services in response to requests made under the California Public Records Act by Americans for Nonsmokers’ Rights. These materials document the internal response to the events occurring outside of the Department. Finally, a draft of the paper was circulated to 11 observers of the 1996–1997 conflict for their comments.

    Early controversies over the media campaign

    The flexibility the media campaign enjoyed under Deukmejian dissipated with the inauguration of Pete Wilson (R) as governor in January, 1991. Deukmejian had taken a “hands off” policy with regard to the development and production of the advertisements, leaving the control of the campaign in the hands of the professionals in the Department of Health Services.14 15 According to Kizer, once Wilson became governor, there were comments from Wilson’s office that they wanted the subsequent advertisements toned down and wanted to review them.15 Wilson eventually attempted to shut the media campaign down completely and, failing that, imposed increasingly tight political control over it.

    Wilson’s first overtly hostile action toward the media campaign was to attempt to end it entirely. In his budget proposal of 10 January 1992, Governor Wilson suspended the media campaign by diverting all of its funding for the current and subsequent fiscal years, claiming that it was of “secondary” importance.16 Dr Molly Joel Coye, who had replaced Kizer as the director of the Department of Health Services, and Betsy Hite, departmental spokeswoman, claimed that the local programmes funded by Proposition 99 were a more effective use of resources and that the smoking decrease that followed the beginning of the media campaign was actually part of a trend that began in 1987, rather than the result of the anti-smoking advertising campaign.17 18 19 The move was supported by the tobacco industry,20 which had planned as early as 1990 to work with a variety of minority groups, the hospital groups, the California Medical Association, and business groups to divert money from the media account into other health programmes.13

    The claims that the media campaign was unimportant or ineffective were contradicted a few days later, on 14 January 1992, when John Pierce, a professor from the University of California at San Diego and director of the California Tobacco Survey (which is done under contract to DHS), speaking at the American Heart Association Science Writers Conference, released preliminary data from the survey. The data demonstrated a 17% drop in the percentage of adults who smoked since Proposition 99 passed, and Pierce attributed this drop to the combined effects of the tax, educational efforts, and the media campaign.21 22

    Rather than claiming credit for this success, the administration attacked Pierce’s result, asserting that the conclusions were overstated.17 23 24 Hite pressured staff members in the DHS Tobacco Control Section (TCS) to provide data to show that the tobacco control programmes were ineffective. Hite specifically told Jacquolyn Duerr, then head of the media campaign, to back up Hite’s assertion that the rapid decline in smoking had nothing to do with Proposition 99. Duerr and Michael Johnson, the head of the DHS’s evaluation efforts, and Pierce’s contract monitor, refused to comply. (Hite’s activities did not come to light until December 1996.)25 26

    Wilson and Coye, however, refused to issue the contract of 1 January 1992 to the advertising agency to continue the media campaign, which shut the campaign down immediately.27 28 Although the local programme efforts kept the tobacco control programme moving forward,8 during the time the media campaign was suspended, the decline in tobacco consumption did slow11(figure 3) . The American Lung Association sued successfully to restore the media campaign,29 30 and the administration was required to sign the contract with the advertising agency for the period 20 May 1992 to 30 June 1993.31

    Figure 3

    Long-term patterns of cigarette consumption in California show that when the media (and other aspects of the tobacco control programme) were suspended or weakened, the progress in reducing cigarette use was arrested.

    In the fiscal years, 1994–95 and 1995–96, the legislature continued to allocate money—nearly $12 million annually—to the media campaign. The allocation of money, however, did not ensure that a quality programme would result or even that the money would necessarily be spent. There was little new anti-tobacco advertising produced during that period, and none at all between September 1995 and 20 March 1997. In 1995–1996, the Wilson administration only spent $6.5 million of the $12.2 million the legislature appropriated for the media campaign. This weakening of the media campaign, in content and intensity, was associated with a lessening of the effect of the overall anti-tobacco programme on tobacco consumption and an increase in adult smoking prevalence11 (figure 3).

