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					P O P U L A R          G O V E R N M E N T




Putting Research and Best Practices into Action
to Prevent and Control Tobacco Use in North Carolina
Sally Herndon Malek and Jana Johnson

       obacco use is the leading pre-       drug abuse, car crashes, homicide, sui-     health of North Carolinians and reduc-

T      ventable cause of death in North
       Carolina and the nation. It ac-
counts for more deaths than alcohol,
                                            cide, and HIV/AIDS combined. As a
                                            matter of public health, tobacco use and
                                            its associated diseases have huge costs,
                                                                                        ing their health care costs.
                                                                                           Most people who become users be-
                                                                                        gin using tobacco in early adolescence,
                                            and policy changes offer perhaps the        and almost all people who become
                                            greatest opportunities to improve the       users begin before age twenty-four.
Malek is head of the Tobacco Prevention
                                            health and well-being of thousands of       The average age of initiation is between
and Control Branch, North Carolina
Division of Public Health. Johnson is a     North Carolinians. This article describes   twelve and fourteen. Of those who
pulmonologist and medical director of the   recent gains in prevention and control      smoke and do not quit, more than
Tobacco Prevention and Control Branch.      of tobacco use in North Carolina. Also,     half will die prematurely from cigarette-
Contact them at sally.malek@ncmail.net      it provides a constructive framework for    related diseases, losing an average four-
or jana.johnson@ncmail.net.                 decision makers to use in improving the     teen years of life.1




46   popular government
Figure 1. Prevalence of Adult Smoking in North Carolina, 2004




                                                                                                                                             15%–19%
Source: From N.C. State Ctr. for Health Statistics, Behavioral Risk Factor                                                                   20%–23%
Surveillance System (BRFSS) Survey Results: North Carolina, Tobacco Use Prevention                                                           24%–27%
(last visited July 28, 2005), available at www.schs.state.nc.us/SCHS/brfss.                                                                  28%–31%


   In addition to the health risks that                  Not only does tobacco use cost lives,            North Carolina’s Changing
smokers face, evidence mounts on the                 but it costs the state billions of dollars a         Policy Environment for
serious health consequences of exposure              year in medical costs and lost produc-
                                                                                                          Tobacco Use
to secondhand smoke. It has been shown               tivity. In North Carolina in 1998, the last
to cause lung cancer and heart disease               year for which medical costs attribu-                Tobacco use in North Carolina is begin-
in nonsmoking adults, and respiratory                table to tobacco use were isolated from              ning to decline but still is prevalent: 22
infections, chronic ear infections, and              other costs of tobacco use, the medical              percent of the adult population cur-
asthma in children and adolescents.                  costs were $1.9 billion (see Table 1). In            rently smokes. Rates of smoking vary
There is no known safe level of ex-                  2002, tobacco use cost North Carolina                by age group: The highest rate, 28 per-
posure to secondhand smoke. A recent                 an estimated $5.4 billion in medical and             cent, is among young adults aged 18–24.
study by the Centers for Disease Control             productivity costs. Further, for that                From there the rates decline gradually
and Prevention (CDC) concludes that                  same year, North Carolina’s Medicaid                 across age groups until adults aged 65
even limited exposure can precipitate a              costs attributable to smoking were                   and older, whose rate is less than 13
heart attack in someone with coronary                estimated to be more than $940 million,              percent. Rates of tobacco use, including
heart disease.2                                      or $113.23 per capita (see Table 1).                 cigarettes and other tobacco products,

Table 1. Tobacco-Related Monetary Costs in North Carolina

In 1998 Dollars
 Annual health care expenditures directly caused by tobacco use                                                               $1.92 billion
 Total Medicaid program payments caused by tobacco use                                                                        $600 million
 Citizens’ state and federal taxes to cover smoking-caused government expenditures                                            $1.59 billion
                                                                                                                              ($488 per household)
 Smoking-caused productivity losses                                                                                           $2.82 billion
 Smoking-caused health costs and productivity losses per pack sold                                                            $6.59

In 2002 Dollars (Estimated)
 Smoking-caused health costs and productivity losses                                                                          $5.4 billion
 Total Medicaid costs attributable to smoking                                                                                 $940 million
                                                                                                                              ($113.23 per capita)
Source: Base numbers are from OFFICE ON SMOKING, CENTERS FOR DISEASE CONTROL AND PREVENTION, SUSTAINING STATE PROGRAMS FOR TOBACCO CONTROL: DATA
HIGHLIGHTS 2004 (Atlanta: CDC, n.d.), available at www.cdc.gov/tobacco/datahighlights/page6.htm. Expenditure forecasts are based on an N.C.
population of 8,307,748.
Note: Other nonhealth costs caused by tobacco use, in 1998 dollars, include direct residential and commercial property losses from smoking-caused fires
(more than $500 million nationwide); the costs of extra cleaning and maintenance made necessary by tobacco smoke and tobacco-related litter (more
than $4 billion per year for commercial establishments alone); and additional work-productivity losses from smoking-caused work absences, on-the-job
performance declines, and disability during otherwise productive work lives (in tens of billions of dollars nationwide). The productivity loss amount above
is solely from work lives shortened by smoking-caused deaths.



