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5
Strengthening Traditional Tobacco Control Measures

During the 1990s, substantial progress was made in laying the foundation for an effective tobacco control policy, but that progress has stalled for at least three reasons. First, it is difficult to sustain public attention on endemic problems; in particular, on the challenges of prevention and cessation. Public attention (including the priority-setting driven by public opinion) is easily diverted to the crisis of the moment, and in times of austerity, expenditures on prevention and cessation efforts always seem to be the most dispensable. These tendencies explain in part why the political commitment needed for a sustained effort is lacking. Second, the political and commercial power of the tobacco industry remains substantial, even following the disclosures of past misconduct arising out of recent state reimbursement litigation, the Master Settlement Agreement (MSA), and the U.S. Justice Department’s suit under the Racketeering Influenced and Corrupt Organization Act. Third, all the tobacco control measures described in Chapter 3 have had to be implemented in the context of a largely unregulated market in which tobacco products continue to be aggressively promoted. These promotion efforts are still at work, and it is difficult for public health programs to keep up, especially when the economy falters and public revenues fall short. The behavioral potential of aggressive prevention and cessation efforts is amply illustrated by the successes achieved in California, Massachusetts, and other states. So, too, however, is the fragility of these efforts—when the money disappeared, so did the programs.

The nation needs to muster the political will to intensify the efforts implemented so successfully during the 1990s and to build on them. These



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Ending the Tobacco Problem: A Blueprint for the Nation 5 Strengthening Traditional Tobacco Control Measures During the 1990s, substantial progress was made in laying the foundation for an effective tobacco control policy, but that progress has stalled for at least three reasons. First, it is difficult to sustain public attention on endemic problems; in particular, on the challenges of prevention and cessation. Public attention (including the priority-setting driven by public opinion) is easily diverted to the crisis of the moment, and in times of austerity, expenditures on prevention and cessation efforts always seem to be the most dispensable. These tendencies explain in part why the political commitment needed for a sustained effort is lacking. Second, the political and commercial power of the tobacco industry remains substantial, even following the disclosures of past misconduct arising out of recent state reimbursement litigation, the Master Settlement Agreement (MSA), and the U.S. Justice Department’s suit under the Racketeering Influenced and Corrupt Organization Act. Third, all the tobacco control measures described in Chapter 3 have had to be implemented in the context of a largely unregulated market in which tobacco products continue to be aggressively promoted. These promotion efforts are still at work, and it is difficult for public health programs to keep up, especially when the economy falters and public revenues fall short. The behavioral potential of aggressive prevention and cessation efforts is amply illustrated by the successes achieved in California, Massachusetts, and other states. So, too, however, is the fragility of these efforts—when the money disappeared, so did the programs. The nation needs to muster the political will to intensify the efforts implemented so successfully during the 1990s and to build on them. These

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Ending the Tobacco Problem: A Blueprint for the Nation comprehensive state programs, as well as their individual components, have been shown to be effective. Failure to sustain these efforts will cost lives. This chapter of the committee’s report outlines the core components of tobacco control as they have been implemented within the existing legal structure. It should be emphasized, however, that one of the constraints on the current legal structure is that no federal agency has regulatory jurisdiction over tobacco products. Another constraint is that the federal statute regulating the labeling and advertising of cigarettes forecloses state regulation of advertising and marketing of cigarettes “based on smoking and health.” This unfortunate circumstance, addressed in Chapter 6, preempts most state efforts to regulate the appearance, display, promotion, and placement of cigarettes in retail outlets. Chapter 5 begins with a discussion of the effectiveness of comprehensive state programs, as well as the states’ current approaches toward funding these programs. The states’ expenditures for tobacco control are placed in the context of the revenue streams generated by tobacco excise taxes and payments received under the MSA. The remainder of the chapter focuses on seven key substantive elements of comprehensive state programs: Tobacco excise taxes Smoking restrictions with broad coverage Youth-access restrictions with adequate enforcement Prevention programs based in schools, families, and health care systems Media campaigns Cessation programs Grassroots community advocacy The recommendations made throughout the chapter are meant to set forth a blueprint for strengthening and intensifying current tobacco control policies and programs, assuming that the current legal structure of tobacco control remains unchanged. The chapter closes with a projection of the likely impact of following (or not following) this blueprint on the national prevalence of tobacco use over the next 20 years. COMPREHENSIVE STATE PROGRAMS During the early days of tobacco use prevention, after the publication of the 1964 Surgeon General’s report (HEW 1964), many state health departments relied on the funds in their state budgets for tobacco control and treatment. Interventions tended to be targeted toward smoking cessation for individuals. By the late 1980s, however, funding for comprehensive state