    There was also growing political control and controversy over the content of the campaign. Three anti-industry advertisements—two for television and one billboard—were pulled from use. One advertisement, “Nicotine Soundbites” (figure 4), was constructed from news coverage of the hearing of 14 April 1994 conducted in the United States Congress by Representative Henry Waxman, in which tobacco industry executives were shown claiming that nicotine is not addictive. The advertisement ended with the tag line: “Do they think we’re stupid?” The advertisement was shown briefly in autumn 1994. RJ Reynolds threatened to sue, claiming defamation,32 but Kimberly Belshe, the new DHS director, publicly defended “Soundbites”, and it remained on the air.33 After this public display of support, however, DHS quietly shelved “Nicotine Soundbites” in early 1995,34 and it has not been shown since in California, despite repeated requests to do so by public health advocates, including the Tobacco Education and Research Oversight Committee (TEROC),10 which has statutory oversight over the programme. Another advertisement, “Insurance”, pointed out that insurance companies owned by the tobacco industry charged non-smokers less for life insurance. The advertisement was reportedly finished but was not being used. Public health advocates held a press conference on 12 December 1995, to urge that the advertisement be broadcast,35-37 but the Wilson administration refused.38

    Figure 4

    The “Nicotine Soundbites” advertisement was based on the Congressional hearings at which tobacco executives denied that nicotine was addictive. The Wilson administration pulled the advertisement after the tobacco industry complained, and kept it off the air, despite repeated demands by public health advocates that it be put back on the air.

    A billboard was also pulled from use. In September 1994 (although this information did not become public until two years later), Sandra Smoley, secretary of health and welfare, the cabinet secretary over DHS and a Wilson appointee, personally ordered that 190 billboards saying: “Are you choking on tobacco industry lies?” be papered over at a cost of $10 000, even though the billboards had been approved by Belshe. When challenged on this, and related actions by the American Cancer Society, the American Heart Association, and Americans for Nonsmokers’ Rights, Smoley defended her position, saying:

    “The billboard ‘Are you choking on tobacco company [sic] lies?’ was pulled because it was found to be offensive for government to use taxpayer funds to call a private industry a liar.  . . . I also supported DHS’s decision to stop airing the ad called ‘Nicotine Soundbites.’ DHS made the judgment call that continuing to air the ad would raise unacceptable legal risks  . . . Your organisations have given unwarranted emphasis to the decision not to air an ad known as ‘Insurance’.  . . . While the ad had much potential, and could have been aired with further work, DHS dropped the ad immediately after your press conference [emphasis in the original].”39

    Smoley, a registered nurse, did not approve of accusing the tobacco industry of lying.

    Legislative attempts to weaken the media campaign

    Following litigation and political action by programme advocates,2 40 in June 1996, the legislature provided full funding for the Proposition 99 education and research programmes for the first time since Proposition 99 passed, including $25 million for media. Although he acquiesced in the decision to provide full funding, Assembly Speaker Curtis Pringle (R–Garden Grove) attempted to include language in the budget to prohibit the media account from being used to attack the tobacco industry. His proposed bill language specified that advertisements “be based solely on the health implications of tobacco use and on the health implications of refraining from tobacco use.”41 Such messages, stressing health effects of smoking, are not particularly effective at preventing young people from smoking or motivating adults to stop.11 42 Pringle’s justification was that taxpayer dollars should not be used to attack a legal industry,41 a position similar to that taken by Smoley.

    The governor’s office reportedly did not support the proposed budgetary language restricting the media account,41although the governor reportedly thought Pringle’s points were valid. According to the Contra Costa Times, Governor Wilson said that: “There is not a necessity to defame people in order to send a very strong message that smoking is not a good thing.”43

    Pringle was widely criticised for his stance. The editorial in theSacramento Bee on 28 June 1996 was representative. It said:

    “Tobacco industry executives plainly don’t enjoy turning on the television and seeing ads telling Californians that the industry profits at the expense of their health. They don’t like it when researchers unmask their marketing and political strategies. It’s not hard to understand why they want the legislature to undermine those elements of Proposition 99. What’s harder to explain, and impossible to justify, is the speaker’s willingness to do their work.”44

    Pringle’s language putting limits on the media account was eventually dropped because of opposition from key Democrats who were involved in the final budget negotiations.

    Using contracting procedures to cut the media campaign

    The successful defeat of legislative language to restrict the media account, however, did not mean that public health professionals would be allowed to run the media campaign without political interference. As the year unfolded, it became clear that the Wilson administration was restricting the media account quietly and behind the scenes without legislation. Before the budget even passed, those inside the administration were already implementing restrictions similar to those Pringle had proposed.

    At the time the 1996–1997 budget was signed, the contract to administer the media account was held by the advertising agency Asher/Gould, which had been awarded the contract in May 1994. When the new budget passed in 1996, the Department of Health Services extended Asher/Gould’s contract for producing media through 31 December 1996 and issued a new Request for Proposals (RFP) for the media campaign for the period from 1 January 1997 through 31 December 1999. The new RFP was not necessary because the existing contract with Asher/Gould had an option by which the state could have extended it through June 1998 without going through the lengthy process of rebidding the contract.

