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In less than a decade, the Massachusetts Tobacco Control Program (MTCP) has evolved into one of the leading public health initiatives of our time.1 Under the aegis of the Massachusetts Department of Public Health (MDPH), MTCP has dropped overall per capita adult cigarette consumption at a rate far exceeding the rest of the country and prompted striking declines in both adult and youth smoking prevalence.2,3 In this supplement to Tobacco Control, we document some notable milestones of this public health work in progress by showcasing the results of research and evaluation studies.
From the outset, the MTCP has committed to a comprehensive, aggressive, and integrated intervention. Promoting tobacco treatment and prevention strategies has not only served individual persons but also has improved the health of the entire state's population.4 Specifically, we set goals to assist adult smokers to receive treatment, to prevent children and youth from smoking, and to protect the general public from exposure to second hand tobacco smoke. Galvanising outrage at the local level has also accelerated policy changes that denormalise tobacco use. Massachusetts' legal challenges to the tobacco industry have led to hearings before the US Supreme Court. The constant “air war” of innovative, rotating anti-tobacco media messages further deglamorise this addiction.
In 1992, Massachusetts voters created MTCP by passing an initiative petition (Question 1) to raise the state cigarette tax (from $0.26 to $0.51 a pack) to fund tobacco control.1 Subsequently, in 1996, the state legislature increased the tax another $0.25 to fund health care for uninsured children and senior pharmacy services. Other state imposed surcharges include taxes of 15% on the wholesale price of cigars (1996) and 25% on the wholesale price of smokeless tobacco products.5 Annual funding for the MTCP has varied, ranging from a high of $52 million (1993-4) to a low of $31 million (1999). The passage of the 1998 Master Settlement Agreement provided MTCP with another $13 million to $22 million annually to provide comprehensive services for a statewide population of six million.
WHAT HAS BEEN ACCOMPLISHED?
Innovative and aggressive media messages on television, radio, billboards and in newspapers have featured many notable spokespersons, including former tobacco advertising models, former tobacco company lobbyists, and a range of Massachusetts residents who have suffered deep personal loss because of tobacco addiction. In addition, in this issue, Robbins and colleagues6,7 describe the range of comprehensive community based tobacco treatment services now available to assist smokers, including counselling, nicotine replacement therapy, a statewide quitline8 and an internet based counselling and referral system. Increasing collaboration between MTCP, health care providers, and health maintenance organisations throughout the state promises to improve the coordination of such services in the future.
As a result of these programmes, adults have quit smoking.9 A previously published population trend analysis found that from 1993 on, adult per capita consumption in Massachusetts showed a consistent annual decline of more than 4%, compared to less than 1% a year in comparison states (the other US states excluding California).2 In this issue, Weintraub and Hamilton10 document a statewide drop in adult smoking prevalence to 19.4% in 1999 (from 23.5% in 1990), a decline several times greater than in those states without such programmes. Nyman and colleagues document a decrease in cigar smoking.11 Accelerating the decline in smoking even further will require innovative strategies for special populations. We have begun to define and address the challenges of special populations, such as college students, people with disabilities, and immigrant populations.12–15
YOUTH PREVENTION INITIATIVES
In addition, MTCP has targeted youth for prevention initiatives.1 MTCP has promoted prevention messages through various venues, such as the media, comprehensive school based programmes, and community based youth activities fostering peer leadership. Also, local health departments in virtually every municipality in the Commonwealth have passed and enforced policies prohibiting tobacco sale to underage youth, reinforced by a system of compliance checks that numbered up to 15 000 in 2000 alone. The end result has been a decline in the rate of illegal sales to minors to 11% in 1999 (from 44% in 1994).16
By examining trends in grades 7–12 (age 12–18 years) for youth tobacco use from 1996 to 1999, Soldz3 and colleagues now document significant decreases in lifetime (48.3% to 41.9%) and current (30.7% to 23.7%) cigarette use. The decreases for youth in grades 8 and 10 exceed national trends. A prior four year longitudinal survey has also shown that younger Massachusetts adolescents (age 12 and 13 years) with baseline exposure to television anti-smoking advertisements were half as likely to progress to established smoking than their non-exposed peers.17 In addition, in this issue Biener18 documents that youth are particularly receptive to media messages featuring the serious consequences of smoking.
