Regulation Tabacco

Chapter 7

Changing Public Policy Around Tobacco Control in the COMMIT Communities
David S. Carrell, Carolyn L. Johnson, Len C. Stanley, Juliet Thompson, and Sandy Tosti

INTRODUCTION Public policy is a potentially powerful tool for changing individual and group behaviors (Jason et al., 1991). Through ordinances, regulations, and other policies, local governments can influence a wide variety of behaviors concerning the promotion, sale, and consumption of tobacco products (Bierer and Rigotti, 1992; Thompson et al., 1990-91; U.S. Department of Health and Human Services, 1991). Creating smoke-free indoor air spaces, preventing illegal sales of tobacco to minors, and prohibiting the distribution of free cigarette samples are policy actions that can influence individual behavior and community norms regarding health-related behaviors. Over the past decade local governments have become the primary innovators in the use of public policy as an instrument for preventing or controlling tobacco use (Samuels and Glantz, 1991; U.S. Department of Health and Human Services, 1993). This chapter describes the contributions of the Community Intervention Trial for Smoking Cessation (COMMIT) intervention activities to tobacco control policy changes in selected communities and distills lessons from these experiences that may be useful to others engaged in or considering similar undertakings. Although every attempt to bring about policy change is unique, some themes, challenges, and strategies are common. Familiarity with the experiences of others can be valuable. Intervention designers anticipated that many COMMIT activities were likely to translate into demands for more aggressive and better enforced tobacco control policy (COMMIT Research Group, 1991). Media campaigns were designed in part to raise public awareness of tobacco hazards and foster community ownership of the problem. COMMIT Board and task force membership often included local government officials, other influential members of the community, and advocates for improving the health of the community. As these individuals became more fully informed about the hazards of tobacco use, their commitment to intervention opportunities (including policy change) was expected to increase. Invigorated grassroots advocacy groups helped to keep these issues on local government agendas and in the public eye. The COMMIT field office acted as a clearinghouse for technical information (e.g., how to conduct compliance checks, provide model language for proposed clean indoor air policy) and a center of communication among various local groups and influential leaders. Recognition and ownership of tangible local problems, public support for government action, committed leaders, coalition building, and technical know-how are among the important factors affecting the political climate

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for local policy change (Reich, 1988; Kingdon, 1984; Weiss and Tschirhart, 1993). Although policy change was recognized as an important avenue of community change, it was not a primary objective of COMMIT. Federal regulations prohibited use of COMMIT monetary contributions for lobbying in State and local political arenas. However, there were no such restrictions on indirect activities, such as provision of information and coalition building. In addition, project staff and Board and task force members were allowed to advocate for policy change as long as they did so on their own behalf, not as representatives of COMMIT. During the intervention, important policy changes occurred in many intervention communities. Tobacco control policy is defined here as any ordinance, regulation, or directive issued by a governmental body intended to alter individual behavior regarding the promotion, sale, or consumption of tobacco products. Some governmental policies affect the general public, such as smoking restrictions in cityor county-owned facilities. Others may affect only city or county employees, such as office no-smoking policies or city personnel policies requiring newly hired police officers and firefighters to be nonsmokers. It is important to remember that “policy” includes both the scope and content of the policy “on paper” as well as related efforts by official agencies to monitor and enforce its provisions. Other entities, such as employers, retailers, and restaurants, also set policy that may influence the public. Such regulations are sometimes referred to as “informal” public policy. When shopping malls, public schools, or individual restaurants decide to become smoke-free, a limited but potentially significant portion of the community is affected. Smokers encounter domains in which they cannot smoke, and nonsmokers enjoy and become accustomed to smoke-free air. (For a discussion of informal, nongovernmental policies, see Chapters 10, 12, and 13.) RATIONALE The rationale for promoting tobacco control policy change in community-based health promotion interventions is compelling. First and foremost, public policy is believed to have a powerful influence on the broad social environment or context within which health-related individual behavior occurs (U.S. Department of Health and Human Services, 1989; Glynn, 1991; Bracht, 1990; Frankel, 1988; Wynder, 1988). Regulating or preventing the promotion and use of tobacco products may significantly affect social norms and practices concerning tobacco use. Over time, as the public presence of smoking, environmental tobacco smoke (ETS), and tobacco product promotion is reduced within a community, members of that community may grow increasingly accustomed to tobacco-free

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environments. Whereas it was once normal for people to smoke in enclosed public places, for cigarettes to be advertised on television, and for merchants to sell tobacco to underage youth (despite laws to the contrary), public attitudes toward these activities have begun to change. Many communities now consider smoke-free public environments to be the norm and have come to believe that youth should be protected from the hazards of tobacco use by putting a stop to illegal sales and youth-oriented promotion of tobacco products. Public policy can be an effective tool for promoting and reinforcing norm changes by giving official, communitywide sanction to the regulation of tobacco-related behaviors. Policy is also an important health promotion tool because it is capable of reaching people who are difficult to reach through other intervention channels, such as cessation counseling or public education campaigns. Some members of minority populations, blue-collar workers, and youth are included in this category (Escobedo et al., 1990). Many of those who do not receive public health education messages or health care provider-based cessation interventions will be employed at worksites or will patronize public places where smoking is restricted or banned for health protection reasons. Protecting youth from the health hazards of both firsthand and secondhand tobacco exposure continues to be a powerful argument for policies restricting smoking in public places and preventing tobacco sales to minors. Finally, substantial experience from Project COMMIT indicates that there is a potential for synergy between local policy efforts and other intervention activities, such as youth education, workplace policy, cessation campaigns, and media advocacy efforts (see also U.S. Department of Health and Human Services, 1991). Messages conveyed through public school curricula, the media, or health care providers can be bolstered and reinforced by the messages implicit in smoking restrictions at the workplace, in restaurants, or in public buildings. Once smoke-free office policies are demonstrated to be feasible and desirable in local city or county offices, private sector offices may be encouraged to follow suit. Thus, policy can be an important component of a community’s multifaceted approach to reducing tobacco-related morbidity and mortality. Over the past two decades the tobacco control policy movement in the United States has moved its focus away from Federal and State policy arenas and is now aggressively and effectively pursuing means within local jurisdictions (U.S. Department of Health and Human Services, 1993). As policy activity within cities and counties continues to build momentum, excellent opportunities to improve public health through tobacco control policy will continue to present themselves.