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Ending the Tobacco Problem: A Blueprint for the Nation tobacco control programs increased, beginning with California and then expanding to all states. California launched the first statewide comprehensive tobacco control program in 1990, one and a half years after the passage of Proposition 99. This landmark referendum mandated an increase in state tobacco taxes and directed 20 percent of the revenues to tobacco control programs (Bal 1998; Glantz and Balbach 2000; Najera 1998). At that time, the National Cancer Institute (NCI) was already preparing to launch the seven-year national American Stop Smoking Intervention Study (ASSIST) program. In 1991, the ASSIST program funded community-level interventions to prevent tobacco use in 17 states (NCI 2005; Stillman et al. 2003). By the mid-1990s, every state in the United States had some funding for comprehensive tobacco control, either from the ASSIST program or from the Initiatives to Mobilize for the Prevention and Control of Tobacco Use (IMPACT) program, funded by the Centers for Disease Control and Prevention (CDC). In addition, from 1994 through 2000, some states1 also received funding for tobacco control efforts from the Robert Wood Johnson Foundation’s (RWJF) SmokeLess States program (Gerlach and Larkin 2005; Tauras et al. 2005). In addition to educational and cessation programs, the funding supported statewide coalitions of individuals and organizations that pursued action strategies to strengthen tobacco control policies. The ASSIST program promoted three types of interventions: program services, policy changes, and mass media. However, the ASSIST program guidelines stated that “efforts to achieve priority public policy objectives should take precedence over efforts to support service delivery” (NCI 2005, p.23). Mass media initiatives were intended to support those policy changes. The four ASSIST program priority policy areas were eliminating environmental tobacco smoke (ETS), increasing tobacco excise taxes, limiting tobacco advertising and promotion, and reducing youth access (NCI 2005). Evaluation of Comprehensive State Programs In 2005, the CDC’s Office on Smoking and Health (OSH) released a summary of the literature on evidence of the effectiveness of state tobacco control programs (Kuiper et al. 2005). Organized by major reviews and five outcome indicators (tobacco-related mortality, prevalence, consumption, cessation, and smoke-free legislation and policy), the results are generally organized by state. The evidence provided can be considered a guide to state health departments for measuring the success of their comprehensive 1 Smokeless States funded all states and the District of Columbia in its final round of grants in 2000.

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Ending the Tobacco Problem: A Blueprint for the Nation tobacco control programs. Of the five indicators of success, one is a health outcome—tobacco-related mortality—and three are markers that lead to improved health outcomes: decreases in smoking prevalence, decreases in consumption of tobacco products, and smoking cessation. The fifth indicator, smoke-free legislation and policy, is an intermediate outcome that alters the environment that supports tobacco use. This review appeared six years after the publication of the CDC’s Best Practices for Comprehensive Tobacco Control Programs. Published in 1999, Best Practices had concluded that the evidence was sufficiently compelling to encourage all states to pursue comprehensive programs. This conclusion was drawn on the basis of analyses of the excise tax-funded state programs in California, Massachusetts, Oregon, and Maine, as well as the agency’s experience in providing assistance to four other states: Florida, Minnesota, Mississippi, and Texas. The 2005 review reiterates the effectiveness of these programs, while also documenting the successes of other state programs that have appeared since 1999. Over the past decade and a half, a number of investigators have tried to assess the contribution of comprehensive state programs to policy changes and reductions in smoking (DHHS 2000; Elder et al. 1996; Siegel 2002; Stillman et al. 2003; Tauras et al. 2005; Wakefield and Chaloupka 2000; Warner 2000). By design, a comprehensive tobacco control program consists of several elements (e.g., antismoking media campaigns, counseling services, and school-based prevention initiatives), and some authors have focused on evaluating the effectiveness of individual program components. Later in this chapter, the committee refers, for instance, to several studies that have assessed the impacts of state-sponsored antismoking media campaigns on smoking prevalence and changes in smoking-related beliefs. This section reviews studies that have looked at the effects of comprehensive programs as a whole. One study that evaluated state programs throughout the country found that a program’s intensity had a very large negative correlation with the prevalence of current smoking (r = −0.81, p < .0001) and a large positive correlation with the quit rate (r = 0.82, p < .0001) among adults 30 to 39 years of age (Jemal et al. 2003). Another study determined that states with better-funded programs have lower prevalence and consumption rates (Tauras et al. 2005). However, many states have substantially cut their tobacco control programs’ budgets in recent years. Description of Programs Over the course of the 1990s, several other states—including Arizona, Florida, Massachusetts, and Oregon—followed California’s lead and developed their own comprehensive tobacco control programs (Wakefield

