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EXECUTIVE SUMMARY • Montana is the fourth largest state in the U.S. (147,138 sq. miles), with a population of 902,195. Smoking use is 21.2% among adults and 23% among high school students. In 1999, the health cost of smoking related illness in Montana was $216 million and the total number of smoking related deaths was 1,434. • When the Montana Clean Indoor Act of 1979 was proposed, the tobacco industry coordinated state ally groups to weaken the mandatory smoke-free section law into a signage law that only required the posting of signs to indicate optional non-smoking areas. • Though Montana did not have an organized tobacco control advocacy movement in the 1980s, the tobacco industry formed alliances with state organizations to oppose possible tobacco control legislation. • In 1990, the first organized tobacco control effort was made with a state cigarette tax increase initiative (from 18 cents to 43 cents), which was defeated by a sophisticated tobacco industry campaign (costing over $1 million) using local ally groups and front groups whom claimed to be concerned citizens and business owners. • The tobacco industry spends a significant amount of money in Montana on campaign contributions and lobbying expenditures to influence the behavior of political candidates. $98,043 was spent by the tobacco industry and its allies on political campaigns from 1999-2002. • A strong relationship between legislative behavior, tobacco industry contributions, and political affiliations exists in Montana. Increased tobacco industry contributions are associated with an increase in pro-tobacco industry behavior, and Republicans legislators are more favorable to pro-tobacco industry positions than Democrats. • When proposals to divert the Master Settlement Agreement (MSA) funds to non-health related programs were made in 1999, tobacco control advocates directly lobbied the legislature to allocate money to health programs. As a result, much of the MSA money went into the state's general fund for other government programs. • After getting a minimal amount of the MSA money allocated for health programs in 1999, health advocates used a statewide ballot initiative (CA-35) to get 40% of the MSA money into a health care trust fund. The statewide ballot initiative would become a powerful strategy for tobacco control advocates. • Montana's Tobacco Use Prevention Program (MTUPP) was launched in March 2000 as a pilot program. However, Governor Judy Martz (2001-2004), who had financial and political ties to the tobacco industry, severely cut the state tobacco use prevention program in 2003 to its lowest funding level, and eliminated the media activities of MTUPP. • In November 2002, tobacco control advocates again passed a successful statewide initiative (I-146) to get 32% of the MSA money for tobacco use prevention. However, state legislators in 2003 diverted 65% of the tobacco prevention program money to other health programs until 2006. • Legislators in 2003 passed a cigarette tax increase from 18 cents to 70 cents to raise revenue during the state's budget deficit. Health advocates followed the 2003 cigarette tax increase with another successful ballot initiative (I-146) in November 2004, increasing the cigarette tax to $1.70 per pack. • Communities in Montana started passing smoke-free ordinances in 1999, which would be opposed by the tobacco industry through ally and front groups that spread the myth that smoke-free laws would hurt the hospitality industry. These claims became the main argument against smoke-free ordinances. • The tobacco industry lobbied through the Montana Tavern Association (MTA) and the gambling industry to support state preemption in House Bill 758, which quickly achieved passage despite complaints of legislative procedural violations. However, health advocates successfully defeated HB 758 with a lawsuit in December 2004 when the Montana Supreme Court held that it was invalid. • In January 2005, with the support of Governor Brian Schweitzer, tobacco control advocates successfully lobbied to increase the MSA allocation for tobacco use prevention to $6.8 million per year in the 2006-2007 biennium. • Health groups negotiated with the MTA to create a statewide clean-indoor-air act. Conflict between the health groups arose over the resulting weakened compromise bill. Some health groups nevertheless moved forward with the MTA, and The Montana Clean Indoor Air Act passed in April 2005. • In September 2005, after tobacco control advocates discovered that MTA lobbyist Mark Staples had influenced the development of the new law's educational materials, new management for the tobacco use prevention program was brought in, and tobacco control advocates believed that undue influence would cease. • DPHHS failed to finalize implementation rules or launch an educational campaign before the law went into effect in October 2005. Unless the DPHHS promptly addressed these problems, they risked having a law that did not receive strong acceptance, and which would be vulnerable to further tobacco industry efforts to weaken the law.

