7. Implementing the
Tobacco Control Program
Despite the budgetary compromises that tobacco control advocates had
made in AB 75, they still emerged with the largest budget ever allocated to a tobacco
control program. The field of play shifted to the state bureaucracy, which had to
implement California's Tobacco Control Program. While the Department of Health Services
(DHS) ran the anti-tobacco media campaign and some competitive grants, the vast majority
of the money flowed through DHS and the California Department of Education (CDE) to the
county health departments, county offices of education, and local school districts. This
program design meant that two state-level agencies, sixty-one local health departments,
fifty-eight county offices of education, and over 1,000 school districts went overnight
from having virtually no money dedicated to tobacco control to having over $100 million
annually. The challenge for these organizations was to put into place immediately, with
virtually no existing infrastructure, an unprecedented tobacco control program. Throughout
the development and passage of Proposition 99 and the subsequent battle over the
implementing legislation, there was a constant tension between those who wanted the money
to go to programs specifically designed to reduce tobacco consumption and those who wanted
to see the money go into health promotion generally, with the promise that there would be
a tobacco control component.
In addition to active efforts by the tobacco industry to undermine the
program (discussed in chapter 8), there were five significant operational barriers to
successful implementation of a well-coordinated tobacco control program. First, the
administration of the program was split between two state agencies that reported to
different, and competing, elected officials. The director of DHS reports to the governor
(who in 1989 was Republican George Deukmejian) while CDE reports to the independently
elected superintendent of public instruction (in 1989 this was Democrat Bill Honig, who,
to complicate matters, was thinking of running for governor). This partisan division
between DHS and CDE persisted through the first ten years of the Tobacco Control Program.
Honig was succeeded by Democrat Delaine Eastin, and Deukmejian was succeeded by Republican
Pete Wilson. There was no authority available to mediate disputes between the two
departments. Second, in the absence of a sure model for tobacco use prevention, each
agency could define its approach to tobacco control as it saw fit, and very different
models emerged. DHS dealt with tobacco specifically, and CDE subsumed tobacco control
within a larger health promotion model. Third, with so many independent agencies
participating in the program, a scheme for monitoring and oversight had to be developed
that combined program accountability with creativity in achieving goals. Program
administrators found these two goals ”accountability and creativity ”difficult
to achieve simultaneously. Fourth, lacking experience in tobacco control, health and
education agencies had little capacity to mount a massive tobacco control program. Fifth,
AB 75 gave these agencies only a short time to produce results; as noted in the previous
chapter, AB 75's sunset provision took effect just twenty-one months after the bill was
Two Different Models
Although the voluntary health agencies had insisted that health
education programs focus specifically on tobacco issues, the final legislation was
permissive about what could be done with Proposition 99's Health Education Account money.
According to the final language of AB 75, the agencies were to provide preventative
health education against tobacco use. The bill broadly defined what such education
might be. It included programs of instruction intended to dissuade individuals from
beginning to smoke, to encourage smoking cessation, or to provide information on the
health effects of tobacco on the user, children, and nonsmokers. These programs may
include a focus on health promotion, disease
prevention, and risk reduction, utilizing a `wellness perspective' that encourages
self-esteem and positive decision-making techniques.  The
tobacco-specific model, which the voluntary health agencies had advocated, and the blended
model, which the legislation allowed, were both implemented, the former by DHS and the
latter by CDE. Because these differing models became the basis for programming in health
departments and schools, they complicated the relationship between health and education
DHS chose to develop a tobacco-specific program based on a model for
tobacco control developed at the National Cancer Institute (NCI).
According to this model, tobacco use, especially the adolescent progression to adult
smoking, was the result of a specific and identifiable set of influences ”including
the tobacco industry's promotional activities (figure 6). The program sought to break the
chain of events which led people to smoke or continue smoking. The NCI model guided
program planners in designing tobacco interventions for delivery through four channels
”health care settings, schools, community groups, and worksites ”using one of
three types of programs: mass media, policy, or direct program services. The first
comprehensive plans from local health departments used a slightly modified version of this
In contrast, CDE simply incorporated the tobacco money into existing
school-based programs designed to deal with the factors that put children at risk
for using illegal drugs and alcohol. In the risk
factor approach, children who have problems in their own lives or with family,
school, peers, or the community are considered at risk (figure 7). This approach seeks to
enhance protective factors for these youth through the following specific activities:
- Promoting bonds to family, school, and positive peer groups through opportunities for
- Defining a clear set of tactics against drug use.
- Teaching the skills needed to learn the tactics.
- Providing recognition, rewards, and reinforcement for newly learned skills and
With the advent of Proposition 99, tobacco was added to this model
because it was considered a gateway drug to the use of other drugs. CDE,
citing data showing that youth tend to use drugs such as tobacco,
Figure 6. The National Cancer Institute's model of the factors
influencing tobacco use. The model of tobacco uptake is linear and offers specific points
of intervention. The DHS tobacco control program is based on this model. Source:National
Institutes of Health, Strategies to control tobacco use in the United States: A
blueprint for public health action in the 1990s (Bethesda, MD: National Institutes of
Health, 1991), 23.
alcohol, marijuana, and other drugs in a predictable
sequence, concluded that the nature of multi-drug use indicates that preventive
efforts should not be targeted to any single drug. To curb the
use of tobacco, along with other substance use, schools were urged to concentrate on
alleviating the factors that put a child at risk.
Figure 7. The CDE risk and protective factors model of tobacco and
substance abuse. The model is diffuse and does not offer specific intervention points that
can be coordinated with community-based tobacco prevention programs. Source:
California Department of Education, Not schools alone (Sacramento: California
Deparment of Education, 1991), 2-3.
