Question 1 tobacco education expenditures in Massachusetts, USA

BACKGROUND: In 1992, voters in Massachusetts (United States) approved Question 1, a state ballot initiative, which raised the state excise tax to provide funds for tobacco education. OBJECTIVE: To examine Question 1 expenditures for tobacco-specific programmes in the 1994, 1995, 1996, and 1997 fiscal years. DESIGN: This study examined trends in Question 1 expenditures. Data were collected from the Massachusetts Department of Public Health and the Massachusetts Department of Revenue for the 1994, 1995, 1996, and 1997 fiscal years. MAIN OUTCOME MEASURES: The amount of spending on tobacco-specific programmes. RESULTS: Excluding the 1994 fiscal year because the state allocated 18 months of new revenues, from the 1995 fiscal year to the projected 1997 fiscal year, the state will have spent 22% of Question 1 funds for tobacco- specific programmes. Question 1 expenditures for tobacco-specific programmes have declined by 15%, whereas Question 1 expenditures for the other programmes decreased only 0.4%. CONCLUSIONS: The legislature has established a trend that has produced real reductions in Question 1 funding for tobacco education, which appears contrary to the mandate of the voters when they enacted Question 1 in 1992. These reductions undermine the effectiveness of tobacco-specific programmes that are an integral part of the Massachusetts Tobacco Control Programme. These results also highlight the fact that the initial compromises made after initiatives such as Question 1 are adopted have important long-term consequences for funding of tobacco control initiatives.


     

Arizona's tobacco control initiative illustrates the need for continuing oversight by tobacco control advocates

BACKGROUND: In 1994, Arizona voters approved Proposition 200 which increased the tobacco tax and earmarked 23% of the new revenues for tobacco education programmes. OBJECTIVE: To describe the campaign to pass Proposition 200, the legislative debate that followed the passage of the initiative, and the development and implementation of the tobacco control programme. DESIGN: This is a case study. Data were collected through semi-structured interviews with key players in the initiative campaign and in the tobacco education programme, and written records (campaign material, newspapers, memoranda, public records). RESULTS: Despite opposition from the tobacco industry, Arizonans approved an increase in the tobacco tax. At the legislature, health advocates in Arizona successfully fought the tobacco industry attempts to divert the health education funds and pass preemptive legislation. The executive branch limited the scope of the programme to adolescents and pregnant women. It also prevented the programme from attacking the tobacco industry or focusing on secondhand smoke. Health advocates did not put enough pressure at the executive branch to force it to develop a comprehensive tobacco education programme. CONCLUSIONS: It is not enough for health advocates to campaign for an increase in tobacco tax and to protect the funds at the legislature. Tobacco control advocates must closely monitor the development and implementation of tax-funded tobacco education programmes at the administrative level and be willing to press the executive to implement effective programmes.     

An analysis of the successful 1992 Massachusetts tobacco tax initiative

In November 1992, voters in Massachusetts (United States) passed a statewide tax initiative adding an extra 25 cents to the price of a pack of cigarettes. The Massachusetts Coalition for a Healthy Future, led by volunteers from the Massachusetts Division of the American Cancer Society, achieved this victory, despite a public anti-tax mood and $7.3 million spent by the tobacco industry. The tax has since generated millions of dollars for tobacco education and control programmes, leading to acceleration of the decline of tobacco consumption in the state. An analysis of the passage of this initiative should help other states considering this approach to tobacco control.


     

The passage and initial implementation of Oregon's Measure 44

OBJECTIVE: To prepare a history of the passage and early implementation of Ballot Measure 44, "An Act to Support the Oregon Health Plan", and tobacco control policymaking in Oregon. Measure 44 raised cigarette taxes in Oregon by US$0.30 per pack, and dedicated 10% of the revenues to tobacco control. METHODS: Data were gathered from interviews with members of the Committee to Support the Oregon Health Plan, Measure 44's campaign committee, as well as with state and local officials, and tobacco control advocates. Additional information was obtained from public documents, internal memoranda, and news reports. RESULTS: Although the tobacco industry outspent Measure 44's supporters 7 to 1, the initiative passed with 56% of the vote. Even before the election, tobacco control advocates were working to develop an implementation plan for the tobacco control programme. They mounted a successful lobbying campaign to see that the legislature did not divert tobacco control funds to other uses. They also stopped industry efforts to limit the scope of the programme. The one shortcoming of the tobacco control forces was not getting involved in planning the initiative early enough to influence the amount of money that was devoted to tobacco control. Although public health groups provided 37% of the money it cost to pass Measure 44, only 10% of revenues were devoted to tobacco control. CONCLUSIONS: Proactive planning and aggressive implementation can secure passage of tobacco control initiatives and see that the associated implementing legislation follows good public health practice.     

