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• Tobacco use is the leading preventable cause of death in Virginia, taking more than 9,200 lives each year. Tobacco-induced healthcare costs are $1.92 billion annually, including $369 million in Medicaid payments. • The growth of tobacco, and its importance to the economy of Virginia, has declined significantly. In 2008, tobacco was only the fifth most harvested and valuable crop, behind hay, corn, soybeans, and wheat, and constituted only 2.3% of the value of all Virginia agricultural products sold. • Virginia is becoming increasingly urban and its citizens are less concerned with Virginia's tobacco heritage. Significant majorities of Virginians support stronger clean indoor air laws and higher cigarette taxes. In 2009, 75% polled supported strong clean indoor air laws. • The tobacco industry has a significant presence in Virginia: Philip Morris has a large manufacturing and corporate presence in the Richmond area. • The tobacco industry's lobbying expenditures have significantly exceeded spending by tobacco control advocates. The industry also built strong ties to hospitality groups, trade associations, and tobacco growers to oppose tobacco control measures. • Republican legislators are significantly more supportive of the tobacco industry control than Democrats, who are more supportive of public health. • The tobacco industry gave about twice as much money to Republicans than Democrats. Controlling for party and legislative house, greater tobacco industry campaign contributions are statistically significantly associated with more pro-tobacco industry policy behavior. • Between 1970 and 2008, 70 cities and two counties imposed local cigarette excise taxes, an attractive and politically nonvolatile source of revenue. The tobacco industry has not been able to counter this activity. • Prior to 1990, many localities enacted local clean indoor air ordinances. Despite strong support among Virginians for clean indoor air laws and a growing movement among localities for local tobacco control, these measures were blocked in 1990 by the passage of the weak preemptive statewide Virginia Indoor Clean Air Act (VICAA). • Virginia was selected by the National Cancer Institute in 1990 to participate in the 17-state American Stop Smoking Intervention Study (ASSIST). ASSIST established a network of local tobacco control coalitions through Virginia Department of Health. Organizational issues and strong industry interference prevented ASSIST from accomplishing its mission of reducing smoking through policy change. • Virginia was awarded a Robert Wood Johnson Foundation SmokeLess States (SLS) grant in 1994 to support lasting statewide coalitions to reduce tobacco use; the effort failed in Virginia. • Virginia SmokeLess States was involved with the successful Southern Communities Tobacco Project to bring tobacco farmers together with tobacco control advocates; this effort accomplished little substantive change in tobacco control policy in Virginia. • In 1998, Virginia was part of the Master Settlement Agreement (MSA) between 46 states and the tobacco industry and will to receive about $4 billion from the settlement over 25 years. Virginia committed 10% of the proceeds to a youth-only tobacco control program; 40% was directed at financially supporting tobacco-growing communities negatively affected by declining growth of tobacco in the state, and the rest went to the General Fund. • Virginia Tobacco Settlement Foundation (VTSF)was founded in 1999 with the 10% of MSA funds. VTSF mounted a youth multimedia campaign, but little data are available on the effectiveness of VTSF programming. • In 2009, the General Assembly expanded VTSF's mission to include youth obesity prevention and changed its name to Virginia Foundation for Healthy Youth without any additional funding. The consequences for tobacco control programming are not known, but are likely to be negative if resources are diverted from tobacco control. • Virginia had the lowest cigarette tax in the nation from 1993-2004. The 2004 "2.5 Cents to Common Sense" campaign run by Virginians for a Healthy Future (VFHF), comprised of the Virginia chapters of AHA, ALA, and ACS, successfully used polling data to show popular support for an increase, targeted key legislators, and ran an effective media campaign. This effort resulted in a tax increase of 30 cents per pack in 2004. None of the increased tax went to fund tobacco control. • In 2006, with encouragement from VFHF, Governor Tim Kaine (D) issued Executive Order 41, prohibiting smoking in most executive branch buildings and state-owned vehicles. • In 2007, VFHF worked closely with Gov. Kaine and Sen. Brandon Bell (R) to introduce SB 1161, a strong expansion of the VCIAA to extend make most public places, including restaurants, smokefree. This effort failed. • The City of Norfolk decided to pass an ordinance prohibiting smoking in restaurants in 2007, arguing that it not preempted by the VCIAA because of the city's inherent police powers. The ordinance was rescinded before it went into effect because of complaints by local restaurateurs and the likelihood of a statewide law passing. Statewide public health advocates did not effectively support this effort to test state preemption. • In 2009 VFHF focused an intense "district campaign" on Assembly Speaker William Howell's (R) home district of Fredericksburg, forcing Howell to stop blocking all clean indoor air legislation. Instead of supporting 100% smokefree legislation, he proposed a weak amendment to the VCIAA that created exemptions for smoking rooms in restaurants. The member organizations of VFHF split in 2009 over support for the Kaine-Howell compromise legislation. After securing an agreement with Gov. Kaine in a back-room meeting, the Kaine-Howell bill passed and was signed into law by Kaine. The law prohibited most smoking in restaurants and bars but allowed separately vented smoking rooms. • Given strong support from Virginians for stronger clean indoor air laws, Virginia tobacco control advocates should reexamine their strategies. VFHF and its member organizations should provide financial and political resources to expand their successful 2009 Fredericksburg district campaign to repeal preemption. They should also consider identifying and supporting local efforts to enact stronger laws using the Norfolk model.

