Hope or Hype?

At a public hospital in Minneapolis, a physician leads a half-dozen medical students in a discussion on spirituality and health. Posing a question that might have been unthinkable in this secular setting only a few years ago, a student asks, “Is it OK to pray with a patient?”

At a strip mall in Sedona, Ariz., a mecca of the New Age, an Illinois woman who underwent surgery and radiation therapy for a brain tumor visits a naturopath. The “healer” prescribes herbal tinctures, made in an adjacent shop reminiscent of a 19th-century apothecary, to ease her depression.

“My neurologist wasn’t very helpful with that,” the woman says of the disease’s crushing emotional fallout.

At a retirement village in Laguna Hills, an osteopath tells a gathering of senior citizens about unapproved, and perhaps dangerous, treatments for heart disease, stroke and dementia. He jokes about appearing on a list of “quacks” assembled by a watchdog group.

“That’s how we know you’re good,” says a woman in the audience. “If you’ve been to jail, you’re even better!”

Here in all its promise and peril is America’s expanding alternative medicine movement, a vast hodgepodge of treatments, practices and products embraced by young and old.

Once a counterculture phenomenon, alternative medicine is now an $18-billion industry edging into the mainstream, with California leading the rest of the nation. Although it is gaining fast in popularity, alternative medicine is still very much an experiment--one that huge numbers of Americans are conducting with themselves as the guinea pigs.

The movement is touching tens of millions of lives, reshaping the health care system, and pumping enormous sums into industries and professions whose considerable political clout belies any image of the humble neighborhood folk healer.

Despite its astonishing growth, alternative medicine remains riddled by uncertainty and controversy, polarized over even the most basic issue of what constitutes proof that a treatment actually works.

In contrast with standard medicine, government agencies provide relatively little oversight of many alternative practices. Lacking such safeguards, consumers have reasons for concern.

Testing conducted for The Times by an independent laboratory, for example, raises questions about the consistency and quality of some herbal supplements.

Surveying the scene last year, the American Medical Assn.’s Council on Scientific Affairs issued a bottom line that offers consumers small comfort: “There is little evidence to confirm the safety or efficacy of most alternative therapies.”

The label “alternative medicine” covers a range of products and treatments, some derived from centuries-old spiritual and healing traditions of non-Western societies, others as new and high-tech as pressurized oxygen chambers. What all have in common is that they fall outside the list of “standard” therapies approved by government agencies and the medical authorities.

Even advocates acknowledge the deep uncertainty about the impact that alternative medicine is having. “Is this movement taking our health care system backward, or is this the health care system moving forward and maturing?” asks George DeVries, president of American Specialty Health Plans, a San Diego insurance provider covering alternative practices.

Questionable scientific evidence has not kept medical centers and insurance companies--formerly hostile to alternatives--from hopping aboard the trend. Alternative medical practices may provide health plans with a relatively low-cost feature that is attractive to consumers, many entrepreneurs hope. Six major health insurance firms in California decided this year, for example, to cover acupuncture and traditional Chinese medicine.

Cedars-Sinai Medical Center in Los Angeles opened its Integrative Medicine Program in May, after a year of internal debate and turmoil over the legitimacy of offering acupuncture, chiropractic, mind-body techniques and herbs. The Stanford University Medical Center opened a similar patient care program in April.

Californians, ever the experimenters, appear to be blazing the alternative path, according to a Los Angeles Times poll conducted this spring. Statewide, 35% of those polled said they had tried high-dose vitamins at some point in their lives; 32%, chiropractic; 11%, homeopathy; and 8%, acupuncture. Those figures are roughly twice as high as levels found in recent nationwide polls.

No alternative approach has grown more quickly than herbal supplements, from St. John’s wort for mild depression to black cohosh for premenstrual syndrome.

Americans will spend some $3.65 billion on herbal remedies this year, a 100% increase since 1994. Advocates view the herbal boom as a long-overdue embrace of nature’s kinder, gentler drugstore, since many effective pharmaceuticals have been derived from plants. But critics lament the fad as a return to the days of patent medicine, when all kinds of healing powers were ascribed willy-nilly to mysterious herbal blends.