                                                                                                                                     fall     2005       47
have leveled off among high school           grams to prevent and control tobacco          confirm the power of laws like this. In a
students and declined slightly among         use by teenagers. The HWTF’s Teen             draft of a 1994 presentation, Tina Walls
middle school students, to 33.7 percent      Tobacco Prevention and Cessation              of Philip Morris USA wrote, “By intro-
and 14.3 percent, respectively.3 Smoking Program is the recipient of the first dedi-       ducing pre-emptive statewide legislation
rates also vary geographically, from 15      cated state funding for tobacco preven-       we can shift the battle away from the
percent to 31 per-                                               tion and control in       community level back to the state legisla-
cent (see Figure 1).                                             North Carolina.           tures where we are on stronger ground.”7
    The decline in use The decline in use is occurring           Community pro-
is occurring because      because centuries-old social,          grams are actively        Increased Funding for
centuries-old social,                                            promoting evidence-       Prevention and Control Efforts
economic, and             economic, and political                based interventions
                                                                                           in North Carolina
political traditions      traditions are slowly giving way to reduce tobacco
are slowly giving                                                use by teenagers.         In 1964 the first Surgeon General’s
way to the knowl-
                          to the knowledge gained in                 Another major         Report warned about the serious health
edge gained in recent recent decades about the health reason for change is                 consequences of tobacco, yet North
decades about the         effects of tobacco use and             that North Carolina       Carolina did not begin to address tobacco
health effects of                                                is shifting from a        use seriously as a preventable public
tobacco use and           secondhand smoke, and to               tobacco-farming and       health problem until the late 1980s.
secondhand smoke,         policies and programs that have -manufacturing econ-             From 1986 to 1995, Guilford and Wake
and to policies and                                              omy to one based on       counties participated in COMMIT
programs that have        been proven to be effective.           technology and infor-     (Community Intervention Trial for
been proven to be                                                mation. The 2004 to-      Smoking Cessation), a program funded
effective. The 2004–05 session of the        bacco quota buyout, which ended a fed-        by the National Cancer Institute to
North Carolina General Assembly was          eral program regulating tobacco produc-       demonstrate how community-level in-
more active with tobacco- and health-        tion, will compensate tobacco growers         terventions could enhance cessation of
related legislation than any session in      and quota holders with $9.6 billion           tobacco use.8 From 1991 to 1999, the
the state’s history. Among the matters       over the next ten years. The largest          state’s Division of Public Health part-
under consideration were a substantial       share will go to growers and quota            nered with the American Cancer Society
increase in the tobacco tax and restric-     holders in North Carolina.4 There now         of North Carolina to carry out Project
tions on smoking in restaurants and          are fewer farm and manufacturing jobs,        ASSIST (American Stop Smoking Inter-
other public places.                         and there is a decreased perception of        vention Study), also underwritten by the
    One factor in this change is the first-  “tobacco as king.”                            National Cancer Institute. Nationally,
time allocation of significant amounts          Tobacco-farming and -manufacturing         Project ASSIST was funded at about
of state funds. The funds are channeled      interests were the primary source of          $21.5 million to demonstrate the effec-
to geographically and ethnically diverse     media coverage of tobacco in North            tiveness of statewide policy, media, and
community and school groups that edu-        Carolina until the late 1980s and early       program interventions in seventeen
cate people about tobacco use as a pub-      1990s, when the National Cancer Insti-        states. The ASSIST states were compared
lic health problem and build support for tute began to fund programs for preven-           with thirty-two other states that were
effective policy solutions. Only a modest    tion and control of tobacco use. From         funded at about $12 million by CDC,
amount of federal funds was in place in      1993 to 1997, pro-health articles,            and with California, which had a tobacco
North Carolina from the early 1990s          editorials, and letters to the editor about   control program funded by a state
until 2002. A more recent investment of      tobacco in daily newspapers increased         tobacco tax. In North Carolina, Project
state dollars in preventing and reducing     from 20 percent to 70 percent, and pro-       ASSIST was funded at $8.5 million for
teenage tobacco use in schools and com- tobacco news coverage decreased from               seven years. It organized a statewide
munities has allowed for greater educa-      22 percent to 5 percent.5                     effort involving ten community-based
tion about prevention of such use across        In North Carolina, policy decisions        coalitions covering twenty-three counties
North Carolina. In 2002, under the           have long been based predominately on         and all six media markets. The project
Tobacco Master Settlement Agreement,         preserving the economic interests of to-      used the mass media to promote policy
seven tobacco companies being sued by        bacco farmers, quota holders, and com-        change and thereby to increase the
states’ attorneys general agreed to change panies rather than on protecting health         demand for program services. Formal
how tobacco products are marketed            interests and reducing the costs of health    evaluation of Project ASSIST continues,
and to pay the states an estimated $246      care. For example, a state law passed in      but the comprehensive model created by
billion over twenty-five years. That         1993, Smoking in Public Places, was           the National Cancer Institute was
agreement allowed North Carolina to          part of a national strategy of the tobacco    deemed a success, and in 1999 the CDC
create the Health and Wellness Trust         industry to prevent local decision making     picked up the funding for programs in
Fund (HWTF) with about one-quarter           on prohibition of smoking in workplaces,      the health departments of all fifty states.9
of the funds the state received, and to      restaurants, and other public places.6           As noted earlier, the General Assem-
invest a small proportion of them in pro-    Internal tobacco industry documents           bly created the HWTF in 2002 as an

48   popular government
entity in which to invest some of North       and the Old North State Medical So-         research is sufficient. What is sometimes
Carolina’s portion of the Tobacco Mas-        ciety (representing African Americans),     lacking is the political will to apply it.
ter Settlement Agreement. By the terms        and the North Carolina Commission on           Research shows that comprehensive
of the relevant legislation, the HWTF will    Indian Affairs. The demand for the          multifaceted programs, funded in an
receive one-fourth of the state’s tobacco     program has resulted in the HWTF ex-        amount adequate for the size and the
settlement funds in annual installments       panding its funding                                      diversity of a state’s popu-
over twenty-five years.10 Under the leader-   from $6.2 million in                                     lation, are effective in
ship of Lieutenant Governor Beverly           2003–04 to $15 mil-      Most people who become reducing the prevalence of
Perdue, the HWTF became the first state       lion in 2005–06.         users begin using tobacco tobacco use; disease, dis-
funding ever dedicated to addressing                                                                   ability, and death caused by
tobacco use among youth from a public         Comprehensive in early adolescence,                      tobacco use; and health
health perspective. The HWTF’s initia-        Policy                   and almost all people           care costs attributable to
tive, the Teen Tobacco Prevention and         Initiatives
Cessation Program, has been well received     More is known about
                                                                       who become users begin tobacco use. Comprehen-
                                                                                                       sive programs promote
by geographically diverse community           how to prevent and       before age twenty-four.         evidence-based interven-
organizations, school systems, and state-     reduce tobacco use       The average age of              tions that pursue the CDC’s
wide organizations representing diverse       than is known about                                      four goals:11
population groups—for example, El             perhaps any other        initiation is between
                                                                                                       • Preventing the initiation
Pueblo (representing Hispanics-Latinos),      modern public            twelve and fourteen.              of tobacco use among
the General Baptist State Convention          health problem. The
                                                                                                         young people
                                                                                          • Eliminating nonsmokers’ exposure
                                                                                            to environmental tobacco smoke . . .
                                                                                          • Promoting quitting among young
                                                                                            people and adults
                                                                                          • Identifying and eliminating the dispar-
                                                                                            ities related to tobacco use and its effects
                                                                                            among different population groups
                                                                                          These four goals provide the framework
                                                                                          for North Carolina’s programs.
                                                                                             Strong research evidence supports
                                                                                          specific community-based interventions
                                                                                          and policy development in this area. In
                                                                                          2000, Dr. David Satcher, then the assistant
                                                                                          secretary for health and the surgeon gen-
                                                                                          eral of the United States, convened the
                                                                                          Task Force for Community Preventive
                                                                                          Services. This team of scientists reviewed
                                                                                          the research and published the Guide to
                                                                                          Community Preventive Services: Tobacco
                                                                                          Use Prevention and Control.12 The Guide
                                                                                          provides state and local decision makers
                                                                                          with information and evidence-based
                                                                                          recommendations on interventions
                                                                                          appropriate for communities and health
                                                                                          care systems to reduce tobacco use (for
                                                                                          the recommendations, see Table 2).
                                                                                             The task force found that compre-
                                                                                          hensive programs to control tobacco use
                                                                                          provide multiple opportunities to deliver
                                                                                          a variety of consistent anti-tobacco mes-
                                                                                          sages to different populations through
                                                                                          communities, health care systems, and
                                                                                          public and private workplaces and other
                                                                                          settings (such as schools). No single
                                                                                          agency program can address this com-
                                                                                          plex problem alone. The leadership role