Tobacco control advocates must demand high-quality media campaigns: the California experience

OBJECTIVE: To document efforts on the part of public officials in California to soften the media campaign's attack on the tobacco industry and to analyse strategies to counter those efforts on the part of tobacco control advocates. METHODS: Data were gathered from interviews with programme participants, direct observation, written materials, and media stories. In addition, internal documents were released by the state's Department of Health Services in response to requests made under the California Public Records Act by Americans for Nonsmokers' Rights. Finally, a draft of the paper was circulated to 11 key players for their comments. RESULTS: In 1988 california voters enacted Proposition 99, an initiative that raised the tobacco tax by $0.25 and allocated 20% of the revenues to anti-tobacco education. A media campaign, which was part of the education programme, directly attacked the tobacco industry, exposing the media campaign to politically based efforts to shut it down or soften it. Through use of outsider strategies such as advertising, press conferences, and public meetings, programme advocates were able to counter the efforts to soften the campaign. CONCLUSION: Anti-tobacco media campaigns that expose industry manipulation are a key component of an effective tobacco control programme. The effectiveness of these campaigns, however, makes them a target for elimination by the tobacco industry. The experience from California demonstrates the need for continuing, aggressive intervention by nongovernmental organisations in order to maintain the quality of anti-tobacco media campaigns.     

Cigarette taxation in China: lessons from international experiences

This paper draws upon the experiences of foreign countries in implementing tobacco taxation to provide lessons the Chinese government can use when considering the feasibility of raising additional taxes on cigarettes. Based on current international data and Chinese published data, this paper concludes that there is still leeway to raise existing taxes. The Chinese government should consider conducting some pilot experiments in tobacco tax increases, with some of the new revenues allocated for tobacco control programmes as well as for financing healthcare services among the poor.


     

Was there significant tax evasion after the 1999 50 cent per pack cigarette tax increase in California?

OBJECTIVES: Several states, including California, have implemented large cigarette excise tax increases, which may encourage smokers to purchase their cigarettes in other lower taxed states, or from other lower or non-taxed sources. Such tax evasion thwarts tobacco control objectives and may cost the state substantial tax revenues. Thus, this study investigates the extent of tax evasion in the 6-12 months after the implementation of California's 0.50 dollars/pack excise tax increase. DESIGN AND SETTING: Retrospective data analysis from the 1999 California Tobacco Surveys (CTS), a random digit dialled telephone survey of California households. MAIN OUTCOME MEASURES: Sources of cigarettes, average daily cigarette consumption, and reported price paid. RESULTS: Very few (5.1 (0.7)% (+/-95% confidence limits)) of California smokers avoided the excise tax by usually purchasing cigarettes from non- or lower taxed sources, such as out-of-state outlets, military commissaries, or the internet. The vast majority of smokers purchased their cigarettes from the most convenient and expensive sources: convenience stores/gas (petrol) stations (45.0 (1.9)%), liquor/drug stores (16.4 (1.6)%), and supermarkets (8.8 (1.2)%). CONCLUSIONS: Despite the potential savings, tax evasion by individual smokers does not appear to pose a serious threat to California's excise tax revenues or its tobacco control objectives.     

