Enacting tobacco taxes by direct popular vote in the United States: lessons from 20 years of experience.

BACKGROUND: Tobacco tax increases reduce tobacco use, can provide funds for tobacco prevention and enjoy broad public support. Because of tobacco industry influence in legislatures, US public health advocates have shifted the venue for tobacco tax policymaking to direct popular vote 22 times since 1988. METHODS: We combined case studies of individual state campaigns with tobacco industry documents to identify strategies related to outcome. RESULTS: The tobacco industry developed a voter segmentation model to determine which tobacco tax increases it could defeat. Two industry arguments arising from this model often were raised in losing campaigns-the tax increase did not dedicate enough to tobacco control and hospitals and health maintenance organisations would profit. The industry effectively influenced early voters. Success was associated with building a strong base of public support before the campaign, dedicating sufficient funds to tobacco control, avoiding proposals largely devoted to financing hospitals and other medical service providers, effectively engaging grassroots and framing the campaign with clear justifications for cigarette tax increases. CONCLUSIONS: Tobacco tax ballot measures commonly allocated substantial funds to medical services; tobacco companies are becoming more successful in making this use of funds an issue. Proponents' campaigns should be timed to account for the trend to voting well before election day. Ballot measures to increase tobacco taxes with a substantial fraction of the money devoted to tobacco control activities will probably fare better than ones that give priority to funding medical services.

Civil society and the negotiation of the Framework Convention on Tobacco Control.

Tobacco control civil society organisations mobilised to influence countries during the negotiation of the World Health Organisation (WHO) Framework Convention on Tobacco Control (FCTC) between 1999 and 2003. Tobacco control civil society organisations and coalitions around the world embraced the idea of an international tobacco control treaty and came together as the Framework Convention Alliance (FCA), becoming an important non-state actor within the international system of tobacco control. Archival documents and interviews demonstrate that the FCA successfully used strategies, including publication of a newsletter, shaming symbolism and media advocacy to influence policy positions of countries during the FCTC negotiation. The FCA became influential in the negotiation process, by mobilising tobacco control civil society organisations and resources with the help of the Internet, and framing the tobacco control discussion around global public health.

Signed, sealed and delivered: "big tobacco" in Hollywood, 1927-1951.

OBJECTIVE: Smoking in movies is associated with adolescent and young adult smoking initiation. Public health efforts to eliminate smoking from films accessible to youth have been countered by defenders of the status quo, who associate tobacco imagery in "classic" movies with artistry and nostalgia. The present work explores the mutually beneficial commercial collaborations between the tobacco companies and major motion picture studios from the late 1920s through the 1940s. METHODS: Cigarette endorsement contracts with Hollywood stars and movie studios were obtained from internal tobacco industry documents at the University of California, San Francisco (UCSF) Legacy Tobacco Documents Library and the Jackler advertising collection at Stanford. RESULTS: Cigarette advertising campaigns that included Hollywood endorsements appeared from 1927 to 1951, with major activity in 1931-2 and 1937-8 for American Tobacco Company's Lucky Strike, and in the late 1940s for Liggett & Myers' Chesterfield. Endorsement contracts and communication between American Tobacco and movie stars and studios explicitly reveal the cross-promotional value of the campaigns. American Tobacco paid movie stars who endorsed Lucky Strike cigarettes US$218,750 in 1937-8 (equivalent to US$3.2 million in 2008) for their testimonials. CONCLUSIONS: Hollywood endorsements in cigarette advertising afforded motion picture studios nationwide publicity supported by the tobacco industry's multimillion US dollar advertising budgets. Cross-promotion was the incentive that led to a synergistic relationship between the US tobacco and motion picture industries, whose artefacts, including "classic" films with smoking and glamorous publicity images with cigarettes, continue to perpetuate public tolerance of onscreen smoking. Market-based disincentives within the film industry may be a solution to decouple the historical association between Hollywood films and cigarettes.

