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Literature Review on the Effectiveness of State Tobacco Control Programs

Entire Article in Portable Document Format (PDF Logo PDF - 182k)

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Table of Contents
• Navigational Guide—View Select Data by Outcome Measure
• Mortality
• Smoking Prevalence
• Consumption
• Cessation
• Smoke-free Policies
• Table 1—Recent Reviews on the Effectiveness of State Tobacco Control Programs
• Table 2—Major Peer-reviewed Evaluation Studies
• Table 3—State Reports Not Published in Peer-reviewed Journals
• Reference List

How do we know that comprehensive state tobacco control programs are effective in reducing tobacco use? As state programs lose funding, there is an urgent need to collect and update the evidence for their effectiveness.

The purpose of this literature summary is to present findings on the effectiveness of state programs. Several recent reviews have been published, including those by Siegel (2002) and the Institute of Medicine (2000). This document outlines the results of these studies according to major outcome measures (see Table of Contents). After the outcome measure tables, the recent reviews of state programs, the major studies from the reviews, and selected major state evaluation reports are briefly summarized. In addition, several peer-reviewed studies published since 2002 are included. CDC/OSH has summarized each of these studies, maintains a repository of the hard copies, and will continue to collect and update this collection of evidence on a regular basis. This is not a listing of all available evidence on state programs; rather it is a focused selection of the most relevant, recent evidence and attempts to include states other than those cited most often.

Navigational Guide—View Select Data by Outcome Measure

Each study is listed by major outcome categories in reverse chronological order of publication (the most recent evidence is listed first). Studies may be listed more than once in these tables as they often present more than one type of outcome evidence. Statistical testing (p values, etc.) is referenced when available. The “State” column indicates which state the data come from; studies which examined the United States as a whole are indicated by “U.S.” For more detailed information about a particular study, refer to the summary (Table 2 if peer reviewed) or the individual articles. Studies with an asterisk (*) are state evaluation reports (Table 3).

Mortality

Heart disease
Citation State Time frame Finding
Fichtenberg & Glantz, 2000 CA 1980–1988 Regression coefficient for CA vs. U.S.: 0.67 (p < 0.001).
1988–1991 Further age-adjusted annual rate of heart disease decline in CA: –2.93/100,000 (p < 0.001).
1992–1998 Further age-adjusted annual rate of heart disease decline in CA: –1.22/100,000 from previous period (p = 0.03); (reduced effect of previous period by 1.71 deaths per year per 100,000 population per year); 33,000 fewer deaths to heart disease were prevented overall (an additional 8,300 after 1992 might have been prevented had campaign not been scaled back).
Lung cancer
Citation State Time frame Finding
Jemal et al., 2003 U.S. 1990–1994 Index of strength of state TC correlation with lung cancer death rates for ages 30–39 years: –0.54 (p = 0.0013).
1995–1999 Index of strength of state TC correlation with lung cancer death rates for ages 30–39 years: –0.80 (p < 0.0001) Index correlation with percent change ages 30–39 years lung cancer death rates 1990–99: –0.56 (p < 0.0008).
CDC, 2000 CA 1988–1997 14% total decline in CA (average annual decline 1.9%, p < 0.01), 1.5 times that of non-CA SEER5; 2.7% total decline in non-CA SEER (average annual decline –0.4%, not significantly different from zero).

Men: 2.9% average annual decline (p < 0.01) in CA vs. 1.8% average annual decline (p < 0.01) in non-CA SEER.

Women: declined 4.8% (average annual decline 0.6%, p < 0.01) in CA vs. increased 13.2% (average annual increase 1.5%, p < 0.01) in non-CA SEER.

 

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Smoking Prevalence

Adult prevalence
Citation State Time frame Finding
Jemal et al., 2003 U.S. 1990–1999 Index of strength of state TC correlation with current adult smoking: –0.81 (p < 0.0001)
Stillman et al., 2003 U.S. 1992–1999 ASSIST status vs. non-ASSIST states, adjusted difference:  –0.63% (95% CI = –1.38%, 0.12%; p = 0.49); for women –0.96% (–1.90%, –0.02%; p = 0.023); for men 0.09% (–0.80%, 0.97%; p = 0.42).