Leadership at DHS
The Department of Health Services is part of the State Health and
Welfare Agency, which reports to the governor. At the time Proposition 99 passed, DHS was
headed by Dr. Kenneth Kizer, who was personally committed to the success of the
Proposition 99 programs and recognized
that Proposition 99 created a unique opportunity to create a whole new approach to
public health, especially tobacco control. He took a strong personal interest in seeing
that an effective and innovative tobacco control program was put in place and was willing
to stand up to the tobacco industry and its allies inside the state government in order to
do so. Jennie Cook, an American Cancer Society (ACS) volunteer, a national chair of ACS,
and a member of the Tobacco Education Oversight Committee (TEOC) since its inception,
observed, Kizer was probably the most honest person I've ever run across where
tobacco was concerned ¦ .You knew up front he was an advocate for tobacco control. He
felt strongly that he was going to make this program really work. 
In a 1995 interview, Kizer himself expressed his strong commitment to the program:
I can tell you in all candor that basically the approach that we took
was one that we were going to try to do it right. ¦The Health Department took the
position early on ¦that the Health Education Account should be used for health education,
for media and local education campaigns, etc. That was not supported, or at least it
didn't appear to be supported, strongly at the agency level. And it was absolutely not
supported at the Governor's Office. ¦I think they [the Health and Welfare Agency] felt
that was a huge amount of money ¦and there was no way that we could reasonably spend that
in the time period.
Kizer created a separate Tobacco Control Section (TCS) within
DHS and ordered the administrative support units within DHS to give priority to staffing,
issuing its requests for proposals, and adding other services needed to get the fledgling
program up and running as quickly as possible.
TCS was to develop the state's anti-smoking media campaign and run a
series of statewide projects and technical support activities as well as develop, fund,
and oversee local tobacco control activities. The local activities were to be delivered
and coordinated by local lead agencies (LLAs) in each of the California's sixty-one local
health departments. Each LLA was designed to be an identifiable, tobacco-specific
organization. This local structure, which was to emerge as one of the California Tobacco
Control Program's greatest strengths, however, was relatively long in coming. TCS had to
write guidelines for the local programs, the LLAs had to develop and submit plans, the
plans had to be reviewed and approved, and the money distributed. And, of course, hundreds
of people had to be recruited and trained to complete all these tasks, a process that took
nearly a year.
The Media Campaign
In contrast to the complexities of getting the local programs off the
ground, it was a relatively simple bureaucratic task to launch the anti-smoking media
campaign that AB 75 had established. It merely required writing one request for proposals
and issuing one contract to one advertising agency. It was the one way that DHS could show
the public and politicians that it was doing something with Proposition 99 money in a
DHS moved quickly to implement the media campaign. The request for
proposals was released on December 1, 1989, fifty-nine days after Governor Deukmejian had
signed AB 75; responses from advertising agencies were due just six weeks later, on
January 10, 1990. On January 26, DHS selected the Los Angeles advertising agency
keye/donna/perlstein to run the campaign. The first anti-tobacco
advertisements reached California's television viewers on April 10, 1990, sixty-five days
after the contract was signed.
The campaign was like nothing the world had ever seen. Rather than
talking about the dangers of smoking, or even secondhand smoke, the campaign directly and
explicitly attacked the tobacco industry.
The first television advertisement, Industry Spokesmen,
showed a group of actors portraying tobacco industry executives sitting around a
smoke-filled room (figure 8). Their leader says:
Gentlemen, gentlemen. The tobacco industry has a very serious
multi-billion-dollar problem. We need more cigarette smokers. Pure and simple. Every day,
2,000 Americans stop smoking and another 1,178 also quit. Actually, technically, they die.
That means that this business needs 3,000 fresh, new volunteers every
day. So, forget all that cancer, heart disease, stroke stuff.
Gentlemen, we're not in this for our health.
At the end, he laughs, joined by the other executives.
This radical new approach grew out of discussions between Kizer, Dileep
Bal, head of the Cancer Control Branch (which includes TCS), and ad agency principal Paul
Keye, who brought a new perspective to the question of how to reduce tobacco consumption.
As Keye later explained,
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.
Figure 8. California's first anti-tobacco television advertisement,
Industry Spokesmen, was a frontal attack on the tobacco industry. This
advertisement set the tone for the California Tobacco Control Program when it was first
aired in April 1990. (Courtesy California Department of Health Services)
Instead of falling back on the traditional public health
messages ( tobacco is bad for you ), Keye urged that the campaign directly attack
the tobacco industry. The first reaction to the campaign within TCS was surprise, with
some wondering aloud, Can we say that? But TCS soon agreed that it could and
should, and the anti-industry emphasis became an integral part of the campaign. TCS was out to raise the temperature around tobacco as an
issue, convincing people that smoking was not normal, ordinary behavior and the tobacco
industry was not just another legal business.
To reinforce this message and to announce the new aggressive campaign
against the tobacco industry, TCS ran full-page advertisements in all the major newspaper
in California on April 11, 1990, with the headline First, the Smoke. Now, the
Mirrors (figure 9). The text began:
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
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?
Figure 9. California's first anti-tobacco newspaper advertisement. The
Department of Health Services announced the new California Tobacco Control Program with
this full-page advertisement in newspapers throughout the state on April 11, 1990.
(Courtesy California Department of Health Services)
Smoking was not just a health problem; it was also a
social and political one.
The tobacco industry and its allies in the advertising industry went
wild. Walker Merryman, vice president for communications at the Tobacco Institute in
Washington, protested that the ads themselves have broken faith with the voters.
¦They are an unsavory assault on tobacco companies. He claimed that they were not
educational advertisements. Tom Lauria, a spokesman for the
Tobacco Institute, agreed: They pitched Prop 99 as: `We want to reach underaged
children. We want to educate children to the purported health effects of smoking.'
