State Tobacco Prevention and Control Activities: Results of the 1989 - 1990 Association of State and Territorial Health Officials (ASTHO) Survey Final Report

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service Centers for Disease Control National Center for Chronic Disease Preventionand Health Promotion Office on Smoking and Health Atlanta, Georgia 30333

The MMWR series of publications is published by the Epidemiology Program Office, Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services, Atlanta, Georgia 30333.

SUGGESTED CITATION Centers for Disease Control. State Tobacco Prevention and Control Activities: Results of the 1989-1990 Association of State and Territorial Health Officials (ASTHO) Survey Final Report. MMWR 1991:40(No. RR-11):(inclusive page numbers).

Centers for Disease Control William L. Roper, M.D., M.P.H. Director

The material in this report was prepared for publication by: National Center for Chronic Disease Prevention

and Health Promotion Jeffrey P. Koplan, M.D., M.P.H. Director

Office on Smoking and Health Virginia S. Bales, M.P.H. Acting Director

Program Services Activity Corinne Meltzer, M.P.H. Public Health Education Specialist

The production of this report as an MMWR serial production was coordinated in:

Epidemiology Program Office Stephen B. Thacker, M.D., M.Sc. Director Richard A. Goodman, M.D., M.P.H. Editor MMWR Series

Scientific Communications Program R. Elliott Churchill, M.A. Director Amanda Tarkington, M.C. Writer-Editor Ruth C. Greenberg Editorial Assistant Copies can be purchased from Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402-9325. Telephone: (202) 783-3238

The staff members listed below served as authors of State Tobacco Prevention and Control Activities: Results of the 1989-1990 Association of State and Territorial Health Officials Survey Final Report

CENTERS FOR DISEASE CONTROL Won S. Choi, M.P.H. Thomas E. Novotny, M.D. Ronald M. Davis, M.D.

ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS Joy Epstein, M.P.A.

Acknowledgment: The authors wish to thank staff from the National Cancer Institute, the National Heart, Lung, and Blood Institute, the 51 state health departments, and in particular, George Degnon, Executive Vice President of ASTHO, and William I. Thomas of HCR, Inc., for providing invaluable assistance in preparing, disseminating, and analyzing the ASTHO Survey.

Contents

Summary 1 Introduction 1 Methods 2

Data Collection and Analysis 2 Results 2

Background Information on Tobacco and Tobacco-Use Control 2 Surveillance of Adult Tobacco Use 3 Surveillance of Youth Tobacco Use 3 Tobacco-Related Impact Data-Reporting and Analysis 3 Regulatory Activities 4 Tobacco-Control Coalitions 4 Special Populations 5 Community Information/Education 5 Economic Incentives and Deterrents 5 Educational Institutions 5 Discussion 6 Appendix 39 References 40 Association of State and Territorial Health Officials 41

State Tobacco Prevention and Control Activities:

Results of the 1989-1990 Association of State and Territorial Health Officials (ASTHO) Survey Final Report

Summary

In October 1989, the Association of State and Territorial Health Officials (ASTHO) conducted a survey of state health department personnel regarding programs, policies, and public health systems that stress the prevention and control of the use of tobacco. This survey provided detailed data associated with state tobacco-use control programs and their essential components (e.g., budgets, planning, coalitions, surveillance systems, smoking cessation programs, educational activities, legislative actions, and health department policies). States vary widely in the strength and coverage of their programs for preventing and controlling tobacco use. The ASTHO survey data may be used to help plan and evaluate state health department programs as part of an effort to prevent chronic diseases related to tobacco use. Outcomes of state activities may be evaluated through surveys such as CDC's Behavioral Risk Factor Surveillance System (BRFSS) and the Current Population Survey (CPS) of the Bureau of the Census. Future surveys of state activities for controlling the use of tobacco may be included in the evaluation of the upcoming (1993) American Stop Smoking Intervention Study (ASSIST), which is cosponsored by the National Cancer Institute and the American Cancer Society.

INTRODUCTION

The Association of State and Territorial Health Officials (ASTHO) conducted a survey in October 1989 to assess progress among the states in the public health practice of preventing and controlling tobacco use. The survey was also conducted to provide states with incentives to create and implement efforts to control tobacco use. The survey covered several components of effective state programs that address such efforts among targeted populations. Additional sources either supplemented or validated state information on tobacco-use control data collected through the ASTHO survey. In the fall of 1989, ASTHO established a network of health professionals responsible for communication between the federal government and state health departments on issues related to tobacco-use prevention and control. As the identifiable contacts for information transfer on tobacco-related matters, these persons served as respondents to the ASTHO survey.