ENVIRONMENTAL TOBACCO SMOKE AND PRODUCT REGULATION
For the general population, MTCP has supported restricting environmental tobacco smoke and promoting clean air in public places. In 1988, the state legislature first passed a clean indoor air law requiring restaurants of 75 or more seats to set aside 200 square feet (16 seats) for non-smoking sections.19 The legislation also explicitly upheld the authority of local communities to restrict smoking further. Since then, smoking has been banned in many public venues around the state, including the grounds of all public schools (1993), airports (1994), state buildings (1996), and major sports stadiums, including the Boston Red Sox's Fenway Park (2001).16
To move toward the goal of a statewide smokefree environment, MTCP has funded local boards of health to promote clean indoor air policies.7 As a result, 76% of the state's population now lives in communities that severely restrict restaurant smoking (up from 25% in 1992).16 In fact, 38% of the state's residents live in communities that ban smoking restaurants entirely. In this issue, Bartosch and Pope20 find that highly restrictive restaurant smoking policies do not have a statistically significant effect on business (as measured by Massachusetts meals and alcohol tax revenue).
A major focus for MTCP has been to build on the strong Massachusetts history of tobacco product regulation as a public health priority. In 1985, Massachusetts was the first state in the country to require health warnings on oral snuff, an action that ultimately triggered passage of the federal law requiring a uniform label nationwide.21 Laws and regulations passed by Massachusetts and California for cigar warning labels have recently (1999) culminated in a consent decree between cigar manufacturers and the Federal Trade Commission to place uniform national cigar warnings.22
Furthermore, in 1996, Massachusetts passed a first in the nation Tobacco Product Disclosure Law that required tobacco manufacturers to report: (1) cigarette nicotine yields under average smoking conditions, and (2) additives in all brands by descending order of weight. For this action, MDPH was sued by the major cigarette and smokeless tobacco manufacturers. While a federal court subsequently ruled that the ingredient disclosure provision was unconstitutional,23 that ruling has recently been appealed by the state. The federal appeals court reversed a lower court ruling affirming the department's authority to require tobacco manufacturers to disclose tobacco product additives by brand and level. That decision has been appealed by the tobacco industry. In a related activity, in 1998, the MDPH proposed regulations requiring manufacturers to test for the major toxins in cigarette smoke of 75 brands.24 The industry voluntarily tested 33 brands to determine the feasibility of the protocol. Legislation is pending which would address the legal issues of the court case and allow MDPH to regulate the levels of nicotine, additives, and smoke constituents.25
In this issue, Slade and his colleagues address product testing and health claims made about alternative tobacco products.26
Of national importance, in 2001, the US Supreme Court heard a lawsuit whereby the tobacco industry challenged youth access and advertising restrictions drafted by the Massachusetts attorney general under the state Consumer Protection Act. The regulation, derived from the unsuccessful proposed Food and Drug Administration rule, prohibited tobacco advertisements within 1000 feet of schools and playgrounds. The regulation was driven by an MDPH survey27 of 3000 storefronts that showed a greater likelihood of tobacco advertising in storefronts within 1000 feet of schools, compared to those further away. In June 2001, the Supreme Court ruled against Massachusetts, stating that the tobacco companies' first amendment rights had been violated. In addition, the court also concluded that the state illegally preempted the federal Cigarette Labeling and Advertising Act of 1965 which bars states from restricting tobacco advertising.28 In this issue, Celebucki and Diskin address changes in storefront tobacco advertising,29 and Truitt and colleagues investigate recall of health warnings in smokeless tobacco ads.30
The tobacco industry will continue to push its product in creative ways. Marketing to youth by the tobacco industry shifted after the Master Settlement Agreement, by redirecting resources previously aimed at billboard advertising to magazine advertising.31 Recently, Philip Morris and Brown & Williams agreed, under pressure from MDPH and the attorney general, to stop advertising Marlboro and its other major brands in magazines with up to 15% youth readership (or more than two million youth readers).32
With this monograph, we are honoured to add to the growing body of successful interventions in tobacco control.33 But despite steady progress, we will always have much more to do. As a society, we have just left behind a 20th century which should be forever remembered by medical historians as the “tobacco and cancer” century.34 Only through a public health commitment in the 21st century to eradicate fully this addiction will we someday reach our goal to “make smoking history”.
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