Multiple Streams Approach to Tobacco Control Policymaking in a Tobacco-Growing State

Abstract

Smokefree policies (SFPs) have diffused throughout the US and worldwide. However, the development of SFPs in the difficult policy environment of tobacco-producing states and economies worldwide has not been well-explored. In 2007, Tennessee, the third largest tobacco producer in the US, enacted the Non-Smoker Protection Act (NSPA). This study utilizes the multiple streams model to provide understanding of why and how this policy was developed by triangulating interviews with key stakeholders and legislative debates with archival documents. In June 2006, the Governor unexpectedly announced support for SFP, which created a window of opportunity for policy change. The Campaign for Healthy and Responsible Tennessee, a health coalition, seized this opportunity and worked with the administration and the Tennessee Restaurant Association to negotiate a comprehensive SFP, however, a weaker bill was used by the legislative leadership to develop the NSPA. Although the Governor and the Tennessee Restaurant Association’s support generated an environment for 100 % SFP, health groups did not fully capitalize on this environmental change and settled for a weak policy with several exemptions. This study suggests the importance for proponents of policy change to understand changes in their environment and be willing and able to capitalize on these changes.

Introduction

Tobacco use in tobacco-growing states is higher than the national median [1]. In 2012, the US national median adult smoking prevalence was 19.6 %, and Tennessee’s was 24.9 %. In 2007, Tennessee enacted and implemented its Non-Smoker Protection Act (NSPA), one of the earliest smoke-free policies (SFPs) among the major tobacco-growing states, to address this public health problem [2]. While the NSPA made most enclosed public and work-places smokefree, it exempted age-restricted venues (i.e., bars), semi-enclosed spaces, nursing homes, private businesses employing three or fewer people, tobacco businesses and private clubs with no employees. The NSPA also left the existing preemption of local tobacco control authority enacted in the 1994 Prevention of Youth Access to Tobacco Act (PYATA) in place [2, 3]. SFPs have diffused throughout the US and worldwide since first enacted by Arizona in 1973. SFPs protect nonsmokers from the adverse effects of secondhand smoke (SHS) exposure [4-6], prevent smoking initiation [7, 8], have economic benefits [9-11], including for the hospitality industry [12-14], and have strong public support [15-17]. However, only a few studies on SFPs focus on the policymaking process and outcomes [18-22], especially in tobacco-growing states. This paper analyzes why and how SFP ended up on the policy agenda of Tennessee, the third largest tobacco-growing state [2], to lead to the NSPA.

Until the NSPA, economic, normative and structural factors in Tennessee created a difficult environment for tobacco control [2]. First, tobacco farming has tied families to large cigarette manufacturers to maintain a favorable environment for the tobacco industry. Second, the tobacco policy subsystem, a web of relationships among governmental and nongovernmental actors [23, 24], was dominated by a pro-tobacco iron triangle [25, 26]. Third, institutional arrangements and norms in the state legislature led tobacco control policies to originate mostly from the agriculture committees and be implemented by the Department of Agriculture. Fourth, preemption stifled local tobacco control policy developments and innovations and forced tobacco control efforts to focus on the legislature [2], where the tobacco industry is powerful [22]. The NSPA shifted the historical trajectory of tobacco policy in the state because it recognized tobacco use as a public health issue, opened the tobacco policy subsystem to smokefree networks, and changed the agency that controls tobacco policy [2]. The development of the NSPA provides lessons (both positive and negative) for other states and tobacco economies worldwide.

Theoretical Approach

Research on state SFPs has mostly relied on the pluralist approach to explain the power and influence of actors such as the tobacco companies and health groups on policy outcomes [21, 27-29], diffusion models to explain the spread of SFPs across states and localities [30-32], social movement theory to explain how policy change results from bottom-up activities of health groups [33, 34], and the multiple streams model to explain how SFPs gain the attention of policymakers [23, 35, 36]. We apply the multiple streams model [37] because it postulates that issues become prominent on government agendas when three independent streams—problems, policies/solutions and politics—converge to open a “window of opportunity” [38, 39]. This window allows interest groups and “policy entrepreneurs” [40] to advocate for preferred policies that may have been borrowed from different jurisdictions [37, 41] and expand [23] and promote issues through media and public channels [42, 43]. In Tennessee, the problems and policy streams in the tobacco policy subsystem were coupled with a favorable policy/political environment in the summer of 2006 to open such a window. A change agent, Campaign for Healthy and Responsible Tennessee (CHART), seized this opportunity to elevate the SFP into the state’s policy agenda, which led to policy development by June 2007. CHART was a coalition of health groups that was formed in 1999 to work for tobacco control in the state. Ironically, the health groups ultimately settled for a relatively weak bill from the tobacco industry-dominated legislature because of inadequate understanding of the new policy/political environment that favored a strong SFP.