Sociodemographic predictors of success in smoking intervention

AIM: To examine the role of sociodemographic factors as predictors of sustained smoking cessation for the population who volunteer to participate in intervention programmes. METHOD: Data for the 3575 smokers who participated in the CEASE (collaborative European anti-smoking evaluation) trial, a European multicentred study that used transdermal nicotine patches as an adjunct to smoking cessation in the chest clinic, were analysed. The effects of age, sex, smoking habit, socioeconomic status (housing conditions, education, and employment), disease, smoking habits of relatives, and baseline markers of tobacco use on sustained smoking cessation (self-reported abstinence and expired carbon monoxide < 10 parts per million) were assessed using logistic regression modelling (odds ratio (OR), 95% confidence interval (CI)). RESULTS: 477/3575 smokers were sustained abstainers one year after the intervention (overall success rate 13.3%). In the univariable logistic regression models an effect of active treatment on smoking cessation was observed (OR 1.50, 95% CI 1.15 to 1.96), and additional effects on outcome were found for age (OR 1.02, 95% CI 1.01 to 1.03), sex (men v women: OR 1.38, 95% CI 1.14 to 1.68), housing conditions (OR 1.43, 95% CI 1.25 to 1.65), current respiratory (OR 0.79, 95% CI 0.67 to 0.92) or cardiac disease (OR 0.46, 95% CI 0.28 to 0.75), and markers of tobacco use (cigarettes per day: OR 0.79, 95% CI 0.69 to 0.90; expired carbon monoxide: OR 0.98, 95% CI 0.97 to 0.99). Education and employment did not have a significant effect on the outcome. The effect of the variables associated with success in smoking cessation persisted after adjustment for covariates. CONCLUSION: Age, sex, and housing conditions have a major effect on smoking cessation in European smokers participating in smoking cessation programmes.     

Tobacco industry manipulation of the hospitality industry to maintain smoking in public places

OBJECTIVE: To describe how the tobacco industry used the "accommodation" message to mount an aggressive and effective worldwide campaign to recruit hospitality associations, such as restaurant associations, to serve as the tobacco industry's surrogate in fighting against smoke-free environments. METHODS: We analysed tobacco industry documents publicly available on the internet as a result of litigation in the USA. Documents were accessed between January and November 2001. RESULTS: The tobacco industry, led by Philip Morris, made financial contributions to existing hospitality associations or, when it did not find an association willing to work for tobacco interests, created its own "association" in order to prevent the growth of smoke-free environments. The industry also used hospitality associations as a vehicle for programmes promoting "accommodation" of smokers and non-smokers, which ignore the health risks of second hand smoke for employees and patrons of hospitality venues. CONCLUSION: Through the myth of lost profits, the tobacco industry has fooled the hospitality industry into embracing expensive ventilation equipment, while in reality 100% smoke-free laws have been shown to have no effect on business revenues, or even to improve them. The tobacco industry has effectively turned the hospitality industry into its de facto lobbying arm on clean indoor air. Public health advocates need to understand that, with rare exceptions, when they talk to organised restaurant associations they are effectively talking to the tobacco industry and must act accordingly.     

Tobacco lobby political influence on US state legislatures in the 1990s

BACKGROUND: Throughout the 1990s the tobacco lobby was a potent political force in US state legislatures advancing its pro-tobacco agenda. OBJECTIVE: To describe the market and political motivations of the tobacco lobby and the strategies they use to achieve these goals in US state legislatures. DESIGN: This study is a content analysis and summary overview of recently released historical tobacco industry documents; tobacco related government documents; and recent state tobacco control policy reports. RESULTS: In the 1990s, the tobacco lobby engaged in a comprehensive and aggressive political effort in state legislatures to sell tobacco with the least hindrance using lobbying, the media, public relations, front groups, industry allies, and contributions to legislators. These efforts included campaigns to neutralise clean indoor air legislation, minimise tax increases, and preserve the industry's freedom to advertise and sell tobacco. The tobacco lobby succeeded in increasing the number of states that enacted state pre-emption of stricter local tobacco control laws and prevented the passage of many state tobacco control policies. Public health advocates were able to prevent pre-emption and other pro-tobacco policies from being enacted in several states. CONCLUSIONS: The tobacco lobby is a powerful presence in state legislatures. Because of the poor public image of the tobacco lobby, it seeks to wield this power quietly and behind the scenes. State and local health advocates, who often have high public credibility, can use this fact against the tobacco lobby by focusing public attention on the tobacco lobby's political influence and policy goals and expose links between the tobacco lobby and its legislative supporters.     

