Florida’s tobacco control program had funding secured by a constitutional amendment, a legal structure that required following CDC’s Best Practices
, an oversight committee with a broad mandate and strong membership, and a state history of the TPP’s innovative leadership and success,18–22,24
so it was reasonable to expect it to have a strong and effective program. Instead, Governor Crist’s DOH pursued low-impact tobacco control strategies and attempted to dismantle even the weak oversight provided by TAC. Failing to hold the Crist administration accountable for low-impact BTPP programming was part of a larger pattern in which ACS, ALA, and AHA were mildly reformist and avoided confrontational strategies to protect effective tobacco control in Florida, repeating their earlier failure to protect TPP funds.16,30
As required by Amendment 4 and its implementing legislation, the DOH created a program that had the components required by Best Practices
(), then undermined implementation with programming decisions contrary to Best Practices
. Program administration was hampered by hiring decisions and high staff turnover. The media campaign was severely restricted by a refusal to build on Florida’s successful Truth campaign18–22
and by limits on messaging and execution. The legislature and the BTPP focused resources on cost-ineffective direct cessation programs. The DOH attempted to limit TAC’s role in program oversight.
The media campaign stands as a conspicuous missed opportunity. Recognizing the power of a well-executed media campaign, the tobacco industry has attempted to limit such campaigns in many states,9,11,25
particularly regarding industry denormalization messages,11,25,26
such as Florida’s Truth campaign95,96
and the American Legacy Foundation’s subsequent Truth campaign.26
An effective Florida media campaign highlighting the industry’s behavior would be particularly threatening to the industry because more than 8000 individual97,98
smoking and health lawsuits against major domestic cigarette manufacturers (stemming from the original Engle v RJ Reynolds Tobacco99
class action smokers’ liability case) have been filed by Floridians since 2006. Indeed, a representative of Brown and Williamson Tobacco Company publicly recognized this threat to the industry in Florida in 1999, when he told the Associated Press, “[I]t seems as if these [Truth] ads are designed not to reduce teen smoking but rather to influence a jury pool for future lawsuits.”100
Similarly, in 2002, RJ Reynolds unsuccessfully sued California to stop its industry denormalization media campaign on the grounds that it represented “jury tampering.”26
Governor Crist’s office was directly involved in selecting BTPP media messages, and Governor Crist had a history of warm relations with the tobacco industry. Between his first term in the Florida Senate in 1992 and his US Senate bid in 2010, Crist accepted campaign contributions totaling $40 050 from the tobacco industry.16,101,102
Between 1998 and 2008, only 3 Florida politicians received more tobacco industry money than Crist for in-state elections,101
and in the 2010 US Senate election, only 4 candidates received more nationwide.102
Previous research demonstrates that tobacco industry campaign contributions are associated with policy decisions favorable to the industry.103–105
Tobacco industry internal documents reveal a long history of mutual support between the tobacco industry and Crist.106–109
In a 1994 letter, Crist, then a state senator, wrote to Tobacco Institute lobbyist Guy Spearman III,110
I deeply appreciate all of the support and assistance that you have extended to me in the past. I am certainly looking forward to working with you in the future…. As always, if I can ever be of assistance to you, please feel free to call me.109
Spearman represented Altria/Philip Morris as an executive branch lobbyist since at least 2001,111
coinciding with Crist’s entire term as governor, and made the maximum legal personal campaign contribution ($4800) to Crist’s 2010 US Senate campaign.112
Whether limits on the media campaign were a direct result of tobacco industry pressure is unknown, but the tobacco industry has a history of working through state executive branches to limit media campaigns.9,11
Certainly health advocates exerted little pressure to mount a high-quality media campaign. The comprehensive program that the public health groups promoted to Florida voters to win support for Amendment 4 included
an advertising campaign to discourage the use of tobacco and to educate people … which shall be designed to be effective at achieving these goals … funded at a level equivalent to one-third of each total annual appropriation required by this section.31
After passage, however, they failed to insist that the DOH effectively implement such an advertising campaign.
