Tobacco control: a brief review of its history and prospects for the future.

Smoking prevalence among American adults is at its lowest point in the last 30 years, and there is unprecedented popular support for tobacco control measures. The financial resources to carry on the battle for tobacco control are still heavily stacked in favor of the industry, which by current estimates is worth $45 billion, including $6 billion spent each year on advertising and promotion alone. Nonetheless, industry executives must realize that, even if they can win individual battles, they are losing the war. This article has discussed key events in the history of tobacco control, as well as some of the most innovative strategies currently being used for tobacco control. Although it is important that tobacco control efforts be disseminated widely and through novel channels, the challenge facing public health advocates in the next several decades will be to anticipate the industry's response to key initiatives, as well as to launch organized and strategic counterattacks against efforts to dissuade acceptance of such initiatives. The history of tobacco control demonstrates that public health advocacy resources should be strategically focused in precisely the areas in which the industry feels most vulnerable (e.g., nicotine addiction, regulation of nicotine, environmental tobacco smoke), rather than in areas in which the industry maintains a vocal presence for the purposes of public relations (e.g., youth access). Through its lobbying efforts and financial clout, the tobacco industry has played a key role in the development of public health policy. Although it is no secret that the tobacco industry regularly makes campaign contributions to both Republicans and Democrats, the impact of these donations on public policy making have only recently begun to be quantified and documented. Moore et al found that the more tobacco money a politician received, the less likely he or she was to support tobacco control legislation. Similar distortional effects of tobacco money have been demonstrated at the state level. The political expenditure of 12 tobacco firms increased 10-fold in California after the implementation of Proposition 99 in California--from $790,050 in the 1985-1986 election, to $7,615,091 in the 1991-1992 election. In an analysis of the behavior of the California legislature between 1991 and 1992, a statistically significant relationship was found between members' receipt of tobacco money and their likelihood of opposing tobacco control measures. Tobacco control advocates as well as health professionals in general have an important role to play in holding their legislators accountable for developing public health policy that reflects the concerns of their constituencies, not of the tobacco lobby. Public health advocates should pay particular attention to the recent regulations placed on cigarettes as a key tobacco control strategy for the next several decades. For the first time in the history of the United States, a President has introduced legislation that will allow a governmental agency to regulate tobacco. The FDA has faced relentless attacks by the tobacco industry, and it will continue to be a target. Public health advocates and health care providers have a critical role to play in the FDA's efforts to bring this issue to fruition. If the public health community fails to support this initiative and create an active and forceful opposition to the industry's efforts to derail it, it is likely that the impact on tobacco control efforts will be resounding and far-reaching.