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Tobacco War charts the dramatic and complex history of tobacco politics in California over the past quarter century. Beginning with the activities of a small band of activists who, in the 1970s, put forward the radical notion that people should not have to breathe second-hand tobacco smoke, Stanton Glantz and Edith Balbach follow the movement through the 1980s, when activists created hundreds of city and county ordinances by working through their local officials, to the present--when tobacco is a highly visible issue in American politics and smoke-free restaurants and bars are a reality throughout the state. The authors show how these accomplishments rest on the groundwork laid over the past two decades by tobacco control activists who have worked across the U.S. to change how people view the tobacco industry and its behavior. Tobacco War is accessibly written, balanced, and meticulously researched. The California experience provides a graphic demonstration of the successes and failures of both the tobacco industry and public health forces. It shows how public health advocates slowly learned to control the terms of the debate and how they discovered that simply establishing tobacco control programs was not enough, that constant vigilance was necessary to protect programs from a hostile legislature and governor. In the end, the California experience proves that it is possible to dramatically change how people think about tobacco and the tobacco industry and to rapidly reduce tobacco consumption. But California's experience also demonstrates that it is possible to run such programs successfully only as long as the public health community exerts power effectively. With legal settlements bringing big dollars to tobacco control programs in every state, this book is must reading for anyone interested in battling and beating the tobacco industry

In this paper, we examine efforts by health organizations seeking comprehensive smokefree ordinances over Louisiana casinos and bars between 2010 and 2020 to determine best practices for increasing coverage. Bars and casinos remain less protected from secondhand smoke compared to other workplaces in the United States. Casino behavior is compared to the Policy Dystopia Model (PDM), a tobacco industry strategy framework. We performed a historical case study using snowball searches for news on the Access World News Database and the internet. We performed web searches using the names of key actors, organizations, and locations and interviewed nine participants. Starting in 2010, the Louisiana Campaign for Tobacco-Free Living ran ordinance campaigns supplemented by an ongoing statewide smokefree media initiative. Utilizing consistent strategies, including promoting performers as cultural emblems deserving protection, health organizations coalesced in New Orleans during 2014 and Baton Rouge in 2016 and 2017 to pursue ordinances. The coalitions secured ordinances in Louisiana's population and tourism centers despite business resistance. Organizations obtained 30 smokefree laws across Louisiana by 2021. Casinos used PDM strategies to resist ordinances, indicating the framework may predict strategies by non-tobacco entities resisting tobacco control. Louisiana shows that ongoing local campaigns, social justice themes and cultural messaging with coalitions in cities can secure smokefree laws covering casinos and bars and that local ordinance campaigns are a viable method for advancing smokefree protections over those venues in states where the state legislatures are resistant to action.

In 2019, San Francisco, California, prohibited the sale of electronic cigarettes lacking US Food and Drug Administration authorization. JUUL then promoted a ballot initiative (Proposition C) to replace San Francisco's e-cigarette legislation with legislation JUUL wrote that required future legislation to be approved by the voters. JUUL promoted Proposition C as a way to reduce youth e-cigarette use while allowing adult choice. Health groups argued that JUUL's measure could nullify San Francisco's prohibition on selling flavored tobacco products. Health groups benefitted from having an established campaign network that recently defended the flavor ban. They successfully framed Proposition C as a tobacco industry ploy to undo San Francisco's e-cigarette regulations, particularly the prohibition on selling flavored tobacco products. JUUL ended its campaign on September 30, 2019, and the measure failed on election day, with 82% voting against it. Lessons learned from the campaign include the importance of framing an industry initiative as a threat to local public health lawmaking and the potential for the e-cigarette issue to attract parents as new leaders and engage a powerful constituency to support tobacco control measures.