    The short extension that was given to Asher/Gould was done with the anticipation that new media could be developed by September 1996, and that the placement of advertisements could continue, both hard-hitting ones from the California archives and ones from other states.45 This effort to bridge the gap, however, was largely cosmetic, because no new media was produced under the contract extension and the effort to re-run advertisements from the archives was effectively stopped. Even after Asher/Gould was issued a new contract on 1 December 1996, at the conclusion of the public bidding process, new media was not released until 20 March 1997,40 which meant that from September 1995 until March 1997 no new media was released. By the time the new media was released, prevalence rates in adults had begun to rise, and those under the age of 18 were showing increased susceptibility to smoking.10 During the period when no new media was being produced, DHS continued to run a few of the most recently produced advertisements, despite warnings from departmental staff that the advertisements were so over-exposed that they had likely lost their effectiveness.46 The contracting process was also used as an excuse to, in effect, cut the size of the media campaign in half; in 1995–1996, only $6.5 million of the $12.2 appropriated by the legislature for media was spent, because of the delays in approving the extension.40

    Implementing Pringle’s policies administratively

    Asher/Gould had been prepared to issue new advertisements under the contract extension. As early as June 1996, Asher/Gould had delivered story boards (pen and ink versions of the proposed advertisements) to TCS for new media production under the contract extension. Following a presentation of the story boards set for 1 and 2 July 1996, production was scheduled to begin on 15 July with a proposed air date of 2 September.47

    Based on the past successes of the campaign, several of these proposed advertisements featured attacks on the tobacco industry. One of these advertisements was “Cattle”, which showed cowboys rounding up children as a metaphor for the tobacco industry hooking kids on cigarettes. “Cattle” began with the words: “This is how the Tobacco Industry wants you to see them  . . .”, and was originally to feature a kid being lassoed by one of the cowboys and dragged to where another cowboy was waiting with a brand reading, “Tobacco Industry”. The brand was to be photographed moving towards the camera, which represented the child’s point of view. The final line was: “The Tobacco Industry. If you knew what they thought of you, you’d think twice.” Another advertisement: “Thank you”, a television advertisement that eventually became a radio spot, was a sarcastic “thank you” letter from the tobacco industry to kids in appreciation for their loyalty despite overwhelming evidence that tobacco kills. It began with the line: “The Tobacco Industry would like to thank  . . .” and ended with the line: “Sincerely, the Tobacco Industry”. Three billboards were also presented, two of which are shown in figure 5.

    Figure 5

    Two billboards produced in March 1997. These billboards were submitted to the Department of Health Services by the advertising agency in June 1996. During the intervening nine months, there was a tug-of-war between administration officials, who watered down the advertisements, and public health advocates, who wanted the advertisements strengthened. The nine-month review process resulted in no changes in these billboards.

    In July 1996, Mike Genest, assistant deputy director for prevention services at DHS, who was widely viewed as representing the governor’s interests in the department, was concerned that everything that Asher/Gould had presented for young people was controversial and would need to be approved several layers up the chain of command. He questioned the efficacy of the approach of attacking the tobacco industry, prompting Bruce Silverman, president of Asher/Gould, to write to Dileep Bal, Chief of the Cancer Control Branch (which includes TCS), that: “The only effective method I know of to achieve that [reduction in tobacco use] via advertising is with the “Manipulation” strategy that we just tested”.48 In addition to general concerns about attacking the industry, Genest wanted the words: “Tobacco Industry” changed to “Big Tobacco”.49 Nothing was approved to go into production. It would take nearly nine months for these advertisements to appear, with minor changes from the original proposals. During this time, the ads would be watered down, then re-strengthened.

    In addition to slowing the approval process, the Wilson administration made other changes designed to tone down and slow down the media campaign. Prior policy had been that once an anti-tobacco advertisement was approved, it was up to TCS and the media contractor’s professional judgement when to run a given advertisement. In August 1996, when Asher/Gould suggested running “Industry Spokesman” again because it had not been aired for several years, Genest announced a new policy that every advertisement, even those previously approved, be cleared for each use.50 Bal described this new policy as “a fundamental change that I for one was unaware of until now.”51 Between the delay over the new media and the need for re-approval of the old, there was clearly no intention of getting the media campaign up and running in a hurry.

    There were other steps taken inside the administration to impose tighter political controls on the media campaign. On 16 September 1996, the DHS Office of Public Affairs (OPA) released a memo requiring that all advertising concepts be reviewed by OPA before being focus group tested or shared with “stakeholders/interested parties”.52 In other words, an official charged with protecting the administration’s political and public relations positions would review proposed advertisements for political acceptability before any formal evaluation of the advertisements for quality or effectiveness as public health messages could take place.