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CHANGING This section illustrates the challenges, strategies, and themes—some POLICIES common and others unique—encountered in local policy change efforts. Vending machine bans, clean indoor air ordinances, smoke-free school policies, and a billboard ban are described. Many of the policy activities focused on youth. This was because policy changes directed at restricting youth access are generally not controversial; thus, such activities could be used to gain the participation of many community members. Vending Machine Bans Communitywide policy change was not a focus of COMMIT intervention activities. However, some of the COMMIT intervention communities’ efforts to reduce youth access to tobacco resulted in policy actions to restrict or ban cigarette vending machines. Children can easily purchase cigarettes from unattended vending machines with little fear of being detected. Vending machine ordinances are particularly popular among tobacco control advocates because vending machines are one of the most common sources of illegal sales to underage youth, particularly the very young (U.S. Department of Health and Human Services, 1990). As a result, local youth and community groups are often eager to assume ownership of and work toward addressing this problem, and the case for banning machines can be effectively communicated to local policymakers. As of 1992, 161 communities throughout the United States were known to have ordinances restricting or banning the use of tobacco vending machines (U.S. Department of Health and Human Services, 1993). In this section, experiences with vending machine ordinances in the North Carolina, California, and Oregon intervention communities are described. In 1991, COMMIT sponsored a 14-month initiative, the Tobacco-Free Youth Project, designed to reduce illegal tobacco sales to youth through merchant education. This initiative continued beyond COMMIT and was a major factor in the successful passage of a Raleigh, NC, city ordinance restricting placement of cigarette vending machines. Although banning vending machines was not one of COMMIT’s intended goals, the ordinance came about as a direct result of the activities and actions of people involved in the initiative. Strategic framing of the issue, effective use of locally collected information, and a readiness to seize the moment were key ingredients in the passage of this ordinance. Compliance in Raleigh with an existing State law prohibiting tobacco sales to persons younger than 18 years of age was poor, as is the case in many communities throughout the United States. Because the local community was generally unaware of the extent of illegal sales (or even the existence of the State law), it was decided that an awareness-raising effort was needed.

Raleigh, NC

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Project personnel believed that city authorities were unlikely to improve enforcement efforts unless they perceived the community to be informed of and concerned about the problem. Therefore, the Tobacco-Free Youth Project initiative began with an undercover compliance check (see Chapter 13 for a complete description of such operations) to document the ease with which underage youth could purchase cigarettes, both over the counter and from vending machines. The procedure involved underage youth going out with an adult superior to buy cigarettes, which they are not legally allowed to do. Two-thirds of over-the-counter and more than 90 percent of vending machine purchase attempts were successful. To communicate this information to the general public, a youth-led press conference was orchestrated that received excellent media coverage and followup through editorials, feature stories, and a local radio talk show. Two months later, in an attempt to keep the issue in the public eye, the same youths presented their compliance check results to the Raleigh City Council. They also presented national data showing that vending machines are a primary source of cigarettes for very young (11- to 12-year-old) adolescents. Their presentation concluded with a plea to ban vending machines by a city ordinance. The youths reminded the council that, although it may be feasible to achieve compliance with tobacco sales laws by educating merchants, “You can’t educate a vending machine” (unpublished quotation). The Raleigh City Council had voted down a similar proposal several months earlier; however, this time they referred the vending machine proposal to their newly created Substance Abuse Commission, to whom the youths again presented their compliance check results. Subsequent negotiations between the Raleigh city attorney, tobacco industry representatives, and local vending machine owners yielded a compromise proposal allowing machines only in establishments licensed by the State to serve liquor, which mollified the vending machine owners. Although the Tobacco-Free Youth Project went back to the city council with data showing that most liquor-licensed establishments were family restaurants or local motels where youngsters gathered, by that time the compromise proposal had been drafted into a policy statement that the city council was reluctant to alter. The city council soon passed a precedentsetting municipal tobacco vending machine restriction in the capital city of the largest tobacco-producing State in the Nation. The Tobacco-Free Youth Project claimed victory. Vallejo, CA Before the COMMIT intervention began in Vallejo, CA, the North Bay Health Resources Center launched a 5-year project called the Solano County Cancer Prevention Program to address the problem of illegal access to tobacco by youth. The cancer prevention program laid thorough groundwork in Vallejo in 1988 and 1989 by conducting undercover compliance checks to assess the ease with which over-the-counter and vending machine sales could be made to minors. This activity was followed by a merchant education campaign, another compliance check, more merchant education, and a third compliance 101

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check in May 1990. By this time the COMMIT intervention was under way with 1 year of community organizing and intervention behind it. COMMIT was a resource to the Solano County Cancer Prevention Program during this first year by providing background data from the COMMIT baseline survey regarding local public opinion in support of tobacco control efforts. In addition, the coalition network built by COMMIT provided a natural clearinghouse for information sharing and cooperation among the various related agencies in Vallejo. In June 1990, COMMIT cosponsored a dinner meeting with the cancer prevention program to bring together community leaders and interest groups to discuss ways to deal with illegal sales to youths and the lack of consistency in civil fines levied on merchants for illegal sales. The primary outcome of discussion among the 30 community representatives attending the dinner was a proposal to ban vending machines and prohibit free distribution of tobacco products in Vallejo. A key advantage in the passing of the proposal was a political one: The chair of the Solano County Cancer Prevention Program was also a member of the Vallejo City Council. Members of the cancer prevention program joined forces with the Minority Coalition for Cancer Prevention, a Vallejo organization that targeted African-Americans, to expand their own networks and mobilize a newly formed ad hoc coalition to propose the legislation to the Vallejo City Council. COMMIT served as a resource here also, with staff members providing supporting survey data as background information. Because many members of this new coalition were also COMMIT Board and task force members, COMMIT meetings provided an avenue for information sharing. In fact, individual COMMIT volunteers were directly involved in testifying at the city council hearings and orchestrating the passage of the vending machine ordinance. Those individuals, representing their own organizations, included the administrator of the local private hospital (and COMMIT Board chair), the executive director of the local American Lung Association (ALA) (and COMMIT Board member), and the project directors of the Solano County Cancer Prevention Program and the Minority Coalition for Cancer Prevention (and COMMIT Board members). The most important factor contributing to the successful passage of the vending machine ordinance was the role of three Vallejo youth groups: the Students Against Cancer (a subgroup of the minority coalition), the city-sponsored Youth Activities Commission (whose two adult advisers were another city council member and a COMMIT task force member), and the Vallejo chapter of Friday Night Live. Ironically, these three youth groups were pulled together earlier in the year by a North Bay Health Resources Center staff member on contract with

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COMMIT to involve community teens in an activity that would monitor youth access to tobacco. As the teens organized themselves around this activity, became educated about youth access problems, and began to develop ways to educate the public about the problem, the coalition was mobilizing and planning its strategy for proposing a vending machine ordinance. For their COMMIT activity, the three youth groups launched a media campaign called “Fight It, Don’t Light It.” One of the teens sketched a poster drawing, which was enlarged, duplicated, and placed inside Vallejo transit buses in June 1990. This was the first time the transit company allowed anyone to place “advertisements” in the interior of its buses. The contribution of this COMMIT youth group was significant for two reasons. First, the youth coalition was organized and in place at the time of the city council’s public hearings on the proposed ordinance. Now knowledgeable about the issues of youth access, the teens were invited to speak at the public hearings. The passion of the teens’ testimony and the public evidence of their ability to buy cigarettes just prior to the council meeting swayed at least one council member from a “no” to a “yes” vote. Second, the posters indicated their design was the work of Vallejo teens. Although the posters appeared in city buses after the ordinance was passed, they added impetus to the fact that local youth demanded that their community protect their health. One source of embarrassment in the vending machine ordinance campaign was the lone vote in opposition to the ban. That council member was a member of the COMMIT Board of Directors! After the ordinance passed, the COMMIT Board chair wrote a letter to the editor of the Vallejo Times Herald praising the work and wisdom of the city council. Medford/ Ashland, OR Community-based youth groups also played a central role in efforts to obtain vending machine bans in Medford/Ashland, OR. In preparation for these efforts, a COMMIT task force reviewed the community analysis report (see Chapter 5) to identify existing youth groups that could be asked to participate. It was felt that local youth would be most effective in pressuring law enforcement agencies to regulate access to tobacco products by minors. COMMIT staff members approached the Medford Mayor’s Youth Commission, a group of 15 high school students representing 5 high schools.