A measure of change in TC policy outcomes (initial outcomes index) was associated with declines in adult prevalence when the District of Columbia was removed from analyses (regression coefficient  –0.15 [–0.28, –0.02; p = 0.015]).
Meshack et al., 2003* TX 2000–2002 Declines in pilot areas: absolute percentage declines 5.1% vs. 2.5%, relative reductions 21% vs. 11%

Estimated 90,000 fewer smokers because of pilot programs.
OR DHS, 2003* OR 1996–2003 Overall: 23.4% to 20.4%, 13% relative decline, compared with 8% decline in U.S.
WA State DH, 2003* WA 1999–2002 8% fewer smokers (83,000 fewer adult smokers).
Biener et al., 2002 MA 1993–1999 MA slope: –0.44 per year (95% CI = –0.66, –0.21; p = 0.001) vs. U.S. slope: 0.03% per year (–0.05, 0.09; p = 0.46).
Fichtenberg & Glantz, 2002 U.S. Varies (review) Smokefree work sites: –3.8%; –3.1 cigarettes/day in continuing smokers.
Rohrbach et al., 2002 CA 1996–1998 Changes in absolute percentage in adult prevalence associated with lowest, moderate, and highest exposure categories: +2.53%, +0.23%, –0.95%, respectively (p = 0.03).
Weintraub & Hamilton, 2002 MA 1990–1999 MA: 23.5% (95% CI = 21, 26.1) to 19.4% (18, 20.8); relative decline of 17% after demographic adjustments (AOR 3 = 0.83, 95% CI = 0.70, 0.99).

U.S.: 24.2% (23.7, 24.7) to 23.3% (22.9, 23.7); no significant change (AOR = 1.01, 0.97, 1.05); difference between MA and other states was significant in 1999 (p < 0.001), not in 1990 (p = 0.62).
MA men: 25.9% (22, 29.8) to 19.5% (17.3, 21.6); relative decline of 27% after demographic adjustments;

U.S. men: 26.0% (25.2, 26.7) to 25.6% (24.9, 26.2); no significant change; (multivariate OR 4 = 1.03; .97, 1.08); difference between men in MA and other states was significant in 1999 (p < 0.001), not in 1990 (p = 0.97)
MA women: 21.5% (18.2, 24.8) to 19.3% (17.5, 21.1); relative decline of 5% not statistically significant (p = 0.62).

U.S. women: 22.5% (21.9, 23.2) to 21.2% (20.7, 21.7); no significant change (multivariate OR = 0.99; .95, 1.04); difference between women in MA and other states was significant in 1999 (p = 0.04), not in 1990 (p = 0.54).
CDC, 2001 AZ 1996–1999 23.1% (95% CI = 21.9, 24.3) to 18.3% (17.1, 19.5) in AZ (p ≤ 0.05)
Gilpin et al., 2001* CA 1990–1999 Of remaining smokers, >60% smoke <15 cigarettes/day and >20% are non-daily smokers.
Norman et al., 2000 CA  1998 Average daily consumption in smokers (outcome), home smoking ban β (beta coefficient) = –0.301 (p < 0.01).
Porter, 2000* AZ 1996–1999 23.8% to 18.8%, relative decline of 21%.
Abt Associates, 2000* MA 1994–2000 22.6% to 17.9%, after accounting for demographic changes in MA.

25.1% to 19.6% (p = 0.02) in MA men vs. 1.6% annual decrease vs. 0.8% annual decrease in U.S. men (p = 0.02 for difference).

Pregnant women: 25% to 11% in MA.
Farrelly et al., 1999 U.S. Sep 1992–May 1993 Smokefree work sites: –5.7%; –2.7 cigarettes/day in continuing smokers; subgroups varied in these effects
Harris, 1999 MA 1990–1996 Pregnant women: 47.8% relative decline in MA vs. 26.1% in U.S.; 1996 MA rate 13.2%.