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Ending the Tobacco Problem: A Blueprint for the Nation and Chaloupka 2000). Studies reviewing the effects of each of these states’ efforts have been published, and many of these are listed in CDC’s 2005 literature summary (Kuiper et al. 2005). As the first two states in the country to implement comprehensive programs, California and Massachusetts have received a particularly large amount of attention. A specific examination of these two states’ pioneering efforts reveals that comprehensive state programs can be effective in reducing tobacco use and tobacco-related disease, especially when they are fully-funded and operational. California In November 1988, California voters passed Proposition 99, which increased the state tobacco tax by 25 cents per pack of cigarettes. One year later, the California Assembly passed legislation that distributed the revenue earned from the tobacco tax increase as follows: 35 percent for hospital services, 20 percent for a health education account, 10 percent for physician services, 5 percent for research, and 5 percent for environmental conservation concerns (25 percent of the funds remained unallocated). Funds from the health education and research accounts were used for the creation of a statewide tobacco control program. The California Tobacco Control Program (CTCP), the first of its kind in the country, debuted in the spring of 1990 (Bal 1998; Najera 1998; TEROC 2000). Together, the California Department of Health Services (CDHS) and the California Department of Education (CDE), along with the University of California, support a decentralized network of local health departments (LHDs), schools, researchers, and competitive grantees that forms the core of the CTCP. The CDE’s Healthy Kids Program Office oversees the program’s school-based components, whereas the University of California administers various research activities through its Tobacco Related Disease Research Program. The Tobacco Control Section of CDHS, which receives approximately two-thirds of the available funds from the Health Education Account, coordinates the public health elements of the program. These elements include programs conducted at the local level by LHDs and community organizations; a statewide media campaign; cessation counseling services (such as the California Smokers’ Helpline); a materials clearinghouse; and four networks that seek to better integrate California’s African American, American Indian, Asian and Pacific Islander, and Hispanic populations into the state’s tobacco control efforts. California has also coordinated its efforts with other tobacco control initiatives, including the RWJF’s SmokeLess States program (CDHS 1998; State of California 2004; TEROC 2000, 2003). Throughout the 1990s, the CTCP’s funding fluctuated dramatically. Between 1989–1990 and 1995–1996, for instance, the program experienced