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The group was looking for a project and was willing to put youth access to tobacco on their agenda. With organizational assistance from COMMIT, they conducted a compliance check in which 95 percent of over-the-counter purchase attempts were successful. The group presented these findings at a press conference and to the Medford City Council. The presentations concluded with a plea for police cooperation in enforcing the existing State law. The following day the chief of police called a press conference to pledge support for an educational campaign to increase voluntary compliance among area merchants. In conjunction with this announcement, the Youth Commission sent a letter asking store managers to provide in-service training for their clerks. A cash register sign reminding clerks and patrons of the State law also was included in the mailing. In 1990 the Mayor’s Youth Commission repeated the compliance check, this time including vending machine purchases. The success rate for overthe-counter purchase attempts dropped to 72 percent, but 100 percent of vending machine attempts were successful. With evidence that illegal sales were persisting and with other background information provided by the COMMIT staff, the students met with the city attorney who helped them draft a vending machine ordinance proposal. The proposal would restrict tobacco vending machines to premises not accessible to persons younger than age 18, private workplaces, or retail locations where the machine would be within direct view of an employee who could see the facial features of machine users at all times. Failure to comply would result in a $250 fine. The students testified at a public hearing to consider the proposal. Only one vending machine distributor testified against the ordinance. Another tobacco distributor was quoted in the newspaper as being supportive of the goal to help prevent youth from smoking. He complained that the only reason he had cigarette machines is that some local employers requested them. The council adopted the ordinance by a unanimous vote. Realizing that youth access to vending machines remained unabated in the county’s 10 other cities and unincorporated areas, the following year COMMIT staff members and task force volunteers approached the youth group of a countywide drug prevention organization. The group was readily mobilized and eager to conduct its own compliance check. With evidence of successful purchases in 75 percent of over-thecounter and 100 percent of vending machine purchase attempts, the students presented their findings to the district attorney and asked that an ordinance similar to that in Medford be drafted. Representatives of the youth group also made a presentation to the county commissioners, who subsequently ratified the ordinance.

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COMMIT then focused attention on the city of Ashland. High school students associated with Students Against Drunk Driving (SADD) and Responsible Educated Adolescents Can Help (REACH) were recruited to conduct compliance checks, draft an ordinance, and make a presentation to the city council. The night of the public hearing, because of final exams, only one student was available to testify. Despite this, the city council adopted an even stricter ordinance limiting tobacco vending machines to places not accessible to minors. Both ordinance campaigns in Oregon took about 3 months to plan, execute, and complete. It was very labor intensive for COMMIT staff members to plot the locations of businesses on maps, set up routes for each team, obtain subjects’ permission as required by the research institute, obtain parental permission as required by local law enforcement agencies, recruit volunteer drivers, perform fundraising for the money used in purchase attempts and a pizza party following the compliance checks, draft ordinances, rehearse their testimony before appearing in front of government bodies, and make presentations. Such efforts are essential to the success of these campaigns. The presence of several municipal or county jurisdictions within a single geographical area can complicate policy change efforts and multiply the amount of work required. In the campaign for a county vending machine ban, the Oregon COMMIT staff members had to gather data and present arguments in each separate city within the county and in the unincorporated areas. The result was three different ordinances, each with different provisions. After COMMIT staff members worked for 3 years of effort to work within the many jurisdictions, the State of Oregon passed a law prohibiting tobacco vending machines from places accessible to minors but exempted hotels, motels, industrial plants, and restaurants with liquor licenses. This excludes, for example, many pizza parlors. Not only was this a much weaker law, but it also included a preemption provision, requested by the tobacco industry, that prevented local governments from having more stringent ordinances. This law undermined many of the provisions of the ordinances enacted in Medford/Ashland and continues to prevent other communities from aggressively controlling illegal cigarette sales to youth. Initial sponsorship of State laws by the “right” organizations does not eliminate the preemption threat. The Oregon law was originally promoted by a coalition composed of the American Heart Association, American Cancer Society, State Department of Health, and ALA. However, once a proposed law enters the State legislative arena, the tobacco industry lobbyists can be counted on to do everything within their power to alter, minimize, or undermine the proposal’s original intent. Often, what tobacco lobbyists convince legislators is a “fair compromise” is a relatively weak State bill that is difficult to enforce or incorporates preemptive language forbidding cities and counties from adopting more stringent local ordinances (Pertschuk and Shopland, 1989). 105

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Clean Indoor The enactment of new or strengthened clean indoor air ordinances Air Ordinances was a policy change strategy pursued in many COMMIT communities. During the trial, policy changes restricted smoking in a variety of public places, including government buildings and vehicles, restaurants, office buildings, schools, retail shops, sporting venues, and public transportation facilities. This section describes the events leading up to the adoption of three such ordinances, one in Medford and two in Raleigh. Medford, OR When the COMMIT intervention began, Oregon had a State law requiring designated smoking areas in public buildings, and Ashland had already adopted a smoke-free policy for city employees. The COMMIT staff members thus focused their attention on Medford. A consultation with the city personnel director was arranged to provide information on the benefits of clean indoor air policies and to discuss effective strategies for developing and implementing a policy that was acceptable to employees. Medford was advised to conduct an in-house survey of its employees to determine their attitudes toward an office smoking ban. The survey indicated strong support, even among smokers. Three months later Medford adopted a smoke-free workplace policy for its employees. Jackson County, within which Medford and Ashland are located, decided to take a more radical step. Following informational consultations with COMMIT staff members, county officials announced in July 1990 that all county-owned buildings would become smoke-free within 30 days. Designated smoking areas were to be eliminated entirely. The ruling exempted the baseball park, the fairgrounds, an outdoor music arena, and the airport. The policy banned smoking in the county jail (by employees and the 190 inmates) and in all county vehicles. The policy was supported by the public employees union and the sheriff’s employees union, both of which had been notified beforehand of the county’s intentions. The media reported that the county adopted the policy in response to rising health costs. The county, which underwrites its own insurance, had an active wellness program and expressed concerns about the health effects of ETS. Despite the lack of forewarning, the ban was implemented with little fanfare or controversy. Six months later a group of inmates staged a brief hunger strike to protest conditions in the jail and included the smoking ban along with other complaints. Jailers reported that cigarettes replaced other drugs as the primary contraband smuggled into the jail and that inmates were observed drying lettuce leaves, wrapping them in paper, and short-circuiting the television cord to get a light. Raleigh, NC, Wake The first clean indoor air ordinance passed in Raleigh during the County Ordinance COMMIT project was a Wake County ordinance banning smoking in all county buildings, including offices housing county employees. The campaign to pass this ordinance was led by the director of the county health