Objective: To document how the tobacco industry has used Wall Street analysts to further its public policy objectives. Methods: Searching tobacco documents available on the internet, newspaper articles, and transcripts of public hearings. Results: The tobacco industry used nominally independent Wall Street analysts as third parties to support the tobacco industry's legislative agenda at both national and state levels in the USA. The tobacco industry has, for example, edited the testimony of at least one analyst before he testified to the US Senate Judiciary Committee, while representing himself as independent of the industry. Conclusion: The tobacco industry has used undisclosed collaboration with Wall Street analysts, as they have used undisclosed relationships with research scientists and academics, to advance the interests of the tobacco industry in public policy.

Objective: To describe how the transnational tobacco industry has collaborated with local Asian tobacco monopolies and companies to promote a scientific and regulatory agenda. Methods: Analysis of previously secret tobacco industry documents. Results: Transnational tobacco companies began aggressively entering the Asia market in the 1980s, and the current tobacco industry in Asia is a mix of transnational and local monopolies or private companies. Tobacco industry documents demonstrate that, in 1996, Philip Morris led an organisation of scientific representatives from different tobacco companies called the Asian Regional Tobacco Industry Science Team (ARTIST), whose membership grew to include monopolies from Korea, China, Thailand, and Taiwan and a company from Indonesia. ARTIST was initially a vehicle for PM's strategies against anticipated calls for global smoke-free areas from a World Health Organization secondhand smoke study. ARTIST evolved through 2001 into a forum to present scientific and regulatory issues faced primarily by Philip Morris and other transnational tobacco companies. Philip Morris' goal for the organisation became to reach the external scientific and public health community and relators in Asia. Conclusion: The Asian tobacco industry has changed from an environment of invasion by transnational tobacco companies to an environment of participation with Philip Morris' initiated activities. With this, participation, tobacco control efforts in Asia face new challenges as Philip Morris promotes and integrates its scientific and regulatory agenda into the local Asian tobacco industry. As the local Asian tobacco monopolies and companies can have direct links with their governments, future implementation tobacco control may be at odds with national priorities.

Background: Minnesota was the first state in the USA to implement a large state funded tobacco control programme ( in 1985). Despite evidence of effectiveness, it was dismantled in 1993. Objective: To describe and analyse how and why these events transpired and identify lessons for tobacco control advocates facing similar challenges in the 21st century. Design: Case study based on previously secret tobacco industry documents, news reports, research reports, official documents, and interviews with health advocates and state government officials. Results: Unable to defeat funding for this campaign in 1985, the tobacco industry organised groups which eliminated it later. Despite the programme's documented effectiveness, it was dismantled based on claims of fiscal crisis. These claims were not true; the real debate was what to do with the state's surplus. Health advocates failed to challenge the claim of fiscal crisis or mobilise public support for the programme. Conclusions: Simply quoting evidence that a tobacco control programme is effective does not ensure its continuing survival. Claims of fiscal crisis are an effective cover for tobacco industry efforts to dismantle successful programmes, particularly if health advocates accept these claims and fail to mobilise political pressure to defend the programme.

