Tobacco control programs and tobacco consumption.

• Author: Marlow, Michael L.
• Position: Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) believe that adequate funding of tobacco control programs by all 50 states would reduce the number of adults who smoke by promoting quitting, preventing young people from ever starting, reducing exposure to secondhand smoke, and eliminating disparities in tobacco use among population groups. CDC has established guidelines for comprehensive tobacco control programs, including recommended funding levels, in Best Practices for Comprehensive Tobacco Control Programs (CDC 1999; hereafter called Best Practices). Recommendations are based on best practices in nine program elements: community programs to reduce tobacco use, chronic disease programs to reduce the burden of tobacco-related diseases, school programs, enforcement, statewide programs, countermarketing, cessation programs, surveillance and evaluation, and administration and management. CDC recommends annual funding per capita to range from 87 to $20 in smaller states (population less than 3 million), $6-817 in medium-sized states (population 3-7 million), and $5-$16 in larger states (population more than 7 million).

CDC (2002) estimates that total expenditures of $861.9 million in 2002 were allocated to tobacco control from national and state sources in the United Sates, or $3.16 per capita. Actual spending in all states was roughly 56 percent of the "lower-bound" or minimum Best Practices funding recommendation for that year, with only six states (Hawaii, Maine, Maryland, Minnesota, Mississippi, and Ohio) meeting or exceeding minimum recommendations, and 18 states providing less than 33 percent of recommended floors (CDC 1999). CDC called for more than $3 billion in additional tobacco control spending in each of 2001 and 2002 to meet minimum Best Practices recommendations.

This article examines whether state tobacco control programs lowered both adult tobacco consumption and youth smoking during 2001 and 2002 using newly available data published in CDC (2001, 2002) on expenditures of these programs. A secondary issue is whether or not divergence of actual funding from minimum Best Practices recommendations explains any of the differences between tobacco consumption in the states. That is, does the fact that a state funds above or below minimum levels indicate anything about tobacco consumption in that state relative to other states'? The informational content of the Best Practices funding guidelines has not been previously examined. This study examines whether spending expansion along the lines of the Best Practices guidelines provides a useful benchmark based on past effectiveness of those programs in controlling tobacco consumption.

Previous Literature

Studies of the impact of tobacco control programs often focus on consumption changes following a particular policy event such as a new control program. Manley et al. (1997) concluded that per capita monthly sales fell in states participating in the ASSIST (American Stop Smoking Intervention Study) program relative to states not participating. Pierce et. al. (1998) reported that California control programs significantly lowered tobacco use. While these and other studies show falling tobacco use following implementation of new tobacco control programs, they fail to control for factors that may also cause consumption to fall. Tobacco control programs themselves therefore may or may not be causing observed declines in tobacco use and, even if in fact they do contribute, studies overstate impacts of control programs on tobacco use when they do not properly control for other contributing factors.

Three studies control for one or more factors outside of the tobacco control programs themselves. Hu, Sung, and Keeler (1995a) control for state excise taxes and tobacco firm media expenditures when concluding that state media expenditures, or counteradvertising, exert a negative impact on cigarette consumption. The authors measured tobacco control expenditures as "media placement expenditures" by the Tobacco Control Section of the California Department of Health Services and calculated that California spent almost $20 million over the 1980-93 study period. The authors suggest that counteradvertising by tobacco control authorities may not be a particularly cost-effective method of lowering tobacco use because tobacco firms appear to effectively reverse this tobacco control policy through their own advertising. Hu, Sung, and Keeler (1995b) estimate that sales of cigarettes in California were reduced by 819 million packs from the third quarter of 1990 through the fourth quarter of 1992 owing to an additional 25-cent state tax increase, while the anti-smoking media campaign reduced cigarette sales by 232 million packs during the same period.

Farrelly, Pechacek, and Chaloupka (2003) examine the impact of state tobacco control expenditures on cigarette sales over 1981-2000 and conclude that increases in such expenditures lower per capita cigarette sales after controlling for excise taxes, smuggling, and other state-specific factors. The authors collected their own data from federal, state, and private funding sources and then considered three specifications for estimating effects of expenditures on cigarette consumption: contemporaneous, lagged annual, and cumulative. Lagged annual and cumulative specifications allow for past expenditures to affect current consumption. The authors concluded that past and current expenditures on tobacco control influence current tobacco use and, based on their empirical results, estimated that aggregate cigarette sales would have fallen by an additional 9 percent by year 2000 if states had spent at minimum funding levels associated with CDC's Best Practices. The authors did not directly examine the effectiveness of minimum Best Practices funding recommendations, but rather calculated the effect on consumption in their model if spending were to be increased to the minimum recommendation.

This literature survey suggests that examination of more recent data is an obvious avenue for further research since data collected in Farrelly, Pechacek, and Chaloupka (2003) ended in 2000. The authors report that real tobacco control expenditures averaged $1.29. in 2000, which is below the averages of $3.73 (2001) and $4.00 (2002) in the CDC data set used here. More recent tobacco control programs therefore appear more generously funded, reflecting perhaps greater use of tobacco settlement revenues, greater urgency on the part of public health authorities to control smoking, or measurement differences between data sets. A new research avenue concerns whether the Best Practices funding recommendations are useful targets for states to follow when allocating additional funds to their tobacco control programs. This article addresses that issue by examining whether states that fund closer to the Best Practices guidelines exert greater reduction in tobacco use than those programs that do not. If so, then it might be argued that the Best Practices guidelines offer useful comparisons of how well various state programs are funded according to a valid benchmark.

Tobacco Control Funding and Expenditures

While four states (Arizona, California, Massachusetts, and Oregon) were early pioneers in tobacco control programs, most states have only recently been funding programs in a comprehensive effort aimed at lowering tobacco use (CDC 2001, 2002). Programs previously relied primarily on raising excise taxes to discourage tobacco use and this focus probably explains the extensive literature assessing price and tax elasticities of demand for tobacco. Laws on smoking in public places are another form of tobacco control program that vary considerably across states. The American Lung Association (2004) ranks states by laws ensuring smoke-free air and, in 2003, gave three states (California, Delaware, and New York) a grade of A, seven states a grade of B, four states a grade of C, and all other states a grade of F. Following Farrelly, Pechacek, and Chaloupka (2003), such laws can be considered a goal of tobacco control programs rather than a tool, thus allowing tobacco control expenditures to reflect a comprehensive array of tobacco control program characteristics. This assumption is applied to this study as well.

State spending on tobacco control programs comes from a variety of sources. In 2004, for instance, the Government Accounting Office (GAO 2004) reported that 46 states received more...