                                                                                                                  fall     2005      49
for such initiatives varies from state to            Table 2. Guide to Community Preventive Services: Interventions
state but generally takes the form of high-                   for Communities
level public policy and public health                    Goal                                                  Recommended Interventions
program stewardship, with active and
                                                         Increase cessation                                    Increase in price (tax)
engaged private partners and community-
based coalitions. The delivery of anti-                                                                        Mass media campaigns*
tobacco messages from a variety of                                                                             Telephone quitlines
sources (for example, the media, physi-                                                                        Smoking bans
cians, and workplace policies) contri-
                                                         Reduce initiation                                     Increase in price (tax)
butes to individual changes in behavior
(such as quitting). Two decades of                                                                             Mass media campaigns*
evidence from state-based prevention                     Reduce exposure to secondhand smoke                   Smoking bans
programs indicate that the most success-             Source: Adapted from Centers for Disease Control and Prevention, Strategies for Reducing Exposure
ful approach for reducing tobacco use is             to Environmental Tobacco Smoke, Increasing Tobacco-Use Cessation, and Reducing Initiation in
fully funded comprehensive programs                  Communities and Health-Care Systems: A Report on Recommendations of the Task Force on
                                                     Community Preventive Services, 49 MORBIDITY AND MORTALITY WEEKLY REPORT (No. RR-12, tab. 2, Nov.
that combine or coordinate a variety of              2000, at 6–10).
interventions.13 The Guide tells what is
                                                     *When combined with other interventions.
effective; the challenge to state and local
stakeholders is to build community                   to reduce exposure to environmental                  campaigns when combined with other
support for putting effective interven-              tobacco smoke; and strategies to in-                 (local) interventions. North Carolina
tions into place.                                    crease cessation of tobacco use.                     has added a third strategy, a campaign
                                                                                                          to make all of its 115 school districts
Effective Strategies and North                       Strategies to Reduce Initiation of                   100 percent tobacco free.
Carolina’s Applications of Them                      Tobacco Use
The surgeon general’s task force                     The task force strongly recommends                   An Increase in the Unit Price
grouped its recommendations into three               two strategies for reducing tobacco use              Despite all that is known about the ef-
types of strategies: strategies to reduce            by children, adolescents, and young                  fectiveness of substantial price increases
initiation of tobacco use by children,               adults: an increase in the unit price for            in reducing the burden of tobacco use
adolescents, and young adults; strategies            tobacco products and mass media                      on the health of North Carolinians, the


Table 3. Projected Revenues and Benefits from Various Increases in N.C. Cigarette Tax
 Tax Increase per Pack                                          $0.25             $.35            $.45             $.50             $.75          $1.00
 Additional New State Cig. Tax Revenue (millions/yr.) $134.7                    185.3            232.0           253.9            348.9           419.6
 Fewer State Packs Sold/Yr. (millions)                          221.6           241.0            260.4           270.1            318.6           367.1
 Youth Smoker Decline                                           5.2%            7.3%             9.4%           10.4%            15.7%           20.9%
 Fewer Future Youth Smokers                                   33,800           47,400          60,900          67,700          101,600         135,400
 Related Lifetime Health Savings (millions)                   $540.8           $758.4          $974.4        $1,083.2          $1,625.6       $2,166.4
 Adult Smoker Decline                                           1.2%            1.7%             2.2%            2.4%              3.6%           4.8%
 Fewer Adult Smokers                                          18,800           26,400          33,900          37,700            56,600         75,500
 Related Lifetime Health Savings (millions)                   $159.4           $223.9          $287.5          $319.7            $480.0         $640.2
 Youth Future Smoking-Caused Deaths Avoided                   10,800           15,100          19,400          21,600            32,500         43,300
 Adult Smoking-Caused Deaths Avoided                            4,900           6,900            8,900           9,900           14,900         20,000
 5-Year Smoking-Harmed Births Avoided                           4,380           6,140            7,890           8,770           13,150         17,540
 5-Year Heart & Stroke Savings (millions)                        $ 8.8          $12.3            $15.8           $17.5            $26.3           $35.0
 5-Year Smoking-Births Savings (millions)                        $ 6.3            $8.8           $11.3           $12.5            $18.8           $25.0
 Overall Long-Term Health Savings (millions)                  $700.2           $982.3        $1,261.9        $1,402.9          $2,105.6       $2,806.6
Source: Compiled by Eric Lindblom (Mar. 30, 2005), Campaign for Tobacco-Free Kids, www.tobaccofreekids.org. See, e.g., Frank J. Chaloupka, Macro-
Social Influences: The Effects of Prices and Tobacco Control Policies on the Demand for Tobacco Products, 1 NICOTINE AND TOBACCO RESEARCH (Supp. 1,
1999, at 71), and other price studies available at http://tigger.uic.edu/~fjc and www.uic.edu/orgs/impacteen.
Note: All projected savings are in 2002 dollars and were calculated using the same methodology that the Centers for Disease Control and Prevention
have used to update their data on state smoking-related costs. The revenue projections are fiscally conservative because they include a generous
adjustment for lost state pack sales (and tax revenues) from new tax-avoidance efforts (tax evasion) by continuing instate smokers after the tax increase.
They also adjust generously for resulting fewer sales to smokers from other states, and fewer sales to supply informal smugglers, criminal smuggling
organizations, or multistate Internet sellers.


50   p o p u l a r g ov e r n m e n t
state’s cigarette tax, which has been         The North Carolina Alliance for Health      lina campaign aimed at prevention of
5 cents per pack since 1993, has ranked       is a nonprofit coalition of health advo-    tobacco use that is paid for by the state
fifty-first in the nation. Nationally the     cates that has argued strongly for a        government.19 It follows research that in-
average tax per pack is 91.2 cents.14         75-cent increase. As of March 2005,         dicates the effectiveness of showing real
    As part of its consideration of the       it had the endorsement of most major        people telling true stories about the devas-
2005–06 budget, the North Carolina            daily newspapers in North Carolina and      tating human consequences of tobacco
General Assembly wrestled with in-            about 125 organi-                                                 use. Dr. Adam
creasing the state tax on cigarettes and      zations.17 A 2004                                                 Goldstein of Family
other tobacco products. Governor              survey conducted by                                               Medicine at the
Michael Easley’s budget proposed an           the State Center for                                              University of North
increase of 45 cents per pack, with 35        Health Statistics re-                                             Carolina (UNC) at
cents to be added in fiscal year 2005–06      vealed that 21.5 per-                                             Chapel Hill, an
and 10 cents in fiscal year 2006–07.          cent of North Caro-                                               independent
The Senate proposed a 35-cent increase        lina adults favor a                                               evaluator of the
for 2005–06, and the House, a 25-cent         cigarette tax increase                                            HWTF’s Teen
increase. In August 2005 the General          of $.50–$1.00 and                                                 Tobacco Prevention
Assembly approved a budget that pro-          34.6 percent favor                                                and Cessation
vides for the following:                      a cigarette tax in-                                               Program, studied the
                                              crease of more than                                               campaign and
• A 25-cent increase in the tax
                                              $1.00.18                                                          commented,
  on cigarettes (from 5 cents per
  pack to 30 cents), effective
                                              Mass Media                                                       Virtually all the
  September 1, 2005
                                              Campaigns When            A 100 percent tobacco-free             experimentation
• An additional 5-cent increase (to 35        Combined with             school policy prohibits tobacco        in smoking that
  cents), effective July 1, 2006              Other Interventions                                              occurred in non-
                                              The task force found use by anyone, anywhere,                    susceptible, non-
• An increase in the tax on other
                                              that mass media           anytime, on school property or         smoking youth at
  tobacco products from 2 percent of
                                              campaigns were                                                   baseline [of the
  cost to 3 percent of cost
                                              effective in reducing     at school events. Such a policy        evaluation study]
   The Task Force on Community Pre-           tobacco use by child- helps prevent tobacco use by               occurred among
ventive Services found that increasing        ren, adolescents, and                                            those unaware of
the price of tobacco products is effective    young adults when
                                                                        teenagers by providing positive
                                                                                                               the campaign . . .
in both (1) reducing the prevalence of        they were combined        role models in schools, and it         This translates into
tobacco use among adolescents and             with other tobacco-       helps tobacco users quit.              approximately
young adults and (2) increasing cessa-        control measures. As                                             9,000 fewer youths
tion of tobacco use. In fact, numerous        noted earlier, the                                               experimenting with
studies indicate that a 10 percent            HWTF provided the first state funding          tobacco than might have occurred
increase in a product’s price results in an   for mass media campaigns in North              without their having seen the
overall 3–5 percent decrease in cigarette     Carolina. It allocates funds for tobacco       campaign. Ultimately, this would
consumption and a 7 percent decrease          control interventions to seventy geo-          translate into almost $4 million of
in youth smoking.15                           graphically and culturally diverse             cost savings in preventing future
   Regarding the optimum amount for           organizations, including communities,          tobacco-related diseases among
a tobacco tax, the research is clear that     schools, and groups representing priority      North Carolina citizens.20
from a public health perspective, the         populations (Hispanics-Latinos, Native
greater the increase as a percentage of       Americans, and African Americans).          Tobacco-Free Schools Campaign
the price, the greater the public health      They must spend the money on policies       One of the successes of the HWTF’s
benefit. The projected health benefits        and programs that affect children and       Teen Tobacco Prevention and Cessation
from decreased initiation and increased       teenagers.                                  Program has been accelerated progress
cessation of tobacco use, and the                 In 2005 the HWTF allocated some of in making all North Carolina schools
revenues that would be generated from         its assets for use with college-age popu-   100 percent tobacco free. A 100 percent
various increases in North Carolina’s         lations, and North Carolina colleges        tobacco-free school policy prohibits
low cigarette tax, are considerable (see      and community colleges submitted            tobacco use by anyone, anywhere, any-
Table 3). The projections are based on        strong applications. The highest rates      time, on school property or at school
research findings that a 10 percent in-       of tobacco use in North Carolina occur      events. Such a policy helps prevent
crease in the price of a pack of cigarettes   in these settings.                          tobacco use by teenagers by providing
reduces youth smoking rates by 6.5 per-           The HWTF’s paid media campaign,         positive role models in schools, and it
cent or more, adult rates by 2 percent,       Tobacco. Reality. Unfiltered, commonly      helps tobacco users quit. It has been
and total consumption by 4 percent.16         known as TRU, is the first North Caro-      well received by local school leaders.


