Strong Tobacco Control Program Requirements and Secure Funding Are Not Enough: Lessons From Florida

Abstract

Florida’s Tobacco Pilot Program (TPP; 1998–2003), with its edgy Truth media campaign, achieved unprecedented youth smoking reductions and became a model for tobacco control programming. In 2006, 3 years after the TPP was defunded, public health groups restored funding for tobacco control programming by convincing Florida voters to amend their constitution. Despite the new program’s strong legal structure, Governor Charlie Crist’s Department of Health implemented a low-impact program. Although they secured the program’s strong structure and funding, Florida’s nongovernmental public health organizations did not mobilize to demand a high-impact program. Implementation of Florida’s Amendment 4 demonstrates that a strong programmatic structure and secure funding are insufficient to ensure a successful public health program, without external pressure from nongovernmental groups.

Large-scale, well-executed state tobacco control programs reduce tobacco use,^1–4 tobacco-induced disease,^5–7 and health costs.^3,4 Despite this proven effectiveness, many state governments have eliminated or restricted the scope of tobacco control programs, often under pressure from the tobacco industry,^8–10 which recognizes such programs’ power.¹¹ In response, tobacco control advocates in some states have tried to create stronger tobacco control program structures to insulate these programs from political attacks.^8,12–14 However, absent consistent pressure from public health groups, strong programmatic structures are not sufficient to protect these programs from attacks or to ensure successful implementation.^8,10,14,15

Following the 1997 settlement of Florida’s Medicaid lawsuit against the tobacco industry, Governor Lawton Chiles (D, 1991–1998) immediately created and provided strong political support for Florida’s large youth-focused Tobacco Pilot Program (TPP).¹⁶ The TPP and its edgy Truth media campaign, focusing on tobacco industry behavior (a strategy known as industry denormalization¹⁷), achieved unprecedented success^18–22: smoking prevalence among middle school students dropped by 40% and among high school students by 18% during the program’s first 2 years (Figure 1).²⁴ Despite its success, and perhaps because of the threat the program posed to the tobacco industry,^11,25,26 the TPP was subject to almost immediate funding cuts from Governor Jeb Bush (R, 1999–2007) and the Florida legislature. Even after the Florida Department of Health (DOH) released its 1999 Florida Youth Tobacco Survey, showing large drops in youth smoking associated with the TPP,¹⁶ the legislature and governor reduced TPP funding from $70.5 million to $36.8 million for fiscal year 2000. For fiscal year 2004, the program was essentially eliminated, with a budget slashed to $1 million. These cuts significantly decreased youths' Truth campaign recall^27,28 and increased cognitive precursors to smoking initiation²⁷ (although the effect on smoking rates continued until the youth cohort exposed to the Truth campaign aged out of survey samples²⁹).

FIGURE 1—

Declines in current smoking prevalence rates among Florida youths during the Tobacco Pilot Program Truth campaign (1998–2002) and the BTPP (2008–2010).

Note. BTPP = Bureau of Tobacco Prevention Program. Solid line is regression fit allowing for slope changes at the end of the Truth campaign and beginning of the BTPP campaign.²³

Florida’s public health groups did not effectively protect TPP funds.^16,30 Nevertheless, in 2006, the local affiliates of the American Cancer Society (ACS), American Lung Association (ALA), and American Heart Association, along with the Washington, DC–based Campaign for Tobacco-Free Kids, ran a successful $5.2 million campaign for a state constitutional amendment to restore tobacco control funding. Amendment 4 passed 61% to 39%, demonstrating a significant political constituency for tobacco control.

Amendment 4 created a strong legal foundation for a new tobacco program. In addition to securing funding, it mandated a youth-focused, comprehensive tobacco control program comprising an advertising campaign, youth programs, community-based partnerships, youth access enforcement, and evaluation.³¹ Although Amendment 4 did not explicitly reconstitute the TPP, recreating it was a central theme of the political campaign.³² Public health groups sought to ensure the quality of the program by requiring that it adhere to the updated Best Practices for Comprehensive Tobacco Control Programs from the Centers for Disease Control and Prevention (CDC).^31,33 Amendment 4 allocated an annual 15% of the value of Florida’s 2005 tobacco settlement dollars ($57.9 million for the tobacco control program in 2005, about two thirds of the 1999 Best Practices lower-bound funding recommendation³³) and required annual inflation adjustments to protect the program’s purchasing power.³¹