Methods

The study utilized a case study approach that triangulated interviews and legislative debates with archival documents [44-46].

Interviews

Between September 2010 and April 2011 we used purposive and snowball sampling to interview 34 informants (legislators and staff, 9; governor and staff, 3; state agency officials, 6; health groups, 11; hospitality and business, 3; farm bureau, 1; labor organization, 1). All efforts to interview tobacco companies’ representatives and/or lobbyists failed. Although we did not encourage anonymity in the interviews, all interviewees were informed of the right to be anonymous. Follow-up interviews for clarification of issues raised were conducted between May 2011 and April 2012.

All interviews were conducted in accordance with protocols approved by the first author’s Institutional Review Board.

Archival Documents

We used standard snowball approaches to locate and screen tobacco industry documents [47, 48] at legacy.library.ucsf.edu and tobaccodocuments.org, and Tennessee legislative records on tobacco control and tapes of legislative debates on the NSPA at the State Library. Of approximately 7,000 retrieved documents, about 2,000 were relevant. Additionally, we searched media websites (newsbank.com, Tobacco.org, http://www.discoveret.org/nosir/news.htm, http://www.discoveret.org/nosir/newsarchives.htm) and retrieved 114 reports from 27 Tennessee news outlets.

Analysis

The archival documents were evaluated and the transcribed interviews and legislative debates were thematically coded using grounded theory methodology [49]. Two researchers (HMM and SD) conducted open-ended line-by-line text coding to identify conceptual labels and themes with the NVivo 8 (QSR International, Victoria, Australia) with high inter-rater reliability (κ = 0.97). Descriptive statistics (frequencies and percentages) were computed with PASW 18 (IBM, Chicago, USA) and NVivo 8.

Results

Development of the Non-Smoker Protection Act (NSPA)

The idea of a statewide SFP for Tennessee was unimaginable among proponents of smokefree environments as of mid-2006. Mary Bryan, President of Children’s Hospital Alliance of Tennessee (a member CHART), reported, “When we [the health groups] started first working on this [SFP in the 1990s], tobacco had such a strong coalition in the legislature that no one thought we would pass any of these, a [SFP] and a very significant tax increase in 1 year. It’s something we really would not have dreamed of!” (interview, November 24, 2010). Representative Eddie Yokley (Democrat; D) also said, “There were so many factors that were negative that caused these [SFP] issues to come up and I just think this all came together to cause this to happen. It could not have happened 20 years ago; the environment was totally different!” (interview, November 5, 2010).

Setting the Agenda for the Smokefree Policy

The policy/political environment for SFP in Tennessee changed in June 2006, when Governor Phil Bredesen (D) unexpectedly announced his support for a statewide [2]. As the preeminent policy initiator, his announcement reverberated through the state’s policy subsystem, which limited opposition to and garnered support for the SFP. Additionally, this announcement triggered year-long efforts for a SFP (Tables 1, 2) and changed the debate from whether the state should have a SFP to the timing and type of the SFP.

Table 1.

