The campaign to raise the tobacco tax in Massachusetts.

OBJECTIVES: Question 1 raised the Massachusetts state tobacco tax to fund tobacco education programs. This paper examines the process of qualifying and passing Question 1. METHODS: Information was gathered from internal memoranda, meeting minutes, newspaper articles, internal documents, letters, newsletters, news and press releases, and personal interviews. Data about campaign contributions were obtained from the Massachusetts Office of Campaign and Political Finance. RESULTS: Three factors help explain why Question 1 passed: (1) the policy environment was favorable because of the social unacceptability of smoking; (2) the activists assembled a large coalition of supporters; and (3) the activists countered industry claims that the new tax would hurt small business and lower-income smokers and would be wasted by the legislature. The ballot initiative passed despite the industry's $7 million campaign to defeat it. CONCLUSIONS: The apparent influence of the tobacco industry on the legislature was the driving force behind the decision of public health activists to qualify Question 1. Moving policy-making out of the legislature into the public arena widened the scope of conflict and enabled public health activists to win.     

The tobacco industry, state politics, and tobacco education in California.

OBJECTIVES. Proposition 99 added 25 cents to the California state cigarette tax and mandated that 20% of the new revenues be spent on tobacco education and prevention programs. This paper examines the implementation of these programs and the tobacco industry's response to Proposition 99. METHODS. Political expenditure data for twelve tobacco firms and associations were gathered from California's Fair Political Practices Commission and secretary of state's Political Reform Division. Tobacco education expenditure data were collected from Governor's Budgets and the Department of Finance. RESULTS. Since Proposition 99 passed, tobacco industry political expenditures in California have risen 10-fold, from $790,050 in the 1985-1986 election to $7,615,091 in the 1991-1992 election. The tobacco industry is contributing more heavily to the California legislature than to Congress. A statistical analysis of data on campaign contributions indicates that California legislators' policy-making is influenced by campaign contributions from the tobacco industry. Since fiscal year 1989-1990, the state has ignored the voters' mandate and spent only 14.7% of the new revenues to tobacco education. Medical care programs received more money than permitted by the voters. CONCLUSIONS. The tobacco industry has become politically active in California following the passage of Proposition 99. One result may be that the state has underfunded tobacco education by $174.7 million through the 1993-1994 fiscal year. The estimated redirection of funds to medical care would essentially eliminate the tobacco education campaign by the year 2000.     

Tobacco use among adults--Arizona, 1996 and 1999

In 1994, Arizona passed the Tobacco Tax and Healthcare Act (Proposition 200) that increased the tax on cigarettes from $0.18 to $0.58, and allocated 23% of the resulting revenues to tobacco-control activities. Since 1995, Arizona has used the tobacco-control funds (approximately $30 million per year) to support the Arizona Department of Health Services (ADHS) Tobacco Education and Prevention Program (TEPP), a comprehensive program to prevent and reduce tobacco use. To track changes in tobacco use, the knowledge and opinions of Arizona residents about tobacco use, and the proportion of smokers advised to quit smoking by health-care providers, ADHS conducted the Arizona Adult Tobacco Survey (ATS) in 1996 and a follow-up survey in 1999. This report compares results of these two surveys, which indicate that prevalence of tobacco use among adults decreased, and the proportion of adults who were both asked about tobacco use and advised to quit by health-care providers and dentists increased. On the basis of these findings, if all states implemented comprehensive programs similar to those in Arizona, the national health objective for 2010 of reducing the adult smoking rate by half during this decade could be achieved.     

Simulated effect of tobacco tax variation on population health in California

OBJECTIVES: This study simulated the effects of tobacco excise tax increases on population health. METHODS: Five simulations were used to estimate health outcomes associated with tobacco tax policies: (1) the effects of price on smoking prevalence; (2) the effects of tobacco use on years of potential life lost; (3) the effect of tobacco use on quality of life (morbidity); (4) the integration of prevalence, mortality, and morbidity into a model of quality adjusted life years (QALYs); and (5) the development of confidence intervals around these estimates. Effects were estimated for 1 year after the tax's initiation and 75 years into the future. RESULTS: In California, a $0.50 tax increase and price elasticity of -0.40 would result in about 8389 QALYs (95% confidence interval [CI] = 4629, 12,113) saved the first year. Greater benefits would accrue each year until a steady state was reached after 75 years, when 52,136 QALYs (95% CI = 38,297, 66,262) would accrue each year. Higher taxes would produce even greater health benefits. CONCLUSIONS: A tobacco excise tax may be among a few policy options that will enhance a population's health status while making revenues available to government.     

