摘要：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 denormalization 17 ), 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 initiation 27 (although the effect on smoking rates continued until the youth cohort exposed to the Truth campaign aged out of survey samples 29 ). Open in a separate window 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 recommendation 33 ) 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.
