The National Spit Tobacco Education Program

The 1986 Surgeon General's report on the Health Consequences of Smokeless Tobacco Use focused attention on oral cancer and other diseases caused by "smokeless" or "spit" tobacco. At that time, the smokeless or "chewing" tobacco industry was in the midst of a campaign, begun in the late 1970s, to change attitudes toward its products while ramping up efforts to reach a more youthful audience. The industry, which used celebrity baseball players as models in its advertisements, attempted to convey a message that smokeless was synonymous with harmless.

The marketing strategy was successful. Sales of moist snuff--commonly referred to as "dip"--rose by 55 percent between 1978 and 1985. Baseball players, particularly, took to spit tobacco. A 1985 survey of male college baseball players found that 40 percent used spit tobacco regularly. A survey taken two years later revealed that over half of professional baseball players had a history of spit tobacco use and that 34 percent were current users.

Staff members at The Robert Wood Johnson Foundation were involved with early efforts--led mainly by the National Cancer Institute--to reverse the trends and decrease the use of spit tobacco. One strategy was to form partnerships with Major League Baseball to break the link between spit tobacco use and the game of baseball. Star players, league officials, and public health leaders were actively engaged in the program, which also had the support of the Major League Teams Physicians Association and the Professional Baseball Athletic Trainers Society.

In 1990, the NCAA banned the use of tobacco in all tournament play. In 1992, Major League Baseball banned spit tobacco for all minor league players in its Rookie and Class A leagues. The Los Angeles Dodgers and the Oakland A's were among the first teams to address the problem of spit tobacco. Los Angeles banned players from carrying snuff or chewing tobacco while in uniform, and Oakland banned tobacco advertising in its program.

In the fall of 1995, The Robert Wood Johnson Foundation held discussions with Oral Health America to develop a program aimed at increasing the level of engagement by major league players. This new program built on the work of Joe Garagiola--former major leaguer, television broadcaster, and recognized ambassador for baseball. Named the National Spit Tobacco Education Program (NSTEP), the initiative involved all twenty-eight major league teams. The Foundation's initial support of $800,000 included community outreach in six major-league cities to build bridges between the team and the local tobacco control and public health community. In its first year the campaign generated more than $30 million worth of media publicity, including national broadcast and print advertising and in-stadium and player promotions. In 1997, support for NSTEP was renewed for three years at a level of $3.5 million in 1997.

The cooperation of Major League Baseball can be attributed largely to the passion and persistence of Joe Garagiola. Garagiola brings a reputation for honesty and integrity within baseball and outside the game. That reputation, combined with his status as a baseball insider, grants him access to many people--from owners and league officials to players, coaches, trainers and to the media and the public. His particular brand of leadership may serve as a lesson for other public health campaigns.

In this chapter, Leonard Koppett, a baseball Hall of Fame sportswriter, chronicles how Joe Garagiola led an effort that changed the way Major League Baseball viewed and responded to the problems of spit tobacco. Joe Marx, a senior communications officer, and Tracy Orleans, a senior scientist, at The Robert Wood Johnson Foundation, reviewed drafts of the chapter. Their comments and suggestions were invaluable.

As a boy in St. Louis, Joe Garagiola was the second-best baseball player on his block. The best was Larry Berra, also known as Yogi. After World War II, both Joe and Yogi became major league players, and Yogi went on to make it into the Hall of Fame. Yogi's malapropisms, many of them given circulation by Joe, have become a part of the language. "It ain't over till it's over" was one of Berra's maxims, and on another occasion he said, "It was déjà vu all over again." When Garagiola's baseball career ended, his own wit and way with words led him to a second career as a broadcaster and speaker. His work on nationally televised weekly broadcasts and World Series broadcasts gave his style a major showcase, and led to other broadcasting work.

Garagiola became a host on the Today show, wrote a couple of books, and in due course took a leadership position in the Baseball Assistance Team, or BAT, which is devoted to helping former players in need of financial aid and other help, especially those who did not enjoy the benefits of baseball's big-money era. It was through BAT that the scope of the tobacco problem involving ballplayers came to his attention.