    Finally, DHS was asked not only to justify media spots attacking the tobacco industry, but was also required to justify the whole “countering pro-tobacco influences in the community” strategy.53 This strategy, along with “reducing exposure to environmental tobacco smoke” and “reducing youth access to tobacco”, is one of the three main themes in all of DHS’s programming, including media, local programmes, and the competitive grants. Robin Shimizu, chief of technical services, TCS, who oversees the media campaign, warned that:

    “These priorities were developed and renewed with the assistance of the tobacco control communities throughout California and do not simply belong to DHS/TCS. To back away from, or to have to justify the use of any one of them, or to eliminate one of the priorities would be viewed harshly by everyone involved in tobacco control in the state as well as other states, unless there were a very strong rationale for doing so.”53

    Bal, writing to Don Lyman, chief, Division of Chronic Injury and Disease Control, gave a similar assessment:

    “Countering pro-tobacco influences in the community’ is the very signature piece of our efforts to date, as any of the cognoscenti within or without the state will attest to. To have that questioned in an issue memo you or I have not seen is beyond anything. Any fundamental shift of these proportions without community input will produce quite a mushroom-cloud, besides being ill-conceived.Caveat emptor.54

    Bal further offered to host “a full-scale consensus conference of the national cognoscenti” to discuss the issue, suggesting that those who were requesting the justification did not really want this level of public discussion of the issue. He also suggested that the “countering” strategy was being held to a higher burden of proof that it worked than other interventions pursued by DHS.55

    Shutting the public health community out of the process

    Bal’s offer to open up discussion of the basic campaign strategy to include the public health community flew in the face of the general approach taken by DHS in the fall of 1996. During the first years of the California anti-tobacco media campaign, DHS and the advertising agency had actively involved members of the public health community in the development of the advertising campaign.5 Recognising that efforts to slow down and weaken the media campaign would spark controversy within the public health community, the administration shut the public health community out of the review process. In the initial stages of the campaign, DHS had involved a broad cross-section of the public health community in the process of developing new media through a large, somewhat informal media advisory committee. This committee stopped being convened, and the administration even quit involving TEROC in the review of the story boards.

    At its meeting on 10 December 1996, TEROC discussed the delays in the media campaign and the new closed review process. James Stratton, the state health officer and DHS deputy director for prevention services, announced that decision making about the media campaign had been removed from TCS and that he had the final say over the content of the advertisements. TEROC made a formal request to be allowed back into the process, in particular to have the opportunity to see and comment on the story boards when new advertisements were being developed.56 Stratton refused.57

    The veil of secrecy extended to the advertising firm as well. The new Asher/Gould contract issued on 1 December 1996 contained a new clause barring it from discussing the media campaign with anyone outside the official process.58

    Administration secretly toned down the ads

    The administration had, in fact, weakened the June advertisements, just as public health advocates had feared. All the story boards submitted by Asher/Gould in June 1996 had been modified by removing the words “the tobacco industry” and “addiction”. For example, “Cattle” now began: “This is how the guys who make cigarettes  . . .” and the final line was: “If you knew what they thought of you, you’d think twice.” The words “tobacco industry” did not appear. The advertisement, “Thank you” had also been changed from: “The Tobacco Industry would like to thank  . . .” to: “Those of us who make cigarettes would like to thank you  . . .”. The final line: “Sincerely, the Tobacco Industry” was still included in the presentation attended on 5 December by TCS staff, Lynda Frost, the deputy director of the office of public affairs, Genest, and Stratton, but it was later deleted.59

    A new anti-industry advertisement, “Rain”, featured cigarettes raining down on a playground and discussed the tobacco industry’s need to hook kids, but it never mentioned the tobacco industry by name. The opening line was: “We have to sell cigarettes to your kids” and the final line was: “How low will they go to make a profit?”

    Another proposed new advertisement, “Voicebox”, did attack the industry as it was proposed. It featured a woman smoking through a tracheotomy, stating that the tobacco industry had lied to her about the addictive nature of its products. In December, the industry attack was deleted, and the advertisement instead promoted the state’s toll-free (freephone) quit line. In the revised December version neither addiction nor the tobacco industry is mentioned by name. The advertisement instead featured a smoker who could not quit despite having a tracheotomy, urging others to give quitting a try. An anti-industry advertisement had been converted into a cessation spot that said that quitting was impossible—a strange message from a public health department.