Tobacco use is the leading preventable cause of death in South Carolina. Smoking-related medical costs amount to $1.1 billion each year, including $393 million for Medicaid. Tobacco growing in South Carolina declined by over 50 percent from 1997 to 2008. Tobacco accounted for less than 10% of the state's cash receipts from all crops in 2007. Despite the low levels of actual tobacco growing and the small role tobacco played in the state's economy in 2008, the cultural construct of being a "tobacco growing state" continued to have a disproportionately large impact on tobacco control policy making. Between 1997 and 2008, the tobacco industry lost its alliances with the Farm Bureau Federation and Commissioners of Agriculture, former staunch industry allies, because of negotiations over the Master Settlement Agreement, the buyout of the Tobacco Price Support system, and increasing purchase of foreign tobacco. Tobacco control Policy Score rankings of 2007/2008 legislators by knowledgeable tobacco control advocates revealed that legislators from the Pee Dee region, historically the stronghold of tobacco agriculture, were similar to the rest of the state's legislators in their attitudes towards tobacco control. Tobacco area legislators were formerly strong allies of the tobacco industry and historically worked with industry lobbyists to ensure defeat or manipulation of tobacco control bills. The 2007/2008 Policy Scores indicated that this was no longer the case. Tobacco control advocates should take advantage of the growing distance between tobacco companies and its former tobacco-growing allies and the decline in the actual importance of tobacco agriculture to challenge the rhetoric and resistance to tobacco control policies in the state. The tobacco industry built significant political influence in South Carolina through lobbyists, alliances with prominent trade associations, campaign contributions and other political expenditures. From 1996 to 2006, tobacco companies, trade associations and producers contributed a total of $680,541 to candidates for state office and to political parties. There is a measurable relationship between tobacco industry contributions and legislative behavior. As rated on a Policy Score scale from 0 to 10, with 10 being extremely receptive to tobacco control and 0 being extremely pro-tobacco industry, for every $1,000 received from the tobacco industry during the 2006 election cycle, a legislator's Policy Score decreased by 1.5 points. Democrats were on average 3.6 points more favorable towards tobacco control than Republicans, after controlling for campaign contributions. South Carolina was selected by the NCI in 1990 to participate in the 17-state ASSIST program. ASSIST funded tobacco control programming within the Department of Health and Environmental Control and established the state's first formal tobacco control coalition, the Alliance for a Smoke-Free South Carolina. The Alliance disbanded in 1997, leaving tobacco control advocacy disorganized and ineffective through 2003. ASSIST ended in 1999 and was replaced by a minimally-funded DHEC Tobacco Division supported primarily by about $1 million annually from the US Centers for Disease Control and Prevention. In 1998, the state signed the Master Settlement Agreement, securing approximately $70 million per year from the major cigarette companies. In 2000, the state securitized its settlement revenue, receiving a lump sum of $900 million up front in lieu of its annual payments through 2019. Refinancing in 2008 moved this date back to 2012. The 2000 General Appropriations bill set up 4 trust funds from the securitized MSA funds, with 73% ($574 million for healthcare), including tobacco control. Only $3.34 million of the MSA revenue was spent on tobacco control between 2000 and 2008. The state allocated an additional $6 million from the General Fund to the DHEC Tobacco Division between 2002 and 2008, with no state funding for the program between 2003 and 2006 and again in 2008. The Tobacco Division developed small-scale but innovative tobacco control programming, particularly community programs to promote policy change and the Rage Against the Haze youth movement. The DHEC leadership did not prioritize tobacco control between 2000 and 2008, although its support increased gradually due to efforts by the Tobacco Division, DHEC regional staff and the voluntary health groups. Funding requests remained at $2 million, significantly below the CDC recommended $62.2 million per year. Limitations by DHEC leadership on the role that DHEC staff play in local community-wide policy change efforts changed in 2007 to allow direct participation, but remained limited in scope. The voluntary health groups failed to prioritize increased funding for the DHEC Tobacco Division relative to their other lobbying focuses and continued in 2008 to act hesitantly in their lobbying of DHEC leadership to support tobacco control funding and policy change. In 2001, tobacco control advocates formed the South Carolina Tobacco Collaborative. It received 83% of its funding from the state health department, limiting its advocacy capacity. Increased funding from voluntary health groups and national partners between 2005 and 2008 allowed the Collaborative and the other prominent tobacco control advocacy groups, the South Carolina African-American Tobacco Control Network and the Smoke-Free Action Network, to increase advocacy between 2005 and 2008. These developments led to notable successes in clean indoor air policies and attempts to increase the state's tobacco tax. The cigarette tax in South Carolina remained the lowest in the nation in 2008, at 7 cents per pack. The last cigarette tax increase was in 1977, with nearly annual attempts to increase the tax