Update:
Soon after announcing a 10% drop in teen smoking during the first year
of the program, several key members of the Florida campaign resigned or
were fired. Former staffers, say new restrictions imposed by the
legislature
may cripple the program's efforts to prevent teens from smoking. (More
background on the program is available in a paper
written in March 1999.)
Science, Politics and the
Florida Tobacco Pilot Program
Copyright 1999 Andrew Holtz
Executive Summary
During the 1990’s the prevalence of cigarette smoking and other
tobacco
use among youth has been increasing. In response to the health threat
posed
by tobacco, Florida’s late Gov. Lawton Chiles led the creation of the
Florida
Tobacco Pilot Program. The program used proceeds from Florida’s 1997
legal
settlement with the tobacco industry regarding Medicaid spending claims
to mount a comprehensive statewide effort to reduce tobacco use by
youth.
After just one year, the Florida Tobacco Pilot Program announced
a dramatic decline in youth smoking. But instead of celebrating,
program
supporters found themselves under assault. Gov. Chiles had died just
before
his term ended, and when critics in the 1999 legislature chopped away
parts
of the anti-tobacco program, supporters found they had no strong
political
champion. The Florida experience is a stark demonstration of the need
for
public health advocates to be as skilled at politics as they are at
science.
The Problem
Tobacco is considered the leading preventable cause of death in
the
United States. (McGinnis, 1993) Public health leaders have increasingly
taken the perspective that tobacco use is a “pediatric disease” since
almost
all current cigarette smokers began regular smoking during their teen
years.
(Kessler, 1996) Yet even as adult smoking prevalence continues to
decline,
during the 1990s the prevalence of cigarette smoking among teenagers
has
been rebounding. While 30% of high school seniors said they had smoked
during the last 30 days during mid-1980s, by 1997 the 30-day prevalence
had increased to 36.5% (CDC, 11/5/1999)
Florida Acts
Against this background, in 1997 the late Florida Governor Lawton
Chiles created a statewide program to prevent tobacco use among youth.
With Gov. Chiles’ strong support, the Florida legislature appropriated
$70 million dollars for the first full year of the program, using
proceeds
of the state’s $13 billion legal settlement with the tobacco industry.
With the mission of “empowering youth to live tobacco free,” the
Florida
Tobacco Pilot Program has four goals:
1. Change attitudes about tobacco;
2. Empower youth to lead community involvement against tobacco;
3. Reduce accessibility and availability of tobacco to youth; and
4. Reduce youth exposure to second hand smoke.
(Florida Department of Health, 9/28/1998)
The program employs a comprehensive strategy with five components:
Youth Programs and Community Partnerships, including
local coalitions in each of Florida’s 67 counties,
local chapters of Students Working Against Tobacco (SWAT);
Education and Training, including
curriculum materials with tobacco prevention themes,
smoking cessation programs in high schools;
Marketing and Communications, including
paid media campaign,
“Truth Train” and other special events;
Enforcement, including
retailer compliance education,
School-Proximity Tobacco Enforcement;
and Research and Evaluation, including
Florida Youth Tobacco Survey.
Each of these components also addressed the particularly needs of
minority
communities in Florida. (Florida Department of Health, 2/4/1999)
Florida’s effort built on previous research (Flynn, 1992; Flynn,
1994) showing that mass media campaigns coupled with school-based
education
produced significant and durable reductions in smoking acquisition in a
cohort of students compared to students in control communities. It also
benefited from the experience of other states, particularly California
and Massachusetts, that demonstrated the effectiveness of comprehensive
statewide tobacco prevention programs (along with tobacco tax
increases.)
In the period 1992-1996, per capita consumption of cigarettes declined
15.8% in California, 19.7% in Massachusetts, and only 6.1 % in the rest
of the United States. (CDC, 2/26/1999)
Measuring Progress
With an annual budget of $4.3 million, the Research and
Evaluation
component was a fundamental part of Florida’s tobacco control program
from
the very beginning. The flagship of this effort is the Florida Youth
Tobacco
Survey, overseen by the University of Miami Coordinating Center. The
baseline
survey in 1998 included a representative sample of 22,540 middle and
high
school students in 255 schools across the state. The first follow-up
survey
included 20,978 students from 242 of the schools that took part in the
first survey. The results of the 1999 survey came as a pleasant
surprise
to program leaders. From 1998 to 1999, the prevalence of current
cigarette
use among middle school students declined from 18.5% to 15.0%
(p<0.01);
among high school students, use declined from 27.4% to 25.2% (p=0.02).
(Bauer, 1999) Although Florida’s results could not be immediately
compared
to national figures, the CDC noted that the decline in smoking
prevalence
among youth was the largest seen in a single year since 1980. (Bauer,
1999)
(See Appendix A for
prevalence
results by sex, race/ethnicity and grade for 1998 and 1999.)