Analysis of the implementation of Amendment 4 by the DOH of Governor Charlie Crist (R, 2006–2011), suggests that, despite the strong legal structure and secure funding in Amendment 4, the DOH did not recreate Florida’s successful tobacco control program. Instead, the administration restricted effective staffing of the program, pursued low-impact tobacco control strategies, and attempted to limit program oversight. Public health groups credited with passing Amendment 4 did not use their strong voter mandate or galvanize Florida’s tobacco control leadership to demand a high-quality, aggressive tobacco control program. The Florida experience reinforces the lesson that a strong legal structure and secure funding are not enough to ensure implementation of a high-quality evidence-based tobacco control program. It is necessary for public health groups to continually maintain pressure on tobacco control programs to ensure that their efforts are not in vain and an effective program is realized.

METHODS

We conducted a qualitative case study, gathering triangulated information from media reports, public documents, tobacco industry documents, and interviews. We reviewed Florida news sources, legislative documents, meeting transcripts, vendor contracts, tobacco industry campaign contributions, and other material accessed by public record requests to state agencies. We used standard techniques^34,35 to search tobacco industry documents in the University of California, San Francisco Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) between January and May 2010. Our initial search terms included Florida Department of Health, Florida Truth, and Charlie Crist and yielded 38 relevant documents. We interviewed 61 individuals between 2008 and 2011: DOH staff, legislators and legislative staff, state and national tobacco control experts and advocates, CDC staff, former TPP staff, members of the Florida Tobacco Education and Use Prevention Advisory Council (TAC), and program vendors.

We assessed the effects of Florida’s tobacco control efforts with a piecewise linear interrupted time series implemented as a multiple linear regression, with smoking prevalence (high school or middle school) as the dependent variable and time as the independent variable, for which we allowed the slope to change in 2003 after the Truth campaign ended and again in 2008 when the Bureau of Tobacco Prevention Program (BTPP) media campaign started.

We used data from the Florida Youth Tobacco Survey collected between 1998 and 2010.²³ We performed calculations with Minitab version 14 (Minitab Inc, State College, PA). Further details of our methods are in Appendix A (available as a supplement to the online version of this article at http://www.ajph.org).

RESULTS

The Florida legislature passed legislation implementing Amendment 4 in 2007,³⁶ incorporating recommendations from CDC and Florida public health groups (Brenda Olsen, chief operating officer of ALA of Southeast, interview with A. K., October 30, 2009).³⁷ The implementing legislation added adult programming to the components specified in the amendment (Table 1). CDC updated its Best Practices, to which the program was required to adhere, in late 2007.³⁸

TABLE 1—

Constitutional and Statutory Programmatic Requirements for Florida's Comprehensive Statewide Tobacco Education and Prevention Program

	Amendment 4 (2006)31	CDC (1999)33	Implementing Legislation (2007)36	CDC (2007)38
Funding level, $	15% of 2005 tobacco settlement funds (57.9 million), adjusted for inflation	78.4–221.3 million	Not included	210.9 million
Advertising/countermarketing campaign, all media	One third of annual appropriations	One fifth of annual budget	One third of annual appropriations	One fifth of annual budget
Cessation programs	Not included	Population based, medical systems change, underserved populations	Population based, chronic disease prevention, train health care practitioners, smoking cessation counselors, and teachers in prevention and cessation	Population based, medical systems change, underserved populations
AHECs	Not included	Not included	AHEC smoking cessation initiative in 2007–2008 and 2008–2009a	Not included
Surveillance and evaluation	Yes	Yes	Yes	Yes
School programs	Evidence-based curricula	Evidence-based curricula; tobacco-free policies, training, parental involvement, cessation; link to statewide efforts	Evidence-based curricula	Youth programs focus on policy change
Community programs	Community-based partnerships, emphasis on youth involvement	Community-based partnerships, emphasis on education and policy change	Community-based partnerships, emphasis on chronic disease prevention	Community-based partnerships, emphasis on disparities, youths, and chronic disease programming (coupled with statewide programs)
Chronic disease	Not included	Community focus on tobacco-related diseases	Part of cessation and community programs	Part of community and statewide programs
Administration and management	Not included	Statewide coordination, strong staffing and management	Not included	Statewide coordination, strong staffing and management
Statewide programs	Not included	Build capacity statewide	Not included	Plan, support, and coordinate local and regional efforts (coupled with community programs)
Enforcement	Minors’ access, Minors' possession	Minors’ access, clean indoor air	Minors’ access, clean indoor air	Part of state and community policy change