The tobacco industry is a potent force in Albany. Since 1983 (not including 1988-89, were data are not available) tobacco interests spent $1.3 million on campaign contributions to candidates and political party committees. Of this, $277,905 went to legislative candidates, $38,650 went to candidates for constitutional office, and the remaining $1 million went to party committees. The members of the 1997-98 legislature who collected the most money from campaign contributions were Assemblymember Jeffrey Klein(D-Bronx)($16,275), Assembly Speaker Sheldon Silver (D-Manhattan)($10,425), Assemblymember Michael Bragman (D-Onondaga)($8,420), Senator Ronald Stafford (R-Plattsburgh)($7,500), and Senate Majority Leader Joseph Bruno (R-Brunswick)($7,300). The tobacco industry spent $5.9 million on lobbying expenditures between 1992 and 1998. Of the $998,884 contributed to party committees between 1983 and 1998 (not including 1988-89), $815,840 (81.7%) was donated after 1994, when contributors realized that contributions to party committees were unlimited. As in other states, the tobacco industry donates more to Republicans than Democrats; Republican party committees received $752,709 (75%) of the money between 1983-98, while Democrats received $191,175 (19%). The information we have on tobacco industry political activity is incomplete and underestimates the magnitude of tobacco industry activity. Between 1998 and 1999, the tobacco industry was found to have under-reported its lobbying expenses on several occasions. In 1998, the Tobacco Institute admitted to under-reporting by $443,572 and in 1999, Philip Morris admitted to under-reporting lobbying expenses 15 times over the period 1993-96. These developments indicated that the lobbying law was ineffective at providing accurate information for public disclosure, and prompted a revision of the law in 1999. However, the revision is insufficient to prevent this kind of influence to be accumulated by an industry such as the tobacco industry. These contributions are having an effect on policy making. On the average, for each $1000 contributed to an individual legislator, that legislator scored 1.82 points more pro-tobacco on a 0 to 10 scale. At the same time, legislators who support the tobacco industry are rewarded; for each 1 point more pro-tobacco, contributions increase by an average of $380. Republican legislators were more pro-tobacco than Democrats by an average of 1.39 points. As in most states, in New York State, progress in tobacco control begins at the local level. New legislation is generally passed first on Long Island, which inspires New York City to do the same. Legislation passed in New York City sparks progress in the upstate area, and until the Pataki Administration, at the state level. The importance of localities passing restrictions to initiate the momentum to pass state legislation is why preemptive state legislation is a major threat to tobacco control in New York State. The documents released through state litigation of the tobacco industry have played a critical role in the passage of tobacco control legislation in the face of an unsympathetic legislature and Governor. Advocates in other states should recognize that researching the documents can help them pressure political leaders and recognize industry front groups. The Long Island counties of Suffolk and Nassau lead the tobacco control movement in the downstate area, whereas Erie County sets the standard upstate. The ASSIST program has been successful in setting up local coalitions and galvanizing against industry tactics. The industry organizes and finances "grassroots" coalitions, and "smokers' rights" groups such as the National Smokers Alliance, mobilizes its Tobacco Action Network, forms alliances with other organizations affected by anti-tobacco bills and finances groups such as the United Restaurant, Hotel, and Tavern Association to oppose clean indoor air legislation. It promotes "studies" claiming that tobacco control legislation will hurt the hospitality business, even though objective studies have consistently shown no effect or a positive effect on the hospitality industry. At the state level the industry has sought to preempt local tobacco control activity; at the local level, the industry tries to pass weak laws promoting "accommodation" to prevent the passage of effective tobacco control policies. New York tobacco control advocates have vigorously – and generally successfully – opposed these efforts. Since 1986, New York City has distinguished itself as a national leader in tobacco control legislation. While its clean indoor air laws have not been the strongest in the country, they are remarkable in light of the city's size and the fact that Philip Morris' corporate headquarters are located in New York City. The city was also one of the first localities to sue the tobacco industry. Both Nassau County and Niagara County Boards of Health enacted regulations (in 1994 and 1998, respectively) to eliminate smoking in restaurants. However, both were overturned in lawsuits sponsored by the tobacco industry. Both rulings determined that the Boards of Health were in violation of the state constitution because they considered economics in their decisions. These decisions have discouraged counties from using Boards of Health to pass clean indoor air regulations. When Republican George Pataki succeeded Democrat Mario Cuomo as governor in 1994, state tobacco control legislation abruptly ceased. Pataki ignored the Health Department's tobacco advisory panel, the Commission for a Healthy New York, and only formulated tobacco control programs when he feared criticism from the media. Between 1990 and 1998 Pataki accepted $8050 from the tobacco industry. In November 1998, forty-six states agreed to a $206 billion dollar settlement with the tobacco industry. The agreement settled the states' claims for smoking-related Medicaid costs. New York State received $25 billion to be paid over 25 years as a result of the settlement agreement. In December 1999, health advocates, working the other interests, were able to increase the tobacco tax by 55 cents and dedicate part of the tobacco settlement funds to fund health care in New York State. New York's cigarette tax of $1.11 per pack is the highest in the nation. Of the approximately $1.5 billion generated annually by the settlement and additional tobacco tax, only $37 million annually is dedicated to the state tobacco control program. During the 1999 legislative session, the New York Medical Society supported the Civil Justice Reform Act which would provide the tobacco industry protection against product liability litigation. The tobacco industry has probably used every strategy they have developed in fighting tobacco control policies in New York State. Despite these daunting challenges, advocates have achieved many notable successes and recognized and avoided counterproductive compromises. They have done so by exposing tobacco industry front groups and affiliations and holding politicians and organizations accountable for their actions.