"I can't really pinpoint the day that I started with this tobacco thing, any more than I can say that I had a plan to form a national group and do what is being done today," Garagiola said one day in Phoenix, where he now lives. "I'm very grateful for how it has evolved. But I'm not doing a humility act when I tell you that it just happened. I used to do my own little campaign, all by myself, when I was doing the Game of the Week. I'd have my scorebook with me all the time, and I always tried to find a newspaper clipping about oral cancer. I would paste it on the left-hand side of my scorebook so that when I wrote down the lineups it would be there."

Garagiola went on, "Well, you know how ball players are. They're going to come over to see what you're writing. So they would come over and see me writing the lineup--and one or two or more would wind up reading about chewing tobacco. It was always some simple headline, like 'Tobacco Causes Cancer,' and if we talked about it, it was always a one-on-one exchange. I would get on certain guys. One in particular who comes to mind is Bobby Cox. He was managing Toronto. I was sitting on the bench with him, and we talked about it. 'Bobby, that stuff is really bad,' I said. 'And I think you've got a sore in your mouth. You ought to let the trainer look at you.' One day he had the trainer look and found that he had a little sore there. The next time I saw him, he had switched to herbal, the nontobacco thing. I said, 'Bobby, that's great. But are you going to stand at home plate and tell kids who are watching you chew this stuff that it's herbal, that it really is not tobacco? It's just as important to get the message out that you're not using tobacco as it is to stop using it. Don't you see?' And he said, 'Well, what do you want me to do?' I told him, 'Use gum.' The last time I saw him, even before he said hello, he said, 'My jaws are about to fall off from chewing this gum,' and I said, 'Well, you're not going to die from tired jaws.' That's the way it went. I would talk to these guys and kind of get on them, but that didn't do much. It was like trying to hit with a broken bat."

As a writer, I was around all the same people at the same time as Joe Garagiola. One of the first things you learned as a writer was where to put your feet so that the tobacco-chewing players wouldn't ruin your shoes when they spat. Nobody seemed to object to their chewing.

"It was just so prevalent," Garagiola said. "I chewed when I played. I didn't know why. I thought it was part of being a ballplayer. Now I'm convinced guys chew, first of all, out of peer pressure; second, out of boredom; and third, to give off a macho image. I don't lean too much on the macho image part because I think a lot of guys get upset at that, but I do know about boredom. What happens is that you start to play games with the stuff. I spent enough time in the bullpen to know how bored you can get out there.

"In those days, there was none of this dip that you put next to your gums. It was all leaf tobacco, and you put the big chew in your mouth and kept it to one side and did a lot of spitting. So you think of games: who could spit the farthest, who could spit the straightest; hold out your foot, a dollar you can't hit it; there's an ant, let's see who can drown the ant. First guy to drown the ant wins the pot. So it was kind of like a fun thing, and yet it was becoming pretty addictive. That's why I don't minimize it. Guys tell me, 'I only chew when I come to the ball park. I never chew at home. I only chew when I play golf. I only use this stuff when I fish.' But that's not true, because the stuff is addictive. I know I wound up using it at home and thinking nothing of it. So what I was trying to do was simply to tell the other side of the story."

The other side of the story was never mentioned. Writers always write what the people they cover are talking about, and nobody ever talked against chewing. Smoking a cigarette in the dugout became unacceptable at some point, so a player--or the manager--would step down into the passageway to the clubhouse for a smoke. We wrote about that, taking it lightly or not, but that's what we do: reflect what's going on around us.

"The tobacco companies have a word, and the guy who came up with that word should get a huge bonus, because with that one word they really put a whole new spin on this tobacco business, be it chew, be it snuff, be it dip," Garagiola went on. "The word is 'smokeless.' They refer to it as 'smokeless tobacco.' My big battle is to convince people that 'smokeless' is not 'harmless.' Now, 'smokeless' is a nice, fuzzy, protective kind of word, making you think it's a substitute for cigarettes--so go ahead and use it. I don't know how much stronger it is, but I've heard experts say that the nicotine from just one dip is the equivalent of what you can get from four cigarettes. Then how much is one can?

"Well, we did start to carry the message into the clubhouses, and they passed a rule against using tobacco in the minor leagues. There's a fine for doing it, and in the minors any fine is significant. But the policing is supposed to be done by managers and umpires, and they don't do it. They can't. So I don't think we can just ban tobacco use in the minors or the majors. There's no way to police it. That's why education is the key. When you finish a presentation, ballplayers will come up to you and say, 'Man, I really want to quit. What do I do?' Well, up to last year all we could do was give them a '1-800 FOR CANCER' number, and they could call and get some brochures. That was not really the answer."