defeated by coordinated efforts from the tobacco industry. Tobacco control advocates began to push for a cigarette tax increase in 2000, without success. Between 2006 and 2008, the Collaborative developed a well-funded and well-coordinated public education and lobbying campaign to support a cigarette tax increase. In 2008, the General Assembly passed a 50-cent increase, with $5 million of the annual revenue directed to the DHEC Tobacco Division, over active opposition from the tobacco industry and its allies. Governor Mark Sanford vetoed the bill for its lack of revenue neutrality, and Speaker of the House Bobby Harrell successfully prevented a veto override in the House. The 2006-2008 cigarette tax increase campaign showed that well-funded tobacco control advocacy could be successful over tobacco industry opposition in the legislature. The defeat of the increase bill demonstrated the need for stronger grasstops lobbying and relationship building with legislative leadership. Between 1977 and 1989, local policymakers passed 19 limited clean indoor air ordinances, building momentum for consideration of a state-level clean indoor air bill. In 1990, tobacco control advocates compromised with tobacco industry lobbyists to allow the passage of a weak statewide Clean Indoor Air Act, halting significant progress on clean indoor air through 2005. In 1996, the tobacco industry succeeded in using the Synar Amendment to integrate preemption into a youth access to tobacco amendment. The tobacco industry and tobacco control advocates assumed the provision also preempted local clean indoor air activity. Beginning in 1999, local policymakers in Charleston began to support local clean indoor air ordinance attempts despite assumed preemption. While Charleston did not pass an ordinance until 2006, news coverage of the city's efforts began a wave of consideration of local ordinances, eventually supported by state and local tobacco control advocates and the Municipal Association. Between May 2006 and December 2008, 21 local clean indoor air ordinances passed, 12 of which passed before the state Supreme Court rejected the argument that preemption applied to clean indoor air ordinances. Two localities were sued over their ordinances on preemption grounds, but won both cases in the Supreme Court. During the 2007/2008 legislative session, tobacco control advocates joined together to successfully defeat multiple attempts to institute express preemption through weak clean indoor air legislation supported by the tobacco industry. Given the success of local clean indoor air efforts, the strategy of tobacco control advocates developed during 2008 should be maintained: continue to promote comprehensive local smoke-free ordinances, while avoiding any action on clean indoor air in the General Assembly.

Tobacco policy has been an issue in Indiana since 1893, when the legislature passed a law prohibiting selling tobacco to people under 16. Beginning as early as 1969, Indiana General Assembly members and tobacco control advocates launched uncoordinated efforts to pass a law restricting smoking in government buildings. The tobacco industry responded with a well-financed and well-connected network of lobbyists, campaign contributions and third-party allies which's lobbyists that defeated every statewide clean indoor air proposal from 1969 to 1986. In 1986, tobacco control advocates formed the Indiana Campaign for a Tobacco-Free Society and, in 1987, successfully advocated for Indiana's first clean indoor air law that created nonsmoking areas in government-owned buildings. Participating in the National Cancer Institute's American Stop Smoking Intervention Study (ASSIST; 1991 to 1999) provided Indiana with its first funded tobacco control local infrastructure, which laid the foundation for future progress. In 1997, despite opposition from tobacco control advocates, the Tobacco Institute, the tobacco industry's lobbying organization, convinced the Indiana Legislature to preempt local governments from regulating the sale, distribution or display of tobacco products. Between 2000 and 2009, the tobacco industry spent over $4 million on lobbying. From 1994 to 2008, the tobacco industry contributed $560,884 to elected officials. Nine of the 10 officials who accepted the highest amounts of money held high-ranking leadership positions. Industry contributions were associated with more pro-industry behavior by legislators. Tobacco Industry campaign contributions peaked during 1999-2000, when legislators were considering how to spend money from the Master Settlement Agreement (MSA), and during 2003-2004, when legislators cut the state tobacco control budget by 70 percent. In 2000, the Legislature created the Indiana Tobacco Use Prevention and Cessation (ITPC) Agency as an independent agency governed by an Executive Board with $35 million of MSA money for FY 2001, meeting the US Centers for Disease Control and Prevention's minimum funding recommendation. The ITPC Executive Board created the Hoosier Model, an adaptation of CDC's Best Practices for Comprehensive Tobacco Control Programs, with a particularly strong emphasis on community programs. In 2002, with active support from tobacco control advocates and ITPC, the Governor proposed and the Legislature enacted a 40¢/pack cigarette tax increase, the first increase since 1987. None of the money went to tobacco control. In 2007, again with support from the health advocates and ITPC, the Legislature enacted Governor Mitch Daniels' (R) Healthy Indiana Plan financed by a 44¢/pack cigarette tax increase (to 99.5¢). Only $1.2 million of the new tax revenues were allocated to ITPC, and even this small amount ended after just one year. As of 2010, Indiana's cigarette tax was still 45.5¢ below the