From Voices from America: Ten Healthy Communities Stories from Around the Nation, published by the Health Research and Educational Trust of the American Hospital Association,1998
by Christopher Freeman Adams
Lodi, California might be considered an unlikely place for a revolution to begin. As a predominantly agricultural town on the Eastern edge of the fertile Central Valley, it is even less likely that it would be the birthplace for a revolution that would place limits on individual freedoms or personal behaviors in order to support the public health of an entire community. But when the Lodi City Council passed an ordinance that completely banned smoking in restaurants and public places, this town found itself in the vanguard of local governments seeking to limit the damage inflicted on citizens by second-hand smoke. It also found itself the site for an enormous battle being waged by the tobacco industry to prevent any attempt to control tobacco use.
The ordinance started out innocently enough. The City Council had convened a study session to consider how it could create designated smoking sections in restaurants-a measure that had already been undertaken by hundreds of other cities. But when concerns were raised about the difficulty of enforcing the ordinance and opposition was anticipated from local restaurateurs about the cost of separate rooms and ventilation systems, the Mayor sought to simplify the ordinance by simply having it ban all smoking in restaurants and public places. Only one council member opposed the ordinance, and it was passed.
Far from being the end of the story, within two weeks the ordinance had become a political lightening rod, with opponents eventually collecting enough signatures to place the issue on the ballot for a referendum.
The opposition to the ordinance was led by Taxpayers United for Freedom (TUFF), which funneled money from the tobacco industry via a San Francisco consultant, to be used for advertising and mailers. One of their slogans was, "The issue is not a health issue; it is a rights issue-your rights-everyone's rights-American rights." Their strategy was to shift the topic from public health to individual rights and personal freedom of choice.
Public opinion is often swayed by such demagoguery, and yet this time it backfired. Realizing that health information alone was not enough to win this fight, those in favor of the ordinance based their strategy on an appeal to other democratic values, such as local control. One of their pieces of literature said, "Measure M upholds the principle that Lodians should legislate for themselves, without intrusion of the tobacco industry. If you believe that big, out-of-state tobacco companies should not control our local legislation, vote yes on Measure M."
As it turned out, even with the TUFF money, 60 percent of Lodians did vote yes, confirming that Lodi would become the first city in California to have 100 percent smoke-free restaurants. Even when the battlefield was changed from that of public health to democratic values, the citizens of Lodi led the way for scores of other California cities-and eventually the entire state-to restrict tobacco use in restaurants and other workplaces.
California Smoke-Free Cities
The Lodi experience demonstrated the power of local officials to take local control of their community's health. Second-hand smoke (also called environmental tobacco smoke, or ETS) had been a widely acknowledged killer, but public policy-especially at the state and federal levels-had been unresponsive to convincing data. For example, a 1991 study by the University of California, San Francisco found that passive smoking takes 53,000 American lives a year-a grisly statistic which places it third on the list of causes of preventable deaths (behind active smoking and alcohol related deaths.) A 1990 study published in The New England Journal of Medicine suggested that nonsmokers who grew up with parents who smoked have twice the risk of lung cancer as nonsmokers whose parents did not. And in a 1991 report, the National Institute for Occupational Safety and Health concluded, "all available preventive measures should be used to minimize occupational exposure" to ETS. Given this information-and a multitude of confirming studies about the effects of tobacco smoke on smokers and nonsmokers-it is no surprise that the Environmental Protection Agency has classified tobacco smoke as a Class A carcinogen, a designation which places it in the company of such substances as benzene and asbestos.
Based on such overwhelming information, severe limitations of nonsmokers exposure to ETS would seem to be an obvious course of action. But experience has shown that public health data-even when it is as overwhelming as it is in this case-does not by itself translate into public policy. In this situation, the translation to policy is even more difficult because of the activities of the well-funded and politically aggressive tobacco industry, which has historically fought any attempt to control tobacco by shifting the debate away from health to Constitutional rights of speech and expression. For decades the industry had been winning in this effort. But when the people of Lodi reaffirmed their city government's action in 1990, the tide began to turn. Four years later, 108 cities had followed suit with complete bans on smoking in restaurants and 89 cities had banned smoking in workplaces. Furthermore, from 1990 through 1994, 110 cities were added to the list of those which had enacted ordinances to restrict or ban the sales of cigarettes through vending machines. Emboldened by such local action, the state legislature passed a law requiring all workplaces to be smoke-free in 1994 and a law restricting the sales of cigarettes from vending machines in 1995.