Evidence secondhand smoke causes breast cancer in 2005 stronger than for lung cancer in 1986.

OBJECTIVES: To compare the strength of evidence from epidemiologic studies of secondhand smoke of the US Surgeon General's 1986 conclusion that secondhand smoke caused lung cancer with the California Environmental Protection Agency's (CalEPA) similar 2005 conclusion on breast cancer in younger, primarily premenopausal women. METHODS: We reviewed each report for criteria used to assess causality: numbers of studies, statistically significant increases in risk, and pooled summary risk estimates. RESULTS: Both the Surgeon General and CalEPA used updated Bradford Hill criteria for assessing causality and found that the evidence met those criteria. Six of 13 lung cancer studies (46%) had statistically significant increases (one of three cohort studies). Pooled risk estimates for lung cancer for spousal exposure were 1.53 for 10 combined case-control studies and 1.88 for seven studies with dose-response results. The CalEPA reported 10 of 14 studies (71%) had statistically significant increases in breast cancer risk (two of four cohort studies). Pooled relative risk estimates for younger, primarily premenopausal women were 1.68 (95% CI: 1.33, 2.12) for all exposed women and 2.19 (1.68, 2.84) for five studies with better exposure assessment. CONCLUSIONS: The evidence from epidemiologic studies of secondhand smoke in 2005 for breast cancer in younger, primarily premenopausal women was stronger than for lung cancer in 1986.

Eliminating child labour in Malawi: a British American Tobacco corporate responsibility project to sidestep tobacco labour exploitation.

OBJECTIVES: To examine British American Tobacco and other tobacco industry support of the Eliminating Child Labour in Tobacco Growing Foundation. DESIGN: Analyses of internal tobacco industry documents and ethnographic data. RESULTS: British American Tobacco co-founded the Eliminating Child Labour in Tobacco Growing Foundation (ECLT) in October 2000 and launched its pilot project in Malawi. ECLT's initial projects were budgeted at US2.3 million dollars over four years. Labour unions and leaf dealers, through ECLT funds, have undertook modest efforts such as building schools, planting trees, and constructing shallow wells to address the use of child labour in tobacco farming. In stark contrast, the tobacco companies receive nearly US40 million dollars over four years in economic benefit through the use of unpaid child labour in Malawi during the same time. BAT's efforts to combat child labour in Malawi through ECLT was developed to support the company's "corporate social responsibility agenda" rather than accepting responsibility for taking meaningful steps to eradicate child labour in the Malawi tobacco sector. CONCLUSION: In Malawi, transnational tobacco companies are using child labour projects to enhance corporate reputations and distract public attention from how they profit from low wages and cheap tobacco.

German tobacco industry's successful efforts to maintain scientific and political respectability to prevent regulation of secondhand smoke.

OBJECTIVE: To examine the tactics the tobacco industry in Germany used to avoid regulation of secondhand smoke exposure and to maintain the acceptance of public smoking. METHODS: Systematic search of tobacco industry documents available on the internet between June 2003 and August 2004. RESULTS: In West Germany, policymakers were, as early as the mid 1970s, well aware of the fact that secondhand smoke endangers non-smokers. One might have assumed that Germany, an international leader in environmental protection, would have led in protecting her citizens against secondhand smoke pollution. The tobacco manufacturers in Germany, however, represented by the national manufacturing organisation "Verband" (Verband der Cigarettenindustrie), contained and neutralised the early debate about the danger of secondhand smoke. This success was achieved by carefully planned collaboration with selected scientists, health professionals and policymakers, along with a sophisticated public relations programme. CONCLUSIONS: The strategies of the tobacco industry have been largely successful in inhibiting the regulation of secondhand smoke in Germany. Policymakers, health professionals, the media and the general public should be aware of this industry involvement and should take appropriate steps to close the gap between what is known and what is done about the health effects of secondhand smoke.

Tobacco industry successfully prevented tobacco control legislation in Argentina.