¦anything beyond that is not educational, it's political.  Bob
Garfield, a columnist in Advertising Age, an advertising industry trade newspaper,
accused TCS of inciting racial paranoia by trading on a vile stereotype: the
wealthy, white embodiment of evil. ¦This `public service' message is inflammatory and
racist and it will feed paranoia. ¦Californians should indeed be careful of what they
breathe. There is something foul on their air. 
Governor Deukmejian was cool toward the advertisements. One of his
spokesmen explained: It's not in the nature of the governor to go on an attack like
this. He's always been genteel and civilized in his approach to public affairs.  Deukmejian, however, took a hands-off approach to the campaign and
allowed Kizer and DHS to proceed according to their professional judgment. Indeed, the
Tobacco Institute lamented the way Governor Deukmejian was giving Kizer free rein over the
campaign: As a `lame duck,' the Governor is not likely to get into a public sparring
match with Dr. Kizer, even though he disagrees with the Department of Health Services'
attack approach with the anti-tobacco advertisements.  Rather
than submitting the detailed, multilayer political review of the media campaign that came
to be required when Pete Wilson succeeded Deukmejian as governor, TCS simply made a
brown bag run to the Governor's Office the night before new ads were aired so
that the governor would know what was about to hit.
The other first-wave advertisements in 1990 were just as strong. One
featured black rappers attacking the tobacco industry for targeting African Americans with
mentholated cigarettes, using the tag line We used to pick it; now they want us to
smoke it.  Another showed a husband and his pregnant wife
sitting together. When the man lights up and inhales deeply, the smoke comes out the
woman's mouth. The tag line was Smokers aren't the only ones who smoke. 
The advertisements attracted international attention. Indeed, in 1997,
seven years after it had originally run and over a year after Governor Pete Wilson's
administration had ordered it off the air permanently, Industry Spokesmen
still had the highest recall rate ”96 percent of adults and 93 percent of teens
”of any advertisement that DHS produced. The
advertisements stimulated strong public interest in the Tobacco Control Program. They also
set the overall tone for the program as one that considered tobacco a social and political
problem well beyond the bounds of traditional public health thinking at the time.
The Local Lead Agencies
While the media campaign was jump-starting the Tobacco Control
Program, the LLAs were still getting organized. In addition to the efforts within each
local health department, each LLA was required to encourage the formation of a local
coalition made up of players from the private and nonprofit sectors, including local
units of the voluntary health agencies as well as new players in tobacco control. These
local coalitions would play an increasingly important role in the evolution of
California's Tobacco Control Program. The counties were required to submit preliminary
plans in December 1989, before the media campaign had reached the public.
For most counties the tobacco revenue represented a substantial amount
of new money, especially since Proposition 13 had hit the counties so hard. Each county
received at least $150,000 a year, with the larger counties receiving considerably more:
Los Angeles ($12.2 million), San Diego ($1.8 million), San Francisco ($1.6 million), and
Santa Clara ($1.6 million). Even medium-sized counties like Ventura and Sonoma received
TCS recognized that, in addition to guidelines, the LLAs needed a state
infrastructure that would provide them with ongoing training and technical assistance. TCS
hired a contractor to establish the Tobacco Education Clearinghouse of California, which
kept existing tobacco resource materials on file and added to its collection all materials
developed by Proposition 99-funded health programs. TCS also created the California
Tobacco Survey, a large statewide telephone survey of tobacco use in California, to
provide information on how well the tobacco control program was working. Dr. John Pierce
of the University of California at San Diego won the contract to run the survey. The
survey was to provide feedback throughout the program on the overall effectiveness of the
California Tobacco Education Program and some of the reasons for the program's success or
failure. To provide technical assistance to the LLAs and competitive grantees, TCS
contracted with the American Nonsmokers' Rights Foundation (ANRF), Stanford University,
and the Western Consortium for Public Health to create the California Tobacco Control
Resource Partnership, which was to provide ongoing training, conferences, and other forms
of technical assistance to DHS-funded programs. Over time, the California Tobacco Control
Resource Partnership, particularly through a series of regular teleconferences, became the
central nervous system for the local programs. The teleconferences were hosted
by ANRF and designed to give the LLAs (and other Proposition 99 participants) help in
countering pro-tobacco strategies as well as other technical assistance. The rapid sharing
of information ”especially about tobacco industry tactics and how to respond to them
”increased reaction times of the local programs and thus their effectiveness.
Getting the LLAs off the ground, however, was a cumbersome process.
Although Kizer had forced DHS to help TCS get up to speed quickly, most county tobacco
control operations got no such special treatment. The slowness of county paper processing
and the complex nature of county procedures impeded rapid program development. Part of the
problem faced by one LLA director had to do with the unusual nature of her program design.
She said, The reality is no one had really had money like that to do anything
innovative in the health department. So I think people had to get used to the idea of
something different, including purchasing. I mean, you never had people buying some of the
things we were buying before all this. Now they're used to it but it was unusual. ¦it
took a lot of work, we had to go back two, three times sometimes. 
Eventually some LLAs cut back the number of grants to local groups for tobacco control
work simply because of the time it took. On the other hand, some county administrators and
politicians were important program advocates. Another LLA director described her
health officer as a very strong tobacco [control] advocate [who] ¦was willing to
fight battles and take the heat. She emphasized that the health officer was
one of the reasons we had these successes ¦and it wouldn't have happened without
In contrast to the state level, the earliest local program designs
reflected a traditional view of public health, focused on promoting smoking cessation,
even though policy and media were part of the NCI model. But
smoking cessation programs were comfortable. Most people who had trained in public health
were familiar with providing direct services, especially cessation. The tobacco industry
generally sits quietly when people run smoking cessation programs because such programs
are expensive and not very effective. Generally only about 10 percent of those enrolled in
cessation programs are still abstinent a year later, and cessation programs, because they
approach smokers one person at a time, simply cannot reach a significant portion of the
smoking population. Cessation programs do nothing to keep people from starting to smoke.