All adults: 140,000 fewer smokers since program implementation.
Pierce et al., 1998a* CA 1989 17.3 cigarettes/day in CA vs. 19.5 in U.S.
1992–1993 15.3 cigarettes/day in CA vs. 18.1 in U.S.
1995–1996 13.7 cigarettes/day in CA (10.4% decrease from previous period) vs. 7.3 in U.S. (4.4% decrease from previous period).
Pierce et al., 1998b CA Pre–1989 23.3% (0.74% decrease) in CA vs. 26.2% (0.77% decrease) in rest of U.S.
1989–1993 18% (1.06% decrease) in CA  (p < 0.001 for change) vs. 23.2% (0.57% decrease) in rest of U.S. (p < 0.05 for CA vs. U.S.)
1994–1996 18% (0.01% increase) in CA vs. 22.4% (0.28% decrease) in rest of U.S. (p < 0.001 for change in both from previous period).
Siegel et al., 1998 CA 1978–1985 Estimated annual change: –0.60 (95% CI = –0.79, –0.40) in CA vs. –0.50 (–0.67, –0.33) in U.S.
1985–1990 Estimated annual change: –1.22 (95% CI = –1.51, –0.93) in CA vs. –0.93 (–1.13, –0.73) in U.S. (p < 0.05 for both rates increasing from previous period).
1990–1994 Estimated annual change: –0.39 (95% CI = –0.79, –0.40) in CA vs. –0.05 (–0.34, +0.24) in U.S. (p < 0.05 for both rates slowing).
CDC, 1996 MA 1990–1992 23.5% in MA (95% CI = 22.1, 24.9), 20.1% (19.2, 21.0) in CA, vs. 24.1% (23.8, 24.4) in rest of U.S.
1993–1995 21.3% in MA (95% CI = 20.1, 22.5), 17.4% (16.5, 18.3) in CA, vs. 23.4% (23.1, 23.6) in rest of U.S.
Young adult prevalence
Citation State Time frame Finding
Rigotti et al., 2002 MA 1999 Public college students who currently live away from parents and attended high school in state vs. out of state: all tobacco use, AOR = 0.66, 95% CI = 0.45-0.96 (p = 0.03); current smoking, AOR = 0.58, 95% CI = 0.40, 0.87 (p < 0.01).
Porter, 2000* AZ 1996–1999 27.5% to 21%, 24% relative decline (ages 18–24 years).
Youth prevalence/initiation
Citation State Time frame Finding
AZ DHS, 2003* AZ 1997–2000 High school: 31.3% to 24.6%, 21% relative decline in AZ.

Middle school: 18.7% to 11.4%, 29% relative decline in AZ vs. 15.1% in U.S. in 2000.
Chen et al., 2003 CA 1990–1999 Never smokers: males, 60% to 69% (0.87% annually); females, 66% to 70% (0.29% annually).
Gallup, 2003* ME 1997–2001 Current (last 30 days), high school: 39.2% to 24.8%, 38% relative decline in ME.
McMillen & Baldwin, 2003* MS 1999–2002 Current (last 30 days): public middle school 23% to 11.9% (p<0.05), 42% relative decline in MS; public high school 32.5% to 23.1% (p < 0.05), 24% relative decline in MS.
OR DHS, 2003* OR 1996–2003 Relative declines: 47% for grade 8, 26% for grade 11 in OR.
WA State DH, 2003* WA 1999–2002 Relative declines (last 30 days): grade 6, 53%; grade 8, 39%; grade 10, 40%; grade 12, 35%

Estimated 55,000 fewer youths smoking; high school rates are twice national rate of decline.
Willet et al., 2003* NE 1997–1999 Current (last 30 days): 39.2% to 37.3%.
2000–2003 Current (last 30 days): 30.5% to 24.1% (p < 0.05).
Rohrbach et al., 2002 CA 1996–1998 Current (last 30 days): 27.4% to 21.8% (p < 0.05) for grade 10, not associated with exposure to program components.
Soldz et al., 2002 MA 1996–1999 Current (last 30 days): grade 8, 26% to 15.6% (p < 0.01) in MA vs. 21% to 17.5% in U.S.; grade10, 33.6% to 24.6% (p < 0.05) in MA vs. 30.4% to 25.7% in U.S.; grade 12, 40.7% to 34.9% in MA vs. 34.0% to 34.6% in U.S.