Note. AHEC = area health education center; CDC = Centers for Disease Control and Prevention. Florida's tobacco control implementing legislation requires the Department of Health to conform to the most recent version of CDC's Best Practices for Comprehensive Tobacco Control Programs. Best Practices was first published in 1999 and updated shortly after the implementing legislation passed.

^aThis requirement was extended for fiscal year 2010 by 2009 legislation³⁹ and extended indefinitely in 2010.⁴⁰

The implementing legislation also created the 23-member TAC, with 11 tobacco control experts (including required membership for ACS, ALA, the American Heart Association, and Campaign for Tobacco-Free Kids) to oversee the program.³⁶ The secure funding and programmatic requirements in Amendment 4, combined with robust statutory requirements, provided the foundation for a strong, successful tobacco control program.

Despite opposition from health groups, however, the implementing legislation earmarked $10 million annually of Amendment 4 funds for area health education centers (AHECs), a network of community health centers organized through Florida’s medical schools, to provide smoking cessation counseling ($4 million) and health care provider cessation training ($6 million; Brenda Olsen, interview with A. K., October 30, 2009).^36,39,41 In 2010, the legislature made AHEC funding permanent and removed the statutory requirement that AHECs spend the money on tobacco control,⁴⁰ although the 2010 state appropriations legislation still required that AHECs use this money for this purpose.

Managerial Staff Selection

The Florida DOH created the BTPP within the Division of Health Access and Tobacco to run the new program. In early 2007, Governor Crist appointed Kimberly Berfield, a former Florida state representative (R, 2000–2006) with no public health administration experience, as deputy secretary of health in charge of the program after she lost her 2006 reelection campaign.⁴² Alan Rowan, an experienced DOH employee in the bureaus of epidemiology and laboratory services, was appointed director of the Division of Health Access and Tobacco. In the program’s first 3.5 years (2007–2010), the division and the BTPP underwent high turnover in key managerial positions: experienced staff were replaced with inexperienced individuals. In July 2008, Berfield dismissed Rowan; in October 2008, she replaced him with Janine Myrick, a DOH lawyer with no public health administration experience (Janine Myrick, interview with A. K., February 18, 2010).

In June 2008, Lori Westphal, a tobacco epidemiologist for the BTPP, became bureau chief (Lori Westphal, interview with A. K., February 19, 2010). Westphal was terminated in December 2008; she was replaced with Janet Baggett, a DOH chronic disease expert, in May 2009 (Janet Baggett, interview with A. K., February 22, 2010). In spring 2010, Terrie Fishman, from the Florida Department of Agriculture and Consumer Services, who had management experience, although not in tobacco control, was hired as deputy bureau chief (Florida Department of Health Bureau of Tobacco Prevention Program Tri-Agency conference call, April 13, 2010, A. K. in attendence). In late 2010, Baggett left.

Media Campaign

Amendment 4,³¹ consistent with Best Practices,³³ required an advertising campaign funded with one third of the program budget, roughly $20 million annually. The DOH opted not to restore Florida’s ground-breaking Truth campaign.^18–22 Seven firms bid for the DOH media contract, including Golin Harris, which had helped launch the Truth campaign in 1998 and had extensive tobacco control experience in 16 states and Europe.⁴³ Golin Harris proposed building on the Truth campaign and using the established Truth brand.^43,44