OBJECTIVE: To evaluate how transnational tobacco companies, working through their local affiliates, influenced tobacco control policymaking in Argentina between 1966 and 2005. METHODS: Analysis of internal tobacco industry documents, local newspapers and magazines, internet resources, bills from the Argentinean National Congress Library, and interviews with key individuals in Argentina. RESULTS: Transnational tobacco companies (Philip Morris International, British American Tobacco, Lorillard, and RJ Reynolds International) have been actively influencing public health policymaking in Argentina since the early 1970s. As in other countries, in 1977 the tobacco industry created a weak voluntary self regulating code to avoid strong legislated restrictions on advertising. In addition to direct lobbying by the tobacco companies, these efforts involved use of third party allies, public relations campaigns, and scientific and medical consultants. During the 1980s and 1990s efforts to pass comprehensive tobacco control legislation intensified, but the organised tobacco industry prevented its enactment. There has been no national activity to decrease exposure to secondhand smoke. CONCLUSIONS: The tobacco industry, working through its local subsidiaries, has subverted meaningful tobacco control legislation in Argentina using the same strategies as in the USA and other countries. As a result, tobacco control in Argentina remains governed by a national law that is weak and restricted in its scope.

Tobacco industry consumer research on socially acceptable cigarettes.

OBJECTIVE: To describe tobacco industry consumer research to inform the development of more "socially acceptable" cigarette products since the 1970s. METHODS: Analysis of previously secret tobacco industry documents. RESULTS: 28 projects to develop more socially acceptable cigarettes were identified from Philip Morris, RJ Reynolds, British American Tobacco, and Lorillard tobacco companies. Consumer research and concept testing consistently demonstrated that many smokers feel strong social pressure not to smoke, and this pressure increased with exposure to smoking restrictions. Tobacco companies attempted to develop more socially acceptable cigarettes with less visible sidestream smoke or less odour. When presented in theory, these product concepts were very attractive to important segments of the smoking population. However, almost every product developed was unacceptable in actual product tests or test markets. Smokers reported the complete elimination of secondhand smoke was necessary to satisfy non-smokers. Smokers have also been generally unwilling to sacrifice their own smoking satisfaction for the benefit of others. Many smokers prefer smoke-free environments to cigarettes that produce less secondhand smoke. CONCLUSIONS: Concerns about secondhand smoke and clean indoor air policies have a powerful effect on the social acceptability of smoking. Historically, the tobacco industry has been unable to counter these effects by developing more socially acceptable cigarettes. These data suggest that educating smokers about the health dangers of secondhand smoke and promoting clean indoor air policies has been difficult for the tobacco industry to counter with new products, and that every effort should be made to pursue these strategies.

Tobacco industry influence on the definition of tobacco related disorders by the American Psychiatric Association.

OBJECTIVE: The Diagnostic and statistical manual of mental disorders, third edition (DSM-III), published by the American Psychiatric Association (APA) in 1980, included the first official definitions by the APA of tobacco dependence and tobacco withdrawal. Tobacco industry efforts to influence the DSM-III were investigated. METHOD: Searches of previously secret tobacco industry documents, primarily the University of California San Francisco Legacy Tobacco Documents Library and British American Tobacco collections. Additional information was collected through discussions with editors of DSM-III, and library and general internet searches. RESULTS: The tobacco companies regarded the inclusion of tobacco dependence as a diagnosis in DSM-III as an adverse event. It worked to influence the content of the DSM-III and its impact following publication. These efforts included public statements and private lobbying of DSM-III editors and high ranking APA officers by prominent US psychiatrists with undisclosed ties to the tobacco industry. Following publication of DSM-III, tobacco companies contracted with two US professors of psychiatry to organise a conference and publish a monograph detailing controversies surrounding DSM-III. CONCLUSIONS: The tobacco industry and its allies lobbied to narrow the definition of tobacco dependence in serial revisions of DSM-III. Following publication of DSM-III, the industry took steps to try to mitigate its impact. These actions mirror industry tactics to influence medical research and policy in various contexts worldwide. Such tactics slow the spread of a professional and public understanding of smoking and health that otherwise would reduce smoking, smoking induced disease, and tobacco company profits.

