Tobacco Control 1996;5: 220-225 special communication



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Tobacco Control 1996;5:220-225 SPECIAL COMMUNICATION

An analysis of the successful 1992 Massachusetts tobacco tax initiative

Howard K Koh

Abstract

In November 1992, voters in Massachusetts (United States) passed a statewide tax initiative adding an extra 25 cents to the price of a pack of cigarettes. The Massachusetts Coalition for a Healthy Future, led by volunteers from the Massachusetts Division of the American Cancer Society, achieved this victory, despite a public anti-tax mood and $7.3 million spent by the tobacco industry. The tax has since generated millions of dollars for tobacco education and control programmes, leading to acceleration of the decline of tobacco consumption in the state. An analysis of the passage of this initiative should help other states considering this approach to tobacco control.



Introduction

In November 1992, voters in Massachusetts (United States) approved a statewide initiative that levied an extra 25 cent tax on cigarettes to fund new tobacco education and control programmes. Spearheaded by the Massachusetts Coalition for a Healthy Future, this victory made the state only the second in the country to raise the tobacco tax through the initiative process. Outspent by the tobacco industry by almost 10:1, the Coalition achieved victory despite the political inexperience of its lead organisation, the Massachusetts Division of the American Cancer Society (ACS). As the history of tobacco tax initiatives is young, an analysis of the creation, passage, and execution of the Massachusetts campaign can identify successful strategies potentially applicable to other states.


The initiative evolved in four phases:
1990: creation of the Massachusetts tobacco tax initiative;
1991 and 1992: establishment of the Massachusetts Coalition for a Healthy Future and the successful completion of signature petition drives; summer and autumn of 1992: the campaign;
1993-96: evolution of the Massachusetts Tobacco Control Program

1990: Creation of the Massachusetts tobacco tax initiative


In 1990 Dr Blake Cady, newly elected president of the Massachusetts Division of the ACS and Professor of Surgery at Harvard Medical School, first proposed the tax initiative as a new means for statewide tobacco control. At that time, rising lung cancer mortality rates had helped push statewide, age-adjusted cancer death rates past the death rates for heart disease.1 2 Despite the overall decline in smoking prevalence to 28.2%, smoking-related illness caused 15% of all Massachusetts deaths (11 000 per year),3 4 costing more than $1.6 billion in medical expenses and lost productivity.3
At the urging of Cady and Candace Pierce-Lavin (ACS Director of Government Affairs), the ACS Tobacco Control Task Force studied the lessons of previous tobacco tax initiatives, with particular attention to the success in California and the failure in Montana. The 1988 passage of Proposition 99 in California was propelled by a coalition of voluntary health agencies, medical organisations, and environmental groups that collected more than a million signatures to place the initiative on the ballot. Spending only $1.6 million (in the face of $21.4 million spent by the tobacco industry), the campaign used extensive media exposure to convince 58% of voters to favour the initiative.5 7 The extra 25 cents per pack generated more than $750 million in the first year, 20% of which was intended to fund new tobacco control programmes, including counter-advertising through the media. As a result, overall tobacco consumption statewide declined by more than three times the national average. 5 7 However state deficits and tobacco industry political pressure8 motivated the governor and the legislature to divert more than $220 million out of the tobacco education account, prompting a round of lawsuits.
Meanwhile, in 1990, Montana voters defeated Initiative 115, a proposal to raise the cigarette tax by 25 cents (59% to 41%).9 Afterwards, leaders from that campaign strongly recommended three tactics in future initiatives: firstly, build a broadbased coalition that could provide the proper political and financial support; secondly, enlist experienced media handlers; and thirdly, anticipate a well-financed tobacco industry attack that will frame the initiative as a tax issue, not a health issue.9
With these lessons in mind, the ACS Tobacco Control Task Force favoured a tax initiative for three reasons.
Economic analyses have documented price elasticity, that is, increasing the price of cigarettes led to decreased cigarette consumption (a sales drop of 0.75 packs per capita for each l-cent increase in cigarette taxes).10 12 Some studies indicate that teenagers are at least as cost sensitive as adults, and perhaps more so.13 14

The tax would generate more than $100 million dollars annually for a new Health Protection Fund to create statewide tobacco control programmes (including an anti-smoking media campaign and health education for schoolchildren).

