Tobacco Documents Online

436 Journal of Health Politics, Policy and Law PerceM Year Figure 4 The Stigmatization of Cigarettes, 1964-1987. Source: U.S. DHHS 1989. Note: Survey items (percent agree): (1) Cigarette smoking causes lung cancer, (2) cigarette smoking causes heart disease; (3) it is annoying to be near a person who is smoking cigarettes; (4) smoking is hazardous to nonsmokers. Item wording varied. and 1987, support for more draconian policies was considerably weaker. Neither a ban on cigarette sales nor even a ban on smoking in restaurants was ever supported by more than 23 percent of those surveyed. Among the goals articulated most clearly by early antismoking activists was to make smoking so unpopular that smokets would be forced to quit. The data presented in Figure 4 are evidence of how successful the effort has been to stigmatize smokers as harmful to themselves and to others. Translating this stigmatization into public policy consensus has proved more difficult. ~ Public Policies. Stronger local, state, and federal regulation has been among the major goals of the smoking/tobacco control movement (and of the gun control movement as well). Major regulatory achievements at the federal level were noted in Table 2. However, the antismoking move- ment has had its greatest success at the local and state levels. By 1993, over 500 local communities had enacted some form of smoking regu- lation, almost all since 1980 (U.S. DHHS 1993). By 1995, all but ten states regulated smoking in state government work sites; all but twenty restricted smoking in restaurants (CDC 1996a). ao PerceM GO w M ea Nathanson • Social Movements as Catalysts 437 74 ]9 Year 9a Figure 5 Public Support for Legal Restrictions on Cigarettes, 1964- 1987. Source: U.S. DHHS 1989. Note: Survey items (percent agree): (1) Smoking should be allowed in fewer public places; (2) smoking should be limited in restaurants; (3) smoking should be banned in restaurants; (4) cigarette advertising should not be permitted; (5) selling cigarettes should be stopped completely. Items varied. Guns Mortnliry. Gun-related deaths fall into three categories: homicide, sui- cide, and accidents. Homicide and suicide account for approximately equal numbers of deaths (in 1994, 17,527 and 18,765 respectively); accidents are a distant third (1,356) (Anderson, Kochanek, and Murphy 1997). Of these categories, only accidental deaths have shovm a consistent decline over several decades (Spitzer 1995: 74). Since the early 1960s, age-adjusted death rates for firearm homicides have doubled and such rates have increased by half for firearm suicides (Karlson and Hargarten 1997: 1).'Ihe age-adjusted homicide firearm death rate declined slightly in 1994 (and the crude rate has continued to decline, along with the total homicide rate). Half of all homicide victims are minorities (double their representation in the total population); the highest rate is among African Americans: "For African Americans, the risk of being killed in a homicide is nearly seven times greater than for whites and more than twice as great as for Hispanics" (Karlson and Hargarten 1997: 6). Firearms are the leading cause of death for adolescent black males. 9£SOZBZLOZ

434 Journal of Health Politta, Policy and taw sp Percent 10 1966 1970 1974 1979 1984 1989 1994 Year Figure 2 Percent Current Smokers by Education, 1966-1995. Sources: Giovino et al. 1994; CDC 1994, 1996b, 1997. in 1994 was about the same as the percentage of the highly educated who smoked in 1966. Furthermore, absence of recent change-even increase -in the percentage of smokers is most evident among the least well edu- cated. In contrast to its democratic pattern in the 1960s, smoking is now concentrated in the lower socioeconomic strataJs A third basis for cau- tion, one that has received a great deal more public attention, are recent increases in the percentage of smokers among high school students. These data are presented in Figure 3. Smoking prevalence among high' school seniors declined steadily until the mid-1980s, rose and fell errati- cally until around 1992, and since then has sharply increased. Attitudes and Beliefs. Attitudes and beliefs about cigarettes and guns may be compared using two dimensions: beliefs about the degree and nature of the danger that these products represent, and responses to that danger 15. Unfortunately, current smoking prevalence date arc grouped by educational level rather than by occupation or income (with theezception of poveny level statua, which is a fairly crude income index). Data on smoking prevatence by occupetion in 1955 published by the National l:ent¢r for Health Statistics show remarkably tiuie variation in prevalence by occnpation: among men, between 67 and 70 penxnt of white collar workers and between 69 and 74 percent tfblue co))arworkers reponpdcurrentd regular, smoking. A much smalkr penxntage of women smoked, but there waa an equal absence of variation by occupation (U.S. DH9W 1956). Nathanson • Soclal Movements as Catalysts 435 Figure 3 Percent Current Smokers among High School Seniors, 1976-1995. Source: Giovino et al. 1994. in the form of support for or opposition to legal restrictions on their use.l6 Data on changes over the past several decades in attitudes and beliefs about cigarettes are presented in Figures 4 and 5. Two dimensions of belief about the danger of cigarettes are included in Figure 4: first, the belief that cigarette smoking causes harm to the smoker, and second, the belief that cigarette smoking causes harm to (or at the very least) incommodes individuals in the smoker's environment. The former belief stigmatizes the cigarette; the latter belief stigmatizes the smoker as well. All of these beliefs increased markedly during the period of observation. Particularly notable is the near doubling between 1974 and 1987 (from 46 percent to 81 percent) of the proportion of the survey sample who believed that smoking is hazardous to the health of nonsmokers. Public support for legal restrictions on smoking, advertising, and sales of cigarettes is described in Figure 5. While support for limitations on where people could smoke clearly increased over the period between 1964 16.'tlsese are net, of courx, the only relevant attitudes and beliefs. They are, howeverr the ones for which data are av®itabk. In evatuating the data to be prescntcd in this section, it is important to be aware that the exact wording of the questions about cigarettes varied in the dif- ferent surveys carried out by differentorganieations. Some ofthe apparent variation in aa0udea over titro may be explsined by these diffrrenccs.'Ihedata on guns arc frmn avrveys mrdu4ed by the Gallup organization and NORC, using the satne question wording. 5080ZSZLOZ

422 Journal of Hea@h Politics, Policy and Law ments have received relatively little attention from social movement scholars. This article employs an analytic framework drawn from social movement and related sociological theories to account for the relative success of the United States' campaigns against smoking and guns in bringing about change in the policies and behaviors targeted by these movements. While the article's primary focus is on the smoking/tobacco control movement, the analytic strategy is comparative. Aspects of the move- ment that may account for its relative success (as well as for the pitfalls it may still face) are best identified through comparison with the experi- ence of another contemporary health-related social movement. Gun con- trol was selected because it has certain initial similarities with smoking/ tobacco control. Cigarettes and guns were both widely used "democratic" consumer products accessible to and enjoyed by millions in all walks of life, romanticized in film and (in the case of cigarettes) advertising. Movements against these products were initiated in the late 1960s and early 1970s. Both movements confronted well-connected, well-financed opponents. Based on a detailed comparison of the two campaigns I argue that the success of the smoking/tobacco control movement may be accounted for by an ideologically persuasive construction of the relevant health risks, by grassroots mobilization for nonsmokes' rights, and-in the end-by important weaknesses in the movement's opposition. Sources for the analysis presented include interviews with movement activists and observers, participant-observation in movement-related activities, archival materials, and published books and articles by advo- cates, journalists, and scholars.' Research was largely completed by the end of 1996, but some reference is made to later events. The choice and definition of variables to be examined as well as the analysis of research materials were guided by two bodies of theory: social movement theory as elaborated by sociologists and political scientists (e,g., Gamson 1990; Tarrow, 1994; Kriesi 1995; McAdam, McCarthy, and Zaid 1996) and work on the social construction of public problems and per- ceptions of risk by Joseph R. Gusfield (1981), Mary Douglas and Aaron Wildavsky (1982), and others (Kunreuther and Linnerooth 1983; Wynne 1987). Where quantitative measures of particular variables were avail- able and appropriate, they have been used. However, for the most part the method used was qualitative and comparative (see, e.g., Glaser and Strauss 1967; Lofiand 1996). t. A detailed descdpuon of these saurre.c is available from the author. Nathanson • Social Movements as Catalysts 423 The analytic framework employed includes three sets of variables. These are, first, movements' supporting ideologies; second, each move- ment's capacities for mobilizing potential constituencies and organiza- tional resources; and, third, political opportunity structures, defined to include a broad range of opportunities and threats external to the move- ments themselves. Each variable is more fully described in the context of analysis of the movements themselves. The article is organized in four sections. The first section consists of brief historical overviews of each movement. Measures of movement success are described and then the movements' reiative success by these criteria are compared in the second section. The third section is devoted to a comparative analysis of the two movements, and in the fourth and concluding section I reflect on what can be learned from this analysis. Historical Overview Movements have histories. The content and relative importance of each of the elements I have identified-ideologies, organization, and political opportunities-shift over time. Aspects that appear highly important at an early stage of movement evolution may become much less important and, indeed, change their character altogether as the movement either declines or becomes institutionalized. Political opportunities, in particu- lar, are subject to marked change as elites more or less friendly to the movement's cause gain or lose power, What Charles Tilly (1986) has labeled "repertoires of contention"-the sit-in, the protest march, the courtroom battle-shift over time in popularity and in value as vehicles of expression and influence. Particularly in the case of movements that attract substantial media attention, immediate drama (or what the media defines as drama) tends to obscure the complex reality of how change comes about. This complexity is illuminated by close attention to each movement's history. Onl ll January 1964, less than two months after President John F. Kennedy's assassination, the Commission on Smoking and Health that Kennedy had appointed two years earlier issued its report. The assassi- nation and the report each generated substantial pressure for change toward greater control, respectively, of guns and smoking, and produced corresponding opposition to the changes proposed. Here I present a sum- mary and highly selective account of these events. 6Z80Z9ZLOZ

488 Journal of Health Politics, Policy and Law Research Could Endanger Public Safety. Ameican Journal of Public Health 1 87(6):918-921. Wills, G. 1995. To Keep and Bear Arms. New York Review of Books, 21 September, 62-73. -.1995. To Keep and Bear Arms: An Exchange. NewYork Review ofBooks, 16 November, 61-63. Walinskg H., and T. Bmne. 1994. The Serpenr on the Staff. New York: Putnam. Wynder, E. L., and E. A. Graham. 1950. Tobacco Smoking as a Possible Etiologic Factor in Bronchiogenic Carcinoma. A Study of 684 Proved Cases. Journal of the American Medical Association 143(4):329-336. Wynne, B. 1987. Risk Managemenr and Hazardous Waste: Implementation and the Dialectics of Credibiliry. Berlin: Springer Verlag. Zimring, E B., and G. Hawkins. 1987. The Citizen's Guide to Gun Control. New York: Macmillan. The Missing Millions: Organized Labor, Business, and the Defeat of Clinton's Health Security Act Marie Gottschalk University of Pennsylvania Abstract During the battle over comprehensive health care reform in the early 1990s, organized labor was not only unable to put together a winning coalition but also found itself divided and on the defensive as it struggled to prevent any further erosion of the private-sector safety net of the U.S. welfare state. Labor's mlative incf- fectiveness has deep institutional and political roots and was not merely a con.ce- quence of its dwindling membership base. Several key institutions of the private wel- fare state, notably the Taft-Hartley health and welfare funds and the Employtnent Retirement Income Sccuriry Act (ERISA) preemption, brought the interests of orga- nized labor more closely in line with thuse of large employers and commercial insur- ers and aggravated divisions within organized labor and between unions and public interest groups. In addition, several political factors conspired to reinforce labor's tendency to stick to a policy path on health care issues that was predicated on an employer-mandate solution and that had been charted primarily by business and lead- ing Democrats. As a result, organized labor did not emerge from 1he 1993-1994 struggle with its political base fortified nor with a viable long-term political strategy to achieve universal health care and to shift the political debate over health policy in a more desirable direcdon. In the 1993-1994 struggle over health care reform, organized labor proved to be politically ineffective. Unions, which have played a critical part in the passage of a number of major pieces of social welfare legis- lation, notably Medicare (Matmor 1973; Derthick 1979), were not only unable to put together a winning coalition in the early 1990s, but also I am gateful to 6avd Cameron, David M.yhew, Cethte lo Martln, Rogers Smith, Mark Peter- snn, Srephen Skowmnek, and an anonymous reviewerforlheir helpful commcnts on earlier ver- sioas of thls anicle and to Eric Lonazolf for his indispensable research assistanee Journal uf 8ealrh Fbliricr, Pollcy and Jnw.Vol.1d. No. 3, /une 1999. Copyright ©1999 by Duke tlnivershy Press. 2980Z5ZGOZ

442 lournal of Health Politics, Policy and Law Comparative Analysis of the Smoking/ Tobacco and Gun Control Movements Constructions of Risk Guns and cigarettes are hardly newcomers to the American scene. Spit- zer describes "the long-term sentimental attachment of many Ameri- cans to the gun"grounded in cultural myths about the role of the gun in the struggle for independence and the taming of the frontier (1995: 8). During the early part of the twentieth century cigarettes became power- ful symbols of sexuality, power, autonomy, and modernity (Brandt 1992). The two symbolic traditions merge in the Marlboro man, the fiercely independent, (possibly) gun-mting cowboy smoker. Mobilization against these powerful cultural symbols demanded that their meanings be transformed so as to legitimate and guide protest activity (McAdam 1994: 37). Central to this transformation has been the construction of credible risks. Dangers abound. Whether or not these dangers rise to a commu- nity's threshold of awareness and become defined as risks to the public's health, much less elicit responsive action, depends on the active inter- vention of human agency, on what I have called "constructions of risk" (Nathanson 1996:614-615). The first element essential to this construc- tion is the existence of groups or individuals with the authority to define and describe the danger that threatens. The second element is the asser- tion of a causal framework to account for the danger. The Making of a Credible Threat Snroking. The consequences of smoking for health and morality have been argued at least since James the First wrote his famous polemic in 1604 (I{Iuger 1996: 15). Progressive Era antivice campaigns encom- passed cigarette smoking, along with drinking and sexual adventurism, as immoral, unhealthful, and a corrupter of youth. States passed restric- tive legislation, setting the age at which cigarettes might be legally pur- chased, or in some states, prohibiting the sale of cigarettes altogether. The Progressive Era antismoking movement petered out in the 1930s, along with the other campaigns against vice, only to reappear in new guises more suitable to the tenor of the times. The late-twent9eth-century construction of cigarette smoking as a cred- ible risk was the work of the Surgeon General's Advisory Committee on 6£80ZSZL0Z i Nathanson - Sociaf Movements as Catalysts 443 Smoking and Health.m The committee brought together the large body of existing evidence that cigarette smoking was a danger to human health, summarized that evidence in a scholarly fashion, and put the imprimatur of the federal government on its central conclusion, that "cigarette smok- ing is causally related to lung cancer in men" (U.S. DHEW 1964: 31, emphasis mine). The committee did not collect any new data or make any new discoveries. Its report did. nevertheless, construct new knowledge. It transformed scattered evidence into official authoritative knowledge, pro- viding "power and legitimacy to the epidemiologic findings" (Brandt 1992: 67).'s Gusfield argues that public consensus on the dangers of smoking "represents the hegemony of medical science over the culture of health: ,.. by the time the Surgeon General issued the report of 1964, social conditions had become favorable to the transmission and credibility of medical science and the position of the federal government as a source of authoritative advice and activity in the promotion of health" (1994: 54-55). Perhaps. Medical authorities have, indeed, made substantial inroads as arbiters of personal conduct; the latest scientific reports are carried on television and the public is highly attentive (but substan- tially more skeptical, I would areue, than it was in 1964).24 Neverthe- less, the smoking story is more complex than Gusfield allows. The federal government did not embrace ownership of the smoking and health issue in the 1950s and 1960s. A reluctant executive branch had ownership thrust upon it by the efforts of the health voluntaries (principally by the American Cancer Society [ACS]) and by a small minor ity of dissident members of Congress who believed that the authoritative voice of the federal government was essential to confer legitimacy on their cause. Further, while Congress in 1965-with its mandate for annual reports on the health consequences of smoking-awarded continuing ownership to the Surgeon General, it was a limited-purpose ownership. The Surgeon General was given authority to define and describe the problem-to assert the risks of smoking-but very little power to limit 22. The seleceion pmcess and the background leading up to the commiua's fomulion are descdbed in many other sources and will not he repeated here (U.S. DUEW 1964: U.S. DHHS 1999; Brandt 1992; Kluger 1996). 23. An important aspect of the Surgeon General's report, as Brandt points out. was that it markedthe beginning of s new, rnte for epideniologists in the construction of risk (1992: 67). 24.InJuly 1995, thejoumal Srientr published an article with the titk,'Eptdemiology Faces tts Limits;'that began, •71te news about health risks comes thick and fast these days, and it scems dnwst constitutionally contradinory" (7hubes 1995). Science's primary cusxzm was the public, not the sciennfic response to a dtluge of "mntrzdictory advice:' ~. .

