Book: Tobacco War: Inside the California Battles
Authors: Stan Shatenstein
Journal: BMJ (2000)

Stanton A Glantz, Edith D Balbach


University of California Press, £12.50, pp 496 




ISBN 0 520 22286 5

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Rating: ★★★

Karl von Clausewitz wrote: “War is nothing more than the continuation of politics by other means” (On War). The dictum is faultless, but its application can be problematic. The devil, as always, is in the detail.

Normally, a war's protagonists are well identified, and the combatants carve their bloody path from the political chambers to the battlefield. The usual presumptions do not always apply, however, a point that is forcefully argued in Tobacco War by Stanton Glantz, lead author of The Cigarette Papers and a professor of medicine at the University of California, San Francisco, and Edith Balbach, director of the Community Health Program at Tufts University, Medford, Massachusetts.

The apparent focus of their book is Proposition 99, the Tobacco Tax and Health Promotion Act, a 1988 California ballot initiative that would raise over $600m a year for health education and medical treatment. Proposition 99 garnered 58% of the vote, despite the tobacco industry's 13 to 1 spending advantage ($21.4m to $1.6m) over pro-99 coalition forces. However, the adoption of Proposition 99 proved not to be the resolution of a Manichaean conflict between lily white public health professionals and the dark forces of the tobacco industry. In fact, Glantz and Balbach relate the voting results in one undramatic sentence and, in an otherwise impeccably researched book, actually get the date wrong by a decade.

For the authors, the divided loyalties and internecine feuds among tobacco control advocates are as central to the story as are their battles with the tobacco industry. The book's most shocking episode is the notorious “Napkin Deal,” a 1987 pact whereby the California Medical Association aligned its interests with those of the tobacco industry. Glantz and Balbach are unstinting in their criticism of the association for its opposition to Proposition 99 and similar initiatives.

The authors analyse the differing approaches of the American Heart Association, American Lung Association, and American Cancer Society. Relying on exhaustive interviews with the principal players, they reach a logical conclusion. The only way to effect policy change, they argue, is by turning to the public, where support for tobacco control is both evident and politically potent. In short, it is necessary to adopt “outside” rather than “inside” strategies.

Equally important, the authors say, is that the change of one key player can mean everything. For several years after the passage of Proposition 99, funds were illegally diverted from smoking prevention by Republican Governor Pete Wilson, abetted by Assembly Speaker Willie Brown, a Democratic party politician heavily financed by the tobacco industry. When Mr Brown left office, the victories of the pro-99 forces finally translated into funding for appropriately aggressive advertising and educational campaigns.

California has a population of 33 million, more than Canada or Tanzania and just less than Poland or Argentina. The lessons from its ongoing tobacco war may apply to as broad a range of countries and to many public health issues. In the case of tobacco control advocacy, the central messages are simple: the tobacco industry lies, nicotine is addictive, and secondhand smoke kills. In other areas of public health the messages may differ, but the same strategies are effective. Glantz and Balbach argue that we should keep the public engaged and should not be afraid of controversy.

War may be hell, but some battles are worth fighting.