Our analysis of the Massachusetts tobacco control programme shows that a strongly implemented, comprehensive control programme can reduce a population's health risks from tobacco use. Data on both cigarette consumption and smoking prevalence indicate a reduction in tobacco use in Massachusetts at a time when there has been little change in the rest of the country, with the exception of California. These results reinforce those from studies of the impact of the California tobacco control programme, which suggest that the programme produced a significant decline in the prevalence of adult smoking during its early years, which has continued at a slower rate in the most recent years.9,10
The impacts of particular aspects of the Massachusetts tobacco control programme have been presented in other studies. A prospective study of the impact of its antismoking television advertisements on children aged 12 and 13 years found that children who reported high levels of exposure to the advertisements in 1993-4 were only half as likely to be established smokers four years later as those who did not report early exposure to the advertisements.11
The increase in the cost of cigarettes in Massachusetts has probably been an important factor in the decline of smoking in both adults and teenagers.12
More than 3% of adult smokers reported that the 1993 price increase was part of the reason they stopped smoking, and a substantial number of adult and teenage smokers reported that they reduced their intake of cigarettes because of the increased cost.13
Massachusetts has spent more money per capita on tobacco control than any other US state. In 1998, 44 of the 50 other states plus the District of Columbia had provided little or no funding for tobacco control. The per capita expenditure of the six states that did provide funds ranged from $0.24 to $4.91.14
Although $6.50 per capita expenditure in Massachusetts is comparatively costly, it pales in comparison with the estimated smoking related healthcare cost to the state of $2.4bn a year,15
or $600 for each man, woman, and child in Massachusetts. An initial econometric analysis of the impact of the Massachusetts programme indicates that, even with conservative assumptions, it has reduced the state's healthcare costs by $85m annually (unpublished data).
Although tobacco consumption has generally been declining in most high income countries, it is increasing in developing countries, which are hard pressed to fund tobacco control interventions.16
When considering the cost of tobacco control interventions, however, it is important to keep in mind the cost of failure to intervene. About 82% of the world's smokers live in low and middle income countries, which will bear the brunt of the expected 500 million tobacco related deaths among those smokers.17
Our attempt to obtain information about expenditures outside the United States yielded little solid data, suggesting that national or state funding for tobacco control is quite rare (see table ). There is an urgent need for investment in tobacco control. The World Health Organization is currently promoting a framework for tobacco control,16
which, if implemented, could lead to substantial improvements in health internationally.
What is already known on this topic
The state of California has had a comprehensive tobacco control programme in place since 1989
Analyses of smoking prevalence and cigarette consumption indicate significantly greater declines in California than in other US states since programme inception.
What this study adds
Analysis of a well funded, comprehensive tobacco control programme in Massachusetts shows that, since its inception, the rate of decline of adult smoking has been significantly steeper than that in other US states except California
This study confirms that consistent, long term spending on antismoking advertisements, programmes to help people stop smoking, and promotion of tobacco control policies can reduce tobacco use in a population
Per capita expenditures for tobacco control, by country or state or province. Values are in $US (year for which data are available)