Emotions for sale: cigarette advertising and women's psychosocial needs.

OBJECTIVE: To explore messages of psychosocial needs satisfaction in cigarette advertising targeting women and implications for tobacco control policy. METHODS: Analysis of internal tobacco industry documents and public advertising collections. RESULTS: Tobacco industry market research attempted to identify the psychosocial needs of different groups of women, and cigarette advertising campaigns for brands that women smoke explicitly aimed to position cigarettes as capable of satisfying these needs. Such positioning can be accomplished with advertising that downplays or excludes smoking imagery. As women's needs change with age and over time, advertisements were developed to reflect the needs encountered at different stages in women's lives. Cigarette brands for younger women stressed female camaraderie, self confidence, freedom, and independence; cigarette brands for older women addressed needs for pleasure, relaxation, social acceptability, and escape from daily stresses. CONCLUSIONS: Psychosocial needs satisfaction can be communicated without reference to cigarettes or smoking. This may explain why partial advertising bans are ineffective and comprehensive bans on all forms of tobacco marketing are effective. Counter-advertising should attempt to expose and undermine the needs satisfaction messages of cigarette advertising campaigns directed at women.

Smoke-free law did not affect revenue from gaming in Delaware.

OBJECTIVE: To determine the effect of the Delaware smoke-free law on gaming revenue. METHODS: Linear regression of gaming revenue and average revenue per machine on a public policy variable, time, while controlling for economic activity and seasonal effects. RESULTS: The linear regression showed that the smoke-free law was associated with no effect on total revenue or average revenue per machine. CONCLUSION: Smoke-free laws are associated with no change in gaming revenue.

ARTIST (Asian regional tobacco industry scientist team): Philip Morris' attempt to exert a scientific and regulatory agenda on Asia.

OBJECTIVE: To describe how the transnational tobacco industry has collaborated with local Asian tobacco monopolies and companies to promote a scientific and regulatory agenda. METHODS: Analysis of previously secret tobacco industry documents. RESULTS: Transnational tobacco companies began aggressively entering the Asia market in the 1980s, and the current tobacco industry in Asia is a mix of transnational and local monopolies or private companies. Tobacco industry documents demonstrate that, in 1996, Philip Morris led an organisation of scientific representatives from different tobacco companies called the Asian Regional Tobacco Industry Science Team (ARTIST), whose membership grew to include monopolies from Korea, China, Thailand, and Taiwan and a company from Indonesia. ARTIST was initially a vehicle for PM's strategies against anticipated calls for global smoke-free areas from a World Health Organization secondhand smoke study. ARTIST evolved through 2001 into a forum to present scientific and regulatory issues faced primarily by Philip Morris and other transnational tobacco companies. Philip Morris' goal for the organisation became to reach the external scientific and public health community and regulators in Asia. CONCLUSION: The Asian tobacco industry has changed from an environment of invasion by transnational tobacco companies to an environment of participation with Philip Morris' initiated activities. With this participation, tobacco control efforts in Asia face new challenges as Philip Morris promotes and integrates its scientific and regulatory agenda into the local Asian tobacco industry. As the local Asian tobacco monopolies and companies can have direct links with their governments, future implementation of effective tobacco control may be at odds with national priorities.

How Philip Morris unlocked the Japanese cigarette market: lessons for global tobacco control.