national average. Bloomington passed Indiana's first comprehensive smokefree ordinance in 2003 which prohibited smoking in public places and enclosed workplaces, followed by bars in 2005. Indianapolis-Marion County passed an ordinance in 2005 prohibiting smoking in public places and enclosed workplaces, except for bars and private clubs. Thirty-five local ordinances passed after the Indianapolis-Marion County ordinance, 21 of which exempted bars and 28 exempted private clubs, mirroring the Indianapolis-Marion County ordinance. In 2006, tobacco control advocates adopted statewide "deal breaker" agreements establishing a minimum standard for comprehensive local smokefree ordinances without exemptions. These agreements resulted in fewer but stronger ordinances: from 2003 through 2006, only 5 of 28 ordinances included bars; between 2007 and 2009, 6 of 10 ordinances included bars. Decreases in ITPC funding to local communities has made it difficult for local coalitions to maintain staff levels and program efficacy. Advocates have been too focused on strengthening the 2005 Indianapolis-Marion County clean indoor air ordinance; advocates should reinvigorate local activity throughout the state to pass comprehensive ordinances in smaller communities. In 2009, statewide tobacco control advocates made a strategic error in not actively supporting a non-preemptive clean indoor air bill covering everything but casinos. In 2010, in an arrangement with House Speaker B. Patrick Bauer, Representative Charlie Brown (D-Gary) introduced essentially the same bill that the advocates passed on in 2009, which again failed without their support. Tobacco control advocates were divided which weakened their coalition. ITPC's funding was never secure; between FY 2001 and FY 2004, legislators cut ITPC's funding by 70%. ITPC received $10.9 million for FY 2010, just 14% of Best Practices. Despite the cuts, ITPC's programs decreased youth smoking. From 2000 to 2008, smoking prevalence decreased among high school students by 42 percent, from 31.6 percent to 18.3 percent and among middle school students by 58 percent, from 9.8 percent to 4.1 percent. During this period adult smoking prevalence remained stable, while per capita consumption dropped, indicating that smokers were smoking fewer cigarettes. The continuing decline in youth smoking while adult prevalence stagnated probably reflected the ITPC Executive Board's decision to give priority to reducing youth smoking in response to cuts in total funding available. State policy makers were correct to establish ITPC as an independent agency and to fund it at CDC-recommended levels. In 2010, tobacco control advocates defeated a proposal from Governor Mitch Daniels and Senator Luke Kenley (R-Noblesville) to dissolve the ITPC Executive Board and transfer the Agency's functions to the Indiana State Department of Health (ISDH). States that have dissolved or transferred their independent tobacco control programs into state health departments have historically raided funds and been left with ineffective programs. In 2011, advocates again fought a similar last minute amendment to the state budget bill to dismantle ITPC introduced by Sen. Kenley, but were unsuccessful in part. ITPC was dissolved and the program's budget transferred to ISDH and reduced by 25 percent. However, the public outcry generated by ITPC supporters influenced ISDH to create a new, high level division reporting directly to the State Commissioner of Health focused solely on tobacco prevention and cessation and to make a commitment to maintaining ITPC"s effective program focus. If advocates can successfully transition ITPC's programs into ISDH, broaden its program focus to reintegrate adults, and restore full funding, it will likely yield rapid decreases in health care costs and other economic losses stemming from tobacco-related illnesses and so contribute not only to the physical health of Hoosiers, but also the fiscal health of their government and businesses.

Tobacco policy has been an issue in Indiana since 1893, when the legislature passed a law prohibiting selling tobacco to people under 16. Beginning as early as 1969, Indiana General Assembly members and tobacco control advocates launched uncoordinated efforts to pass a law restricting smoking in government buildings. The tobacco industry responded with a well-financed and well-connected network of lobbyists, campaign contributions and third-party allies which defeated every statewide clean indoor air proposal from 1969 to 1986. In 1986, tobacco control advocates formed the Indiana Campaign for a Tobacco-Free Society and, in 1987, successfully advocated for Indiana's first clean indoor air law that created nonsmoking areas in government-owned buildings. Participating in the National Cancer Institute's American Stop Smoking Intervention Study (ASSIST; 1991 to 1999) provided Indiana with its first funded tobacco control local infrastructure, which laid the foundation for future progress. In 1997, despite opposition from tobacco control advocates, the Tobacco Institute, the tobacco industry's lobbying organization, convinced the Indiana Legislature to preempt local governments from regulating the sale, distribution or display of tobacco products. Between 2000 and 2009, the tobacco industry spent over $4 million on lobbying. From 1994 to 2008, the tobacco industry contributed $560,884 to elected officials. Nine of the 10 officials who accepted the highest amounts of money held high-ranking leadership positions. Industry contributions were associated with more pro-industry behavior by legislators. Tobacco Industry campaign contributions peaked during 1999-2000, when legislators were considering how to spend money from the Master Settlement Agreement (MSA), and