Timeline for the Non-Smoker Protection Act (NSPA), 2006–2007

June 2006	Governor Phil Bredesen (D) unexpectedly  announced support for a statewide smokefree  policy (SFP) at a bill signing ceremony for  smokefree state buildings in Nashville, Tennessee Campaign for a Healthy and Responsible  Tennessee (CHART) observed the governor’s  announcement as a “window of opportunity” and  began working for a statewide SFP
October 2006	American Cancer Society, a member of CHART,  conducted public opinion polls to test the public  support for smokefree environments and policy
November  2006	CHART had a meeting with policy advisors of the  governor, which began the administration and  civil society collaboration for the SFP
December  2006	Governor’s policy advisors, Department of Health,  CHART and Tennessee Restaurant Association  (TRA) began to negotiate an SFP for the  Bredesen administration based on a proposal by  CHART
February 2007	TRA’s Board of Directors unanimously voted to  support the negotiated SFP for Bredesen’s  administration, Tennessee Smokefree Air Law  (TSAL)
February 2007	A competing SFP bill, Non-Smokers Protection Act  (NSPA; SB1325/HB1851), emerged in  legislature. Senator Jim Tracy (R) sponsored  SB1325 in the Senate on February 8th, which was  referred to the Commerce, Labor and Agriculture  Committee on February 12th. In the House, Rep.  Stratton Bone (D), Chairman of the Agriculture  Committee, sponsored HB1851 on February 15th  and was referred to the Agriculture Committee on  February 22nd. NSPA became the basis for  development of a SFP for the state The original TSAL by CHART became the TSAL  of 2007 (SB2255/HB2335) in the legislative  process. Senator James Kyle, Jr. (D) sponsored  SB225 in the Senate on February 16th and was  referred to the Commerce, Labor and Agriculture  Committee on February 22nd. Rep. Gary Odom  sponsored HB2336 on February 15th in the  House, but was referred to the Agriculture  Committee on April 4th. Both HB2336 and  SB2255 were defeated in the agriculture  committees
February–June,  2007	Smokefree Tennessee Coalition (STC) emerged by  February, which campaigned throughout the state  and lobbied legislators for the SFP
May 2007	May 15, the Senate Commerce, Labor and  Agriculture Committee voted 6–0 to approve  SB1325 with no amendment May 21, Senate voted 15–12 to adopt an  amendment (SA 0638) on the floor proposed by  Senator Tim Burchett (R). Additionally,  amendment (SA 0639) by Jim Tracy (R) was  passed by 14–13, but tabled May 24, the entire Senate voted 22–25 to approve  the amended SB1325 and was transmitted to the  House May 30, HB1851 passed the House Agriculture  Committee by voice vote and subsequently the  Finance, Ways and Means Committee and the  Calendar and Rules Committee May 31, The House substituted the amended  SB1325 for HB1851 and voted 84–10 for it, and  the Senate voted 29–2 for it
June 2007	June 4, Speaker of Senate, Jimmy Naifeh (D),  signed the NSPA June 6, Speaker of House, Rep. Ron Ramsey (R),  signed the NSPA June 11, Governor Bredesen signed the NSPA to  become law
October 2007	October 1, the NSPA went into effect

Table 2.

Bills for developing the Non-Smoker Protection Act (NSPA)

	CHART Tennessee Smokefree Air Law	SB2255/HB2336 Tennessee Smokefree Air Law of 2007 (Governor’s Bill)	S1325/HB1851 Non-Smoker Protection Act (Legislative Leadership’ Bill)	Amended SB1325 Non- Smoker Protection Act As Enacted
Exemptions
Workplaces	Facilities for medical or  scientific research on tobacco  products	Facilities for medical or  scientific research on tobacco  products	Designated areas  with ventilation	Private  businesses with  3 or fewer  employees
Semi-enclosed public spaces*	Smokefree	Smokefree	Exempt	Exempt
Age-restricted venues (i.e., bars)	Smokefree	Smokefree	Exempt	Exempt
Private clubs	Exempt if no employees and  the purpose is not to avoid  compliance	Exempt if no employees and  the purpose is not to avoid  compliance	Exempt	Exempt if no  employees and  the purpose is  not to avoid  compliance
Religious ceremonies with smoking  rituals	Exempt	Exempt	Smokefree	Smokefree
Private residences (not used for  public purposes)	Exempt	Exempt	Exempt	Exempt
Private motor vehicle (not used for  public purposes)	Exempt	Exempt	Exempt	Exempt
Nursing homes	Private or semiprivate rooms  with no more than 1  occupant exempt “provided  smoke does not infiltrate  smokefree areas”	Private or semiprivate rooms  with no more than 1  occupant exempt “provided  smoke does not infiltrate  smokefree areas”	No provision	Exempt
Commercial vehicles (not used for  public purposes)	Exempt	Exempt	Exempt	Exempt
Tobacco venues (Retail stores,  tobacco premises, cigar bars)	Smokefree	Smokefree	Exempt	Exempt
Hotel and motel rooms	Up to 25 % of rooms can be  smoking	Up to 25 % of rooms can be  smoking	Unrestricted  number of  designated  smoking rooms	Up to 25 % of  rooms can be  smoking
Outdoor
	Smokefree within 20 feet of  entrance or window	Smokefree within 20 feet of  entrance or window	No restrictions	No restrictions
Compliance
Signage (“no smoking” symbol)	Yes	Yes	Yes	Yes
“No smoking” sign at the entrance  of places where smoking is  prohibited	Yes	Yes	Yes	Yes
Removal of ashtrays from non-  smoking areas	Yes	Yes	Yes	No
No retaliation against employees  for reporting violations	Yes	Yes	Yes	No
Right of employees to smokefree  workplaces	Yes	Yes	No	No
Penalties
Individuals
Violation	Civil offense (misdemeanor)	Civil offense	Civil offense	Civil offense
Fine	Amount not specified  (collected fines earmarked to  support enforcement)	Not more than $50	Not less than $50  and not more  than $300	Not more than  $50
Businesses
Violation	Civil	Civil or criminal offense	Civil offense	Civil offense
Fine	Not stipulated	Not more than $500	None	Written warning  up to $500
Revocation of permit or license   for violation	Yes	Yes	No	No
Enforcement
Non-government
Owner of facility or establishment	Yes	Yes	Yes	Yes
Employer of a smoke-free facility   or establishment	Yes	Yes	Yes	Yes
Legal actions by employees or   private citizens to enforce Act	Yes	Yes	No	No
Individuals can lodge complaints   of violation with Department of   Health and Department of Labor   and Workforce Development	Not indicated	Yes	No	Yes
Government
Injunctive relief by Commissioner   of Department of Health and   Department of Labor and   Workforce Development for   failure to comply with Act	Yes	Yes	No	No
Any law enforcement officer can   enforce Act	No	No	Yes	No
Department of Health	Yes	Yes	No	Yes
Department of Labor and   Workforce Development	Not indicated	Yes	No	Yes
Mandated inspection of facilities   and establishments	Yes	Yes	No	Yes
Implementation
Department of Health and  Department of Labor and  Workforce Development to  promulgate rules	Not specified	Yes	No	Yes
Preemption
Repeal state preemption	Yes	No	No	No
Education
Notice Business	Yes	Yes	No	Yes
Continuing program to explain and  clarify the Act	Yes	Yes	No	Yes
Employers required to inform  employees about the Act	Yes	Yes	No	No