Lifetime: grade 8, 41% to 30.3% (p < 0.01) in MA vs. 49.2% to 44.1% in U.S.; grade 10,  56.9% to 44.4% (p < 0.01) in MA vs. 61.2% to 57.6% in U.S.; grade 12,  61% to 60.5% in MA vs. 63.5% to 64.6% in U.S.
Gilpin et al., 2001* CA 1990–1999 Youth 30-day prevalence: increased from 1993-96 but 1999 rate of 7.7% was significantly lower than 1990
Sly et al., 2001 FL 1998–1999 Ever use, youths <16 years: 33.4% (95% CI ± 2.17) to 26.7% (± 2.02), 20.1% relative decline, in FL vs. 30.5% to 29.7% (± 2.42), 2.6% relative decline (p < 0.05 for difference from FL), in U.S.

Current use, youths <16 years: 9.9% (± 1.38) to 7.2% (± 1.12), 27.3% relative decline, in FL vs. 7.0% (± 1.44) to 8.6% (± 1.21), 22.9% relative increase (p < 0.05 for difference from FL), in U.S.
Abt Associates, 2000* MA 1995–2000 36% to 30% in MA vs. remaining stable in U.S.
Bauer el al, 2000 FL 1998–2000 Current (last 30 days): middle school 18.5% to 11.1% (40% relative decline; p < 0.001); high school 27.4% to 22.6% (18% decline; p = 0.01)

Frequent (+20 of 30 days) use: middle school 5.4% to 2.9% (p < 0.001); high school 13.5% to 10.4% (p < 0.001)
Siegel & Biener, 2000 MA 1993/1994–1997/1998 Exposure to television anti-smoking ads: for ages 12–13 years (at baseline) halved progression to established smoking (AOR = 0.49; 95% CI = 0.26, 0.93); for ages 14–15 years had no effect (AOR =  0.94; 0.48, 1.83)
Pierce et al., 1998a* CA 1990–1993 Current (last 30 days): 9.2% in CA
1993–1996 Current (last 30 days): 12.6% in CA, 26% increase from previous period

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Consumption

Total consumption
Citation State Time frame Finding
Farrelly et al., 2003 U.S. 1981–2000 Sales dropped more than twice as much in states that spend more on comprehensive tobacco control programs than in U.S. as a whole. Between 1990-2000, sales decreased an average of 43% in AZ, CA, MA, and OR, compared with 20% decrease in all states combined.
Hu et al., 1995a CA 1989–1991 8–9% reduction in the short run, 10–13% reduction in the long run.
Glantz, 1993 CA 1981–1988 Baseline consumption.
1989–1991 Decline of 2% annually (–45.9 million packs/year) more than tripled to –164 packs/year (p < 0.001).
1992 Deceleration of decline (–1.4 packs/year; p = 0.032), effect to date, June 1992, –802 million packs since Prop 99.
Per capita consumption (PCC)
Citation State Time frame Finding
Stillman et al., 2003 U.S. 1989–1999 Before intervention: ASSIST states 10.64 packs/person/month vs. non-ASSIST states 10.54 (p = 0.88)

During intervention, ASSIST states non-significant decrease (p = 0.22)

