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This report, written in December 1999, is an examination of political alliances worked to create Oregon's Tobacco Prevention and Education Program. It's a clear lesson in how good intentions and even good science is not enough to succeed in shaping public health policy. 

You need allies... with money and influence.

See also:
Florida anti-Tobacco Campaign
Florida Stumbles (an update reviewing moves to cut this successful program.)

Oregon’s Measure 44 

 A Public Health Initiative
Copyright 1999 Andrew Holtz, Craig Mosbaek

Tobacco Prevention as a Public Health Goal

Nationally, tobacco is the most prominent contributor to mortality, accounting for 400,000 deaths annually. (McGinnis, 1993) In 1996, tobacco use contributed to the deaths of over 6,668 Oregonians, causing more than 4 times as many deaths as motor vehicle crashes, suicide, AIDS, and homicide combined (Figure 1). In Oregon, the annual medical costs due to tobacco use are estimated to be $800 million, with over 40% of these costs paid by public funds. (Oregon Health Division, 1999)
Previous research has shown two population-based approaches to be effective in reducing tobacco use: (1) increasing the price of tobacco and (2) instituting a comprehensive statewide tobacco prevention program. In November 1996, voters in Oregon passed Measure 44, increasing taxes on tobacco and dedicating a portion of the new revenue to tobacco prevention. In this paper, Measure 44 will be analyzed in terms of the public health principles, the motivations of the constituencies advocating for the measure, and the messages used in the pro-Measure 44 and anti-Measure 44 campaigns.

Tobacco Taxes and Tobacco Prevention Programs — Ethical Principles

Autonomy. Tobacco taxes and the current prevention programs discourage tobacco use but do not forbid it for adults. These efforts are an attempt to counterbalance the enormous amounts of money the tobacco industry spends to promote tobacco use. It is possible that given a more truly "free" choice, without the influence of persuasive media messages from either side, fewer people would choose to smoke.

Beneficence. Anything that reduces tobacco use also reduces tobacco-related illness and death. Studies have shown that the price elasticity for tobacco is approximately -0.4. (CDC, 1999) The price elasticity model works to reduce tobacco use whether the price increase is promulgated by the tobacco industry or whether it is due to a tax increase. With price increases, the intervention is focused more on the high risk individuals; those who use more tobacco pay more of the new tax. But, price increases are population-based, encouraging tobacco users to use less and discouraging non-users from starting.
Comprehensive statewide tobacco prevention programs have been shown to be effective in California and Massachusetts. Both these programs were funded by citizen initiatives that increased state tobacco taxes, California in 1988 and Massachusetts in 1992. In the period 1992-1996, per capita consumption of cigarettes declined 15.8% in California, 19.7% in Massachusetts, and only 6.1 % in the rest of the United States. (CDC, 1999)

Non-maleficence. Any tax causes harm to the payers by taking money that might be used for other purchases. Lower income individuals are more likely to smoke (Table 2). Given a certain amount of taxes to be collected, the harm from a tobacco tax is greater than the harm from most other taxes because those least able to afford the tax actually pay higher taxes.

Justice. Tobacco taxes are unjust because they place the entire tax burden on tobacco users, who tend to have poorer health, lower incomes, and less education than the general population (Tables 1 and 2). On the other hand, tobacco taxes may be viewed as a user fee, helping to offset the additional health care costs due to tobacco. Most people carry group health care coverage, with the same premiums for smokers and non-smokers. Insured smokers do not have to individually pay the increased health care costs related to their smoking. In Oregon, 293 million packs of cigarettes were sold in 1996 while the annual direct health care costs were estimated at $800 million. (Oregon Health Division, 1999) The health care costs per pack of cigarettes is over $2/pack. Even after passage of Measure 44, the tax on cigarettes does not cover the tobacco-related health care costs (Oregon tax: 68 cents/pack; federal tax: 24 cents/pack).

In conclusion, there are ethical issues regarding taxes and their burden on the lower income groups, but, overall, tobacco taxes and tobacco prevention programs can be considered a public health good. Reducing tobacco use is arguably the greatest tool for health promotion, and taxes and prevention programs are an effective and ethical means towards that end.