    In early 1997, Asher/Gould expressed concerns that all the advertisements as approved lacked clarity, but they were particularly concerned with the way “Rain” had been changed by DHS, because it could be misunderstood to include tobacco retailers and business in general, as opposed to just the tobacco industry. TCS’s relationship with the retailers was fragile and their cooperation was needed to implement the state programme designed to reduce tobacco sales to the young.60

    The effort to tone down the attacks on the tobacco industry flew in the face of the research done for TCS by Asher/Gould. In Asher/Gould’s Summary Report61 of its focus group research on different advertising messages, Christine Steele, an Asher/Gould senior vice president, reported that five advertising strategies were tested on young people, aged 12 to 18, in focus groups in Sacramento and Los Angeles.42 The messages tested were: (a) manipulation of kids by the tobacco industry, (b) the dangers of secondhand smoke, (c) the short term health effects of smoking, (d) the risk of romantic rejection, and (e) the elimination of risks to the environment caused by smoking, including cleaner beaches, fewer trees destroyed to produce cigarettes, and fewer animals harmed by eating butts. Of the five, manipulation by the industry tested very strongly with young people. According to Steele: “The body language of kids clearly revealed that this strategy [the anti-industry strategy] provided kids with an emotional wake up call. They sat up straight, they grimaced, they shook their heads, they became riled up and vocal—they at least became concerned about this formerly ‘low interest’ topic.”42

    Public health advocacy groups begin to protest

    On 4 February 1997, the presidents of the American Cancer Society (ACS), American Heart Association (AHA), and Americans for Nonsmokers’ Rights (ANR) wrote to Smoley to express their frustration with the “administration’s ostensible defense of an industry responsible for the deaths of more than 42 000 Californians each year—the tobacco industry”. The three organisations protested the long delay in the production of new media and urged Smoley to release a campaign that featured the original campaign themes: “the tobacco industry lies”, “nicotine is addictive”, and “secondhand smoke kills”. Meanwhile, John Miller, chief of staff to Senator Diane Watson (D–Los Angeles), chair of the state Senate Health Committee, was threatening to hold hearings on the conduct of the media campaign.

    Cook called an emergency meeting of TEROC for Monday, 10 February 1997, to follow up on Stratton’s refusal to share information about the media campaign with TEROC and to decide what action TEROC should take in response.

    The TEROC purge

    On the Friday before the emergency TEROC meeting, Stratton announced a major shakeup of TEROC. Three physicians on TEROC who had been strong advocates for the anti-tobacco education campaign, were replaced with individuals closely allied with the Wilson administration. Lester Breslow, former dean of the UCLA School of Public Health and former director of DHS, who had been on TEROC since its formation in 1990, and Reed Tuckson, president of Drew University of Medicine and Science in Los Angeles, were told that they had been replaced in an action allegedly taken three months earlier by Assembly Speaker Pringle (R), the day before the Democrats took over the Assembly. Neither Pringle nor DHS had given any indication of these changes before 7 February, even though TEROC had met in December, after the date that Pringle supposedly made the appointments. Jennie Cook, TEROC chair, had been unaware of them. Spokesmen for Pringle and the Governor said that either DHS was not informed or the appointment letters had been lost.62 In the physicians’ places, Pringle appointed Hal Massey, a retired Rockwell executive who had been active in ACS, and Doug Cavanaugh, the president of Ruby’s Restaurants, who was, according to Pringle, “familiar with the tobacco debate, balancing regulations with people’s right to smoke”.62 DHS also announced that Governor Wilson had replaced Dr Paul Torrens of the UCLA School of Public Health with Dr George Rutherford, who had been the state health officer in the Wilson administration and responsible for the Proposition 99 programme until he left to join the faculty at the University of California. Wilson also appointed Stratton to TEROC, making him a member of his own oversight committee.

    On Monday morning, before the TEROC meeting scheduled for that afternoon, ACS, AHA, ANR, and the American Lung Association (ALA) called a press conference to protest the changes in the TEROC membership and to express their concerns about the administration of the programme. Alan Henderson, president-elect of ACS, Carolyn Martin, a volunteer with ALA and former chair of TEROC, John Schaffer, of AHA, and Stanton Glantz, of the University of California at San Francisco, spoke at the press conference. They pointed out that it was inappropriate for Stratton to sit on TEROC, because he had asserted direct responsibility for the day-to-day management of the DHS tobacco programme, particularly the media campaign, setting up a potential conflict of interest. Indeed, Stratton, at the meeting on 10 December, had claimed responsibility for putting in place the secrecy policies that had led to the TEROC emergency meeting in the first place.