BACKGROUND: The Framework Convention on Tobacco Control includes tobacco advertising restrictions that are strongly opposed by the tobacco industry. Marketing strategies used by transnational tobacco companies to open the Japanese market in the absence of such restrictions are described. METHODS: Analysis of internal company documents. FINDINGS: Between 1982 and 1987 transnational tobacco companies influenced the Japanese government through the US Trade Representative to open distribution networks and eliminate advertising restrictions. US cigarette exports to Japan increased 10-fold between 1985 and 1996. Television advertising was central to opening the market by projecting a popular image (despite a small actual market share) to attract existing smokers, combined with hero-centred advertisements to attract new smokers. Philip Morris's campaigns featured Hollywood movie personalities popular with young men, including James Coburn, Pierce Brosnan, Roger Moore, and Charlie Sheen. Event sponsorships allowed television access despite restrictions. When reinstatement of television restrictions was threatened in the late 1980s, Philip Morris more than doubled its television advertising budget and increased sponsorship of televised events. By adopting voluntary advertising standards, transnational companies delayed a television advertising ban for over a decade. CONCLUSIONS: Television image advertising was important to establish a market, and it has been enhanced using Hollywood personalities. Television advertising bans are essential measures to prevent industry penetration of new markets, and are less effective without concurrent limits on sponsorship and promotion. Comprehensive advertising restrictions, as included in the Framework Convention for Tobacco Control, are vital for countries where transnational tobacco companies have yet to penetrate the market.

The tobacco industry's use of Wall Street analysts in shaping policy.

OBJECTIVE: To document how the tobacco industry has used Wall Street analysts to further its public policy objectives. METHODS: Searching tobacco documents available on the internet, newspaper articles, and transcripts of public hearings. RESULTS: The tobacco industry used nominally independent Wall Street analysts as third parties to support the tobacco industry's legislative agenda at both national and state levels in the USA. The tobacco industry has, for example, edited the testimony of at least one analyst before he testified to the US Senate Judiciary Committee, while representing himself as independent of the industry. CONCLUSION: The tobacco industry has used undisclosed collaboration with Wall Street analysts, as they have used undisclosed relationships with research scientists and academics, to advance the interests of the tobacco industry in public policy.

Public health foundations and the tobacco industry: lessons from Minnesota.

OBJECTIVE: To investigate whether private foundations can be created in a way that will insulate them from attacks by the tobacco industry, using the Minnesota Partnership for Action Against Tobacco (MPAAT) as a case study. DESIGN: Information was collected from internal tobacco industry documents, court documents, newspapers, and interviews with health advocates and elected officials. RESULTS: The creation of MPAAT as an independent foundation did not insulate it from attacks by tobacco industry allies. During 2001-2002, MPAAT was repeatedly attacked by Attorney General Mike Hatch and major media, using standard tobacco industry rhetoric. This strategy of attack and demands for information were reminiscent of previous attacks on Minnesota's Plan for Nonsmoking and Health and the American Stop Smoking Intervention Study (ASSIST). MPAAT was ultimately forced to restructure its programme to abandon effective community norm change interventions around smoke-free policies and replace them with less effective individual cessation interventions. Neither MPAAT nor other health advocates mounted an effective public response to these attacks, instead relying on the insider strategy of responding in court. CONCLUSION: It is not possible to avoid attacks by the tobacco industry or its political allies. Like programmes administered by government agencies, tobacco control foundations must be prepared for these attacks, including a proactive plan to educate the public about the principles of community based tobacco control. Public health advocates also need to be willing to take prompt action to defend these programmes and hold public officials who attack tobacco control programmes accountable for their actions.

Hedging their bets: tobacco and gambling industries work against smoke-free policies.

OBJECTIVE: To describe and understand the relationship between the tobacco and gambling industries in connection to their collaborative efforts to prevent smoke-free casinos and gambling facilities and fight smoke-free policies generally. METHODS: Analysis of tobacco industry documents available online (accessed between February and December 2003). RESULTS: The tobacco industry has worked to convince the gambling industry to fight against smoke-free environments. Representatives of the gambling industry with ties to the tobacco industry oppose smoke-free workplaces by claiming that smoke-free environments hurt gambling revenue and by promoting ventilation as a solution to secondhand smoke. With help from the tobacco industry, the gambling industry has become a force at the American Society of Heating Refrigeration and Air Conditioning Engineers opposing smoke-free ventilation standards for the hospitality industry. CONCLUSION: Tobacco industry strategies to mobilise the gambling industry to oppose smoke-free environments are consistent with past strategies to co-opt the hospitality industry and with strategies to influence policy from behind the scenes. Tobacco control advocates need to be aware of the connections between the tobacco and gambling industries in relation to smoke-free environments and work to expose them to the public and to policy makers.