460 Journal of Health Politics, Policy and Law bunch of chapters going we organized all the names we had by states and localities and mailed those names out to local Lung Associations and local GASP groups around the country, saying these are people who have written to us from your area. Contact them, get them active in your group. ... We actually sent them envelopes withjust stacks of little mail- ing labels" (Gouin 1995). Although Gouin mailed the first issue of the newsletter to members of Congress and federal officials were aware of GASP's existence, the group's initial tactics were almost entirely local and on a small scale, focused on getting smoke-free meeting rooms (particu- larly meeting rooms of obvious groups, like environmental groups and the Lung Association itself), doctors' offices, hospitals, natural food stores, and the like. Funding requirements for these activities were minimal (Gouin's budget never went above $10,000 per year) and came from con- tributions and from the pockets of the organizers themselves. Although GASP stmck a responsive chord in some quarters, non- smokers' rights were by no means immediately popular with the gen- eral public: "When I started getting up there an my soapbox, it was a very unpopular issue... they thought who was this crackpot telling us we shouldn't be smoking in public" (Gouin 1995). The media, never- theless, were very interested and "we got a lot of free publicity;" at first locally and then nationally and internationally. Exposure brought new recmits. By the mid-1970s, the focus of nonsmokers' rights activists began to shift from "passing out leaflets and buttons" to the passage of state and local antismoking regulations (Hanauer, Barr, and Glantz 1986: 2). Sev- enteen of the fifty-four GASP groups listed in 1974 were in California. These groups incorporated as California GASP in 1976 and focused increasingly on regulatory action, first at the state and later (after narrow defeats in 1978 and 1990) at the local level.m These activities brought additional groups and individuals into the movement: the Califomiachap- ter of the ACS in particular played "a very crucial role" in the initiative campaigns (interview with smoking/tobacco control activist, 1995). Data presented in Figure 8 on the timing of grassmots organization in relation to the passage of local restaurant nonsmoking ordinances (the first type of 56. In 1981, Califomia GASP became Califomians for Nonsmok<ce Rights and in 1986. Ameriexns for Nonsmokers' Rights (ANR). In an anviversary issue% the ANR newslelter com- mented on the shin from srate to local priaitier.'The experiercx uf hsving bas buvel twlce at Ihe stat<level whik succeeding locally iin &rkeley in 1977 and in Los AIIOS in 19"19] taught the nonsmokere righls sctivists a great deal. They learned that the tnbacco fntluslry, while wealthier and more powerfut at the stxte level. just wasn't ahte to thwan our cRoes lacatly" (ANR 1996). 8ti80Z9Z10Z Nathanson - Social Movements as Catalysts 461 No. Groups -oroaw -ad.nea. Figure 8 Grassroots Organizations and Nonsmoking Ordinances, 1964- 1992: Number of Nonsmokers' Rights Groups and Passage of Local Restau- rant Nonsmoking Ordinances. Sources: U.S. DHHS, NIH 1993; U.S. DHHS 1990. ordinance to be widely adopted) suggest that organization at the tocat level played a critical role in subsequent regulatory action. There are no published surveys of nonsmokers' rights activists, How- ever, some idea of the population groups to whom their activities had most appeal can be gained from an analysis of the relationship between the average family income of Califomia counties and the timing of smok- ing control otdinauce adoption. These data are shown in Figure 9. Counties that adopted smoking control ordinances in 1985 or before are defined as early adopters, counties that adopted ordinances after 1985 are late adopters, and the remaining counties are nonadopters. Wealthiercounties are substantially more likely to be early adopters: the difference in mean income levels across the three adopter groups is highly significant. It is a reasonable inference from these data that individuals active in the non- snickers' rights movement were also likely to be above average in edu- cation and wealth. As the nature and scope of their activities changed, funding require- ments increased and GASP groups became somewhat more profession- alized (although they were still largely voluntary); drafting legislation and engineering its passage demanded legal experience and organizing a No. (hdinances

432 Journal of Health Politia, Potky and Law (1995: 281), while Edwin Amenta and colleagues argue that achievement of "new advantages" not anticipated by the movement should also count as success (and that new advantages are more "meaningful" than accep- tance as a measure of success) (1994: 681). An additional problem arises in the case of ongoing social movements: how successful the movement appears depends on at what point in the movement's trajectory (unknow- able, except in retrospect) success is measured The long-range goals of the smoking/tobacco and gun control move- menrs are to bring about a decline in the relevant parameters of mortality and morbidity. In the short run, both movements advocate behavior change in, respectively, patterns of cigarette smoking and in gun ownership and use. Beyond these generalities, smoking/tobacco control movement repre- sentatives have from the beginning been quite explicit in their aims of stig- matizing cigarettes and the smoker and, more recently (in the words of one activist), of "gening the bully [the tobacco industry] off the block." There is less consensus among gun control advocates, in part because of dis- agreement on the meaning of the word control. In the following paragraphs I evaluate the extent to which each movement has achieved its goals.14 Smoking Mortalitk On 14 November 1996, the New York Times reported an over- all decline in cancer death rates "for the first time since 191p" (Brody 1996). Philip Cole and Brad Rodu (1996), whose work was the basis for the Times' report, attributed about half of the reduction in cancer mor- tality to declines in smoking since 1965 and anticipate continued reduc- tion "as the now rising lung carcinoma mortality rates among women stabilize and then decline," a consequence, presumably, of declines in women's smoking. Their work was foreshadowed in several earlier reports. Morbidity and Mortality Weekly Reporr (MMWR) noted in November 1993 that "the declines in smoking prevalences have resulted in a stabi- lization or decline in the lung cancer death mte for men aged <55 years and for women aged <45 years, respectively" (CDC 1993). Cardiovas- 14. The pmbtem ofoutcwnx measvrcmcnt is particulariy tmuhlesome in ihe caseof gun con- trot for several reasors. Fint, thae is disagrrernent among advocates about the movemeni s goals; second, the involvement of the public health communiry is relatively recent; and third, the movcment itsetf is a moving target, evolving in several directions simuhaneously. In addi- tion, measures of soccess have been setccted, in part, for their comparability across the two muvenmts. As a rewlt, some rrteasures thatmight work to the detriment ofthe smokinyfaUaxo enntrut muvement-for exarnple, suecess in achieving tobacco raa inereaxs or In curbing cig- areite advertising-heve not been used. Nathanson • Social Movements as Catalysts 433 f9e4 1989 1974 1979 1984 Y.w 1999 1994 amm. +an,w«. ~w~al Figure 1 Smoking Behavior Change, 1964-1995. Sources. Giovino et al. 1994; USDA 1995-96, 1998; CDC 1996b, 1997. cular disease (CVD) is responsible for nearly twice as many deaths as lung cancer and it is clear that cigarette smoking plays a substantial role in CVD mortality. Cardiovascular disease mortality, however, has been declining for the past three decades among both women and men and the relative part in this decline played by changes in smoking behavior is dif- ficult to determine with precision (see, e.g., Hunink et al. 1997). Behavioc Change over the last three decades in the behaviors targeted by tobacco advocates are presented in Figure 1. Two measures of change are employed: cigarette consumption per capita per year (in numbers of cigarettes) and smoking prevalence (percent of the population age eigh- teen and over who are current smokers). Both cigarette consumption and the reported prevalence of smoking have declined substantially since 1964. Despite these declines, there are a number of reasons for caution in evaluating changes in cigarette smok- ing. First, both of the aggregate measures employed in Figure 1 have recently plateaued. Second, as shown in Figure 2, by far the sharpest declines in cigarette smoking have occurred in that proportion of the population with a college or graduate school education. Among individ- uals with less than a high school education, the percentage who smoked V£80Z9ZL0Z

430 Journal of Health Politics, Policy and Law the NRA and its congressional supporters, who began work to overturn the act as soon as it had passed (Spitzer 1995: 147). Their efforts culmi- nated in the Firearms Owners Protection Act of 1986, also known as the McClure-Volkmer Act after its principal House and Senate sponsors. As enacted, the bill eased a number of provisions of the 1968 act but retained the ban on interstate sale (but not transport) of handguns. Despite the lat- ter concession to gun control advocates, the McClure-Volkmer Act is regarded by most observers as a victory for the NRA (Davidson 1993; Spitzer 1995). A significant consequence of the bill, however, was that it "solidified the split between the NRA and police organizations" (Spitzer 1995: 151). McClure-Volkmer had been actively opposed by a newly orga- nized coalition of police groups. After a fallow period of over twenty-five years, two pieces of federal legislation strengthening gun restrictions were enacted in quick succes- sion in 1993 and 1994. Neither of these measures was particularly dra- conian; both include exemptions and other provisions favored by gun supporters. Nevertheless, both took over five years to pass from the time of their first introduction in Congress and both were the subject of vim- lent debate between supporters and opponents. Emergence of the Gun Control Movement. Josh Sugarmann reports that gun control became an issue for some women's groups in the early 1930s (1992: 29). However, there is little evidence of an organized gun control move- ment in the United States before the mid-I970s. The National Coalition to Ban Handguns (NCBH) (renamed the Coalition to Stop Gun Violence in 1990) evolved out of church groups' response to the assassination of Presi- dent John F. Kennedy. Following a period of dormancy between 1968 and 1974, the group reorganized in 1975 as the NCBH. Handgun Control, Inc. (HCI) was founded at about the same time by a Republican businessman whose son had been shot and killed with a handgun (Spitzer 1995: 115). Beginning in the early 1980s, the NRA found itself in a series of high- profile political conflicts with the police around the regulation of "cop killer bullets" and plastic guns and around the McClure-Volkmer bill. 13 Important outcomes of these conflicts were independent mobilization by the police to advance their own interests in gun control and a political realignment of sorts, with the Democrats on the side of the police against the Republicans and the NRA. A final important development in this brief history is the redefinition 13. These conHicts are colurfuny described by Osha Gray Davidson (1993:85-127). Nathanson • Social Movements as Catalysts 431 of guns and gun control as issues in the domain of public health as well as, or in addition to, the domains of crime and law enforcement. Among the proponents of this definition have been the federal Centers for Dis- ease Control and Prevention (CDC), which established a violence pre- vention unit in the mid-1980s, and former Surgeon General C. Everett Koop (Koop and Lundberg 1992). Medicalization of the gun question has important consequences for how the problem is characterized and into whose province it falls. This redefmition has triggered a new wave of gun control organization, and in the last few years several gun control groups led by health professionals and by lawyers with training in public health have emerged. Not surprisingly, ntedicalization of guns has been heavily contested by the NRA and by some members of Congress. Measures of Movement Success While scholars' interest in social movements "stems from their belief that movements represent an important force for social change" (McAdam, McCarthy, and Zald, cited in Burstein, Einwohner, and Hollander 1995: 275), the measurement of change and its causal attribution present con- siderable methodological problems (see, e.g., Diani 1997). For example (following Diani), the adoption of arestaurant smoking ban may be due to nonsmokers' rights activism; the activism may have been generated by politicians in support of the ban; or both activism and the ban may result from other social forces (e.g., increased consumer sensitivity to health threats and accompanying media hyperbole around these threats). The problems of causal attribution are somewhat alleviated when (as in the present case) attention is narrowly focused on specific campaigns and the time span over which movements are observed is fairly long. Neverthe- less, while I will argue that nonsmokers' rights activism played a causal role in bringing about change in smoking-related policies and behaviors in the United States, this argument does not preclude the existence of addi- tional causes and causal paths that I may not have fully considered. Conceptualizations of movement success generally begin with William Gamson s two-dimensional criteria of "new advantages" for its constituency and/or "acceptance" of the movement by its targets or by the public as the legitimate spokesperson forthe interests itrepresents (1990:31-34; e.g., Amenta, Dunleavy, and Bernstein 1994; Burstein, Einwohner, and Hollander 1995). Beyond this reference point, there is little consensus. For example, Paul Burstein and colleagues state that "assessing a move- ment's success involves determining whether it has achieved its goals" ££80ZSZLOZ

446 Journal of Health Politics, Policy and Law gered and these cultural presuppositions are remarkably consistent over time and place (Douglas and Wildavsky 1982; Douglas 1992; Dobbin 1994; Nathanson 1996). In the U.S., we concem ourselves with dangers to the individual, not (e.g., as in France) to the state. Furthermore, the dimensions of risk are highly predictable. In any given case, risks may be portrayed as acquired deliberately or involuntarily (and the victims as correspondingly culpable or innocent), as universal (putting us al] at risk) or as particular (only putting them at risk), as arising from within the individual or from the environment, as visible or invisible.n The most acceptable risks are universal, are attributable to the external environ- ment, and are incurred involuntarily by innocent victims. Smoking. The remarkable transformation of the cigarette and smoking from symbols of "modernity, autonomy, power, and sexuality" to sym- bols of weakness, irrationality, and addiction (Brandt 1992: 70) was accompanied and driven by shifts in underlying constructions of risk. The initial constmction of the cigarette as a danger to the health of the male smoker did not disappear, but has been added to and elaborated ever time. Throughout the period in question, advocates for the dangers of smoking were aided and abetted by a highly interested and attentive news media. During the first phase of the tobacco wars, the messages conveyed to the U.S. public were that the hazards of smoking are attributable to the risky choice of the person who smokes and that the individual is respon- sible for risk reduction by making the necessary changes in his or her behavior. The most consistent advocate of this perspective, the American Cancer Society, was also the dominant player in the early stages of the smoking and health drama. The following is from the society's 1957 annual report: "The society believes that at our present state of knowl- edge, the question of whether to start smoking or to give it up must be left to the judgment of individuals. For intelligent decisions everyone should know the facts: There is a definite association between cigarette smoking and cancer" (19). The ACS approach is striking in two respects: first, in its validation of individual choice and, second, in the limitation of its own responsibility to 'just the facts:' Knowledge of the association between cigarette smoking and cancer as well as other diseases accumulated, but the posture of the ACS as 27. Social movement mtrepreneurs (and other interesred actors) pomuy risks in what they ktrow to be culturally resonant terms, thereby reinforcing, in chcular fashion, preexiating eu4 tural preconceptions about the relevant dimensions of dsk. Nathanson . Social Movements as Catalysts 447 articulated in the cited quotations did not, in fact, begin to change until the early 1980s. Lest it be thought that the ACS was unique in its indi- vidualization of the smoking and health issue or in the timidity of its rec- ommendations, federal health officials took much the same tack. Their approach to the preparation of the Surgeon General's report was that of an individual physician advising an individual patient: "What do we [that is, the Surgeon General of the United States Public Health Setvice] advise our patient, the American public, about smoking?" (cited in Brandt 1992: 66). Implicit in this question is not only, as Allan Brandt points out, "a particular model of public health and the role of the state," but also a particular model of where the hazards of smoking are socially located. Themes of personal responsibility for health (and the limits of govern- ment intervention) were echoed in influential publications throughout the 1970s: cigarette smoking became the quintessential exemplar of lifestyle change within the individual's control (Lalonde 1974; Knowles 1977; U.S. DHEW 1979).22 There is a striking disjunction between the Surgeon General's 1964 proclamation of smoking as "a health hazard of sufficient importance in the United States to warrant appropriate remedial action"(U.S. DHEW 1964: 33) and the actions that were, in fact, taken by the major players at the time. While there is a strong libertarian bias in Americans' approach to health protection, early constructions of smoking and health were dri- ven as much by political as by philosophical concerns. In an interview, an ACS official who had worked in the national office from 1960 through 1990 described the society's internal struggles: I was there when the great debates were held on how far the American Cancer Society should go as an organization in taking up an antito- bacco position. And you could well realize that there was tremendous resistance within the American Cancer Society in the late 1950s and early 1960s, because here you have tobacco-growing states and here you have divisions, North Carolina, South Carolina, Kentucky, Ten- nessee, that said, "You are going to destroy us. We are not going to be 28. Bssa7 on quamhative analysis of stories in a range of inedia (major newspapers, televi- sioq news megazines) in 1960 and 1984, Elcanor Singcr md Phyllis M Endreny report that "stories about akuhol and tobaccu diaproportionately blamed vittims for risks associated with these hazuds. In the case of tobacco, victims alsn appear to be disproportionately held respon- sible forprevention., „7hus,judging from theevidence ofthese stories, smohingwas seen pri- ntarily ac an aclivity within the individual's eontmL whereas prevention of thc risks of drink- ing was acen, in the majority of stories, as requiring govertmcn intervention thmugh the imposition of laws and the like' (1993: 117). I 6ti80Z9ZLOZ I