Though many factors contributed to this ground-swell in public policy to protect citizens from tobacco smoke, one effort stands out: California Smoke-Free Cities, an initiative of the California Healthy Cities Project. California Smoke-Free Cities (CSFC) owes its existence to two major occurrences. "The first," according to project Coordinator Anne Klink, "was a renaissance in public health that dates back to the 1970s when public health started to return to its original focuses on public policy and environmental action, in addition to individual behavior." The international Healthy Cities movement (and its California component), which started to gain momentum in the late 1980's, is based on these premises. "The second," Klink said, "was the passage in California of Proposition 99, The Tobacco Tax and Health Protection Act, which levied a tax on tobacco products." Proposition 99 required that twenty percent of the tobacco surtax fund would be earmarked for efforts to reduce tobacco use, including an integrated network of tobacco control programs across the state and a statewide media campaign which attacked the perception of smoking as glamorous and sexy. California Smoke-Free Cities was one of the first projects funded by the California Department of Health Services, Tobacco Control Section, using these tax revenues. The project was finally "retired" in December 1996, two years after California's Smoke-free Workplace law went into effect.
As an initiative of the California Healthy Cities Project (a statewide program to help cities and their local partners promote healthier communities), CSFC was grounded in healthy cities principles, such as inclusiveness, cooperation and building on current assets. This can be seen in the partners whom the Director of the California Healthy Cities project and the Executive Director of its parent organization convened at the initiative's inception: the League of California Cities, the Health Officers Association of California, and Americans for Nonsmokers' Rights. Each of these organizations brought different strengths to the effort and could speak credibly to their respective constituencies.
CSFC supported local cities to implement tobacco control ordinances by providing an array of services and resources for local officials as they navigated an uncharted course into public health. The most popular resource was the provision of technical assistance. CSFC offered personal and immediate help over the phone, with the subsequent transmission of written materials. As of the end of 1994, CSFC had given direct technical assistance to 72% (339/470) of California cities, and 100% of county health departments. Eighty-six percent of the cities which developed smoke-free ordinances through 1994 received such support.
Training sessions for local officials were another way in which CSFC supported tobacco control. More than 1000 city officials and health department representatives took part in one of 50 training and education sessions, which were offered by the League of California Cities and the California Healthy Cities Project. These sessions educated officials about the public health threat posed by ETS, what other cities have done to fight it, and about the resources available to them to begin a local tobacco control campaign. One of the most important elements that made these sessions more than just a dissemination of facts was that elected officials from cities where controls had been adopted spoke candidly about the experience. Randi Snider, the Mayor of Lodi when that city passed its regulations, has continued to serve the cause of limiting the damage of ETS by speaking often to other elected officials about the risks of taking on the tobacco industry.
CSFC also developed many publications to assist local officials. The premier publication was, Tobacco Control in California Cities: A Guide for Action. This 220-page publication is a comprehensive resource that documents the health and economic rationale for tobacco control, as well as discussing strategies for implementation and providing sample ordinances. Over six thousand guides were distributed to all city mayors and council members, county supervisors, health officers and tobacco control coordinators. Thousands of others were distributed to tobacco control advocates statewide.
In celebration of tobacco control leadership in California cities, CFSC gave awards in 1992 and 1994 to honor courageous city governments. The 1994 award program received widespread media attention, and included the participation via video of former Surgeon General C. Everett Koop and Carol Browner, the current Administrator of the Environmental Protection Agency.
Working in combination with the funding of local health departments and the development of the statewide tobacco control infrastructure, California Smoke-Free Cities set the stage for a renewal of interest in policy as a public health intervention and, in so doing, had a major impact in preventing harm from tobacco smoke.
The most significant outcomes for this project were the changes in policy regarding tobacco control. By July 1994,when the state legislature passed the ban on smoking in workplaces, over 44 % of Californians lived in jurisdictions with some form of a 100% smoke-free ordinance (including restaurants and/or workplaces). Moreover, the existence of so many local laws supported implementation of the state law and helped insure that it would be self-enforcing. As Californians become even more used to being smoke-free, Anne Klink predicts that there will be another round of local ordinances spurred on by the public that will get even tougher on smoking.
