Such anti-industry campaigns must have strong support from health advocacy groups in order to withstand industry attempts to dilute or eliminate them through political pressure on the state government, the UCSF team also finds.

The assessment stems from an analysis of the past decade's fight over the content of anti-smoking advertising in California. The 1988 passage of State Proposition 99 mandated anti-tobacco education, to be funded by a portion of an increased tobacco tax.

The new report, in the current quarterly issue of Tobacco Control, published this week, reviews measures and counter-measures taken by the California Department of Health Services (DHS), the office of former Governor Pete Wilson and health advocacy groups to define and influence the content of anti-smoking ads in California.

Use of aggressive billboard, television and radio ads - such as one showing tobacco executives denying nicotine's addictiveness; another asking, "Are you choking on tobacco industry lies?" - led to rapid drops in cigarette smoking in the state, the UCSF researchers note, drawing on their own analysis as well as studies carried out on contract for the state DHS.

The Wilson administration shelved these and other anti-industry ads under pressure from the tobacco industry, the researchers report. After the ads were stopped or toned down, the prevalence of smoking increased. "The data shows that when the tobacco industry succeeded in shifting the focus from the anti-industry ads to educational ads aimed at youth groups, the campaign stopped working and smoking increased," said Stanton Glantz, PhD, co-author of the report, professor of medicine at UCSF and a member of UCSF's Institute for Health Policy Studies.

As a result, Californians smoked an extra 840 million packs of cigarettes, worth more than a billion dollars, between 1994 and 1998, Glantz estimates.

The only thing that got the campaign stiffened up a bit was the fact that health groups like the American Heart Association, the American Cancer Society and Americans for Nonsmokers' Rights were willing to go to the mat, putting a tremendous amount of pressure on the Wilson administration," Glantz added.

First author on the new report is Edith D. Balbach, former assistant policy analyst at the UCSF Institute for Health Policy Studies, now director of the Tufts University community health program.

Some of the most potent ads never aired, the researchers said. One ad points out that tobacco industry-owned insurance companies charged non-smokers less for life insurance. Other ads were pulled or even papered over on billboards, despite objections from public health advocates including the Tobacco Education and Research Oversight Committee (TEROC), with statutory oversight over the program, according to the UCSF researchers. "We are going to see battles all across the country like the one that has taken place in California," Glantz predicted. The state of Maine, for example, recently began airing the ad showing tobacco executives denying nicotine's addictive effect. "They are getting pressured to stop it," he said.

"In many states, the public health people are trying to put together strong campaigns that work, and the tobacco industry is trying to divert the funds to support more educational campaigns which look good, but -- as the California data show - result in an increase in the prevalence of smoking," Glantz said. The experience in California demonstrates the need for continuing aggressive intervention by health advocacy groups to maintain the most effective anti-tobacco media campaigns, he and Balbach stress.

Their paper offers a behind-the-scenes look at the strategies and actions taken by advertising agencies and state health agencies to develop biting new ads, and counter-measures by the Wilson administration to dampen the effect of the most provocative ads. In some cases, they report, efforts were made to introduce legislative restrictions to the law created by the 1988 proposition. In addition, contracts with ad agencies were held up or killed, and new policies put in place to add layers of review to allow censorship of ads already approved by the program's oversight agency. The paper also includes previously secret tobacco industry documents revealing the tobacco industry's efforts to derail the campaign.

Eventually, by mounting outside pressure on the administration, public health groups were able to push the media campaign back towards its original posture," Balbach and Glantz write of the California experience. The lesson:"Public health groups can help campaigns if they are allowed to be involved; if they are not, however, they can still protect the quality of the program through outsider, advocacy strategies designed to hold public agencies accountable for mounting high-quality campaigns," they conclude.

The article by Balbach and Glantz is entitled "Tobacco Control Advocates Must Demand High-Quality Media Campaigns: the California Experience."