The media campaign was launched in the midst of the LLAs' efforts to get
their programs up and running. Cynthia Hallett, then with the Los Angeles LLA, thought the
advertisements were great but that they hit the streets almost too fast:
In trying to launch our education campaign, it was really difficult, given that
media was out there and talking about how bad the tobacco industry was. And here we were
just trying to start our program. People were calling us saying, `Those ads. Well, what
are you guys doing? And can I get some service?' And we were still training staff.  Whether intentional or not, the anti-industry focus of the media
campaign began to shift the emphasis of the other programs toward policy interventions. In
addition, Americans for Nonsmokers' Rights was continuing to support communities in
developing and passing local tobacco control ordinances. ANR's policy-oriented approach
already permeated the state and the LLAs felt its influence. Even so, it took a year or so
to move beyond cessation programs to activities that would change the social environment
enough to reduce tobacco consumption.
One LLA director commented that she moved into other programmatic areas
almost immediately because she had done cessation before and did not want to do it again.
But for most LLAs the transition to community-based strategies took longer. One LLA
director described the process:
We ended up funding Stop Smoking and Smoking Prevention Programs for
every ethnic group and every age group. We even had a preschool program. It was very much
a cessation model, helping individuals quit smoking. People thought that was the logical
way to spend the money. ¦We had a Stop Smoking Program for the Vietnamese, another one
for the Spanish-speaking. We had another one for African Americans. We had another one for
senior citizens. We had one for teenagers. (laughter) I remember thinking, driving around
one year later, Is my program having any effect on this community? Because
everywhere I looked people were smoking inside and outside. I just had the sense that I
was wasting public dollars.
And meanwhile, people were calling me with bad secondhand smoke
problems at their workplace. Totally bombarded. I would look up their [local clean indoor
air] ordinance and say, There is nothing I can do for you. Your employer can smoke
at your workplace. So the laws were very bad at that point. ¦So I remember driving
down the street one day, thinking maybe we could just make everything smoke free.
So I talked to one of the higher-ups in the county, and said, Why
don't we just get a good county ordinance going here? And she leaned over and she
patted my hand and she said, Oh no, dear, you don't know what you are talking about.
This person on the Board [of Supervisors, the county legislative body] smokes, that person
on the Board smokes. Their secretary smokes. Don't do it, don't even consider this.
So I said, Well, OK, what if the cities passed ordinances and that would like
peer-pressure the county into it? And she kind of smiled. So I just hung in and got
started, changed the whole program orientation to policy and ordinances.
This interest in doing policy work was not, however, universal. People
worried about getting involved in local controversies and wanted to avoid confrontation
with the tobacco industry and its political allies. People in public health departments
who had trained as traditional health educators were not used to being confrontational or
political. Their lack of experience was exacerbated by the ambivalence of coalitions
consisting of other public health professionals or representatives of local units of the
voluntary health agencies who were reluctant to get involved in politics.
Over time, however, the values and approaches of the Tobacco Control
Program changed, and most program participants became more policy-oriented. In 1998, when
asked what she would do differently if she had it to do over again, one of the reticent
directors responded, I would be more pro-active with local leaders. I would probably
get into it, and say, `Oh well, if we're going to have a conflict, let's just go for it.' 
Beginning with AB 75, tobacco control programs were required to focus
on certain target populations, especially pregnant women, minorities, and youth. Public
health groups viewed these subpopulations as important
targets because pregnant women who stop smoking early nearly eliminate the excess risk
of delivering a low-birth-weight infant and because the tobacco industry was targeting
minorities and youth in its advertising. In agreeing to focus on youth and pregnant women,
tobacco control groups may have played into the hands of tobacco interests. After all,
Nielsen, Merksamer had recommended the Child Health and Disability Prevention (CHDP) and
Maternal and Child Health programs as good candidates for the diversion of Health
Education Account funds. The industry appears to accept tobacco
prevention programs focused on pregnant women and youth because they have limited impact
on cigarette consumption. At any given time, there are not many pregnant women, so
messages directed at this group will not be relevant to most of the population. And
primary prevention programs directed solely at youth are of limited effectiveness because
they may inadvertently reinforce the belief that smoking is an acceptable adult behavior.
Fortunately, TCS never interpreted this focus narrowly, and the result
was a campaign that addressed the general population while including these groups. The
effort to create an inclusive program brought a wide range of community- based
organizations into the program, such as the Asian American Health Forum, the Watts Health
Foundation, the California Healthy Cities Project, the East Los Angeles Health Task Force,
and KCET Public Television.
For public health professionals working at the state and local level, it
was a challenge to reach minority populations because health departments tended to be made
up primarily of white, middle-class people. The LLAs addressed this problem by encouraging
groups that were already working in the target communities to apply for LLA grants to fund
tobacco control activities in those same communities. While this approach often worked, it
ignored the need for capacity building around the tobacco issue. As a result, as the
program evolved, the LLAs developed more directed strategies to involve these community
groups. One county eventually created a Tobacco 101 orientation that a group
had to complete before they were eligible to receive grants from the health department.
Eventually TCS also funded Ethnic Networks, which provided resources and networking
capacity to community-based programs funded either directly by TCS or by the LLA to serve
African Americans, Native Americans, Asian Americans, and Latinos on a statewide basis.