The growing appeal of alternative medicine is complex. Significantly, many people believe that the treatments work for them, sometimes when standard therapies have fallen short. Other attractions are rooted in ‘60s-style enthusiasm for things natural and ‘90s-style frustration with high-tech medicine and managed care. The overt emphasis on spirituality offered by practices such as India’s traditional medicine, ayurveda, also attracts followers. Then there is the eagerness of now-middle-aged rebels to question the medical powers that be.

Baby boomers “won’t trust just one authority,” said Dr. David Eisenberg, head of the Center for Alternative Medicine Research at Beth Israel Deaconess Medical Center in Boston. A study by Eisenberg estimated that in 1990 Americans spent just under $14 billion on alternative medical practices, a figure updated to $18 billion for 1996 by Nutrition Business Journal.

Whatever the impetus, the alternative quest is transforming medical practice. It wrests decision-making control from physicians, empowering lay people and alternative practitioners--scrupulous and shady alike. And it rattles medicine’s scientific foundations, in that increasingly popular practices such as energy healing and homeopathy defy explanation, if not the laws of nature.

“Yes, patients have needs that are not being met by mainstream medicine, but these needs do not include being subjected to bogus tests, claims and treatments,” said Dr. Lawrence J. Schneiderman, a family medicine specialist and ethicist at UC San Diego.

“Although mainstream medicine is often accused of exploiting its power, it is quite striking to me how much power the alternative medicine establishment has wielded throughout the country with so little demonstration of [effectiveness].”

Increasingly, scientists are attempting to fill the evidence gap. Through the Office of Alternative Medicine, a lightning rod for controversy since opening in 1992, the National Institutes of Health spends some $14.5 million annually on research. For the first time, the flagship journal of the American Medical Assn.--formerly a dedicated adversary of unorthodox practices--will devote an entire issue this November to studies evaluating various alternative treatments.

“There has been a rapid increase in the desire of American physicians to learn about alternative medicine,” said the journal’s editor, Dr. George Lundberg.

Though numerous high-profile physicians and others have tried to effect a truce between the alternative and mainstream camps, the fighting remains fierce. Scientific hard-liners say proponents of alternative therapies are “quacks” or purveyors of “pseudo-medicine,” and that adherents are in thrall of “delusional beliefs.”

Groups such as the Center for the Scientific Investigation of the Paranormal, the Skeptics Society and the National Council Against Health Fraud argue that alternative medicine has no more credibility than astrology, alien abductions or psychic hotlines.

On the other side are advocates, some researchers and many patients, who say that ancient healing systems have evolved gentle, effective methods overlooked by scientific medicine.

“The stance that there’s nothing to [alternative] therapies and the position that it’s just quackery is itself not a scientific position,” said John Astin, a Stanford University health psychologist. “The scientific position is to stay open-minded and examine whether the therapies are safe and potentially useful strategies.”

Dr. Andrew Weil, a University of Arizona physician whose gray-bearded visage is an icon of the alternative movement, promotes what he calls “integrative” medicine in best-selling books, in his monthly newsletter and on the World Wide Web.

“In some cases, Western medicine is the right thing to do and in others it isn’t. In other cases, you want to do a combination” of both. Ultimately, he said in an interview, the goal of research on alternatives is to “pick out what’s useful and discard what is not.”

Frustration With Traditional Medicine

Paradoxically, the alternative medicine movement appears to be reaching full flower at the close of a century whose greatest gift to humanity, some historians say, is scientific medicine. Mainstream Western medicine has been a major force behind an unprecedented lengthening of life expectancy, from 48 in 1900 to 76 in the United States today.

Alternative medicine is flourishing partly because of the successes of scientific medicine and public health: As more people have survived into old age, a spectrum of chronic, debilitating disorders has become more common.

And Western medicine, keyed to the acute medical crisis and the heroic life-saving measure, has made considerably less progress against lingering problems such as Alzheimer’s disease, arthritis and chronic pain, said Michael Goldstein, a professor of public health at UCLA.

“There is a negative feeling toward conventional medicine’s ability to deal with certain problems, particularly chronic disease,” he said.

Medicine’s successes have also fostered the alternative movement by creating unreasonable expectations, said Dr. John Renner, head of the Consumer Health Information Research Institute and a frequent critic of unproven therapies.

“As more medical problems get solved, the unsolved ones become very frustrating to people. There is a great myth that we can solve anything. If the doctor can’t tell them what to do, people think, ‘I can find it on the Internet,’ or, ‘Someone is hiding it from me.’ ”

Yet another impetus has been the rise of managed care, which many patients say has brought out the worst in mainstream medicine.