    Between the controversy caused by the lack of a media campaign and the controversy over the purge of the three widely respected committee members, the media gave substantial coverage to the meeting, particularly to the absence of the media campaign and the lack of information about it.62-68 Well over a hundred people came to the TEROC meeting on the afternoon of 10 February. TEROC normally meets in a conference room and has 10–15 non-members in attendance; this meeting was held in an auditorium. Audience members included the heads of a number of county programmes for tobacco use prevention, who emphasised the key role the media campaign played in their efforts. Without the “air cover” created by the media, the impact of their local programmes was more limited. Steve Hansen, a member of the board of the California Medical Association, suggested Stratton was guilty of “public health malpractice”.57

    TEROC agreed that Cook should write to Belshe, informing her of the committee’s unanimous vote (including Stratton, the person who was refusing to make the story boards available to the committee) to request a meeting to review the story boards for the current media and to request other, similar meetings to include the committee in the media development process. TEROC also voted that it favoured “the most aggressive media ads possible” and “sustaining of continuous media coverage, using, if necessary, the strongest existing ads currently available.”69

    The advertisements are strengthened

    In February 1997, DHS responded to the pressure about the advertisements by again revising them, although this fact was not made public at the time. For example, Frost approved putting “The tobacco industry” back into the “Cattle” advertisement, changing: “If you knew what they thought of you, you’d think twice” to: “The Tobacco Industry. If you knew what they  . . .”. In “Rain”, the voice over at the end was changed to: “The tobacco industry. How low will they go to make a profit?” In addition, “Thank you”, which had become a radio spot, had the words “Tobacco Industry” added back in, both in the opening sentence and in the last line.

    By the time Asher/Gould prepared the final story boards on 3 March 1997, two versions of “Voicebox” were planned. In addition to the cessation advertisement, a version was re-created that emphasised addiction and the behaviour of the tobacco industry. In it, the actor says: “They say nicotine is not addictive. How can they say that?” while the tag line at the end reads: “The tobacco industry denies that nicotine is addictive.”

    On 7 March, ACS, ALA, and ANR received a response to their letter of 4 February to Smoley, which had criticised the administration’s management of the media campaign. Smoley responded by saying that: “It was found to be offensive for government to use taxpayer funds to call a private industry a liar”, although she did state that it was appropriate to counter industry tactics. In response, AHA, ACS, and ANR took out a full-page advertisement in the New York Times, accusing the Wilson administration of refusing to release hard-hitting television spots and removing the “Lies” billboard to protect the tobacco industry. Smoley, with Governor Wilson’s explicit approval, was implementing Pringle’s programme of refusing to attack the tobacco industry, even though the legislature had refused to pass it.70

    Despite movement in private on the media campaign by TCS, the public health community was still shut out of the review process. On 19 March, Belshe responded to the TEROC letter, indicating that TEROC would not be involved in the process of developing the media.71 The administration argued that TEROC was a “security risk” and that sharing the advertisements with TEROC would increase the likelihood that the tobacco industry would gain access to them. Cook expressed her disappointment in a letter on 2 April, commenting that: “The TEROC is not an outside party; it is to be part of the process; and it is being deprived of the tools necessary to function”.69 One of the other TEROC members stated that it appeared that the department considered 12 year olds in a focus group less of a security risk than the members of TEROC.69

    TEROC was finally shown the new advertisements at its meeting on 25 March, after they were released to the public, and Cook indicated that their reactions were mixed.69 Only the version of “Voicebox” that emphasised addiction and the industry was shown. The advertisements as released, nine months after Asher/Gould originally proposed them, were similar to those originally proposed by the advertising agency.

    At the TEROC meeting on 25 March, John Pierce, director of the California Tobacco Survey, presented the latest California smoking prevalence data, which showed that smoking rates for young people and adults appeared to be going up. Overall, youth smoking, which had been as low as 8.7% in 1992, rose to 11.9% in 1995 and remained flat in 1996 at 11.6%. The annual Behavioral Risk Factors Survey conducted in-house at DHS showed that adult smoking prevalence had increased from 16.7% to 18.6% from 1995 to 1996,72 reversing a downward trend that had existed for nearly a decade.10 73 The increase in smoking rates received wide media coverage.73-75 Public health groups blamed the increase on the fact that the administration had not fully funded Proposition 99’s anti-tobacco education programmes and on its reluctance to attack the tobacco industry. Sean Walsh, the Governor’s press secretary, commented that he was frustrated with Wilson being blamed for everything “including [the comet] Hale-Bopp”.73 He referred to criticisms by the public health groups as “Chicken Little-like comments made by zealots in the anti-smoking community”.75 The actions by the public health groups, however, far from reflecting “Chicken Little” zealotry, did call attention to and partially block the administration’s attempt to run a poor quality tobacco control programme.