Non-smoking policies, tobacco education, and smoking cessation programmes in facilities serving the elderly in Michigan, United States

OBJECTIVE: To determine the extent of and impetus for smoke-free policies in facilities serving Michigan's elderly, and the extent of tobacco education and smoking cessation programmes for elders and staff of these facilities. DESIGN: Telephone survey in February 1997 of three types of facilities serving Michigan's elderly population. SUBJECTS: Area Agencies on Aging (n = 12), Councils and Commissions on Aging (n = 31), and senior centres (n = 98) located in Michigan, USA. MAIN OUTCOME MEASURES: Prevalence of smoke-free policies, tobacco education, and smoking cessation programmes in facilities serving the elderly. RESULTS: 99% (95% confidence interval (CI) = 97% to 100%) of 141 facilities surveyed have an indoor smoke-free policy. Eighty-five per cent (95% CI = 79% to 91%) of these policies prohibit all smoking inside the facility. Forty-five per cent (95% CI = 37% to 54%) cited a law as requiring the smoke-free policy, whereas 38% (95% CI = 30% to 46%) indicated the policy was adopted voluntarily for health reasons. Forty-two per cent (95% CI = 34% to 50%) of the facilities provided some education on the dangers of tobacco, while 11% (95% CI = 6% to 16%) arranged smoking cessation programmes for staff or elders. CONCLUSIONS: In Michigan, a very high percentage of non-institutional facilities serving the elderly have smoke-free policies, which appear to increase participation at these facilities. Tobacco education programmes are provided in less than half the facilities, and very few arrange smoking cessation programmes for elders or staff.




     

Tobacco cessation skills certification in Arizona: application of a state wide, community based model for diffusion of evidence based practice guidelines

OBJECTIVE: To describe the development and preliminary results from a community based certification model for training in tobacco cessation skills in Arizona. DESIGN: A programme evaluation using both quantitative pre-post measures and qualitative methods. SETTING: Arizona's comprehensive tobacco control programme of state funded, community based local projects and their community partners providing tobacco treatment services for geographically, socioeconomically, and ethnically diverse communities. INTERVENTION: A three tiered model of skills based training emphasising Agency for Health Care Policy and Research guidelines, and utilising a training of trainers approach to build community capacity. Certification roles addressed basic tobacco cessation skills, tobacco cessation specialist, and tobacco treatment services manager. PARTICIPANTS: Initial target audience was community based local project personnel and their community partners, with later adoption by community organisations unaffiliated with local projects, and the general public. MAIN EVALUATION MEASURES: Process measures: participant satisfaction, knowledge, skills, and self-efficacy. Outcome: participant demographics, community organisations represented, post-training, cessation related activities. RESULTS: During the model's implementation year, 1075 participants attended certification training, 947 participants received basic skills certificates and 82 received specialist certificates. Pre, post, and three month measures of self efficacy showed significant and durable increases. Analysis of participant characteristics demonstrated broad community representation. At post-training follow up, 80.9% of basic skills trainees had performed at least one brief intervention and 74.8% had made a referral to intensive services. Among cessation specialists, 48.8% were delivering intensive services and 69.5% were teaching basic skills classes. CONCLUSIONS: Initial experience with Arizona's state wide, community based model for certification of tobacco cessation skills training suggests this model may be a promising method for broad, population based diffusion of evidence based tobacco cessation guidelines.     

Dissemination of an effective inpatient tobacco use cessation program.

The present study aimed to determine whether tobacco use cessation rates observed in controlled trials of a hospital-based tobacco use cessation program could be replicated when the program was disseminated to a wide range of hospitals in a two-stage process including implementation and institutionalization phases. Using a nonrandomized, observational design, we recruited six hospitals to participate in the study. The research team helped implement the program during the first year of participation (implementation) and then withdrew from active involvement during the second year (institutionalization). The mean 6-month self-reported cessation rates were 26.3% (range = 17.6%-52.8%) for the implementation phase and 22.7% (range = 12.9%-48.2%) for the institutionalization phase. Hospitals with paid professionals providing the program had the best outcomes. Inpatient tobacco use cessation programs are feasible to implement and should target a 6-month self-reported cessation rate of at least 25%.     