                                                                                                                 fall    2005      51
     Some Frequently Asked                      local law may remain in place. The             Are Local Boards of Health Subject
                                                restrictions just described apply only to      to Any Additional Restrictions on
     Questions about Local                      ordinances and rules adopted after             Their Authority to Adopt Rules
     Governments’ Authority                     October 1993.                                  Regulating Smoking?
     to Regulate Smoking in                     What Does “Physically Imprac-
                                                                                               Yes. In addition to the general statutory
                                                                                               limitations placed on the authority of
     Public Places                              ticable” Mean?
                                                                                               local governments to regulate smoking,
                                                As explained earlier, facilities in category 1
                                                                                               local boards of health are subject to
                                                must reserve 20
                                                                                                                  limitations on the scope
     What May Local Governments                 percent of their
                                                                                                                  of their authority
     Do within Their Jurisdictions to           interior space for         The law allows local                   because they are
     Regulate Smoking in Public Places?         smoking unless
     In 1993 the North Carolina General         doing so is physically
                                                                           governments to regulate                appointed bodies
     Assembly enacted a law that limits         impracticable. The         smoking in certain facilities, rather than elected
                                                                                                                  legislative bodies.
     local governments’ authority to            state law does not
     regulate smoking in public places.1        define “physically
                                                                           including buildings owned                  In City of Roanoke
                                                                                                                  Rapids v. Peedin, the
     Dividing buildings and facilities into     impracticable,” and        by local governments, but              North Carolina Court of
     five categories may help readers           North Carolina’s
     understand how this state law and its      courts have not yet        not in restaurants, bars,              Appeals explained the
                                                                                                                  limitations on the boards’
     various exceptions fit together (see       defined the term in        and most other private                 rule-making authority in
     Table 1). In short, the law allows local   the context of smok-
     governments to regulate smoking in         ing areas in local         establishments.                        the context of a smok-
     certain facilities, including buildings    government                                                        ing regulation case.4
     owned by local governments (cate-          buildings. However, in a different con-                           In Halifax County on
     gory 1), but not in restaurants, bars,     text, the North Carolina Court of Ap-          October 12, 1993, the board of health
     and most other private establish-          peals has compared the meanings of             enacted Halifax County Smoking Control
     ments (category 5). If a local govern-     “impracticable” and “impossible.       2 The   Rules. The rules included restrictions
     ment regulates smoking in certain          court stated that the Oxford English           on various types of facilities, such as
     buildings, it must designate at least      Dictionary defines “impossible” as “not        restaurants and bars. These rules were
     20 percent of the interior space for       possible,” whereas it defines “imprac-         subsequently challenged, and the North
     smoking unless doing so is “physically     ticable” as “impossible in practice” or        Carolina Court of Appeals overturned
     impracticable.” The smoking areas          impossible to do effectively.   3              them in 1996.5 The court created a
     must be of equal quality to the non-           Because courts have yet to interpret the   five-part test to which North Carolina
     smoking areas.                             meaning of “physically impracticable”          boards of health must adhere in making
         For example, a county builds a         in the context of regulating smoking, a        new rules:6
     new courthouse, and it does not have       local government must consider the              1. The rules must be related to the
     a local ordinance or rule controlling      definition given by the North Carolina             promotion or protection of health.
     smoking. The county must try to            Court of Appeals and use its best judg-
     reserve 20 percent of the interior         ment in deciding if and when designating        2. They must be reasonable in light
     space of the courthouse for smoking        less than 20 percent of the interior space         of the health risk addressed.
     unless it determines that doing so is      of any given building for smoking is            3. They must not violate any law or
     physically impracticable. In that case     physically impracticable. Some local               constitutional provision.
     the county must reserve a smoking          governments have concluded, for
     area that is as near as possible to        example, that designating any interior          4. They must be nondiscriminatory.
     20 percent.                                space of a facility for smoking is physically   5. They must not make distinctions
         There are several exceptions to        impracticable because the facility’s               based on policy concerns traditionally
     the 20 percent requirement, such as        ventilation system recirculates the smoke-         reserved for legislative bodies.
     schools (category 4) and buildings         filled air and puts all employees at risk.
     housing local departments of health        Using this rationale, they have prohibited      The court relied primarily on the fourth
     and social services (category 2). Also,    smoking entirely inside certain buildings.      and fifth criteria to invalidate the board’s
     if a local government had a valid          Until such local laws are challenged,           smoking control rules. The board had
     ordinance or board of health rule          it is not clear whether courts will support     established different rules for restaurants
     in place before 1993 that is more          this interpretation of “physically              based on how large they were and
     restrictive than the state law, the        impracticable.”                                 whether or not they had a bar. The court

For example, Robert Logan, superin-                use, but also has helped employees to            Although many school systems
tendent of Asheville City Schools, says,           stop tobacco use. The success of the          adopted a tobacco-free policy early in
                                                   policy in our district has served as a        the campaign, some school boards
     Our tobacco-free schools policy               catalyst to address other childhood           were not convinced that they had
     not only has helped to prevent                health issues such as childhood               the clear authority to do so. They
     and intervene in youth tobacco                obesity and juvenile diabetes.21              feared lawsuits based on the 1993 law.