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Ending the Tobacco Problem: A Blueprint for the Nation a 60 percent reduction in funding (from $131.3 million to $53.4 million). In addition, although the CTCP’s budget more than doubled between 1995–1996 and 1997–1998 (from $53.4 million to $140.7 million), funding declined yet again in 1998–1999 as well as in 1999–2000 (Independent Evaluation Consortium 2002). In its first few years, before these major budget fluctuations, the CTCP embraced a mix of policy, media, and program interventions to address a range of factors contributing to tobacco use (CDHS 1998). By 1993, however, looming budget cuts necessitated a more focused approach. Anticipating funding reductions, program administrators revised the CTCP’s structure and priorities to streamline the state’s tobacco control efforts. Administrators refocused the program’s activities into four clearly defined areas: (1) reducing exposure to secondhand smoke, (2) countering the influence of the tobacco industry, (3) reducing youth access to tobacco products, and (4) providing cessation services (CDHS 1998). Since then, however, the CTCP has suffered additional reductions in funding, including a budget cut of 30 percent ($46 million) in FY 2002. Consequently, the gap between tobacco control funding and tobacco industry spending has widened considerably, especially in comparison to the more intensive and better-funded early years of the program. By 2002, California—once the trailblazer in comprehensive tobacco control programming—had fallen to 20th in state rankings for per-capita funding for tobacco control (TEROC 2003). Massachusetts Massachusetts modeled much of its tobacco control program after that of the CTCP. In November 1992, Massachusetts voters passed a ballot initiative (commonly known as Question 1) that—like Proposition 99 in California four years earlier—increased the state tobacco tax by 25 cents per pack of cigarettes. Although the Massachusetts Constitution prohibits the earmarking of tax revenue (as the California legislature had done with money earned from its tobacco tax increase), the drafters of Question 1 composed language that urged—but did not mandate—the state to allocate revenue collected from the tobacco tax to a statewide tobacco control program. Following passage of the initiative, Massachusetts legislators soon allocated revenue from the tobacco tax to a newly created Health Protection Fund for the financing of a tobacco-control program (Cady 1998; Connolly and Robbins 1998; Nicholl 1998). Administered by the Massachusetts Department of Public Health, the Massachusetts Tobacco Control Program (MTCP) began operating in October 1993 with the launch of a mass media campaign, which used a wide spectrum of media, including television, radio, newspapers, and billboards, to disseminate its antismoking message throughout the state. In the follow-

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Ending the Tobacco Problem: A Blueprint for the Nation ing months, the MTCP started implementing additional tobacco control initiatives with an emphasis on three priority areas: (1) preventing youth from starting to smoke, (2) reducing smoking prevalence among adults, and (3) reducing nonsmokers’ exposure to ETS. Massachusetts, like California, embraced a localized approach to achieve these goals. Although the MTCP first managed local programs by program type, it soon restructured its operations by organizing localities into six regional networks. Representatives from local tobacco control programs, along with MTCP representatives, began meeting monthly within their respective regional networks to ensure statewide cohesion and better facilitate exchanges of information. In addition, the MTCP has funded community coalitions to organize mobilization efforts, as well as boards of health and LHDs, to enact and enforce tobacco control regulations. Statewide programming, meanwhile, has included the media campaign and the Try to Stop Resource Center, which offers the Smoker’s Quitline, a website (www.trytostop.org) for smokers seeking cessation support, and educational materials. The Center for Tobacco Prevention and Control at the University of Massachusetts Medical School performs research on tobacco use and nicotine dependence (Connolly and Robbins 1998; Hamilton et al. 2002; MDPH 2002a, 2002b). Massachusetts has also mirrored California in coordinating its activities with other tobacco control initiatives. From 1991 through 1999, for instance, Massachusetts was 1 of 17 states in the country to participate in the NCI’s ASSIST program. Massachusetts participated in various training programs and information exchanges with its fellow ASSIST states, as well as with California and other states with tobacco control programs (Celebucki et al. 1998). As with the CTCP, the MTCP’s early years represented its most intensive period of funding and activity. From 1994 to 1997, for example, the $7.09 per-capita spent on tobacco control in Massachusetts represented the highest investment of its kind in the country. Budgetary cuts have threatened the effectiveness of the MTCP throughout its history, however, and even in the first 3 years of its existence, the MTCP experienced a pattern of decreasing expenditures (Wakefield and Chaloupka 2000). These early reductions, however, pale in comparison with the cuts that occurred at the beginning of the 2000s. Although funds from the MSA helped increase the MTCP’s budget in FY 2000, funding levels dropped again in FY 2001. In addition, between FY 2002 and FY 2003, as the state faced acute budget shortfalls, it decreased the MTCP’s budget from $34 million to $5.5 million. These cuts resulted in a serious reduction of the MTCP’s activities, including the elimination of almost all local programming and the discontinuation of the media campaign. Since these cuts occurred, surviving elements of the program have operated at a level far below that of the previous decade (Hamilton et al. 2003; MDPH 2002a, 2006).