Regardless of ASSIST status, states with higher cigarette price and greater increase in price over time showed a PCC decrease of 0.57 packs/person/month (95% CI 1 = 0.43, 0.72).
Gallup, 2003* ME 1997–2001 PCC decreased from 132.8 to 107 packs/year in ME.
OR DHS, 2003* OR 1996–2003 Relative decrease of 30%, steeper than other states with no comprehensive TC 2 program.
Biener et al., 2002 MA 1988–1992 15% decrease in MA vs. 14% in U.S.; 3–4% annual decrease for both groups.
1993–1999 12% drop in 1993, then >4% annual decrease for MA vs. 4% drop in U.S. when cigarette prices declined, then <1% annual decrease.
Gilpin et al., 2001* CA 1990–1999 Relative decline of 57% in CA vs. 27% in U.S.
Fichtenberg & Glantz, 2000 CA 1980–1988 Regression coefficient for CA vs. U.S.: 1.09 (p < 0.001).
1988–1991 Decrease of –2.72 packs/yr/yr in CA relative to decrease in U.S. (p < 0.001).
1992–1998 Previous decrease reduced by 2.05 packs/yr/yr in CA relative to decrease in U.S. (p < 0.04, compared with previous period).
Abt Associates, 2000* MA 1994–2000 Relative decline of 36% in MA vs. 16% in U.S.
CA DHS, 2000* CA 1989-1999 Decrease >50% in CA to 61.3 packs/adult in 1998-99 vs. 106.8 packs/adult in U.S. in 1999.
CDC, 1999 OR 1993–1996 PCC +2.2% in OR vs. –0.6% in U.S.
1996–1998 PCC –11.3% (92 to 82 packs) in OR vs. –1% (93 to 92 packs) in U.S.; 25 million few packs sold in 1998 than 1996 despite 2.7% increase in state population.
Pierce et al., 1998a* CA Pre-1989 9.7 monthly PCC, 0.40% decrease in CA vs. 12.4 monthly PCC, 0.36% decrease in U.S.
1989–1993 6.7 monthly PCC, 0.65% decrease in CA vs.10.4 monthly PCC, 0.45% decrease in U.S.
1993–1996 6.0 monthly PCC, 0.22% decrease in CA vs. 10.3 monthly PCC, 0.02% decrease in U.S.
Pierce et al., 1998b CA Pre–1989 –9.7 packs/person/month in CA vs. –12.5 for rest of U.S. (p < 0.01 for CA vs. U.S.).
1989–1993 –6.5 packs/person/month in 1993 in CA vs. –10.4 for rest of U.S. (p < 0.001 for CA vs. U.S. and for difference in CA from previous period).
1994–1996 –6 packs/person/month vs. 10.5 in U.S. (each slope significantly different from previous period).
Manley et al., 1997 U.S. 1989–1991 12 packs/person/month in both groups in 1989, 11 in 1991.
1993–1996 1993, ASSIST states maintained low PCC rate while non-ASSIST began to increase; in 1994, increase was statistically significant (p < 0.05); at beginning of 1996, PCC in ASSIST states was 7% less than others; 76% of ASSIST states vs. 55% of comparison states had PCC decrease despite real cigarette price decrease.
CDC, 1996 MA 1990–1992 –6.4% in MA, –11% in CA vs. –5.8% in rest of U.S. (relative declines).
1992–1996 –19.7% in MA, –15.8% in CA vs. –6.1% in rest of U.S. (relative declines).
Elder et al., 1996 CA 1980–1988 Average quarterly PCC decrease, 3.6% in CA vs. 2.4% in rest of U.S.
1989–1994 Average quarterly PCC decrease, 7.9% in CA vs. 3.2% in rest of U.S.
Hu et al., 1995b CA 1990–1992 Decrease of 35 packs/person, 79% and 21% attributable to price increase and media campaign, respectively
Hu et al., 1994 CA 1984–1991 Immediate effect in 1989, 2 packs/person (–25.7%); long–term effect in 1991, 0.75 packs/person (–9.5%)
Glantz, 1993 CA 1980 Baseline PCC (packs/person/year) 122.8 (p = 0.001) in CA vs. 143.5 (p = 0.001) in U.S.
1981–1988 PCC decrease of –4 (p = 0.001) in CA vs. –3.8 (p = 0.001) in U.S.
1989–1991 PCC decrease doubles to –8 (p = 0.001) in CA vs. decrease of –4.7 (p = 0.39) in U.S.
1992 PCC decrease slows to –1.42 packs/year in CA, not significantly different from U.S. decrease (media campaign suspended).