4" Journal of Health Politics, Policy and Law the gun control movement received a major boost when police organiza- tions came to its support in the mid-1980s. Interest in gun control among the larger population is driven, in Spitzer's terms, by a "cycle of outrage, action, and reaction usually [begin- ning] with the sensational and the horrific" (1995: 13). This point was eloquently made by a gun control activist we interviewed: From 1975 [when his group was founded] to 1980 we were a very small, basically inconsequential organization. We werejust a voice out there in the wilderness.... In 1980-81, the Pope, John Lennon, and the president were all shot.... Suddenly, the issue became hot. We were one of the few sources that people had to go to for information, especially the news media. So in 1980, we grew rapidly. And then, it died. The president took that "aw shucks, it didn't hurt" approach, the Pope didti t say anything about the issue, and all we were left with were John Lennon fans. The other folks disappeared.60 The problematic character of its recruitment base may be responsible for what another movement activist described as "probably the greatest short- coming of the gun control movement: even though we have strong pub- lic suppott, we have no organized grassroots." Grassroots support for the gun control movement has been sporadic and difficult to sustain, and the movement has only recently begun to attract support from established organizations comparable to that of the health voluntaries for smoking/tobacco control. Further, while both move- ments have experienced and continue to experience conflict between more conservative and more radical factions, the impact of this conflict on the movement's ability to present a united front may be more serious in the case of gun co¢trol.61 In the mid-1990s, the national stage was shared by two gun control organizations, Handgun Control, Inc. (HCt) and the Coalition to Stop Gun Violence (CSGV). Spitzer gives a concise summary of the groups' background, beginning with HCL' "[HCI] began in partnership with the National Coalition to Ban Handguns (NCBH), formed at about the same 60. The ^cyek" this activist descritxs eppears ckady in daU from ouranalysfs of NewYnrk Times cuverage of the gun control issue.7Te number of anklesjumped frqn fony-two in 1980 to sixty-twu in 1981 fallowing the Rcagan and aher ahootings; i[ dnpped to betwern sixtcen and thirty-nine in the petiod fmm 1982 to 19Ne,JUmped again to seventy-six in 1989 following the Smekton, California schonlyard shooting, and dropped again to forty-six in 1990. 61. Recaitly, however, the prospenive tobacco settlement led to iniense conflict within the smaking/lobeccoeonttul nm¢ment between propptents who belieVed it was the best deel they could get and opponents who believed it was a sellout. 0980Z5ZL0Z Nathanson • Social Movements as Catalysts 465 time. The groups soon parted ways. The NCBH was renamed the Coali- tion to Stop Gun Violence in 1990. It has generally pursued a tougher stand on gun regulation than HCI, and has been overshadowed by HCI's greater size and visibility, especially since Sarah Brady has become a prominent HCI figure" (1995: 115). Only two state-level gun control advocacy groups were identified by our respondents, in Maryland and Illinois. One activist described most other organizations as consisting of "dedicated people with a hunk of lenerhead:' A range of low-profile groups do exist, however. Missing Peace, for example, is a primarily educational rather than political advocacy group (although it has employed direct action occasionally, e.g., a candlelight vigil in front of the White House). The group was founded by a suburban Maryland woman after a twelve-year-old brought a gun to her son's school; its director would like to expand nationally and pointed to affili- ates in eighteen states. At the same time, she suggested that she might quit if additional funds were not forthcoming soon. Missing Peace has much in common with the original GASP: it is small, with meager funds, and is staffed almost entirely by volunteers. A major (and, I believe, crit- ical) difference is the absence of anything comparable to the American Lung Association's support for GASP. A standard question in the interviews we conducted asked respondents to comment on the relationship of their own group with other groups working on the gun control issue. The level of perceived competition, even conflict, elicited by this question was striking. Reactions ranged from strongly negative-extending to an unwillingness to share mailing lists and to uneasiness about appearances on the same platform-to expressions of competition over financial resources, to more thoughtful analyses: There are a couple of splits in the gun control movement. One is between the controllers and the banners. The controllers who want to control handguns through licensing, registration, things like that, tend to view the banners as radicals who give them a bad name. The con- trollers also tend to see gun violence as a crime issue versus gun vio- lence as a public health issue. The banners, we're talking handguns here, tend to be public health people, those who take a public health perspective and one of the problems with the public health argument is that it points out many of the limitations and internal flaws of the gun control's control argument! Which doesn't lead to good relations. I think that's one of the problems in this movement in that whereas in

426 )oumal of Heafth Politics, Policy and Law Table 3 U.S. Tobacco Wars, 1971-1995 Phase 3: Thc Discovery of Innocent Victims 1971 Country's first Grsv up against Smokers' Pollution (GASP) formed in Maryland. 1972 Frst reference in SO report to potential dangers of involuntary smoking. 1973 Civil Aeronautics Board requires no smoking sections in all com- mercial airline fiights. Arizona is the first state to ban smoking in somc public places due to dangers of involuntary smoking. 1975 SG report oomains entire section on involuntary smoking. 1976 Madison, WI, is.the first municipality to restrict smoking in restaurants. 1983 National Institute on Drug Abuse declares smoking to be the natiorrs "most widespread form of drug dependency:" 1986 SG report: The Health Consequences of Involuntary Smoking. 1988 SO report:'lhe Health Consequences of Smoking: Nicotine Addiction. 1993 EPA declares that environmental tobacco smoke (ETS) is a human lung carcinogen (Class A). 1995 Consumer Reporls article: Hooked on Tobacco: The Teen Epidemic. FDA finds that "nicotine ... is a drug" and that cigarMtes are "drug delivery devices" (U.S. DHHS 1995: Table 3). states and administrative encroachment on legislative authority, Congress took back its turf and in 1965 passed the Federal Cigarette Labeling and Advertising Act. This bill was regarded by contemporary smoking control advocates as considerably stronger in its protection for the tobacco indus- try than the "remedial action" recommended by the Surgeon Geneml (Pertschuk 1986; Fritschler 1989). The warning label was far milder and less certainly legible than advocates would have preferred; adding insult to injury, the bill prevented individual states from imposing their own (possibly stricter) labeling requirements. Less noted at the time, but of as donmamted by a major protagonisr-SenalorMaurine B. Neuberger (D-DR)-in herbook, Snmkescreen: Tobacco and the 1'ablicWdfarr. published in I963. Nathanson • Social Movements as Catalysts 427 overriding importance in the long run, was the bill's language mandating annual reports by the Surgeon General on the health consequences of smoking.5 The continuing drumbeat of these reports throughout the 1970s and 1980s played a critical role in fueling the antismoking movement. The pattern established in 1965 of minimal regulation in response to public pressure, combined with significant protection for the tobacco industry, has continued to characterize the congressional approach to regulation in the smoking/tobacco arena.6 After many years of disclaim- ing authority over tobacco, the federal Food and Drug Administration (FDA) took up the regulatory banner in the 1990s, labeling nicotine as a drug "within the meaning of the Federal Food, Drug, and Cosmetic Act" (U.S. DHHS 1995: 41455) and proposing regulation, aimed primarily at the protection of children. The first phase of these regulations went into effect on I March 1997.7 On 11 January 1971-the seventh anniversary of the Surgeon Gen- eral's report-Jesse L. Steinfeld (then Surgeon General) used the oppor- tunity of an address to the Interagency Council on Smoking and Health to urge the adoption of a Bill of Rights for the Nonsmoker to include a ban on smoking in "all confined public places" (Steinfeld 1983: 1258).s Independently, but almost simultaneously, the nonsmokers' rights move- ment was launched. As documented in Table 3, these actions on behalf of smokers' "innocent victims' inaugurated a period of gradually intensify- ing legislative activity to regulate smoking in public places. Downs and Ups of Gun Control, 1963-1996 A chronology of recent struggles over gun control is presented in Table 4. Public attention to this issue has a marked cyclical character, driven by violent acts against individual public figures or by a spectacular mass slaughter of "innocents"v The first significant piece of gun control legis- 5. Ttx Surgcon General wes also required to issue legisletive recommmidations. There is lit- tle evidence of theee recomrncndations in the reports. Kruger states that recommendations to lun smoking in enclosed public places inserted by Surgeon Generallesse Steinfeld were'teg ularly removed by Nixons Office of Management and Budget" (I996: 366). 6. For example, a nujorreccnt attempt atcongressional rcgulatinn was defeeted in June 1998 (Rasr.nbaum 1998). 7. The F'DA's authnrity tu regulate nicotine was recently overtumed by a federal appeals coun, leaving the issue of ils powers unsettled, for the lime being at Iean (Mefer 1998). 8.1tw Interagency Council on Smoking and Health, formed in 1964, was a loose grouping of public and private organicadons interested in the sxnoking and health issue. 9. Interviews for this project were completed during the spring and summer of 1995, before and immediately after the Oklahoma City bombing. Arecent review of Robert 1. Spit>er's book, The Pulirics of Gun Cormal, by Josh Sugarmann. director of thc Yioknce Policy Center, sug- 6£80ZSZLOZ

468 Journal of Health Politics, Policy and Law The importance of independent actors, including the regulatory commis- sions, in spurring governmental action [against smoking] in the United States has been crucial. Without them consideration of the issues and governmental action would have been at least postponed if not pre- cluded" (Friedman 1975: 56). The creation of the Consumer Products Safety Commission in 1973 offered a further opportunity for outside groups (in this case the American Public Health Association [APHA] and Senator Frank Moss [D-UT]) to demand regulatory action against ciga- rettes that, even though unsuccessful, kept the problem in the public eye: "In a large pluralistic system, there are many ways to keep an issue alive" (Fritschler 1989: 118). Among the most important of those ways, as 1 pointed out earlier, was action at state and local levels. Many northern states had little dependence on the tobacco industry and clean-air legislation was consistent with tradi- tional state responsibilities. When the tobacco industry became aware of this threat to their interests and began to exert its influence successfully at the state level, nonsmokers' rights groups turned to the local level where the industry was substantially less effective. Of course, the indus- try has found ways to counter this latter strategy as well (e.g., by state preemption of local clean-air regulations) and the struggle continues. However, without the multiple venues for action offered by the U.S. state, the struggle would have been even more one-sided. The potential importance of federal agencies with authority inde- pendent of Congress, if not (in the case of the FDA) of the executive branch, was demonstrated again in 1980, when the FTC, under Michael Pertschuk, an activist commissioner appointed by President Carter, was instrumental in reviving Ihe cigarette labeling issue, leading to eventual congressional passage of a somewhat stronger system of rotating labels; and, more recently, this was also illustrated in the critical role played by the FDA under another activist commissioner, David Kes- sler, in labeling nicotine as a drug and cigarettes as devices for drug delivery. Published accounts of these events are relatively silent about the role of interest group pressure-for example, from the coalition of health voluntaries newly organized in 1981-in initiating action by the FTC andlor the FDA. If John W. Kingdon's (1995) work is any guide, however, the pressure was there, waiting for the right moment to make its presence felt. Elite AlIies. Pertschuk recounts that in 1965, when the first cigarette labeling bill was under consideration in Congress, President Lyndon Z880Z5ZLOZ Nathanson a Social Movements as Catalysts 469 Johnson personally "called FTC Chairman Paul Rand Dixon and exco- riated him for persecuting the tobacco industry" (1996: 37). President Clinton, by contrast, was "the first avowedly andsmoking president in the White House" (Kluger 1996: 549). Allies (or their absence) in the fed- eral government have played a significant role in the smoking/tobacco control movement. Probably of most importance, Surgeons General and Secretaries of the Department of Health and Human Services friendly to the movement (Terry, Steinfeld, Califano, and Koop) have been able to use the annual Surgeon General's reports on smoking and health as vehi- cles to direct public attention to the problem of smoking and health and to lend the power of scientific legitimacy to smoking's opponents. Indeed, Fritschler credits the 1964 report with dealing the tobacco "subsystem a blow that was to prove fatal" by providing "the Federal Trade Com- mission with an opportunity to make its move" (1989: 43). Allies in the executive branch and, of particular importance, in Congress, have played vital roles in the recent past as well: hearings and the introduction and shepherding of legislation (even legislation that does not pass) con- tribute to the legitimization of smoking/tobacco control as a public pol- icy issue and, of course, keep the issue in the public eye, Depending on one's perspective, the health voluntaries and the major organizations of health professionals may be regarded as elite allies, rather than as part of the smokingftobacco control movement itself, and I have already described the shifting roles these groups have played.63 Another important potential ally whose leadership has not, on the whole, been supportive of the movement are trade unions. As the director of the AFLCIO Department of Occupational Safety and Health stated in oppos- ing federal regulation of environmental tobacco smoke (ETS), "we have a lot of individuals who smoke and don't think this is the kind of thing the government should be involved with" (U.S. OSHA 1995:12217-12218). Since 1991, twenty-eight states and the District of Columbia have passed laws protecting smokers from discrimination in the workplace (McKen- 63. The tompkn and shifting relatinnships among sctors in the smokmgRnbacco arena do not fan resdi]y into existing social movesrcm taxotromies (see, e.g,. McCarthy 1996). While the nNuzmokers' rights movemem c]early quslifies as a M1mbilizing strucmrS' it is less clear that theheWth votuntarks can be uufully su described; it is even less clear for the legal firms now engaged in large-scale li5gation against the tobacco industry. Perhaps the concept oPorgen'vs- tiottal6eld (defined by Scott [ 1994: 71] as "communities of organisations that pxnicipate in the same meaning system, are defined by similar symbolic pmeessex, and are subject to common regulatory pmcessef" is appiica6la particuluiy to the movcmcnt in its current cunfiguration. tndeed, the movemenf s shift from mobilizing structure lo organizational field ts among the najur changes I describe here.

448 Journal of Health Politics, Policy and Law able to raise money in these states. We are not going to get any media attention," et cetera... . Then the question came up, how shall we deal with the tobacco companies? Shall we openly debate them? Shall we condemn them? In the early 1960s a position was taken that there should be no open debates with the tobacco companies. The villain is the cigarette. The victim is the cigarette smoker. So we will con- demn the cigarette. We will help the smoker quit, but there will be no attacks on the Philip Morris Company, R. J. Reynolds, et cetera (ACS fdes)29 Not until the late 1980s did it become fashionable and politically safe to openly attack the tobacco companies. Between 1954 and 1970, the percentage of the U.S. public who agreed that cigarette smoking causes lung cancer increased from 41 to 70 percent (U.S. DHHS 1989: 189). An authoritative case for the hazards of smoking . had been made. The most significant consequences of this successful claims-making were not, however, federal legislation but the legitimation of smoking and the cigarette as actionable targets by aggrieved non- smokers and a marked change in where and by whom the tobacco wars were fought. The Group against Smokers' Pollution (GASP) was founded in early 1971. From its inception, GASP's mission was twofold: first to "get nonsmokers to protect themselves" against the immediate, irritating effects of cigarette smoke, and second "to make smoking so unpopular that smokers would quit" (Gouin 1995). In the first paragraph of the first number of its newsletter The Ventilator, published in March 1971, GASP called on innocent nonsmokers, the "involuntary victims of tobacco smoke," to rise up and assert their "right to breathe clean air (thatj is superior to the right of the smoker to enjoy a harmful habit" (t971.' 1). This new construction of smoking and health as an issue not of smok- ers' health but of nonsmokers' rights represented a radical shift in the assignment of risks and responsibilities: it literally turned the old rhetoric on its head. The hazards of smoking were relocated from the individuals' risky behavior to the behavior of his smoking neighbor; exposure was no longer a matter of choice but of involuntary victimization; and, finally, the responsibility for risk reduction was shifted away from the individual at risk to the "polluting" smoker and to the regulatory agencies of gov- ernment The importance of this reconstmetion is hard to overstate. Sud- 29. A saies of oral history Interviews was conducted in 1990 with high-level staff and ofB- cials of the ACS.'Ihe ACS nationul office was genemus in giving me acccss to these intaviews I quqe from lhese intervtews but do not identify the speakers by name. Zti80ZSZLOZ Nathanson • 5ocial Movements as Catalyshs 449 denly, libertarian ideology-Mill's notion that "the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is ro prevent hamt to orhets" (cited in Beau- champ 1988: 90; emphasis added)-was available to be deployed against the act of smoking. Further, and equally important, movement founders framed their appeals in the language of the civil rights and environmen- tal movements, connecting nonsmokers' rights with the most powerful ideologies of the time.30 Both Brandt (1995) and Gusfield (1993) date the emergence of passive smoking as a central theme in the smoking and health debate from the appearance of authoritative scientifie reports (i.e., by the Surgeon Gen- eral and the National Academy of Sciences) in the mid-19805.31 Based on the data collected for this project, I would date its emergence much ear- lier. The construction of the cigarette as harmful to the nonsmoker and of the smoker as pariah came to public attention in the early 1970s. As early as October 1973, the tobacco industry (among the more attentive mem- bers of this public) warned that "the most potentially dangerous threat to the future of the tobacco industry is not so much legislative smoking advertising bans ... but the developing psychological attitude that smok- ing is somehow socially unacceptable" (cited in Gouin 1975: 355)?2 Earlier observers of the tobacco control movement have tended to focus on'Yhe softness of the scientific case against secondhand smoke" prior to the 1980s, assuming that a strong scientific case was essential to the nonsmokers' rights movement (Kluger 1996: 375). It was not, for two reasons. First, the level of scientific certainty required to reject risks we perceive as imposed on us by others is relatively low.73 Second, the dan- gers of the cigarette to smokers had been well established by the early 30. The civil rights movement is widely credited with provtding an ideological template for the subsequent "cycle af protest" in the late 1961, and 1970s (Snow and Benford 1992: 133; McAdam 1994). 31. Brandt comments perceptively on the social and cultural meanings attached to the dib ferent lebels for other peopk's smoking: "'Passive smokine conrrested with active smaking; 'secondhand smoke contained the ominoas implication that someone else had used it first; 'invduntary smoking indicated that the practice of smoking was indeed a voluntary act. And, ofcourse,'environmentaltobaccosmoke orETS...inviledpublCconcemasen'environ- snental harard"' (1995: 8). 32.17rese fezrs were confirrrnd by a 1978 poll commissioned by the Tobacco Insliwle from the Roper Organiutinn. Roper's report corstuded that "the nonsmokers' rights movement was the single gresteat tkeat to the viability of the tobacco industry" (citid in Hanauer, Barr, and Glenrz 1986: 3). Shortly after,vards, induskry, counterprepaganda began to emphasiGe"smukers• rights' 33. Calculations published in ScYenee suggest that the threshold for public acceptance of "9nvotuntary'ruks is roughly 1,000 times less thnn the threshold for"volunury" risks: "We are loathe to kt others do unto us what we happily do Ia ourselves" (Starr 1969: 1235). I

