This paper examines the relationship between the public health community and the tobacco industry within the framework of a two-factor model of trust and distrust (Lewicki, McAllister & Bies, 1998). We assert that public health’s historical and current interaction with Big Tobacco is best characterized as one of Low Trust/High Distrust, marked by ongoing hostility and preemption. Forced-trust measures based on regulation and litigation and efforts by the tobacco industry to collaborate with public health activists are unlikely to elevate the longer-term level of trust in this relationship, without significantly fuller or more voluntary compliance by tobacco companies. We conclude that distrust of the industry has served and continues to serve multiple purposes for public health activists. There is little incentive for tobacco control activists to adopt a more trusting stance toward the industry, and significant justification for them to maintain a high level of distrust.