52    popular government
  concluded that the rules discriminated            Table 1. North Carolina Local Government Authority to Regulate
  inappropriately because they protected                     Smoking, by Category of Building or Facility
  the health of employees in some
  restaurants but not in others, and they                                                                Local Government Authority
  made policy distinctions reserved for                                                                  (Local Ordinances or Board
  legislative bodies when they allowed              Category Buildings or Facilities                     of Health Rules)
  smoking in some restaurants (that is,             1          Buildings owned, leased, or               May establish nonsmoking
  small restaurants and restaurants with                         occupied by local government            areas. Twenty percent of
  bars) but not in others.                                                                               interior space of equal quality
      With respect to the second conclu-                       Public meetings                           must be smoking area unless
  sion, the court inferred that the board                                                                physically impracticable. If 20%
  drew these policy distinctions on the                                                                  is physically impracticable,
  basis of reasons unrelated to public                                                                   smoking area must be as near
  health, such as potential economic                                                                     as possible to 20%.
  hardship and difficulty of enforcement.
  The court explained that the board of             2          Child care centers                        May regulate/prohibit
  health must consider only health as a                                                                  smoking. Regulation is not
  factor in its rule-making process unless                     Hospitals, nursing and rest homes,
                                                                                                         subject to 20% requirement.
  a legislative body (such as the General                       and mental health facilities
  Assembly or a board of county com-                           Nonprofits that focus on tobacco
  missioners) specifically directs it to                        use prevention
  consider other factors (such as eco-
  nomic ones).                                                 Enclosed elevators
      Additional information about the                         Tobacco manufacturing, processing,
  authority of local governments to                              and administrative facilities
  regulate smoking in public places is
  available at www.ncphlaw.unc.edu.                            Libraries and museums open to public
            —Aimee Wall and Anna Wood                          Public transportation owned or
                                                                 leased by local government
          Wall is a School of Government
          faculty member who specializes                       Buildings housing local health
            in public health law. Wood is a                      departments and departments of
           third-year law student at North                       social services, including grounds
                Carolina Central University.                     surrounding buildings (up to 50 ft.)
                                                               Indoor arenas with seating capacity
  Notes                                                          greater than 23,000
      1. N.C. GEN. STAT. §§ 143-595 through
                                                    3          Indoor spaces of auditoriums, arenas,     May regulate/prohibit
  -601 (hereinafter G.S.).
      2. Morris v. E. A. Morris Charitable Foun-                 and coliseums or appurtenant            smoking. Must designate
  dation, 589 S.E.2d 414, 416 (N.C. Ct. App.                     buildings (except arenas with seating   space for smoking in lobby
  2003) (holding that testator’s intention                       capacity greater than 23,000)           area. Regulation is not subject
  regarding piece of property was impossible                                                             to 20% requirement.
  or impracticable to fulfill because function
  and purpose of property had changed).             4          Schools and school buses                  Smoking is prohibited in school
      3. Id. The court used the terms together,                                                          buildings during school hours.
  and it offered the example that a gift to a                                                            Local boards of education
  charity that never existed is impossible,
                                                                                                         have broad authority to
  whereas a gift to a charity that is so vaguely
                                                                                                         regulate smoking on all other
  described that it cannot be identified is
  impracticable.                                                                                         school property (it is not
      4. City of Roanoke Rapids v. Peedin,                                                               subject to 20% requirement).
  478 S.E.2d 528 (N.C. Ct. App. 1996).
      5. Id.                                        5          Other public places, including            No authority
      6. Id.                                                     restaurants and bars


The 2003–04 North Carolina General                 At this writing, considerably more            Branch and the HWTF’s Teen Tobacco
Assembly removed this barrier by                   than half of the state’s 115 school           Prevention and Cessation Program.22
giving clear authority to local school             districts have passed 100 percent             Lieutenant Governor Perdue, the HWTF,
boards to set stricter policy standards            tobacco-free policies (see Figure 2),         and the State School Board, led by
than the federal guidelines, which                 thirty-nine of them with help from the        Chair Howard Lee, have championed
prohibit smoking in school buildings.              state’s Tobacco Prevention and Control        this effort.

                                                                                                                          fall    2005      53
Evidence-Based Policies and                 areas lessened the impact of work-area          UNC system to enact smoke-free poli-
Strategies to Reduce Second-                bans, and that smoke-free policies              cies in many buildings. Dormitories at
hand Smoke                                  reduced smoking for all demographic             Elizabeth City State College, North
The second policy goal of the state is to   groups and in nearly all industries. The        Carolina Central University, UNC at
eliminate exposure to                                             authors of this study     Chapel Hill, UNC–Greensboro, and
secondhand smoke,                                                 concluded, “Re-           UNC–Wilmington have since become
which has been                                                    quiring all work-         smoke free.
estimated to be the                                               places to be smoke-           In 2005 the North Carolina Associa-
third leading                                                     free would reduce         tion of Local Health Directors requested
preventable cause of                                              smoking prevalence        legislation (H.R. 239) to exempt any
death. Even short-                                                by 10 percent.            building that houses a local health de-
term exposure may                                                 Workplace bans            partment, including 50 feet of grounds
increase a person’s                                               have their greatest       surrounding the building, from the
risk of experiencing                                              impact on groups          state’s preemption law. Not only did
a heart attack. For                                               with the highest          H.R. 239 become law, but it prompted
example, an obser-                                                rates of smoking.”25      H.R. 1482, a bill to allow local social
vational study in                                                     Across the na-        services departments to declare their
Helena, Montana,                                                  tion, some states re-     buildings and 50 feet of surrounding
published in 2004,                                                strict the authority of   grounds smoke free. H.R. 1482 also
demonstrated a 40         The Task Force on Community             local governments         became law.27
percent reduction in      Preventive Services found               to regulate smoking.          Two other smoking-related bills
hospital admissions                                               The American Med-         passed in 2005. The first, S. 482, allows
for acute myocardial
                          that increasing the price of            ical Association has      regulation of smoking in indoor arenas
infarctions during a      tobacco products is effective           stated that such pre-     with a seating capacity of more than
six-month ban on          in both (1) reducing the                emption laws are          23,000.28 It would likely apply only to
smoking in public                                                 “the tobacco indus-       regulation of smoking in the Greens-
places and in work-       prevalence of tobacco use               try’s top legislative     boro Coliseum. The second, S. 1130,
places. After the ban     among adolescents and young             goal, because [they]      prohibits the use of tobacco products
was suspended be-                                                 concentrate[]             inside state prisons.29 The smoking ban
cause of a legal chal-    adults and (2) increasing               authority at the          will be phased in over time. In addition,
lenge, hospital admis- cessation of tobacco use.                  state level where the     the Department of Correction will be
sions rebounded to                                                industry is stronger      conducting at least one pilot program to
previous levels.23                                                and can more              test a smoking cessation program for
                                            readily protect its interest.”26 As noted       staff and inmates.
Smoking Bans and Restrictions               earlier, North Carolina passed its pre-             Preemption of local authority to
The primary recommendation of the           emption law in 1993. Called the “dirty          regulate smoking is not likely to be
surgeon general’s task force regarding      air law” by some, it requires state-            overcome until local elected officials
exposure to secondhand smoke is to          controlled buildings to have some               actively seek control over this issue. In
implement restrictions and bans on          smoking areas and limits the ability of         January 2005, to reassert local control,
smoking. The task force found that no-      local governments to restrict smoking in        the Mecklenburg County commis-
smoking policies reduced exposure to        public places, like restaurants and             sioners endorsed the proposal of a
secondhand smoke by about 74 percent. government-owned buildings (for more                  citizens group called Smoke-Free
Moreover, studies of worksites with no-     information about the law, see the              Charlotte that the delegation represent-
smoking policies have shown that em-        sidebar on page 52).                            ing the county in the General Assembly
ployees in these settings experience in-       Since the adoption of the preemption         be asked to request exemption from the
creased success in quitting tobacco use.24 law in 1993, the state has taken a few           state’s preemption law. Smoke-Free
    Other studies show similar results. For small steps either to limit secondhand          Charlotte’s website states,
example, a 1999 national survey             smoke in public places or to permit state
conducted by the Research Triangle In-      or local government agencies to restrict          The NC General Assembly passed
stitute reported that having a 100 per-     smoking in certain public places. In              a law in 1993 (GS 143-595-601)
cent smoke-free workplace reduced           2003–04 the North Carolina General                prohibiting any local government
smoking prevalence by 6 percentage          Assembly created rules to make both               from banning smoking in public
points and reduced average daily con-       the House and the Senate floor smoke              places. Smoke-Free Charlotte is
sumption among those who continued          free while legislatures are in session. It        asking for an exemption from this
to smoke by 14 percent, compared with       also exempted many state university               law for Mecklenburg County. If
workers subject to minimal or no            buildings, including most dormitories,            granted, this exemption will allow
restrictions. The survey also showed that from the state’s preemption law. This               the county to pass its own ordinance,
allowing smoking in some common             action allowed the campuses of the                if it chooses to do so, which will