Garagiola paused, and then said, "So what I was doing was a one-on-one thing. Wherever I went to make a speech, I would manage, somehow, to get the tobacco issue in there. Then a lot of guys would come up and say, 'Man, I'd like to help in your battle.' Well, that sounds good, but nobody was stepping up. Where it really kind of got started was here in Phoenix. I was doing a banquet, and my motivation had just been intensified by two statistics I saw. One was that in 1993, here in Arizona, 9.8 percent of the third- to sixth-graders were users. Now, I'm not a numbers guy, I'm a people guy, but this really got me. I thought, third- to sixth-graders? That's scary. Somebody has to say something. So I started talking about that, and people found it very hard to believe.

"Then I read a report that 20 percent of American high school boys, grades nine to twelve, are current spit tobacco users. Among white high school boys, it was 25 percent. Well, at this banquet in Phoenix, I was introduced to Don McKenzie, who was on the board of directors of Oral Health America. 'Don may be able to help you fight tobacco.'

"I said, 'If you can, good. But I've been getting nothing but lip service, I want you to know that. So if you're going to help, fine. If not, let's just say hello and I won't waste your time and you won't waste mine.' He looked at me and said, 'I've never been introduced to a guy like that before.' I said, 'Well, if we were just introduced to make friends, I'd be a little friendlier. But I get sick and tired of lip-service people.' He said, 'I think I can help you. I believe we're trying to do something. I'd like to talk to you about it.' So I said, 'Good, let's have a meeting.'"

Garagiola continued, "And he said, 'When can we do that?' I said, 'Any time. You want to do it after the banquet tonight?' He said, 'No, no really, because I have my wife with me and I really can't do it. How about tomorrow?' To myself I thought, I'll find out in a hurry if this guy is for real. 'O.K.,' I said. 'How about seven o'clock?' He said, 'Seven o'clock tomorrow night?' I said, 'No, no, tomorrow morning. I've got a very busy day.'"

"I didn't, but I figured that if this guy would meet me at seven o'clock in the morning, he's serious. Well, he did. We talked. He put me in touch with Oral Health America in Chicago. Their mission is to improve and promote the oral health of Americans. That was the beginning of an important contact."

By that time, Garagiola had collected some powerful real-life examples about tobacco use in baseball. There was the coach in the Cardinal organization known throughout the game for his baseball expertise. He blamed tobacco dip for the fact that a piece of his tongue had to be cut out. "Damn dipping," he said. "My doctor told me I'd better stop, but I had to lose part of my tongue to learn." Unable to speak clearly, he had to learn to speak all over again. Eleven months later, the coach died.

Then there was a young man from Montana who had lost half his face to cancer. Garagiola did a Today show spot with him. He was not a professional, just a guy who loved to play sports. He said that he had started dipping and chewing when he was twelve years old, because everybody else did it. The interview with the young pitcher revealed another aspect of the tragic consequences of tobacco-related disease. The young man talked about his operation, the pain, the inability to raise his arm above his head--and then he told a story about picking up his little boy at school. One day, the boy asked his father to park on the other side of the street. The father thought, He wants to show me how brave he is, that he can walk across the street. But that wasn't it at all. The other kids were teasing his son because of the way his father looked: most of the jaw on the right side of his face had been taken away, and the boy was ashamed of how his father looked.

"Now I'm emceeing the Golden Spikes dinner at the Waldorf in New York, where they honor the college baseball Player of the Year," Garagiola said in Phoenix. "I see all these young faces, and the tobacco thing keeps popping into my mind, and I say to myself, Oh, man, this isn't the spot to do it, but do it. Talk about it. Don't talk about it. I figure they're not paying me, so talking about spit tobacco would be my payday. So I went into my tobacco thing and directed it at these young guys. I gave it my best shot: smokeless is not harmless, the whole number. And the reaction from the audience was really good. In fact, it turns out that Alex Rodriquez, now with the Seattle Mariners, was on the dais at the time and heard me. He was one of the first players who wanted to help. He picked up the phone later, I didn't have to call him, and he said, 'What can I do?'

"Anyway, right after the awards dinner was over, Creighton Hale, the head of the Little League, who knew me, came up to me. 'I didn't realize you had such a passion against tobacco,' he said. I let loose.