Advocates in other states have effectively pressured gubernatorial administrations to implement effective media programming.9,11,25
For example, California tobacco control advocates, including ALA, the American Heart Association, ACS, and Americans for Non-smokers’ Rights, responded to attacks by Governor Pete Wilson (R, 1991–1999) on the state’s aggressive tobacco control media campaign through a successful lawsuit, a public press conference, and a full-page advertisement in the New York Times
criticizing the administration’s media campaign efforts.25
In addition, the advocates leveraged California’s equivalent of TAC to further pressure the administration to stop restricting the media campaign. (As in Florida, the administration began excluding the advisory committee from its media oversight duties.) Ultimately, the advocates were successful, and California’s aggressive industry denormalization media campaign was restored.25
The DOH’s heavy and accelerating emphasis on expensive and relatively cost-inefficient direct cessation services, instead of media- and community-based interventions113–115
to promote unassisted cessation attempts,116
likely also contributed to the program’s low impact. Overall, with a budget of $9.6 million for fiscal year 2010,117
the Florida Quitline served 44 295 callers (reach of 1.37%). Together, the Quitline and AHECs reached a maximum of 51549 smokers in fiscal year 2010, only 1.9% of Florida’s 2.77 million smokers.118
The direct cessation services offered through AHECs were very expensive. The DOH’s contracted evaluation of AHEC reported that in fiscal year 2009, with $4 million, AHECs provided cessation services to 5211individuals, at a cost of $768 per individual.119
In fiscal year 2010, this number increased to 7254,119
but the cost remained high, at $551 per individual. With a quit rate (30-day abstinence measured at 7 months) of 33.5% for fiscal year 2010,120
the cost per quitter of AHEC cessation programs was $1646.
AHECs also spent $6 million annually on educating health care providers about cessation and influencing systems change. Although individual smoking cessation is a cost-effective clinical intervention,121,122
and, along with systems change, is recommended by Best Practices
the reach and impact of the program were low. A DOH evaluation contractor, RTI International, reported in June 2010 that AHECs’ cessation training programs reached just 4.2% of Florida’s physicians, 3.2% of physician assistants, and 2.4% of registered nurses in fiscal year 2009.123
The high cost of AHEC services raises the possibility of not only inefficiency but also diversion of funds to other services provided by AHECs or Florida’s medical schools. In other states,124
state medical schools absorbed tobacco control funds for programs with little impact on tobacco use. The removal of the requirement that AHEC funds be used for tobacco control activities from the 2010 authorizing legislation for AHECs40
made such diversions easier.
Although the major public health organizations in Florida were willing to invest considerable resources to successfully mobilize voter support for tobacco control and create a strong legal framework, they consistently refused to use the political strength created by this solid public support to pressure Governor Crist and the DOH to implement an effective tobacco control program. As in Minnesota, absent vigorous advocacy from nongovernmental organizations, a strong legal structure cannot shield tobacco control programs from diversion of funds to cost-ineffective direct cessation programs8
or from legislative attacks. By contrast to Florida’s experience, in other states, such as California and Indiana, advocates actively and successfully defended tobacco control programs.9,12
Our research was limited by the DOH’s unwillingness, after a period of cooperation, to provide some necessary documents and access to key staff for interviews, beginning in February 2010. When we requested documents regarding a 2008 payment dispute with Zimmerman, we were first told that requested documents did not exist, although some of the documents were already in our possession off the record (Jane Parker, planning consultant, DOH Bureau of Tobacco Prevention Program, e-mail communication, January 13, 2010). Subsequently, the DOH demanded $15 487 in “search and review” and “review and redact” fees to obtain the requested documents and refused to process any more document requests until it was paid (Jane Parker, e-mail communication, February 8, 2010). Among our unfulfilled requests were documents regarding payment disputes between the DOH and Zimmerman over advertisements rejected by the governor’s office; communications between the DOH, Zimmerman, and Macro International regarding approval or rejection of Zimmerman’s proposed advertisements and testing of the Truth campaign; and story boards, video cuts, and finished advertisements submitted by Zimmerman to the DOH and subsequently rejected.
In February 2010, Myrick instructed DOH, county health department staff, and TAC members not to participate in interviews for our research (Janine Myrick, e-mail communication, February 25, 2010). Even before then, an unusually large number of people only agreed to talk off the record (n=12) and numerous others agreed to on-the-record interviews, but then spoke extensively off the record (n = 16). In addition, some interviewees withdrew their consent months after interviews were conducted. Curtis Zimmerman reported that the DOH had also called his firm, requesting that he charge us for any information we collected and expressing a preference that he not agree to an interview (interview with A. K., June 10, 2010). Although several people at the CDC Office on Smoking and Health engaged in off-the-record conversations with us about their opinions that Florida was not following Best Practices, none were willing to go on the record.
We did not include an analysis of adult smoking rates in this article because sufficient data were not available. At the time of writing, adult smoking prevalence data were available only through 2009, providing only 2 years of data since the new program began. A complete history of tobacco control in Florida from 1999 to 2011, including an extended analysis of the events described here, is available elsewhere.94
The inadequate implementation and corresponding poor results of Florida’s BTPP demonstrates that even when funding for a tobacco control program is secure and tied to legal requirements to follow evidence-based practices, continuing public health advocacy is essential to success. The implications of Florida’s low-impact program extend beyond Florida; because the Florida program putatively follows CDC’s Best Practices for Tobacco Control Programs33,38
and is well funded, continuing poor results could undermine the credibility of Best Practices
and become part of a case elsewhere against tobacco control program funding.