In contrast to managed care’s reputation for medicine by stopwatch, many types of alternative healers are known for listening to patients’ stories, offering comforting treatments, and perhaps charging less as well.

“This movement kind of goes back to the old days when nurses gave back rubs,” said Terry Winkowski, vice president of Casa Colina Centers for Rehabilitation, where alternative therapies are highly regarded. Many alternative treatments are “a lot like the way medicine used to be.”

Or as Stanford’s Dr. David Spiegel and his co-authors recently said in the Western Journal of Medicine: “The appetite for complementary medicine is stimulated by a need for attention and compassion that many patients are not getting in modern biotechnological medical care.”

Tish Pollack illustrates the tension that can arise between patients and conservative physicians. A 39-year-old Los Angeles resident with spondylitis, a degenerative joint disorder that gives her stabbing hip and back pain, Pollack asked her physician, a top-flight Beverly Hills rheumatologist, if acupuncture might help.

He scoffed--and is now her former physician.

“He pooh-poohed everything,” she said. “I found another doctor who gave me a prescription for acupuncture. His attitude was, ‘If it works, great.’ ”

The ancient Chinese needle treatments did help Pollack, she said, along with a stretching and exercise program also undertaken with her new physician’s blessing.

What she really liked, though, was that her acupuncturist and new physician approached her as a “whole person,” as she puts it, rather than a mere bunch of symptoms to be zapped with the latest drug or technology.

That “holistic” approach was the leading reason people gave for seeking alternatives in one of the most detailed surveys of the issue. In a national poll of 1,035 people, Astin found that people who pursued alternative treatments were much more likely than others to agree with the statement: “The health of my body, mind and spirit are related, and whoever cares for my health should take that into account.”

Picking Up Speed in the ‘90s

Although historians trace the resurgence of alternatives to the back-to-nature 1960s, the ‘90s have given this once-fringe activity broad new legitimacy. In 1994, two years after the NIH opened its alternative medicine office, Congress passed the Dietary Supplement Health and Education Act, which gave manufacturers of vitamins, minerals and herbs wide latitude to market products without having to prove them safe and effective.

The new law “signaled Congress’ recognition that there is a whole other branch of healing,” said Michael H. Cohen, a professor at Chapman University School of Law in Orange and author of a new book on alternative medicine. “It made it safe to talk about complementary and alternative medicine for the first time.”

Today, as alternative treatments spread in popularity, practitioners are increasingly tapping into new markets--particularly the elderly, who may be especially susceptible to exorbitant claims, and children, who appear to be increasingly the customers coveted by purveyors of dietary supplements and other alternative treatments.

Both these developments raise disturbing medical and ethical questions, critics say.

At Leisure World, a retirement village in Laguna Hills, dozens of residents gathered one recent evening to hear osteopath David Steenblock promote chelation therapy (which involves infusions of drugs designed to remove minerals from the bloodstream) and hyperbaric oxygen therapy (placing patients in a high-oxygen chamber) for heart disease, arthritis, dementia and stroke.

Those therapies are highly controversial--some physicians say worthless and perhaps dangerous--but that did not seem to trouble the audience or Steenblock.

Drawing appreciative gasps from his audience, Steenblock told one elderly woman considering hip replacement surgery: “If you come to me and had hyperbaric oxygen therapy, you could rebuild that hip.”

Steenblock, whose Health Restoration Center is in Mission Viejo, did not mention that a hyperbaric oxygen chamber at his former clinic blew up in 1994, injuring four people. Nor did he say that the Osteopathic Medical Board of California has put him on probation for hiring unlicensed physical therapists, failing to document his treatments, failing to warn patients of side effects, and gross negligence in the case of a 13-year-old girl who later died. And the osteopathic board has filed a petition to take further disciplinary action against him.

Steenblock’s attorney, Laura D. Cason of Walnut Creek, said her client’s actions regarding the physical therapists were proper. “They were at all times directly supervised by a physician,” she said.

Astin, of Stanford, has found that 40% of elderly Californians said they had tried an alternative treatment in the previous year. But little is known about the effects of those treatments, researchers say.

Children also appear to be a growing audience for alternative practitioners and treatments--especially herbal supplements.