438 Journal of Health Politics, Policy and Law -se..~o.ecc +o,., y,.,. rz nwwt *O.m 9u,. rx sa.Sl Figtae 6 Guns: aehavior Change, 1964-1996. Sourcer. McAneny 1993; Kleck 1984; NORC 1997. A recent increase in suicide rates appears to be associated with the increased use of guns: "From 1968 through 1985, the rate of suicide involv- ing firearms increased 36 percent, whereas the rate of suicide involving other methods remained constant" (Kellerman et at. 1992: 467). In con- tmst to the pattern for homicide, the risk of suicide is greatest for young white males. However, the largest recent increases in suicide rates have been among young black males, coming close to convergence with those of their white peers (CDC 1995). Behavioc Change in gun-related behaviors is described in Figure 6. The three measures of change employed are the cumulated stock of fireamtsl per 10,000 population, the percent of households owning at least one gun, and the percent of adults personally owning a gun. The reported per- centage of households owning at least one gun shows a "slow, but notable, decline... over the last twenty-three years" (National Opinion Research Center [NORC] 1997: 13); however, the percentage of individuals own- ing guns has changed very little.t7 Continuing a long-term trend, the esti- 17. The NORC repon from which these dafa are Isken argues that the decline in household gun nwnership "reflects the chsnging liferyles of Amereans. Traditional rural life in general and hunnng in particular have declined during recent decades" (NORC 1997: 13). Consistent Nathanson • Social Movements as Catalysts 439 mated cumulated stock of firearms in the U.S. increased sharply between 1964 and 1978. More recent data from the 1994 National Survey of Pri- vate Ownership of Firearms (NSFOP) suggest that the gun stock may have plateaued; Philip J. Cook and Jens Ludwig (1997) estimate that approximately 192 million guns are in private hands, for a rate of 7,373 per 10,000 population, close to Gary Kleck's (1984) estimate for 1978. Gun ownership is more prevalent among men than women, more prevalent among whites than blacks, and highest among "middle-aged, college-educated people of rural and small-town America" (Cook and Ludwig 1997).is Attitudes and Beliefs. Data on beliefs about the harm associated with guns are not directly comparable over time, due to differences in ques- tion wording. However, surveys conducted by Gallup, AP/Media Gen- eral, Yankelovich, and NORC between 1986 and 1996 show the extent to which public opinion is split on the basic question of whether or not guns are, in fact, harmful (NORC 1997; Newport and Saad 1993). In 1993, the Gallup poll presented respondents with the following question: "Suppose a law were passed making it illegal for all citizens other than the police to have a gun. Would you feel more safe or less safe, or wouldn't it make a difference?" Twenty-five percent of respondents would feel more safe, 39 percent less safe, and for 34 percent it would make no difference. A second question was worded as follows: "Which of the following comes closer to your view: having a gun in the house makes it a safer place to be because you can protect yourself from violent intruders, or having a gun in the house makes it a rnore dangerous place to be because you increase the risk from gun accidents and domestic violence?" Forty-two percent of respondents stated that having a gun in the house makes the house safer (Newport and Saad 1993). Forty-one percent of respondents to the 1996 NORC survey believed that having a gun made the house safer (NORC 1997: 7). Data on patterns of change between 1959 and 1996 in public support for legal restrictions on guns are presented in Figure 7. Percentages of the U.S. population in favor of mandatory handgun registration and of police with this inrerpretation, the decline in household ownershipis entirely andiwtabte to the smallv pert:entage of households owning long guas: hrwsehold ownership of handguns has increased slightly, Irom 20.3 pescent in 1973 to 24.8 petcent in 1996. I8.llespire someclaims to thecotNary, there is no evidence of increased firearm ownership among womcn (NORC 1997: 14). L£80ZSZLOZ

470 Journal of Health Politics, Policy and Law zie 1996), and OSHA's proposed regulations have stalled, possibly as a consequence of trade union opposition. Target Vulnerabilities. The avowed target of the smoking/tobacco control movement has shifted over time between potential smokers (children, adolescents), smokers (first as victims, later as perpetrators), and the tobacco industry itself. The health voluntaries were extremely reluctant to confront the tobacco industry, as I have noted, and it is only in the very recent past that the industry itself has been isolated as a target, if not the major target. While it is evident from hindsight that the industry has become more vulnerable over time, objective indicators of vulnerability are difficult to come by: that is, vulnerability tends to be judged by results (e.g., legislation passed or failed, court cases won or lost) rather than by predictive measures. However, I will suggest a few changes that may have made a difference. First, congressional representation of southern states that grow tobacco as a major crop has shifted over time from predominantly Dem- ocratic to predominantly Republican. For most of the period in question, the majority party in Congress and thus the chairs of congressional committees have been Democrats, and the Democrats with the greatest seniority (and consequently most likely m occupy those chairs) were from the tobacco-growing South. As the South began to send more Republi- cans than Democrats to Congress, the occupants of committee c6airs shifted from southern to northern Democrats, who are less sympathetic to tobacco interests. The change in party representation from tobacco states may have played a role in President Clinton's relative willingness as compared with (for example) Lyndon Johnson's to speak out on issues of smoking/tobacco control. Cigarette manufacturers have benefited from their ability to present a united front with tobacco growers. However, not only have there been changes in the political representation of tobacco-growing states, but changes have occurred in the circumstances of the growers themselves to make them a less certain ally. Both the number of tobacco farmers and the acreage devoted to tobacco have declined since 1964 and manufac- turers' use of tobacco imported from outside this country has substan- tially increased. The latter issue appears to have played an important role in eroding congressional support for the industry in the course of debate on what became the 1994 cigarette labeling bill: Pertschuk quotes North Carolina Democrat Charles Rose, then chair of the House Tobacco Sub- committee, as remarking to the staff director of the Coalition for Smok- ES80Z9ZLOZ Nathanson a Sorlal Movements as Catalysts 471 ing or Health, "Your concern is health, Whatreally concerns me is imports. They're mining my farmers, destroying them!" (1986: 67; see also ffiuger 1996: 546).tuI Finally, the industry's posture of denying either that cigarettes cause disease or that they are addictive was powerfully undermined by the 1994 discovery of company documents dating back to the early 1950s in which these properties were clearly acknowledged (Glantz et al. 1996; Hilts 1996). While this information was hardly new, hard evidence of the industry's knowledge substantially increased its vulnerability not only in the court of public opinion, but (and possibly of even greater long-mn importance) in the courts of law. Lawyers on behalf of clients who claim injury from smoking can now, as the New York 7Fmes pointed out, "rely on industry documents to portray smoking as part of a lethal conspiracy on the part of cigarette makers" (Collins 1997). The increasing political and legal vulnerability of the tobacco industry is part of a downward spiral, inseparable from concomitant changes in the number, composition, and social position of smokers. Thus, as the number of smokers in the population has declined to under 30 percent, as their composition has shifted toward younger and less affluent groups, and as adult smoking has become more and more stigmatized, it has become that much easier to attack the industry that supports the smoking habits-s The Gun Control Movement Many of the external conditions confronted by the gun control move- ment-a lack of public (or scholarly) consensus about the dangers of guns, a high prevalence of gun ownership among ordinary citizens, and a well organized and implacable foe-have stayed relatively constant over time. Consequently, the gun control movement has been more than 64, In an interview published in Sepmmber 1998, the NewYmkTime.r decribes a Kentucky tobacco groweras reserving his "deepest seom ... for the four big cigarette companies, whom he accused of profiteering and price msnipulation. It is they 'who give the farmer a real Ikk- ing, year in and year om'"(Appte 1998). 65. In the year prior to this writing (Noverdxr 1998), events in the srroking/tobacco control arena moved at breakneck pace. Tlvough mid-lune, the tobacco industry appeared to be mntin- uingicc downward spiral: a stmng antitubaccp bill wasimmdumd in Congressand the press reg- utarly referred to the industry as a'pariah" In the second batf of 1998, however the industry and itscongresnional allks defesmd thetobaeoo bi1L the industry received favorable treatment in the couns, and its lawsuits with the states were scnled on better rcerms than the industry might have anticipated. Ikperding on one s perspective, the events of 1998 may be interpre[ed as evidence of the industry's continuing vulnerability (the glass is hatf full) or itn cuntinuing Mlifical dout (the glass is half empty).

458 Journal of Health Politics, Policy and Law ally disappeared as a public advocate on behalf of smoking and health (Troyer and Markle 1983: 68). The banner was taken up by a prolifera- tion of single-issue groups, resource-poor relative to the ACS but unbur- dened by its conservative baggage. Action on Smoking and Health. ASH was founded in 1967 by John Banzhaf, a professor of law at Georgetown University in Washington, D.C., with the sole purpose of engaging in legal action at the federal level. ASH's initial focus was on cigarette advertising, but it soon branched into additional arenas including public transportation, birth control package inserts, and others. By far the largest part of ASH's activities have been actions before the various regulatory commissions involved with tobacco (FCC, FTC, FDA, etc.). ASH's organization and mode of operation dur- ing the 1970s were well described by Ronald 1. Troyer and Gerald E. Markle (1983: 80-86). In no sense was (or is) ASH a grassroots organi- zation- It was a small (eight staff members in 1979), professionally oper- ated, public interest group with a paid staff and no organization or activi- ties at the local and state levels (indeed, ASH members were not allowed to engage in local action under the ASH banner). ASH's income in 1979 was approximately $366,000, well below that of any of the health volun- taries, of course, but far above the income (at that time) of any local non- smokers' rights group. There is evidence (from interviews and the GASP newsletter) of occa- sional ASH cooperation with its relatively near ncighbor, the Maryland GASP. However, it was clear from interviews with other participants in the smoking/tobacco control movement that ASH is perceived as an independent operation, closely identified with its founder and not on the whole a collegial member of the larger movement. The Nonsmokers'Rights Movement. By 197 1, deaths of white males from lung cancer had reached a critical threshold of visibility: fathers and uncles of the generation that came of age in the late 1960s and early 1970s-an activist generation profoundly influenced by the example of civil rights, antiwar, and environmental movements-were dying of lung cancer.53 The activists I interviewed identified a latent constituency com- of the health voluntaries remzins, despite their currentnwre active imolvemu,t as lobbyists in Washington. 53. Between 1960 and 1975 the lung cancer nrortelity rates of white males born between 1901 and 1910 yuadrupled: the nte.c far white mzles born between 1911 and 1920 increattd by a factor of eight (U.S. DHHS 1991: 92). Lti80Z9Z10Z Nathanson • Social Movements as Catalysts 459 posed of two groups: individuals who had lost loved ones to smoking and a much larger group who were profoundly irritated by tobacco smoke. The latter could be induced to come out of the closet, so to speak, by per- suading them first that their irritation was legitimate and, second, that it was shared. Clara Gouin, the founder of GASP, had been active in a local environ- mental movement. She attributed her father's death from lung cancer at the age of fifty-seven to cigarette smoking and friends complained to her about cigarette smoke in their hair and clothes.u In her own words, "You suddenly get an inspiration. That's what it was. I convened a meeting of my friends. There were several friends in the neighborhood, and several friends at church, and some mothers of young children my girls' age, and we had a meeting in our living room and said let's start this group and see what we can do" (Gouin 1995). Gouin contacted local branches of the health voluntaries and the interest of the local lung association's program director made possible the combination of her "inspiration" with certain critical resources: space, a mimeograph machine, and-of inestimable importance-a mailing list. The first issue of The Ventilator, published in March 1971, went out to local lung associations (then the TB and Respiratory Disease Association) throughout the country. Buttons (reading "GASP-nonsmokers have rights, too") and posters were offered, plus a subscription to the newsletter for $1 per year. The response was far beyond the group's anticipation. Chapters were quickly formed in Berkeley and San Francisco. By 1974, the newsletter listed fifty-six local chapters in the U,S. and two in Canada. At least twenty-two (and proba- bly more) of these chapters were unofficially associated with their local lung associations; in 1973, Clara Gouin and Willard Morris (the program director mentioned above) received the Public Relations Award of the American lung association on behalf of GASP and the Lung Association of Southern Maryland.55 From the beginning, GASP chapters were locally organized auton- omous groups, staffed almost entirely by volunteers. "Once we got a 54.Ofthe seven early (i.e., hu:ame aative in the 1970s or, in one case, the early 19gOs) norrm srnokers' rights activists we inter+iewed, three had close relstives who died from cau.us the activists attributed to s®aking, and two had previously been acdve In related soetat movernet or public imerest organi>sGons. 55, GASP's success was so grcat that in 1973 certain Icaden of the Lung Association of Southern Maryland became concerrred that the tail was wagging the dog and a report was gen- erased recnmmending "disassacfation" of GASP from the Incal esmciatfon.'Rte iavue was resolved and dissociation did nut occur (although relationships became more formalimd), but the episode is evidence of the rcmarkebk public response to GASP's message.

444 Journal of Health Politics, Policy and Law those risks. Location of political responsibility for the smoking and health issue was and is controversial within the federal government as well as without.25 Second, the "hegemony of medical science" was fragile at best. The most prominent representative of medical science in the United States, the American Medical Association (AMA), actively disowned the smok- ing and health issue: in 1965, the AMA House of Delegates refused to endorse the 1964 Surgeon General's report (Wolinsky and Brune 1994: l52). The AMA's emergence as an active player on the side of the an[i- smoking forces is of very recent vintage (Friedman 1975; Wolinsky and Brune 1994). Less surprisingly, ownership of the cigarette smoking issue by government and medical science was hotly contested by the tobacco industry and its political allies. A stated objective of the Tobacco Insti- tute, founded by the industry in 1958, was "to secure recognition for the Tobacco Institute, Inc., as the central source of authoritative information concerning all aspects of the industry with which the Institute is con- cerrted" (cited in Friedman 1975: 26). The Surgeon General's report was as much a political as a scientific document-a salvo, powerful and effective as it was-in the ongoing tobacco wars. Guns The challenge to tobacco industry authority over the portrayal of ciga- rettes was based on a high level of scientific consensus on the dangers of smoking. Each Surgeon General's report includes a long and impressive list of the names and affiliations of the physicians and scientists whose work has contributed to the report's findings. The gun control movement enjoys no such scholarly or scientific consensus. Not only is there dis- agreement on the existence and nature of a causal relationship between guns and injury or death, there is also disagreement on who is qualified to speak about these dangers. Health professionals are relative newcom- ers to this debate. They were preceded by and have continued to share the "gun scholarship" stage with criminologists, political scientists, soci- otogists, historian.c, and lawyers. These scholars disagree on fundamen- tal issues of conception and fact, as evidenced, for example, by a recent exchange between scholars at the University of Chicago and Johns Hop- 25. The recent consuucdon of dgareues as an addktive dwg has contributed to the redenl governmem's assertion, avough the FDA, of both ownership of and political responsibility for the smokinrJtobaeco connol issue. Whether the FDA's amhority will be sustained in coun rcmai. mrcenain. Nathanson • Social MovementsasCatalysts 445 kins University concerning whether or not recently enacted state laws granting the right to carry a concealed weapon reduce violent crime (Lott and Mustard 1997; Webster et al, 1997). Further, they have notably little respect for each others' ideas (see, e.g., the exchange between Gary Wills and his critics in the 16 November 1995 issue of New York Review of Books and published comments by Franklin E. Zimring and Gordon Hawkins [1987: 99] and William R. Tonso [1984]). Law enforcement agencies have recently become an additional com- petitor for ownership of the gun control issue, pushing some movement activists toward the promotion of gun control for the purpose of crime prevention rather than as a response to danger inherent in the gun itself.26 The identification of gun control with law enforcement has been politically effective. Nevertheless, competition for ownership of the gun issue continues internally as well as with the NRA. Advocates disagree on the construction of gun control as crime prevention (Sugarmann 1992) and on the promotion of "safe" guns (Glick 1998). The NRA cam- paigns to have the CDC's firearms research program (premised on the public health construction of guns) defunded (Lewis 1995) and attacks police organizations and the Bureau of Tobacco, Alcohol, and Firearms (LaPierre 1994). The question arises as to whether these disagreements may be explained by inherent differences between guns and cigarettes. Clearly, widespread public perception of inherent differences is part of the gun control move- ment's problem, particularly when it comes to framing guns as a danger to health. I would argue, however, that the differences are not in fact inherent, any more than, say, the differences between marijuana and nicotine are inherent. Guns and cigarettes do not have essences; they have histories and cultural baggage with which social movement entre- preneurs must contend. The Framing of Risk Public health policies are adopted in response to perceived danger. The framing of danger (or risk, in modern parlance) is culturally patterned. Societies vary in the things or events considered dangerous, in ideas about the sources of danger, and in conceptions of who or what is endan- 26.1Le history and politics of police realignment are comptex.nd beyond the scope of this article (see Davidson 1993 and Anderson 1996 for deuiled aawnts). However, f will refer to this realignment again in the section of the articlodiscussingpolitical opportunities. Oti80ZSZ10Z