54   popular government
   protect its citizens, workers and              tobacco use. Recommendations for the        This initiative, launched in 2003, pro-
   visitors from the health hazards of            community setting include increasing        motes the evidence-based cessation
   secondhand smoke.30                            the price of tobacco (via a tax), intro-    counseling methods published in 2000
                                                  ducing smoking bans, conducting mass        by the Public Health Service and trains
    Although Smoke-Free Charlotte has             media campaigns, and providing pro-         health care providers in how to provide
strong grassroots backing and the en-             active telephone quitlines. (A “quitline”   this counseling.32 It also fosters partner-
dorsement of the county commissioners,            is a telephone service that tobacco users   ships, influences policies, sponsors con-
it needs to increase its support among            may call to receive comprehensive assis-    ferences, and develops resources for a
the ten-member Charlotte-Mecklenburg              tance with quitting from trained cessa-     healthier North Carolina. Quit Now NC!
delegation to the House of Representa-            tion counselors. On a “proactive”           continues to work to help providers es-
tives. Smoke-Free Charlotte plans to              telephone quitline, counselors may call     tablish cessation reminder systems and
continue promoting nonsmoking policies            users back.) Recommendations for            other components of cessation counsel-
to protect the health of citizens and to          health care systems include decreasing      ing in their practice settings.
encourage businesses, particularly those          out-of-pocket costs for cessation ser-
in the restaurant and service industry, to        vices for patients, establishing systems    Reduction of Out-of-Pocket Costs
put forth a healthy, nonsmoking image.            in the practice setting to remind pro-      Because of efforts by North Carolina
    Despite the legal and policy barriers,        viders to deliver cessation counseling,     Prevention Partners, a nonprofit
significant voluntary progress has been           and providing proactive telephone           organization dedicated to improving the
made in recent years, particularly with           quitlines. Mass media campaigns, tele-      health of North Carolinians through
private smoke-free policies in white-             phone quitlines, and provider reminder      prevention, health care insurers in
collar worksites. More than 73 percent            systems are most effective when combined    North Carolina are increasingly cover-
of the North Carolina indoor workforce            with any of the other interventions         ing treatment for tobacco use as a basic
now is covered by a nonsmoking policy             (smoking bans, etc.).                       benefit. On its website, North Carolina
for public and work areas at their work-              Earlier sections discuss the tobacco    Prevention Partners tracks what benefits
sites, compared with less than 33 percent         tax, smoking bans, and mass media cam-      are covered.33
in 1992. Although the state has made              paigns. This section addresses provider        North Carolina Medicaid also has
consistent progress in protecting workers         reminder systems, reduction of out-of-      made progress. Currently it covers
from job-related secondhand smoke,                pocket costs, and telephone quitlines.      prescription drugs that are approved by
some workers are less protected than                                                          the Food and Drug Administration for
others. For example, blue-collar and ser-                                                     cessation of tobacco use and over-the-
                                                  Provider Reminder Systems
vice workers are considerably less pro-           In North Carolina, tobacco control ad-      counter nicotine-replacement medica-
tected than white-collar workers are.31           vocates and public health officials have    tions. However, it still does not cover
                                                  made great strides in educating health      cessation counseling.
Strategies to Increase                            care professionals about effective cessa-      The State Health Plan, which pro-
Cessation of Tobacco Use                          tion counseling and about implementing      vides health care coverage for all state
In the Guide to Community Preventive              such an intervention in their practices,    employees, is piloting a cessation benefit,
Services, the surgeon general’s task force        primarily because of the establishment      with the goal of incorporating it into the
outlines a number of evidence-based               of a statewide infrastructure to promote    plan depending on findings from the
strategies to increase the cessation of           cessation, known as Quit Now NC!            pilot study. Results are due in late 2005.

Figure 2. N.C. School Districts with a 100% Tobacco-Free School Policy, August 2005




                School districts with 100%
                tobacco-free school policies


Source: NCTobaccoFreeSchools.com (last modified June 17, 2005).
Note: The Eastern Band of the Cherokee Indians, a federally funded Native-American
school district, also has adopted a 100 percent tobacco-free school policy.