Kavatrol, made by the Chatsworth company Natrol, is an herbal preparation containing extract of kava kava, a Polynesian plant prized for its sedative properties. This fall, the company plans to release Kavatrol for Kids, a chewable tablet meant for children 6 to 12 who have anxiety problems or trouble relaxing.

However, no studies on kava kava’s active ingredients have been done in the United States on adults, let alone children. And even the pro-industry Herb Research Foundation has recommended that kava not be used by anyone under 18.

Other manufacturers interested in the children’s market have created Yummi Bears, a multivitamin supplement resembling a popular gummy candy, and Zinc Pops, a lollipop containing zinc, which has been shown in some studies of adults to limit cold symptoms. The fact that zinc can be toxic in large doses has led health advocates to question the wisdom of marketing it in a product that resembles candy.

The greatest potential harm of alternative treatments, medical experts agree, would be for a patient in dire need to shun standard therapy for an unorthodox treatment that does not work. That appears to be what happened to Debbie Benson.

Benson was 54 when she was diagnosed with breast cancer. A nurse in Portland, Ore., she underwent surgery to have the tumor removed, but declined chemotherapy and radiation therapy, which usually follows lumpectomy, because of her deep disenchantment with standard medicine.

“She had a vision of herself as a warrior making a principled stand against the evils of modern medicine,” said her friend of three decades, Sallie Francis, a psychotherapist in Berkeley.

Instead of chemotherapy, Benson turned to other healers, including naturopaths, who are licensed in Oregon and 12 other states to serve as primary caregivers. They administer natural remedies such as acupuncture, homeopathy, nutrient supplements and herbal products.

Among other things, Benson received a mysterious salve from a naturopath that was supposed to draw the cancer out of her body, recalled her former oncologist, Dr. Steve Chandler; her brother, Paul Benson; and a longtime friend, Kenneth Spiker, a woodworker in Fort Bragg, Calif. When her treatments failed, Spiker said, one of the healers blamed Benson, saying shehad “given up.”

The cancer spread to her lymph nodes, liver and lungs, her brother said, and she died in July 1997, a little more than a year after being diagnosed. Generally, a woman with breast cancer has an 86% chance of surviving five years if she receives standard medical care, according to the American Cancer Society.

Her brother, a computer programmer in New Jersey, said he was open to alternatives and supported his sister’s right to choose the care she wanted. But, looking back, he doubts that the natural healers were completely honest with Debbie about their ability to reverse her cancer.

“I guess she lowered her chances [of survival] by not having conventional treatment,” Paul Benson said.

Homeopathy Among Most Controversial

Between the experiences of Tish Pollack, whose embrace of alternative medicine may have led to relief, and Debbie Benson, whose rejection of standard therapy may have hastenedher death, lies a vast unknown.

“The hardest challenge right now is the gray area--where we know something doesn’t hurt [patients] but we don’t know if it helps them,” said Marla Orth, CEO of Landmark Health Care, an alternative managed care company based in Sacramento.

For many practices, little is known at all. Five of the 20 top-selling herbs--goldenseal, cat’s claw, astragalus, dong quai and grape seed extract--have never been subjected to a controlled clinical study, said Norman Farnsworth, an expert in herb pharmacology at the University of Illinois.

Chiropractic manipulation has been shown to be effective at treating garden-variety acute low-back pain. But on the question of chronic pain, “it seems uncertain whether chiropractic does more good than harm,” the British Medical Journal concluded in an editorial last month.

Then there is homeopathy--one of the most controversial alternative treatments.

Devised two centuries ago by a German physician named Samuel Hahnemann, homeopathy is based on the theory that extremely diluted extracts of various natural substances could ameliorate diseases, presumably by inducing mild symptoms of the disease itself. Hence the name homeopathy, which means “like treats like.”

What riles scientists is the treatment’s seeming irrationality: Some homeopathic preparations are so diluted that the laws of physics dictate that they contain no extract at all. Proponents agree, but counter that science has not figured out how the treatments work.

That makes critics fume. “Homeopathy does not work--period,” said Dr. Wallace Sampson, a retired oncologist and editor of the Scientific Review of Alternative Medicine, a skeptical publication.

Homeopathy also fails to impress some experts who are comfortable with other alternatives.

“The great virtue of homeopathy is it can’t hurt people,” Weil said in an interview. But it is “not one I’m inclined to use a lot myself,” he added.

