Tobacco Documents Online

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