Sources Tennessee Legislature; Campaign for a Healthy and Responsible Tennessee (CHART)

^*Non-enclosed areas of public places, including: (1) Open air patios, porches or decks; (2) Any area enclosed by garage type doors on one (1) or more sides when all such doors are completely open; and (3) Any area enclosed by tents or awnings with removable sides or vents when all such sides or vents are completely removed or open

CHART decided to “hold the [Governor’s] feet to the fire and push [the SFP] through [at the state level]” by amplifying his announcement in the media, while mounting grassroots mobilization activities to pressure legislators for the SFP (Courington interview, December 1, 2010). To advance this process, the American Cancer Society (a member of CHART) conducted a survey in October 2006 that showed overwhelming public support for smokefree environments and for policies to require such environments (Fig. 1). CHART arranged a meeting with Robert Gowan, the governor’s senior policy advisor, and then publicly announced before the meeting that Gowan was going to take the issue to the governor. This announcement made the policy advisors uncomfortable because it limited their options on how to handle the issue (Gowan interview, October 19, 2010). During the meeting, CHART showed Gowan the public opinion polls, which became a reference point for the administration [50] in support of the Governor’s already stated desire for a SFP and by legislators during the debates over the NSPA in spring/summer 2007. Recounting the meeting with CHART, Gowan said,

[CHART] sat down and the first thing they did was went through a poll. …. It showed [SFP was] overwhelmingly popular. It was actually to a point where to get to that percentage that they had… you would have to have smokers who were in support of it [SFP]. So when I saw that many people felt strongly about the issue, I did obviously change my mind and told them I would talk to the governor and see if there was any opportunity for us to support or introduce a [SFP] legislation.

Gowan was initially reluctant to push for a SFP because the governor’s advisors sought to shy away from any “controversial” issue in an election year. Gowan reported, “The biggest thing was the concern about the governor’s reelection and desire that he not be placed in any controversy, that he [governor] not be involved with greatly controversial issues during that re-election process” (interview, October 19, 2010). However, the opinion polls, as well as Gowan’s own personal experience of high smoking prevalence in his family led him to meet with and strengthen the Governor’s commitment to a SFP. Additionally, the Governor’s policy advisors’ believed that “it’s time to have stronger [statewide SFP]” because of the successful enactment of the smokefree state buildings policy in 2006 [2] (Gowan interview, October 19, 2010).

Fig. 1.

Results of survey conducted by the American Cancer Society, October 10–12 and 16–17, 2006, with 600 registered voters in Tennessee

The confluence of the Governor’s commitment to a SFP, public opinion polls in support of smokefree environments, CHART’s lobbying, personal experiences, and a few legislators’ success in creating smokefree state government buildings in 2006, contributed to the Governor’s policy advisors supporting efforts for a SFP.