In between the statewide annual surveys, evaluators performed
dozens of focus groups and smaller surveys to track progress in
specific
groups and to measure the impact of components of the program on
knowledge,
attitudes and beliefs. For example, the Florida Anti-Tobacco Media
Evaluation
(FAME) performed by Florida State University specifically examined the
effects of the program’s $25 million dollar Marketing and
Communications
component. Within 6 months, more than 9 out of 10 teens in Florida were
aware of the campaign. (Florida Department of Health, 2/4/99)
“Truth”
The most prominent component of the program was its $25 million
anti-tobacco
advertising campaign. The private advertising firms hired to produce
media
spots quickly learned that youth were already aware that smoking is
unhealthy
and they would tune out a health-based campaign. Jared Perez, who was
SWAT’s
18-year-old SWAT marketing director, said they had to try a different
approach,
“So instead of saying smoking’s bad for you, which everybody knows
anyways,
it’s kinda beating a dead horse, we say, ‘the tobacco industry has lied
to you, it’s manipulated you, it’s using you, and now that you know
that,
do you still want to smoke, do you want to be a pawn and pay with your
life and your pocketbook?” (Jared Perez, personal communication,
2/16/99)
Youth responded to the “Truth” campaign’s anti-industry thrust
(Florida Department of Health, 2/4/99), but the frequent lampooning of
middle-age business executives did not go over as well with Republican
leaders of the state House.
And Consequences
The late Democratic Gov. Chiles had intended the program to be a
legacy of his administration. As the then-Acting director of the
program
put it, “He was willing to fight for this program, whatever it took. In
the last hours of the legislature, when the Speaker, the President and
the Governor make up their lists of the five or six things they gotta
have,
this was on the list for Governor Chiles.” (Peter Mitchell,
personal
communication, 3/31/99) However, the significance of the governor’s
commitment
also revealed a weakness in the political underpinnings of the program.
After Gov. Chiles died just before he was due to leave office, the
tobacco
program was left without a strong champion.
The new Republican governor, Jeb Bush, moved the program out of the
governor’s office and placed it under his Secretary of Health. Although
Gov. Bush asked the 1999 legislature to appropriate $61.5 million for
the
second year of the tobacco program, critics considered his support to
be
tepid. When House leaders threatened to kill the program, Gov. Bush’s
staff
said he favored the program, but he did not wage a public battle to
save
it. (Kennedy, 3/24/1999) The Bush administration also forced out Peter
Mitchell, the outspoken Acting Director of the program. The Florida
Secretary
of Health said he just wanted to take the program in a new direction,
but
Mitchell said that he was being sacrificed to appease the program’s
opponents
in the legislature. (Peter Mitchell, personal communication, 3/31/99)
Newspaper editorials from around the state came to the program’s
defense,
and polls by supporters indicated four out of five Florida voters
wanted
funding held stable, or even increased. (Campaign for Tobacco Free
Kids,
4/6/99) But other allies, such as the Florida chapters of the American
Cancer Society, American Heart Association and American Lung
Association
declined to criticize legislators. (Givel, 1999; William Novelli,
personal
communication, May 26, 1999)
Ultimately, the program survived, but funding declined from $70
million to less than $39 million. Eleven of 31 staffers were laid off,
including three of the most outspoken SWAT youth staff. Just before
leaving
her post, program spokeswoman Carlea Bauman expressed doubts about the
future of the program. “I’m concerned at this point, because I haven’t
seen much there to reassure me that there are people who understand
this
fight against the tobacco industry. (Clark, 6/3/1999)
After blazing out of the starting blocks, the Florida Tobacco
Pilot Program seemed to go into hibernation as it entered its second
year.
News on the program’s website has not been updated since May 1999.
Anti-tobacco
advocates warn the program has turned dull. (Kennedy, 10/30/1999)
Conclusions
The Florida Tobacco Pilot Program had solid public health science
on its side, but good science isn’t enough. As the director of the
Evaluation
component, Dr. Ed Trapido noted, “I can talk about research, I can’t
talk
about, I don’t know how to talk yet to politicians, and necessarily be
effective. I’m just learning that. That’s not what they teach you in
programs
of epidemiology.” (personal communication, 3/29/99)
The problem is not just that tobacco lobbyists have deep pockets;
although the tobacco industry made nearly $400,000 dollars in
contributions
to legislators and state political parties during 1997 and 1998.
(Givel,
1999) Anti-tobacco advocates and other observers say the political
hazards
in Florida were more subtle, that the brash, youth-oriented campaign
alienated
conservative legislators who were already skeptical of government
efforts
to change individual behavior. (Peter Mitchell, personal communication,
3/31/1999; John Kennedy, personal communication, 4/1/1999)
In order to achieve their goals, public health advocates need
to do a better job of navigating political channels. To say tobacco is
the leading preventable cause of death is correct, but insufficient.