The tobacco industry's trend of giving generously to California legislators continued in the 1997-1998 election cycle. Between January 1, 1997, and December 31, 1998, the tobacco industry contributed $615,145 to state legislators and legislative candidates. Since 1991-1992, campaign contributions to legislative candidates and parties by the tobacco industry favored the party in power. However, in the 1997-1998 election cycle, reflecting increasingly partisan contributions by the tobacco industry, Republicans received 81 percent of tobacco industry campaign contributions even though the Democrats controlled both houses of the Legislature. The tobacco industry contributed a total of $848,635 to state legislators and legislative candidates, state constitutional officers, political parties and party controlled committees for the 1997-1998 election cycle. This total is less than the three previous election cycles in the 1990s, and is in part most likely due to the passage of Proposition 208, which placed spending limits on individuals, corporations, and PACs for 1997. On a per member basis, California legislators received more money than the members of Congress, $5,117 per member compared to $4,373 per member. For the 1997-1998 election cycle, Senator Minority Leader Ross Johnson (R- Irvine) the top recipient in California Senate ($111,500) received more money than Senator Lauch Faircloth (R-North Carolina), the top recipient in the United States Senate ($87,999). In addition, Assembly Minority Leader Bill Leonard (R- Rancho Cucamonga) received more tobacco industry campaign contributions ($82,250) than Representative Edward Whitfield (R-Kentucky), who was the top recipient of tobacco industry campaign contributions in the House of Representatives ($34,000). On January 1, 1998, California enacted the country's first state-wide smoke free bar law as an extension of the state smoke free workplace law. The tobacco industry attempted nine times to either delay the enactment of the law, or have the law repealed. The tobacco industry, working primarily through the National Smokers' Alliance, sought to undermine the law by depicting the issue as unfair to small businesses, and problematic in terms of enforcement. Even so, health advocates prevented the law from being repealed. In November 1998, California elected a Democrat to the governorship for the first time since 1982. Governor Gray Davis had begun to remedy the actions of the Wilson Administration in debilitating the state funded California Tobacco Control Program. Though the funding levels for the Proposition 99 programs were at the voted mandated levels, two suits filed against the state for misappropriation of Proposition 99 funds in 1991 and 1995 remain pending. Governor Davis vetoed $32 million the Legislature had appropriated for anti-smoking education programs. On June 12, 1997, the State of California became the 37th state to file suit against the tobacco industry. The state sought damages for violations of California Business and Professions Code and recovery of public health care expenditures for tobacco related disease. The state's claims for medicaid reimbursement were dismissed. The remaining claims were consolidated with the City of Los Angeles, the City and County of San Francisco et al., and two private citizen suits against the tobacco industry. These suits were settled by the Multi-State Master Settlement Agreement in November 1998. California will receive approximately $25 billion of the $206 billion settlement over the next 25 years from the industry. In September 1999, the Legislature passed a bill to have these funds dedicated for health services in the state. Other civil action suits against the tobacco industry are scheduled to be heard beginning in January 2000. These suits are mainly union trust fund suits against the industry, as well as local government failure to warn suits under Proposition 65, the state's toxic enforcement act. In November 1998, the California voters passed Proposition 10, which resulted in the creation of local agencies throughout the state that will promote child development programs and educational campaigns. The proposition won by a vote of 50.5% to 49.5%, despite the $29,397,147 the tobacco industry spent to defeat it. The program is funded by an additional $.50 tax on cigarettes, and a commensurate tax increase on other tobacco products. The tax increase, along with a price hike from the industry, sales of cigarettes in California decreased 28.6 percent for the first 6 months of 1999.