METHODS

The survey's 10 major sections are 1) background information on tobacco and tobacco control; 2) adult tobacco-use surveillance; 3) adolescent tobacco-use surveillance; 4) reporting and analysis of data on the impact of tobacco-related disease; 5) regulatory activities; 6) coalitions against tobacco use; 7) special populations; 8) community information on education activities; 9) economic incentives, deterrents; and 10) educational institutions. ASTHO contacts solicited the help of state departments of education to answer questions about tobacco-use control activities in educational institutions (public and private schools). This section of the survey assessed the ability of each state to measure progress toward smoke-free schools and the extent to which educational institutions addressed antitobacco education.

Central data sources were used to supplement the survey results for the following areas of this report: legislative activities; taxation; and number of schools, districts, and enrolled students. Sources used to supplement information on legislative issues included State Legislated Actions on Tobacco Issues of the Tobacco-Free America Project (1) and Major Local Smoking Ordinances in the United States, National Institutes of Health (2). The Tobacco Institute also provided state-specific data on taxation (3). For information related to schools and school districts, the 1990 World Almanac was used to supplement information supplied by the states (4). Finally, previously tabulated data were reviewed and updated by the ASTHO network in December 1990.

Data Collection and Analysis

ASTHO sent the questionnaires to all 50 states and the District of Columbia. For the purpose of this report, the District of Columbia is considered a state when summary data are presented. In some cases, supplemental information was obtained by telephone. Responses were tabulated and analyzed using True Epistat and dBase IV (5,6).

RESULTS

The response rates were 100% for both the main section and educational sections.

Background Information on Tobacco and Tobacco-Use Control

As of October 1990, 12 states had developed a specific freestanding plan for preventing and controlling tobacco use (Table 1). In 22 states, the plan is a part of another plan for controlling chronic disease. Most of these plans address areas related to high-risk populations, health care, smoking cessation issues, worksite policies, and other areas in preventing tobacco use. The 12 freestanding plans were all published after 1980, and most after 1985 (7).

Excluding California, the average state budget devoted to tobacco-related health activities was $70,917. The state funds ranged from no funds (27 states) to $151 million in California, where a portion of the state cigarette excise tax is earmarked for health activities (8) (Table 2). In addition to California, six other states had earmarked a portion of the excise cigarette tax for public health activities. Additional funds, including grants, cooperative agreements, and in-kind services, averaged $54,230 per state (including California).

The sixteen states growing tobacco (Figure 1) produced a combined total of $2,381,000,000 in tobacco agricultural revenue in 1989 (Table 3), representing 1.5% of the total U.S. agricultural farm receipts (9). The percentage of state agricultural farm receipts generated by tobacco growing ranged from 0.2% (Missouri and Wisconsin) to 21.8% (Kentucky).

Surveillance of Adult Tobacco Use

CDC's BRFSS is a telephone-based system that collects yearly data on tobacco use and other health-related behaviors among adults 18 years of age and older. In 1990, 46 states participated in the BRFSS (10). Twenty-one states collected data on adult smoking prevalence from non-BRFSS sources (Table 4). Twenty of these states collected data on adult special target populations (blacks, Hispanics, Asians/Pacific Islanders, American Indians, persons with low socioeconomic status, and women of reproductive age (15-44 years old)).

In addition to the BRFFS, state-specific data on tobacco use among adults 16 years of age and older are available from two Current Population Surveys (CPS) that were performed by the U.S. Bureau of the Census in 1985 and 1989 (11,12). The 1985 CPS provided state-specific estimates of both smoking prevalence and smokeless-tobacco use. The 1989 survey provided information only on smoking prevalence.

Surveillance of Youth Tobacco Use

No national system exists for monitoring state-specific tobacco use by adolescents. However, CDC has developed a standard survey (the Youth Risk Behavior Survey (YRBS)) to collect comparable school-based data from the states (13). By the completion of the survey in January 1990, three states had participated in the YRBS; 19 additional states had participated by the end of 1990. From 1986-1990, 32 states reported collecting data on tobacco use among adolescents from sources other than the YRBS (Table 5). The respondents were asked follow-up questions to determine if these surveys covered the basic question topics from the YRBS. The surveys examined such specific areas as tobacco experimentation, current tobacco use, age of initiation of tobacco use, and smokeless tobacco use. Twenty-six states had information on experimentation with tobacco-use, 32 states collected data on prevalence of tobacco use, 19 states had information on age of initiation of tobacco use, and 25 states had information on smokeless tobacco use.