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department, a dynamic dentist who worked closely with COMMIT staff and volunteers throughout the effort. The power to adopt the proposed ordinance ultimately rested with the Wake County Board of Commissioners. Through an informal polling of commissioners, the health department chief learned that support for the ordinance existed but that an influential tobacco grower on the board was likely to challenge the policy change. COMMIT personnel recommended that the county conduct an in-house survey of employee attitudes regarding the proposed no-smoking policy. Such surveys can provide powerful evidence to challenge unsubstantiated claims of those opposed to such policies (tobacco farmers in this case). Previous surveys in other communities (outside North Carolina) indicated that between two-thirds and three-fourths of employees favored workplace restrictions on smoking. However, without tangible evidence of local opinions, some feared that the views of the silent majority would be overshadowed by the impressions created by a small but vehement minority opposing the ordinance. Furthermore, to the extent that a survey would involve those affected by the ordinance in the decisionmaking process, a sense of ownership can be promoted that can, in turn, fortify support. COMMIT staff members and county officials felt that employees would be more inclined to support a policy they helped develop than one mandated from “on high.” When the commissioner opposed to the ordinance learned that the county was preparing to conduct an employee survey, he attempted to influence its content. For example, he suggested that, in addition to questions about ETS, the survey should ask employees whether breathing perfume, aftershave, or another person’s body odors was bothersome. Such questions were perceived by those conducting the survey as an attempt to trivialize the survey and the public health issue it addressed. The commissioner’s questions were not included. Results of the employee survey were presented at a public hearing attended by more than 100 tobacco farmers and their families. Emotional pleas by farmers about the eventual hardships the ordinance would cause them and their families were answered by survey evidence that 77 percent of employees—including many smokers—supported the proposed restrictions. By doggedly insisting that the issue be positively framed in terms of protecting employee health and by giving the commissioners survey evidence justifying a yes vote, backers of the ordinance successfully guided it through local political channels with a 7-to-2 vote, despite vocal and well-orchestrated opposition. Prior to its formal implementation, a single exception to the ban was granted to one section within the county courthouse. Although the exception was presented as a compassionate provision for smokers under the stress of the legal system, the widely acknowledged truth was that a

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prominent judge was a smoker and was furious about the ban. The oftenrepeated maxim “all politics is local” applies to local politics as well. Raleigh, NC, In 1991 Raleigh passed citywide restrictions on smoking in public City Ordinance places. Again, the campaign was spearheaded by the director of the Wake County Department of Health working in conjunction with COMMIT advisers, members of the Raleigh City Council, lawyers, and personnel from the Wake County Department of Health and the North Carolina State Division of Health. This is a case in which a legacy of State-level tobacco policy efforts placed limitations on what was politically feasible at the local level. Some historical background is thus in order. Raleigh is the capital of North Carolina and home to numerous State office buildings. In 1989 the director of the North Carolina Division of Health, a physician, imposed a smoking ban in all State health department offices under the division’s jurisdiction. Within 24 hours the Governor held a press conference in which he publicly rescinded the ban. Such policies, the Governor maintained, were unfair to the tobacco industry and would not be tolerated. Two years later when the Raleigh city ordinance was proposed, it was clear that any attempt to regulate smoking in State buildings would be opposed. Public opinion in Raleigh was far ahead of the Governor on this issue. As two previous COMMIT surveys confirmed, high percentages of Raleigh residents favored restrictions on smoking in a variety of public places. These survey results provided the impetus for proposing a comprehensive nosmoking ordinance for the city. The State policy legacy meant that careful political maneuvering would be required to secure its passage. The proposed city ordinance was among the most stringent in the country at the time. It banned smoking in enclosed entertainment venues, sports arenas, educational facilities, shopping malls, elevators, health care facilities, pharmacies, and publicly accessible restrooms and on public transportation. The ordinance also required employers to provide “reasonable provisions” for smoke-free workplaces, and restaurants were required to reserve at least one-third of their tables for nonsmokers. Ironically, this ordinance was passed by the Raleigh City Council with virtually no public opposition by the tobacco industry. Several factors accounted for the absence of opposition. Perhaps the single most important factor was a strategic decision, made early in the process, to exclude all State government buildings from the provisions of the ordinance. The stated rationale for this was that State buildings are under separate jurisdiction. In reality, the decision was motivated almost entirely by political considerations. In North Carolina, as in many States, the tobacco industry can exert considerable political influence within the State legislature. If the Raleigh ordinance had included State buildings, the tobacco industry would have had an opportunity to

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redefine the issue as a State issue and unleash its lobbying machinery against the ordinance, perhaps defeating it entirely. By conceding State buildings from the outset, this controversy and the involvement of the tobacco lobby were avoided entirely. Another factor accounting for the relative absence of tobacco industry opposition during this campaign was the leadership provided by the health department chief. There is no substitute for the careful planning, political aptitude, thoroughness, and diligence she exhibited in spearheading this effort. The value of such leadership cannot be overstated. Another notable development during this campaign involved the use of survey data to counter the opposition’s attempts to spread misinformation. Prior to the city council vote, the Restaurant Owners’ Association and the chamber of commerce suggested to the news media that there was considerable public opposition to the proposed ordinance. These claims were reported in the local newspaper. Supporters of the ordinance responded immediately by providing the newspaper with results from COMMIT’s 1989 Evaluation Cohort Survey (COMMIT Design and Evaluation Working Group, 1989) refuting the unsubstantiated claims. Ordinance supporters felt that publication of these survey results served to contain the opposition. Another interesting phenomenon observed during the city ordinance campaign was the reluctance of many local businesses to publicly reveal their support for the proposed policy. Fear of alienating other members of the business community appeared to be the motivation behind this behavior. Representatives of these businesses were willing to recount their own experiences with workplace smoking policies at COMMIT-sponsored workshops and for use in a COMMIT-produced policy handbook. When they were asked to testify at public hearings, their enthusiasm waned. Of more than a dozen major companies in Raleigh that could have helped the cause of the campaign by describing their own positive experiences with smoking policies, only two would testify at public hearings. Both of these had strong connections with health care—the North Carolina Medical Society and Duke University. Several contacts within the business community indicated that the decision not to participate was made at the highest levels within some organizations and was motivated out of fear of alienating the tobacco industry, whose representatives sit on the boards of some of these corporations. For other businesses, the reluctance to testify seemed to be an attempt to avoid open conflict with the chamber of commerce, which openly opposed the ordinance. In either case, the experiences in Raleigh suggest that unwillingness to publicly endorse a city ordinance does not necessarily indicate opposition within the business community. Indeed, once the ordinance went into effect, some businesses used the mandate as an excuse for implementing more stringent workplace policies than required. That is, they banned smoking entirely when “reasonable accommodation” of nonsmokers was all the ordinance required. Apparently,

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these businesses were taking advantage of an opportunity to pursue their own more aggressive agendas while channeling any criticisms thereby generated toward the city. Smoke-Free School Ordinances In 1991 the school districts of Medford and Ashland adopted regulations that virtually banned smoking from public school facilities but only after successfully overcoming several political and operational barriers.