"Oh, man, I just think we have to do something. We have an oral cancer epidemic on our hands. It's hidden. It's silent. Nobody's doing anything because smoking is getting all the publicity. Secondhand smoke and stop smoking here and no smoking on planes. And the tobacco companies are laughing. They're going to make their money by exporting the cigarettes, and what they will do is target the young people. You see it, the rodeos, the good-old-boys circuit with the Skoal-branded car, the country-western concerts and the rock concerts. And they give these free samples on the college breaks. You can see they're targeting the young people with this stuff and making it sound like a good alternative to cigarettes even though they put on the packages, 'This is not a safe alternative to cigarettes.' Then there's the whole insidious advertising campaign."

Garagiola went on, "I tell him about those little flavor packs, like little tea bags, which sting a little bit but taste like hard candy. That's how you start. And it says on there, 'Try Skoal flavor packs when you can't smoke,' although they don't actually say that. That's how they get you started. After you use that for a while, you want something stronger, and you go to the middle group, and then that buzz is not enough for you and you graduate to the top of the brand. Then they got you.

"At the time, I didn't know it would come out in the tobacco hearings that, yes, that's how they do it. They have a starter product and a graduation product. So Creighton Hale introduced me to Neil Romano. His company does educational programs, and they had done the anti-spit-tobacco campaign for the Little League. We put him in touch with Oral Health America. We got enough money to set up a press conference at the National Press Club in Washington, at which I would have Bill Tuttle tell his story."

Bill Tuttle's story starts with a request to BAT--I had covered him when he played in the major leagues, but had lost touch with him after he retired. He was a first-rate outfielder with Detroit, Kansas City, and Minnesota for eleven years, ending in 1963--when pay scales were low and long before the players had an effective union. In 1993, his wife, Gloria, called BAT because Bill had to go to the hospital and they wouldn't admit him without a $5,000 down payment. She had noticed a big lump on the side of his jaw and thought he was still chewing in the house, but he said he wasn't. They went to a doctor, who took one look and said get him to a hospital immediately. In a thirteen-hour operation, they removed the biggest malignant tumor in the history of the University of Minnesota Hospital.

Gloria was all for going after the tobacco companies because they hadn't told the whole story about spit tobacco. Garagiola asked if they could come to a press conference in Washington. Gloria said sure, as Bill was going around to high schools and talking about it already.

"So Tuttle would be the story," Garagiola said. "But Bill Tuttle or Joe Garagiola was not going to attract a crowd to the National Press Club. So I called Mickey Mantle, asked him what his feelings were, and would he come? And he proceeded to tell me that he was anti-chewing tobacco. That was kind of interesting, because he said that when he came up to the Yankees, Casey Stengel, the manager, asked him if he had to chew that stuff. Mickey said he didn't have to, but he chewed it because he had done it back in Oklahoma. Anyhow, he said, 'Yeah, I'll come.'"

Garagiola went on, "The other player I wanted was Hank Aaron, because I'm a big Aaron fan. We all know what a great ballplayer he was and what he's done. I've always felt that when Henry Aaron has something to say and he believes it, he is going to say it and let the chips fall where they may. So I called Henry and he said, 'Yeah.' He told me a story about a high school kid he had tried to talk out of tobacco, a football player who eventually died. He told me how when he was running the minor league system for the Braves, he wouldn't even put pockets in the back of the players' pants so that they would have no place to put tobacco. Yes, he'd be happy to come.

"With Mickey Mantle and Hank Aaron as my headliners, and then Bill Tuttle and Leonard Coleman"--the president of the National League--"I knew that we would pack the place, because people would show up to at least try to get Mantle's and Aaron's autograph. And that's exactly what happened. It was a very successful press conference--so successful that Senator George Mitchell was having a press conference next door and nobody was showing up, so he came over to our room. So we had a big crowd, lots of cameras, a lot of publicity. Lo and behold, Mantle told a story. Aaron told a story. Coleman told a story, and Tuttle told his story--and Joycelyn Elders, the Surgeon General, was there to hear it. In fact, she even gave facts and figures on what spit tobacco did and was supportive. We got full coverage because the cameras and newspapers were there. That's when we started to develop a plan: we'd go to the major leaguers and tell our story.

