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Tobacco war
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    Tobacco war: inside the California battles. Stanton A Glantz, Edith D Balbach. Berkeley, California, University of California Press, 2000. ISBN 0-520-22285-7. 469 pages.

    For a decade, since voters there approved a referendum question raising the state's cigarette excise tax and assigning a portion of the revenue to a campaign to reduce tobacco use, California has been a cockpit of conflict between public health forces and the tobacco industry. For most of that time, Stanton Glantz, Professor of Medicine at the University of California, San Francisco, has been an important figure in the struggle. This is his history of it, written with Edith Balbach, Director of the Community Health Program at Tufts University in Boston.

    For readers of this journal, Tobacco war is most useful not for its accounts of tobacco industry perfidy, but for describing the evolution of tactics used by health advocates to counter the industry's political strategy. In California, the war has been fought at the local and state levels, and in the electoral, legislative, and administrative arenas.

    The authors' main theme is that tobacco control advocates most effectively influence public policy by mobilising public opinion, rather than employing traditional lobbying techniques. Glantz and Balbach repeatedly demonstrate that the conventional insider tactics of influence, persuasion, and compromise result in setbacks for tobacco control, while an aggressive public posture that confronts not only the tobacco industry but also its political allies leads to victory.

    Their argument is that public health agencies, which do not make political campaign contributions or employ influential lobbyists, cannot compete at the insider game with the cigarette manufacturers, which do both to an almost unparalleled extent. But, “[t]he agencies . . . enjoy high name recognition and credibility with the public. By contrast, the tobacco industry has very low public credibility. This difference in public standing means that outside strategies are likely to be the public health community's best means to achieve good tobacco policy, because the skills and resources of the voluntary health agencies tend to be amplified in public arenas while those of the tobacco industry are muted. But outsider strategies require a commitment of resources to a continuous public information effort. Equally important, they require a willingness to anger powerful politicians and interest groups by publicizing their misdeeds.”

    Glantz and Balbach understate the importance and necessity of effectively playing the inside game. Effective legislative advocacy helps assure that public opinion is translated into effective, not cosmetic, policy. And they may overestimate the depth and durability of the public's goodwill, once health agencies begin to use it. But the point is well taken. Their halo of disinterested concern for public health is the best weapon voluntary agencies have in fighting the tobacco industry, and its judicious use, combined with effective lobbying, is the surest path to success.

    The recent infusion of tobacco settlement money into the US states has changed the political dynamics of tobacco control advocacy. Voluntary agencies, which only recently adopted an aggressive stance towards Big Tobacco, are now learning that they must confront both the industry's allies in public office and other interests, some of them quite worthy, competing for the funds. The California experience is sure to be repeated, and careful attention to the history recounted inTobacco war will help others avoid some of the mistakes made there.

    A most depressing element of the California story is the role played by organised medicine. The California Medical Association (CMA) paid lip service to the 1988 Proposition effort while working behind the scenes to undermine it because the CMA wanted to avoid alienating the tobacco industry, with which it had made common cause in weakening medical and product liability laws. When the Proposition won, the CMA embarked on a years long effort to shift money from the tobacco control programme into medical care accounts (and, incidentally, doctor's pockets).

    One hopes that most physicians would not endorse this kind of political deal making at the expense of public health. But the people they hire through their associations to represent them, committed to playing the inside game, will continue to sell out tobacco control over pocketbook issues until the membership tells them to do otherwise. Providers concerned about tobacco control need to do more to hold their professional organisations accountable for tobacco control advocacy.

    Despite Glantz's involvement in many of the events described,Tobacco war is a largely even-handed account of the major issues confronted by California's tobacco control movement, particularly during the 1990s. In writingTobacco war, the authors drew on interviews with many of the players (including some from the other side), contemporaneous memoranda and news reports, and internal company documents uncovered through state lawsuits against the cigarette manufacturers. These last help elucidate the industry's strategy and its analysis of the health advocates' activities.

    This reader would have appreciated a brief description of the research methodology, particularly the interview procedures. Not everyone's viewpoint is adequately represented, and there are occasions when the actions of tobacco control advocates are questioned by the authors or by other participants, without any response from the accused. This is jarring in view of how much of the text consists of verbatim quotes from participants.

    But, all in all, this is an important book for the tobacco control movement. It is an interesting, at times compelling, narrative, containing many object lessons that anyone engaged in tobacco control policy advocacy will benefit from.