during 2003-2004, when legislators cut the state tobacco control budget by 70 percent. In 2000, the Legislature created the Indiana Tobacco Use Prevention and Cessation (ITPC) Agency as an independent agency governed by an Executive Board with $35 million of MS money for FY 2001, meeting the US Centers for Disease Control and Prevention's minimum funding recommendation. The ITPC Executive Board created the Hoosier Model, an adaptation of CDC's Best Practices for Comprehensive Tobacco Control Programs, with a particularly strong emphasis on community programs. In 2002, with active support from tobacco control advocates and ITPC, the Governor proposed and the Legislature enacted a 40¢/pack cigarette tax increase, the first increase since 1987. None of the money went to tobacco control. In 2007, again with support from the health advocates and ITPC, the Legislature enacted Governor Mitch Daniels' (R) Healthy Indiana Plan financed by a 44¢/pack cigarette tax increase (to 99.5¢). Only $1.2 million of the new tax revenues were allocated to ITPC, and even this small amount ended after just one year. As of 2010, Indiana's cigarette tax was still 45.5¢ below the national average. Bloomington passed Indiana's first comprehensive smokefree ordinance in 2003 which prohibited smoking in public places and enclosed workplaces, followed by bars in 2005. Indianapolis-Marion County passed an ordinance in 2005 prohibiting smoking in public places and enclosed workplaces, except for bars and private clubs. Thirty-five local 2 ordinances passed after the Indianapolis-Marion County ordinance, 21 of which exempted bars and 28 exempted private clubs, mirroring the Indianapolis-Marion County ordinance. In 2006, tobacco control advocates adopted statewide "deal breaker" agreements establishing a minimum standard for comprehensive local smokefree ordinances without exemptions. These agreements resulted in fewer but stronger ordinances: from 2003 through 2006, only 5 of 28 ordinances included bars; between 2007 and 2009, 6 of 10 ordinances included bars. Decreases in ITPC funding to local communities has made it difficult for local coalitions to maintain staff levels and program efficacy. Advocates have been too focused on strengthening the 2005 Indianapolis-Marion County clean indoor air ordinance; advocates should reinvigorate local activity throughout the state to pass comprehensive ordinances in smaller communities. In 2009, statewide tobacco control advocates made a strategic error in not actively supporting a non-preemptive clean indoor air bill covering everything but casinos. In 2010, in an arrangement with House Speaker B. Patrick Bauer, Representative Charlie Brown (D-Gary) introduced essentially the same bill that the advocates passed on in 2009, which again failed without their support. Tobacco control advocates were divided which weakened their coalition. ITPC's funding was never secure; between FY 2001 and FY 2004, legislators cut ITPC's funding by 70%. ITPC received $10.9 million for FY 2010, just 14% of CDC's recommended level. Despite the cuts, ITYPC's programs decreased youth smoking. Between 2000 and 2008, smoking prevalence decreased among high school students by 42 percent, from 31.6 percent to 18.3 percent and among middle school students by 58 percent, from 9.8 percent to 4.1 percent. During this period adult smoking prevalence remained stable, while per capita consumption dropped, indicating that smokers were smoking fewer cigarettes. The continuing decline in youth smoking while adult prevalence stagnated probably reflected the ITPC Executive Board's decision to give priority to reducing youth smoking in response to cuts in total funding available. State policy makers were correct to establish ITPC as an independent agency and to fund it at CDC-recommended levels. In 2010, tobacco control advocates were correct in defeating a proposal to dissolve the ITPC Executive Board and transfer the Agency's functions to the Indiana State Department of Health. States that have dissolved or transferred their independent tobacco control programs into state health departments have historically raided funds and been left with ineffective programs. ITPC should be maintained as an independent agency. If advocates can restore full funding and ITPC broadens its program focus to reintegrate adults it will likely yield rapid decreases in health care costs and other economic losses stemming from tobacco-related illnesses and so contribute not only to the physical health of Hoosiers, but also the fiscal health of their government and businesses.

• Tobacco control in Arizona flourished from 1997-2007, thanks to public support at the ballot box and the hard work of Arizonan tobacco control activists. • Arizona's state-run Tobacco Education and Prevention Program (TEPP), created by Proposition 200 in 1994 from 23% of a 40 cent tobacco tax increase, provided a key component in Arizona tobacco control, spending between $15 and $36 million annually. • Tobacco control advocacy between 1997 and 2007 resulted in more than tripling tobacco excise taxes from 58 cents to $2.00, enacting comprehensive local clean indoor air ordinances, defeating tobacco industry counter-initiatives, and passing Smoke-Free Arizona, Arizona's statewide comprehensive clean indoor air law. • Arizona tobacco control advocates instituted 18 local clean indoor air ordinances between 1997 and 2007. The tobacco industry has never won at the ballot box in Arizona, locally or statewide. • On November 7, 2006, Arizona became the 16th state to pass a comprehensive clean indoor air act. The law went into effect on May 1, 2007. The Arizona Department of Health Services enforces the law with revenues from a 2 cent tobacco excise tax included in the Smoke-Free