The DOH used an invitation to negotiate (a procurement process comprising an initial proposal phase and subsequent negotiations) for the media contract.⁴⁵ In the initial proposal scoring (evaluating quality of proposed marketing, production, media buying, and public relations, among other categories) the Zimmerman Agency, which had no tobacco control experience, scored 694 points; Golin Harris scored 745.⁴⁶ Both firms were selected for second-round negotiations. Officials questioned Golin Harris about its proposed use of Truth branding and the political sensitivities surrounding the Truth campaign,⁴⁷ which had been used to justify cutting the TPP. With the Amendment 4 mandate, similar cuts were not a threat to the BTPP.³¹ Golin Harris indicated a willingness to let market research guide decisions about using the Truth motif.⁴⁸ Final first-year cost proposals were $17.1 million from Zimmerman⁴⁸ and $14.3 million from Golin Harris.⁴⁹

Despite its lower proposal score and higher price, Zimmerman won the contract. As part of its justification for this choice, the DOH cited a need for a new media strategy “set apart from the ‘truth’ campaign.”⁵⁰ The DOH's market research firm, Macro International, nominally tested a Truth industry denormalization message in 2007.^51,52 Rather than presenting actual Truth television ads, however, Macro tested a text-only concept message,⁵² which did not capture a full advertisement’s salience and creative value (Figure 2). Furthermore, the industry denormalization message was only tested among adult audiences,⁵² not the youth audiences for which the Truth campaign had been shown to be effective.^{17–19,21,22,54–64} The aggregated adult audiences responded unfavorably to the message, expressing proindustry attitudes.⁵² As found in other research,^{19,22,65–67} the industry denormalization message resonated with the 2 young adult (aged 18–24 years) focus groups that viewed it,⁵² a finding omitted from Macro’s conclusions.⁵²

FIGURE 2—

Contrasting anti-smoking ads in Florida.

Note. The Tobacco Pilot Program Truth television ad (left image) depicts the Demon Award presented to the tobacco industry for “most deaths in a single year”⁵³; the Florida Department of Health contractor Macro International's purported test of industry denormalization message with focus groups (right box) consists of a single text slide.^51,52

The Zimmerman Agency and Deputy Secretary Berfield presented these findings at a Florida House of Representatives Committee on Health Quality oversight hearing on January 22, 2008 (hearing transcript available from the authors). Zimmerman reiterated the Macro results, without mentioning that the test was conducted only among adults, to justify a media campaign very different from Truth:

One of the things that we discovered during that [testing] process, was that people wanted to take responsibility. They no longer wanted to blame big tobacco. They'd heard it. They'd seen it.

Zimmerman also told the committee that the American Legacy Foundation, which had based its national Truth campaign on the Florida experience, was moving away from the Truth industry denormalization messaging:

The original message platform for ‘truth' was anti big tobacco. What we learned … [was] people were ready to take responsibility for their own actions… . Actually, American Legacy is finding out the same thing.

When questioned in 2009 about Zimmerman’s statement, Legacy responded,

Zimmerman misstates what Legacy staff told Zimmerman—which was that anti-industry messaging was not effective with respect to adults in the cessation context. We clearly stated that all of our research shows that anti-industry messaging remains compelling with teens [emphasis in original; E. Vargas, analysis of references to Legacy in January 22, 2008, hearing testimony of Curtis Zimmerman, requested by A. K., December 15, 2009].

In developing the BTPP’s new and distinct media campaign, DOH contractor Macro market-tested 2 Zimmerman-developed campaigns, “I Don’t Care if I Smoke” and “Smoking Is Not Okay,” between December 2007 and March 2008 for youth prevention, cessation, and environmental tobacco smoke messaging.^52,67–69 Macro concluded that I Don’t Care if I Smoke was “not the preferred campaign” among any audience⁶⁸ and that Smoking Is Not Okay was the preferred campaign because the message was direct, provided facts, and made cessation and secondhand tobacco smoke audiences stop and think about smoking.⁵¹ Macro’s research also indicated that audiences had mixed reactions to 2 other proposed prevention campaigns: I Care. I Don’t Smoke and I Don’t Care. I Dip.^68,69

A comparison of the ads tested and the ads launched^70,71 reveals that messages from both platforms were launched (under the I Don’t Care–I Care logo), including many that received mixed or negative reviews from focus groups.^68,70 In an interview (with A. K., June 10, 2010), Curtis Zimmerman stated that his firm’s lack of involvement in Macro’s research limited some of its applicability. The DOH ran Zimmerman’s I Smoke. I Don’t Care–I Care. I Don’t Smoke campaign in 2008 and Be Free (for which we could not locate any evidence of prelaunch market research) in 2009 and 2010.

