A Few More Laps to Go: Tobacco Industry Political Influence, Public Health Advocacy and Tobacco Control Policy Making in Indiana
AbstractTobacco 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 40Â¢/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 44Â¢/pack cigarette tax increase (to 99.5Â¢). 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 45.5Â¢ 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 â€œdeal breakerâ€ 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 ITPCâ€Ÿs 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.
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