State-Level Tobacco Control and Adult Smoking Rate in the United States : An Ecological Analysis of Structural Factors

Context: A variety of population-level tobacco control measures (TCMs) exist, such as excise taxation, smoking restrictions, cessation program funding, counter-advertising, and restrictions on tobacco marketing. Several factors may contribute to often-suboptimal levels of implementation of TCMs at the state level. Objective: To use the American Lung Association (ALA) grading framework to assess impacts of TCMs and to explore relationships between environmental factors and level of implementation of TCMs as rated by the ALA. Design: Secondary data analysis of publicly available data, using linear regression to examine relative effects of state TCMs on adult smoking rates and the extent to which environmental factors influence the strength of each TCM in states. Setting and Participants: The 50 US states, excluding territories, districts, and possessions. Interventions: Cigarette excise taxes, state-level tobacco control expenditures relative to Center for Disease Control and Prevention recommendations, smoking restrictions, and support for smoking cessation by state Medicaid programs. Main Outcome Measures: Adult smoking rate in each state for 2010; strength of TCMs as measured by the ALA. Results: The ALA smokefree score ([beta] = -.045, P = .005) and tax rate per pack ([beta] = -1.205, P = .019) were significant negative predictors of state adult smoking rates in 2010. Percentage of seats in lower houses of state legislatures held by Republicans was significant in predicting tax per pack ([beta] = -.032, P < .001), and ALA smokefree score was negatively influenced by tobacco revenue as a percentage of state gross product ([beta] = -15.663, P = .039), although this effect was not significant in the presence of covariates. State funding both for TCMs and for cessation coverage was also negatively influenced by tobacco-related economic factors. Conclusions: Consistent with previous literature, taxation and smoking restrictions have the most immediate statewide impacts on smoking rate. Probusiness/antitax politics and tobacco manufacturing affect level of implementation of these and other effective TCMs