At the start of the COMMIT intervention there was some awareness within the Medford and Ashland School Districts of smoking as a public health issue. Both districts had established wellness committees focusing on school health issues and had participated in local health fairs and The Great American Smokeout events. Still, smoking was allowed in designated teachers’ lounges, and there were designated smoking areas for students on high school campuses. Student smoking areas had been established to accommodate neighbors bordering the school who complained about students smoking in their front yards. In 1990 both the Medford and Ashland School Districts’ wellness committees began to spearhead efforts to achieve smoke-free school buildings, although efforts were slowed by union negotiations. Custodians wanted a policy that would allow them to drive off campus to smoke during their breaks. Initially, there was no plan to eliminate designated outdoor smoking areas on school grounds. However, in June 1991 the State legislature passed a law making possession of tobacco by minors illegal. This legislation also required schools to adopt policies regarding smoking and the use of other drugs on public school grounds. Concerned that previous State laws regarding youth access to tobacco products had been poorly and inconsistently enforced, COMMIT staff members arranged two meetings to discuss the new State law and the need for coordination of policies across the county’s seven school districts. In attendance were representatives from COMMIT, the school districts, law enforcement, and the juvenile justice system. Frustration with the poor enforcement of minor-in-possession laws by local police was expressed. Ultimately, school officials decided to take an active approach to enforcement and handle most violations in-house; they would not simply notify local police when violations occurred. Each school district adopted its own multistage disciplinary policy. Generally, these policies began with confiscation of the tobacco (or other drug) for a first offense and ended with suspension from school in the case of frequent repeated offenses. With respect to smoking policies for teachers and staff, COMMIT personnel presented the argument that adults, and especially teachers, should act as role models for healthy lifestyle behaviors for children. They argued that teachers and students should be subject to the same smoking policy; smoking should be banned entirely, for everyone, on all school grounds. 110

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Heeding this appeal, the Ashland School District adopted a tobacco-free campus policy that stipulated no tobacco use by anyone at anytime on any school grounds, including the football stadium. The Medford School District adopted a similar policy but allowed teachers to smoke in their cars in the faculty parking lot. Billboard Ban In spring 1990 the city of Bellingham, WA, passed an ordinance phasing out all billboards within the city limits. By 1996 this ordinance will have eliminated what in most communities is a pervasive form of tobacco advertising. Passage of the billboard ban was the result of cooperation by several different community groups. Although motivations for supporting the ban differed, the groups’ collective efforts produced an outcome that was beneficial to all. Two years before the question of a billboard ban caught the attention of local policymakers, a COMMIT project staff member sought and obtained information from Scenic America, a national organization advocating removal of billboards as a means of beautifying the environment. Her interest in Scenic America was less associated with its goal than its means; elimination of billboards was one way to reduce the promotion of tobacco products because a large percentage of Bellingham’s billboards regularly displayed cigarette advertisements. In an attempt to initiate local action on this issue, the Scenic America materials were sent to a Bellingham City Council member who chaired the council’s Public Works Committee and who was a personal friend of the COMMIT field director. In a followup contact, the council member was polite but indicated no interest in the matter. About a year later Bellingham was in the throes of a transition. In summer 1987, a large regional shopping mall had opened north of the downtown area, an event that divided both the business community and the general public. The result was a relocation of businesses from the downtown area to the mall, leaving one city building after another vacant. At this same time Bellingham was receiving numerous requests for permits to erect billboards on newly vacated downtown properties, a development that alarmed several members of the city council. The council swiftly imposed a moratorium on all new billboards until it could study the issue. At this point the council member who had been given the Scenic America materials reconnected with the COMMIT field director and asked whether she would be willing to testify at a Public Works Committee hearing on the billboard issue. Support was building within that committee for addressing the billboard problem by proposing a full ban on all billboards to the city council. Several billboards at that time displayed liquor advertisements featuring a reclining blond model in a revealing black gown. These advertisements played an important role in the outcome of the proposal because they

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angered and activated other local groups, including alcohol abuse treatment professionals, parents, and women’s groups. The hearing was attended by an attorney representing the community’s largest billboard owner, another local billboard owner, and numerous local advocates and concerned citizens. Most of the people in the latter group favored the ban. Much of the testimony focused on the liquor advertisements. The COMMIT representative detailed the enormous amounts of advertising revenues spent by both tobacco and alcohol companies each year, how the advertising affects youth who are captive viewers, and how the advertising gives youth the impression that alcohol and tobacco are socially acceptable. One argument that played well in the discussion was that, because it was impossible to selectively ban “bad” advertising messages, the only recourse was to eliminate the vehicle for these messages. Many, including the billboard owner’s attorney, were surprised and moved by the power of the COMMIT field director’s testimony. When it was the attorney’s turn to speak, he looked sheepish and confessed in an apologetic tone that he did not even let his own youth wear T-shirts with beer logos on them. To enhance the effectiveness of her presentation, the field director had invited a retired Washington State senator who was a highly respected member of the community to accompany her in the hearing. The retired senator briefly reiterated and endorsed the field director’s remarks. The proposed ordinance was approved by the Public Works Committee and shortly thereafter passed by a majority vote of the city council. A 6-year phase-in period was provided to give billboard owners time to absorb and adjust to the economic impact of the ordinance. Several months later COMMIT was asked to provide the same testimony to the Whatcom County Council as it reviewed its outdoor advertising policies. This time the billboard owners were more organized and presented more effective counterarguments. Instead of instituting a ban, the county council voted to forbid construction of any new billboards and specified that when existing structures were removed, they could not be replaced. Ultimately, the billboards will go, but it will be a more gradual process. When attempts are made to change policy, the importance of laying foundations early on to ensure that some of those changes take place in the future cannot be overemphasized. Providing a council member with the billboard abatement materials long before the issue was on the local political agenda illustrates this point. That the mayor was a member of the COMMIT community Board also was not accidental. The COMMIT project wisely chose to hire a field director who was well known in the community and who knew how to “work the community” to ensure some success. The initial informational contact with the chair of the council’s Public Works Committee was facilitated by a previously established relationship. The willingness of a