Public opinion analysis regarding the uses of master settlement agreement (MSA) funds

OBJECTIVES: In the present research, we assessed the relationship between characteristics of the residents of Long Beach, California, a typical city in America, and their opinions regarding the uses of master settlement agreement (MSA) funds. METHODS: The statistical analyses used in the present research included univariate frequency distributions, cross-tabulations, and classification and regression trees. RESULTS: The results indicate that the majority of Long Beach residents share the opinion that the MSA funds should be allocated to health programmes. They do not, however, feel that these funds need to be earmarked solely for smoking prevention or cessation. CONCLUSIONS: Due to state budget deficits, legislators may strongly advocate for the MSA funds to be used for non-health purposes. Our findings provide support for community advocates who wish to bring the current uses of MSA funds and tobacco taxes to the forefront of national and international public debate.     

Increasing tobacco taxes: a cheap tool to increase public health

INTRODUCTION: Several studies have estimated health effects resulting from tobacco tax increases. However, studies on the cost effectiveness of tobacco taxes are scarce. The aim of this study was to estimate the cost effectiveness of tobacco tax increases from a health care perspective, explicitly considering medical costs in life years gained. METHODS: The effects of a tax increase were translated into effects on smoking quit rates. A dynamic population model then projected incidence, prevalence and health care costs of the major chronic diseases conditional on smoking status over time. Comparing to a current practice scenario, the differences in healthcare costs, tax revenues, life years and QALYs from a tobacco tax increase resulting in a price increase of 10% increase were estimated. RESULTS: Including effects on health care costs in life years gained, the tax increase costs about 2500 euro per QALY gained. Only 3% of additional tax revenues are enough to compensate additional health care costs in life years gained. CONCLUSIONS: Even if the health care costs in life years gained are taken into account and even if additional tax revenues do not flow to the health care sector a tax increase is a cost-effective intervention to increase public health from a health care perspective.     

State legislators' attitudes and voting intentions toward tobacco control legislation.

OBJECTIVES: This study describes state legislators' knowledge, attitudes, and voting intentions with regard to tobacco-related issues. METHODS: A cross-sectional survey of state legislators was conducted in North Carolina, Texas, and Vermont in 1994. RESULTS: Most legislators agreed that secondhand smoke can cause lung cancer in nonsmokers, and a majority believed that smokers are addicted to nicotine. More than 75% stated that they would support a measure to enforce laws preventing tobacco sales to youth. A majority of Texas and Vermont legislators supported an increase in the state cigarette excise tax; 43% of North Carolina legislators would support an increase if revenues were directed toward tobacco farmer diversification. CONCLUSIONS: State legislators believe tobacco to be addictive, and they support policies to protect youth from tobacco. Support for other legislative measures differs significantly across states.     

States' allocations of funds from the tobacco master settlement agreement

This study assesses six states' allocation decisions for funds from tobacco settlement agreements, using information from newspaper articles and other public sources. State allocation decisions were diverse; substantial shares were allocated to areas other than tobacco control and health, including capital projects and budget shortfalls. The allocations did not reflect the stated goals of the lawsuits leading to the settlements. This outcome reflects a lack of strong advocacy from public health interest groups, an unreliable public constituency for tobacco control, and inconsistent support from state executive and legislative branches, all combined with sizable budget deficits that provided competing uses for settlement funds.     

State and federal revenues from tobacco consumed by minors.

OBJECTIVES: The purpose of this study was to estimate the value of cigarettes consumed in 1997 by youths younger than 18 years. METHODS: Price, population, and consumption data were used to compute conservative and comprehensive estimates, which were then averaged. RESULTS: An estimated 3.76 million daily smokers aged 12 through 17 years consume an estimated 924 million packs of cigarettes per year, generating $222 million in federal tax revenues, $293 million in state tax revenues, and $480 million in tobacco company profits, and producing a retail value of $1.86 billion. CONCLUSIONS: The revenues from cigarettes smoked by youths could be used to enforce laws prohibiting the sale of tobacco to minors.     