Many academic scientists also doubt the existence of the “meridian” system of traditional Chinese medicine, a sort of bodily energy grid that acupuncturists assert they tap into with their needles, piercing particular points to elicit particular healing responses.

Some experts who believe that acupuncture does relieve some aches and pains still argue that the underlying meridian system is irrelevant; piercing the skin with needles activates natural pain-killing neurochemicals, they say, regardless of where the needles are placed.

Yet another disputed facet of traditional Chinese medicine is “pulse diagnosis,” in which the practitioner feels a patient’s wrist pulse, claiming to detect the condition of several different organ systems.

“There is no scientific explanation for how you can put three fingers on the radial pulse of the wrist and obtain a reading of six different organs, but it has worked well for a thousand years,” said Dr. Ira Zunin, president of Mana Kui International, a provider of acupuncture and other alternative services in Hawaii.

Other debates surround the mind-body link--and the question of how much practitioners may be able to influence it.

Few doubt the value to an addled spirit of meditation or focused relaxation, onetime marginal activities that have been taken up in earnest by the likes of Harvard Medical School. A growing body of research suggests that meditating, combined with a very low-fat diet and plenty of exercise, can reduce cardiovascular disease risk.

But what about guided imagery--imagining one’s disease-fighting cells doing battle with, say, a tumor? Or hypnosis? Or prayer? Studies of those techniques have yielded some encouraging results. Skeptics, however, counter that the studies have been too skewed or subjective to withstand scrutiny.

A more vivid example of the mind-body dispute is therapeutic touch, or energy healing, advocated by some 40,000 nurses in North America. Practitioners, focusing their minds on healing, move their hands above a reclining patient’s body to adjust disrupted “energy fields.”

But do such fields even exist? A study of two dozen practitioners recently published in the Journal of the American Medical Assn. found that practitioners could not reliably detect another person’s “energy field,” thus undermining a cornerstone of the practice.

Supporters of therapeutic touch argue that science simply has not solved the mystery of human energy fields.

Skeptics, however, say it is not intellectually honest to invoke undiscovered forces as proof of a treatment’s effectiveness. “Something like therapeutic touch is . . . biologically not only implausible but ludicrous,” said Dr. Marcia Angell, executive editor of the New England Journal of Medicine. “And yet people believe in it. People are beginning to [drop] any effort at critical analysis of these things and just embrace superstition.”

In many cases, consumers care less about theories than perceived benefits. Sunshine Au, a Manhattan Beach real estate agent, said she visits a traditional Chinese herbalist about once a month.

At the Tak Shing Hong store in Los Angeles’ Chinatown, she displayed a collection of dried plants prescribed to her by a state-licensed acupuncturist, who occupied a desk inside the store.

After testing Au’s pulse, the acupuncturist said her stomach was “weak,” and the herbs, which Au planned to steep and drink as a tea before bedtime, were to “help my blood flow,” she was told.

“I find [the herbs] give me tremendous energy,” she said. “I’m 58, work seven days a week, 10 hours a day, and I’m still a size 4. I still believe in modern medicine. I get mammograms and so forth.” But, she said, the traditional Chinese herbs she has been taking for the last 20 years enable her to squeeze the most vitality out of “every minute of life.”

Further exploration of alternative treatments may reveal that what people like Au experience is nothing more than a placebo response--the well-established phenomenon in which a “treatment” as inactive as a sugar pill can spur patients to get better simply because they believe they will.

That is no small matter, said Dr. Kat Kit Hui, director of the UCLA Center for East-West Medicine. The “placebo response,” he argues, is central to the body’s ability to heal itself, and alternative practices that trigger the response should be cultivated, not dismissed.

Different Standards of Proof

Beneath such arguments lies a more profound disagreement over what people are willing to accept as “proof” of a cure.

For scientists, the gold standard for testing a treatment’s effectiveness has for decades been what researchers refer to as a randomized, placebo-controlled, double-blind trial: Patients are randomly placed either into a group that receives the treatment being tested or a control group that receives a placebo. Neither the researchers nor the subjects know which group is which until the study is over.

Although that kind of study may be ideal for testing a drug or herbal supplement, it does not so readily lend itself to many alternative treatments, advocates say. It is hard to think of a convincing placebo for the likes of chiropractic manipulation or group counseling, they say.

So tests of those sorts of treatments fail to impress mainline academic scientists.