Over the years, the traditional state legislative process had rejected proposals to raise the cigarette excise tax. In Massachusetts, stable excise taxes for almost a decade left room for upward movement.

In a 1990 memorandum to the ACS detailing thc two-year process required to pass the initiative, Pierce-Lavin urged that this activity receive the highest priority. Initially, ACS volunteers statewide voiced fears that advocacy would compromise fundraising, tarnishing the organisation as a political activist group. After extensive discussion with the ACS board of directors and the 42 local units (representing some 12 000 statewide volunteers), the Massachusetts division agreed to spearhead the initiative, as long as opinion polls showed strong popular support and a broad coalition could provide the necessary human resources and funding.15


In April 1991, the political consulting firm Marttila and Kiley conducted a statewide poll which found that nearly 70% of Massachusetts registered voters favoured the initiative. Even after hearing eight of the most common arguments against the tax, 54% still favoured it, foreshadowing the actual vote by the same proportion on election day in 1992.15
1991 and 1992: Establishment of the Massachusetts Coalition for a Healthy Future and successful completion of signature petition drives
Buoyed by polling results, the ACS formed the Massachusetts Coalition for a Healthy Future, which ultimately united nearly 250 state businesses, human services groups, health organisations, hospitals, and community organisations. Pierce-Lavin temporarily left the ACS to serve as the Coalition's campaign manager. An executive committee of the Coalition, consisting of the Massachusetts Medical Society, Blue Cross and Blue Shield of Massachusetts, and the Massachusetts Association of Health Maintenance Organizations (HMOs),15 contributed a minimum of $20 000 each. This strategy committee also recruited political and legal consultants. Overtures to Massachusetts' many medical institutions yielded few additional groups willing to commit financially to the controversial realm of initiative politics. However, the Group Against Smoking Pollution (GASP) and the Massachusetts Nurses Association contributed substantial donations in kind.
Coalition members received assurance that the prominent statewide group Citizens for Limited Taxation would not oppose the initiative. Lawyers for the Coalition then crafted the proper wording of the initiative, anticipating inevitable legal challenges by the tobacco industry. Because the Massachusetts state constitution prohibits earmarking tax revenues for specific purposes, the initiative proposed establishing a Health Protection Fund from tax revenues "subject to appropriation by the state legislature" without legally mandating that money be spent on tobacco control.16
Massachusetts law required 71 000 voter signatures of support (3% of the total voter turnout in the previous statewide election)17 to place the initiative on the statewide ballot. Because challenges to signatures had stalled previous efforts in Oregon, Colorado, and Arkansas, Coalition leaders aimed to gather twice that number as a buffer against disqualifications.
The initiative process required two signature drives. The first, starting shortly before election day, in November 1991, lasted for 60 days. Although each contributing organisation targeted a certain predefined number of signatures, ACS volunteers and staff directed by Pierce-Lavin ultimately procured the vast majority. The drive gathered more than 120 000 signatures15 16 18 at settings ranging from supermarkets and holiday parades to influenza immunisation clinics and school registration days. The sheer volume of signatures deterred a team of handwriting experts14 hired by the tobacco industry; city and town clerks eventually certified more than 90%.
State law17 required a second signature drive in the spring of 1992 (6 May to 17 June), which gained over 25 000, much more than the required 12 000. Altogether, volunteers collected nearly 150 000 signatures, the most for any Massachusetts initiative campaign. On the 1 July deadline, more than 100 children of the "Smoke-Free Class of 2000" sponsored a "kids only" press conference and delivered a petition-filled red wagon to the office of the Secretary of State.19 The tobacco tax initiative became "Question 1" on the autumn Massachusetts ballot.
As expected, the tobacco industry countered. Their proposed compromise of a lower tax increase, dedicating a percentage to school-based tobacco control programmes, was ignored as a diversionary tactic. Then, industry lawsuits contending that the proposed tax was unconstitutional for earmarking revenues specifically for anti-smoking programmes were dismissed by the Massachusetts Supreme Judicial Court in July 1992.
Summer and autumn of 1992: the campaign
COMMITTEE AGAINST UNFAIR TAXES
