STATE PROGRAMS IN TOBACCO CONTROL

The goal of state or provincial tobacco-control programs is to reduce the death and disease caused by tobacco use, the single most preventable cause of death and disease in developed societies. Annually, tobacco use causes more than 400,000 deaths in the United States, at a cost of approximately $50 billion to $73 billion in medical expenses alone. Comprehensive tobacco-control programs combine a variety of strategies and tactics to prevent the initiation of tobacco use, to promote smoking cessation, to protect the nonsmoker from environmental tobacco smoke (ETS), and to identify and eliminate disparities in tobacco use and disease among different population groups. The Centers for Disease Control and Prevention (CDC) recommends that state tobacco-control programs be comprehensive, sustainable, and accountable. The term "tobacco control" has come to mean both the control and the prevention of tobacco use, and includes all forms of tobacco.

State tobacco-control programs underwent an evolution during the 1990s. Prior to 1990, state programs focused on individual cessation programs offered in group settings, dissemination of self-help materials for quitting, and the distribution of information via public-service campaigns. During the 1990s, state tobacco-control programs shifted away from the provision of education and services as a means to achieve individual behavioral change. The next generation of programs was designed to impact whole populations by addressing political, social, and environmental factors that support the use or nonuse of tobacco. This also marked a shift away from a focus on individual responsibility for tobacco use to documenting and exposing tobacco industry tactics to market their product. The tobacco industry spends an estimated $5 billion annually in advertising and promotion aimed at sustaining or increasing tobacco use in the United States.

California led this evolution when, in 1988, voters passed Proposition 99, which raised the tobacco excise tax by twenty-five cents and dedicated approximately $90 million annually for tobacco control. The California program initiated a statewide social change to indirectly influence current and potential future tobacco users by creating a social milieu and legal climate in which tobacco was less desirable, less acceptable, and less accessible. The state tobacco-control program did this in part by implementing an unprecedented, hardhitting media campaign that placed responsibility for the problem of tobacco use on the shoulders of the tobacco industry. While the program was intended to prevent individuals from suffering the health consequences of smoking, the program made it clear that this could not be achieved without holding the tobacco industry accountable for its actions and the products it sold. In the 1990s, Massachusetts, Arizona, and Oregon passed voter referendums earmarking increases in the tax on tobacco products for comprehensive tobacco-control programs.

In addition to implementing hard-hitting media campaigns, these states focused on changing norms regarding tobacco use at the community level through the support of local coalitions. In 1991, the National Cancer Institute partnered with the American Cancer Society to launch the American Stop Smoking Intervention Study (ASSIST). ASSIST's goal was to build a capacity within seventeen health departments to prevent and reduce tobacco use, primarily through the application of policy-based approaches that would alter the sociopolitical environment. Interventions included media advocacy to increase pro-tobacco-control media coverage, strengthening support for clean indoor air laws, reducing youth access to tobacco products, limiting tobacco advertising and promotion, increasing tobacco taxes, and increasing the demand for smoking-cessation services.

In 1993, the CDC Office on Smoking and Health (OSH) established funding for state-based programs for the District of Columbia and the thirty-two states that were not part of the ASSIST project. CDC funding provided state health departments with a core capacity to create a nucleus of trained staff, to conduct assessments and collect data, to develop program plans, and to establish coalitions and partnerships that later would be instrumental in implementing tobacco-control programs. At the conclusion of the ASSIST project, in 1999, the CDC established the National Tobacco Control Program, which provides approximately $57 million annually in funding to the fifty states. The National Tobacco Control Program supports the implementation of several program elements, including community interventions, counter-marketing, program policy, and evaluation and surveillance. These program elements combine to achieve changes in the four goal areas.