As the thrust of the LLA programs began to shift away from cessation to
community-based, policy-oriented work, the reliance on community-based organizations
(CBOs) also meant that these groups had to be educated in the new paradigm and away from
cessation classes. According to one LLA director, leaders of these community organizations
often reacted skeptically: `Why the hell should I be interested in this? I know that
tobacco's bad, so what?' Moving them more toward looking at this issue globally, how
does it impact them, what can they do about it. And again giving them the skills then
to say, `Okay, now that I know that this is bad, what do I do?' Trying to get the CBOs
to understand that they had to have an ongoing relationship with the community, to get
them to understand why it's important to have smoke-free environments (emphasis
added). While there were difficulties in involving the new
constituencies in tobacco control in California, community activities were to emerge as
one of the strongest and most innovative aspects of the California Tobacco Control
Peter Hanauer, a veteran of the Proposition 5, 10, and P campaigns, was
impressed with the difference that this outreach made in the tobacco control movement:
Things had changed. I walked into a meeting in San Francisco, ¦this
was sometime in the late eighties or early nineties, and I had been used to going to
meetings with almost all white males, a few women occasionally, a token black
occasionally. I walked into this meeting and it was like every spectrum of San Francisco
society was represented there. ¦And I was overwhelmed when I walked in there and saw all
of these people from all the different minority communities, who were up in arms because
they had come to realize that the industry was preying on them, that the industry was not
the good Samaritan that it pretended to be.
While the original goal of involving community organizations had
simply been to reach their constituencies with tobacco control messages, this effort was
having much deeper effects. In particular, it was beginning to undermine the acceptance
that the tobacco industry had built up over the years in these communities by providing
financial support for community groups.
The effort to create diversity through grants, however, was more
successful than creating diversity through volunteers. The LLAs were required by TCS to
create a diverse coalition to help with their programs. But there were almost universal
problems in trying to keep a coalition active and involved. In two of the fifteen counties
where interviews were conducted, the coalition was an active body, involved in program
design and local politics. Dynamic chairs from outside the LLA provided a great deal of
leadership. In the other counties, the coalition was more reactive, made up of paid staff
from other public agencies, the voluntary health agencies, and grantees.
TCS's push for coalitions brought mixed reactions from the LLAs, as did
some of TCS's other actions. In the early days, life for the LLAs was chaotic, and people
at the county level had mixed feelings about the TCS. In general, the directors of the
larger, urban LLAs seemed to be happier with TCS than the smaller, rural ones. One LLA
director from a large county made this comment:
They [TCS] were very, very supportive. And TCS has always been
profoundly advanced in terms of policy, Carol Russell [who headed the local programs unit]
especially. They could not have been better. They funded teleconferences through ANR
[ANRF, American Nonsmokers' Rights Foundation]. They had workshops directly. I mean, they
just did everything they could; they understood early on how important this was. And
they began to encourage us to move away from changing individual behavior more into the
community norm and changing the environment. [emphasis
Those working in the rural areas, however, felt from the beginning
that the TCS program was not designed with them in mind. One blunt LLA director said,
They [the staff at TCS] are very controlling, very, very strong. ¦TCS
has a very strong hand in what we do and what we don't do and how we do it. They want it
on the paper in a certain way. They want us to do X, Y, Z and only X, Y, Z. And don't be
interjecting any of your own creative problems into it. You do what you are told, you
accept our money, and you play with our money within our realms. ¦They have no sense or
feel [of] what is going to happen in a rural environment. We've never been asked by TCS,
not to my knowledge have we ever been asked for input on what our areas of priority should
A number of the rural LLA directors, when they were interviewed in
1998, were still stung by early accusations that they were racist when they protested that
the targeted groups excluded the vast majority of their population, which was white.
The other major complaint from the rural areas had to do with the
concentration of the media campaign in the major media markets. According to one LLA
director, When the media campaign was all over the state, that really was good, that
was just so helpful and so beneficial. And then they started cutting down on ¦media
coming up into this area, based on ¦population. ¦California does extend 300 miles north
of Sacramento, and I was really indignant about [it] when they cut the media. And I still
think it's a big loss to us.  In another rural county, the LLA
director wished that the advertisements at least existed in a format that could be shown
in the local movie theater. In general, there was a feeling
that not a lot of creative thinking had gone into reaching the rural markets. This problem
was aggravated by the dominance in some rural areas of out-of-state satellite television
and other media.
Some of these tensions between the field and TCS would remain throughout
the program, reflecting the struggle between local-level program autonomy and
state-level control. On March 12, 1993, TCS hosted a Statewide Projects Meeting in San
Francisco, where the LLAs again expressed a desire for TCS to provide more leadership and
less project supervision. Despite these problems, the local
programs funded by Proposition 99 emerged as a key element in its success. They quickly
evolved away from traditional smoking cessation efforts to a variety of approaches
designed to change the social environment ”through passage of local clean indoor air
ordinances and other efforts to counter directly the influence of the tobacco industry in
their communities. In addition, TCS directly funded some service delivery projects whose
scope was multicounty and sometimes statewide. In one innovative project, a tobacco-free
race car brought a tobacco-free message to racetracks, a venue where pro-tobacco messages,
both on the cars themselves and around the track, had gone unchallenged. The involvement
of minority groups and other new players deepened and strengthened the statewide
constituency that was working actively to reduce tobacco consumption in California. In
California's war against tobacco, the media campaign provided the air cover and the local
groups provided the ground troops.
The Schools: A Different Approach
If it was a challenge for local health departments to build a
mechanism for delivering tobacco control programs quickly, the schools faced an even
greater problem. Every county had a health department, and those health departments had a
tradition and mandate to do prevention-oriented activities directed at specific diseases
or risks. Within schools, the situation was different. Health was not a central part of
their mandate, and schools varied in their capacity to provide any kind of health
education, much less something as specialized as tobacco use prevention. Moreover,
teaching health issues of any kind in schools can expose the local elected board of
education to controversy, which it may not be willing to tackle. This approach, avoiding
controversy, contrasted sharply with DHS's approach: using controversy in the media
campaign to engage the public in the debate over tobacco.