420 7ournal of Health Politicsr Policy and Law 038839 References Bailey, Sydney D. 1971. British Parliamentary Democracy. 3d ed. Boston: Houghton Miftiin. Baumgartner, Frank R„ and Bryan D. Jones. 1993. Agendas and Instability fnAmer- ican Palitics Chicago: University of Chicago Press. Baumgartner, Frank R, and Beth L. Leech. 1998. Basic lnterests: The Importance of Groups in Polirfcs and Polirica! Science. Princeton, NJ: Princeton University Press. Bentley, AnhurF 1908. The Process ofGovernmenr. Chicago: University of Chicago Press. de Tocqueville, Alexis. 1969, Democracy in America. Trans. George Lawrence, ed. J. P. Mayer. Garden City, NY: Anchor Books. Greider, William. 1992. Who Will Tell the People? The Betrayal ofAmerican Democ- racy. New York: Simon and Schuster. Hamilton, Alexander, John Jay, and James Madison. 1941. The Federalist: A Com- mentary on the Cavstirrrtion of the United Stares. New York: Modem Library. Immergut, Ellen M. 1992. Health Politics: Interesrs and fnsritutians in Western Europe. New York: Cambridge University Press. Johnson, Haynes, and David S. Brodec 1996. The System: The American Way of Pol-" frics at the Breaking Point. Boston: Little, Brown. Latham, Earl. 1952. The Group Basis of Politics. Ithaca, NY: Cornell University Press. Olson, Mancur Jr. 1965. The Logic of Collective Action. Cambridge: Harvard Uni- versity Press. Schanschneider, E. E. 1960. The Senrisovereign People: A Realist's Yew of Democ- racy in America. New York: Holt, Rinehart, and Winston. Skocpol, Theda. Boomerangr Health Care Reform and the lhrn against Government. New York: Norton. Stigler, George. 1971. The Theory of Sconomic Regulation. Bell Joumal of Econom- icr and Management Science 2(1):3-21. von Clausewitz, Karl.1956. On War. Translation J. J. Graham. New York: Bames and Noble. Walker, Jack L. Jr. 1991. Mobilitjng lnterest Groups inAmerica Palrons. Professiont, and Social Movements. Ann Arbor: University of Michigan Press. Wilson, James Q. 1995. Political Organimtions. Princeton, NJ: Princeton University Press. 8Z80ZSZL0Z Social Movements as Catalysts for Policy Change: The Case of Smoking and Guns Constance A. Nathanson Johns Hopkins University Abstract Social movements organized around perceived threats to health play an important role in American life as advocates for change in health policies and health behaviors. This article employs a framework drawn from social movement and related sociological theories to compare two such movements: the smokinghobacco control movement and the gun control movement. A major purpose of the article is to identify specific social movement ideologies and actions that are more or less likely m facilitate achievement of the movement's health policy objectives. The ani- cle concludes that the success of health-related social movements is associated with (1) the articulation of a socially (as well as scientifically) credible threat to the pub- lic's health, (2) the ability to mobilize a diverse organizational constituency, and (3) the convergence of political opportunities with target vulnerabllities. The United States is unique both historically and today in the major role played by health-related social movements in changing health policies and health behaviors (Nathanson 1996; Mechanic 1993). With a few notable exceptions (e.g., Gusfield 1963; Staggenborg 1991), these move- Preperation of this article was supported by the Association af Schools of Publle Health and the Centers for Dixease Control and Prevention; by a Health Policy Research Award to Dr. Nwhanson from the Robert Wood Johnson Foundation; by a Visiting Scholar Award from the Russell Sage I'-aundadon; and by the Hopkins Population Center (NICHD ¢ant no. 5 P30 H006266).'Dtis svpport is gratefully aeknowkAgcd Alan &andt, Mayer 7ald, plark Peterson, and an ananymous reviewer read the manuscript in various stages and made estremety helpful comments; their important contributions are gratefully acknowledged as well. Finally, I would like to express particular thanks to Laury Oaks, currently assisunt pmfessor in the Womens Studies Program at the University of Califumia-Sama Barbas., who carried out much of the research on the gun contral movensent reported in this anicle. Her assistance was, in every respect,invalusbk. Journaf cit'Health Polhic; Policyandlaw,Yal.24, No.3, June 1999. Copyright 0 1999 by Duke University Press.

440 lournal of Health Politics, Policy and Law Percent '.mr.ro.wwnan -Rlr.w ~~ *plrvue pe....aan Figure 7 Public Support for Legal Restrictions on Guns, 1959-1996. Source: NORC 1997. Note: Survey items: (1) Do you favor or oppose mandatory registration of handguns or pistols? (2) Do you favor or oppose police permhs for gun purchase? (3) Do you think there should/should not be a law to forbid handgun possession except by police or other authorized personst permits for gun purchase increased sharply during the 1980s. Consistent with these data, Gallup polls carried out between 1988 and 1993 demon- strated strong support for the Brady bill (ranging from 88 to 95 percent) (McAneny 1993: 3). At the same time, as Figure 7 demonstrates, support for a ban on the possession of handguns "except by police or other autho- rized persons" declined duting the 1960s and 1970s and has changed very little since 1980. Advocates of more restrictive gun laws confront the public's belief (hat guns-unlike cigarettes-not only have harmless uses but may, indeed, be protective. There is little evidence in these data that the gun control movement has as yet been successful in making gun ownership unpopular; personal ownership of a gun has increased in recent years. Support for restrictive gun control policies has increased as well, but in a selective and somewhat inconsistent fashion.N 19. My evaluation ofpubIIc support for gmr conlrol is less positive than thatof several recent books on thia topic (Spitzer 1995; Davidson 1993). Spitxer opens his discussian of pubfx opin- ion on gun control with the statement, "'1Le initial and most important fact about public opinion on gun control has bcen its remarkable wnsutency in suppon of greater goremmen W control of guni' and cummments exansivdy on the "opinion-poticy gapPC.e., the disjunction between popr ular support and the failure m eaaa stronger antigun laws) (1995: 1188.). Although sopport for Nathanson a Social Movements as Catalysts 441 Public Policies. Legislative action to strengthen gun regulation has occurred primarily at the fe&ral rather than at the state or local levels. With the important (and very recent) exception of California (Gorovitz 1996), there has not been an upsurge of local regulation comparable to what has taken place in the tobacco arena.20 Indeed, many states "are passing laws that make access to guns easier" (Karlson and Hargarten 1997: 121; Gorovitz 1996). Summary The antismoking campaign in the United States has made remarkable progress toward achieving its goals. Dectines in lung cancer death rates, a marked shift toward stigmatizing the cigarette and the cigarette smoker, the passage of significant legislation to limit smoking in public, and a substantial reduction in the overall prevalence of smoking qualify as "new advantages" for the movement's beneficiaries. The gun control movement is arguably at an earlier point on the same trajectory. While the movement has achieved some important changes in public policy, guns remain reiatively unstigrnatized, and trends in gun ownership are inconsistent, depending on how ownership is measured. lt is too early for firm conclusions about the sustainabiliry of recent declines in gun-related mortality rates.2t the Brady bill, essaull weapcvu bans and pennit and registration laws is extremedy high, exam- inadon of a wider range of public opinion. in partlcular opinion abeut the dangers of guns, points to a far more ambivalent set of publb beliefs about gun risks than about risks front tobacco. 20.'The vast najority of gun laws exist at state and tocal levels; as Spitur points out, but these laws are often mom remaekable for what they allow than for what they prevent. Fur- thermore, "sutes and cities with tougher gun laws find Ihem at leaat partly neutndizcd by the ease with which guns can be transported itom areas with weak gun laws" (Spitzer 1995: 6). Restsurant and workplace cigarette snraking regulations are less easily evaded by crossing smte anev. 21.1 have adopted Amenu and colleagues' argument (1994) that collective benefits are the bestmeasure of movcroent success. Employing the acceptxnee criteria would give mixed results forboth movcmevta. While thc kgitunacy of snwkingaobaz.r.o and gun control policy positions is recognized, few of the original nwveme.m organizets appear as current spokespersons for these posiuons. Tnis is pnrtkularly true of srtakingAobacco control: attorneys general are twt social tnovemem represmtatives. 8£80Z5ZLOZ

454 Journal of Health Politics, Policy and Law atively easy task of smoking/tobacco as compared with gun control advo- ca=es can be gained by comparing the faintly oxymoronic sound of "safe cigarette" and "responsible smoker" to the widespread use-even by many advocates-of parallel characterizations in the world of gun con- trol. Risks are most persuasive when they can be portrayed in black and white. Guns come in shades of gray. Lay and public health advocates of gun control have tended to charac- terize the risks of guns as universal-everyone is at risk-or to focus on risks to children. In a forum at the Johns Hopkins School of Hygiene and Public Health, Martin Wasserman, Secretary of the Maryland Depart- ment of Health and Mental Hygiene, invoked universality: "This is a statewide problem, not just [a problem in) Baltimore City and Prince George's County [subdivisions with high crime rates]. It is urban and rural" Calling attention to the health care costs of gun injuries is another universalizing construction, intended to address the public as taxpayers. Children, however, are central figures in current discourse on guns, just as they are at the center of discourse on smoking/tobacco control. Statistically, the most likely victims of gun violence are young black men living in the inner city and suicides (Fingerhut, Ingram, and Feldman 1992; Spitzer 1995: 71). Children are, however, a substantially more appealing risk group, so much so that in the article cited Lois A. Finger- hut and colleagues characterize black male homicide victims aged fif- teen to nineteen as "children" (3058)a3 As a rallying cry, "protect our children" is politically safe. Whether or not it is effective remains to be seen.44 In smoking/tobacco control rhetoric, the "innocent victimization" of nonsmokers and their "righf"to clean air are two sides of the same coin: innocence and rights are conBated. Rights discourse has been effectively employed to empower the movement's adherents and to agitate for gov- ernment regulation. By contrast, rights discourse in the gun control arena has been almost entirely controlled by the NRA and its adherents, as in their selective recitation of the Second Amendment to the U.S. Constitu- tion, "the right of the people to keep and bear arms shall not be infringed:' In public debate, Spitzer observes, this right is "constantly invoked" by gun mn Medicnl As.rociarion and the New Eng(and,lommaf oJMedtcine (e.g., Kellertnan and Reay 1986; Kelkrman et al. 1992; Kel lennan et al. 1993; Saltzman a al. 1992). 43, This characreriution has an exact parallel in advocacy Ihemture an teenage pregnmcy: ntahcrs aged fifteen to nineteen are invariably described as "children having children:' 44. Research results tu datc are congicting (Rigotti a a]. 1997; Forstcr et al. 1998), and the pol'xy focus on children ia controvaaial arnmtg tobacco cantrol advocates (Glsrtz 1996). Nathanson • Social Movements as Catalysts 455 control opponents: 'To pick a single example from publications of the National Rifle Association (NRA), its October 1993 issue of American Hunter contained thirty-four references to the Second Amendment or the ownership of guns as a constitutionally protected right. Its November 1993 issue of theAmerican Rifieman contained fourteen such references" (1995: 25). Mary Ann Glendon has called attention to what she characterizes as "bm increasing tendency to speak of what is most important to us in tenns of rights, and to frame nearly every social controversy as a clash of rights" (1991: 3-4). The NRA's successful appropriation of this frame, which res- onates not only with the American individualist tradition but also with the powerful late-twentieth-cenmry ideologies associated with civil rights and women's rights, has severely limited the gun control movement's rhetorical maneuvering room.^5 Predictably, the tobacco industry experimented with the rights framework as well (taking out full page ads in major newspapers to advocate "smokers' dghts") with little evident impact on public opinion. Mobilization and Organization Critical to the emergence of social movements are, first, mobilizing struc- tures, preexisting formal and informal social networks through which individuals with common grievances are brought together (the role of black churches in initiation of the civil rights movement is a classic exam- ple) and, second, the command of resources, including tangible assets such as financing, space, and mailing lists as well as intangible assets- organizational experience, scientific expertise, and social and political con- tacts (McCarthy and Zald 1977; Jenkins 1983; McAdam 1982; McAdam, McCarthy, and Zald 1996). From this perspective, a critical difference betwcen the movements against smoking and guns is that the former was sparked by an innovative and highly energetic grassroots movement, while the latter not only lacked a strong grassroots base itself, but con- fronted (and continues to confront) a powerful, well-financed, and well- organized grassroots movement already in the field.46 45. Glendon evaluam rights discouru in negative termc, as being absolutist and inimical to reasoned dialogue. I would argue that rights discuurse ha been the principal strstegy through vAtich historically matginaliud graups have obtained government protection against those who would deprive them of their rights. At issue is not the discousse but the uses to which u ia put. 46. The atmemem that the gun cuntml movement tacked a srmng gnss-soota base is based on interviews with gun control advacate.e during 1995 and was accurate at that time. There has been a vay recent upsurge of local activism in Califumia leading to local legislation. This aetiv'rsm follows the path pioneered by stnoking/tobacco contml activists fn California and. tndeed is led by many of the :arre individuats, whohave moved overfram the smokinpJtaL+ecco control movamcnt to the gun control muvement. 9b80Z9ZL0Z I

466 Journal of Health Politics, Policy and Law most movements certainly you have differences of opinion, differences in approach, but there's a recognition that for the greater good, you should work together on specific issues you can agree upon. That had never really happened in the gun control movement. And that's been one of our big failings. (Gun control activist, 1995) While smoking/tobacco control groups have had their share of conflict as well, these remarks suggest that conflict within the gun control move- ment has been more profound and has contributed to movement frag- mentation. It must be emphasized that both the smoking/tobacco and gun control movements are moving targets, shifting their character as different actors move onto and off the stage. The recent wholesale entry of lawyers into the smoking/tobacco control arena and of health professionals and lawyers with public health training into the gun control arena will inevitably change how these movements are organized and the constituencies to whom they appeal. Political chJportunities The Smoking/Tobacco Control Movement A full analysis of the role of shifting political opportunities-in particu- lar, analysis of critical actions of relevant elites with the power to push or block the smoking/tobacco control agenda-would require a level of data gathering and insider access that was beyond the scope of this pro- ject. Thus, my account depends primarily on interpretation and inference from published sources and may be incomplete. The Permeable American State. The purpose of social movements is to "force their targets and public decision makers to recognize their con- cerns and to commit institutional resources to implement movement goals" (Oberschall 1993: 32). Recognition by public decision makers is substantially easier in a nation-state with many different points of access: "The chaos [in the American system] allows citizens to utilize multiple cracks to gain their ends" (Morton Grodzins, cited in Friedman 1975: 170; emphasis in the original). A. Lee Fritschler argues that the "normal relationship" among institu- tions of government (including outside interest groups) was typified by pre-1964 tobacco politics. Policies were made "in a spirit of friendly and quiet cooperation" among members of what Fritschler calls the "tobacco 6S80ZSZ10Z Nathanson • Social Movements as Catalysts 467 subsystem": "Me tobacco subsystem included the paid representatives of tobacco growers, marketing organizations, and cigarette manufactur- ers; congressmen representing tobacco constituencies; the leading mem- bers of four subcommittees in Congress-two appropriations subcom- mittees and two substantive legislative committees in each house-that handle tobacco legislation and related appropriations; and certain offi- cials within the Department of Agriculture who were involved with the various tobacco programs of that department" (1989: 4). The 1964 Sur- geon General's report was the opportunity that threw a monkey wrench into this system by creating openings for dissident individual members of Congress, federal agencies unconnected with the tobacco subsystem (the FTC, DHEW, FCC), the health voluntaries, and not least, the states, by virtue of their traditional responsibility for public health. There was no grassroots antismoking movement in 1964. Of course, opportunities must be grasped, and these entides varied substantially in the aggressiveness with which they took advantage of the openings that the Surgeon General's report offered. The FTC and certain states (e.g., New York) were prepared to take action quickly, until they were slapped down by Congress in the form of the 1965 cig- arette labeling act. The DHEW was relatively timid, perhaps due to an absence of presidential support for aggressive antismoking measures, and the health voluntaries, although they had played a major rale in ini- dating government action that led to the report, were less than enthusi- astic in their endorsement of government action in response to the report's findings.62 Jill Quadagno has hypothesized that "the permeability of state agen- cies to social movement demands depends on their autonomy from the targets of social movement goals" (1992: 631). Kenneth Michael Fried- man and Fritschler, political scientists who have studied the smoking and health controversy, both emphasize the critical role played by indepen- dent regulatory agencies in initiating policy and in sustaining public attention to smoking as a public health problem: "The FCC and the FTC have been able to act because their relative independence in the present situation has protected them from economic and political pressures.... 62. The consensus of observers, both scholariy and nonacedenuc, is that the 1965 cigarette labeling act was a vkxory for the tobaceo industry and that health groups were weakened by 'their failure to agree on a plan of acFlon" (Frirschler I989:107; 1 infer that this is a reference to Ihe noopanicipation of the AMA) and by other orguniutional limitations (Friedman 1975; Frinchkr 1989; Fenschuk 1986). While I agree with the second point, I think the fint point underestimates the rde of evcn weak congressional action in legitimating subsequent anti- amuMng pmtesl.