Political realities of statewide smoking legislation: the passage of California's Assembly Bill 13

OBJECTIVE: To prepare a history of the enactment of California Assembly Bill 13 (AB 13), a state law prohibiting smoking in most workplaces passed in 1994, and to discuss its initial impacts. METHODS: Data were gathered from open ended interviews with representatives of voluntary health organisations, local government organisations, and principal legislators involved in the process, as well as observers around the state who could provide insight into the legislative process. Information was also obtained from legislative hearings and debates, public documents, letters and personal communications, internal memoranda, and news reports. RESULTS: The success of local tobacco control legislation in California led to a situation in which some health groups were willing to accept state preemption in order to attract the support of the state restaurant association for a bill. The decision to accept this preemption compromise was made by the state level offices of the voluntary health agencies without consulting the broader tobacco control community within California. In contrast, local tobacco control advocates did not accept this compromise, in part because of their belief that local legislation was a better device to educate the public, generate media coverage, and build community support for enforcement and implementation of clean indoor air and other tobacco control laws. Enactment of AB 13 was associated with a slowing of all local tobacco control legislation, including youth oriented laws. CONCLUSIONS: Because its supporters initially doubted that AB 13 would pass, there was never an effort to reconcile the policy differences between state oriented and locally oriented tobacco control policies. This lack of consensus, combined with the political realities inherent in passing any state legislation, led to a bill with ambiguous preemption language which replaced the "patchwork of local laws" with a "patchwork of local enforcement."


     

Development of a model of the tobacco industry's interference with tobacco control programmes

Objective: To construct a conceptual model of tobacco industry tactics to undermine tobacco control programmes for the purposes of: (1) developing measures to evaluate industry tactics, (2) improving tobacco control planning, and (3) supplementing current or future frameworks used to classify and analyse tobacco industry documents. Design: Web based concept mapping was conducted, including expert brainstorming, sorting, and rating of statements describing industry tactics. Statistical analyses used multidimensional scaling and cluster analysis. Interpretation of the resulting maps was accomplished by an expert panel during a face-to-face meeting. Subjects: 34 experts, selected because of their previous encounters with industry resistance or because of their research into industry tactics, took part in some or all phases of the project. Results: Maps with eight non-overlapping clusters in two dimensional space were developed, with importance ratings of the statements and clusters. Cluster and quadrant labels were agreed upon by the experts. Conclusions: The conceptual maps summarise the tactics used by the industry and their relationships to each other, and suggest a possible hierarchy for measures that can be used in statistical modelling of industry tactics and for review of industry documents. Finally, the maps enable hypothesis of a likely progression of industry reactions as public health programmes become more successful, and therefore more threatening to industry profits.     

中国烟草重税政策对增加政府收入和减少烟草消费的影响

从历史的角度阐述了政府对烟草产品长期实行重税政策在增加政府收入中做出的重要贡献,分析了政府对烟草产品征收重税的基本理由是增加政府收入和减少烟草消费,找出了在减少烟草消费方面效果并不明显的原因,主要是烟草税收对各级政府的内在激励、卷烟价格结构的多层次性和卷烟承载的社会交往功能。      

British Columbia capital regional district 100% smokefree bylaw: a successful public health campaign despite industry opposition

Objective: To describe how the British Columbia Capital Regional District successfully passed, implemented, and enforced a 100% smokefree bylaw in all public places, including restaurants and bars, despite an aggressive campaign by the tobacco industry (acting through the hospitality industry) to stop it. Methods: Information was obtained from news reports, internal tobacco industry documents, reports, public documents, and interviews with key players. Tobacco industry documents were accessed between February and April 2002. This project was approved by the University of California San Francisco committee on human research. Results: As in the USA and elsewhere in the world, the tobacco industry in British Columbia, Canada, recruited and created hospitality associations to fight against the district smokefree bylaw. They used the classic industry rhetoric of individual rights and freedoms, economic devastation, and ventilation as a solution. Public health authorities were able to counter industry strategies with a strong education campaign, well written bylaws, and persistent enforcement. Conclusion: It is possible to overcome serious opposition orchestrated by the tobacco industry and develop and implement a 100% smokefree bylaw in Canada. Doing so requires attention to detail in drafting the bylaw, as well as a public education campaign on the health dangers of secondhand smoke and active enforcement to overcome organised resistance to the bylaw. Jurisdictions considering smokefree bylaws should anticipate this opposition when developing and implementing their bylaws.     