From the beginning, the schools viewed the tobacco money as just another
categorical program. Educators tend to resent categorical programs because they believe
that such programs limit their authority to do what is best for their students and because
the programs require excessive paperwork. Thus, while the Proposition 99 dollars were
welcome, the mandate that the schools provide tobacco-specific prevention activities was
not. In addition to these problems, AB 75's rapid sunset also caused difficulties. No one
knew what would happen when AB 75's twenty-one months ran out, and this uncertain future
made the schools even less interested in developing a long-term commitment to tobacco
When Proposition 99 passed, California schools were under financial
siege. Proposition 13, which had limited the ability of local governments to raise local
revenues, had hit the schools particularly hard. Bill Honig, who served as superintendent
of public instruction when Proposition 99 passed and when AB 75 was being implemented,
explained the situation this way:
There are four things that were going on in California that would make
anything hard. Number one is this huge growth. Many places are just trying to accommodate
new kids. ¦They're just coming out of the woodwork and we are not building the buildings.
¦Secondly, there has been this demographic shift of poverty. The explosive growth of
poverty conditions makes schooling much tougher. More kids are coming with deep problems.
Then the third one was this whole language demographic shift where you've got now, one out
of three kids in that early elementary school level doesn't speak English. So we've got
that problem. And then you have the funding crisis on top of that, we're trying to do it
with less and less and less dollars.
In this difficult climate, Proposition 99's new money was viewed by
the schools as a way to solve some of their pressing problems.
At approximately the same time that Proposition 99 was passed, the
California school superintendents were working to establish a regional structure to
provide the school districts with health expertise. At the state level, CDE had already
established a program and an administrative unit called Healthy Kids, Healthy California,
which was responsible for carrying out health and drug-related programs. CDE decided to
use the Healthy Kids Regional Centers to implement Proposition 99. CDE pooled the
Proposition 99 monies with two other funding sources to create the Drug, Alcohol, and
Tobacco Education (DATE) program. CDE required each county office to have a Tobacco Use
Prevention Education (TUPE) coordinator, and generally this person was also responsible
for the drug and alcohol programs and, in smaller counties, other categorical programs as
well, including some that were not health programs.
According to Kathy Yeates, who was the acting director of the Office of
Healthy Kids, Healthy California in 1994, schools were not really committed to doing much
about tobacco for a variety of reasons:
There was no commitment to it. It was like one more thing, given
reading programs and bilingual and all the pressing problems ”the obvious problems.
Yeah, some kids smoke, but who cares. You know, smoking. Big deal. ¦It's the least
of our discipline problems right now. We've got kids fighting with guns; tobacco, that's
just a passive problem. It's not as active as fighting or something like that. A lot
of school folks smoke and it was just too controversial with unions and whatever. So
schools really didn't want to take it on. In addition to everybody having someone that's
an alcoholic, everybody's got somebody in their families that smokes. And people on staff.
¦So they kind of tiptoed around it and didn't want to take it on. Didn't see it as a
problem ¦as long as they weren't smoking in their classrooms, who cares what they do? ¦I
mean like Oh yeah, bad drugs, but you know that's not the biggest problem.
This attitude, coupled with the risk and protective factors model,
provided schools with an opportunity to spend their Proposition 99 monies creatively. For
schools, a program that addresses the problems that educators consider most pressing was
much more appealing than taking on tobacco directly. From this perspective, if school
failure is an underlying cause of tobacco use, then tobacco money could be spent on just
about anything that would improve the schools.
The method used to distribute funds added to the problem. In contrast to
the critical mass of funding created in the health departments, money went to the county
offices of education and the school districts based on average daily student attendance.
Once the money was spread over 1,003 districts, fifty-eight county offices, and ten
regional centers, the amounts could be quite small. Some of the small districts received
under $500, hardly enough to create an identifiable presence for tobacco control. By
contrast, even the smallest county health department received $150,000. With a lack of
commitment to Proposition 99 at the top, inadequate programming, and sometimes small
amounts of money, it is not surprising that schools saw themselves as the recipients of a
categorical funding stream, driven by entitlements, which they could try to use for
dominant priorities of the schools. And tobacco, especially at first, was not a
particularly high priority for schools.
The poor condition of health education generally in California, due to
years of Proposition 13-inspired budget cuts, created further problems for implementing
meaningful tobacco prevention programs in the schools. (Increasing numbers of districts
were cutting back or eliminating their school nurses at that time.) As one TUPE
coordinator said, All of this money has been flowing to schools with the assumption
that there was an infrastructure in place for health education. 
The infrastructure to absorb this money and use it effectively simply did not exist. There
is no high school graduation requirement for health education in California, and there is
a very minimal requirement for health education in teacher credentialing. One of the
county TUPE coordinators explained how the lack of infrastructure in schools set them up
for failure, not just in tobacco programs but other health programs as well:
There wasn't an infrastructure there to accept the money. A lot of us
were afraid that all this money was coming down and it was going to be misused because
there wasn't anybody in place. This is kind of a Catch-22, it's a chicken-egg thing. We've
got the money but nobody in place, so then we put the money in, we say, Look, it's
failing, it isn't working ¦ . This is the typical thing that's happened in health
education in many instances where the person who ends up teaching it at the high school is
the person who's on their last leg. We don't know what to do with Charlie so we'll
have him teach health. 
The $36 million that schools were given each year during the two years
of AB 75 would have been a substantial increment to an existing backbone for the delivery
of health messages in the schools had it existed.