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highly regarded community influential (the retired senator) to advocate for this policy provided additional credibility and stature to the effort. Another critically important strategy is to be poised and ready to “seize the moment” whenever it may arise. The success of the billboard bans turned largely on the fact that when an opportunity presented itself, tobacco control advocates were able to assemble their resources swiftly and strike with a certain element of surprise. Surprise was not an element in the hearings for the county ordinance, and the results were less impressive. It is also essential to consider how issues are framed. From beginning to end, the supporters of the billboard ban focused exclusively on the issue of youth exposure to unhealthy images and messages. Because they did not deviate from that posture, the hazards of being portrayed as antibusiness or as infringing on first amendment rights were avoided. Opponents’ attempts to reframe the issue must be assiduously resisted. Diligence is essential in all efforts to change local policy, the process of which is often long and arduous. Even after ordinances are adopted, opponents may later attempt to have them overturned. As this volume goes to press, the billboard ban in Bellingham (which is not yet fully phased in) is under attack by a small but vocal group of local entrepreneurs who view the policy as an infringement of their business opportunities. CHALLENGES It is often the case that more is learned from failures and mistakes than TO POLICY from successes. This section examines two unsuccessful attempts at CHANGES policy change. The first involved a county ordinance to address youth access problems; the second was an attempt to pass a local clean indoor air ordinance that was preempted by a tobacco industry-sponsored State law. Unsuccessful Early in the intervention (1989), the Public Education Task Force in Youth Access Bellingham identified the need for a policy initiative restricting youth Ordinance access to tobacco products. Task force members arranged a joint meeting of the mayor of Bellingham, the chief of police, two city council members, and a task force member who was a highly respected and influential member of the community. Everyone at the meeting agreed that this was a great idea, but there was no commitment by anyone to spearhead the initiative. Vague promises were made that something would happen, but nothing was forthcoming. Several months later the county health officer contacted the COMMIT offices and discussed the possibility of putting forth some sort of effort toward restricting youth access to tobacco. His idea was to cast this effort as a health department initiative promoting the health and well-being of youth rather than as an effort to beef up law enforcement or a program that could be construed as blaming the business community (retailers) for the problem. The effort would include the entire county. The proposal called for licensing all tobacco vendors in the county and collecting a licensing fee. The fees would be earmarked for health

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department-sponsored educational and enforcement activities. The proposal also prohibited the sale of single cigarettes. One surprising twist in this venture was the rapid response of the tobacco industry. The proposal was first presented to the county executive and chief of police in a closed-door meeting with the health officer and county counsel on a Friday afternoon. The following Monday morning the health officer received a telephone call from a representative of the tobacco industry asking about the proposed health department activity and requesting that the industry be kept informed of any further progress in this area. All involved became understandably paranoid. Nevertheless, there appeared to be no further involvement on the part of the tobacco industry. Prior to the presentation of the proposal to the county council, COMMIT conducted two compliance checks to document the ease with which underage youth could purchase tobacco products in the county (for a discussion of compliance checks, see Chapter 13). Additional political groundwork was completed by the health officer, who made several informational presentations to various sectors of the community (such as a meeting of small retailers). At the health officer’s request, COMMIT made a presentation to the county health advisory board. It was the health officer’s belief that all stakeholders should have input into the initiative. The presentation was made, and the proposed ordinance was forwarded to the county council for action. This was the last anyone heard of it. Apparently, the council simply did not put the proposal on its agenda for discussion. The reasons for this are unknown. There are a multitude of potential barriers and challenges that must be successfully negotiated to pass an ordinance of this type. It is thus difficult to say with certainty why the effort failed. That there were seven separate municipal jurisdictions within the county that had to sign off on the policy undoubtedly complicated matters. In addition, the local political climate during the time the ordinance was under consideration was unfavorable for any significant policy change: Budgetary anxieties were high, and relationships between the county executive, the county council, and the health officer were strained. There was a sense among some people close to the effort that key players involved were not able to respond swiftly enough—to seize the moment—at critical junctures during the process. Leadership plays a central role in determining the tone and course of such endeavors. In the opinions of some, the deliberate and at times overly cautious style of the health officer leading this effort did little to mitigate what was already a slow and inherently cumbersome process that called for exceptional political sophistication. The best of motives do not mitigate such shortcomings. Ultimately, the passage of a State-level youth access bill made all attempts to reactivate the county ordinance moot because the State bill preempted similar local policies.

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State Preemption In 1992 an attempt was made to pass a county ordinance in Wake of a Clean Indoor County, NC, restricting smoking in public places. Although this Air Ordinance ordinance was almost identical to a successful city ordinance passed a year earlier (described above), the controversy surrounding it was much larger. The successful city ordinance had been proposed by the county board of health but was actually voted on by the city council. In the case of the attempted county ordinance, when the county commissioners succumbed to tobacco industry pressure and would not consider the proposal, the Wake County Board of Health decided to conduct hearings and exert its authority to protect the public health. Citing the recently released U.S. Environmental Protection Agency report (U.S. Environmental Protection Agency, 1992) as a justification for action, the board of health passed a countywide policy (as a health board directive) in early 1993. The opponents to this action consisted of tobacco farmers, the tobacco industry, and restaurant owners. The industry’s primary strategy was to challenge the board of health’s authority to regulate smoking in public, arguing that the board was not an elected lawmaking body. Meanwhile, the industry sponsored a preemption bill at the State level that was passed in June 1993 and took effect in October. It purported to be a clean indoor air bill. It required that allowing smoking (or nonsmoking— many say the wording is deliberately unclear) be guaranteed in 25 percent of seating sections in public places across the State. A “small print” clause at the end of this bill stated that no municipalities could pass more stringent regulations. A “grandfather” clause permitted more stringent ordinances only if they were in place before October 1993. Most preemption laws are extremely damaging to local policy efforts. However, in this case the process had a surprise ending. Local tobacco control proponents joined forces with the League of Municipalities (which was furious at this transgression of local ordinance-making authority) and other allies across the State to urge local governments to quickly enact smoking control policies under the grandfather clause. Some counties went to their county commissioners or city councils for ordinances, but many proposed ordinances through the more sympathetic and less industryinfluenced county boards of health. In the ensuing flurry of local policy action, more than 40 counties in North Carolina passed or strengthened no-smoking ordinances, rendering the industry’s preemption bill much less effective than it otherwise would have been. A local newspaper story describing the tobacco industry’s attempt to preempt local actions of this sort ran under the headline “Snatching Defeat From the Jaws of Victory” (Williams, 1993). In retaliation, the tobacco industry targeted one “weak” county with lawsuits challenging the authority of every North Carolina county board of health to pass smoking control regulations. It will take years to resolve, and

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counties do not have the resources for protracted legal battles, so the outlook is not optimistic. The industry (through a 15-restaurant front group) had already sued the Wake County Board of Health for its ordinance on similar grounds. As this experience illustrates, the strength that tobacco control proponents have at the local level can be offset by the strength of the tobacco industry in State legislative and legal arenas. WHAT COULD How could the design of the COMMIT intervention be altered HAVE BEEN to improve opportunities for and the outcomes of policy DONE DIFFERENTLY? change efforts? The major design feature that significantly impeded progress in these efforts was the prohibition on the use of COMMIT resources, especially money, to engage in political lobbying efforts (such as advocating an improved clean indoor air ordinance). Virtually everyone involved in the project’s policy-related activities felt frustrated by this restriction. It was unavoidable in that COMMIT’s funding came from the Federal Government, and Federal law prohibits use of Federal funds for State or local lobbying activities in deference to principles of jurisdictional separation. Identifying funding for political lobbying is an everpresent challenge. The Federal Government is not the only entity that limits use of its funds. Even independent, nonprofit organizations that are otherwise free to engage in lobbying efforts may have self-imposed limits of this nature, often to avoid being seen as overly “political” by the public or to avoid the appearance of conflict with elected officials. There is no simple solution to this problem. In some cases it may be possible to forge an alliance with another local group supportive of the policy change that is able and willing to fund a particular lobbying activity. In Paterson, NJ, the National Council of Negro Women (NCNW) initiated a campaign to petition State legislators and citizens to support a bill prohibiting cigarette advertisements on billboards in low-income and minority neighborhoods. Although this was not a COMMIT-sponsored activity, COMMIT played an important role in the effort. The NCNW member who organized the campaign was also a member of the COMMIT Board. Once NCNW decided to pursue the campaign, it turned to COMMIT for advice and assistance, illustrating the importance of being open to creative approaches to dealing with restrictions on use of funds. GENERIC LESSONS The experiences recounted above and numerous others not mentioned here suggest certain generic lessons or rules of thumb useful in planning and carrying out tobacco control policy change campaigns. This section summarizes some of these lessons. First, framing tobacco control policy issues in terms of health promotion, such as the protection of young people from unhealthy influences, is usually 116