Arizona was the first state in the US to pass a state clean indoor air law (in 1973) and has a long tradition of grass roots nonsmokers' rights activity. 38 localities in Arizona have passed tobacco control ordinances dealing with clean indoor air (Flagstaff, Mesa, Tucson, among others) and youth access to tobacco products (Tucson, Scottsdale, Somerton, among others). In 1994, Arizona voters passed Proposition 200, which increased the tobacco tax by 40 cents per pack of cigarettes and allocated 23% of the revenues for tobacco control activities, yielding more than $27 million a year for anti-tobacco efforts. It was the third state to do so. The tobacco industry, working through Governor Symington and allies in the Legislature, has successfully limited the scope of the tobacco control program to youth and pregnant women. This limitation will probably limit program effectiveness. Although the coalition of health groups that enacted Proposition 200 has prevented funds from being diverted to non-tobacco uses, it failed to force the Arizona Department of Health Services (ADHS) to develop a comprehensive tobacco control program. Arizona tobacco control advocates have made great progress at the local level, not only in passing local tobacco control ordinances, but also in defeating tobacco industry efforts to overturn these ordinances. The campaign finance and lobbying disclosure laws in Arizona are so weak that it is not possible to quantify the exact amount of money the tobacco industry is spending to influence policy making in that state, it is clear that the tobacco industry has intensified its lobbying efforts in the Legislature. The tobacco industry has focused national resources on Arizona through organizations such as the National Smokers' Alliance in unsuccessful attempts to stop or overturn local tobacco control ordinances. Despite tobacco industry claims to the contrary, local tobacco control ordinances mandating smokefree restaurants and bars have not affected revenues in those businesses.

INTRODUCTION: Nigeria ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005. Tobacco control advocates in Nigeria achieved some success in countering tobacco industry interference to implement the FCTC. METHODS: We triangulated interviews with key informants from local and international organisations who worked in Nigeria with documentation of the legislative process and Nigerian newspaper articles. Data were analysed and interpreted using the Policy Dystopia Model and WHO categories of tobacco industry interference that had been developed mostly based on experience in high-income countries. RESULTS: As in high-income countries, the tobacco industry continued to oppose tobacco control policies after Nigeria ratified the FCTC, including weakening Nigeria's 2015 National Tobacco Control Act. Both tobacco control advocates and industry used discursive (argument-based) and instrumental (activity-based) strategies. The industry argued self-regulation and the economic importance of tobacco. They exploited legislative procedures, used front groups and third parties to push for pro-industry changes. Advocates, with help from international organisations, mobilised prominent Nigerians and the public. Advocates preempted and countered the industry through traditional and social media, monitoring and exposing tobacco industry activities, and by actively engaging lawmakers and citizens during the legislative process. CONCLUSION: The Policy Dystopia Model and WHO categories of industry interference provide a helpful framework for understanding tobacco control debates in low/middle-income countries (LMICs) as in high-income countries. One difference in LMIC is the important role of international tobacco control advocates in supporting national tobacco control advocates. This partnership is important in pushing for FCTC-compliant legislation and countering industry activities in LMIC.

In the 1990s several American states passed term limits on legislators with the stated intention of reducing the influence of wealthy industries on career legislators. Although term limits in the United States do not have a direct relationship to public health, the tobacco industry anticipated that term limits could have indirect effects by either limiting or expanding industry influence. We detail the strategy of the tobacco industry in the wake of term limits using internal tobacco company documents and a database of campaign contributions made to legislators in term limited states between 1988 and 2002. Despite some expectations that term limits would limit tobacco industry access to state legislators, term limits appear to have had the opposite effect.