 

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Cessation

Quit ratio
Citation State Time frame Finding
Jemal et al., 2003 U.S. 1990–1999 Index of the strength of state TC correlation with state quit ratio: –0.82 (p < 0.0001)
Siegel et al., 1998 CA 1978–1985 Estimated annual change: 0.73 (95% CI = 0.22, 1.24) in CA vs. 0.73 (0.40, 1.05) in rest of U.S.
1985–1990 Estimated annual change: 1.36 (95% CI = 0.74, 1.97) in CA vs. 1.04 (0.62, 1.46) in rest of U.S.
1990–1994 Estimated annual change:  0.18 (95% CI = –0.80, 1.15) in CA vs. 0.15 (–0.47, 0.77) in rest of U.S.
Other Cessation Measures
Citation State Time frame Finding
Meshack et al., 2003* TX 2000–2002 Regions with most intensive pilot activities: more awareness (23.1% vs. 13.8%), use of telephone counseling services (2.7% vs. 1.2%), and cessation (11% vs. 9%); receipt of telephone counseling services led to 1-year cessation rates significantly higher (20.7% vs. 13.2%, or 10.3% vs. 6.6% if assume those lost to follow-up failed).
WA State DH, 2003* WA 1999–2002 Smokers making serious quit attempts: 15% to 26%.
Gilpin et al., 2001* CA 1990–1999 Smokers making quit attempts: 49% to 60.
Abt Associates, 2000* MA 1993–1999 Quit success rate: 17% to 25% .
Norman et al., 2000 CA 1998 Smokers with home smoking ban were twice as likely to report wanting to quit smoking (OR = 2.16, 95% CI = 1.26, 3.7; p < 0.01) than smokers with no rules in the home, after controlling for multiple predictors.
Popham et al., 1998 CA 1990–1991 Influence of media campaign on decision to quit: via qualitative self-report, influenced at least 173,000 former smokers and was major influence for 33,000.

 

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Smoke-free Policies

Citation State Time frame Finding
McMillen et al., 2003* MS 2000–2002 Smoking ban at all work areas: 53.2% to 64.7% (p < 0.05) in MS vs. 65.7% to 65% in U.S.
OR DHS, 2003* OR 1996–2003 >95% of work sites covered by smoke-free law; 71% to 81% homes with smoke-free polices.
Bartosch & Pope, 2002 MA March 1999 Local tobacco policy index: maximum 100 points, 50 points each to smoke-free environments and youth access Variance in policy enactment: 47% explained; significant factors were state funding and larger town size.
Rohrbach et al., 2002 CA 1996–1998 Changes in absolute percentage in home smoking bans associated with lowest, moderate, and highest exposure categories: +2.01%, +0.89%, and +4.15%, respectively (p = 0.04).

Changes in absolute percentage in perceived violations of work no-smoking policies associated with lowest, moderate, and highest exposure categories: +2.01%, +0.89%, and +4.15%, respectively (p =  0.03).
Siegel, 2002 U.S. Varies (review) State TC programs focused on controlling secondhand smoke usually enact policies at state and local levels (precluding existence of state preemption laws); e.g., in CA and MA over three-quarters of indoor workers report working in smoke-free workplaces.
Gilpin et al., 2001* CA 1990–1999 Indoor workers with smoke-free policies: 35% to 93%.

Indoor smoke-free policies: 73%, 30% relative increase from 1993; 88.6% of children and 47% of smokers in smoke-free homes.
Norman et al., 2000 CA Mar-July 1998 Smokers with home smoking ban: more than twice as likely to have heard of community programs (AOR = 2.27; 95% CI = 1.23, 4.21), almost three times as likely to have seen and discussed television ad about smoking around children (AOR = 2.87; 95% CI = 1.11, 7.41); in multivariate models, home smoking ban associated with average daily consumption (p < 0.01) and desire to quit (OR = 2.16; 95% CI = 1.26, 3.7).
Porter, 2000* AZ 1996–1999 Indoor home smoking bans: increased from 32.2% to 41.1% for smokers, 30% to 43.9% for nonsmokers; total home smoking bans (including outdoors) decreased from 15.7% to 6.9% for smokers and 50.6% to 39.4% for nonsmokers.

 

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Table 1—Recent Reviews on the Effectiveness of State Tobacco Control Programs

The conclusions of recent major reviews of comprehensive state programs are summarized in Table 1. The major studies identified in these reviews were identified and subsequently used for Table 2.