The Massachusetts Coalition for a Healthy Future squared off against the Committee Against Unfair Taxes, organised and funded by the tobacco industry. The committee's strategy capitalised on the anti-tax climate of the state. Spokesperson Jack Flood, former gubernatorial candidate and former House of Representatives chairman of thc Massachusetts Legislature's Joint Committee on Taxation, led arguments that the tax was unfair and regressive (disproportionately affecting people with low incomes). As expected, he raised the spectre of class warfare, arguing that this regressive tax pitted upper middle class liberals (mostly white) against lower middle class working people (mostly minority).16 18 Tapping into rising public cynicism about elected officials, Mr Flood further warned that :ax-generated monies would be diverted from their intended purposes, as had occurred in California after the passage of Proposition 99. Mr Flood reminded voters that politicians diverted revenues from a 1991 Massachusetts gasoline tax hike intended to fund new roads and bridges to balance the budget.20 One prominent committee television advertisement featured water disappearing down a sink, suggesting that any tobacco tax money would be similarly disposed. Other arguments suggested that the tax would harm Massachusetts small businesses by motivating people to buy cheaper cigarettes outside the state. Lastly, they portrayed smokers as beleaguered victims, and argued to "let the smokers hack in peace".21
MASSACHUSETTS COALITION FOR A HEALTHY FUTURE
In response to the charges of unfair taxes, the Massachusetts Coalition for a Healthy Future focused on the unfairness of the $45 billion tobacco industry, their addiction of children, and their efforts to buy the election. The Coalition maintained that cancer was far more unfair and regressive than any tax, disproportionately afflicting the poor and minority groups while burdening taxpayers with huge costs. Questioning the motivation of the industry to protect the poor or tax freedoms, the Coalition argued that new health and education programmes from a tax could, in fact, benefit the poor and minority groups.
The total budget for the Massachusetts Coalition for a Healthy Future was $800 000 (including contributions in kind), with only $40 000 from private donors (C Pierce-Lavin, personal communication, March 1996). Included in the Coalition's budget was an unprecedented donation of $250 000 in the final hours of the campaign from the national office of the American Cancer Society, keenly aware of the nationwide ramifications of a Massachusetts success. In contrast, the Committee Against Unfair Taxes waged a $7.3 million campaign.22
Financial pressures forced the Coalition to seek free media. Meetings with editorial boards of major newspapers, television stations, and radio outlets gained critical support. Of note, the Boston Globe (with 40%, of the state's readership) published nine favourable editorials as well as steady news coverage and many supportive commentaries.15 The Boston Herald and daily newspapers in major cities such as Worcester, Springfield, New Bedford, and Fall River publicised the initiative, thereby reaching an audience unattainable through paid advertising alone. Furthermore, the Coalition pursued newspaper endorsements, letters to thc editor, calls to radio talk shows, and press events.
The Coalition focused on children as their theme, promoting a slogan of "Tax tobacco --protect kids". Related publicity events included a children's press conference and a teleconference starring Keshia Knight-Pulliam, who was honorary class president of the Smoke-Free Class of 2000, and who played the daughter of Bill Cosby in the actor's popular television programme.15
Other Coalition efforts underscored the David-versus-Goliath scenario. Weekly updates publicised the large sums of tobacco industry money being spent around the state. A regular newsletter updated all Coalition members on effective responses to tobacco industry arguments.15 To draw on the public's special trust in nurses, members of the Massachusetts Nurses Association, in their white uniforms, held a press conference in front of Mr Flood's office and challenged him to visit their cancer wards.15 After negotiations with all three major television stations in the state, one imposed a limit on the purchase of all air time related to Question 1 to offset the overriding monetary advantage of the tobacco industry. For the first time in recent memory, health professionals in white coats joined volunteers to hold signs at busy highways and intersections. Doctors also wrote letters to the editor in virtually every daily and weekly newspaper in the state, placed campaign literature in their patient waiting areas, and distributed preprinted "prescriptions".
The Committee responded with a variety of strategies. Television advertising designed for Massachusetts liberalism urged tolerance, equating images of Martin Luther King, Jr, pro-choice (favouring abortion rights) activists, and patients with AIDS to "smokers' rights".15 23 In collaboration with the tobacco industry, an out-of-state, ultra-conservative, Catholic voters organisation distributed thousands of letters claiming that Question 1 would fund abortion counselling and condom distribution in schools as part of comprehensive school health education.15
Several vivid public debates personalised the battle between spokespersons Flood and Cady. In one exchange, Mr Flood dismissed the bowtie-bedecked Cady and raised the spectre of class warfare by charging that "only the bow-tie and brie crowd" would favour the tax. In the same debate, responding to criticisms that the committee's discussion about taxes avoided any mention of tobacco, Flood snapped "Everyone wants me to say tobacco, tobacco, tobacco. Everybody happy now? But the question is still taxes, taxes, taxes, taxes."24 Declining public opinion of Mr Flood was epitomised by a Boston Globe political cartoon depicting him as a monkey dancing to the tune of the tobacco industry's organ grinder.