Arizona initiative. Any tax funds not used to enforce clean indoor air go to Arizona's tobacco control program TEPP. • Tobacco taxes were raised to 58 cents per pack by Arizona voters in 1994. In 2002, voters raised tobacco taxes 60 cents to $1.18 per pack, with the revenue going to the Arizona Health Care Cost Containment System (AHCCCS). Tobacco taxes were raised again by voters in 2006 to $2.00 per pack with 80 cents paying for early childhood care. • Deciding how to spend Master Settlement Agreement (MSA) money was contentious and politically difficult, as illustrated by an unwillingness to compromise among the Legislature, Governor, and County Health Departments. Ultimately voters decided in November 2000 to allocate all of the MSA funds to AHCCCS to expand Arizona's medicare program to 100% the federal poverty level. No MSA money goes to tobacco control. • The Tempe smokefree ordinance, passed by initiative in May 2002, became Arizona's first 100% clean indoor air act including bars. Dr. Leland Fairbanks led the Arizona tobacco control organization Arizonans Concerned About Smoking (ACAS) to spearhead the successful effort and defended Tempe's smokefree ordinance against the ensuing legal challenges and attempted referendum by pro-tobacco groups. • Local efforts to pass other clean indoor air ordinances in Arizona often led to compromises that routinely exempted bars. Also, elected officials in Phoenix resisted adopting a smokefree ordinance despite tobacco control leaders' concerted efforts. Tempe's successful comprehensive clean indoor air act in 2002, however, paved the way with Guadalupe (2002) for Prescott (2003), Coconino County (2003), Flagstaff (2005), and Sedona (2006), to successfully pass comprehensive clean indoor air acts of their own. • In FY2002 Governor Jane Hull and the Legislature, looking for available funds during a recession period, diverted $60 million from the Health Education and Research Accounts, which fund TEPP and research on tobacco-related disease. These funds were never recovered. • To prevent further seizures of TEPP funds, in November 2002 voters passed the referendum Proposition 303 which increased the tobacco tax 60 cents (two per cent of which went to tobacco control) and re-enacted the original 1994 Proposition 200 tobacco control measure bringing TEPP under voter protection, preventing it from further legislative tampering. Voluntary health organizations now turned their attention from protecting TEPP funds to translating their electoral success into a comprehensive statewide smokefree campaign. • While TEPP expenditures exceeded the Centers for Disease Control (CDC) minimum recommended levels for state tobacco control expenditures (at the time, $27.8 million) from FY1999 through FY2001, in October 2007 the CDC increased its Best Practices estimate for Arizona to $68.1 million annually, a figure Arizona has not yet approached in its tobacco control spending. • In 2004, prompted by citizens (but not the ALA, AHA, or ACS), Arizona Legislator Linda Lopez (D-Tucson) introduced a statewide clean indoor air bill including bars into the Republican-controlled House. The bill, however, was assigned to three committees, denied a hearing, and died in the Commerce Committee. • In Arizona, the tobacco industry spent a total of $16,201 in direct campaign contributions between 1997 and 2006 on legislators, constitutional officers, and political parties. Tobacco industry lobbyists spent $25,367 on legislators during this period. Republicans received more than 5 times the tobacco companies' contributions as Democrats. • In the 2006 election cycle RJ Reynolds mounted an $8.8 million counter-initiative (Proposition 206, the Non-Smoker Protection Act) in an attempt to confuse voters and preempt local tobacco control. The campaign concentrated much of its resources attacking Proposition 201, the health group-driven Smoke-Free Arizona initiative. Despite Reynolds' superior resources and negative campaigning, 57.3% of voters rejected Reynolds' initiative, while 54.8% of voters approved Smoke-Free Arizona. • TEPP's media campaigns with Riester-Robb from 1996-2001 enjoyed commendations nationally. The TEPP-contracted ad agency sold over 2 million units of merchandise with the media campaign's tagline Tobacco: Tumor causing, teeth staining, smelly puking habit. In July 2001 the Arizona Department of Health Services (ADHS), which manages TEPP, did not renew the media contract with Riester-Robb, instead favoring the E.B. Lane agency. This rough transition from one agency to the next occurred just as the Legislature appropriated TEPP's funds, throwing TEPP into disarray, resulting in a dead year (approximately Fall 2001-Fall 2002) under the E.B. Lane contract when tobacco control media came to a virtual halt. E.B. Lane provided TEPP's lower intensity media campaigns from 2002 through 2005. From 2005 to 2007, TEPP did not coordinate media through a contracted ad agency, instead working on a more fragmented ad hoc basis. In late 2007, TEPP contracted again with the Riester firm, though with a smaller budget. • TEPP suffered from a lack of leadership since the program's inception, with a revolving-door Office Chief position, inconsistent directives from the ADHS, and overcautiousness concerning crossing the lobbying-advocacy/advocacy-education line. Between 2005 and 2007 every TEPP employee left, leaving the agency without many employees having any prior experience in tobacco control. As a result, many tobacco control advocates perceived TEPP as an ineffective program, not making best use of its resources. While TEPP leadership in 2007 painted an optimistic vision of TEPP's future, concrete programmatic action that reflects current best practices remains to be demonstrated.