The Governor’s policy advisors became emboldened to pursue a tobacco control legislative package that included a SFP, a 42 cent tax increase on tobacco products, and $10 million in funding for smoking cessation after the Governor was re-elected in November 2006. Between November 2006 and February 2007 they worked with the Department of Health, CHART, and the Tennessee Restaurant Association (TRA) to develop the Tennessee Smokefree Air Law (TSAL), which was based on a comprehensive SFP proposal by CHART (Mitchell interview, September 24, 2010; Tables 1, 2).

There was little involvement by tobacco interests in the development of the TSAL. Although tobacco companies initially tried to influence the negotiations by seeking a place at the negotiating table, their opposition to the SFP from the start led the Governor’s policy advisors to see no need to negotiate with them (Gowan interview, October 19, 2010; Spain interview, November 11, 2010). Second, the Governor’s tobacco control legislative package included a tobacco tax increase and the tobacco companies were more interested in fighting the tax than a SFP supported by a popular Governor. Rep. Bill Dunn (Republican; R) said,

I remember [tobacco companies] were not for [the SFP bill]. I think [tobacco companies] were a bit subdued because the governor came out in support of [the SFP] and [tobacco companies] probably recognized that you got to pick your fights, but obviously the tobacco companies were not supportive of it [SFP bill] (interview, October 10, 2010).

Third, the tobacco companies, particularly R.J. Reynolds and Philip Morris, could not agree on a common position because R.J. Reynolds was receptive to some kind of SFP while Philip Morris was not (Mitchell interview, September 24, 2010). This disagreement prevented companies from mounting a united front.

The momentum for a SFP increased during the negotiations of the TSAL in the winter of 2006/7. By February 2007, CHART had created the broader Smokefree Tennessee Coalition (STC), which included non-traditional partners such as the TRA, the First Lady of Tennessee and prominent legislators such as Senator Roy Herron (D) [50]. Chastity Mitchell, CHART’s chief lobbyist for developing the TSAL, recalled,

[TRA] endorsed [the SFP] early on and [TRA] wanted to see all places covered [100 % SFP]. [TRA] did not want it piecemeal. [TRA] wanted to achieve consistency from county to county to see that 100 % places are smokefree. [CHART] also brought in labor because [labor] wanted to see workplaces and workers protected from [SHS]. And then we also sought the Chamber of Commerce and other businesses support as well because they had concerns of health care, and frankly concerns that businesses could be sued for exposing their workers to smoke environments (interview, September 24, 2010).

TRA’s support for a 100 % SFP and membership in the STC was an important development because it had previously worked with tobacco companies against SFPs [51]. In exchange for TRA joining the coalition, CHART agreed not to seek to remove state preemption of SFP (Courington interview, December 1, 2010). The TRA’s Board unanimously voted in February 2007 to support the TSAL (Table 2) [2], which removed any threat of opposition to or possible alliance with tobacco companies in the legislative process.

TRA representatives pointed out in interviews that TRA changed its position on SFPs because, unlike previous SFP efforts they had opposed, the TSAL was framed as a workplace policy that did not specifically target restaurants. Additionally, there was continuous demand by customers for smokefree environments and increasing belief among the TRA membership that SFP was good for businesses. Greg Adkins, the CEO of TRA, said,

For many years, the TRA…. opposed [SFP] legislation… because it singled out restaurants. In 2007 when the [SFP] bill was filed it did not just single out restaurants. What it did was, it became a bill about all employers. It became a typically no smoking in the workplace. And that’s when the TRA Board unanimously said that this is becoming such a big issue and we are starting to have customers who complain about smoking. And something needs to be done and the Board unanimously approved this particular [SFP] bill (interview, March 9, 2011).

In contrast, all other interviewees indicated that the prime reason for the TRA’s change in position was the governor’s support for the SFP. The change in TRA’s position had an impact on the position of legislators who had previously sided with the TRA and tobacco companies to oppose all SFPs.

Development of the NSPA

In February 2007, before the negotiated TSAL of 2007 (SB2255/HB2336) by the administration could be introduced in the legislature, legislative leaders, Senator Jim Tracy (R) and Rep. Stratton Bone (D), the Chairman of the House Agriculture Committee (Tables 1, 2), introduced the NSPA (SB1325/HB1851) as competing bills for SFP [2]. (The NSPA included exemptions for age-restricted venues (i.e., bars), semi-enclosed spaces, nursing homes, private businesses employing three or fewer people, tobacco businesses and private clubs with no employees, and neither repealed preemption; Table 2.) The NSPA was considered a “the tobacco industry bill” by pro-health legislators, including Senator Herron (D), a member of the STC [50], because it was weaker than the TSAL in every aspect: exemptions, compliance, penalties, enforcement and education. Despite its weak provisions, the NSPA represented a major structural shift by assigning implementation to the Departments of Health and Labor and Workforce Development instead of Agriculture. The weaker NSPA received bipartisan support in the legislature and became the basis for legislative debates and negotiations because pro-health legislators considered it the only way to get a SFP bill out of the agriculture committees. Both the Senate and the House overwhelmingly passed an amended NSPA (SB1325) that improved enforcement, but maintained exemptions in the original bill (Table 2), on May 24 and 31, 2007, which Governor Bredesen signed into law on June 11, 2007, with an October 1 effective date.