National figures provided public backing. US Surgeon General Antonia Novello, although officially unable to endorse Question 1, visited Boston to draw-attention to tobacco control efforts. Former US Surgeon General C Everett Koop also voiced his support and later published an article stating tobacco taxes were "good for you".15 Former US senator and presidential candidate Paul Tsongas, a cancer survivor and one of the most respected politicians in the state, supported Question 1 as the campaign's honorary chairman. In particular, his angry response to a tobacco industry brochure urging "tolerance" by depicting a political rally featuring one of his campaign signs galvanised public support for the tax.25
As election day approached, the Committee Against Unfair Taxes stepped up anti-Question 1 media advertising, causing a precipitous erosion of public support. In response, the Marttila and Kiley firm conducted focus-group sessions uncovering two critical points: firstly, even in the closing weeks, many voters still did not grasp that the ACS served as the primary sponsor of Question 1; secondly, more than 70% of voters trusted the ACS to direct public health smoking issues, a public credibility rating higher than for other anti-smoking groups and dwarfing the 4% rating for the tobacco industry. Hence the Coalition decided to reframe the initiative. Volunteers subsequently distributed one million brochures explicitly urging citizens to "Help the American Cancer Society Fight the Tobacco Industry".
With less than a month to go, the Coalition released their only television advertisement. This piece opened with a shadowy montage of cigarette packages arrayed like tombstones in a graveyard, urged voters to support Question I, and closed with a full frame of the ACS logo. Two days before the election, a full-page advertisement in most of the state's daily newspapers argued the effectiveness of the cigarette tax hike in California. On election day, 3 November 1992, Question 1 passed by 54% to 46% with the support of almost one and a half million Massachusetts citizens.17
1993-96: Evolution of the Massachusetts Tobacco Control Program
As of 1 January 1993, the Massachusetts cigarette excise tax rose to 51 cents a pack—-one of the highest in the nation at the time. Post-election polling23 showed that 64%, (not 54%) of voters recalled voting in favour of Question I, evidence of a so -called "halo effect".
From the first 18 months of tobacco taxes, $96 million from the new Health Protection Fund launched the Massachusetts Tobacco Control Program (MTCP). This included $33 million to the Department of Education for comprehensive school health education, $28 million for local community tobacco control initiatives, $18 million for media counter-advertising, and $5.5 million for statewide initiatives including a Smoker's Quitline. Tax money also funded a tobacco education clearinghouse, research and evaluation, Drug Abuse Resistance Education (DARE) programmes administered by local police departments, and other health programmes, such as those supporting community health centres, substance abuse treatment, the Women, Infants, and Children Supplemental Nutrition prograrnme, breast cancer and AIDS research, and family health. A full description of the MTCP, beyond the scope of this article, will be forthcoming in future publications (Harris J, Connolly G, personal comunication, 1996).
However, the Massachusetts Statehouse has now become the crucial arena where tobacco industry lobbyists, tobacco control advocates, public health officials, and politicians grapple for control over the roughly $10 million per month generated from the tax. The stark reality that the legislature ultimately controls these tobacco tax dollars has led Question 1 supporters to remain mobilised as watchdogs. Political struggles caused the $96 million budget for fiscal year (FY) 1994 to fall steadily to $77 million (FY95), then to $76 million (FY96), and now to $67 million (FY97). In addition, by appropriating increasing amounts of tax dollars to non-tobacco health programmes, the legislature essentially has pitted health groups against each other to fight about how money should be appropriated.26
Early data showed that cigarette sales dropped by 11%, and 15%, in October and November of 1992 (compared with the same period in 1991) probably reflecting the Coalition's activity. Moreover, since January 1993 (when the new tax was initiated and the MTCP began), per capita cigarette consumption has dropped by at least 17%, the largest single decline in Massachusetts history and a rate three times higher than predicted.28
Summary
In the final analysis, what factors led to successful passage for the Coalition?29
The timing was right. After decades of public education linking smoking to adverse health outcomes (and newer reports linking environmental tobacco smoke to disease), public opinion about the tobacco industry was at an all-time low. Non-smoking had become the statewide norm, with 75% of the population abstaining.

