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In this case study, we describe and analyze the development and passage of California's tobacco tax initiative, Proposition 99, the Tobacco Tax and Health Promotion Act of 1988. We gathered information from published reports, public documents, personal correspondence, internal memorandums, polling data, and interviews with representatives from organizations that participated in the Proposition 99 campaign. Proposition 99 passed as a result of the efforts of a coalition of voluntary health agencies, medical organizations, and environmental groups. They organized a long-term effort by conducting essential polling, planning strategies, gaining media exposure, developing a coalition, and running a successful campaign to enact the tax by shifting the venue from legislative to initiative politics. To build the coalition that was needed to pass Proposition 99, public health proponents enlisted the help of medical organizations in exchange for additional revenue to be allocated to medical services. By shifting the venue from the legislature to the general public, advocates capitalized on public concern about tobacco and for youth and took advantage of the tobacco industry's low credibility. The passage of Proposition 99, despite a massive campaign against it by the tobacco industry, represents a milestone in the tobacco control and public health fields. From its passage in 1988 through 1993, tobacco use in California declined by 27 percent, which is three times faster than the United States average. As a result, Proposition 99 has served as a national model for other states and the federal government. Although allocation of tobacco tax revenues specifically to health education and prevention was a primary goal during the development and passage of Proposition 99, when the venue shifted back to the legislature for implementation, medical organizations successfully advocated illegal diversions of Proposition 99 tobacco control and research funds to medical services. Organizations seeking to enact Proposition 99-like tobacco tax increases must be prepared to mount aggressive campaigns to pass the initiative in the face of major tobacco industry opposition and then must continue to work to protect the program after passage by voters.

Objectives: Proposition 99 added 25 cents to the California state cigarette tax and mandated that 20% of the new revenues be spent on tobacco education and prevention programs. This paper examines the implementation of these programs and the tobacco industry's response to Proposition 99., Methods: Political expenditure data for twelve tobacco firms and associations were gathered from California's Fair Political Practices Commission and secretary of state's Political Reform Division. Tobacco education expenditure data were collected from Governor's Budgets and the Department of Finance., Results: Since Proposition 99 passed, tobacco industry political expenditures in California have risen 10-fold, from $790,050 in the 1985-1986 election to $7,615,091 in the 1991-1992 election. The tobacco industry is contributing more heavily to the California legislature than to Congress. A statistical analysis of data on campaign contributions indicates that California legislators' policy-making is influenced by campaign contributions from the tobacco industry. Since fiscal year 1989-1990, the state has ignored the voters' mandate and spent only 14.7% of the new revenues to tobacco education. Medical care programs received more money than permitted by the voters., Conclusions: The tobacco industry has become politically active in California following the passage of Proposition 99. One result may be that the state has underfunded tobacco education by $174.7 million through the 1993-1994 fiscal year. The estimated redirection of funds to medical care would essentially eliminate the tobacco education campaign by the year 2000.

We examined the tobacco industry's new strategy to defeat and then repeal tobacco control ordinances in California and the efforts of health professionals to pass and defend these ordinances. Case studies were conducted in California communities in 1991 and 1992, using published reports, public documents, attendance at public meetings, and interviews. The tobacco industry is spending millions of dollars to intervene in California communities to oppose legislation protecting nonsmokers from secondhand smoke. The tobacco industry has moved beyond organizing smokers to use professional public affairs and political campaign firms to defeat or weaken local tobacco control ordinances. The industry used front groups to conceal its involvement because public knowledge of the industry's involvement increases support for legislation controlling smoking. Some firms closely monitor developing ordinances, while others actively organize and direct local opposition. If these efforts do not weaken or defeat an ordinance, the tobacco industry initiates a referendum petition drive to suspend it to pressure local elected officials to repeal or weaken it. If this tactic fails, the industry often finances an election campaign to repeal the ordinance by popular vote. Although the tobacco industry's new strategy has hindered the passage of some local tobacco control ordinances, when health professionals and elected officials remained active and committed, the industry's efforts have failed and the ordinances have been upheld.