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Ending the Tobacco Problem: A Blueprint for the Nation Description of Evaluations From the start, both California and Massachusetts incorporated evaluation mechanisms into their tobacco control programs. California developed a multidimensional evaluation structure that comprised local program assessments, in-house surveys, and an independent review. Through the “10 percent” clause, which requires local grantees to devote 10 percent of their program budgets to evaluation, the state can review the effects of programs carried out at the local level, where most CTCP activities take place. The CDHS’s in-house data-gathering efforts, meanwhile, have included the Behavior Risk Factor Survey, the California Adult Tobacco Survey, and the California Youth Tobacco Survey. CDHS contracts with the University of California San Diego (UCSD) to operate the much larger California Tobacco Survey (CTS). UCSD conducts this survey every 3 years through interviews of individuals from randomly selected households, and reaches approximately 78,000 adults and 6,000 youth. The CTS provides CDHS with statewide smoking prevalence rate estimates (broken down into county and regional estimates) as well as data on attitudinal changes (Russell 1998). The CTCP’s enabling legislation mandated an independent evaluation of the program. The Gallup Organization has conducted this independent review, subcontracting various elements of its evaluation to Stanford University and the University of Southern California (USC). In their reviews, Gallup and its subcontractors have examined the overall impact of the program as well as the relative effectiveness of its various components (media campaigns, local initiatives, school-based programs, etc.). Other surveys used in the evaluation of the CTCP include the CDHS’s annual survey of the rate of illegal sales of tobacco products to minors and occasional surveys targeting specific issues, such as the Field Institute poll on the number of smoke-free bars in the state. The Evaluation Task Force, with members from across the United States and Canada, advises the state on evaluation efforts (Independent Evaluation Consortium 2002; Russell 1998). Massachusetts has used a similar multidimensional approach to evaluating the MTCP’s success in reducing tobacco use. From October 1993 through March 1994, MTCP conducted the Massachusetts Tobacco Survey, a baseline survey that collected data on tobacco use among adults and youth through randomized telephone interviews. Beginning in March 1995, MTCP began conducting the Massachusetts Adult Tobacco Survey, a monthly follow-up cross-sectional survey, to monitor changes in tobacco use and related attitudes. In addition, along with the RWJF, the MTCP funded longitudinal surveys to evaluate the program’s impact on adults and youth. Finally, like California, Massachusetts commissioned an independent assessment of its tobacco control program. In evaluating the success of the

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Ending the Tobacco Problem: A Blueprint for the Nation MTCP, Abt Associates Inc. has reviewed data on smoking prevalence, quit attempts, smoking cessation, exposure to ETS, incidents of tobacco sales to minors, and changes in attitudes regarding tobacco use and tobacco-control policy (Hamilton et al. 2002). Frequent budget cuts, however, have impacted the regularity of the MTCP’s surveillance efforts, restricting the extent and consistency of program evaluation (Hamilton et al. 2002). Findings Regarding Effects The results of the evaluations and surveys mentioned above, along with the findings from a number of peer-reviewed studies, indicate that California and Massachusetts have made progress in their tobacco control efforts; this progress is most notable when the respective programs have been well-funded and fully-implemented. On the basis of data from the CDC’s Behavior Risk Factor Surveillance System, Figure 5-1 illustrates the successes that both states have had in reducing tobacco use in comparison with the rest of the country. Figure 5-1 shows that a 23.2 percent reduction in the prevalence of current smoking in California took place between 1990 (the first full year of the state’s tobacco control program) and 2005, whereas the reduction in the U.S. median during the same period was FIGURE 5-1 Percent reduction in current adult smokers in California and Massachusetts from the first year of their tobacco control programs (1990 and 1994, respectively) to 2005 (the year for which the most current data are available) compared with the percent reduction in the U.S. median for the same two time periods, based on data from the Behavior Risk Factor Surveillance System. SOURCE: (CDC 2006a).