"The contact had been made with The Robert Wood Johnson Foundation because they had people who were interested. A proposal was made and they funded our effort, which we called The National Spit Tobacco Education Campaign. We started in the spring of 1996. Until Robert Wood Johnson came along, I was working with a broken bat--now I had a Louisville Slugger.

"When I'd go into a clubhouse, I could see the look on their faces that said, 'Oh, God, here comes another one of those sermons.' They get one from the FBI guy about unsavory characters and betting and all that, and then the insurance people come in. So I tell them right away that baseball did not pay our way. We're here because we believe in it and we thank the ball clubs for giving us the opportunity. But I'm also here to tell you we are going to talk about tobacco, but I'm not saying you should quit. I'm telling you it's a choice. Baseball is a game of choice. I chose to be a catcher. Some of you choose to be pitchers. Some choose to be infielders. I talk choice. You take a curve ball, you choose to hit a fast ball. That's the way it is with tobacco. We want you to make the right choice.

"Then Tuttle tells his story, and when he's finished, I say, 'You know, guys, now I want you to think about your wife or your father or your mother or your sister or brother or loved one, because you heard Bill Tuttle say that the doctor told him his operation was going to take two to two-and-a-half hours--and it took thirteen. Think of your wife or your loved one sitting in that waiting room thinking you're going to come out in two hours, and now it's hour five. It's hour seven.' And then I say, 'But I'm not going to tell you because I didn't live it. Gloria will tell you.'"

Garagiola continued, "And Gloria's even more powerful than Bill, because she doesn't have a script. But she also gets frustrated and angry. One time, she got angry and called me. 'Why don't you just write a letter, just to get it out,' I told her, 'and send it to me.' The letter was so powerful that I called USA Today and asked if they would print it. They did. The opening line was 'I'm watching the man I love die.' When I saw it in print, I thought, we have to get this into the hands of the wives. So I called Don Fehr, the head of the Players Association, and with his help we were able to get it to the wives. We got a big reaction from the wives.

"We also had a lot of help from the ballplayers themselves, and most were willing to help. The first players we approached to participate in the campaign were Jeff Bagwell, Frank Thomas, and Hank Aaron. Other players were volunteering to come up and help us. At a typical visit to the ballpark, players would walk up to me and say, 'how's the tobacco thing going? If there's anything I can do, let me know.' Now, because of The Robert Wood Johnson Foundation, we were able to do videos, posters, and all that good stuff. We were able to do things we couldn't do before. So we went to guys like Lenny Dykstra, Mike Piazza, Tino Martinez, Alex Rodriquez, and Paul Molitor, and they agreed to do television spots broadcast during major-league games. We did events in the stadiums and health and antitobacco people brought in kids from the community, and the ballplayers would join us after batting practice--on their own time--to speak to the press and the young people and the Little Leaguers who were in the audience. And we'd hand out a poster featuring a player from every major-league team. Every town we went to, we got newspaper columns, we did interviews in the team's broadcast booth and we did radio and television shows. I also sent a letter and a brochure ('Talking About Spit Tobacco and Baseball with Joe Garagiola') to the networks and the baseball card companies. Fox, NBC, and others tried to keep the cameras away from players who were chewing and spitting. The trading card companies stopped photographing players with a big wad in their cheek. We had our ads in team magazines and other publications. The Seattle Mariners, for one, even made the decision to ban tobacco advertising in all of its publications and in the stadium. And Major League Baseball gave us full-page ads in the World Series and All Star Games programs.

"More help came from Charles Schulz--Sparky--who does the 'Peanuts' comic strip. He not only did a cartoon, he did it on a Sunday, the day before the All-Star Game in 1996. The coverage on that was tremendous. Not only that, he used his own money to do an animation piece for us. It's used by most ball clubs. It's a very powerful one.

"I told my story to President Clinton and urged him not to refer to it as smokeless tobacco but as 'spit tobacco.' I told him why, and he agreed, and he used that in an announcement he made in the East Room of the White House about their effort to keep tobacco away from kids. That was the beginning of getting really big support, because the President talking about not only cigarettes but also spit tobacco brought this subject to the forefront.

"We were doing our spring training tour, and the President wanted to single us out. He called a press conference, and two young women from the Olympic soccer team were to be singled out for their battle against tobacco. Gloria and Bill Tuttle were there with me, and the President singled us out, so that was a sign of approval. Before such a press conference, you get a chance to talk to the President. I asked him if he was going to throw out the first ball at Baltimore--after the strike--and he said yes.