The Advocacy Campaign

The Tennessee legislature was dominated by tobacco interests when the SFP was introduced in February 2007. Built on strong support for the SFP from the Bredesen Administration, the STC mounted a statewide campaign between February and June 2007 to influence the legislative process. Both outside strategies, ranging from grassroots mobilization to enhance awareness among legislators’ constituents about the SFP to direct pressure on legislators through public rallies, and inside strategies, including direct lobbying and testifying, were used to influence the legislative process. All the legislators interviewed, including Rep. Mike Bell (R), the staunchest opponent of the NSPA and one of the 10 representatives to vote against it, agreed that these activities impacted the law. Senator Ramsey (R), the lieutenant governor of Tennessee at the time of interview, said,

Well, they [CHART] had a lot of members. They could write letters, send e-mails, make phone calls to legislators, encourage them [their members] to do this [contact their legislators]… So it was helpful that they were involved [in the legislative development] (interview, March 10, 2010).

During the legislative process tension emerged between CHART and TRA. While CHART accepted exemptions, particularly for “age-restricted venues” (i.e., bars) based on concerns that a strong resistance could derail the entire SFP, TRA wanted 100 % SFP. Describing this tension, CHART’s lobbyist Mitchell said,

At this point [in the middle of the legislation development], we have the bill on the floor and we know that we do not have support from both houses [of the Legislature] for comprehensive [SFP] bill. … At this point, we think where we came from, the health groups, we very much identified that we could not get a 100 % comprehensive law. We also had come so far that we knew we were going to cover 90 % of Tennesseans with this law. To see progress made we did what we had to, make a compromise and that’s the point where the [TRA] and the health groups went in different directions (interview, September 24, 2010).

In contrast, TRA’s lobbyist Haskell contended that given the TRA’s firm position for a 100 % SFP, the majority of the legislators would have supported it had CHART not accepted the exemptions so quickly (interview, October 1, 2010). In the end, the TRA accepted the compromised NSPA with exemptions by the Senate. Julie Griffin, Assistant Director of Government Affairs of the Tennessee Medical Association (a member of CHART), said,

I think [TRA] could have hurt us a great deal…not being on our side. I don’t think that their influence is the reason that we passed the law. But if [TRA] had been against us [CHART], it could have been very hurtful to us (interview, November 23, 2010).

More importantly, the disagreement between CHART and TRA did not spill over into tension with the administration, which allowed the STC to work collaboratively for the SFP.

The Tobacco Industry

In contrast to the STC, tobacco interests (Farm Bureau and tobacco companies) were not openly involved in the legislative process. The Farm Bureau “tried to stay away from [the SFP] issue” because of “other issues going on nationally and on the state issue of taxing tobacco products which also have a detrimental effect on production and tobacco use out there” (Stefan Maupin, Associate Director of the Farm Bureau, interview, February 10, 2011). For the Governor’s chief policy advisor, Gowan, the Farm Bureau was quiet on the SFP issue because of the Governor’s support for it and programs initiated by the Governor to benefit farmers such as a grass program and a $70 million ethanol plant to help farmers switch to alternative crops (interview, October 19, 2010).

Unlike the Farm Bureau, the tobacco companies wanted a watered-down SFP even after the failed initial attempt to influence the TSAL (interviews, Gowan, October 19, 2010; Jason Spain, November 11, 2010). Courington pointed out, “The tobacco industry, their lobbyist had said that they expected the [SFP] to be passed and that was not something they were going to fight tooth and nail. They definitely wanted some things like 21 and above exemption” (interview, December 1, 2010) because it would effectively continue smoking in bars [52, 53]. To achieve this, the tobacco companies mostly used individual bar owners to fight for exemptions and, while keeping a low public profile, urged legislators to pass a weak SFP (interview, Courington, December 1, 2010). Thus, although the tobacco companies did not mobilize aggressively to derail the entire SFP process once changes in policy/political dynamics environment suggested the state was going to have a SFP, they succeeded in diluting the NSPA with exemptions (Tables 1, 2).