After review by the DOH, all creative materials Zimmerman produced were sent to the governor’s chief of staff (Curtis Zimmerman, interview with A. K., June 10, 2010). Curtis Zimmerman reported that the governor’s deputy chief of staff, Lori Rowe, reviewed ad storyboards and sometimes the produced ads, “and if something was controversial, in a lot of cases it was getting killed,” even if the marketing strategies were validated by the market research (Curtis Zimmerman, interviews with A. K., June 10, 2010, and April 12, 2011). For example, an edgy prevention billboard advertisement that target audiences liked^51,68 and that was subsequently presented to TAC as a potential ad for launch⁵² was not used⁷⁰ because, according to Zimmerman (interview with A. K., April 12, 2011), Rowe felt it was “too controversial.” Zimmerman told us that on at least 1 occasion he was instructed to remove a tagline from an ad that cigarettes kill more people than handguns because the governor did not want to offend the National Rifle Association.

Evaluations by the University of Miami, under a DOH contract, reported that the campaign’s television, radio, and promotional advertisements achieved very low confirmed awareness among youth and adult audiences.^72–75 In the campaign’s first 6 quarters, it met CDC’s target rating points recommendation only 40% for prevention messaging and 50% for cessation and environmental tobacco smoke messaging.⁷⁶ Low salience and lack of a cohesive and overarching strategy also limited the effectiveness of the media campaign.^72,75

According to Zimmerman (interview with A. K., June 10, 2010), his agency was often asked by TAC members why it was not pushing more edgy messages, but his firm “couldn’t say … because the governor's office won't let us.” At the January 2010 TAC meeting, members asked why the DOH was using ads that were less edgy than recommended by reviewers and whether the media campaign’s ineffectiveness could be attributed to the ad approval process and limits imposed by the governor’s office.^76–78 ALA’s representative suggested that the DOH’s review process bypassed TAC’s statutory responsibility^76,78 to “review broadcast material prepared for the internet, portable media players, radio, and television as it relates to the advertising component of the tobacco education and use prevention program”⁷⁹ and requested that TAC review the advertisements before they were sent to the governor’s office.⁷⁸ In March 2010, the DOH informed TAC members that they could view the DOH’s online media hub; it is unclear whether and at what stage in the process this material was made available.⁸⁰

Cessation

Instead of focusing on cost-effective policies to change social norms about smoking,^81,82 the BTPP focused on less cost-effective direct cessation programming. Legislative appropriations guided this focus by channeling a significant and accelerating portion of the program’s resources for cessation. Consistent with the increases requested in the Crist administration’s annual budget requests from fiscal years 2008 to 2010,^83–86 the legislature increased the annual appropriation for cessation from $15.4 million to $23.8 million,^41,87 amounting to 37.3% of the state appropriation for the program.

According to Paul Hull, vice president of advocacy and public policy at the Florida division of ACS, the group lobbied for an increased appropriation for cessation for fiscal year 2010 to accommodate anticipated increased demand for the state’s cessation services following the 2009 state ($1.00) and federal ($0.62) cigarette tax increases (Paul Hull, interview with A. K., February 4, 2011). DOH vendor contracts for fiscal year 2011 indicated plans to continue to accelerate the resources devoted to direct cessation, for example, a planned contract for up to $15 million for the Quitline⁸⁸ and $4 million for AHECs' direct cessation services. In addition to direct cessation funding, AHECs have received $6 million annually to educate health care providers about cessation counseling. Significantly, Hull described the legislature’s large appropriations to cessation versus prevention as the “path of least resistance” politically, avoiding the offensive messaging that had been part of Florida’s former Truth campaign (interview with A. K., February 4, 2011).

Tobacco Advisory Council

The DOH attempted to restrict TAC’s (and its tobacco control experts’) oversight of the program. Even though grants supervision was a major TAC statutory responsibility, the DOH awarded year 1 grants before convening TAC.⁸⁹ Several TAC members questioned this decision; at TAC’s first advisory council meeting, a member described the move as putting TAC “out of business.”⁸⁹ Excluding TAC from the initial round of grants administration could be attributed to poor timing, but it reflected a larger pattern of actions suggesting that the DOH wanted to marginalize TAC’s program oversight.