Authors States Program components Main findings
Siegel, 2002 CA, MA, AZ, OR, FL Comprehensive state programs Media campaigns are the most critical component of successful state programs, and suspending campaigns and limiting their aggressiveness has resulted in reversals of consumption trends. Intervention at the local level is critical to success, especially in passing clean indoor air (CIA) policies. CIA policies are crucial to state programs because they protect the public from secondhand smoke, increase cessation, and reduce consumption. Campaigns that expose tobacco industry marketing techniques are demonstrably more effective in reducing initiation.
CA Dedicated excise tax, media campaign, smoke-free policies Prop 99 (passed in 1988) resulted in a significant decline in consumption and prevalence among adults relative to the rest of the country; the media campaign in particular was effective at reducing consumption, beyond the effect of the tax increase. As funding for the program and the media campaign was cut, however, declines in consumption also slowed. Prop 99 also led to the proliferation of local CIA policies, with over 3/4 of indoor workers reporting smoke-free work sites. Reduced heart disease mortality (33,000 lives saved) within 1–3 years of the program’s inception was shown.
MA Dedicated excise tax, media campaign, smoke-free policies Question 1 (passed in 1992) was associated with a significant reduction in consumption and adult prevalence. Evidence suggests that youth exposure to media campaigns may be linked with lower rates of progression to established smoking. Local CIA policies, including smoke-free restaurants, have proliferated and over 3/4 of private sector indoor workers report smoke-free work sites.
AZ Dedicated excise tax, limited media campaign for youths and pregnant women Prop 200 (passed in 1994) and resultant price increases resulted in reduced PCC, but no rigorous studies on adult or youth prevalence have been completed. Comparison of adult and youth trends with national data suggests prevalence may have decreased because of AZ's program. Prop 200 appears to have accelerated development of local CIA policies.
OR Dedicated excise tax resulting in comprehensive program Measure 44 (passed in 1996) has been linked with a significant decrease in consumption, above that expected from price elasticity 6 estimates, suggesting that components of the programs other than the tax increase are responsible. No published analyses have examined prevalence, but Behavioral Risk Factor Surveillance System (BRFSS) evidence suggests that prevalence might have declined as a result of the program. Preliminary evidence suggests that declines in youth prevalence may be due to varied implementation of programming, but further analysis is needed to verify that reductions are attributable to the program. In 1997 the first local smoke-free restaurant ordinances were established.
FL Youth-focused "truth" campaign Medicaid Fraud suit (settled in 1997) resulted in funding of the "truth" media campaign focused on youths. Within 2 years of program implementation, youth smoking prevalence dropped significantly in middle and high school youths whereas rates increased in other states. Studies have also linked reported exposure to the truth campaign with decreased initiation for up to 2 years and showed a dose-response relationship between awareness and risk of initiation. State preemption laws have precluded local CIA policies.
Institute of Medicine, 2000 CA, MA, OR, WA, FL, AZ Counter-advertising/education, smoke-free environments, taxation, cessation, youth access Multifaceted programs reduce tobacco use, and a dose-response effect exists between intensity of programming and declines in consumption. Effects of counter-advertising depend on intensity and dose. Smoke-free work sites reduce illness and death from secondhand smoke, increase cessation, and reduce consumption among continuing smokers. Raising excise taxes decreases smoking prevalence and increases state revenue. Cessation programs are cost-effective. To be effective, youth access restrictions require maximum retailer compliance.
Wakefield & Chaloupka, 2000 CA, MA, AZ, OR, FL Comprehensive state programs Critical to program success are the extent of funding and the degree to which that is undermined by tobacco industry and other funding competitors. Prices influence adolescent and adult tobacco use; the addition of TC programs reduces consumption more than would be expected by price increases alone. Programs are associated with a decrease in adult prevalence (CA, MA, OR; AZ and FL data not yet available); because programs focus more on youths, the effects on adult prevalence are not yet known. Early evidence shows that programs can reduce youth smoking. Although youth prevalence rose across the rest of the U.S. in 1993–1996 (29% increase in grade 8 and 23% in grade 10), the comparable rates in CA were less (16% and 6%, respectively). MA reported a similar experience; FL reported greater relative declines than national trends in 30-day prevalence for middle and high school students in Feb 1998–99.

 

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