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INTRODUCTION
Accomplishments of the Massachusetts Tobacco Control
Program
H K Koh
.............................................................................................................................
Tobacco Control 2002;11(Suppl II):ii1–ii3
I
n 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?
.......................
Correspondence to:
Howard K Koh, MD MPH,
Commissioner of Public
Health, Commonwealth of
Massachusetts, 25
Washington Street, Boston,
MA 02108, USA
.......................
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
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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
TOBACCO ADVERTISING
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
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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
CONCLUSION
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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A comprehensive environmental tobacco smoke campaign helped to educate public opinion leaders to
pass smoke-free ordinances.
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Accomplishments of the Massachusetts
Tobacco Control Program
H K Koh
Tob Control 2002 11: ii1-ii3
doi: 10.1136/tc.11.suppl_2.ii1
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