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the best strategy. Opponents will often attempt to reframe the issues as antibusiness or in terms of infringements of individual rights. Anticipate this and be prepared to respond without delay. As illustrated in several examples above, attempting to pass ordinances in geographical areas where political jurisdiction is shared by several entities can be especially challenging. Sometimes this is unavoidable, as is the case when a county ordinance is needed and the county encompasses several municipalities. Whenever possible, work within one jurisdiction at a time. Be prepared to devote considerable attention to consensus building when working with more than one jurisdiction. Be poised to seize opportunities as they arise. Unanticipated developments often occur in the political arena. As some of the examples discussed above indicate, such developments can often be used to advance the tobacco control policy agenda. When policies are being considered, do not let momentum and attention wane while a governing body “sits” on the issue. Keep your issue in the news to build public pressure. High public visibility creates pressure for political figures to act. Strategies for maintaining visibility include announcing new endorsements or resolutions of support for the initiative by locally influential groups such as medical societies, parent and teacher associations, and health promotion organizations; writing opinion editorials and letters to the editor; conducting and reporting followup data-gathering efforts (such as compliance checks for sales of chewing tobacco after having done the same for cigarettes); requesting time in the policymaking body’s meeting agenda to present new findings or arguments; and linking your issue to media coverage of related events or activities (such as a quit-smoking contest) by highlighting the connections between the issues. Attentiveness to stages of change is essential in policy change efforts. For example, in youth access policies many communities may feel tough enforcement is the only way to make an ordinance work. However, raising a strong cry for more aggressive police action may only alienate the community, particularly when law enforcement is preoccupied with other problems. When there is little awareness of the legal buying age for tobacco (let alone awareness of how easily underage youth can purchase tobacco), educating the community as well as policymakers must be the first order of business. Once awareness of a problem exists, fostering ownership of the problem and, ultimately, promoting community involvement in the solution are important second and third steps. When the community becomes involved in a policy change effort, it is much more difficult for opponents to claim that the need for policy action is merely a false perception created by a few zealots. A corollary to this kind of community ownership is to involve a broad, diverse group of advocates in the effort. In addition to building clout and

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momentum, this also helps protect against being labeled and dismissed as “those zealots” or “those health people.” A coalition of advocates from multiple sectors of the community tells the public and policymakers that this issue is important to many people and that something needs to be done about it. Recruit “victims” or others directly affected by an issue to be public spokespersons. Even if they are not the most articulate, they tend to be the most powerful proponents. Sometimes this is because they lack the polished style of a professional or “expert.” Youth can be particularly powerful. They can say things to elected officials that adults could never say, and they can give the issue a reality that can impress even the most cynical media representatives. Locally collected data, such as opinion surveys and compliance check results, can be powerful tools, especially when opponents are trying to deny the magnitude or relevance of the issue in the local community. Such surveys, conducted by major employers and city and county agencies, were used to great advantage several times during the COMMIT project. The enactment of an ordinance is not a guarantee of success from a health promotion perspective. Getting a law on the books does not mean that it will be enforced. Nor does it mean that the underlying health promotion objective—changing community norms concerning healthrelated behaviors—has been accomplished, especially if increasing community awareness and involvement did not contribute to the law’s passage. Remember that forging strong community alliances, fostering leadership opportunities for youth and other members of the community, and involving citizens in the public health policymaking process are worthy ends in themselves. Know your opponents and understand their strategies. Exchanging information with advocates undertaking similar efforts in other communities can be invaluable. National information networks can facilitate this. Count on the tobacco industry to use State preemptive legislation to foil local tobacco control efforts whenever they can. To combat this, be watchful of all State laws related to tobacco control, even if they appear to be uncontroversial. Seemingly minor 11th-hour changes in the wording of proposed laws have been used by the tobacco industry to cripple otherwise sound legislation. A dismal example of this occurred in Washington State in 1993, when a bill originally intended to strengthen the law against illegal sales of tobacco to youth was ultimately passed with language preempting many local ordinances that were stronger than the new State policy. The bill also incorporated weakened enforcement provisions. Finally, be bold and persistent. In the examples cited, many times the “gatekeepers” were acting on the basis of assumed or feared reactions by industry, businesses, influential officials, or even their allies. Politicians are especially prone to see certain issues as “sacred cows” and are loath