In 1999, the CDC issued Best Practices for Comprehensive Tobacco Control Programs, which drew upon evidence from the analyses of the past decade's comprehensive state tobacco-control programs to support nine specific elements of a comprehensive program. CDC recommends that states establish tobacco control programs that contain the following elements:

• Community programs to reduce tobacco use
• Chronic disease programs to reduce the burden of tobacco-related disease
• School programs
• Enforcement
• Statewide programs
• Counter-marketing
• Cessation programs
• Surveillance and evaluation
• Administration and management

Approximate annual costs to implement all of the recommended program components have been estimated to range from $7 to $20 per capita in small states (population under 3 million), $6 to $17 per capita in medium-sized states (population 3 million to 7 million), and $5 to $16 per capita in larger states (population over 7 million).

Three other publications have summarized the results from comprehensive state tobacco-control programs. The Institute of Medicine, National Research Council report State Programs Can Reduce Tobacco Use (2000) concluded that state programs can make a difference. In 2000, Surgeon General David Satcher released the first-ever Surgeon General's Report on the effectiveness of various methods to reduce tobacco use—educational, clinical, regulatory, economic, and social. The report offers a science-based blueprint for achieving the Healthy People 2010 objectives to reduce tobacco use and its health impact. Also in 2000, the Task Force on Community Preventive Services released a report and recommendations on strategies to reduce exposure to ETS and to increase smoking cessation.

The evidence that state comprehensive tobacco control programs work is demonstrated by:

• Major reductions in the consumption of tobacco
• Reduction in the prevalence of tobacco use
• Increases in medical coverage for cessation efforts
• Declines in the initiation of tobacco use
• A growing number of places that are 100 percent smoke-free
• Declines in the illegal sale of tobacco
• Greater restrictions on the promotion and marketing of tobacco
• Additional regulation of tobacco products
• Increase in the price of tobacco products

The states that have implemented tobacco control programs have achieved varying degrees of these outcomes, as well as others, depending on amount of funding and length of time necessary to implement programs. After a decade of implementing California's programs there is evidence that long-term health outcomes can also be achieved. Two studies released in December 2000 indicate that California's declines in lung cancer rates and in heart disease deaths can be associated with the impact of the comprehensive tobacco-control programs.

Another major evolution occurred within state tobacco-control programs during the 1990s. The accumulation of a half century of work by researchers, policymakers, states, economists, advocates and many others resulted in the states suing the tobacco industry to reclaim Medicaid costs incurred by the states for treating patients with tobacco-related illnesses. Mississippi was the first to file such a lawsuit, and the first to settle. Florida, Texas, and Minnesota also settled individually with the tobacco industry. The other forty-six states reached a collective agreement with the tobacco industry, known as the Master Settlement Agreement (MSA), which would provide an estimated $206 billion over twenty-five years to the states. In 1998, Florida and Mississippi committed $100 million and $64 million, respectively, in settlement funds to prevent tobacco use. This presents a historic opportunity to secure state funding for tobacco control.

Jeffrey P. Koplan, director of the Centers for Disease Control and Prevention, has characterized tobacco control as one of the greatest public health achievements of the twentieth century, and as one of the greatest challenges of the twenty-first. The Healthy People 2010 goal of achieving a 12 percent prevalence rate has been reached by only one population segment—those individuals with sixteen years or more of education.

The states have demonstrated that tobacco use can be reduced. The next steps are to assure that the states have the resources to plan, conduct, and evaluate comprehensive tobacco-control programs. A state's ability to carry out such programs will be dependent on the social, economic, and political context that supports the use or nonuse of tobacco products. But it also includes such factors as past experiences with tobacco-control programs, the level of knowledge and skill of the practitioners, the commitment and resolve of state leadership, collaboration with others, adequate funding to support all the components of a program, and the commitment to long-term funding.

Dearell Niemeyer

Melissa Albuquerque

(see also: Addiction and Habituation; Cancer; Cardiovascular Diseases; Chewing and Smokeless Tobacco, Snuff; Clean Indoor Air Ordinances; Environmental Tobacco Smoke; Office on Smoking and Health; Smoking Behavior; Smoking Cessation; Smuggling Tobacco; Tobacco Control; Tobacco Sales to Youth, Regulation of )

Bibliography

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