Smoking

The 2001 Surgeon General's report on women and smoking highlights smoking as a critical women's health issue. (1) State anti-smoking efforts are critical to ensuring both that non-smokers do not start smoking and that current smokers stop. The Report Card examines several different policies that promote smoking cessation. Given that a lack of health insurance coverage for cessation is a barrier to receiving the treatment and support needed to quit, particularly for low-income women, who have higher than average smoking rates, (2) the Report Card first examines Medicaid coverage of smoking cessation treatments. Each state is also evaluated on its rate of tobacco sales to minors. All states have laws prohibiting the sale of tobacco to minors pursuant to a federal law known as the "Synar Amendment," which they are required to enforce through random unannounced inspections of tobacco vendors. (3) A state's effectiveness in enforcing its ban is measured by a "tobacco sales rate" that reflects the annual percentage of merchants who break the law by selling tobacco products to minors. (4) Because increasing the excise tax on cigarettes is one of the most effective ways to reduce smoking, the Report Card examines state excise tax policies, which can have a particularly strong impact for certain populations. Data indicate that policies such as tax increases may be more effective in decreasing smoking during pregnancy because the likelihood of quitting smoking is higher during this time in a woman's life. (6) Finally, state comprehensive tobacco control programs are examined. (7) These programs have been shown to be effective in preventing and reducing tobacco use, particularly among youth. (8) The November 1998 multi-state settlement of the lawsuits against tobacco companies for over $200 billion over 25 years, as well as states' individual settlements with tobacco companies, greatly increased the funds available to states for tobacco control. The CDC has studied states with successful comprehensive tobacco control programs to distill their essential elements and has made recommendations for how much funding is required in each state to implement such a program. 9

Data Points for this Issue:

Medicaid Smoking Cessation Coverage
Tobacco Sales Rate to Minors
Excise Tax
State Funding for Tobacco Prevention

Medicaid Smoking Cessation Coverage

	Strength Of Policy 2007	Change From 2004
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING

Meets Policy	18
Limited Policy	18
Weak Policy	6
No/Harmful Policy	9
Better	22
Worse	2
Same	27

Does the state’s Medicaid program cover comprehensive smoking cessation treatment?

States receive a "meets policy" if their Medicaid programs cover the three forms of smoking cessation treatment shown to be most effective (over-the-counter treatments, prescription treatments, and smoking cessation counseling). States receive a "limited policy" if their programs cover two of the three treatment categories. States receive a "weak policy" if their Medicaid programs cover only one category of treatment and a "no policy" if they cover none.

Data Source: Medicaid Smoking Cessation Coverage, 2005.

The Henry J. Kaiser Family Foundation, "State Medicaid Program Coverage of Tobacco Dependence Treatments by Type of Coverage, 2005" available at http://www.statehealthfacts.org/comparetable.jsp?ind=85&cat=2, accessed May 23, 2007.

Tobacco Sales Rate to Minors

	Strength Of Policy 2007	Change From 2004
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING

Meets Policy	21
Limited Policy	28
Weak Policy	2
No/Harmful Policy	0
Better	10
Worse	5
Same	36

What is the state’s sales rate of tobacco products to minors?

States receive a "meets policy" if they have a sales rate to minors below ten percent (the target set by health experts). States receive a "limited policy" if their sales rates are between ten and up to and including 20 percent (the target set by the federal government), and states receive a "weak policy" if they have a sales rate over 20 percent.

Data Source: Tobacco Sales Rate to Minors (%), 2005.

Center for Substance Abuse Prevention, Tobacco/SYNAR, "State Synar Non-Compliance Rate Table," 2005, available at http://www.prevention.samhsa.gov/tobacco/01synartable.aspx, accessed May 23, 2007.

Excise Tax

	Strength Of Policy 2007	Change From 2004
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING

Meets Policy	14
Limited Policy	9
Weak Policy	16
No/Harmful Policy	12
Better	15
Worse	0
Same	36

Does the state have an excise tax on cigarettes of $1.50 or more per pack?

States receive a "meets policy" if their excise tax is $1.50 or more per pack (a pack is 20 cigarettes). States receive a "limited policy" if their excise tax is between $1.00 and $1.50 per pack. States receive a "weak policy" if their excise tax is between $0.50 and $1.00 per pack. States receive a "no policy" if their excise tax is $0.49 or less.

Data Source: Excise Tax ($), 2007.