476 Journal of Health Politics, Policy and Law comparison for the relationship of social movements to social change, and, finally, the implications for public policy. Movement Outcomes I have elected to judge the success of the smoking/tobacco and gun con- trol movements based on the goals articulated by movement activists and have concluded on this basis that the antismoking campaign has been rel- atively more successful than the campaign against guns. It is important to note, however, that the very use of this criterion favors the smoking/ tobacco control movement. First, the greater consensus among smoking/ tobacco control activists made their goals easier to identify. Second, the public attitude change that they accomplished so successfully was an explicit goat of the nonsmokers' rights movement from its initiadon. The focus of gun control activists was more exclusively on change in public policies, and both movements have encountered resistance in that arena. The question of a causal relationship between the nonsmokers' rights movement and decline in cigarette consumption in the United States dur- ing the 1970s was addressed directly by Kenneth Warner in an article published in Science in 1981. Warner used multiple regression techniques to take account of changes in media attention to smoking's health effects and in taxation and concluded that "both declining consumption and growth in legislation (restricting smoking in public places) probably reflect a prevailing nonsmoking ethos" induced by the movement for nonsmokers' rights (1981: 730). This article is particularly interesting and important for the time period to which it refers, when the nonsmok- ers' rlghts movement was virtually the only game in town. Accounting for Success The initial circumstances confronting the smokingltobacco and gun con- trol movements were quite similar. Differences emerged over time and consisted both in advantages enjoyed by the smoking/tobacco control movement and in disadvantages it avoided. The smokingltobacco control movement benefited enormously from the "good cop/bad cop" combination of the conservative, highly respect- able and respected health voluntaries with the initially radical (or per- ceived as radical) nonsmokers' rights movement. When the American Cancer Society dropped the ball in the late 1960s, it was taken up by movement activists, aided and abetted by the silent partnership of another 9990Z9ZL0Z Nathanson . Social Movements as Catalysts 477 health voluntary, the American Lung Association. The movement's grass- roots base enabled it to engage in local actions beyond the capacities (or inclinations) of the health voluntaries, actions that the tobacco industry found it difficult to contain. Gun control has been weak at the grassroots level, and until the adherence of police organizations in the mid-1980s, the movement had no allies comparable in size and respectability to the health voluntaries. The recent reframing of guns as a public health prob- lem has attracted a new set of allies, however, and these groups have had considerable success in California (Gorovitz 1996). Their impact nation- ally remains to be seen. Of greatest importance both to the smokingftobacco control move- ment's initial mobilization and to its enduring impact has been the con- stmetion of credible risks. The authority of medicine and science in the smoking/tobacco control arena was well established before the orga- nized movement emerged; the movement drew on this authority and on a culturally powerful discourse of innocence and rights both to transform public perceptions of cigarettes and smoking and to create a new collec- tive identity, that of the nonsmoker. A second critical difference between the smokingltobacco and gun control movements is a negative one: the absence of a credible or effec- tive countermovement to nonsmokers' rights (or to the larger movement that it spawned). Opposition to gun control, by contrast, has been orches- tmted by a grassroots organization with substantial elite support, the abil- ity to mobilize its constituency at every level of government, and com- mand of an ideologically resonant cultural frame. Social Movements and Social Change Doug McAdam has written that "given the entrenched political and eco- nomic opposition movements are likely to encounter, it is often true that their biggest impact is more cultural than narrowly political or eco- nomic" (1994: 49). This article has described a striking case of move- ment-created cultural change. What can be learned from the comparison between smoking and guns about the conditions under which cultural change is more or less likely to occur7 With few exceptions, discussion of outcomes in the social movement literature (and in the partially par- allel political science literature on interest groups) assume that move- ments' targets are political elites and that the outcomes of interest are policy and political change. Findings presented here are consistent with this work: movements benefit from elite allies (particularly allies who

450 Journal of Health Politics, Policy and Law 1970s. Little more in the way of scientific evidence was required for movement entrepreneurs to persuasively argue that involuntary exposure to this deadly product was dangerous to nonsmokers as wel]?4 Powerful as this argument has been, it has been more persuasive to some segments of the public than to others. The early nonsmokers' rights activists were well-educated members of relatively affluent (often university) communities. While they were notably successful in per- suading groups like themselves that smoking in others' presence was socially unacceptable,}5 they have been less successful among blue col- lar workers. Data were presented earlier showing sharp differences in the decline in smoking prevalence by level of education. The meaning and persistence of these differences is suggested in recent statements by a representative of the AFL-CIO, commenting on the fact that many union members smoke: "Well, there has been a change in the culture, but there are still a lot of people who smoke who think that they should be able to smoke in workplaces. They think they should be able to smoke in bars and restaurants. And so I would say that there has been a change in the culture, but I think that it is not evenly distributed and that there are a lot of places in this country where the culture is not the same as it is in Washington, DC, of in southern California" (U.S. OSHA 1995: 12281).J6 Prevention of harm to others is, of course, a legitimate responsibility of government. Characterizing its members as the "involuntary victims of tobacco smoke" allowed GASP to call on government for redress: "Sur- geon General suggests ban on public smoking" was headlined in the first number of its first newsletter. Over the past twenty-five years, "innocent victims" rhetoric has proved to be a powerful force in obtaining local, state, and sonre federal smoking regulation. Alternative constructions of smoking-as an issue of personal habits, individual rights, even of cul- tural differences-continue, however, to be readily available and are deployed in opposition to regulation when occasion requires. 34. Scientific controversy over the health effe<ts of passive smuking is ong%ng. In a recent article, fJeborah Bames and Lise Beroreport, based an analysis of 106 review aaticles, that "the only factor associated with concluding that passive smoking is not harmful was whether an author was affiliated with the tobacco industry' (Bemes and Bero 1998: 15fi6). 35. A favorite tmtio of the arly antismaking campaigners was to call aucntion to ihe hypocrisy of smoking by enviromnenulisis, health crusaders (e.g., board members of groups such aa the ACS and the ALA), and physicians. 36. 7Le nnderlying reasons for AFL,CtO opposition [o federal regulation of smoking in the workplece are, of course, broader than this brief reference would suggest I will refer to this opposition again when I discuss the political opponunilies that havc favored and impeded the movement for amokingltobacoo conuol. £V80Z9ZLOZ Nathanson a Social Movements as Catalysts 451 The most recent phase in the cigarette's downward spiral is the dis- covery that smoking is addictive. The 1964 Surgeon General's report analogized smoking to drinking coffee, tea, and cocoa (U.S. DHEW 1964: 350). Today it is more likely to be linked with heroin and cocaine (U.S. DHHS 1988)?7 This linkage does not reflect new scientific knowledge- the addictive properties of nicotine "have been common knowledge in medical and public health circles for years' (Slade et al. 1995: 225)-so much as it reflects the increased vulnerability of the tobacco industry and the shifting political and legal strategies of its opponents.33 The addiction label allows opponents to make the identical argument employed on behalf of nonsmokers' rights: exposure is not a choice. "The Health Consequences of Smoking: Nicotine Addiction provided a comprehensive review of the evidence that cigarettes and other forms of tobacco are addicting and that nicotine is the drug in tobacco that causes addiction. These two factors refute the argument that smoking is a mat- ter of free choice. Most smokers start smoking as teenagers and then become addicted" (Koop 1989: v). This construction has a number of consequences, some of which may be less predictable than others. It is the basis for FDA efforts to regulate cigarettes as drug delivery devices; it gives plaintiffs' lawyers a counterargument against the industry's long- standing claim that smokers assume the risk of their behavior; it enables opponents to characterize tobacco industry executives as drug dealers and to play on deep-seated American fears of adolescent vulnerability to seduction by unscrupulous predators.w Insofar as the addiction label results in increased government regu- lation of access to and advertising of cigarettes, it may act to further decrease the prevalence of smoking. On the other hand, there is little 371t is unclearto what extent Ihis linkage is accepted by thegeneral publk.Jt is pervasive In public health circles, as evidenced, for example, by a marked increase over time in the num- ber of anicks in the Americon Joumul af Public Health assocuting tobacco with alcohol and drugs and by the naming of an American Public Health Association (APHA) conference section "Alcohd, tobacco, and other drugs:' It is popnlar in legal argurnents againat the tobacco indua- try (e.g., Brief fur the State of Maryland at 52, Stnre ofMaryland u Philip Morrit er al ) and in aniismoking messages focused on the industryk alleged targetingaf children. 38. Tfre faet that medical and public health tircles knew that nicotine was sn addictive drug has clearly been far tess powerfW than the fact thatthc tobacco industries knew it as well. The conpzuiei knowkdge is critical m lidgation against them, but the discovery of their knowledge had an impact beyond mcre lawycrly concems, perhaps akin to the discovery of Oedipus paremage in Sophocles' play. 39. "Pmtett our children from nx tobacco compeniea" waa a tnessage sponsored by a pub- Ik service announcement from the Ancrkan Cancer Society broadcast on CNN in March 1996. This message is stanling in evoking widespread fears in the early twentieth cenmry of children being kidnapped into "wlute slavery" (Nethznson 1991: 125).

462 Journal of Health Politics, Policy and Law 25 Family Income (1979) 20 15 10 /Income 5 0 Early Adopters Late Adopters Non-Adopters Timing of Ordkance Adoption Figure 9 Smoking Ordinance Adoption and Wealth: Timing of Smoking Control Ordinance Adoption and Family Income (California Counties). Sources: U.S. DHHS, NIH 1993; U.S. Department of Commerce 1980. Note: Significance of difference between income means (ANOVA): F= 14.91, p <.0000. statewide initiative campaign (i.e., in California) was expensive. Along with these changes came greater bureaucratization, concerns about incor- poration and tax exemption and, ultimately, paid staff. The early activists I interviewed remarked on the movement's evolution with evident nos- talgia for an earlier time: "Maybe part of the secret of [GASP's] success was that it was never thoroughly otganized. Sometimes you have a good idea and in the beginning stages there is great enthusiasm, and then once the idea gets structured into rules, regulations, formal dues, offices, and all of that, it loses a bit of its initial impeNs....[People in the movement now] didn't have to join a group and cany a banner. When you feel you're alone, have to join a group. Don't need little organizations when every- body's doing it" (Gouin 1995). The transformation Gouin describes is a classic process of organizational change, the price a social movement pays for public acceptance and success.s7 A significant characteristic of the smoking/tobacco control movement has been the shifting participation over time of several groups with quite 57. Gouin was not alone in her perceptions either of the fsc[ or of the nature of movetmnt evolution. Her remarks were echoed by several other early activisu we interviewed. 6ti80ZSZLOZ Nathanson . Social Movements as Catalysts 463 different goals, resources, and constituencies. Although these groups have often appeared antagonistic, I would argue that their roles were, jn fact, complementary and contributed in important ways to the movement's relative success. The Gun Control Movement. The gun and smoking/tobacco control move. mentc have certain things in common: both movements have reformist goals of health-related social change through public education and polit- ical advocacy, both draw on largely white, middle-class constituencies, and both have a clearly identifiable, large, well-financed, and politically well-connected opponent. At the time of our research, however, there were major differences with implications both for the mobilization potential and for the organizational resources of the gun control movement. First, not only the smoMngltobacco control movement but other social movements that have achieved substantial success in the latter half of the twentieth century-the civil rights, gay rights, and feminist movements, as well as health-related movements (e.g., breast-cancer survivors, Moth- ers against Drunk Driving)-have been in a position to draw heavily on self-defined victims with the personal and social resources to engage in social movement activity. Among the leaders of the gun control move- ment we interviewed, almost all had direct experience with gun violence. However, large sectors of the gun control movement's potential con- stituency-victims of gun violence or individuals in fear of victimiza- tion-are unlikely candidates for mobilization by a white, middle-class reform movement.58 Half of all victims of homicide are minorities, as 1 have pointed out. A high proportion of these victims are inner-city black youth.59 Fear of victimization is as much or more likely to result in the purchase of a gun than in joining Handgun Control, Inc. Police are per- haps the most obvious potential middle-class victims of gun violence, and 5g.-ILe executive director of the Coalition to Stop Handgun Viotence (CSGV) describes his constituency as fallows: "It's still mostly older, colkge-educated people living in urban areas on the east xat, west coast, and Chicago. Primarilylewish probabty: I mean we just fit the sun- dard profile in the direct mail [merkeGng]: collegeaducated, third generanon, living in a sub- nrb or urban area:' 59. My point is not that these individuals cannot be mobilized at all-Louis Farrakhan has clearly demonstrxted otherwise-it is that they are unlikely to he mobiliwd by the gun con- trul movement as presently constituted. This point is strikingly illustramd by the following comments from a gun control activist: "Cneres an urganiaatioo in the city called'Dont Smoke the Bmtbers-Cease Fne: And they were founded by Farrakhan. Now they do good work. Ye4 they do. But they also promote hate against cer[ahi organizations. I don t want that. And that was a very difficult decision because there are things that they do that are of value. But they were an willing to modify their language so that they weren't offcading anybody other than elack:'

472 Journal of Health Politis, Policy and Law usually dependent for recognition in the public and political arenas, as well as for the successes it has so far achieved, on its ability to take advantage of often transient political opportunities. The most obvious of these opportunities have been the high-profile assassinations and whole- sale killings of young children and other innocent victims that have marked the last three decades. These events have led to brief openings of opportunity, resulting in temporary increases in recruitment to the gun control movement and in gains to the movement's financial resoutces. The impact of these events on the movement's success in achieving its regulatory goals is less clear: the first piece of federal gun legislation passed after the 198/ shootings of Reagan, John Lennon, and the Pape was the McClure-Volkmer Act, which was explicitly intended to weaken the 1968 Gun Control Act. Whether and how the gun control movement has been able to take advantage of the opportunities offered by public outrage, indeed the exis- tence of any opportunities for action in the gun control arena, has been almost wholly dependent on the National Rifle Association. The National Rifle Association. Both the tobacco industry and the NRA are well organized and well funded, with powerful political allies. There is a critical difference, however, in the constituencies each of these enti- ties represent. The tobacco industry is a business (in reality, of course, several businesses a0iedlargely in response to external threat). The NRA is an interest-group organization of firearms users, described by one observer as "the protorypic single-issue interest group in America" (cited in Spitzer 1995: 99). Several thousand local sporting and gun clubs came under its umbrella during the NRA's early years, and for most of its his- tory the group's primary focus was marksmanship and (particularly after World War II) hunting (Spitzer 1995: 100). The NRA has long benefited fmm a range of government subsidies (e.g., donations of surplus guns, permission for target ranges on federal land) and has close ties to the gun industry.'The key to the NRA's [political] effectiveness," however, "9ies in its highly motivated mass membership and the organization's ability to bring pressure from that membership to bear at key moments and places" (Spitzer 1995: 108). Smokers' rights groups in this country were organized in reaction to the antismoking movement, but they have never been more than barely disguised window dressing for the tobacco industry and have never been taken seriously. The gun control movement, by contrast, has had to con- front a powerful organization already on the ground, one that included VS80ZSZLOZ ' Nathanson • Social Movements as Catatlxu 473 among its members not only past presidents of the United States and influential members of Congress, but a large and extremely loyal follow- ing of ordinary citizens. Given the NRA's perceived power, it comes as little surprise that observers of recent gun control politics attribute the gun control move- ment's legislative successes (the Brady bill, the assault weapons ban) less to movement influence than to NRA missteps.66 Spitzer (1995). Osha Gray Davidson (1993), and others have described in some detail the series of events leading to the NRA's alienation of important allies, including not only major political figures (former President George Bush resigned in 1995), but the police. Beginning in the late 1970s, the NRA took an increas- ingly hard and uncompromising line towanl all forms of regulation, both of guns and of ammunition: "One of the most highly publicized conse- quences of this unyielding approach has been the alienation of most national police organizations" (Spitzer 1995: 114). The NRA's split with the police and its rigidity on other issues have resulted in isolation fram its natural allies among conservative groups and from the gun industry as well (Spitzer 1995: 115; Wayne 1997). Among the consequences of the NRA's increased vulnerability was that it lost the ability to keep legislation it disliked off the congressional agenda (Spitzer 1995: 170). And, in further parallel with the tobacco industry, having lost in Congress once, the NRA's vulnerability the next time around increased: "People realized that there's life after voting against the NRA" (Representative Charles E. Schumer [D-NY], cited in Spitzer 1995: 162). The NRA's vulnerability should not be exaggerated, however. Like the antiabortion movement and the smoking/tobacco control movement, the NRA responded to loss on the federal level by turning to state and local venues, and it has been reasonably successful. Since 1986, twenty-two states have adopted what are known as right-to-carry or shall-issue laws, laws that "[require] authorities to issue, without discretion, concealed weapon permits to qualified applicants" (Lott and Mustard 1997: 4). In contrast to cigarettes, guns are easily concealed. These laws are strongly opposed by gun control advocates (see, e.g., Webster et at. 1997, com- menting on the Lott and Mustard study). The NRA has become active on the international stage as well. It obtained observer status at the United 66.It matters tedztively little whether the NRA Is as potitically Powerful rs it is pa<eived tu h<aslong ae puliticians, as we11 as pttential gun control mnrement allies, pnrceive it to be all pWwetful.77at which we perceive as real is ttal in ilsconuqurnces.

