摘要：Objective . We examined the relationship between state-level tobacco control expenditures and youth smoking prevalence and cigarette consumption. Methods . We estimated a 2-part model of cigarette demand using data from the 1991 through 2000 nationally representative surveys of 8th-, 10th-, and 12th-grade students as part of the Monitoring the Future project. Results . We found that real per capita expenditures on tobacco control had a negative and significant impact on youth smoking prevalence and on the average number of cigarettes smoked by smokers. Conclusions . Had states represented by the Monitoring the Future sample and the District of Columbia spent the minimum amount of money recommended by the Centers for Disease Control and Prevention, the prevalence of smoking among youths would have been between 3.3% and 13.5% lower than the rate we observed over this period. Significant resources are currently being devoted to programs aimed at reducing tobacco use and the damage it causes to the public. Comprehensive programs have been developed to prevent the initiation of tobacco use among young people, promote cessation of tobacco use among adults and young people, eliminate exposure to environmental tobacco smoke, and identify and eliminate disparities among population groups in order to reduce the disease, disability, and death that result from tobacco use. 1, 2 Successful programs have included the following key components: community interventions and programs, countermarketing, program policy and regulation, and surveillance and evaluation. 2, 3 Many of these programs are funded by state cigarette excise tax revenues earmarked for tobacco control programs that come from either voter initiatives or state-legislated increases in cigarette and other tobacco product taxes; others are supported from general revenues. The first major comprehensive state programs resulted from ballot initiatives that increased state cigarette and other tobacco product taxes and earmarked some of the new revenues generated by the tax increases for tobacco control. California led the way in 1988 when voters passed Proposition 99, which raised the cigarette tax by 25 cents per pack. California used funds from the tax increase to support antitobacco initiatives, including a media campaign, community education programs, school education programs, research funding, surveillance and evaluation activities, and other initiatives. Massachusetts was next in 1992 when voters passed the Question 1 referendum, which raised the cigarette tax by 25 cents per pack. Revenues from tobacco taxes in Massachusetts were used to fund a large antismoking media campaign, school and community antismoking education programs, increased enforcement of local tobacco ordinances, and various other initiatives. Several states followed the lead of California and Massachusetts by using ballot initiatives to raise tobacco taxes and fund comprehensive programs. Other states legislated for an earmarked excise tax–funded program. Most recently, in November 2001, voters in the state of Washington overwhelmingly adopted a 60-cent increase in the state cigarette excise tax, with a significant portion of the new revenues earmarked for a comprehensive state program. Other state tobacco control programs are funded by state settlements with cigarette manufacturers or by the funds states receive through the Master Settlement Agreement with the tobacco industry. In 2002, the 4 states that settled individually—Mississippi, Texas, Florida, and Minnesota—spent a portion of their settlement funds on state tobacco control programs. 1 Similarly, 38 of the states that were a part of the Master Settlement Agreement have set aside some of their settlement funds for a tobacco control program. 1 (Settlement funding for tobacco control in Arizona and Massachusetts was not included in these calculations because their state budgets had not been finalized at the time the Centers for Disease Control and Prevention [CDC] released its report.) Federal and private funding for national programs also have supported state efforts to reduce tobacco use. The first major effort was the American Stop Smoking Intervention Study (ASSIST) program, a partnership between the National Cancer Institute and the American Cancer Society that supported state-based coalitions focused on changing tobacco control policies in 17 states from 1991 through 1998. During this same period, the CDC funded the remaining states (excluding California) and the District of Columbia under its Initiatives to Mobilize for the Prevention and Control of Tobacco Use (IMPACT) program. In 1999, these 2 programs were replaced by the CDC-funded National Tobacco Control Program that supports tobacco control efforts in all 50 states, the District of Columbia, and 7 territories. 2 Since 1994, the Robert Wood Johnson Foundation’s SmokeLess States program has also funded tobacco control coalitions in 42 states. This program, which is administered by the American Medical Association, emphasizes strengthening state tobacco control policies. Overall, the CDC estimated that state investment in tobacco control efforts was $861.9 million, or $3.16 per capita, in fiscal year 2002. 