Campaign for Tobacco-Free Kids, "State Cigarette Excise Tax Rates and Rankings," May 1, 2007, available at http://www.tobaccofreekids.org/research/factsheets/pdf/0097.pdf, accessed May 9, 2007.

State Funding for Tobacco Prevention

	Strength Of Policy 2007	Change From 2004
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING

Meets Policy	4
Limited Policy	11
Weak Policy	30
No/Harmful Policy	6
Better	4
Worse	2
Same	45

Does the state’s funding for tobacco prevention meet the CDC’s minimum recommended funding for that state?

States receive a "meets policy" when they fund tobacco prevention annually at levels falling within or above the CDC's recommended range. States receive a "limited policy" when they have funding levels that are at or greater than 50 percent of the CDC's recommended range. States receive a "weak policy" with funding levels less than 50 percent of the CDC's minimum recommendation. States receive a "no policy" if they have not committed any annual funds to tobacco prevention or have not yet decided how to allocate their settlement funding.

Data Source: State Funding for Tobacco Prevention, FY 2006.

Campaign for Tobacco-Free Kids, "History of State Spending for Tobacco Prevention," December 2005, available at http://www.tobaccofreekids.org/research/factsheets/pdf/0209.pdf, accessed May 9, 2007. For many states, the primary source of funding is the tobacco settlement monies.

1. U.S. Department of Health and Human Services, Women and Smoking, A Report of the Surgeon General (Rockville: U.S. Department of Health and Human Services, Office of the Surgeon General, 2001).

2. Centers for Disease Control and Prevention, "Cigarette Smoking Among Adults—United States, 2004," Morbidity and Mortality Weekly Report 55 (November 11, 2005), available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5444a2.htm.

3. In 1992, the federal government enacted a law known as the "Synar Amendment" to prohibit the sale of tobacco to minors. Alcohol, Drug Abuse, and Mental Health Agency Reorganization Act of 1992, § 1926, 42 U.S.C. § 300x-26. In particular, the law required states by 1994 to pass laws banning the sale of tobacco to anyone under age 18 and to enforce these laws in a way that can reasonably be expected to restrict minors' access, including random, unannounced inspections of retailers. Regulations issued by the U.S. Department of Health and Human Services in 1996 set as a goal a 20% annual sales rate to minors. Federal Register 66 (September 4, 2001), 46225-46227. As a way to ensure states' compliance, the law requires the U.S. Department of Health and Human Services to reduce states' block grant funding from the Substance Abuse and Mental Health Services Administration by a certain percentage for all subsequent years for which the state is out of compliance.

4. Center for Substance Abuse Prevention, Tobacco/SYNAR, "State Synar Non-Compliance Rate Table," 2005, available at http://prevention.samhsa.gov/tobacco/01synartable.aspx.

5. Jeanne S. Ringel and William N. Evans, "Cigarette Taxes and Smoking During Pregnancy," American Journal of Public Health 91 (November 2001), 1851-1856.

6. Centers for Disease Control and Prevention, Office on Smoking and Health, Best Practices for Comprehensive Tobacco Control Programs (Atlanta: Centers for Disease Control and Prevention, August 1999), 85.

7. According to the CDC, the goal of such programs is to reduce disease, disability, and death related to tobacco use by: (1) preventing young people from starting to use tobacco; (2) promoting quitting among young people and adults; (3) eliminating nonsmokers’ exposure to environmental tobacco smoke (also known as "second-hand smoke"); and (4) identifying and eliminating the disparities related to tobacco use and its effects among different population groups. Centers for Disease Control and Prevention, Office on Smoking and Health, Best Practices for Comprehensive Tobacco Control Programs (Atlanta: Centers for Disease Control and Prevention, August 1999), 3.

8. The 2002 National Youth Tobacco Survey conducted by the American Legacy Foundation revealed that youth smoking rates had seen a decrease during the two-year period when funding for state tobacco control programs were at their highest. Campaign for Tobacco Free Kids, "New Survey Showing Large Decline in High School Smoking is Proof that Tobacco Prevention Measures Work," November, 2003, available at http://www.tobaccofreekids.org/Script/DisplayPressRelease.php3?Display=709.

9. Each recommendation is based on specific characteristics of the state and is in the form of a range of funding, with a lower and upper estimate for the total annual cost of a comprehensive tobacco control program. Centers for Disease Control and Prevention, Office on Smoking and Health, Best Practices for Comprehensive Tobacco Control Programs (Atlanta: Centers for Disease Control and Prevention, August 1999), 24.