Efforts to Increase Tobacco Taxes and Fund Tobacco Prevention in Oregon

Over the past thirty years in Oregon, state tobacco taxes have been raised several times and, in 1996, state cigarettes taxes were 38 cents per pack. Although in past years, some of Oregon’s tobacco tax revenue was earmarked for certain programs, no money was allocated to tobacco prevention. In 1993, the Legislature added a temporary 10 cents per pack tax on cigarettes, dedicating the new revenue to fund the Oregon Health Plan (OHP). This new tax was supported by the Oregon Association of Hospitals and Health Systems (OAHHS). Passage of the new tax, in a general Legislative climate of "no new taxes", demonstrates the power of the hospital lobby. OAHHS strongly supports the OHP as the net revenue of hospitals has increased because of the OHP. (Santa, 1999)

Anti-tobacco groups felt that it was nearly impossible to persuade the Legislature to substantially increase tobacco taxes or fund a statewide tobacco prevention program. (North, Patterson, 1999) The practical alternative was to collect signatures and get a citizens initiative on the ballot as was done in California, Massachusetts, and Arizona. Groups including the American Cancer Society, American Lung Association, and American Heart Association (the Voluntaries) had tried to get tobacco tax initiatives on the ballot a couple times in the early 1990’s. These attempts had failed to get enough signatures to qualify for the ballot. (Weller, 1999)

In 1995 a new initiative to raise tobacco taxes was proposed, not by the traditional anti-tobacco organizations, but by a health care company. PeaceHealth, a hospital system in Eugene, approached OAHHS with a proposal for a ballot initiative to increase tobacco taxes and dedicate the money to the OHP and tobacco prevention. OAHHS, the Oregon Medical Association, and Blue Cross and Blue Shield of Oregon, formed a committee (later called the Committee to Support the Oregon Health Plan) to design the initiative and conduct the campaign. The committee hired a political consulting firm, PacWest, to conduct a public opinion poll. (Patterson, 1999)

The poll indicated that the public supported a tobacco tax increase that would help fund the Oregon Health Plan. However, spending the new revenue on "educating kids about tobacco" was viewed even more favorably (Figure 2). When asked which organizations or individuals would be most influential to their voting decisions, the American Cancer Society and other Voluntaries were at the top of the list (with greater than 60% favorable ratings), far higher ratings than the Oregon Hospital Association (40%) or the Oregon Medical Association (47%) (Figure 3).

Initially, the initiative sponsors wanted all of the tax revenue to go to the OHP, but the poll results showed the political advantages of dedicating a portion of the revenues to anti-tobacco efforts. As Ed Patterson, OAHHS lobbyist, said, "There was a strong sense that our goal was to raise funds for the Oregon Health Plan, our goal was not to run an anti-tobacco campaign. There was a big debate about zero percent for anti-tobacco, and finally, because of some heavy lobbying that went on, we agreed to the 10 percent [for tobacco prevention.]" The inclusion of tobacco prevention funding helped the campaign in two important ways. First, it allowed the campaign to say that the initiative would fund tobacco prevention, especially tobacco prevention for kids. Second, it was enough to get the Voluntaries on board as the public spokespersons for the initiative. As campaign consultant Paul Phillips summarized, "the true believers were essential to the campaign. I couldn’t win without them and they couldn’t win without me."

The Voluntaries might have had some uneasiness working on Measure 44 since one of the main players at PacWest was Phillips, a former Republican legislator who had sponsored "pre-emption" legislation that would have prevented local governments from passing tobacco-related ordinances more restrictive than state law. (North, 1999) If there is pre-emption, the tobacco industry does not have to fight political battles at the city and county levels. Indeed, Phillips had considered including pre-emption language in Measure 44, but the wording did not poll well. (Phillips, 1999)

Measure 44 would support public health objectives. It had the support of the private medical groups and the Voluntaries, albeit each with their own motivations. How would it be sold to the voters of Oregon?