Dedicated leaders and volunteers created a strong coalition. The resources of the Coalition, led by Cady, Pierce-Lavin, and the ACS, made the initiative victory achievable. Cady, a senior Harvard professor and cancer surgeon, enhanced the image of the campaign as a mainstream effort. The campaign capitalised on the public trust in the ACS by directly pitting its image against that of the tobacco industry, and successfully coordinating thousands of ACS volunteers. The Coalition, which provided dollars, momentum, and visibility during the campaign, became even more important post-victory in holding legislators accountable to the promise of Question 1.

Polling, complemented by focus groups, helped shape a campaign framed as one that protected children. Initial polls indicated wide support of the tax and the feasibility of this initiative. Continued polling helped guide and refine a campaign strategy that never blamed the smoker, but rather painted the tobacco industry as the villain. Never avoiding the word "tax", the Coalition rather linked it to the health of children. In so doing, the Coalition successfully upheld health issues as paramount to possible adverse effects on small business, smokers' rights and cross-border sales.

The active volunteer involvement of health professionals kept the emphasis on health issues, not simply tax issues. The unprecedented work of doctors, nurses, and other health professionals, particularly in their letters to editors and their public demonstrations in white coats and uniforms, kept the focus on health. Their involvement dramatised the health benefits of Question 1.

Legal help was critical. Strong legal and political consultation helped meet the formal demands of the initiative process, such as proper wording.

Publicity events yielded free media coverage. The strong support of many media outlets, especially the Boston Globe and the television stations, galvanised public awareness and provided the intense level of publicity needed to counter the anti-tax advertising.


The passage of Question 1, in addition to the passage of Proposition 99 in California, has sparked interest in similar initiatives elsewhere around the country. In 1994, a similar tobacco tax initiative was passed in Arizona. In addition, a 50-cent increase in the state cigarette tax was approved by voters in Michigan in March 1994 as part of a multifaceted ballot initiative to replace property tax revenues with revenues from other taxes (especially sales and tobacco taxes). Hence, initiatives have now succeeded in four states while failing in others, presenting lessons for public health professionals contemplating future initiatives.29 For Massachusetts, the initiative has opened a new dimension for tobacco control. The new climate may have contributed to the 1996 Massachusetts legislative approval of yet another 25-cent state cigarette tax increase (to, 76 cents) to fund improvements in healthcare access for uninsured children and the elderly poor. Despite continuing major obstacles to retain funding, to implement programmes, and to evaluate their effectiveness, tobacco tax initiatives offer new avenues to improve public health for the future. Sponsored in part by the Judge Bernard Cohen Research Fund. I thank Alan Geller, Karen Rouse, Lauren Holm, Don Gudaitis John Marttila, Kathy O'Connor, Gail Gramarossa, Candace Pierce-Lavin, Lori Fresina, Stanley Shmishkiss, Barbara LeStage, Jack Nicholl, Representative John McDonough, Brad Krevor, Ed Sweda, John Bloom, Judge Bernard Cohen and Drs Blake Cady, Robert Lew, Greg Connolly, and Al Winder for their comments on this paper. I am also grateful to Dr Claudia Arrigg for unending encouragement and support.


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