Tobacco industry money has not been successful in recent years in buying support from lawmakers in Hawai'i. Since 2001, major legislation on clean indoor air, tobacco tax increases and a tobacco tax stamp measure have passed by comfortable margins. In 1994, the City Council of Honolulu passed smokefree workplaces ordinances that exempted bars and nightclubs. Mayor Jeremy Harris vetoed the bill because it covered restaurants. In 1997, Honolulu made all workplaces smokefree except restaurants and bars, which Mayor Harris signed because of the restaurant exemption. In December 2001, county government leaders of Honolulu, Kaua'i and Maui Counties announced they would be introducing legislation that would end restaurant smoking because of the state Legislature's inaction. Honolulu passed Hawai'i's first smokefree restaurant law in 2002. The State Department of Health media campaign that started June 1, 2001 focusing on the health impact of secondhand smoke on restaurant workers may have contributed to the polling data released in January, 2002 that showed strong support for a smokefree restaurant law. In the end, it was the persistence of the tobacco control advocates that carried the day. Honolulu's law set the stage for the Kaua'i and Maui ordinances that would follow shortly. During 2002 and 2003, each county in Hawai'i passed a smokefree restaurant or workplace law. By February 1, 2004, well over 80% of Hawai'i workplaces were smokefree and smoking was prohibited in virtually all restaurants. This status would set the tone for the passage of a sweeping statewide smokefree law. Polling data released in December, 2005 showed very strong public support for a statewide smokefree law. The statewide clean indoor air measure passed in 2006 with virtually no amendments from introduction to final passage, and with only three Nays in the Senate (out of 25) and three Nays in the House (out of 51). In 2007, a group of bar owners tried to undo the new statewide smokefree law in the Legislature and through a lawsuit claiming the law was unconstitutional. Tobacco control advocates prevailed in killing all of the bills that would have exempted some or all bars and restaurants with smoking rooms and the court dismissed the lawsuit. The Department of Health, however, as of July 1, 2008, had still failed to take any effective enforcement action against repeat violators of the smokefree law, to get local law enforcement agencies to act, or to issue the administrative rules required by the state law that went into effect November 16, 2006. There has been no sustained public education campaign about the public's power for enforcement. This failure made proactive implementation of the law all but impossible and created a situation that invites pro-tobacco forces to undermine the law's long-term effectiveness. Hawai'i has taken modest steps to control illegal sales of tobacco products to minors. Cigarette vending machines are restricted to venues in which minors under the age of 18 are not permitted, mobile food vendors (lunch wagons) are prohibited from selling or distributing cigarettes within 1,000 feet of any school, and the sale or distribution of single cigarettes or packs of cigarettes containing fewer than 20 cigarettes is prohibited. In 1998, the fines levied against individuals who sell or distribute tobacco products to minors were raised to $500 for the first offense and $2,000 for subsequent offenses. However, the law does not penalize the business owner for illegal sales to minors, which probably accounts for the large number of violations found in sting operations. In 1993, the tobacco industry was successful in replacing the Hawai'i ad valorem tax on cigarettes (40% of the wholesale price) with an excise tax, but this plan to reduce the size of the cigarette tax by switching to a per unit tax backfired. The per unit taxes established by state legislation between 1997 and 2007 exceeded the rates that cigarettes would have been taxed if the 40 percent ad valorem tax had remained in place. In 2006, the cigarette tax was increased by $.20 per pack per year over six years to $2.60. However, there were lost opportunities to add some of the new revenue from the increased cigarette taxes to tobacco control programs. In 2001, Hawai'i became one of the last states to require a tax stamp on cigarette packages to reduce smuggling and improve tax collections. The tax stamp was credited in a Department of Health report with reducing the number of smuggled cigarettes sold in Hawai'i and for increasing the tax revenues by $20 million annually. When the Legislature in 1999 split MSA funds into two accounts for tobacco control, one for the Department of Health and one in a Trust Fund, tobacco control advocates did achieve one goal of protecting funding from administrative diversion to programs other than tobacco control by putting the money in a nongovernmental organization. What they were not able to protect was the amount of funding that went into that Trust Fund, which was cut from 25% of MSA monies to 12.5% in 2002. Heavy lobbying by the University of Hawai'i to raid the MSA funds to build medical school facilities robbed tobacco control programs of vital resources. The 25% of the MSA funds that goes to the Department of Health is to be spent for a variety of health promotion and disease prevention programs, but the Department allocates relatively little to tobacco control. While Hawai'i has slowly improved its spending on tobacco control, it has never reached the 1999 CDC Best Practices recommendation of $10.8 to $23.4 million per year (reduced by CDC to $9.6 to $19.6 million per year in 2007. The closest it has come was 2006 when the Department of Health and the Trust Fund spent a total of $8.2 million on tobacco control. Despite these issues, there have been continuing declines in adult and youth smoking prevalence, though per capita cigarette consumption is not showing the steady decline we see nationally. When the Trust Fund was created from MSA monies, the legislation established an independent source of tobacco control funding, with its own Advisory Board, separate from the Department of Health which had its own MSA monies and its own tobacco control advisory group. Without any apparent statutory authority, the Department of Health has substantially interfered with that independence by effectively controlling how the Trust Fund spends its money on tobacco control by disapproving or requiring modifications of Trust Fund Advisory Board recommendations on funding, budgets and tobacco control programs.