428 Journal of Health Politics, Policy and Law Table 4 The Downs and Ups of Gun Control, 1963-1994 '1963 Assassination of Presidentlohn F. Kennedy. 1968 Assassination of Rev. Martin Luther King, Jr. Assassinadan of Senator Robert Kennedy. Congress passes Gun Control Act of 1968. 1972 Congress excludes guns from regulation under the Consumer Product Safety Am. 1975 National Coalition to Ban Handguns (NCBH) founded. Handgun Cornrol ine. (HC]) founded. 1977 HCI splits from NCBH. 1980 lohn Lensron shot, killed. 1981 President Ronald Reagan shot. Pope John Paul shoc Morton Grovq IL, passes a ban on handgun possession. 1983 CDC labels gun violence a threat to public health. 1985 Sarah Bradyjoins HCI board. 1986 Congress passes Firearm Owners Protection Act (McClure-Volkrner Bill). Police split with National Rifle Association (NRA), 1988 Maryland hans Saturday night special. 1989 Stockton, CA, schoelyard killing of five childrrn with an assault weapon. 1991 Killeen, TX, killing of twenty-two people in a cafeteria with an assault weapon. 1993 Congress ptsses Brady bill. 1994 Congress paeses assault weapons ban. gesls that the Oklalpma City bonjlting was a mejor waterihed event etmgizing thegun control movement (SugarntEnn 1997), Recent achoolyarQ killings have led to 1he introtluction in Con- gress of new regulatory legislation addressing childrens access m guns (Legislation Warks 1998;Bunerfield 1998). Nathanson • Social Movements as Catalysts 429 lation, New York State's Sullivan Law (requiring a police permit for pos- session of a handgun), was passed in 1911 in response to an attempted assas- sination of the mayor of New York City. The first recorded instance of NRA lobbying against gun control was in opposition to the Sullivan Law (Sugartnann 1992: 27).1he history of gun control, like that of smokingl tobacco control, is one of ongoing struggle with an implacable foe- ReguZatoryAction, 1968-1994. It took five years of legislative wrangling to pass the Gun Control Act of 1968; the end result was substantially watered down from the more sweeping legislation (including firearms registration and licensing of gun owners) proposed by President Lyndon Johnson.10 Despite its relatively modest advance over previous federal efforts to regulate guns, Robett J. Spiizer notes that "the gun act was one of the most controversial and contentious bills that was considered by Congress" during the twenty-year period between 1954 and 1974 (1995: 146). Gun regulation in the United States is predominantly local, not federal: the NRA estimates that there are 20,000 local, state, and federal firearms laws, nearly all of which exist at the state and local level.ll Thus, in June 1981, shortly after the shootings of President Reagan and the Pope, the vil- lage trustees of Morton Grove, Illinois, banned the private possession of handguns by town residents. The NRA had been active in opposition to the ban; its passage was nationally publicized and was treated as a water- shed event by the NRA and by gun control advocates (Davidson 1993: 133). The Supreme Court refused to hear appeals from two federal court rulings upholding the ban. An equally significant regulatory event at the local level was the Maryland state legislature's passage in 1988 of a ban on the manufacture and sale of "Saturday night specials" (small inexpen- sive handguns). The ban was petitioned to a state referendum by the NRA and upheld by a margin of 58 percent to 42 percent.l2 The 1968 Gun Control Act had little apparent impact on the U.S. stock of guns in private hands (see Figure 6). It was, nevertheless, anathema to 10. As sununarized by Spitmr, the bilt'benned interstate shipment of flreamis... and ammu- nition to private individuals; pmhibilul the sale of guns to nwnors, drug addicts, mcnhl incmn- petents, asd eanvicted felons; strengthened licensing and record-keeping reqvirementa for gun dealers and collectors; catended fMelal regulatian and tazstion to'destnaaive devires' such as land mines, bombs, hand grenades, and the like-, increased penalties for those who used guns in the conunission of a crime covered by federal law; and banned the imponation of foreign-mak surplus fircarms, euept tlwsnappupriatefor syoning Pupaui' (Spiaer 1995:145). 11. The NRA's es5mat<is accepted by Spilser and other authoritfes. 12, Tnereferendum fight was highly imponantin mobilizing an6gun advocates in Maryland, ineluding the police. Z£80ZSZLOZ

474 Joumal of Health Politics, Policy and Law Nations in 1997 and joined with gun groups and firearms manufacturers from other countries to oppose international firearms regulation (Seelye 1997). Following (often consciously) in the footsteps of the smoking/tobacco control movement, some within the gun control movement have begun to target the manufacturers of what the movement defines as a dangerous product (Teret and Wintermute 1993). That this did not happen earlier may be due to the manufacturers' lack of visibility on the public stage. While it supports (financially and otherwise) the NRA's goals, the NRA's aggressive tactics have allowed the firearms industry to adopt a very low profile in gun control debates: "Many firearms manufacturers have cho- sen to remain in the background of the raging debate over tighter restric- tions on the sale and possession of guns, preferring to leave their public talking to the National Rifle Association" (cited in Spitzer 1995: 104).67 However, reluctance to target manufacturers is also due to some move- ment leaders' ambivalence about "safe guns": "On the one hand, [safer guns] could help reduce fatal accidents, unintentional injuries ... On the other hand, if you make the 'safe handgun' are you giving the industry a whole new marketing tool? W here they can go back and re-sell [guns to] every handgun owner in America-hey, this is new, this is safe. ... 1 have very strong concerns about that-I'm not really sure where I come down on it" (gun control activist, interview, 1995). These remarks are, of course, highly reminiscent of smoking/tobacco control advocates' opposition to the promotion of "safe cigarettes" as a public health mea- sure.68 From the advocates' perspective, these are halfway measures, diluting and potentially compromising the purity of their cause. 62 Yhis same point was made by a gun control activist we interviewed, who anributed the difference between the targets of the gun and the smokingAobecco control mnvetronts m the gun industry's lnviaibility, compred with the visibility of tobacm munufacmrers. ANewYork 1'Tme.r attidc suggests that not only gun control advucaks but the gun industry has kzrned from the smokingAaMcca expetierce. A Washington lobbyist for the industry zevaciation ix quoted as saying,'Everyone can vividly remember sedng those tobacco executivea parade up to Capi- tol Hill and deny that tobacco was habit furming.... Everyone knew it was ridicvlous. We arc not going to go before Congress and say that guns are not dangerous and that kids are not killed with theni' (Wayne 1997).7fiis perspective led to a recent votunury agreanent-announced from the White House lawn, that gun manufacturers would install child safety lecks on hand- guns. 68.11re reviewer of a recent book an "the tyranny ofpubfic health" complains that "Ieu dan- gerousalkrnalives"tucigaretes-cigars,pipes,andchewingtobacco-'havebeenrejectedas distractions from the greater overall misxion; advances in smokeless cigarettes atd denkotined cigarettcs have been dismissed" (Skinner 1998: 118-119). 9S80ZSZLOZ P, - - Nathanson • Social Movements as Catalysts 475 Elire Allies. Open support by the police was aocompanied by a significant expansion of the gun control movement's organizational resources. In interviews, the leaders of HCI and Missing Peace made clear their close affiliation with police groups. Asked what other organizations she worked with, an HCI leader responded, "I'd say over the last ten years we worked probably for the most part with law enforcement:' Long-time gun control activists (as well as observers like Spitzer and Davidson) credit police organizations with a principal role in passage of the Brady bill: "We got the Brady bill passed because they made it a police issue.... we're just liberal preachers out there talking about this subject and nobody cares. But [when] a local cop says this is something I'm con- cerned about ... people start caring" (gun control activist, interview, 1995). Recently, several well-established interest group organizations- the Children's Defense Fund (CDF) and the Consumer Federation of America (CFA)-have also begun to take action on behalf of gun control primarily through dissemination of educational materials and, in the case of CDF, through mobilization on a local level through church groups. Our interview with a representative of CFA was striking in the expression of concerns almost exactly parallel with the concerns reflected in interviews with ACS offrcials.69 On the one hand, o n contro] was a good cause ("pre- venting consumer injuries and deaths") and would clearly benefit from association with a "mainstream" (the CFA representative's term), con- servative organization like the CFA. On the other hand, many of the groups under CFA's umbrella were skittish about jeopardizing their "rep- utation" in a fringe cause, about being associated with "people who want to take away people's rights;" and about taking on "the big bad NRA." These groups' actual level of involvement in gun control is unclear-in both cases, it forms a small part of much broader agendas-and their effectiveness remains to be seen.70 Discussion I address four issues in this discussion: the methodological questions of movement outcome and causal attribution, the substantive reasons for the relative success of the antismoking campaign, implications of this 69. 1 refer here to the orel history intuviewa in ACS files. 70. An articfe in the NewYorkTimes suggeats that internationat divamwrrent groups, "once preoccupied with nuclear weapons, are focusing more on the proliferation of smalt anns and handguns as a nmjor threat to individual health and safety" (Seelye 1997). The recently formed 1frtP (Handgun Epidemic Lowering Plan) network includes mainstream medical orgamzations such as the AMA and more activist groups such as Physicians for Social Responsibility. i

424 Journal of Health Politics, Policy and Law Nathanson • Social Movements as Catalysts 425 Table 1 U.S. Tobacco Wars, 1950-1964 Table 2 U.S. Tobacco Wars, 1965-1996 _ _ Phase 1: Making the Health Connection Phase 2: The Struggle for Regulation 1950 Wynder and Graharn. Tobacco Smoking as a Possible Etiologic Factor in 1965 Federal Cigarette Labeling and Advertising Act passed. 1952 Bmnchiogenk Carcinoma: A Study of 684 Proved Cases. Journal of the American Medical Assacfation. Doll and Hill. A Study of the Aetoiology of Carcinoma of the Lung. L Mandetes annual SO reports and legislative recommendations. 2. Requires warning label: "Caution: Cigarette Smoking May Be Hazardous to Your Health" Brituh Medicaf Jourrud. Norr. Cancer by the Carton. Reader's Dige.tt. 1966-1976 3. Preempts more restrictive state action. Congress specifically excludes tobacco from regulation under: 1954 Hammond and Horn. The Relationship between Human Smoking Habits I. Fair Packaging and Labeling Act (1966). 1956 and Death Rates: A Follow-up Study of 187,766 Men. Journal of the American Medical Associatisw. Doll and Hill. Lung Cancer and Other Causes of Death in Relation to 2. Controlled Substances Act (1970). 3. Consumer Product Safety Act (1972), 4, Federal Hazardous Substances Act (1976). Stnoking. British Medical Journal. First official involvement by U.S. Public Health Service: Scientific study group on smoking and health. 1970 5. Toxic Substances Control Act (1976). Public Health Cigarette Smoking Act of 1969 passed. 962 S. G. Bumey publishes statement in SAMA:'The weight of the evidence at present implicates smoking as the principal factor in the increased inci- dence of lung cancer" (2104). Royal College of Physicians of London: "Cigarette smoking is a cause of 1. Renews SG report mandate. 2. Requires warning label: "Waming: The Sutgeon General Has Determined That Cigarette Smoking Is Hazardous to YourHealth" 1964 lung cancer and bronchitis and probably contributes to the development of corottary, heart disease' (S7). Su oeon General's Report on Smoking and Health: "Cigarette smoking is 1984 3. Bans tobacco advertising on radio and TV. 4. Continues preemption. Comprehensive Smoking Education Act passed. Requires four a health hazard of sufficient importance in the U.S. to warrant appropriate remedial action" (33). rvtating warning labels preceded by "SURGEON GENERAL'S WARNING:' 1996 FDA issues regulations of tobacco products. U.S. Tobacco Wars, 1950-1996 The history of smoking control over the past half-century is one of almost continuous struggle-for much of this period a very lopsided struggle-between the tobacco industry and its allies on one side and a disparate array of antismoking forces on the other. I have divided these "Robacco wars" into three partially overlapping phases, outlined in Tables 1-3. These are "Phase I: Making the Health Connection," which runs from 1950 to 1964;'Thase 2: The Struggle for Regulation;' mnning from 1965 to 1996; and "Phase 3: The Discovery of Innocent Vietims;" which tuns from 1971 to 1995,2 The critical events of Phase I are the scientific reports that appeared primarily but not exclusively in the medical press and that established cig- 2. A fully upao-date chroeology would include a fourth phase, "deraonizing the tobacco industry:' begJnning arguably in 1988 when the industry was publicly attacked on national tele- vision by a reprcumatix of the American Cancer Society. arette smoking as a significant hazard to human health? The culminating event in this series was the 1964 Surgeon General's Report on Smoking and Health (U.S. DHEW 1964). Serious congressional attention to smok- ing and health (initiating Phase 2, the struggle for regulation) was trig- gered less by the Surgeon General's report itself than by its political fall- out: actions taken in several state legislatures to pass package labeling laws and an administrative initiative taken by the Federal Trade Commis- sion (FTC) within a week of the report's public unveiling to require pack- age warning labels.4 With much hufHng and puffing about chaos in the 3. An analysis of the timing of smaking declinu among physcians during the periad 1948- 1993 demonslrates very cleady the impact of these publications on the behavior of their pro- fessional audience (Nathaoson et aI. 1996). 4. Whik I have dated the struggle for regulation fmm thc passage of the first na5onal tobacco Iegidatien in 1965, the effort to regulamcigarette advertising began well before 1965, 0£80Z9ZLOZ

456 Joumal of Health Pol'dics, Policy and Law The Smoking/Tobacco Control Movement Until very recently, the core of the smoking/tobacco control move- ment consisted of three sets of players: the health voluntaries (Ameri- can Cancer Society, American Lung Association, American Heart Association), Action on Smoking and Health (ASH), and the nonsmok- ers' rights groups.4t These groups have varied in relative importance over time and have played different and, arguably, complementary roles in advancing the overall tobacco control agenda.*s The American Cancer Society. The ACS was started in 1913 by "a group of public-spirited physicians and laymen" (1950: 7). The society did not, however, begin to move toward its present size until after World War II; it underwent a major reorganization in 1945, bringing "a group of influ- ential (and wealthy) businessmen" onto the ACS Board of Directors (ACS 1950: 7).d9 Among the results of this reorganization were a sub- stantial commitment to cancer research (consistently just under 30 per- 47. The smokinghobacco cuntrol scene shifted markedly in the last two years with the entry in force of state attorneys general to bring suit against the tobacco industry. Thuc suits were settkd in November 1999 by an agrament between individual staes and the tobacco industry. Neitherthefedenl govemment northe snmkine/tobacro control movement participated directly in this agramenL My story ends at the point when this major shift began. I hsve not included govemment as patt ofthe movement core.I have already described the govemment's rvlein cre- atingthc mientificcase for smoking as acredibb threat.In the movement's eady days, agencies of the governrncn wue more often targets thsn major players.lhechange, again, ba.s been very rcccnt. 48.'I1vo gruaupc that might have been expected to play major roles in the smoking/mntrol drams but have nut are the APHA and the AMA. While che relative inactivity of pubik health organizations has been noted by others (e.g., Jacobsun, Was,sermsn, and Itaube 1992), no analy- ces of the APHA'r role in the srrocingRobseco wars have been published, and I have not under- taken such an analysis beyond whal is stated here. Conseguently, it is unclear precisely why tbere was relatively little public health attention to what has now become a majorpublic health issue. While suigeon General lesse Steinfeld played an important role in energizing and kgit- imizing the nonsmokers' rights movement, he appears to have had little impact on organized puhllo health activities. Such activities are, of course, heavily dependent on federal. state, and localgovernment funding, which may help account for this inactivity. A seathing analysis of the AMA's silence on stnoking/tebaao control has been published by Wolinsky and 8rune (1994). 49. ironcally, aprinse nrover in this reorganization was Mary Laskr.r, whose husband-Albert tsskcr, msde at )east some of his foatune in advertising from cigarettes (Kinger 1996: 76). As Kluga describes it, the faskerx brought in other prominent business leaders and, in addition, n,ede use of their access to advertising taleut and of their ennrzcra in the media (cg„ Reader's Digest) to pronrotte the American Cancer Society (renatned-orignally the Anwican Society for the Control of Canar) both as an important humanitarian cause and as "sman business" (Kluger 1996: 143). In its volmneerraruitmenrpolicies immediately following the reorgan'va- tion, the ACS very deliberately targeted •9nnuentiel person%' (ACS 1948), and from this time forward influential business people played major roles in the ACS. By its constitution, the ACS hoard of directors is composed of half laypenons (primarily bnsiMSS) and half phys'xians (all volunteers); the society's leadership is divided between a physician and a layperson. 9b80Z9ZLOZ Nathanson • Social Movements as Catalysts 457 cent of the ACS budget), a major expansion in volunteers (ranging in number between one and three million), and extremely effective fund- raising. The ACS total budget grew from $14 million in 1950 to $347 mil- lion in 1990, a twenty-five-fold increase.50 The ACS's role in the smokingltobacco control movement began to take shape in the late 1940s- In 1948, the ACS Annual Report noted that lung cancer mortality was "increasing' ; in 1951 a National Lung Cancer Committee was created and the society issued its first public warning of the rise in lung cancec In 1952 the ACS began its population-based fol- low-up study of smoking and death rates in "white men between the ages of fifty and sixty-nine" (Hammond and Horn I954).51 [n an interview pub- lished in 1965, E. Cuyler Hammond stated that "only an institution like the American Cancer Society" could have carried out this study (Pfeiffer 1965: 12). Not only did the ACS have the necessary political indepen- dence and sufficient financial resources; it was able to draw on its huge network of volunteers to do the actual fieldwork and on its "goodwill among physicians and hospital authoritie.s"to assist in obtaining follow- up information on men who had died (Pfeiffer 1965: 12). The ACS com- mitted its substantial resources to this project despite considerable skit- tishness on the part of some of the society's officials, who were perfectly aware of the study's potential political sensitivity (Kluger 1996: 146). Many observers have described and commented upon ACS's reluctance to act on the study's striking results (Jacobson, Wasserman, and Raube 1992; Pereschuk 1986: 53; interview with ACS official, ACS files). From the perspective of the larger smoking/tobacco control move- ment, the ACS played its most important role in the 1950s and 1960s, using its substantial resources and authority to help create and then to promote the problem of smoking and health within and outside the gov- emment Conservative leadership and an unwillingness to risk other interests for the sake of the smoking/tobacco control movement pre- vented the society from going much beyond its selSdefined role as health educator until the early 1980s.52 Indeed, during the 1970s the ACS virtu- 5n. By way of comparison, the total budget of the ALA during the same period never roce above $92 million, although in 1960 (the earliest date for which I have ALA data) the budgets of the two associationa wcre close to equal. 51. E Cuyter Hammond, rhe study director and head of the ACS Department of Sutislical Resenmb.joined the ACS in 1946. Hammond was alresdy a well-trained and experienced epi- detNologist when he became the ACS's chief statistician. Evidence suggests that he played a rnajor role in focusing the sockty's attention on the marked rise in lung cences mortality rates (Garfmke11988;Kluger1996). 52. The commrats by Peter Jacobson, Jeffrey Wasaerman, and Kristiana Raube (1996)- wh'n:h refer to the Iate 19gOs and early 199fk, suggest that the relatively conservxtive posture