Both
the goals and methods of public health programs, especially
controversial
ones such as tobacco control, must be presented persuasively to
political
and voters who may have other priorities. One such approach is an
appeal
to the logic and fairness of dedicating revenues from tobacco taxes and
legal settlement funds to the health care needs of smokers, smoking
cessation
programs, and the prevention of smoking among underage youth.
Organizations
that support public health goals should use the reservoir of public
goodwill
they enjoy to pursue ballot initiatives, such as those that created
tobacco
control programs in Oregon and California. It is generally harder for
legislators
to openly repeal a vote of the people, than it is to move
appropriations
around in a committee room.
Above all, public health advocates must realize that they must
work just as hard at building alliances and appealing to public opinion
as they do at devising solid research designs and working through peer
review. Unlike cell culture studies, public health is not performed in
a laboratory, but on the larger stage of politics, money and social
attitudes.
Specific Disclaimers:
Even though Florida boasted a dramatic decrease in smoking
prevalence
among youth in the first year of the Tobacco Pilot Program, questions
about
the actual effectiveness of the program remain. National figures that
can
be directly compared to the results of the Florida Youth Tobacco Survey
are needed, in order to see if what happened in the state was truly
exceptional,
or just part of a larger trend. (Jeff McKenna, CDC, personal
communication,
3/21/99) Although focus groups and other instruments indicate that the
program did affect knowledge, attitudes and beliefs of youth, the
effects
on prevalence of price hikes during the study period has not been
directly
assessed. (Bauer, 1999) Just as some uncertainty remains about the
effectiveness
of the first year of the program, if progress stalls during the second
year, it may be difficult to assign blame to program cuts and changes
made
by the 1999 legislature and the new program managers.
In addition, the viewpoints of program critics cannot be simply
dismissed as wrong-headed, for they raise fundamental issues of
autonomy
and the relative roles of individuals, business and government. There
is
no doubt that reduce tobacco use would reduce tobacco-related illness
and
death, but anti-tobacco advocates must make a convincing case for the
manner
in which they seek to interfere with self-destructive behavior. The
Florida
program focused on youth who are too young to legally smoke cigarettes,
but the critics main complaint was the vilification of tobacco industry
executives, who contend that they market their products to adults only.
The Florida Tobacco Pilot Program experience raises issues of
science, politics, advocacy and ethics; in other words it is an example
of the practice of public health in all its dimensions.
Bauer, U; Johnson, T; Pallentino JD; et al. Tobacco Use Among Middle
and High School Students – Florida, 1998 and 1999. MMWR. April 2, 1999.
48(12). 248-253.
Campaign for Tobacco Free Kids press release, April 4, 1999.
Retrieved
on April 7, 1999 from
http://www.tobaccofreekids.org/html/releases.cfm?id=204
Centers for Disease control and Prevention, Office of Smoking and
Health.
Tobacco Use – United States, 1900-1999. MMWR. 48(43). 986-994.
Centers for Disease Control and Prevention. Decline in Cigarette
Consumption
Following Implementation of a Comprehensive Tobacco Prevention and
Education
Program - Oregon, 1996–1998. MMWR. February 26, 1999. 48 (7):140-3
Clark, L. Anti-tobacco ad staff cut, alarming activists in The Miami
Herald. June 3, 1999.
FDA Commissioner David A. Kessler, as quoted in an FDA press release
on August 23, 1996. Retrieved on December 8, 1999 from
http://www.os.dhhs.gov/news/press/1996pres/960823a.html
Florida Department of Health, Department of Business and
Professional
Regulation, Florida Tobacco Pilot Program Progress Report, Second
Quarter
Fiscal Year 1998-99, February 4, 1999
Florida Department of Health, Department of Business and
Professional
Regulation, Florida Tobacco Pilot Program Progress Report, Fiscal Year
1997-98 & First Quarter Fiscal Year 1998-99, September 28, 1998
Flynn BS, Worden JK, Secker-Walker RH, Badger GJ, Geller BM,
Costanza
MC (1992). Prevention of cigarette smoking through mass media
intervention
and school programs. American Journal of Public Health, 82, 827-834.
Flynn BS, Worden JK, Secker-Walker RH, Pirie PL, Badger GJ,
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JH, Geller BM, (1994). Mass media and school interventions for
cigarette
smoking prevention; effects two years after completion. American
Journal
of Public Health, 84,1148-1150.
Givel, MS; Glantz, SA. Tobacco Industry Political Power and
Influence
in Florida From 1979 to 1999. Institute for Health Policy Studies,
School
of Medicine, University of California, San Francisco. San Francisco CA
94143-0936. May 1999
Kennedy, J. Critics say state sends wrong smoking signals, in The
Orlando
Sentinel, October 30, 1999.
Kennedy, J. Is governor blowing smoke on 'Truth?' in The Orlando
Sentinel,
March 24, 1999.
Mcginnis, J; Foege, W. Actual causes of death in the United States.
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