CONTEXT: As of November 2018, medical cannabis was legal in 33 US states and recreational cannabis in 10, mostly enacted via ballot initiative. METHODS: We identified 32 cannabis legalization initiatives from 2004 to 2016 and obtained campaign contribution and state political and demographic data. After exploratory analyses of 15 potential independent variables, we quantified effects of 4 factors (initiative year, voter turnout, population born before 1946, advocate funding advantage) on voter support and likelihood of passage. FINDINGS: A small number of campaign contributors dominated both sides of the issue, with little involvement by health advocates. Time and turnout, not money, were the factors most associated with electoral outcomes, consistent with increases in public opinion favoring cannabis legalization over time. Year, turnout, and population age were associated with voter support, while year, turnout, and advocate funding advantage were associated with likelihood of passage. When adjusting for an anomalous result, initiative year was the only variable that remained significantly associated with odds of passage, with a 1-year increase in initiative date associated with 2.02 times higher odds of passage (p < .01). CONCLUSION: These results underscore the importance of health advocate participation in developing cannabis legalization frameworks.

Cannabis is widely used in the U.S. and internationally despite its illicit status, but that illicit status is changing. In the U.S., 33 states and the District of Columbia have legalized medical cannabis, and 11 states and D.C. have legalized adult use cannabis. A majority of state medical cannabis laws and all but two state adult use laws are the result of citizen ballot initiatives, but state legislatures are beginning to seriously consider adult use legislation. From a public health perspective, cannabis legalization presents a mix of potential risks and benefits, but a legislative approach offers an opportunity to improve on existing legalization models passed using the initiative process that strongly favor business interests over public health. To assess whether state legislatures are acting on this opportunity, this article examines provisions of proposed adult use cannabis legalization bills active in state legislatures as of February 2019 to evaluate the inclusion of key public health best practices based on successful tobacco and alcohol control public health policy frameworks. Given public support for legalization, further adoption of state adult use cannabis laws is likely, but legalization should not be viewed as a binary choice between total prohibition and laissez faire commercialization. The extent to which adult use cannabis laws incorporate or reject public health best practices will strongly affect their impact, and health advocates should work to influence the construction of such laws to prioritize public health and learn from past successes and failures in regulating other substances.

Although the acceleration of cannabis legalization in the United States has spurred innovations in public administration and policymaking, there have been news accounts of public employees engaged in cannabis licensure or enforcement that constitute conflicts of interest (COIs). After conducting 3 surveys in 50 states (including Washington, DC as a state), we found that COI provisions pertaining to cannabis-related public employment fell into 2 categories: subject matter general and cannabis specific. Only 20% (6/30) of the states that legalized medical cannabis had COI provisions in their medical cannabis codes, whereas the remaining 80% rely on subject matter general provisions relating to all areas of regulated subject matter, highlighting the need for thoughtful creation of COI rules in future policymaking. By contrast, 88% (7/8) of states that have legalized adult use cannabis put their COI provisions directly in their cannabis codes or regulations. Governments should enact cannabis-specific COI policies applicable to broadly defined categories of public employees that are responsive to the unique context of bringing cannabis from the black market into the regulated market.

BackgroundCigarette packs are a form of advertising that distributes brand information wherever smokers go. In the 21st century, tobacco companies began using onserts on cigarette packs to communicate new advertising messages to smokers.MethodsWe reviewed tobacco industry documents dated 1926 to 2017 to identify how the tobacco industry developed and used onserts in marketing and to serve the industry's political and legal objectives.ResultsOnserts added to cigarette packs became a more cost-effective way for brands to market in the year 2000. Manufacturers then began studying them, finding that new messages were appealing, while repeated messages were ignored. By 2005, tobacco companies were using onserts to effectively communicate about new tobacco products and packaging changes. They also used repeated 'corporate responsibility' messages that were, according to the industry's own research, likely to be ignored.ConclusionsTobacco companies have expanded on cigarette pack-based advertising. Twenty-first century onserts simultaneously seek to increase sales using materials that are novel, attractive and provide independent value, while undercutting public health messages about the risks of tobacco use using materials that repeat over time and are comparatively unattractive. Health authorities can use this industry research to mandate onserts to communicate effective health messages.