                                                                                                                     fall   2005      55
Quitlines                                           North Carolina twenty-first in the na-           • Maintain a commitment to that
With funding from the CDC and the                   tion in spending on prevention and con-            funding level until tobacco use by
HWTF, North Carolina now has a state-               trol of tobacco use (see Table 4).                 teenagers and young adults drops
wide proactive quitline for youth and                                                                  below 10 percent.
adults. This free, evidence-based, com-             Future Policy Directions                     • Fund programs to meet the needs of
prehensive service, available at 1-800-             for North Carolina                             all populations struggling with
QUIT-NOW, provides effective cessation
                                                    North Carolina                                                  addiction to tobacco,
support for all North Carolinians who
                                                    leaders are to be con-                                          regardless of age, in-
want to quit using tobacco. Participants                                      Treatment for dependence on
                                                    gratulated for                                                  cluding adults, preg-
may choose to have cessation specialists
                                                    increasing the            tobacco is not only clinically        nant women, and
call them back at agreed-on times to
                                                    cigarette tax to 35                                             disparate populations
answer questions and check on quitting                                        effective but also cost-effective. in which the preva-
progress. Special protocols are available           cents. Increasing the
for pregnant women and for users of                 tobacco tax toward        Smoking cessation treatments lence of tobacco use
spit tobacco. The quitline operates from            the national average      compare favorably with routine or of health problems
                                                                                                                    attributable to tobac-
8 A.M. to midnight seven days a week, in            (91.7 cents) will
                                                    provide additional        medical treatments such as            co use is higher
multiple languages, including Spanish.
                                                    health benefits and       those for hypertension and            than average. Also,
    Treatment for dependence on tobacco
                                                    cost savings for                                                adequately fund the
is not only clinically effective but also                                     high cholesterol.
                                                    North Carolinians.                                              North Carolina
cost-effective. Smoking cessation treat-
                                                    Challenges to                                                   quitline and market
ments compare favorably with routine
                                                    continued tobacco-control funding and          the services to disparate populations.
medical treatments such as those for
hypertension and high cholesterol. In               effective evidence-based policy remain,      • Provide comprehensive coverage of
fact, they have been referred to as the             however. If North Carolina is to make          evidence-based treatment for cessa-
“gold standard of preventive interven-              further progress, its leaders must take        tion of tobacco use to people eligible
tions.”34 Quitlines have been found to              more steps to implement what is known          for Medicaid and to state employees.
be just as effective as more traditional            to be effective:                               Further, encourage private employers
interpersonal or group counseling and                                                                   to cover such treatment. Coverage
may be more efficient in terms of cost.35           • Rescind North Carolina’s preemptive               should include all drug therapy and
                                                      “dirty air law,” which does not                   tobacco use counseling approved by
                                                      reflect what researchers and practi-              the Food and Drug Administration
Funding for Programs to
                                                      tioners now clearly know about the                and provided through the North
Address Tobacco Use                                   serious and immediate risks of                    Carolina quitline.
The research not only recommends                      secondhand smoke. If this barrier
evidence-based interventions to address               were eliminated, the state could set a             Although currently falling short of
tobacco use but also speaks to funding                minimum standard that all work-                the CDC’s recommendation, funding
levels adequate to support such inter-                places and surrounding grounds be              of tobacco control efforts in North
ventions. In 1999 the CDC published                   smoke free (or at least all workplaces         Carolina has increased in the last two
Best Practices for Comprehensive To-                  covered by the State Health Plan)              years. Also, momentum is growing
bacco Control Programs.36 This resource               and, what is more important, allow             for implementation of effective policy
estimates that North Carolina should in-              local governments to enact and                 interventions.
vest a minimum of $42.6 million annually              enforce stricter standards.                        North Carolina is making tremendous
in evidence-based interventions at the                                                               strides in preventing and reducing
state and community levels. Current                 • Commit themselves to increasing                tobacco’s toll on health and the health
federal funding, plus the state investment            funding over the next 4–6 years to at          care economy. Solid scientific evidence
of HWTF dollars, amounts to 35 percent                least the minimum recommended by               indicates what is effective. Diverse
of that minimum expenditure and ranks                 the CDC in Best Practices.                     geographic populations support change.
                                                                                                     Strong state and local advocates are
                                                                                                     working to advance evidence-based
Table 4. State Spending on Tobacco Prevention                                                        efforts. North Carolina now needs to
                                                      Fiscal Year 2004        Fiscal Year 2005       implement all that research and best
  Spending on tobacco prevention                        $10.9 million           $15.0 million        practice have shown to be effective.
  Percent of CDC–recommended                                                                         Notes
  minimum ($42.59 million)                                 25.59%                  35.22%
                                                                                                        1. National Cancer Institute, Scientific
  Rank among states (1–51)                                    30                      21             Priorities for Cancer Research: NCI’s
Source: Adapted from Campaign for Tobacco-Free Kids, Special Reports: State Tobacco                  Extraordinary Opportunities (last updated
Settlement (last modified Dec. 2, 2004), available at www.tobaccofreekids.org/reports/settlements/   Apr. 16, 2000), available at http://2001.
state.php?StateID=NC.                                                                                cancer.gov/tobacco.htm.


56   p o p u l a r g ov e r n m e n t
   2. Richard P. Sargent et al., Reduced Inci-     10. Brief Overview of the Tobacco                 mentation? 20 JOURNAL OF HEALTH
dence of Admissions for Myocardial Infarction    Settlement (last visited July 27, 2005),            ECONOMICS 261 (2001); W. DOUGLAS EVANS
Associated with Public Smoking Ban: Before       available at www.hwtfc.org/pdffiles/                & L. X. HUANG, CIGARETTE TAXES AND TEEN
and After Study, 328 BRITISH MEDICAL             hwOverviewTobaccoSettlement.pdf.                    SMOKING: NEW EVIDENCE FROM PANELS OF
JOURNAL 977 (2004).                                11. Nat’l Ctr. for Chronic Disease Prevention     REPEATED CROSS-SECTIONS (College Park:
   3. Chronic Disease and Injury Section,        and Health Promotion, Centers for Disease Con-      Dep’t of Economics, Univ. of Md., Working
N.C. Div. of Public Health, 2003 North           trol and Prevention, Best Practices for Compre-     Paper, 1998); Jeffrey E. Harris & Sandra
Carolina Youth Tobacco Survey Results (last      hensive Tobacco Control Programs, August            W. Chan, The Continuum of Addiction:
updated May 4, 2005), available atwww.           1999, Executive Summary (last updated Jan. 31,      Cigarette Smoking in Relation to Price among
communityhealth.dhhs.state.nc.us/tobacco/        2005), available at www.cdc.gov/tobacco/            Americans Aged 15–29, HEALTH ECONOMICS
Survey03/YouthSurveyResults03.htm.               research_data/stat_nat_data/bestprac-exec           LETTERS, Sept. 1998, at 3, available at
   4. A. Blake Brown, A Summary of the           summay.htm.                                         www.mit.edu/people/jeffrey; JOHN A. TAURAS
Tobacco Buyout, available at the Tobacco           12. Thomas D. Hopkins and Johnathan E.            ET AL., EFFECTS OF PRICE AND ACCESS LAWS ON
Buyout Information Website (last visited         Fielding, The Guide to Community Preven-            TEENAGE SMOKING INITIATION: A NATIONAL
July 16, 2005), www.cals.ncsu.edu:8050/          tive Services: Tobacco Use Prevention and           LONGITUDINAL ANALYSIS (Chicago: Univ. of
advancement/tobaccobuyout/buyoutbkgd.htm.        Control, 20 AMERICAN JOURNAL OF PREVEN-             Chicago, ImpacTeen—Yes! Research Paper
   5. Sally Herndon Malek et al., Coverage       TIVE MEDICINE supp. 2 (Feb. 2001), available        Series No. 2, 2001), and other price studies
of Tobacco in North Carolina Newspapers,         at www.cdc.gov/tobacco/comguide.htm.                available at www. impacteen.org.
Presentation at the American Public Health         13. U.S. DEP’T OF HEALTH AND HUMAN                  16. See, e.g., Chaloupka, Macro-Social
Association Roundtable (1997) (on file with      SERV., REDUCING TOBACCO USE: A REPORT OF            Influences; MATTHEW C. FARRELLY ET AL.,
the Tobacco Prevention and Control Branch,       THE SURGEON GENERAL (Atlanta: Office on             STATE CIGARETTE EXCISE TAXES: IMPLICATIONS
N.C. Div. of Pub. Health).                       Smoking and Health, Centers for Disease             FOR REVENUE AND TAX EVASION (Research
   6. N.C. GEN. STAT. §§ 143-595 through -601.   Control and Prevention, 2000).                      Triangle Park, N.C.: RTI International, May
   7. Tina Walls, Draft CAC Presentation           14. Campaign for Tobacco-Free Kids, State         2003), available at www.rti.org/pubs/8742_
(July 8, 1994), from Philip Morris USA Trans-    Cigarette Excise Tax Rates & Rankings (last         Excise_Taxes_FR_5-03.pdf.
cript, Document No. 2041183751-3790,             modified July 20, 2005), available at                 17. N.C. Alliance for Health, Organizations
Philip Morris USA Document Site (last visited    http://tobaccofreekids.org/research/factsheets/     Supporting a Significant Increase in North
Aug. 23, 2005), available at www.pmdocs.com/     pdf/0097.pdf.                                       Carolina’s Cigarette Excise Tax (as of
getallimg.asp?DOCID=2041183751/3790.               15. Frank J. Chaloupka, Macro-Social              March 2005) (last visited Aug. 24, 2005),
This is an internal document of Philip Morris    Influences: The Effects of Prices and Tobacco       available at www.ncallianceforhealth.org/take
USA that was made public in the discovery        Control Policies on the Demand for Tobacco          action.htm (follow “Endorsers of Cigarette
phase of litigation.                             Products, 1 NICOTINE AND TOBACCO RESEARCH           Tax Increase as of Mar. 2005” hyperlink).
   8. NAT’L CANCER INST., Community and          (Supp. 1 1999, at 71), and other price studies        18. N.C. State Ctr. for Health Statistics,
State Intervention Research, in TOBACCO          available at http://tigger.uic.edu/~fjc; FRANK J.   2004 BRFSS [Behavioral Risk Factor Surveil-
RESEARCH/IMPLEMENTATION PLAN: PRIORITIES         CHALOUPKA & ROSALIE L. PACULA, AN EXAMI-            lance System] Survey Results: North Carolina,
FOR TOBACCO RESEARCH BEYOND THE YEAR             NATION OF GENDER AND RACE DIFFERENCES               Tobacco Use Prevention (last visited July 28,
2000 chap. 6 (Washington, D.C.: NCI, Nov.        IN YOUTH SMOKING RESPONSIVENESS TO PRICE            2005), available at www.schs.state.nc.us/
1998), available at http://dccps.nci.nih.gov/    AND TOBACCO CONTROL POLICIES (Chicago:              SCHS/brfss/2004/nc/all/tax.html.
TCRB/TRIP/index.html.                            Nat’l Bureau of Economic Research, Working            19. Tobacco. Reality. Unfiltered (last
   9. Marc Manley et al., The American Stop      Paper No. 6541, Apr. 1998), available at            visited July 15, 2005), at www.reality
Smoking Intervention Study for Cancer Pre-       http://tigger.uic.edu/~fjc (follow “Working         unfiltered.com.
vention: An Overview, 6 TOBACCO CONTROL          Papers” hyperlink); Sherry Emery et al., Does         20. Press Release, David Williamson for
(Supp. 2 1997).                                  Cigarette Price Influence Adolescent Experi-        UNC News Services, Study: Statewide Teen