480 Journal of Health Politics, Policy and Law Individuals with the interest, resources, and network connections to initiate health-related social movements tend to be white and middle class. Unlike many refomt movements, the first targets of the nonsmok- ers' rights movement were people much like themselves: white, middle- class professionals and business people who smoked. These efforts were successful to the point where smoking has become a status rnarker. The shock we feel when a professional colleague lights up a cigarette is due to the contradiction between his or her perceived high status and the low status we now attach to the act of smoking. The other side of this coin, however, is that as smoking becomes increasingly concentrated among people unlike movement activists-blue collar workers and adoles- cents-behavior change efforts will, almost inevitably, be less success- ful. The social gulf between reformers and those whom they would pro- tect or reform is a problem generic to reform movements (including the gun control movement). The smokingltobacco control movement was unique in its ability to avoid this problem for so long. A last reflection has to do with the shifting target of the smoking/ tobacco control movement. As the movement has changed from one of citizen activists to one that is professionalized and, to a large extent, lawyer-dominated, it has experienced some level of what might be called goal displacement-from smoking and smokers to the tobacco industry. The wealth, visibility, and political clout of the smokinghobacco control movement's opponents makes them easy for advocates to demonize: struggles between David and Goliath have an obvious romantic appeal and there is satisfaction in mounting attacks on greedy corporations. However, the degree to which these attacks serve movement advocates' long-term goals is unclear. Declines in smoking prevalence occurred because smoking was made socially unacceptable, not-or at least not directly-as a result of pressure on the industry itself. if they are to be successful, health-related social movements need to keep their long-term goals in mind. References Amenta, E., K. Dunleavy, and M. Bernstein. 1994. Stolen Thunder? Huey Long's "Share Our Wealth; Political Mediation, and the Second New Deal. American Sociological Review 59(5):678-702. American Cancer Society (ACS). 1948, 1950, 1957 Annual Report. New York: ACS. 8980ZSZLOZ Nathanson • Social Movements as Catalysts 481 -. ACS Files Adantz: ACS. Americans for Nonsmakers Rights (ANR). 1996. ANR Update 15(1):1. ' Andersoq 1. 1996. fnside the NRA: Armed and Dangemus Beverly Hills, CA: Dove Books. Anderson. R. N., K. D. Kochanek, and S. L. Murphy. 1997. Report of Final Mortality Statistics, 1995. Monthly iktal Statistics Report 45 (11, suppl. 2):97-1120. APgle, R. W. Jr. 1998. For Tobacco Growers, a Changing Life. NewYorkTunes, 14 September 1998, A12. Barnes, D. E., and L. Bero. 1998, Why Review Article.s on the Health Effects of Pas- sive Smoking Reach Different Conclusions. Journal of the Anmrican Medical Association 279(l9):1566-1570. Beauchamp, D. E. 1988. Ihe Health ofrhe Republic. Philadelphia: Tempte University Press. Brandt- A. 1992. The Rise and Fall of the Cigarette: A Brief History of the Anti- smoking Movement in the United States. In Advancing Healrh in Developing Countries, ed. L. C. Chen, A. Kleinman, and N. C. Ware. New York AuMrrn House, -. 1995. Blow Some My Way: Passive Smoking, Risk, and American Culture. Paper presented at a Symposium on the History of Smoking and Health, Wellcome Institute for the History of Medicitte, London. 26-27 April. Brody, 7. 1996. Decline Seen in Death Rates from Cancer as a Whole. New York limes, 14 November, A21. Bumeg L. E. 1959. Smoking and Lung Cancec A Statement of the Pub(ic Health Ser- vice. Journal of the Americnn Medical Association 171(13):1829-1837. Burstein, P.. R. L. Einwohner, and 3. A. Hollander. 1995. The Success of Political Movements: A Bargaining Perspective. In The Politics ofSocia! PmterC Compar- alive Perspecrive,r on Stares and Social Movemenrs, ed.1. C. Jenkins and B. Klan- dennans. Minneapolis: University of Minnesota Press. Butterfield, F. 1998. Chicago Is Suing over Guns from Suburbs. NewYork7imes, 13 November, A18. Centers for Disease Control and Prevention. 1993. Mortality Trends for Selected Smoking-Related Cancers and Breast Cancer-United States, 1950-1990. Mnr- bidiry and Morraliq• Weekly Report, 12 November, 865. -. 1994. Health Objectives for the Nation: Cigarette Smoking among Adults- United States, 1993. Morbidity and Mortality Weekly Report, 23 December, 925- 930. -. 1995. Suicide among Children, Adolescents, and Young Adults-United States, 1980-1992. Morbidity and Mortality Weekly Report, 21 April, 289. -. 1996a. Stare Tobacco HighligMs-1996. Centers for Disease Control and Preveation Publication No. 099-4895. Atlanta: Centers for Disease Control and Prevention, Natinnal Center for Chronic Disease Prevention and Health Promo- tion, Office on Smoking and Health. --. I996b. Cigarette Smoking among Adults-United States, 1994. Morbidity and MortaliryWeekll' Report,12 July, 588. - . 1997. Cigarette Smoking among Adults-United Smtes, 1995. Morbidity and Morr¢liy Weekly Reporr, 26 DecembeC 1218.

478 Journal of Health Politics, Policy and Law can play roles complementary to that of the movement proper) and from being positioned to take advantage of political windows of opportunity (Shapiro 1985; Walker 1991; Tarrow 1994; Kingdon 1995; McAdatn, McCarthy, and 7ald 1996). Organizational advantages, however, are no guarantee of movement impact on the larger society (see, e.g„ Schwartz and Paul 1992),,tl McAdam's coinments suggest that one reason for the smoking/tobacco control movement's relative success is that cultural change is easier to accomplish than social and economic change. While the relative success of the two movements considered here is consistent with this proposition, I doubt its universal truth: in France, for example, laws were passed in 1976 and 1990 regulating tobacco advertising and smoking in public places, but there has been relatively little change in the French culture of smoking. I advance two factors to account for the cultural impact of the smoking/tobacco control movement in the United States: first, the con- struction of credible risks already described at length and second, the culturally receptive climate into which this risks discourse was inserted. Moral crusades-and the nonsmokers' rights movement is, in many respects, a moral crusade-are a recurring feature of American life. The timing of this particular crusade, however, contributed to its success. In the 1970s, the United States was characterized by an increasing demand for health as an individual right (see, e.g., Fox 1979; Freeman 1983) and, at the same time, there was increasing concern about the costs of medical care, disenchantment with the value of medical care in improving health, and a "growing reaction against liberalism and government" (Statr 1982: 380). Across the political spectrum, from Ivan Illich to John Knowles, critics argued that greater access to medical care was not the path to bet- ter health. In this context the crusade against smoking appealed both to middle-class liberals concerned about the environment and generally 71. In considering the relationship between social mavemeats and social changa it u impor- tant In distinguish between conditions for movement emcrgence, conditions for movement endurance, and conditions For movement<ffected social change. These conditions are clearly related, since movenamta must enwrge and be sustained ovec some period of time in otder to produce change. But they are not the same. For example. a number of authurs (e.g., Shapiro 1985; Schwanz and Paul 1992) suggest that conflict is a conditiun for movement auccesa: "It is very hard ta work on an issue over a long period of time where all one is doing is education work. , . . What draws people in . . . is the contest over power" (movemem activist cited in Shapiro 1985: 101). However, the eondict hypothesis refers to conditions for successful maN- lization, nm successful change. Meyer and Suggenhorg hypothesize, to the contrary, that movarcms with strong opposition ere "unable to take advantage of favorable political condi- tions after vetories" (1996: 1652). In any case, the presence of"strong opposition" hardly dis- tinguishes the smokinghob:ccn and gun comiol movements. More important is the source and credibility of the opposition. LSSOZ9ZLOZ Nathanson • Social Movements as Catalysts 479 sympathetic to rights-based movements and to conservative advocates of "individual responsibility" (as opposed to government responsibility) for health. This compatibility with ideologies of both the left and right may partially explain one of the enduring puzzles of the smokingltobacco con- trol case: why no credible or effective countermovement developed. David S. Meyer and Suzanne Staggenborg have proposed that the "like- lihood that opposition to a movement will take the form of a sustained countetmovement is directly related to the opposition's ability to portray the conflict as one that entails larger value cleavages in society" (1996: 1639). Neither proponents of smokers' rights nor the tobacco industry have been successful in making that case.72 Policy Implications The power of social movements in the health policy arena raises a ntmt- ber of questions. First, what is the role of science in the construction of health risks? Second, what is the movements' class-based impact? And third, what are the risks to the movement of its own success? Health-related movements must invoke credible risks. However, whether those risks are perceived as credible by the audience addressed has more to do with ideology than science. In the case of passive smok- ing, credibility was present far in advance of scientific knowledge; in the case of nicotine addiction, knowledge long preceded either public or institutional acceptance. The lesson from these observations is that there may be little correlation between the scientific grounding of health- related social movements and their success in the policy or public arenas- Publications in the Jousnal of the American Medical Association or the New England Journal of Medicine, however sound, are seldom persua- sive an their own. Movement success in reaching the policy agenda may be only tangentially related to the scientific importance of its public health message, and movements with important messages may fail. 72. Meyer and Slaggenborg define a countermovement as "a movement that makes contrary claims simuhaneously to those of the original movement" (1996: 163p. By ihis criteda, nei- ther af our movements' principal antagonists qualify as countennovements, yet many of the propositions advanced by theae authors apply to the relationships of the smoking/tohacca con- troi opvetnent with the tobacco industry and the gun control movement with the NRA. Thus, in both cases "the opposing movement (or organi>ztion in the present case) is a critical cnmpn- nentof the structure of political upponunity the osher side faces" (1633); "movcments losgani- zatiuns] often respond to a defeat in one venue by prateting in an alternative arena" (1645); movements thrlve on threats, and so on, These parallels suggest that the critical dimension in these relationships is nm that the parties are social movements hut that they are engaged in ongoing political confiicL

452 Journal of Health Politics, Policy and Law reason to believe that the label itself will change behavior-indeed, it could lead adolescents to prefer smoking as the cheapest, least dan- gerous form of addiction and it is unclear why judges and juries would find addicted smokers more sympathetic plaintiffs than risk-assuming smokers. Inherent in the attribution of risks is the designation of potential vic- tims. Who, precisely, is at risk? Citing limitations in the available dara, the 1964 Surgeon General's report focused on men: "Cigarette smok- ing is causally related to lung cancer in men" (U.S. DAEW 1964: 31; emphasis added). As early as 1957, however, the American Cancer Soci- ety began to develop educational programs targeted at adole.scents (ACS 1957: 47) and by 1997, forty years later, children dominated the roster of victims?o In the interval, nonsmokers, women, minorities, pregnant women, the fetus, and residents of third-world countries have received attention as designated victims. This is not, of course, a random selection. In varying degrees, these categories lend themselves to portrayal as inno- cents, deserving of government protection and control. In the foregoing scenarios, the tobacco industry was virtually invisi- ble,^I The most striking recent shift in constructions of cigarette risk has been the explicit ahribution of causal responsibility to the industry itself. The government's rhetoric, initially veiled in the bureaucratic language of the FDA, has become increasingly explicit: the language employed by private health organizations is unambiguous. Slogans like "protect our children from the tobacco companics" and "tobacco lawyers versus America's kids" appeared in public service announcements in major media outlets (CNN, the New York Times) in 1996 and 1997, sponsored in the first case by the Ametiean Cancer Society and in the second by the American Heart Association, the American Lung Association (ALA), the Association of State and Territorial Health Officials, and other health, religious, and educational organizations. 40. During 1996, amismoking advatlsing messages in the print aud televhion ind'u spoo- sored by private sources appeared lo focus exclusively on the harardc of smoking to children. Tha recently esiablished National Center for Tabacco-Free Kids, funded by the ACS and the Robert Wood Johnson Foundation, is a majar source for these musagcs Recent action at the federal level to require identification for cigarette purchasers under the age of twenty-seven i< targeted at teenagers. 41. The industry was almost invisible, but noa quite. In the same year that Healthy Peay/a appeared, Secretary of HEW Joseph Califano referred in the Surgeon Cxneral'a report on stmk- ingand hcaRhto the millions of doltars spent on cigarene advertising every yearand lothe exts- ten<e of a"veated ivterest" in srcwking. I have found no parallel references in subserryent Stu- geon Generals reports, however, and according to Richard Kluger, Seeretary Califano was forced lo resign as a result of his vigurous antitobacco campaign (Ktuger 1996: 465). Nathanson • Social Movements as Catalysts 453 The ACS official quoted earlier explained the ACS's change of course: In the 1970s when the laws went into effect banning cigarette adver tising from broadcasting, putting tougher warning statements on ciga- rette packages and in advertising (1984), when more and more con- gressmen became articulate on this subject, we began to see that we could now openly criticize notjust the cigarette but the manufacturer of the cigarette- And I'll never forget when I ended up on a MacNeil/ Lehrer show one day (7 April 1988) with a representative from the Tobacco Institute and I was able to say tobacco companies are mer- chants of death. (ACS files) As political opportunities change, so do constructions of risk. Guns. Every element in the construction of risk-claims of danger, attri- butions of causality, and designation of victims-has proved more prob- lematic for the gun control movement than for the smoking/tobacco con- trol movement. First, as I noted earlier, claims of danger are disputed. Second, even when the existence of danger is admitted, causal attribu- tions vary widely between and among the different groups who claim ownership of the gun question. Third, different causal attributions are associated with different categories of victims. For those to whom guns are a problem only insofar as they are associ- ated with crime (a category that includes not only the NRA but also many criminologists and representatives of the criminal justice system), the cause of gun-related mortality and morbidity is not guns as such, but guns in the hands of bad people. The public health community casts a wider net. First, crime-associated injuries and death are often conflated with gun-related injuries and death generally (e.g., from suicide or acci- dents) and labeled as gun violence. Second, causal attributions cover a broad range: criminogenic circumstances, inappropriate use of guns, poorly designed guns, guns in the horne, and so on.42 An idea of the rel- 42. Crinunogcnic circumstanccs were blamed by Mark H. Moore et. at: "FacWrs influene- ing individual incidents and aggregate levels of violence include (a) the availability and use of criminogenic commodities (such as guns, drugs, and alcohoq; (b) the dwsity of crimino- gpsic situations (such as ongoing unresolred conBcts); and (c) a variay ofcultural factors that help tojustify andencourage vrolence" (1994: 170). iMse authms wae carefui to presentthcir perspective as complemenuary to, not competitive with, the "csiminatjustke' perspective. The concept crlminagen(c, however, constructs causality in tums far removed from the wodd of offendns and perpetrators inhabited by poticc, prosecutors, and defense lawyers. Ceusea of r'rime become equivalent W causea of diseasq implicitly beyond indivlduat control and within the domain of medical (or at least public health) scicnce. Gun design has been a pasticnlar focus ofihe7ohns Hopkins Center forGun Policy and Resesrch, led by Steven Teret. Hazards of guns in the home have been examined in numbers of articles published by the /owrnuf ofrheMneri- titi80ZSZLOZ

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