BACKGROUND: Cigarette packs are a form of advertising that distributes brand information wherever smokers go. In the 21st century, tobacco companies began using onserts on cigarette packs to communicate new advertising messages to smokers. METHODS: We reviewed tobacco industry documents dated 1926 to 2017 to identify how the tobacco industry developed and used onserts in marketing and to serve the industry's political and legal objectives. RESULTS: Onserts added to cigarette packs became a more cost-effective way for brands to market in the year 2000. Manufacturers then began studying them, finding that new messages were appealing, while repeated messages were ignored. By 2005, tobacco companies were using onserts to effectively communicate about new tobacco products and packaging changes. They also used repeated 'corporate responsibility' messages that were, according to the industry's own research, likely to be ignored. CONCLUSIONS: Tobacco companies have expanded on cigarette pack-based advertising. Twenty-first century onserts simultaneously seek to increase sales using materials that are novel, attractive and provide independent value, while undercutting public health messages about the risks of tobacco use using materials that repeat over time and are comparatively unattractive. Health authorities can use this industry research to mandate onserts to communicate effective health messages.

In the United States, state laws establish a minimum age of legal access (MLA) for most tobacco products at 18 years. We reviewed the history of these laws with internal tobacco industry documents and newspaper archives from 1860 to 2014. The laws appeared in the 1880s; by 1920, half of states had set MLAs of at least 21 years. After 1920, tobacco industry lobbying eroded them to between 16 and 18 years. By the 1980s, the tobacco industry viewed restoration of higher MLAs as a critical business threat. The industry's political advocacy reflects its assessment that recruiting youth smokers is critical to its survival. The increasing evidence on tobacco addiction suggests that restoring MLAs to 21 years would reduce smoking initiation and prevalence, particularly among those younger than 18 years.

BackgroundIt has been argued that as smoking prevalence declines in countries, the smokers that remain include higher proportions of those who are unwilling or unable to quit (a process known as 'hardening'). Smokeless tobacco and e-cigarettes have been promoted as a strategy to deal with such smokers. If hardening is occurring, there would be a positive association between smoking prevalence and quitting, with less quitting at lower prevalence. There would also be a neutral or negative association between prevalence and the number of cigarettes smoked.MethodsWe examined US state-level associations using the Tobacco Use Supplement (1992/1993-2010/2011) and Eurobarometer surveys for 31 European countries (2006-2009-2012) using regressions of quit attempts, quit ratios, and number of cigarettes smoked on smoking prevalence over time.ResultsFor each 1% drop in smoking prevalence, quit attempts increase by 0.55%±.07 (p0.24), with significantly lower consumption at any given prevalence level as time passed in the USA (-0.15 (cig/day)/year±0.06, p<0.05).ConclusionsConsistent with prior research using different data and methods, these population-level results reject the hypothesis of hardening as smoking prevalence drops, instead supporting softening of the smoking population as prevalence declines.

Cumulative exposure to on-screen smoking is a major recruiter of new young smokers. Policy solutions—including R-rating films with tobacco imagery and making productions with tobacco ineligible for public subsidies—are backed by health authorities in California and worldwide. Exposure to on-screen smoking accounts for nearly 100,000 current smokers in California aged 12-17. Total costs of medical services for this group, through age 50, are estimated at $1.6 billion (discounted present value). Two-thirds of the cost will be borne by government. Top-grossing films made in California accounted for one-third of United States audience exposure to on-screen tobacco imagery 2002-11. From mid-2009 through 2011, California approved $374 million in film and television production subsidies, in the form of tax credits. $128 million was approved for 27 feature films, released widely 2010-11, that achieved top-grossing status. Sixteen of these films featured tobacco imagery; $75 million was approved for these films, which made $1.1 billion at the box office. More than two-thirds ($51 million) of California tax credits approved for top-grossing films with tobacco imagery went to PG-13 films. Nearly 80 percent (2 billion/2.5 billion) of in-theater tobacco impressions delivered in the US and Canada by California-subsidized, top-grossing films came from films rated PG-13. (The rest came from R-rated films.) Tobacco content of top-grossing films varies by company. Forty-four percent of California subsidies approved for top-grossing feature were reserved for films released by Sony and Viacom (Paramount). Films from these two companies garnered 71 percent of California subsidies for films with tobacco and 83 percent of subsidies for youth-rated (PG-13) films with tobacco. Of the $1.6 billion in costs of direct medical services that will be incurred for teen smokers in California recruited by their exposure to films with tobacco imagery, $510 million is attributable to adolescents' exposure to films made in California. If the California film subsidy program continues and the pattern of subsidies and smoking films remains the same as in the past, films containing tobacco and subsidized by California taxpayers will contribute an estimated 17,000 new 12-17 year old smokers among the next cohort of 12-17 year old smokers in California, who will incur an estimated $270 million in smoking-induced costs. Public health authorities, including the US Centers for Disease Control and Prevention, the World Health Organization, the director of Los Angeles County's Department of Public Health, and the chair of California's Tobacco Education and Research Oversight Committee (TEROC) have highlighted the policy contradiction between state subsidies for films with tobacco imagery and state tobacco prevention programs. The policy solution is to amend the California tax credit program statute, adding the following to the existing list of productions disqualified from eligibility for subsidy: …any production that depicts or refers to any tobacco product or non-pharmaceutical nicotine delivery device or its use, associated paraphernalia or related trademarks or promotional material. Such a change would end the practice of taxpayers paying for commercial films with tobacco imagery that subvert the important public goal of reducing youth smoking and its consequent health costs, many of which are borne by the public.