                                                                                                                             fall    2005      57
Tobacco Prevention Media Campaign Shows
Early Successes (May 2, 2005) (last visited           at the                                      benefit a student in The University of
Aug. 2, 2005), available at www.unc.edu/
news/archives/apr05/goldstein050205.html.
  21. Testimonial Summary (Training Material),
                                                         School                                   North Carolina at Chapel Hill’s Master
                                                                                                  of Public Administration Program who
                                                                                                  has shown an interest in working for
NC School Leaders Speak Out about 100%                                                            local governments in the Tar Heel State.
Tobacco Free Schools 1 (Sept. 3, 2004). Available
on request from Tobacco Prevention and               Scholarship Fund to                              So far, more than $67,000 has been
                                                                                                  raised for the scholarship fund at the
Control Branch, N.C. Div. of Public Health.
  22. NCTobaccoFreeSchools.com
                                                     Honor Aycock                                 School of Government, including dona-
                                                         n August 2005, C. Ronald Aycock          tions by more than thirty county govern-

                                                     I
(last visited Aug. 15, 2005), at www.
nctobaccofreeschools.com.                                retired as executive director of the     ments. It is not too late to contribute.
  23. Sargent et al., Reduced Incidence.                 North Carolina Association of            Contributions are accepted via mail or,
  24. Nat’l Ctr. for Chronic Disease Preven-         County Commissioners (NCACC), a              if you are using a credit card, by fax.
tion, Best Practices.
                                                     position that he held for twenty-eight       Please make your checks payable to the
  25. Matthew C. Farrelly et al., The Impact
of Workplace Smoking Bans: Results from a            years. He spent his entire working           SOG Foundation—Aycock #0527, and
National Survey, 8 TOBACCO CONTROL 272,              career in North Carolina and more than       send them to School of Government
272 (Autumn 1999).                                   half his life working for and representing   Foundation, CB# 3330 Knapp-Sanders
  26. AM. MEDICAL ASS’N, PREEMPTION:                 counties and local governments in North      Building, UNC at Chapel Hill, Chapel
TAKING THE LOCAL OUT OF TOBACCO CONTROL 2            Carolina. No single honor can adequately     Hill, NC 27599-3330.
(Chicago: the Association, 2002).                    reflect his legacy, but an idea conceived        Credit card payments and pledges
  27. Act of Apr. 28, 2005, SL 2005-19, and
                                                     by former NCACC Deputy Director Ed           also may be faxed to Ann Simpson at
Act of July 7, 2005, SL 2005-168 (allowing
regulation of smoking in buildings housing
                                                     Regan will ensure that Aycock’s contri-      (919) 843-2528. You may download
health departments and departments of social         butions to North Carolina local govern-      a pledge form at the NCACC’s web-
services, respectively, and on the grounds           ments will not be forgotten.                 site, at www.ncacc.org/documents/
surrounding those buildings).                           The NCACC and the School of Gov-          aycockscholarship.pdf.
  28. Act of July 29, 2005, SL 2005-239              ernment have established the C. Ronald           The School of Government sincerely
(exempting large indoor arenas with seating          Aycock Public Administration Scholar-        thanks the NCACC and all who have con-
capacity greater than 23,000 from smoking            ship Fund. An annual scholarship will        tributed to this important scholarship.
regulations provided for in G.S. 143, art. 64;
amending G.S. 143-599).
  29. Act of Aug. 25, 2005, SL 2005-372
(establishing a new G.S. 148-23.1, which
prohibits smoking in state correctional
institutions, and requiring the state to establish
pilot programs testing the smoking ban and
smoking cessation programs).
  30. Smoke-Free Charlotte, Petition and
Information (last visited July 15, 2005),
available at www.smokefreecharlotte.org.
  31. Marcus G. Plescia et al., Protecting
Workers from Secondhand Smoke in North
Carolina, NORTH CAROLINA MEDICAL
JOURNAL, July 2005, at 186.
  32. U.S. PUBLIC HEALTH SERV., TREATING
TOBACCO USE AND DEPENDENCE (Washington,
D.C.: U.S. Gov’t Printing Office, 2000). The de-
tails of comprehensive, evidence-based tobacco
cessation counseling are beyond the scope of
this article. More information is available at
www.surgeongeneral.gov/tobacco/default.htm.
  33. N.C. Prevention Partners, Preventive
Benefits (last visited July 15, 2005), available
at www.ncpreventionpartners.org/index.
html?ssfocus=383.
  34. David M. Eddy, David Eddy Ranks the
Tests, HARVARD HEALTH LETTER, (Special
Supp., July 1992, at 10).
  35. S. H. Zhu et al., Evidence of Real World
Effectiveness of a Telephone Quitline for
Smokers, 347 NEW ENGLAND JOURNAL OF
MEDICINE 1087 (2002).
  36. Nat’l Ctr. for Chronic Disease Preven-
tion, Best Practices.


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