Fiscal versus social responsibility: how Philip Morris shaped the public funds divestment debate

Calls for institutional investors to divest (sell off) tobacco stocks threaten the industry's share values, publicise its bad behaviour, and label it as a politically unacceptable ally. US tobacco control advocates began urging government investment and pension funds to divest as a matter of responsible social policy in 1990. Following the initiation of Medicaid recovery lawsuits in 1994, advocates highlighted the contradictions between state justice departments suing the industry, and state health departments expanding tobacco control programmes, while state treasurers invested in tobacco companies. Philip Morris (PM), the most exposed US company, led the divestment opposition, consistently framing the issue as one of responsible fiscal policy. It insisted that funds had to be managed for the exclusive interest of beneficiaries, not the public at large, and for high share returns above all. This paper uses tobacco industry documents to show how PM sought to frame both the rhetorical contents and the legal contexts of the divestment debate. While tobacco stock divestment was eventually limited to only seven (but highly visible) states, US advocates focused public attention on the issue in at least 18 others plus various local jurisdictions. This added to ongoing, effective campaigns to denormalise and delegitimise the tobacco industry, dividing it from key allies. Divestment as a delegitimisation tool could have both advantages and disadvantages as a tobacco control strategy in other countries.     

Public health foundations and the tobacco industry: lessons from Minnesota

Objective: To investigate whether private foundations can be created in a way that will insulate them from attacks by the tobacco industry, using the Minnesota Partnership for Action Against Tobacco (MPAAT) as a case study.

Design: Information was collected from internal tobacco industry documents, court documents, newspapers, and interviews with health advocates and elected officials.

Results: The creation of MPAAT as an independent foundation did not insulate it from attacks by tobacco industry allies. During 2001–2002, MPAAT was repeatedly attacked by Attorney General Mike Hatch and major media, using standard tobacco industry rhetoric. This strategy of attack and demands for information were reminiscent of previous attacks on Minnesota's Plan for Nonsmoking and Health and the American Stop Smoking Intervention Study (ASSIST). MPAAT was ultimately forced to restructure its programme to abandon effective community norm change interventions around smoke-free policies and replace them with less effective individual cessation interventions. Neither MPAAT nor other health advocates mounted an effective public response to these attacks, instead relying on the insider strategy of responding in court.

Conclusion: It is not possible to avoid attacks by the tobacco industry or its political allies. Like programmes administered by government agencies, tobacco control foundations must be prepared for these attacks, including a proactive plan to educate the public about the principles of community based tobacco control. Public health advocates also need to be willing to take prompt action to defend these programmes and hold public officials who attack tobacco control programmes accountable for their actions.

     

Tobacco use among youth: a cross country comparison

Methods: The GYTS employs a standard methodology where self administered questionnaires, consisting of a set of core questions, are completed by a representative school based sample of students primarily between the ages of 13–15 years.

Results: Data are presented from 75 sites in 43 countries and the Gaza Strip/West Bank region. Current use of any tobacco product ranges from 62.8% to 3.3%, with high rates of oral tobacco use in certain regions. Current cigarette smoking ranges from 39.6% to less than 1%, with nearly 25% of students who smoke, having smoked their first cigarette before the age of 10 years. The majority of current smokers want to stop smoking and have already tried to quit, although very few students who currently smoke have ever attended a cessation programme. Exposure to advertising is high (75% of students had seen pro-tobacco ads), and exposure to environmental tobacco smoke (ETS) is very high in all countries. Only about half of the students reported that they had been taught in school about the dangers of smoking during the year preceding the survey.

Conclusions: Global youth tobacco use is already widespread throughout the world, but there is great variation among nations. Valid and reliable data on the extent of youth tobacco use, and correlates of use, are essential to plan and evaluate tobacco use prevention programmes. The GYTS has proven the feasibility of an inexpensive, standardised, worldwide surveillance system for youth tobacco use. The GYTS will be expanded to the majority of countries in the next few years, and can serve as a baseline for monitoring and evaluating global and national tobacco control efforts.