Tobacco control advocates began to use ballot initiatives to enact tobacco control policies in the late 1970s. In response, the tobacco industry worked for over two decades to change laws governing initiative and referendum processes to prevent passage of tobacco control measures. In 1981, the tobacco industry's political lobbying arm, the Tobacco Institute, created a front group that presented itself as a neutral initiative research clearinghouse to affect changes in state initiative and referenda laws. In 1990, the Tobacco Institute began creating an in-house team, and worked with third party groups to try to change state initiative laws. While the industry ultimately abandoned both efforts when neither achieved immediate success, over time, the industry's goals have penetrated legitimate discourse on the I&R process in the United States and many specific ideas it advocated have garnered mainstream support. Direct democracy advocates, as well as public health advocates and policymakers, need to understand the tobacco industry's goals (which other industries adopted) of limiting the direct democracy process in order to ensure that any changes do not inadvertently increase the power of the special interests that direct democracy was developed to counterbalance.

Objetivo. Analizar cómo la industria tabacalera influyó en la formulación de las políticas de control del tabaco en Costa Rica. Materiales y métodos. Revision de documentos de la industria tabacalera, de la legislación costarricense de control del tabaco y de periódicos y entrevistas con informates clave. Resultados. Durante los años ochenta, el Ministerio de Salud aprobó varios decretos para restringir el consumo de tabaco, lo que causó que British American Tobacco y Philip Morris International fortalecieran su presencia politica, cuyo resultado fue la promulgación de una ley débil en 1995 todavia vigente. Desde 1995 la industria tabacalera ha ultizado a Costa Rica como piloto para los programas latinoamericanos y ha dominado la formulación de politicas influenciando al Ministerio de Salud, incluyendo negociaciones privadas con la industria tabacalera en violación de las directrices del Articulo 5.3 del Convenio Marco para el Control de Tabaco (CMCT) de la Organización Mundial de la Salud. Conclusión. La experiencia de Costa Rica demustra la gran importancia que tiene la implementación del Articulo 5.3 del CMCT para proteger las políticas de la salud pública de la interferencia de la industria tabacalera. Objective. To analyze how the tobacco industry influenced tobacco control policymaking in Costa Rica. Materials and Methods. Review of tobacco industry documents, tobacco control legislation, newspaper articles, and interviewing of key informants. Results. During the mid-to-late 1980s, Health Ministry issued several advanced (for their time) smoking restriction decrees causing British American Tobacco (BAT) and Philip Morris International (PMI) to strengthen their political presence there, resulting in passage of a weak 1995 law, which as of August 2011, remained in effect. Since 1995 the industry has used Costa Rica as a pilot site for Latin American programs and has dominated policymaking by influencing the Health Ministry, including direct private negotiations with the tobacco industry which violate Article 5.3's implementing guidelines of the World Health Organization Frameowrk Convention on Tobacco Control (WHO FCTC).Conclusions. The Costa Rica experience demonstrates the importance of vigirous implmentation of FCTC Article 5.3 which insulates public health policymaking from industry interference.