    The key role played by tobacco activists was confirmed in October 1998, by asher & partners (the new name of the Asher/Gould agency), when they responded to questions from the Senate Judiciary Committee regarding censorship of the media campaign. The Judiciary Committee subpoenaed asher & partners to allow them to speak frankly despite the “gag clause” that the Wilson administration had added to their contract. They said: “We were told in 1997 that we should not use the wordsThe Tobacco Industry in our advertisements.  . . . After intense pressure from tobacco control activists, the administration finally allowed us to use the phrase the tobacco industry and asked us to quickly redo all of our creative materials to reflect the reneging of this restriction [emphasis in the original].”76

    Since 27 March 1997, the policies of secrecy and the cumbersome approval process surrounding the media campaign have remained in place. On 15 April 1997, ACS, AHA, and ANR wrote to Governor Wilson, asking him to intervene personally to get the programme back on track. They specifically requested that he allow “Nicotine Soundbites” and “Insurance” to the air and that he actively support the implementation of Assembly Bill 13 (AB13), California’s law mandating smoke-free workplaces. The governor’s deputy chief of staff wrote back on 16 May 1997, saying that Belshe and Smoley “forthrightly” represented the governor’s position.70 Public health professionals within TCS still do not control the content of the advertisements.

    Smoley took several actions to prevent the media campaign from interfering with the tobacco industry’s efforts to overturn smoking restrictions in California. In 1994, Smoley prohibited use of the advertising campaign to publicise AB13,77 because Philip Morris was mounting an initiative campaign, Proposition 188,78 to overturn California’s workplace smoking restrictions. Even after Proposition 188 was defeated, however, there was still no advertising to educate the public that virtually all workers had a right to a smoke-free workplace. In 1997, Smoley delayed advertisements to implement California’s smoke-free bar law (which went into effect on 1 January 1998) for several months. Those advertisements, first proposed in May 1997, were not approved until October, because Smoley did not want advertisements on the air promoting the smoke-free bar law while the tobacco industry was attempting to get the law overturned in the legislature. In late November 1997, DHS began running two advertisements promoting smoke-free bars—one on the radio and one on television.

    Discussion

    Anti-tobacco media campaigns are key components of effective tobacco control programmes.4 With adequate funding, it is possible for tobacco control professionals to pursue a sophisticated marketing strategy that includes market segmentation and research on the effectiveness of anti-smoking messages.11 79 These advertisements can then be professionally produced and aired in prime television and radio times, providing “air cover” for other tobacco control efforts, such as community-based programmes or policy interventions.

    The recent influx of tobacco control monies into the public sector has, in fact, allowed this kind of marketing effort to occur, and the marketing research that has been conducted by professional firms has indicated that the media messages that are likely to be effective for prevention are not those that emphasise the health consequences of tobacco use but instead appeal to other emotions, such as resentment at being manipulated by the tobacco industry.42 This need to appeal not to facts or reason but instead to emotions and feelings has long been recognised by the tobacco industry as a key to its success at selling tobacco products.80

    The efforts of the tobacco industry to curtail or end various media campaigns indicates that it understands that media campaigns, correctly designed and run, can help to lower prevalence and consumption, and thus, it uses its political influence to weaken media campaigns (if it cannot simply prevent them from being funded). In California, it worked through the legislature and the administration to limit the scope and aggressiveness of the media campaign. In Arizona, another state with a large anti-tobacco advertising campaign funded by a dedicated tobacco tax, the Arizona Department of Health Services has mounted a large campaign that does not mention or attack the tobacco industry and avoids the word “addiction”.81 When the tobacco industry settled the Florida and Texas lawsuits designed to recover the state’s smoking-induced Medicaid costs, the settlement included funding for an anti-tobacco education programme, but explicitly prohibited advertisements that attack specific tobacco companies or brands.11

    Effective advertisements must personify and expose industry manipulation, but the experience of California and other states demonstrates that these advertisements are precisely the ones that the industry will work the hardest to stop. Given the importance of media to tobacco education programmes, tobacco control advocates must be aware of the industry’s efforts to place controls on anti-tobacco media campaigns, and be willing to take strong actions to see that executive branch officials charged with implementing the campaign do not succumb to this pressure.

    The California experience also illustrates the key role that programme advocates in non-governmental organisations can play in protecting media campaigns. The public health professionals who work in government agencies will be subject to the limits set by their politically appointed superiors. Thus, advocates outside of government must carefully monitor the quality and scope of government funded media campaigns and be ready to pressure these agencies to run effective advertisements. Public health interventions that are opposed by the tobacco industry will survive only through the continuing advocacy efforts of the public health community.