Discussion

SFPs are part of the Healthy People 2020 to attain the goal of 12 % national adult smoking rate in the US and by the World Health Organization to curb the global tobacco use. Because of the paucity of tobacco control policy research in tobacco-growing states [20, 21, 54] and localities [9, 35], as well as economies worldwide [55], we investigated the development of SFP in Tennessee, the US’ third largest tobacco-growing state, to illuminate the SFP process and inform advocates and the public health community about policy change in such pro-tobacco environments.

SFP became part of the policy agenda of Tennessee when the Governor unexpectedly announced support for it in June 2006. As a political “focusing event,” the announcement modified the tobacco policy environment [37, 43], which converged with the problem of tobacco use and policies/solutions to create a window of opportunity for SFP change. The change agent CHART seized the “window of opportunity” and advocated and lobbied for the SFP. The “window of opportunity” principally benefited the health groups as it gave them access to a policy subsystem that hitherto was dominated by tobacco interests.

The rise of the SFP onto the state’s policy agenda was aided by other changes within the political stream and contextual factors that favored tobacco control.

The problem stream involves how an issue is framed (to define a policy’s image) [37, 56]. Framing an issue in a tobacco-friendly environment required raising awareness among people that tobacco use is more than an individual problem and changing the policy image of tobacco as an economically beneficial commodity to that of the problems it poses to the society. Although state policy elites were familiar with the negative impacts of tobacco use, changing the image of tobacco was helped by national phenomenon and generally championed by CHART and its members through smokefree advocacy efforts and by public opinion polls [50]. In the process of developing the NSPA, there was no contest over framing tobacco use in the state as a problem, even among legislative opponents and tobacco companies that historically contested scientific evidence on health hazards of SHS in the state [50, 57]. The 1998 Master Settlement Agreement that settled state lawsuits against the cigarette companies [58] and the ruling that the companies violated the Racketeer Influence Corrupt Organizations (RICO) Act [59] barred the companies from contesting these facts. Workers’ and nonsmokers’ rights were important frames in debates over the NSPA, particularly for TRA and legislators.

The policy stream focuses on solutions in the “primeval soup”, a situation whereby ideas float around, combine, split, rise and/or sink in popularity [37]. In the US, SFPs have diffused nationwide since Arizona first enacted one in 1973 [60], 34 years before February 2007 when policymakers entered SFP into the Tennessee’s legislative process. Senator Bill Ketron (R) indicated that the legislators were aware of SFP issues around the country, including in the neighboring state of Georgia (interview, March 10, 2011). Additionally, and Rep. Bill Dunn (R) observed that members of the House Agriculture Committee, despite mostly from agricultural districts, were inclined to support a SFP because they were acquainted with the Surgeon General reports on smoking and health (interview, October 20, 2010). Similarly, Jason Spain, a policy advisor to the Governor, indicated that the advisors were aware that states around the country continued to develop different types of SFPs and that nonsmokers in Tennessee had been complaining about exposure to SHS in restaurants, workplaces and other public facilities (interview, November 11, 2010) [50]. For Gowan, the administration’s decision to pursue a statewide SFP was a natural expansion of the smokefree environments created by the state and through voluntary actions of businesses (interview, October 19, 2010).

Until the mid-2000s, the political stream [37] for tobacco control in Tennessee had been dominated by a tobacco iron triangle [25, 26], involving tobacco interests, agriculture committees in the legislature and the Department of Agriculture [2]. As typical in other states nationwide [61-63], tobacco companies worked with political allies in agriculture committees of the legislature and third parties, including the TRA and the state grocers’ association to thwart development of SFP [2]. Changes within the political stream occurred when a “window of opportunity” [38, 64] opened because of an endogenous “focusing event” [37, 43], the Governor’s announcement of support for SFP. His announcement suddenly changed the policy/political dynamics in the tobacco policy subsystem by making it more favorable for proponents of smokefree environments to advocate for a SFP, while weakening opposition from entrenched groups that had resisted it.

CHART’s past activities positioned it to capitalize on the window of opportunity the Governor created. TRA’s changed position to support 100 % SFP represented a major change in the policy environment. This situation led the legislature’s agriculture committees to be less hostile to a SFP, and the Commissioner of Agriculture (a gubernatorial appointee) to support the Governor’s agenda. Development of the SFP was facilitated by the absence of direct and overt counter-mobilization by the tobacco interests to derail the entire process. This failure contradicts the counter-mobilization thesis that overt mobilization for a political action leads to adverse political activity on the part of opposing interests [65, 66], alliance participation [67, 68], and venue shopping [69] as the group becomes threatened by the activities of opponents [70, 71]. The absence of direct and overt counter-mobilization by tobacco companies was likely due to the fact that CHART accepted exemptions that protected their important venues (e.g., bars [52, 53]) and did not advocate for the repeal of the state preemption.