Objective. To analyze how the tobacco industry influenced tobacco control policymaking in Costa Rica. Materials and Methods. Review of tobacco industry documents, tobacco control legislation, newspaper articles, and interviewing of key informants. Results. During the mid-to-late 1980s, Health Ministry issued several advanced (for their time) smoking restriction decrees causing British American Tobacco (BAT) and Philip Morris International (PMI) to strengthen their political presence there, resulting in passage of a weak 1995 law, which, as of August 2011, remained in effect. Since 1995 the industry has used Costa Rica as a pilot site for Latin American programs and has dominated policymaking by influencing the Health Ministry, including direct private negotiations with the tobacco industry which violate Article 5.3's implementing guidelines of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). Conclusions. The Costa Rica experience demonstrates the importance of vigorous implementation of FCTC Article 5.3 which insulates public health policymaking from industry interference. ; Objetivo. Analizar cómo la industria tabacalera influyó en la formulación de las políticas de control del tabaco en Costa Rica. Materiales y métodos. Revisión de documentos de la industria tabacalera, de la legislación costarricense de control del tabaco y de periódicos y entrevistas con informantes clave. Resultados. Durante los años ochenta, el Ministerio de Salud aprobó varios decretos para restringir el consumo de tabaco, lo que causó que British American Tobacco y Philip Morris International fortalecieran su presencia política, cuyo resultado fue la promulgación de una ley débil en 1995 todavía vigente. Desde 1995 la industria tabacalera ha utilizado a Costa Rica como piloto para los programas latinoamericanos y ha dominado la formulación de políticas influenciando al Ministerio de Salud, incluyendo negociaciones privadas con la industria tabacalera en violación de las directrices del Artículo 5.3 del ...

North Carolina, the top U.S. tobacco producing state and home to RJ Reynolds and Lorillard tobacco companies, has a historic, economic, and social legacy tied to tobacco, creating particular resistance to tobacco control efforts. The tobacco manufacturers historically relied on tobacco grower organizations, which had more influence on political and public opinion than tobacco manufacturers, to act on their behalf to shape policy in North Carolina. To influence policymakers, between 1996 and 2008, the tobacco industry contributed nearly $1.3 million to North Carolina political parties and individual candidates for state-level office, focusing contributions around pivotal elections, with candidates for governor and key legislative leadership being the largest recipients. There is a statistically significant relationship between the amount of tobacco industry campaign contributions a legislator received and his or her support for pro-tobacco policies. In 1969, North Carolina became the last state in the nation to enact an excise tax on tobacco, a modest 2 cents. Due to the passage of the 1969 excise tax, the Tobacco Institute increased its lobbying presence in 1972. As early as the late 1960s, the tobacco manufacturers anticipated that if North Carolina increased their tobacco excise tax other states would follow. They devoted considerable resources to defeating tobacco excise tax increase proposals, and as a result there were only small incremental increases in the tax during the 1990's and 2000's, still placing North Carolina 45th for tobacco excise taxes in 2011 (at $0.45 per pack). North Carolina was one of a few states, and the only tobacco growing state, that participated in both the National Cancer Institute COMMIT (1986-1995) and ASSIST (1991-1998) studies. ASSIST allowed the state to create a lasting tobacco control infrastructure by setting up local tobacco control coalitions in the majority of key media markets throughout the state. The resulting state tobacco control infrastructure remained active even after the studies ended and was still active in 2011. Beginning in the late 1980s, local jurisdictions began adopting policies to restrict smoking in publicly owned government buildings. By 1993, 15 counties and 22 cities had some kind of policy to restrict public smoking including in restaurants throughout North Carolina. In response to health advocates' growing success in passing local clean indoor air ordinances and board of health regulations, in 1993 the tobacco industry secured passage of a weak, preemptive state "dirty air" law which only allowed local jurisdictions to pass smoking restrictions for 90 days. (Eighty-nine more communities passed ordinances during his 90 day window.) The tobacco industry sued and invalidated the local county board of health regulations, prompting the tobacco control advocates to implement a strategy to "chip away" at resistance to tobacco control policies, beginning with youth access laws. In 1997 advocates began working to implement voluntary tobacco free school campus policies, an important step in changing social norms around tobacco use, with support in 2000 from