Tobacco-Related Disease Impact Data-Reporting and Analysis

All 51 state health departments used a software package developed by the Minnesota Department of Health, the Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC), to obtain data on smoking-attributable deaths and economic costs (14).

In five states, a record of the decedent's smoking history was required on death certificates (Table 6). Four states reported data on smoking-attributable hospital discharges, and eight states have information on smoking-attributable state-funded medical care costs. In 33 states, maternal smoking history was recorded on birth certificates.

Regulatory Activities

Smoking in Public Places

In 1989, 45 states had laws restricting smoking in public places (Table 7); in 38 of these states, the restrictions also applied to public-sector workplaces. In 17 states, these restrictions extended to private-sector workplaces (1). The Surgeon General's 1989 report on smoking and health defined extensive regulations as those that restricted smoking in the private-sector workplace (Figure 2) (15).

Local smoking ordinances in cities and counties encompassed a wide range of public settings, including restaurants, elevators, hotels, libraries, museums, retail stores, schools, public transit, and other enclosed public places. In all, 490 local ordinances restricted or prohibited smoking in public places (Table 8).

Health Department Tobacco-Use Policies

With the exception of North Carolina and Virginia, all state health departments had a written policy on smoking in state health department buildings in 1989 (Table 9). Twenty-four (47%) of these states completely banned smoking in state health department facilities; 31 states (61%) permit the sale of tobacco products in health department buildings.

Restrictions on Minors' Access to Tobacco Products

As of October 1990, 46 states prohibited the sale of tobacco products to underaged persons (Table 10). The minimum age for purchasing tobacco varied from 16 years of age (Kentucky, Virginia) to 19 years of age (Alabama, Alaska, Utah); the most common minimum age is 18 years of age (37 states) (Table 10) (1,16). Nine states restricted the placement of vending machines that contain tobacco products (Table 10); one state (Colorado) banned the sale of smokeless tobacco in vending machines, and another (Utah) banned the sale of all tobacco products in vending machines. Twenty-two states required a state-issued retail tobacco license for vendors selling tobacco products (Table 11). The fees for these retail licenses ranged from $0 to $250 (average: $33).

Restrictions on Tobacco Advertising

Two states (Massachusetts and Utah) have policies that restrict advertising of tobacco products on state property or property under the state's jurisdiction. Local policies in six states (Arizona, California, Colorado, Hawaii, Massachusetts, and Nebraska) restrict advertising of tobacco products on local government property, such as buses, transit stations, or sports facilities.

Tobacco-Control Coalitions

As of October 1990, 50 states had tobacco-related working groups or coalitions of individuals or agencies concerned with preventing and controlling tobacco use (Table 12) (17). The coalition members represent the health professions, the general community, groups concerned with legislation and policy, and educational groups (Table 13). Eighty-two percent of these state coalitions carried out public education and information activities, 72% addressed legislative efforts, 48% educated professionals, 44% worked on developing a plan for tobacco-use control, and 26% carried out research and evaluation (Table 14). The average funding for coalitions in reporting states (excluding California) is $5,536 (Table 12).

Special Populations

Special populations targeted for intensive tobacco-use prevention and control efforts by the U.S. Department of Health and Human Services include adolescents, women of reproductive age (15-44 years old), Asians/Pacific Islanders, American Indians, Hispanics, and blacks (18). Forty states have programs (in addition to the BRFSS) that include education and information for some or all of these groups (Table 15). Thirty-three states had cessation programs, and 26 states collected behavorial data on these high-risk populations.

Community Information/Education

Public Information Activities

Twenty-two state health departments produced public service announcements designed to prevent tobacco use (Table 16). Forty-five states used public service announcements produced by federal agencies (such as the Office on Smoking and Health and the National Cancer Institute). Thirty-two states initiated public information campaigns in their states within the last 2 years. These campaigns used various forms of media (billboards, radio, television, etc.) (Table 17).

Smoking Cessation Programs

Thirty-five states offered smoking cessation programs to state health employees, and 26 states offered such programs to members of the community (Table 18).

Economic Incentives and Deterrents

Colorado, Kansas, and Washington were the only states that had health benefits packages with differential rates for smokers and nonsmokers for state government employees (Table 19). Fourteen states reported having third-party payers of medical care that offered differential rates to consumers, and seven states had third-party payers of medical care that offered reimbursement for treatment of tobacco addiction. These data may be an underestimate, however, because some large national insurers sold policies in many states, (e.g., Blue Cross and Blue Shield Company of Southwestern Virginia) (19). State tobacco excise taxes ranged from 2 cents per pack in North Carolina to 41 cents per pack in Texas (Table 2) (3). The average state excise tax collected per pack was 23 cents. The lowest tax rates were primarily in the tobacco-producing states.