不同试点地区收支两条线投入政策比较

通过分析了不同试点地区在实行收支两条线改革过程中，政府财政预算的测算方式和投入标准、投入方式和收支两条线资金的管理模式，并比较分析了各地实践与各部委文件之间的异同点，说明各地可以根据本地区实际情况，因地适宜，制定有关收支两条线的投入政策和管理模式。     

Sustainable funding of health initiatives in Wonju, Republic of Korea via a tobacco consumption tax

Wonju is the first municipality in the Republic of Korea to fund the Healthy City project through municipal revenues from the local tobacco consumption tax. We investigated the process of the local tobacco consumption tax being approved as the main source of financing for the local Healthy City project. We also examined the sustainability and sufficiency of the funding by looking at the pricing policies instituted for cigarettes, smoking prevalence, cigarette consumption and revenues from local tobacco consumption as well as the budgetary allocations among programs in the city. The strong initiative of the mayor of Wonju was one of the factors that enabled the earmarking of the local tobacco consumption tax for the Healthy City Wonju project. He consulted academic counselors and persuaded the municipal government and the City Council to approve the bill. Despite the increasing price of cigarettes in Korea, adequate funding can be sustained to cover the short-term and mid-term programs in Wonju for at least 5 years of the mayor's term, because the smoking rate is persistently high. Analyzing the effects of strong leadership on the part of local authorities and the balance between revenues from the tobacco tax and the prevalence of smoking in the face of anti-smoking policies would be helpful for other countries and communities interested in developing sustainable Healthy Cities projects.     

Independent evaluation of the California Tobacco Education Program.

OBJECTIVE. To monitor the implementation of tobacco control programs and research in accordance with California''s Proposition 99, approved by the voters in 1988, which increased the state''s cigarette tax by 25 cents and designated one quarter of the increased revenue-approximately $100 million per year-to develop statewide media campaigns and to fund local health departments, community-based organizations, schools, and agencies working with high risk populations. METHODS. The authors evaluated the extent and the effectiveness of the implementation independently with standardized forms developed to track any tobacco-related information and activities, local media campaigns, changes in local policies and ordinances, training sessions, and prevention and cessation programs. Activities were reported on the forms to the authors monthly or quarterly. RESULTS. The evaluation indicated that local health departments, community-based organizations, and other group produced an exceedingly high volume of diverse tobacco control activities throughout the state. They reached a variety of ethnic groups and high risk populations with their programs. The data also show that local health departments and competitive grantees responded with an overall shift in their approach to tobacco control and moved from interventions focused primarily on individual people to broader, more community- and environment-oriented interventions. Additionally, analysis of the wholesale tobacco tax revenues revealed that per capita purchasing continued to decline in California at a rate greater than in the rest of the United States. CONCLUSION. The evaluation demonstrated that Proposition 99 accomplished much of what it set out to do-reducing tobacco prevalence, reaching out to underserved populations, and heightening the awareness of the dangers of environmental tobacco smoke.     

The politics of stem cell policy: ballot initiative in Missouri

In of November 2006, Missouri became the first state in the United States to pass a constitutional amendment designed to protect stem cell research in the state when voters approved a citizen-initiated ballot proposal known as Amendment 2. This article examines the juxtaposition of science, religion, politics, and economics surrounding the campaign by the supporters and the opponents of the ballot initiative. The outcome of Amendment 2 was also closely intertwined with the U.S Senate race in Missouri. The article also provides an analysis of the outcome of the ballot initiative through the use of county-level data.     

Registered indians and tobacco taxation: a culturally-appropriate strategy?

Taxation of tobacco is a widely-used strategy that prompts smoking cessation among adults and reduces cigarette consumption among continuing smokers. Registered Indian tobacco use prevalence is at least double that of the rest of Canadians and is in part due to the lower cost of tobacco products purchased on reserve by Registered Indians (RIs) as they are tax exempt. Although registered Indian communities have the ability to collect tax on tobacco products and direct the use of these revenues, this strategy is rarely utilized. Tobacco taxation could have substantial health and economic benefits to RI communities, but perhaps is not culturally-appropriate. In order to better support RI communities, governments and other organizations need to examine this policy instrument in the context of RI populations.     

Oral Cancer Screening at Workplace in India��One-year Follow-up

Background:

Oral cancer remains the commonest form of cancer and cancer-related deaths among Indian males due to popularity of avoidable risk factors such as tobacco and alcohol use. A workplace oral cancer screening and tobacco cessation study was commenced on World No Tobacco Day 2007 at a chemical industry in rural Maharashtra.

Aims:

The objectives were to screen the employees for oral neoplasia and to correlate it with their tobacco consumption pattern. In addition, the objective was to provide tobacco cessation services at the workplace.