Getting on the Ballot

The funding from the medical industry made a difference from the beginning, with the successful effort to gather about 100,000 signatures (73,261 plus a margin for disqualified signatures,) necessary to qualify for the ballot. (North, 1999) The earlier failed attempts to qualify tobacco tax measures had relied on volunteer signature gatherers, whereas the political professionals running this campaign hired gatherers to ensure success. (Patterson, 1999) The voluntary organizations supplemented the paid gatherers and ultimately provided more than 23,000 signatures. (North, 1999)
The tobacco industry took its first action against the Measure 44 coalition by challenging the initiative’s ballot title. The challenge was dismissed because their lawyers missed the filing deadline. Regardless of the outcome of a ballot title challenge, the court process would have delayed the signature gathering effort, possibly keeping the initiative off the ballot. (Weller, 1999)

Additionally, the tobacco industry paid more than the usual rate to hire signature gatherers for Measure 39, an initiative that would require insurers to reimburse "alternative" health care providers. That competition increased the going rate for signature gatherers thereby sapping funds from the Measure 44 coalition. It also meant that the medical industry would have to divert some funds to the campaign against Measure 39. Ensuring that Measure 39 was on the ballot was "pay-back" for the medical groups’ involvement in tobacco issues. (Nelson, 1999)

The Election Campaign

Supporters of Measure 44 knew the tobacco industry opposition would outspend them many times over, and indeed it did. Tobacco lobbyist Mark Nelson created the Fairness Matters to Oregonians Committee, which raised $4.7 million to oppose Measure 44. All but $30 came from the Tobacco Institute. (Oregon Sec. of State, 1997) Measure 44 supporters spent just $750,000. (Glantz, 1998)

Fairness was a key theme of the opposition advertising campaign, along with arguments that the new tax "isn’t what it seems" (Table 4). As Mark Nelson puts it, "This is a tax on a minority of Oregonians to fund somebody else’s healthcare, and it didn’t necessarily mean any more people would be covered, either because general fund money would go out the back door or reimbursement increases, necessitated by the way the Oregon Health Plan was set up, would just chew them up." The opposition campaign ads also used general anti-government and anti-tax arguments. For example. one radio spot said that much of the tax money would go to "Oregon’s own Bermuda Triangle: the black hole in Salem" In a post-election survey, people who voted against Measure 44 were asked what their primary reason was for opposing it. The two most common answers were "tobacco users should not be forced to pay a disproportionate share of health costs" (47%) and "it will lead to wasteful spending by government" (36%). (Sahr, 1997)

Supporters of Measure 44 aired only one television advertisement. The ad said the new tax would give more children health care coverage and fund a new program to prevent children from smoking. The spot argued that the only opposition to the tax came from the tobacco industry. A parallel series of anti-smoking TV spots was funded by the Robert Wood Johnson Foundation. These ads did not mention Measure 44 and were not part of the official campaign, but they supported the campaign’s anti-tobacco industry message. A few weeks prior to the election, supporters won a ruling from the Federal Communications Commission (FCC) requiring broadcast ads from the opposition to identify the sponsor as the Tobacco Institute rather than the "Fairness Matters to Oregonians Committee." Phillips said the FCC ruling was significant in the campaign. "It validated all the earned media we were doing, saying, ‘this is all the tobacco industry’…not some kind of business coalition or anything else." (Phillips, 1999)

Although excluded from the campaign’s decision-making committee in the beginning, the American Cancer Society (ACS) became the most visible proponent of the new tax. ACS-Oregon Vice President Rick North, other staff, and volunteers made a number of media and public appearances to make the following points:

the tax was fair because it was actually less than the direct medical costs incurred by smokers,
it would fund efforts to prevent kids from smoking, and
it was a blow against a "deceitful" tobacco industry.
Since the Voluntaries were the public face of the campaign they defused attempts by the tobacco industry to label Measure 44 as a money grab by health insurers.

