also become law in Arizona, Hawaii, and Oregon. As noted previously, Alaska and Hawaii have each raised the state excise tax on cigarettes to $1.00, with Washington and New Jersey approaching that level. Maine, Wisconsin, and Utah are mounting new tobacco control programs. Much of the action in tobacco control has been and will continue to occur at the state, county, and community levels.

The federal government must support state and local infrastructure for tobacco control.

Many increases in nonfederal excise taxes and restrictions on advertising, promotion, and levels of exposure to environmental tobacco smoke depend on the actions of state and local governments. Bans on smoking in public places and in workplaces not only reduce environmental tobacco exposure to nonsmokers, but have also proven to be powerful interventions to enhance cessation and to reduce the dose exposure among smokers. The vast majority of progress on this front has taken place at the state and local levels. Counteradvertising and public education have also been largely state and local efforts, although they would likely be more effective if implemented nationally. All of these are elements of tobacco control efforts and complement federal measures. Success at the federal, state, and local levels has depended in part on funding not only government efforts, but also nongovernment organizations that can hold federal, state, and local governments to account. This pattern of funding should be designed into future tobacco control programs. For now, attention is focused on the terms of the proposed national settlement. If the settlement is translated into legislation, it should provide funding for state and local tobacco control efforts. If no settlement results, however, state and local efforts will nonetheless likely remain the bulwark of tobacco control.

Most federal support comes from the ASSIST program of the National Cancer Institute (NCI) and the IMPACT program of the Centers for Disease Control and Prevention (CDC). California and Massachusetts fund the largest state programs. States that are part of the ASSIST program spend less, but more per state and with more intensive interventions than IMPACT states. In effect, for the past few years, states have engaged in a dose-response test of tobacco control. Evidence from that experiment was presented at the July 1997 IOM workshop; it showed that the program impact roughly parallels the intensity (dose) of tobacco control efforts. California and Massachusetts have the largest programs and greater decrements in tobacco consumption than ASSIST states, which in aggregate show a 7-10 percent greater reduction in consumption than IMPACT states (i.e., all others). These programs are reviewed in the 1994 IOM report, which recommended that federal support for state efforts be increased to the level of ASSIST in all states, with the increase in funding that would entail. This is, in essence, a recommendation to implement ASSIST as a universal program, based on its demonstration in one third of the states. The new evidence reinforces the 1994 recommendation. It is time to apply the lessons of ASSIST nationwide.

Implementing the transition has several implications. First, it is important that the program content of ASSIST be carried forward as it is expanded. This includes retaining program elements as well as drawing on the expertise of those at NCI, in the ASSIST states, and in the nongovernmental organizations that have made it a success. Second, it entails a



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