Economically, there is an overall expectation of tremendous savings. A 1993 study found that the total cost of smoking to business (including direct costs, morbidity costs, and mortality costs for smokers) in California was estimated to be $10 billion each year. This number should decrease dramatically. The public should also see a decrease in health care costs. Currently, the cost of caring for damage caused by smoking for each Californian is $314 annually, and $2014 per smoker. With decreased exposure to ETS, this number should also drop.
The oft-cited fear that smoking restrictions will ruin restaurants has also been found to be without merit. Before the state-wide ban was enacted, a study of eight cities-four with smoke-free restaurants and four without similar restrictions-found that the restaurants in the smoke-free cities actually did slightly better as a percentage of total retail sales in the city than their counterparts.
And finally, even at this early stage, California is starting to be able to measure a decrease in smoking related disease. In April of 1998, the California Department of Health Services announced that cancer incidence and deaths in the state are declining at rates faster than the nation as a whole. "We are just beginning to see the long-term impact of the reduction in tobacco use in California," said State Health Director Kim Belshe. The study showed that lung cancer rates for women and minority groups are beginning to decline, and the fall is even sharper for white males, whose rates have been declining since the late 1980s. Other studies have shown that heart disease rates also are also falling.
The large scope and multiple successes of California Smoke-Free Cities are a rich source for lessons about the role that the healthy cities/communities model can play in the formation of public health policy. A major impact was the raised consciousness in the public health community about the role municipalities could play in protecting the public's health. CSFC provides a clear illustration that local governments have a significant role to play in enacting regulations to protect health. In fact, this effort illustrates how local governments can actually be effective where state and federal governments had previously failed or been ineffective. Seeing health as a local policy issue can be a major incentive for people to take more active responsibility for the health of their communities.
Joan Twiss, California Healthy Cities Project Director, remarked " When we began CSFC in 1990, we never could have predicted the speed with which comprehensive environmental tobacco control would sweep through California. With the support of the Department of Health Services, Tobacco Control Section and our alliance with the key membership organizations, we were well positioned to assist policy makers, statewide, in their locally-driven approaches to protect the public from secondhand smoke. We see no reason why this approach would not work equally well in other settings and for other issues."
A corollary to this insight is that state legislatures may not be the best place to try to initiate tobacco regulation. For the most part, local officials are not as susceptible to influence by the tobacco industry because they are freer from the influence of campaign donations and other tactics of the tobacco industry. State officials, on the other hand, have more use for the benefits the tobacco industry supplies to its allies, and thus are not as likely to take a stand.
In addition to these points, CSFC also offers some practical lessons:
- The best way to persuade elected officials to try something new is to engage other elected officials. It takes an act of political courage to attempt something as controversial as tobacco regulation-especially given the resistance from the industry. Therefore, the best people to encourage this risk-taking are those who have done it themselves.
- Local elected officials usually have other jobs in addition to their public offices. Therefore, training and education needs to be convenient, possibly by linking it with other meetings they already attend.
- Design a project that is efficient and effective by using partnerships among already existing organizations with an interest in tobacco control. Health departments, advocacy organizations, good government groups and others can all play a role.
- Embedding tobacco control in a healthy city/community framework places the issue in a positive context and positions it for local action.
The work of California Smoke-Free Cities is essentially about two things: health and responsibility in a democracy. For decades the hazards of tobacco smoke had been well known, but environmental approaches were not part of the prevention framework. The Healthy Cities model changed this by bringing inter-sectoral collaboration and resident involvement to the making of public policy.
When asked what makes her most proud of the project she coordinated Anne Klink reels off a litany of regulatory successes. But then, after thinking about it for a few moments, she also adds another. "One of the unexpected side effects of this project has been that we have created an opportunity for citizens to become involved in fighting for something important, something close to home-and winning against great odds."
Christopher Freeman Adams is president of Healthy Outcomes, and the general editor of this collection of case stories. He frequently writes and speaks about healthy communities, as well as providing meeting facilitation. His email is firstname.lastname@example.org.
For further information on this project contact:
California Healthy Cities and Communities
Center for Civic Partnerships
1851 Heritage Lane, Suite #250
Sacramento, CA 95815
fax (916) 646-8660