In 2009, as part of an omnibus bill, and again in 2010 as a stand-alone bill, the DOH sought legislation to eliminate or reduce nearly all of TAC’s responsibilities, including oversight of the media campaign and grants.^90–93 When asked by TAC members about the 2010 legislation, the DOH (represented by state surgeon general and DOH head Ana Viamonte Ros, Deputy Secretary Berfield, and Division Director Myrick) said that the agency was uninvolved in the legislation.⁸⁰ By contrast, an aide to Senator Charles Dean (R, District 3), the 2010 House bill’s sponsor, reported that Berfield personally requested the bill on behalf of the DOH (Kevin Sweeny, senior legislative aide, interview with A. K., March 4, 2010). The 2009 omnibus legislation passed in both houses by substantial margins, but was withdrawn from consideration by its author on the last day of the session; 2010 House and Senate companion bills both died in committee from lack of support.

Public Health Groups

State-level public health groups (ACS, ALA, and the American Heart Association) have been the primary drivers of tobacco control advocacy in Florida, supported by their national organizations and Campaign for Tobacco-Free Kids. Between 2002 and 2009, these groups, led by ACS, mobilized public support for 3 tobacco control public policy campaigns: Amendment 6, to make restaurants and workplaces smoke free (passed in 2002 with 71% of the vote); Amendment 4, to restore tobacco control funding (passed in 2006 with 61% of the vote); and legislative support for a 2009 $1 tobacco tax increase. The public health groups demonstrated strategic effectiveness in running these campaigns.⁹⁴ In their 3-year effort, which resulted in the 2009 cigarette tax increase, the health groups overcame entrenched legislative anti-tax ideology to achieve unanimous support in the Senate and majority support in the House.

Although public health groups effectively advocated for changes in tobacco control laws, they did not act on the mandate they won from Florida’s voters to oversee appropriate allocation of Amendment 4 money and demand high-impact programming from Governor Crist’s administration. Meaningful engagement between the health groups and the DOH on the issue of the media campaign appears to have been limited to discussions of the media campaign’s effectiveness by their representatives on TAC (Paul Hull, February 4, 2011, and Brenda Olsen, February 1, 2011, interviews with A. K.). When asked specifically for examples of their efforts to push a more effective media campaign outside of TAC, leaders from ACS and ALA did not provide any concrete examples. Similarly, ACS, although recognizing the legislature’s and the DOH’s emphasis on cessation programming, appears to have made no meaningful attempts to change the program’s focus (Paul Hull, interview with A. K., February 4, 2011). ALA asserted that the DOH’s large expenditures on direct cessation were consistent with running an effective program but that the nonprofit had encouraged the BTPP to focus on policy change (Brenda Olsen, interview with A. K., February 1, 2011).

Effects on Tobacco Use

Smoking prevalence among high school students dropped by 2.42% per year (SE = 0.15%; P < .001) during the Truth campaign (Figure 1), consistent with other findings on the impact of Truth.^18–22,24 This rate of decline slowed significantly after the Truth campaign ended, dropping by 1.86% per year (SE = 0.23%; P < .001) to 0.56% per year. The BTPP, which began in 2008, accelerated the rate of decline by only a nonsignificant 0.06% per year (SE = 0.28%; P = .848).

Results for middle school students were essentially the same. During the Truth campaign, smoking prevalence fell by 2.28% per year (SE = 0.23%; P < .001). With the end of the Truth campaign, the rate of decline slowed significantly, dropping by 1.85% per year (SE = 0.36%; P < .001), to 0.43% per year The BTPP’s campaign achieved only a nonsignificant improvement of 0.03% per year (SE = 0.45%; P = .949). We also analyzed the data by building logarithmic models and including the real price of cigarettes (in both linear and logarithmic models); results were essentially the same.

DISCUSSION

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 (Table 1), 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 campaign^18–22 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 campaign^95,96 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 individual^97,98 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 Nonsmokers’ 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 interventions^113–115 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 51 549 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 5211 individuals, 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,³⁸ 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

Limitations

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

Conclusions

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 Programs^33,38 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.