Even worse, they say, are testimonials or anecdotes--uncorroborated success stories. In Weil’s “Spontaneous Healing,” he relates such stories, including those of John, who got rid of a rash by eating lemons and applying vinegar, and Kristin, who overcame aplastic anemia partly by consulting a psychic healer.

Narratives like that are what sell alternative medicine, objects Angell--”anecdotes with a very loose glue of the sheerest speculation about how this miracle treatment might work. But no data. No scientific evidence worthy of that name.”

Critics such as Angell fear that excessive tolerance of alternative methods is leading to the dumbing down of the profession--a prevailing “medical correctness” that keeps physicians from speaking out against what they believe are nonsense treatments, lest they alienate patients/customers.

“We owe it to patients to be honest with them,” said Angell, and treat them like “grown-ups.”

Weil, by contrast, defends success stories as a catalyst for further study. “I get very irritated . . . when people dismiss the kinds of case examples I give as being anecdotes. That trivializes something.

“Science begins with uncontrolled observation where there is something interesting, and that gives you the idea to set up some controlled experiment,” he said. “But just to insist that the only thing you’re going to look at is the results of randomized, clinical trials, that’s not good science.”

Others hope for a synthesis, arguing that most mainstream treatments have never been subjected to controlled trials. Instead, they are in use largely because they have stood the test of time.

In trying to raise awareness of the pitfalls of alternative medicine, critics suggest that physical harm is not the only risk. “It’s dangerous for the public to have false health beliefs,” Renner said. “Even if [a treatment] is harmless, it gets people involved in illogical thinking. It can mess up their ability to think logically later on.”

“There is no question that people are putting too high hopes on alternative medicine,” Goldstein countered. But “having high hopes is in the nature of healing.”

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Growth Spurt

HERBAL SUPPLEMENT SALES IN U.S.

* $2.09 billion in 1994

* $3.65 billion in 1997

NUMBER OF HOMEOPATHS

* 200 in 1970

* 3,000 in 1998

MASSAGE SCHOOLS

* 15 in 1969

* 800 in 1998

DRUGSTORE SHELF SPACE

Space per store for vitamin, mineral and herb supplements at Rite-Aid pharmacies

File name: Alternative Medicine Day 1 A1

* 8 feet in 1995

* 22 feet in 1998

Sources: Nutrition Business Journal, Business and Health, Rite-Aid Pharmacies, Times files

Alternative Care Use in the Last Year

Californians, according to a Los Angeles Times poll, are about twice as likely to have used alternative medical practices as are people nationwide.

IN CALIFORNIA

Chiropractic: 32%

Herbal products: 30%

Homeopathy: 11%

Hi-dose Vitamins: 35%

Acupuncture: 8%

Other: 11%

Source: L.A. Times Poll of 1,409 people. Results are plus or minus 2%.

*

IN THE U.S.

Chiropractic: 16%

Herbal products: 17%

Homeopathy: 5%

Hi-dose vitamins: 13%

Massage: 14%

Acupuncture: 2%

Source: Landmark Healthcare 1997 survey of 1,300 households.

Changes in Opinion

A significant percentage of Americans have become more enthusiastic about alternative health care in the last five years.

More Positive: 40%

Remained same: 58%

More Negative: 2%

Source: Landmark Healthcare

Improving Impressions

Of the people who say they have more positive attitudes on alternative care, personal experiences are often cited as an explanation.

Learned more about it: 47%

Had positive experience: 41%

Friend/relative had positive experience: 23%

Media made me open-minded: 22%

Not satisfied with traditional care: 11%

Source: Landmark Healthcare

About This Series

Today--Growing at an astonishing rate, the alternative medicine movement has moved into the mainstream. But do these treatments work?

Monday--Independent laboratory tests raise questions about whether herbal supplements live up to their advertised potency.

Plus--Alternative practices: what are they, how do they work? In the Health section.

Tuesday--How Utah has become the headquarters of the nation’s herbal supplement business.

Wednesday--HMOs and hospitals are jumping onto the alternative medicine trend but often are cutting corners as they do so, experts warn.

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How the Poll Was Conducted

The Times Poll contacted 1,409 adults in California by telephone April 4-9. Telephone numbers were chosen from a list of all exchanges in the state. The margin of error for all adults is plus or minus 3 percentage points. Interviews were conducted in English and Spanish.