While smoking prevalence in California continued its decline (reaching an historic low of 13.3% in 2006), this rate was slower than in earlier years, reflecting the fact that tobacco control efforts in California in the period 2003-2007 continued to drift, with no clear indications that California would regain its international leadership in tobacco control. Neither the Schwarzenegger Administration nor the California Legislature sought to divert the Proposition 99 funding allocations, but continued the policy of the Davis administration to emphasize aspects of the California Tobacco Control Program that are not proven to be effective, such as school-based education programs, while moving slowly with those that are effective, particularly a strong media campaign. The Administration has continued to shift increasing amounts of funds from the Proposition 99 Research Account away from the Tobacco Related Disease Research Program to the Department of Public Health Cancer Registry, leading to marked reductions in funding for important and innovative tobacco control research. The state continued to refuse to use any money from the Master Settlement Agreement for tobacco control. In 2003 and again in 2006, the Legislature sold the state's share of the Master Settlement Agreement payments for immediate revenues ("securitization") by the tobacco companies through 2030. Counties and municipalities, which receive 50% of California's Master Settlement Agreement funds, have increasingly securitized their share of these monies. Only 30% of the 58 counties allocated any MSA funds for tobacco control. Under Bill Lockyer, the Attorney General's office has vigorously enforced tobacco industry compliance with the Master Settlement Agreement. Campaigns to end tobacco industry violations of the Master Settlement Agreement (primarily by R.J. Reynolds Tobacco Company) with regard to youth marketing tactics and youth access to tobacco products were successful. Former Attorney General Lockyer was active in the campaign of a multi-state group of Attorneys General to get smoking out a movies targeted at children; but Attorney General Jerry Brown has not participated in this effort since taking office in 2007. The tobacco industry intensified its efforts to influence California politics with its campaign contributions to legislators, legislative candidates, political parties and constitutional officers. The industry steadily increased monies spent on state level political activities in the period 2003-2007, from $4,086,553 in 2003-2004 ($1,083,448 to candidates) to $4,359,205 in 2005-2006 ($1,895,584 to candidates). Campaign contributions from the tobacco industry continue to heavily favor Republicans. In 2005-2006, $1,797,484 was contributed to the Republican candidates and officeholders, to the California Republican Party and other Republican controlled committees compared to $98,100 to the Democrats. In the 2006 general election for constitutional offices, neither candidate for Governor, State Treasurer, Insurance Commissioner, or Superintendent of Public Instruction took any tobacco for industry campaign contributions. The Republican candidates for Lt. Governor (McClintock, $8,364), Secretary of State (McPherson, $15,200), State Controller (Strickland, $7,100), Attorney General (Poochigian, $8,100) and two Board of Equalization seats (Leonard, $7,600 and Steel, $1,500) all took tobacco industry money. Among Democratic candidates for onstitutional offices, only Jerry Brown ($5,600) for Attorney General and Betty Yee ($2,000) for Board of Equalization took tobacco industry money. In the Legislative races in 2006, Dutton (R) in the Senate ($9,100) and Garcia (R) in the Assembly (($14,800) were the top recipients of tobacco company money. Of the 56 legislators who took no tobacco industry campaign contributions in 2005-2006, 52 were Democrats. By far the most significant tobacco-related event in the 2003-2007 period was the defeat of the effort to increase cigarette taxes through Proposition 86 in 2006. The proposition would have increased the cigarette tax by $2.60 a pack. What began as a well-planned initiative petition campaign by health groups for a $1.50 tobacco tax increase became an excessive, badly structured joint initiative with the California Association of Hospitals and Health Services. The fact that most of the money from the proposed tax was directed towards funding hospitals, the size of the tax, and the fact that only 10.7% of the money would go to genuine tobacco control provided legitimate points of criticism that the tobacco industry could use to attack the proposal in its $66 million campaign against Proposition 86. Voters rejected Proposition 86, with 51.3% voting "no." In 2003, the Legislature passed a tobacco sales licensing law (AB 71) that requires every entity in the commercial chain from manufacturers to retailers to obtain state licenses to sell tobacco. While it lacks any penalty for selling tobacco to minors, it did not preempt local jurisdictions from enacting stronger licensing laws. Forty-two California communities have strong local retailer licensing ordinances that include fees high enough to sufficiently fund administration and enforcement, and fines and penalties including suspension and revocation of license to deter violations. In 2005, the Legislature passed AB 178, which mandated that all cigarettes sold in California on and after January 1, 2007 be so-called "fire safe" cigarettes or reduced ignition products (RIP). Manufacturers are required to certify that the cigarettes are self-extinguishing at least 75% of the time. Governor Schwarzenegger vetoed two important tobacco control bills in 2006, a ban on internet sales of cigarettes (SB 1208) and a mandate for health insurance coverage of smoking cessation services (SB 576). Six tobacco control measures were passed in the 2007 Session. SB 7 prohibits smoking in any motor vehicle with any minors present, and AB 1467 would have eliminated the remaining exceptions in the original 1994 smoke-free workplaces law (AB 13). The other four bills strengthen youth access laws. AB 1617 would have prohibited the shipping or transporting of cigarettes to individuals in California (another attempt to control internet sales of cigarettes), and SB 624 broadens enforcement of the STAKE (Stop Tobacco Access to Kids) Act from just the Department of Public Health to all law enforcement agencies and increases penalties for violations. The Governor vetoed two of the 2007 tobacco control bills, another ban on internet cigarette sales (AB 1617) and a bill closing loopholes in the original California smoke-free workplaces law (AB 1467). Local tobacco control policymaking in California since 2003 has seen innovation. Momentum for nonsmoking multi-unit housing has been building, with surveys showing that 80% of nonsmoking tenants in California wish to live in smoke-free buildings. In 2004, the Thousand Oaks City Council unanimously became the first city in the nation to pass a mandate on by requiring that one-third of new multi-unit affordable housing units funded by the city would be nonsmoking. Another important first in California local tobacco control policymaking came when the City of Calabasas in 2006 mandated an all-inclusive smoke-free policy in the entire city except in small (no more than 40 square feet) designated smoking areas in shopping malls, so long as no smoke is permitted to enter adjacent areas in which smoking is prohibited, and outdoor areas in which no nonsmoker is present or likely to be present. Then in October 2007, Belmont became the first city in California to ban smoking in the residential units of all multi-unit housing. Adding to this expansion, smoke-free ordinances for public beaches have also been passed by local communities in many locales in California. The history of tobacco control in California has been local activism and voter initiatives, with statewide legislation following. Local activism is still the key source of innovation in California.