A coherent approach to tobacco education in the schools was further
undermined by the absence of training, materials, or expertise in tobacco use prevention.
This lack of materials reinforced the tendency of the schools to teach health as
body systems. There was little in the way of good age-appropriate material
that focused on tobacco as a social and political issue.
For early program implementers, CDE's lack of commitment to the program
was reflected in the nature of its tobacco-free mandate. Schools were not required to have
tobacco-free policies in order to qualify for Proposition 99 funds, and they were given
until 1996 to become tobacco free. CDE promulgated a definition of tobacco free
that was more rigorous than the definition used by other organizations
”schools could not allow any smoking in the buildings, on the grounds (including
service yards), or in vehicles. But with the long deadline, schools could receive
Proposition 99 funding without having to do anything at all about tobacco use on the
school site. For those believing in policy-based health interventions, this long deadline
was not a good start to the program.
Early Leadership Problems
It might have been possible to overcome the financial and structural
problems that the schools faced in delivering anti-tobacco education if there had been
strong and committed leadership at high levels within CDE, as Kizer had provided for DHS,
but such leadership never materialized. Robert Ryan, who was the head of the Healthy Kids,
Healthy California office and responsible for the anti-tobacco education efforts until he
left in 1994, brought the right credentials to the job. With a background that combined
training and education in both health and prevention, he had vision for the program, but
his own drug and alcohol problems got the better of him and he quit coming to work.
Kathy Yeates, who worked with Ryan and his assistant Bill White (who
headed CDE's tobacco program) and who was eventually named to succeed him, described the
Robert was already in big trouble with his own using of drugs,
alcohol, and tobacco. He was in big trouble. ¦I had told Robert that if he messed up one
more time that I would have to do something about it, which I followed through and went
¦[to an] associate superintendent who went to the deputy and they just called him in and
chewed him out. Nothing happened ¦so I watched Robert go downhill. ¦He hated
confrontation of the mildest kind. And he just didn't come to work. ¦And it was too big
of a task for the two of them to do without more competent staff. And they just didn't
have additional competent staff that understood prevention. ¦And he didn't have the
support of the agency, because he had jeopardized that. So he was taking all this flack
”deserved, a lot of it deserved ”but it was doing him in more than supporting
him. So I think that he had the potential but he lost it. And the field was disenchanted.
The CDE staff was disenchanted. And so because of that the program did suffer.
At a conference in Millbrae, held in the spring of 1990, White told
educators to put enough tobacco material in their drug programs so that if any parent was
an executive at a local voluntary health agency, he or she would see something for the
Proposition 99 dollars. Rather than encouraging schools to become a partner in the larger
California Tobacco Control Program, the leadership appeared to be offering cash-strapped
school districts a wink and a nod to use the money however they wanted.
Monitoring and Accountability
CDE's initial program simply involved distributing the money based on
average daily attendance (ADA), with few program or fiscal guidelines. ADA-based funding
is easier to distribute and is politically less volatile than a contract or grants program
because it avoids the need to apply what some may consider subjective criteria.
Distributing the money according to such a formula also means that no one has to consider
the minimum amount of money that a small district needs to mount a credible program or the
maximum that a large district can responsibly use. (Severe
understaffing at CDE ”three people were charged with monitoring 1,003 school
districts ”aggravated this problem.) In addition, when funds are distributed on an
ADA basis, monitoring the expenditures presents difficulties because districts receive an
entitlement regardless of their interest in participating in the program.
Carolyn Martin, the first TEOC chair, was asked whether the
accountability problems were the result of incompetence or a lack of interest in keeping
track of the money. She replied, I think it was both. I think that they were
incompetent or they could have written much tighter guidelines for the schools. They full
well knew that schools were in desperate shape for money, and, man, if they didn't ride
herd on every penny, it was going to disappear. I mean you don't have to be a genius to
figure this out. Nonetheless, the message that was sent out was `Do the best you can,
guys.' Well, if you tell the schools to do the best you can, ¦believe me, the money will
disappear. And indeed it did just go down a hole.  Assembly
Member Phil Isenberg (D-Sacramento), who chaired the Conference Committee that wrote AB
75, also became cynical about how schools were spending their money. He was invited to a
celebration of Red Ribbon Week, an anti-drug program, during the 1989-1990 school year and
was not happy to discover that the ribbons and balloons for the anti-drug week were
purchased with tobacco funds. According to Isenberg, this incident inspired him to keep
after the schools about their tobacco program:
They had this elaborate anti-drug program that was funded by the
tobacco funds. And sure, did I mention that? Yes, I did. They were so pained because I
probably mentioned it in at least three or four speeches. But nobody tried to take that
money from them. On the other hand, it's pretty clear that health people don't control
where the money goes once it reaches the schools. I mean it's just out there. It may be
wonderfully spent, it may be well intentioned, but if the smoking rate of kids is any
indication, it's not having ¦much impact.
¦Once the money reaches the school site, nobody has much of an idea how it's spent or
whether it does any good. And as we got into the latter years, and began to fumble around
with performance information and outcome tests and so on, it reinforced again, the schools
don't comfortably deal with that conceptually whether it's the cigarette tax money or
Adding to the accountability problem of the blended model was the lack
of a plan to evaluate program effectiveness. When asked about evaluation and reporting
requirements at the first tobacco orientation conference held by CDE in San Diego in 1990,
White simply told one TUPE coordinator, Do the best you can. 