Consistent with the multiple streams model, the convergence of these three streams was a necessary condition for the SFP in Tennessee, but not sufficient without other contextual factors helping to change the dynamics of the general political environment [2]. The key contextual factors include public support and demand for smokefree environments, declining dependence on tobacco production, changing norms about tobacco use and control, voluntary actions by businesses and restaurants to create smokefree environments, and historical efforts at youth smoking prevention. This study suggests that contextual issues matter to policy change. When the NSPA was adopted on June 30, 2007, none of the major tobacco-growing states (North Carolina, Kentucky, Tennessee, Virginia, South Carolina, Georgia, Pennsylvania) had a 100 % SFP [72]. In comparison, 63 % of the other states (i.e., 27 of the 43 states) had 100 % SFPs covering work-places, restaurants and bars and gambling facilities by June 2007. This difference suggests that tobacco control policymaking in these two categories of states is likely influenced by different factors. Tobacco control policy change is enhanced where the health department has control over tobacco policy, the smokefree network is strong, contextual factors favor tobacco control, tobacco control policy is framed as a public health issue, and knowledge about the health effects of tobacco use has permeated through policy elites and the general population [29]. Across the country, three of these conditions are consistently met: health departments typically have jurisdiction over tobacco control, tobacco control advocacy and campaigns have made public health the dominant frame for tobacco control and knowledge about the harmful effects of tobacco use and of SHS exposure have diffused [29, 31, 60, 73]. Therefore, it is possible that differences in the strength of networks and in the socioeconomic context that influence the political stream of the multiple streams model explain differences in policymaking in tobacco-growing and non-tobacco-growing states.

The influence of pro-tobacco network (i.e., tobacco industry and allies) in policymaking in state legislatures has been well-documented [22, 74, 75]. This influence is stronger in the major tobacco-growing states where a dominant and strong pro-tobacco iron triangle controls the policy subsystem, which makes policy change more difficult [35, 76]. Thus, as a pluralist democratic society, differences in the power of networks in the political stream of the multiple streams model contribute to tobacco control policy differences in the states. A shift of power to the smokefree network, triggered by the Governor’s support for SFP, facilitated the development of tobacco control policies in Tennessee.

Tobacco control policy change also reflects contextual changes, such as the declining prevalence of tobacco use, decreasing dependence on tobacco production, and improving positive attitudes toward tobacco control, which could enhance the potential for policy change in the tobacco-growing states in a manner similar to the other states [17, 29, 73]. Similar to trends in the non-tobacco-growing states, the usage of tobacco has been declining in the tobacco growing states since the 1960s [77, 78]. Further, the federal tobacco buyout program [79, 80] and the tobacco industry’s increasing reliance on imported tobacco have decreased the dependence on tobacco production in tobacco-growing states. For this reason, the role of key policymakers in the tobacco-growing states is critical in tobacco control as they help provide opportunities for change.

Conclusion

The Tennessee Governor’s unexpected announcement of support for a SFP opened a window of opportunity that led to the convergence of the three independent streams—problems, policy and politics—under the multiple streams model [37] to create a conducive policy/political environment for the enactment of a stronger SFP in Tennessee. However, the NSPA was diluted with exemptions, and the 1994 preemption that had inhibited policy progress at the local level was not repealed [2]. Although the NSPA was a strong piece of legislation compared to other tobacco-growing states at the time (in June 2007 [81]), the preemption arrested further progress. The health groups did not adequately understand the new policy/political environment and failed to force the strong SFP (the Governor’s TSAL) that the new environment enabled and settled on weaker NSPA written by the industry-dominated legislature. Since then, there has been continuous progress at the local level in other major tobacco-growing states (Kentucky [82] and South Carolina [76]) and at the state level in North Carolina [20]. Nevertheless, the NSPA resulted in a major shift in the tobacco policy trajectory of Tennessee by making tobacco use a major public health issue [83], by helping health groups gain access to the tobacco policy subsystem of the state, and by shifting institutional control of tobacco control policy from the Department of Agriculture to the Departments of Health and Labor and Workforce Development. Proponents for policy change need to understand their policy/political environment and be alert for any change that will facilitate the development of SFP, then adapt their goals and strategies to this new environment. Better appreciation of these changes could have helped CHART secure stronger legislation that would have protected all Tennesseans from SHS exposure and allowed for continuing progress.