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to take stands perceived to be politically risky. However, with diligence, community-based advocates armed with locally relevant data and forming a united front with other community groups and supporters can challenge the status quo and bring about effective change. REFERENCES
Bierer, M.F., Rigotti, N.A. Public policy for the control of tobacco-related disease. Medical Clinics of North America 76: 515-539, 1992. Bracht, N. (Editor). Health Promotion at the Community Level. Newbury Park, CA: Sage, 1990. COMMIT Design and Evaluation Working Group. “1989 Evaluation Cohort Survey.” (5/26/89 version.) Unpublished document, 1989. COMMIT Research Group. Community Intervention Trial for Smoking Cessation (COMMIT): Summary of design and intervention. Journal of the National Cancer Institute 83(22): 1620-1628, 1991. Escobedo, L.G., Anda, R.F., Smith, P.F., Remington, P.L., Mast, E.E. Sociodemographic characteristics of cigarette smoking initiation in the United States: Implications for smoking prevention policy. Journal of the American Medical Association 264(12): 1550-1555, 1990. Frankel, B.G. Reducing tobacco consumption: Public policy alternatives for Canada. Canadian Medical Association Journal 138: 419-423, 1988. Glynn, T. Comprehensive approaches to tobacco use control. British Journal of Addictions 86: 631-635, 1991. Jason, L.A., Ji, P.Y., Anes, M.D., Birkhead, S.H. Active enforcement of cigarette control laws in the prevention of cigarette sales to minors. Journal of the American Medical Association 266(22): 31593161, 1991. Kingdon, J. Agendas, Alternatives, and Public Policy. Boston: Little, Brown, 1984. Pertschuk, M., Shopland, D.R. (Editors). Major Local Smoking Ordinances in the United States: A Detailed Matrix of the Provisions of Workplace, Restaurant, and Public Places Smoking Ordinances. NIH Publication No. 90-479. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1989. Reich, R.B. Policy making in a democracy. In: The Power of Public Ideas, R.B. Reich (Editor). Cambridge, MA: Harvard University Press, 1988. pp. 123-156. Samuels, B., Glantz, S.A. The politics of local tobacco control. Journal of the American Medical Association 266: 2110-2117, 1991. Thompson, B., Wallack, L., Lichtenstein, E., Pechacek, T. (for the COMMIT Research Group). Principles of community organization and partnership for smoking cessation in the Community Intervention Trial for Smoking Cessation (COMMIT). International Quarterly of Community Health Education 11(3): 187-203, 1990-91. U.S. Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. DHHS Publication No. (CDC) 89-8411. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1989. U.S. Department of Health and Human Services. Youth Access to Cigarettes. DHHS Publication No. OEI-02-90-02310. Rockville, MD: U.S. Department of Health and Human Services, Office of Inspector General, Office of Evaluations and Inspections, 1990. U.S. Department of Health and Human Services. Strategies To Control Tobacco Use in the United States: A Blueprint for Public Health Action in the 1990’s. Smoking and Tobacco Control Monographs–1. NIH Publication No. 92-3316. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1991. U.S. Department of Health and Human Services. Major Local Tobacco Control Ordinances in the United States. Smoking and Tobacco Control Monograph No. 3. NIH Publication No. 93-3532. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1993. U.S. Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. EPA600/6-90/006F. Washington, DC: Office of Research and Development, Office of Health and Environmental Assessment, 1992. Weiss, J.A., Tschirhart, M. Public information campaigns as policy instruments. Journal of Policy Analysis and Management 13(1): 82-138, 1993.

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Williams, B. Snatching defeat from the jaws of victory. Raleigh News and Observer, September 19, 1993. pp. F1, F7.

Wynder, E.L. Tobacco and health: A review of the history and suggestions for public health policy. Public Health Reports 103: 8-18, 1988.

AUTHORS David S. Carrell, Ph.D. Research Assistant Professor Community Health Care Systems, SM-24 University of Washington Seattle, WA 98195 Carolyn L. Johnson, R.N. Program Manager Healthy Start Program Jackson County Department of Health and Human Services Building A 1005 East Main Street Medford, OR 97504 Len C. Stanley, M.P.H. Program Director Tobacco Control Training Center Department of Family Medicine University of North Carolina Aycock Building, CB-7595 Manning Drive Chapel Hill, NC 27599 Juliet Thompson Field Director Bellingham COMMIT Site 4407 Wilkin Street Bellingham, WA 98226 Sandy Tosti, M.A. 7335 Franco Lane Vacaville, CA 95688

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References: Bierer, M.F., Rigotti, N.A. Public policy for the control of tobacco-related disease. Medical Clinics of North America 76: 515-539, 1992. Bracht, N. (Editor). Health Promotion at the Community Level. Newbury Park, CA: Sage, 1990. COMMIT Design and Evaluation Working Group. “1989 Evaluation Cohort Survey.” (5/26/89 version.) Unpublished document, 1989. COMMIT Research Group. Community Intervention Trial for Smoking Cessation (COMMIT): Summary of design and intervention. Journal of the National Cancer Institute 83(22): 1620-1628, 1991. Escobedo, L.G., Anda, R.F., Smith, P.F., Remington, P.L., Mast, E.E. Sociodemographic characteristics of cigarette smoking initiation in the United States: Implications for smoking prevention policy. Journal of the American Medical Association 264(12): 1550-1555, 1990. Frankel, B.G. Reducing tobacco consumption: Public policy alternatives for Canada. Canadian Medical Association Journal 138: 419-423, 1988. Glynn, T. Comprehensive approaches to tobacco use control. British Journal of Addictions 86: 631-635, 1991. Jason, L.A., Ji, P.Y., Anes, M.D., Birkhead, S.H. Active enforcement of cigarette control laws in the prevention of cigarette sales to minors. Journal of the American Medical Association 266(22): 31593161, 1991. Kingdon, J. Agendas, Alternatives, and Public Policy. Boston: Little, Brown, 1984. Pertschuk, M., Shopland, D.R. (Editors). Major Local Smoking Ordinances in the United States: A Detailed Matrix of the Provisions of Workplace, Restaurant, and Public Places Smoking Ordinances. NIH Publication No. 90-479. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1989. Reich, R.B. Policy making in a democracy. In: The Power of Public Ideas, R.B. Reich (Editor). Cambridge, MA: Harvard University Press, 1988. pp. 123-156. Samuels, B., Glantz, S.A. The politics of local tobacco control. Journal of the American Medical Association 266: 2110-2117, 1991. Thompson, B., Wallack, L., Lichtenstein, E., Pechacek, T. (for the COMMIT Research Group). Principles of community organization and partnership for smoking cessation in the Community Intervention Trial for Smoking Cessation (COMMIT). International Quarterly of Community Health Education 11(3): 187-203, 1990-91. U.S. Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. DHHS Publication No. (CDC) 89-8411. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1989. U.S. Department of Health and Human Services. Youth Access to Cigarettes. DHHS Publication No. OEI-02-90-02310. Rockville, MD: U.S. Department of Health and Human Services, Office of Inspector General, Office of Evaluations and Inspections, 1990. U.S. Department of Health and Human Services. Strategies To Control Tobacco Use in the United States: A Blueprint for Public Health Action in the 1990’s. Smoking and Tobacco Control Monographs–1. NIH Publication No. 92-3316. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1991. U.S. Department of Health and Human Services. Major Local Tobacco Control Ordinances in the United States. Smoking and Tobacco Control Monograph No. 3. NIH Publication No. 93-3532. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1993. U.S. Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. EPA600/6-90/006F. Washington, DC: Office of Research and Development, Office of Health and Environmental Assessment, 1992. Weiss, J.A., Tschirhart, M. Public information campaigns as policy instruments. Journal of Policy Analysis and Management 13(1): 82-138, 1993. 119 Smoking and Tobacco Control Monograph No. 6 Williams, B. Snatching defeat from the jaws of victory. Raleigh News and Observer, September 19, 1993. pp. F1, F7. Wynder, E.L. Tobacco and health: A review of the history and suggestions for public health policy. Public Health Reports 103: 8-18, 1988. AUTHORS David S. Carrell, Ph.D. Research Assistant Professor Community Health Care Systems, SM-24 University of Washington Seattle, WA 98195 Carolyn L. Johnson, R.N. Program Manager Healthy Start Program Jackson County Department of Health and Human Services Building A 1005 East Main Street Medford, OR 97504 Len C. Stanley, M.P.H. Program Director Tobacco Control Training Center Department of Family Medicine University of North Carolina Aycock Building, CB-7595 Manning Drive Chapel Hill, NC 27599 Juliet Thompson Field Director Bellingham COMMIT Site 4407 Wilkin Street Bellingham, WA 98226 Sandy Tosti, M.A. 7335 Franco Lane Vacaville, CA 95688 120