1 Although considerably higher than it was even a few years ago, the investment in most states is well below the level the CDC recommends as the minimum needed to support a comprehensive tobacco control program. 1, 3 In its initial Best Practices guidelines released in 1999, the CDC recommended a minimum average per capita spending of $5.98 for the United States, with the state levels ranging from a low of $5.12 in California to a high of $15.39 in Wyoming. 3 On average, the CDC upper estimate was nearly 3 times as high, at $15.85 per capita for the United States. The CDC funding recommendations for each state depended on state-specific characteristics, such as demographic factors, tobacco use prevalence, and other factors. As of 2002, funding in 18 states was one third that of the minimum recommended by the CDC or lower; only 6 states had reached the minimum level of funding. 4 (Settlement funding for tobacco control in Arizona and Massachusetts were not included in these calculations because their state budgets had not been finalized at the time the CDC released its report.) By comparison, total marketing expenditures for the 5 major US cigarette companies in 2001 (the latest year available) were $11.2 billion, more than 13 times the total investment in state tobacco control efforts. 5 The 2001 marketing expenditures were a record high for these companies and represented a 66.6% increase from spending in 1998. Evaluations of major individual state programs provide compelling evidence that these programs are correlated with reduced tobacco use. 2, 6, 7 In California, for example, per capita cigarette sales were cut almost in half from 1988 to 1999, whereas the decline was only about 20% in the rest of the Unites States. The prevalence of youth smoking in California fell by 43% from 1995 to 1999. 8, 9 The health benefits of the reductions in tobacco use in California are beginning to appear. Recent estimates indicate that the rate of death caused by heart disease and lung cancer has fallen sharply. 10, 11 After adopting a large-scale comprehensive state tobacco control program, Massachusetts, 12– 15 Oregon, 16 Arizona, 17 and Florida 18, 19 observed large reductions in smoking. However, in contrast to the growing number of state-specific reports, little evidence exists from national-level analyses of the impact of investments in tobacco control. An early analysis that compared per capita cigarette sales in ASSIST states to sales in non-ASSIST states found that sales declined 28% faster in the ASSIST states in the first several years after the program began, whereas in the years before the program, trends in sales between the 2 groups were similar. This finding suggests that the investment in ASSIST reduced smoking. 20 More recently, a multivariate analysis relating state-level per capita expenditures on all major tobacco control programs (tax and settlement funded, ASSIST, IMPACT, and SmokeLess States) to state-level per capita cigarette sales for the period from 1981 through 2000 concluded that investments in tobacco control programs have reduced aggregate cigarette consumption. 21 To date, only 1 analysis has used national data to study the impact of these programs on youth smoking. Using data from the 1991, 1993, 1995, 1997, and 1999 Youth Risk Behavior Surveys, Farrelly and colleagues 22 found little evidence that increased spending on state tobacco control efforts reduced the prevalence of smoking among youths. However, they did provide some evidence that greater spending was associated with a reduction in the average number of cigarettes smoked among young smokers. However, as the authors noted, this study was limited by the exclusion of several states with comprehensive programs in place during the period covered by their analyses (including Massachusetts, Arizona, and Oregon), because of the lack of consistent data from the Youth Risk Behavior Surveys for these states over this period. Although much is known about the impact of some individual state programs on cigarette smoking within the state, very few studies have looked at the impact of state programs on cigarette smoking at the national level. Our study adds to the growing body of evidence on the impact of state tobacco control programs on smoking by examining the relationship between state-level per capita tobacco control expenditures and youth smoking prevalence and consumption using data taken from the nationally representative Monitoring the Future (MTF) surveys of 8th-, 10th-, and 12th-grade students, matched with information on tobacco control spending, cigarette prices, and measures of state tobacco control policies. As such, it provides the best assessment to date on the impact of these programs on youth smoking. The findings from this research should be particularly important for state policymakers debating the use of the Master Settlement Agreement and other funds for state tobacco control programs.