CDE did not attempt to account for how the schools were spending the
Proposition 99 Health Education Account until 1993, when it included use of these funds in
its biennial Coordinated Compliance Review, whereby CDE evaluated how local districts were
implementing state education mandates. The effort to put TUPE into the Coordinated
Compliance Review reflects the effort under Yeates to give the program more
accountability. By 1998, the inclusion of tobacco in the Coordinated Compliance Review was
regarded as a help by virtually all of the county-level TUPE coordinators. According to
one, It took me a long time to come to this. I used to think if you just gave
education the money and leave them alone, they will do the right thing. But I have learned
that is not always the case. 
Formalizing Noncooperation between DHS and the Schools
Even though it was theoretically desirable to have a close
relationship between the DHS-funded community programs and the programs in the schools,
there were many political and bureaucratic impediments to effective collaboration. The
increasingly specific tobacco control programs of DHS, the LLAs, and their coalitions
diverged over time from the schools' diffuse efforts. Tobacco control advocates
increasingly viewed the schools as black holes into which money would disappear with
little or no effect on tobacco consumption. TCS decided to limit LLA involvement in the
classroom because of concern that the schools would coopt LLA funding to serve needs that
CDE was supposed to be financing. TCS was also worried that, as with the early focus on
cessation, LLAs would spend their time doing one-shot presentations in the schools rather
than moving into policy-based activities for community change. In September 1990 TCS was
sufficiently concerned about the way that CDE was spending its money that it drew up the
- DHS funds cannot be used for the development or implementation of in-classroom
curriculum in public schools without prior state contract approval.
- DHS-funded programs in school settings must be non-curricular programs that supplement
ongoing Department of Education (DOE) funded curriculum programs in the classroom or are
extra-curricular activities for which DOE funding is not available to support.
In 1993, in a study of eight counties, the three LLAs that were trying
to collaborate with the schools voiced strong objections to the guidelines because the
guidelines second-guessed and impeded their efforts. By 1998,
when fifteen of the sixty-one LLA directors were interviewed, no one mentioned them
because most were no longer trying to work in schools very much.
Carolyn Martin, who headed TEOC at the time the classroom guidelines
were established, was angry about them:
We found out later that, as the money became tighter, Dileep Bal had
told his friends at DHS, Under no circumstances are you to do anything whatsoever in
the schools. They have their own money and we don't need to help them out. Well, on
the community level this is a source of great anger and resentment because it's stupid
¦and the local yokels know it. So we have absolutely given Dileep marching orders that
they are to cooperate and spend time and money in the schools. Now whether or not that
will happen, I don't know.
The LLA directors had mixed reactions about the Proposition 99 program
in the schools, generally more negative than positive. Of the fifteen LLA directors
interviewed in 1998 for this book, seven thought that their schools had done very little
on the tobacco issue. Five thought some tobacco programming had occurred, although they
had hoped for better. Only three of the fifteen were supportive of the effort in their
Thanks to the strong leadership that Ken Kizer showed at the
Department of Health Services, the Proposition 99 program got up and running quickly. The
media campaign was developed rapidly ”so rapidly that it was on the air before the
tobacco industry and its political allies could stop it. Rather than offering traditional
anti-smoking messages, the media campaign set an aggressive tone that confronted the
tobacco industry directly. While DHS's local programs started as traditional smoking
cessation programs, they rapidly evolved into ones that concentrated on public policy
interventions, particularly encouraging passage of local clean indoor air and other
tobacco control ordinances. The DHS was on its way to redefining tobacco as a social and
political problem (as opposed to a medical one) and undermining the whole social network
that supports tobacco use and the tobacco industry.
In contrast, the schools failed to make effective use of the money to
develop and implement specific programs for reducing tobacco use. The justification was
based on a broader desire to reduce high-risk behavior among students, but the schools
never produced convincing evidence that this program worked. This failure to develop
effective tobacco control programs stemmed partly from the unique financial and political
problems that the schools faced in post-Proposition 13 California and partly from a lack
of leadership or even interest in tobacco control within CDE.
These two different approaches to spending the money that Proposition 99
made available were reflected in how these two communities reacted to potential
controversy. The DHS programs often sought to create controversy as a way of engaging the
public and increasing the visibility of the tobacco issue. The schools sought to avoid
controversy. DHS sought to build a local network of people and institutions seeking to
confront the tobacco industry and stimulate social change; the schools were trying to
All the pressure was amplified by the size of the amount of money that
Proposition 99 had suddenly made available and the knowledge that AB 75 would last only
twenty-one months before the Legislature would have to pass a new law to continue
authorizing the Proposition 99 programs. Joel Moskowitz, the project director for one of
DHS's early evaluation contracts, observed, The Legislature basically had set this
whole thing up for failure anyway with the short enabling legislation. ¦When they passed
AB 75, the word had gone out that this program was going to end with the demise of AB 75.
The Legislature was going to rip off the money. I think that many people believed that, on
the health side as well as the education side, the Legislature wasn't real serious about
this program, just because of the short period of the enabling legislation. 
Nearly two years before AB 75 passed, the health groups had originated
the idea for a sunset provision in Senator Diane Watson's SB 2133 to ensure
experimentation, evaluation, and accountability in the new programs that Proposition 99
created. But instead the sunset provision impaired program development.
At the same time that tobacco control advocates were struggling to get
the programs up and running and develop some idea of what worked and what did not work,
the tobacco industry was already developing a sophisticated understanding of the damage
that the media campaign and the local programs were doing and could do. The industry also
recognized that the schools would not be a problem.
The fact that AB 75 would end only twenty-one months after it passed
created unanticipated political problems for the people implementing the programs. It
would take the Legislature several months to pass new authorizing legislation and
additional time to launch the new Proposition 99 programs, which meant that proponents
would be back in the Legislature debating the future of Proposition 99. This situation
would create tremendous political problems for tobacco control advocates interested in
defending the fledgling programs.
No one understood this reality better than the tobacco industry and its
allies who wanted to see Health Education money diverted to medical services.
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