The initiative began as a way to help fund the Oregon Health Plan, the campaign focused more on tobacco issues. The basic message was captured in a newspaper ad that displayed two columns. One side, labeled "Yes", listed 36 supporting organizations and individuals. The other side, labeled "No", listed one opponent on a black background: the tobacco industry. According to the post election survey, the primary reasons people voted for Measure 44 was "to discourage tobacco consumption" (66%) and "to expand the Health Plan" (27%). (Sahr, 1997)

The Measure 44 campaign began with an almost 2-to-1 lead in the polls. (Nelson, 1999) Although the opposition reduced that margin, the measure passed with 56 percent of the vote. Oregon’s cigarette tax increased from 38 cents to 68 cents a pack on February 1, 1997. The tax on other tobacco products rose from 35 percent to 65 percent of the wholesale price. The Oregon Health Plan got an infusion of cash and the Oregon Health Division received funding to create the Tobacco Prevention and Education Program (TPEP).

The Effects of Measure 44

As predicted by both sides of the campaign, the jump in tobacco taxes reduced tobacco consumption. (North, 1999; Nelson, 1999) In the three years prior to the vote, per capita cigarette consumption in Oregon had risen slightly. While two years after the tax hike, per capita cigarette consumption in Oregon had decreased 11.3 percent, or the equivalent of 10 packs per person annually (Figure 4). Based on price elasticity calculations, the tax hike itself would be expected to decrease sales 6.3 percent, or slightly more than half the observed decline. The rate of decline in Oregon was almost 50 percent steeper than the national average. (Centers for Disease Control and Prevention, 1999) The Oregon results, adding to the experiences of California and Massachusetts, confirm that a comprehensive tobacco control program and tax increases can reduce smoking.

It is worth noting that the passage of Measure 44 is likely to have a greater long-term effect on Oregon public health efforts than a legislative vote for anti-tobacco funding would have had. By specifically dedicating a share of tobacco taxes to the TPEP, Oregon voters institutionalized tobacco control. The Legislature can repeal the tax or eliminate funding for the TPEP, but that action would require legislators to overturn a vote of the people. Tobacco prevention infrastructure is being created throughout the state. Both supporters and opponents point to the new county coalitions working to promote local anti-tobacco ordinances and policies. Tobacco lobbyist Mark Nelson complains that tobacco control is now a "cottage industry" in every county of Oregon.

Lessons from the Measure 44 Experience

The successful campaign to increase Oregon’s tobacco tax carries important lessons for anti-tobacco activists in other states. When anti-tobacco advocates tried to pass a ballot initiative without external assistance, they failed; but when they accepted an alliance with medical organizations that had superior funding and political expertise, they succeeded.
There is also a more general lesson for public health advocates about the blending of science, politics and advocacy. In the political arena, the voluntary organizations, such as the American Cancer Society, are perceived as single-minded, impractical, and inflexible. Not only their opponents, but some of their allies in the Measure 44 campaign called them "arrogant zealots." "Part of our problem at the beginning was that the Non-Profits were political lightweights, and correctly perceived as such by the Medical Association and the Hospital Association. We were nave," concedes former ACS-Oregon Vice-President North.

However, these practical lessons in politics made an impression. When North arranged for a $75,000 contribution from the national ACS, he told one of the campaign’s leaders that the money was also his ticket into the "inner circle." "I said, ‘We are coming with 75 thousand for a media campaign. You know this thing, you guys are supplying the money and we’re not, doesn’t hold true anymore. We deserve a spot on this Executive Committee, and I think I ought to have it.’ And he said, ‘OK.’ You know, money does talk." Even late in the campaign, it was important for North to be placed on the Executive Committee as it gave him more power to advocate for tobacco prevention in the Legislature. (North, 1999)

The Oregon ACS learned from the success of Measure 44 and has since hired its first full-time Advocacy Manager, in part to maintain political alliances. (North, 1999) In terms of public health accomplishments, the top of North’s list is not a program, but the political campaign. "The one single thing I’m most proud of is Measure 44. The agency was unified like I’ve never seen it before. The atmosphere in that office, in that organization, was honestly it was electric." The 1996 campaign for Measure 44 was faithful to public health ideals and demonstrated how a dose of practical politics can be the key to effective public health actions.

See also:
Florida anti-Tobacco Campaign
Florida Stumbles (an update reviewing moves to cut this successful program.)


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