Educational Institutions

Thirty-nine states had state laws that restricted tobacco use in schools (Table 20). Twenty-seven states banned smoking for students; only eight states banned smoking for both students and staff. In 16 states, the state department of education reported having formal policies on tobaco use in schools. Information in Tables 21-24 was based on states that provided data for those specific questions related to tobacco-use prevention and educational institutions. Only two states, Ohio and Nevada, provided information on private primary and secondary schools.

There are 15,323 school districts in the United States (Table 21) (4). Among the 25 states reporting information on policies in school districts, 2,311 (30.8%) of the school districts in these states banned smoking for both students and staff.

Among the states with information on smoking policies in public primary schools, 4,468 (33.9%) of these schools banned smoking for both students and staff (Table 22). Among the reporting states, 21,097 (96.2%) schools completely banned smoking for students (i.e., students could not smoke on school grounds). Within the 26 states that provided data on tobacco-use education, 18,588 of 21,129 (87.9%) public primary schools taught tobacco-use prevention.

Among the states reporting information on smoking policies in public secondary schools, 1,368 (21.2%) of 6,459 schools completely banned smoking for both students and staff, and 7,481 (83.1%) completely banned smoking for students (Table 23). For the 23 states that provided information on tobacco-use education, 7,623 of the 9,456 public secondary schools (80.6%) taught tobacco-use prevention.

Among 12 states that provided information, approximately 2.8 million (48.5%) public primary and secondary students attended smoke-free schools (Table 24).

DISCUSSION

The 1989 ASTHO survey provides data on the activity of all 51 states regarding the prevention and control of tobacco use. States varied greatly in their approaches to the control of tobacco use. Some states had extensive surveillance systems and programs in place, whereas others had only limited programs and funding. Data from the 1989 ASTHO survey and subsequent surveys may be linked to state-specific data on smoking prevalence, cigarette consumption, and smoking cessation. These state-specific data (from CDC's BRFSS and the Bureau of the Census' CPS) may be used to assess the outcome of recent state activities in preventing and controlling tobacco use. A national guide that may direct state progress in these and other areas of concern is Healthy People 2000: National Health Promotion and Disease Prevention Objectives, which lists 16 tobacco-related objectives for the year 2000 (18). (The Appendix section of this issue reprints those 16 objectives.)

Little information about programs and policies to prevent tobacco use among young persons is available either to the ASTHO tobacco-control network or to state departments of education. Fewer than half of the states reported any information related to the education portion of the survey. Consequently, selective reporting from certain states may overstate the percentage of smoke-free schools. In addition, those states that reported 100% prevalence of tobacco-use education assumed, but did not verify, total compliance to state requirements. Efforts to collect these data are important in assessing the overall public health approach to preventing and controlling tobacco use.

Because the 1989-90 ASTHO survey provided baseline information on broad activities to prevent and control tobacco use, subsequent surveys may be useful in assessing states' progress. To conduct such assessments, state-specific objectives should be established, and a system for measuring states' progress in these objectives should be implemented. The evaluation could initially be applied to the different control activities covered by the survey (such as education, coalitions, and surveillance). An overall measure for each component for controlling and preventing tobacco use should then be developed. The Rocky Mountain Tobacco-Free Challenge has included an evaluation of state activities on tobacco-use control (20). Initiated in 1988, this program is a regional effort among eight states to reduce tobacco use and chronic diseases (21).

The ASTHO survey is an important baseline for monitoring tobacco-use control programs at the state and local levels. Future surveys may provide data that can be used to measure the effects of planned intervention programs, such as the National Cancer Institute's ASSIST, which will begin in 1993 (20). These surveys may also provide means to measure progress toward the year 2000 health objectives for the nation (18).

Appendix

Tobacco-related objectives, outlined in Healthy People 2000: National Health Promotion and Disease Prevention Objectives, provide a national guide for assessing progress in preventing and controlling tobacco use. The following is reprinted from Healthy People 2000 (18).

The Year 2000 Objectives for the Nation call for the following tobacco-related objectives:

3.1 Reduce coronary heart disease deaths to no more than 100 per 100,000 people.

3.2 Slow the rise in lung cancer deaths to achieve a rate of no more than 42 per 100,000 people.

3.3 Slow the rise in deaths from chronic obstructive pulmonary disease to achieve a rate of no more than 25 per 100,000 people.

3.4 Reduce cigarette smoking to a prevalence of no more than 15 percent among people aged 20 and older.

3.5 Reduce the initiation of cigarette smoking by children and youth so that no more than 15 percent have become regular cigarette smokers by age 20.