Materials and Methods:

This is an interventional cohort study among 104 employees of a chemical industrial unit in rural Maharashtra. Naked eye examination of the oral cavity was performed for all employees by a doctor irrespective of the tobacco habits at the beginning and at the end of 1 year. In between, the tobacco users were regularly examined during each follow-up.

Statistical analysis used:

Through personal interviews of the participants, data were manually recorded and were transferred to electronic data base. Data analysis was conducted in STATA™ 8.2 on intention to treat basis.

Results and Conclusions:

Among the 104 employees, 50 (48.08%) were current tobacco users at the beginning of the program. Oral precancers were seen exclusively among 20 (40%) tobacco users. After 1 year of workplace tobacco cessation intervention, 80% of oral precancers regressed. This shows that screening of the oral cavity at the workplace is effective when combined with tobacco cessation.     

Swiss popular initiative for a single health insurer… once again!

The article describes a recent Swiss popular initiative, aiming to replace the current system of statutory health insurance run by 61 competing private insurers with a new system run by a single public insurer. Despite the rejection of the initiative by 62% of voters in late September 2014, the campaign and ballot results are interesting because they show the importance of (effective) public communication in shaping the outcome of a popular ballot. The relevance of the Swiss case goes beyond the peculiarities of its federalism and direct democracy and might be useful for other countries debating the pros and cons of national unitary health insurance systems versus models using multiple insurers.After this electoral ballot, the project to establish a public sickness fund in Switzerland seems definitely stopped, at least for the next decade. Insurers, who opposed the initiative, have effectively fed the “fear of change” of the population and have stressed the good outcomes of the Swiss healthcare system.However, the political pressure favoured by the popular initiative opened a “windows of opportunity” and led the federal Parliament to pass a stricter regulation of health insurers, improving in this way the current system.     

The first decade of the Massachusetts Tobacco Control Program

This article provides a comprehensive overview of the first decade of the Massachusetts Tobacco Control Program (MTCP). Born after Massachusetts passed a 1992 ballot initiative raising cigarette excise taxes to fund the program, MTCP greatly reduced statewide cigarette consumption before being reduced to a skeletal state by funding cuts. The article describes the program's components and goals, details outcomes, presents a summary of policy accomplishments, and reviews the present status of MTCP in the current climate of national and state fiscal crises. The first decade of the MTCP offers many lessons learned for the future of tobacco control.     

Decline in cigarette consumption following implementation of a comprehensive tobacco prevention and education program--Oregon, 1996-1998

In November 1996, residents of Oregon approved a ballot measure increasing the cigarette tax by 30 cents (to 68 cents per pack). The measure stipulated that 10% of the additional tax revenue be allocated to the Oregon Health Division (OHD) to develop and implement a tobacco-use prevention program. In 1997, OHD created Oregon's Tobacco Prevention and Education Program (TPEP), a comprehensive, community-based program modeled on the successful tobacco-use prevention programs in California and Massachusetts. To assess the effects of the tax increase and TPEP in Oregon, OHD evaluated data on the number of packs of cigarettes taxed before (1993-1996) and after (1997-1998) the ballot initiative and implementation of the program. Oregon's results also were compared with national data. This report summarizes the results of the analysis, which indicate that consumption of cigarettes in Oregon declined substantially after implementation of the excise tax and TPEP and exceeded the national rate of decline.     

Ergonomics and regulatory politics: the Washington State case

BACKGROUND: Every year in the State of Washington more than 50,000 workers experience a work related musculoskeletal disorder (WMSD), making up more than 30% of all worker compensation cases. In 2000, the Washington State Department of Labor and Industries (L&I) adopted a workplace ergonomics rule requiring employers to reduce worker exposure to hazards that cause or contribute to WMSDs. In 2003, the ergonomics rule was repealed by a margin of 53.5-46.5 in a statewide voter initiative. METHODS: The official rulemaking record of approximately 100,000 pages, along with supplementary published and unpublished material, was reviewed. The relationship between scientific deliberation and the public policy process in adopting and repealing the ergonomics rule was assessed and described. The deliberative features of the regulatory, judicial, legislative, and ballot processes were compared. RESULTS AND CONCLUSIONS: The ergonomics rule was successful in the regulatory and legal arenas where the process was most transparent and open to public involvement, differing views could be presented fully, and decision makers were expected to explain their decisions in light of the record. The rule fared most poorly in the legislature and at the ballot box when these features were lost and where considered deliberation was replaced by unconstrained political conflict. Additional checks and balances are needed.