Gov. James Hunt (D). By 2007, 75 percent of the school districts were voluntarily tobacco free when the state legislature enacted legislation requiring all school districts to be 100% tobacco free by August 1, 2008. North Carolina attorney general Michael Easley (D) did not sue the tobacco industry in the mid-1990s, but was one of the negotiators of the Master Settlement Agreement in 1998. He filed a pro-forma suit in 1998 so North Carolina could benefit from the cash payouts in the MSA, amounting to $4.6 billion over the first 25 years of the MSA for North Carolina. In 1999, the Legislature allocated 75% of North Carolina's MSA money to diversify the state's tobacco dependent economy and 25% to health related programs, of which a small portion was spent on youth-oriented tobacco-related projects beginning in 2002. In 2000, the Department of Health and Human Services Tobacco Prevention and Control Branch, along with tobacco control advocates, created the Vision 2010 strategic plan for the tobacco control part of the MSA money, including youth prevention programs and tobacco free school campuses, adding resources and funding for programming. The federal tobacco quota buyout in 2004 exacerbated the rift between the tobacco growers and manufacturers, resulting in reduced tobacco farmers' opposition to tobacco control policies. Tobacco control advocates successfully used this lack of opposition to begin a push for stronger tobacco control laws. Despite tobacco manufacturers' opposition, between 2003 and 2009 state tobacco control advocates built strong coalitions including nontraditional partners such as the hospitality industry, cultivated relationships with key legislators, and generated grassroots support resulting in 100% tobacco free schools, prisons and hospitals, and 100% smokefree government buildings, long-term care facilities, restaurants, and bars, effectively "chipping away" at preemption. In 2009 North Carolina became the first tobacco growing state to implement a statewide 100% smokefree restaurant and bar law. The 2009 law also partially repealed preemption, giving local governments the authority to enact more stringent restrictions on outdoor public property. Private workplaces remained preempted. Between 2003 and 2009, it was not uncommon for a state legislator to receive campaign contributions from the tobacco industry and then vote in favor for tobacco control policies, suggesting declining tobacco industry influence among policymakers. Tobacco control gains in North Carolina were incremental and required continue persistence and coordinated collaboration among tobacco control advocates, which allowed meaningful policies to be implemented. Tobacco control advocates should continue to work to strengthen state tobacco control laws including 100% smokefree workplaces, repealing preemption of all smokefree laws, and securing higher excise taxes. Advocates should continue to leverage the existing divergence between the interests of tobacco manufacturers and growers by promoting alternative crop production and uses for tobacco, and coalition building to further strengthen the states tobacco control policies. -

BackgroundComprehensive smoke-free legislation covering all enclosed public places and workplaces was implemented in England on 1 July 2007. This study examines the impact of this legislation on smoking prevalence, number of cigarettes smoked and location of smoking, controlling for secular trends through the end of 2008.Method and findingsRepeat cross sectional survey using nationally representative data from the Health Survey for England (HSE). In total there are 54,333 respondents from 2003-2008. Logit and linear regression models were used to examine the effect of the legislation on smoking prevalence and the number of cigarettes smoked daily among continuing smokers which took the underlying trend into account. Our finding suggest that smoking prevalence (current smoker) decreased from 25% in 2003 to 21% in 2008 (AOR = 0.96 per year, 95% CI = 0.95-0.98, P<0.01) and the mean number of cigarettes consumed daily by smokers decreased from 14.1 in 2003 to 13.1 in 2008 (coefficient for time trend = -0.28±0.06 SE cig/day per year, P<0.01). After adjusting for these trends the introduction of smoke-free legislation was not associated with additional reductions in smoking prevalence (AOR = 1.02, 95% CI = 0.94-1.11, P = 0.596) or daily cigarette use in smokers (0.42±0.28 SE; P = 0.142). The percentage of respondents reporting smoking 'at work' and 'inside pubs or bars' decreased significantly from 14% to 2% (p<0.001) and from 34% to 2% (p<0.001), respectively, after the legislation. The percentage reporting smoking 'inside restaurants, cafes, or canteens' decreased significantly from 9% to 1% (p<0.001) and 'inside their home' decreased significantly from 65% to 55% (p<0.01).ConclusionThere is widespread compliance with the smoke-free legislation in England, which has led to large drops in indoor smoking in all venues, including at home. Declines in smoking prevalence and consumption continued along existing trends; they did not accelerate during the 18 months immediately following implementation.