"'If you would just issue another statement,' I said, 'or even have a press conference, which would be great, I think--I'm sure--I could get Bud Selig and Don Fehr to be there. That would be the first time that these guys had been together and able to agree on anything, and you would be the guy who brought them together."

Bud Selig, owner of the Milwaukee Brewers and the acting commissioner of baseball, and Don Fehr had been the principal opposing figures in the strike that led to cancellation of the 1994 World Series and was settled only after most of the 1995 spring training session had been wiped out. They stood at the opposite poles of the labor war. An earlier attempt by President Clinton to mediate the strike had failed. Garagiola's suggestion had many positive overtones.

Garagiola went on, "The President said, 'I'll talk to my scheduling people.' Well, it worked out. We had the press conference, we went to the ball game with the President, were seen with him, and that really gave us the Good Housekeeping Seal of Approval. Now we were really off and running.

"We got even more funding from The Robert Wood Johnson Foundation in 1997--for three years--to try and get the final piece--cessation programs. We've talked to Major League Baseball and the Players Association and they've agreed to do a cessation program--the job now is to make sure it gets put in place. We can't just do it with brochures. Players have to have experts to help them quit. Guys would walk up to me in the clubhouse after our presentation and say, 'Man, I want to quit.' We want to get to a point where the team doctors and dentists can provide the help. Rather than the players coming up to me for advice ... that wasn't cuttin' it. I'd feel inadequate giving a brochure. So now the players can get checked regularly for signs of oral cancer at spring training and the cessation specialists will be there to help the players who want to quit.

"We'll start to work on the rural areas with rodeo, 4-H kids, colleges, baseball coaches, and the NCAA. That's how we'll spread the word and get the message out. When I spoke to two thousand coaches of the ABCA (that's the American Baseball Coaches Association) in Dallas, I couldn't believe the number of coaches and managers that were using spit tobacco even though they have a big campaign on: 'If you spit, you sit.' I also spoke at the Little League Congress twice trying to get coaches to spread the word. I want these coaches to be ambassadors. It's like throwing a rock out on the lake and getting the ripple effect. I'm deputizing these guys to go back to their towns and carry out the NSTEP, or National Spit Tobacco Education Program, campaign. But when I did a gig for the Arizona State University baseball team, I asked how strongly it was enforced. 'One of the first things the umpires say,' a coach told me, 'is "look, if you're going to use the stuff, try not to use it in the open, okay?"' So they're not encouraging it, but they certainly are condoning it, because they don't want to be watchdogs.

"On the other hand," Garagiola said, "the trainers have been terrifically supportive--minor league, major league, colleges, all of them. Supportive from day one had been Fehr and Gene Orza of the Players Association; Len Coleman and Gene Budig, the major league presidents; and Bud Selig. In one sense, baseball gets a bad rap. People say, 'Look at the big leaguers who use it.' But now we're getting kids into the system who use it in high school and college, as if the big leaguers made them do it. Somehow, baseball has got the reputation that tobacco--chew and dip--are part of baseball tradition. Well, as I tell everybody, cancer has never been a tradition.

"More and more prominent players are speaking out for us. Our poster shows one star from every team. Mark McGwire, whose father is a dentist, told a St. Louis audience recently, 'You know how I feel about spit tobacco. It doesn't help you hit. Don't do it. Don't start.' Major league baseball has been most supportive, and many big stars are speaking up for us. And I'll never forget what Mantle and Aaron did for us."

Listening to Garagiola's account, I was struck by two things in particular. One was the possibility suggested by the incident of spreading the word to the wives. Perhaps the best targets for this education campaign are girls and young women. They have the most direct effect on the behavior of boys and men in the same age group. If girls can be persuaded to show boys that they, the girls, find spit tobacco use disgusting, a powerful force against its use might be generated. The other was how much could be accomplished by one determined and talented person who could continue to be motivated through long periods of little visible result.

Of course, Joe had certain advantages that most people don't. The breadth of his contacts and friendships throughout the baseball world, along with his degree of celebrity, gave him access to people who were also notables in this field. It also gave his message credibility. As an ultimate insider, he had an opportunity outsiders can't match. The steps by which Garagiola moved to develop a wider level of support--his persistence and creative use of publicity when the right circumstances presented themselves--can guide all sorts of health education projects.