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Ending the Tobacco Problem: A Blueprint for the Nation 10.9 percent. In Massachusetts, meanwhile, a 14.6 percent reduction took place between 1994 (the first full year of the implementation of its tobacco control program) and 2005. During those same years, the U.S. median experienced a smaller reduction of 9.7 percent. California During the CTCP’s early years, California experienced significant declines in the prevalence rate of smoking among adults. To determine whether the declines could be attributed to the program or to alternative factors (e.g., national trends or demographic changes) Siegel and colleagues (2000) compared data for California with data for the rest of the country. They found that California’s rate of decline in adult smoking prevalence between 1990 and 1994 was 0.39 percent per year, whereas the rate of decline in the rest of the United States was only 0.05 percent per year. Restriction of the analysis to various demographic groups did not significantly affect the results. Consequently, Siegel and colleagues suggested that the greater reduction in adult smoking prevalence in California in comparison to that of the rest of the country in the early 1990s could be due to the implementation of the CTCP (Siegel et al. 2000). It is important to note, however, that California’s adult smoking prevalence rate has remained relatively level since the mid-1990s (CDHS 2002).2 In an evaluation of the CTCP’s activities from 1989 to 1996, Pierce and colleagues (1998) divided the program’s first 7 years into two distinct periods. They found that during Period 1 (January 1989 to June 1993), adult smoking prevalence and per-capita cigarette consumption declined more than 50 percent faster than in previous years and more than 40 percent faster than in the rest of the United States. During Period 2 (July 1993 to December 1996), however, the rate of decline for both adult smoking prevalence and per-capita cigarette consumption slowed, with the prevalence declining at only 15 percent and consumption declining at only 34 percent of the Period 1 rate of decline. Furthermore, although the rate of decline in cigarette consumption remained substantially higher than the rate recorded in the rest of the United States during Period 2, California’s rate of decline in adult smoking prevalence no longer exceeded that of the rest of the United States. This slowdown coincided with decreased financing of tobacco control programs by the state (Pierce et al. 1998). Fichtenberg and Glantz (2000), meanwhile, analyzed the CTCP’s effectiveness in relation to the rate of decline of deaths attributable to heart 2 The increase in smoking prevalence in 1996 is generally considered to be a result of the fact that the CDC revised its definition of the term “current smoker,” which resulted in the inclusion of more “occasional smokers.”

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Ending the Tobacco Problem: A Blueprint for the Nation disease in California. They found that between 1989 and 1992, both percapita cigarette consumption rates and the annual rate of mortality from heart disease declined significantly more in California than in the rest of the country. Reflecting the trends noted above, however, the rates of decline slowed noticeably after 1992. Consequently, Fichtenberg and Glantz concluded that the CTCP was initially effective in reducing deaths from heart disease but that cutbacks in the scale and funding of the program weakened further progress (Fichtenberg and Glantz 2000). The last independent evaluation of the CTCP to be released by the Gallup Organization and its partners (Stanford and USC) assessed the program’s overall impact in relation to Californians’ exposure to its various elements and messages, as reported in surveys conducted in 1996–1997, 1998, and 2000. The evaluation concluded that the CTCP has had an impact on behavior, as counties with greater exposure to the program showed better outcomes than counties with less exposure, including a greater decline in adult smoking prevalence between 1996 and 2000, lower perceived access to cigarettes among 10th graders, and an increase from 1996 to 2000 in the proportion of adults with complete smoking bans in their homes (Independent Evaluation Consortium 2002). The CTCP has also had success in reducing tobacco use among youth. A study released in 2005 associated the CTCP with reduced uptake and smoking rates among adolescents and young adults. The authors found that the rate of “ever puffing” declined by 70 percent among 12- to 13-year-olds from 1990 to 2002, by 53 percent among 14- to15-year-olds from 1992 to 2002, and by 34 percent among 16- to 17-year-olds from 1996 to 2002. The study identified similar patterns for smoking experimentation (smoking one or more cigarettes ever) and established smoking (smoking more than 100 cigarettes in a lifetime). Although the smoking prevalence among young adults (ages 18 to 24 years) remained constant in the rest of the country from 1992 to 2002, the prevalence among young adults in California decreased significantly (by 18 percent) from 1998–1999 to 2001–2002 (Pierce et al. 2005). Gilpin and colleagues found a similar behavioral trend when they compared the results of two 3-year longitudinal studies (1993–1996 and 1996–1999) that measured smoking initiation rates at the baseline among California adolescents who had never smoked. The authors identified a lower rate of initiation at follow-up in the cohort of the second study than in that of the first study (Gilpin et al. 2005). Data published by CDHS indicate that California has continued to make progress in reducing tobacco use among youth. According to CDHS, from 2000 to 2004, the 30-day smoking prevalence rate among high school students in California decreased from 21.6 percent to 13.2 percent (CDHS 2005). Figure 5-2 shows that although the rate of decline in smoking prevalence among youth in California mirrored the rate of decline in the rest of

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