ObjectiveTo describe the process of approval and implementation of a comprehensive smoke-free law in the province of Santa Fe, Argentina, between 2005 and 2009.MethodsReview of the Santa Fe smoke-free legislation, articles published in local newspapers and documentation on two lawsuits filed against the law, and interviews with key individuals in Santa Fe.ResultsEfforts to implement smoke-free policies in Santa Fe began during the 1990s without success, and resumed in 2005 when the provincial Legislature approved the first 100% smoke-free subnational law in Argentina. There was no strong opposition during the discussions within the legislature. As in other parts of the world, pro-tobacco industry interests attempted to block the implementation of the law using well known strategies. These efforts included a controversy media campaign set up, the creation of a hospitality industry association and a virtual smokers' rights group, the introduction of a counterproposal seeking modification of the law, the challenge of the law in the Supreme Court, and the proposal of a weak national bill that would 'conflict' with the subnational law. Tobacco control advocates sought media attention as a strategy to protect the law.ConclusionsSanta Fe is the first subnational jurisdiction in Latin America to have enacted a comprehensive smoke-free policy following the recommendations of the World Health Organization (WHO) Framework Convention on Tobacco Control. After 3 years of implementation, pro-tobacco industry forces failed to undermine the law. Other subnational jurisdictions in Argentina, as well as in Mexico and Brazil are following the Santa Fe example.

The cigarette companies and their lobbying organization used tobacco industry-produced films and videos about tobacco farming to support their political, public relations, and public policy goals. Critical discourse analysis shows how tobacco companies utilized film and video imagery and narratives of tobacco farmers and tobacco economies for lobbying politicians and influencing consumers, industry-allied groups, and retail shop owners to oppose tobacco control measures and counter publicity on the health hazards, social problems, and environmental effects of tobacco growing. Imagery and narratives of tobacco farmers, tobacco barns, and agricultural landscapes in industry videos constituted a tobacco industry strategy to construct a corporate vision of tobacco farm culture that privileges the economic benefits of tobacco. The positive discursive representations of tobacco farming ignored actual behavior of tobacco companies to promote relationships of dependency and subordination for tobacco farmers and to contribute to tobacco-related poverty, child labor, and deforestation in tobacco growing countries. While showing tobacco farming as a family and a national tradition and a source of jobs, tobacco companies portrayed tobacco as a tradition to be protected instead of an industry to be regulated and denormalized.

Professor Henderson has simply repeated the same two points he made in his earlier critique (Henderson 2007) of our article "Smoke-free Ordinances Increase Restaurant Profit and Value" (Alamar and Glantz 2004). He argues 1.) that secondhand smoke is not an externality, therefore no government intervention is required to protect workers and customers in restaurants and bars, and 2.) the empirical results in the paper are not conclusive because the data are cross-sectional. Henderson also issues a challenge for us to advocate for the repeal of the California law on smoke-free restaurants. While we enjoy a good debate and do not mind adding another publication to our CVs, we do hope that Prof. Henderson will not find the burning desire to restate his position again, after we respond this last time.