3.6 Increase to at least 50 percent the proportion of cigarette smokers aged 18 and older who stopped smoking cigarettes for at least one day during the preceding year.

3.7 Increase smoking cessation during pregnancy so that at least 60 percent of women who are cigarette smokers at the time they become pregnant quit smoking early in pregnancy and maintain abstinence for the remainder of their pregnancy.

3.8 Reduce to no more than 20 percent the proportion of children aged 6 and younger who are regularly exposed to tobacco smoke at home.

3.9 Reduce smokeless tobacco use by males aged 12 through 24 to a prevalence of no more than 4 percent.

3.10 Establish tobacco-free environments and include tobacco use prevention in the curricula of all elementary, middle, and secondary schools, preferably as part of quality school health education.

3.11 Increase to at least 75 percent the proportion of worksites with a formal smoking policy that prohibits or severely restricts smoking at the workplace.

3.12 Enact in 50 States comprehensive laws on clean indoor air that prohibit or strictly limit smoking in the workplace and enclosed public places (including health care facilities, schools, and public transportation).

3.13 Enact and enforce in 50 States laws prohibiting the sale and distribution of tobacco products to youth younger than age 19.

3.14 Increase to 50 the number of States with plans to reduce tobacco use, especially among youth.

3.15 Eliminate or severely restrict all forms of tobacco product advertising and promotion to which youth younger than age 18 are likely to be exposed.

3.16 Increase to at least 75 percent the proportion of primary care and oral health care providers who routinely advise cessation and provide assistance and followup for all of their tobacco-using patients.

References

1. Tobacco-free America: state legislated actions on tobacco issues. Washington, DC: Legislative Clearinghouse, 1990.

2. National Institutes of Health. Major local smoking ordinances in the United States: a detailed matrix of the provisions of workplace, restaurant, and public places smoking ordinances. Washington, DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1989; (DHHS) publication no. (NIH) 90-479.

3. Tobacco Institute. Cigarette Tax Data. Monthly state cigarette tax report, July 1990. Washington, DC: Tobacco Institute, 1990.

4. The World Almanac 1990. New York: Newspaper Enterprise Association, 1990.

5. True Epistat. Epistat Services. 3rd Edition. Richardson, Texas: True Epistat, 1989.

6. DBASE IV. Asthton-Tate Corporation. Torrance, California, 1988.

7. CDC. State tobacco-use prevention and control plans. MMWR 1990;39(8):133-6.

8. Bal DG, Kizer KW, Felten PG, Mozar HN, Niemeyer D. Reducing tobacco consumption in California: development of a statewide anti-tobacco use campaign. JAMA 1990;264:1570-4.

9. US Department of Agriculture. Tobacco situation and outlook report. Washington, DC: US Department of Agriculture, Commodity Economics Division, Economic Research Service, 1990 publication no. TS-213.

10. CDC. Behavioral Risk Factor Surveillance, 1988. MMWR 1990; 39:1-21.

11. Marcus AC, Shopland DR, Crane LA, Lynn WR. Prevalence of cigarette smoking in the United States: estimates from the 1985 Current Population Survey. JNCI 1989; 81:409-14.

12. Novotny TE, Romano RA, Davis RM, Mills SL. The public health practice of tobacco control: lessons learned and directions for the states in the 1990s. Annu Rev Public Health (in press).

13. Harel Y, Kann L, Collins J, Kolbe L. Implementing the Youth Risk Behavior Surveillance System: a progress report. In: Agenda of the Fifth National Conference on Chronic Disease Prevention and Control: From 1990 to 2000. Detroit, Michigan, October 1990:47.

14. CDC. Smoking and health: a national status report: a report to Congress. 2nd ed. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no.(CDC) 87-8396.

15. CDC. Reducing the health consequences of smoking: 25 years of progress. Report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no.(CDC) 89-8411.

16. CDC. State laws restricting minors' access to tobacco. MMWR 1990;39(21):349-53.

17. CDC. Progress in chronic disease prevention. State coalitions for prevention and control of tobacco use. MMWR 1990;39(28):476-85.

18. US Department of Health and Human Services. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (PHS)90-50212.

19. Wroblewski M. Insurance incentives for not smoking. NY State J Med 1985; 85:309.

20. Novotny TE, Thomas WI. The Rocky Mountain Tobacco-Free Challenge: year number two: evaluation report 1990. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Office on Smoking and Health, 1990.

21. CDC. State-based chronic disease control: the Rocky Mountain Tobacco-Free Challenge. MMWR 1989; 38:749-52.

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