    In California, with no experience in running an advertising campaign, the Department of Health Services in 1989–90 launched its media campaign—including writing the Request for Proposals, awarding the advertising contract, developing, approving, producing, and placing the first round of ads—in 189 days, or a little over six months after the governor signed the budget. By 1996–97, with seven years of experience and a seasoned advertising firm, it took the department eight months from the signing of the budget to produce an advertisement. The process slowed rather than becoming more routine because of a variety of political manoeuvres, including adding layers of approvals for the advertisements, rescinding approvals of advertisements that had successful negotiated the approval process, adding in requirements for approvals by political appointees instead leaving the decision in the hands of public health and advertising professionals, and re-bidding contracts that could have been extended. The new DHS procedures have reduced the effectiveness of the anti-tobacco media campaign, once the centerpiece of Proposition 99, and this reduced effectiveness, combined with overall programme budget cuts,2 is reflected in a failure to make progress in reducing tobacco use (figure3).11

    It is clear, however, that the public health groups have been effective in forcing the Wilson administration to run a more aggressive campaign than it wanted. Their repeated requests to be involved in the review process were denied, although by the end of the year the pressure they brought on the programme from the outside, combined with the threat of a legislative hearing, appeared to have had a positive effect on the quality of the media campaign. Through use of paid and free media to call attention to the administration’s behaviour, public health advocates succeeded in forcing the administration to strengthen the advertisements to reflect good public health practice.

    The use of these kinds of outsider strategies are essential in protecting public health programmes from powerful insiders, like the tobacco industry. Outsider strategies are typically used by non-governmental organisations who have popular support and fewer resources, such as campaign contributions, for lobbying elected officials. Among the key outsider strategies that have been used successfully by advocates in California have been using the public forum provided by TEROC, creating print advertisements to call attention to programme problems, taking advantage of free media, and monitoring internal departmental activities through use of the public records act.

    TEROC was established legislatively to provide oversight for the tobacco education and research programmes funded by Proposition 99. By having programme advocates among its members and, importantly, having one as its chair, TEROC has been able to question publicly the conduct of the programme. As its meetings are open to the public, it also creates a venue for members of the press to follow programme controversies. For public health advocates, the existence of oversight bodies for public programmes can create an opportunity for putting public accountability into public health programmes. When such bodies are created by legislation or by administrative action, their responsibilities, powers, and membership are potentially important for the conduct of the programme and should be treated as such by programme lobbyists. It is important who is eligible for membership, who makes appointments to the body, and what responsibilities the body is given.

    The media—both paid advertising and free media—are important vehicles for putting pressure on public agencies. By running their own advertisements, programme advocates can create a forum in which they are able to frame issues publicly in a way that reflects their viewpoint. This is a particularly powerful strategy if other forums, such as legislatures or oversight bodies, have not been responsive. Such advertisements reach decision makers, the public, and reporters, and call attention to the fact that there are problems with the programme. This may also be an important avenue to obtaining free media in the form of news coverage. According to Steve Scott, managing editor of the California Journal, “ A lot of times what we look at as journalists to sort of guide us in determining what’s a real issue and what’s not a real issue is the attitude of the constituent groups.  . . . [T]he assumption was that if nobody’s making any noise about this then it’s just not that big a deal.”82 By taking an action as public as running an advertisement, public health groups can alert the media to an interesting story and thus provide heightened monitoring of programme implementation.

    In recent years, the tobacco industry has been using public records acts to try to impede agency functioning and to discredit agency programmes.83 Public records acts, however, can also be used by programme advocates to monitor how programme monies are being spent and the ways in which political appointees may be impeding the work of public health professionals. If information on programme implementation is not freely shared with programme advocates, then it may be necessary for them to force such information into the public domain.

    The challenge for the public health community is maintaining this level of outsider pressure over long periods of time, because the industry will continue its pressure on the inside to protect its interests. As more states embark on anti-tobacco advertising campaigns, either due to state and local initiatives or due to settlements of industry lawsuits, public health advocates need to understand the importance of helping to establish the rules by which this money will be spent and monitoring the process of spending it. Public health groups can help campaigns if they are allowed to be involved; if they are not, however, they can still protect the quality of the programme through outsider, advocacy strategies designed to hold public agencies accountable for mounting high-quality campaigns.

    Acknowledgments

    This work was supported by the National Cancer Institute (Grant CA-61021).

    References

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