Tobacco industry litigation to deter local public health ordinances: the industry usually loses in court.

BACKGROUND: The tobacco industry uses claims of state preemption or violations of the US Constitution in litigation to overturn local tobacco control ordinances. METHODS: Collection of lawsuits filed or threatened against local governments in the USA; review of previously secret tobacco industry documents; interviews with key informants. RESULTS: The industry is most likely to prevail when a court holds that there is explicit preemption language by the state legislature to exclusively regulate tobacco. The industry has a much weaker record on claims of implied preemption and has lost all challenges brought under equal protection claims in the cases we located. Although the tobacco industry is willing to spend substantial amounts of money on these lawsuits, it never won on constitutional equal protection grounds and lost or dropped 60% (16/27) of the cases it brought claiming implied state preemption. CONCLUSIONS: Municipalities should continue to pass ordinances and be prepared to defend them against claims of implied preemption or on constitutional grounds. If the ordinance is properly prepared they will likely prevail. Health advocates should be prepared to assist in this process.

A tobacco industry study of airline cabin air quality: dropping inconvenient findings.

OBJECTIVE: To examine an industry funded and controlled study of in flight air quality (IFAQ). METHODS: Systematic search of internal tobacco industry documents available on the internet and at the British American Tobacco Guildford Depository. RESULTS: Individuals from several tobacco industry companies, led by Philip Morris, designed, funded, conducted, and controlled the presentation of results of a study of IFAQ for the Scandinavian airline SAS in 1988 while attempting to minimise the appearance of industry control. Industry lawyers and scientists deleted results unfavourable to the industry's position from the study before delivering it to the airline. The published version of the study further downplayed the results, particularly with regard to respirable suspended particulates. The study ignored the health implications of the results and instead promoted the industry position that ventilation could solve problems posed by secondhand smoke. CONCLUSIONS: Sponsoring IFAQ studies was one of several tactics the tobacco industry employed in attempts to reverse or delay implementation of in-flight smoking restrictions. As a result, airline patrons and employees, particularly flight attendants, continued to be exposed to pollution from secondhand smoke, especially particulates, which the industry's own consultants had noted exceeded international standards. This case adds to the growing body of evidence that scientific studies associated with the tobacco industry cannot be taken at face value.

Tobacco industry efforts to present ventilation as an alternative to smoke-free environments in North America.

OBJECTIVE: To describe how the tobacco industry developed a network of consultants to promote ventilation as a "solution" to secondhand smoke (SHS) in the USA. METHODS: Analysis of previously secret tobacco industry documents. RESULTS: As with its other strategies to undermine the passage of clean indoor legislation and regulations, the tobacco industry used consultants who represented themselves as independent but who were promoting the industry's ventilation "solution" strategies under close, but generally undisclosed, industry supervision. The nature of the industry's use of ventilation consultants evolved over time. In the 1980s, the industry used them in an effort to steer the concerns about indoor air quality away from secondhand smoke, saying SHS was an insignificant component of a much larger problem of indoor air quality and inadequate ventilation. By the 1990s, the industry and its consultants were maintaining that adequate ventilation could easily accommodate "moderate smoking". The consultants carried the ventilation message to businesses, particularly the hospitality business, and to local and national and international regulatory and legislative bodies. CONCLUSION: While the tobacco industry and its consultants have gone to considerable lengths to promote the tobacco industry's ventilation "solution", this strategy has had limited success in the USA, probably because, in the end, it is simpler, cheaper, and healthier to end smoking. Tobacco control advocates need to continue to educate policymakers about this fact, particularly in regions where this strategy has been more effective.